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Takotsubo cardiomyopathy triggered by wasabi consumption (bmj.com)
96 points by johanam 20 days ago | hide | past | web | favorite | 77 comments

> a case of a 60-year-old woman that presented to the emergency department with chest pain after she attended a wedding and ate a large amount of wasabi, assuming it to be an avocado

It should probably be cleared up that she suffered left ventricular dysfunction from eating too much wasabi - I had originally read the title thinking she was emotionally distressed from not getting her avocado, but instead it's more like a nervous system shock from the wasabi/wasabi poisoning(?) itself?

Do they mean horseradish dressed up as wasabi (horseradish + mustard + coloring) or do they indeed mean real wasabi?

The paper seems to be Israeli, so presumably they mean the fake horseradish wasabi (which usually includes a tiny amount of real wasabi), as it's very rare to find real wasabi outside of Japan in meaningful quantities.

I've seen it once in an upscale Zurich food department at 70$ a stick.

But even in Japan you don't really get it served in quantity. That stuff is expensive.

How you can confuse ersatz wasabi with avocado after taking a hearty bite mystifies me.

Many years ago I overheard a guy say that with his color-blindness, wasabi looks almost exactly like bean dip. He was at a party once, saw some chips, and a bowl of what he though was bean dip next to it. He took a chip, scooped out a nice dollop of "bean dip", and popped it in his mouth before anyone could react; only to discover that it as definitely not bean dip.

Luckily, he said, he really likes hot things, so while it was quite a surprise, it wasn't as nasty a shock as it could have been.

But yeah, I don't see how you could be confused after the first bite.

Edit: Somewhere else quotes the article as saying that the amount she'd eaten was "about a size of a teaspoon". That sounds similar.

Except the situation where the patient lost both the sense of smell and taste it is impossible imho. Even then I suspect the bodily reaction would indicate something is wrong with that "avocado".

Either we are dealing with a psychiatric patient with some strange food addiction or an idiot using wasabi to who knows, burn calories, clean the nose or rotten tooth/whatever.

The wasabi-avocado mistake sounds bogus to me.

I'm interested if this can indeed be categorized as 'poisoning'. If I understand it correctly, what the wasabi did is similar to what extreme emotional stress can also do... So if the effect of too much wasabi is considered 'poisoning', can extreme emotional stress be considered a poison?

I don't think we're talking about emotional stress here. Eating a teaspoon of wasabi is comparable to eating a teaspoon of habanero chilli sauce. It's a shock to the nervous system unless you have a tolerance.

Yeah, but the effects can be the same as those of extreme emotional stress, i.e. you start crying...

I think crying is a bit of a red herring here.

Chilli and wasabi doesn't make you cry in the emotional sense. They stimulate the sinus and lacrimal glands to dilute and flush the irritant. There are other non-emotional triggers such as cutting onions. In that case we 'cry' to dilute and flush the sulphuric acid formed on the eye.

It's interesting to note that this isn't just a difference in cause. The actual chemistry of tears changes based on trigger, which means there's an objective difference between crying from the pain of a hot pepper and tearing up as a physical reaction to it. (And this shouldn't be totally surprising; any mammal tears up at eye irritants like onions or dust, so humans obviously have some additional mechanism controlling emotional tears.)

In fact, we apparently have (at least) four different types of tear! 'Basal' tears that keep our eyes wet have much higher lipid levels than any other type, and a higher fraction of their lipids are nonpolar. 'Reflex' and 'flush' tears are similar, they're both responses to irritants, but there seem to be differences between tears produced to remove solid/physical and liquid irritants. And then 'emotional' tears (which include pain) come with a host of hormones and other proteins basically absent from the general tear responses.

Well no ? A poison is a substance and emotional stress is a state of mind that causes vaguely similar symptoms. Seems fairly straightforward to me...

All is translated to chemical signals in the end. Emotional stress is just another abstract fit-all sue-a-lot concept

No serious consequences, but a family member mistook fresh horseradish for applesauce in a dimly lit buffet once. Bad enough that we made an early exit :)

How's that? Horseradish effects last only a few seconds, unlike capsaicin, which can incapacitate someone for half an hour if present in high enough quantities.

Eat a tablespoon. It's not pleasant. Wasabi (as in the posted story) is very similar to (and often IS) horseradish.

I've done that, and it passes very quickly, unlike capsaicin. It seems very bizarre that a "horseradish OD" would result in someone needing to leave the restaurant.

Less bizarre than the story we are commenting on. Everyone has a different tolerance for things.

I wonder if it was real or fake wasabi.

There's not a lot of difference between real and fake wasabi. One is horseradish and the other is a close relative of horseradish.

> There's not a lot of difference […] One is horseradish and the other is a close relative of horseradish.

Close relatives of the horseradish include woad (the ancient indigo source), turnips, rapeseed, cabbages, weeds (thale cress) and flowery shrubs & al. "Close relative" is not an indication of "not a lot of difference". You might as well say that mustard (also a close relative) is no different from wasabi.

It's the same chemical allyl isothiocyanate producing the flavor one way or the other. Horseradish isn't faking the flavor.

Have you tasted them? Most people wouldn't notice the difference if you swapped their regular fake wasabi for the real thing. The main difference is the colour, hence the fake stuff being dyed green.

They definitely taste different if wasabi is fresh chopped.

You're missing my point, which is that "close relative" says literally nothing about the effects given how varied "close relatives" of the horseradish are.

You may well be right that there is no big difference between wasabi and horseradish, but them being "close relative" is not an actual argument for that unless they're much closer relative than just being in the same taxonomic family.

You're sort of beating a strawman to death. I just said close relative without specifying how close or what kind of relationship. You picked that to mean "same taxonomic family' and having a go at that being a bad choice of qualification. Okay mate, but you picked it. Being pedantic for no productive reason at all backfires. Often.

> You're sort of beating a strawman to death. I just said close relative without specifying how close. And you picked that to mean "same taxonomic family'

I didn't pick anything, I just looked up what the qualifier you picked meant. They're not the same species, they're not the same genus, they're the same taxonomic family, which also includes all the stuff I listed in my original comment.

You said:

>There's not a lot of difference between real and fake wasabi. One is horseradish and the other is a close relative of horseradish.

There was no strawman. Being a close relative does not imply "not a lot of difference."

Have you tried a teaspoon of Dijon?

But can be a lot of difference on how is cultured and its origin.

The paper abstract is ambiguous on the cause being physical or emotional:

  > Takotsubo cardiomyopathy is a left ventricular dysfunction
  > that typically occurs after sudden intense emotional
  > or physical stress and mimics myocardial infarction.

I'd have expected emotional stress if she'd thought she'd slathered a dish in wasabi and only got avocado, if it was the other way around physical stress is pretty likely.

Though I don't get how you'd eat "a large amount of wasabi", surely the first spoonful would tell you it's not avocado unless you don't have nerve endings, or a nose?

To be fair, if you go in all gun-ho for a huge bite of real wasabi like you would avacado you're going to get a whole load more than most people would mix in with their sushi.

From the paper (see nearby link):

> In our case report, the amount of wasabi our patient consumed was unusually large, about a size of a teaspoon ...

That's a lot of wasabi.

Unless you've never had wasabi before.

I use about a tablespoon (3 x as much) when I eat sushi (~6 pieces) but I like it spicy.

I also eat wasabi in large quantities. I'll eat it on its own with beer. But interestingly, I have problems with chest pains on occasion and the doctors have been at a complete loss to explain it. I wonder... I'll give up wasabi for a while and see what happens.

If you're eating straight up with just beer then I'd say that's hardly a mystery.. that's not a good combo for the stomach.

Sadly, this was my first experience with wasabi. I didn't know what it was, but thought since it was green, that it was avocado-based. I was on a first date with this chick. I took what I believed at the time to be a "small" spoonful and popped it into my mouth directly. I am remarkably good at maintaining my composure under such duress, but that was a lot to handle. You can't hide the sweat and tears behind a smile, although I tried.

To this day, I can't do wasabi. My body decided it was poison at that moment and I'm very sensitive to the flavor.

Many years ago, when I took some friends to an Indian restaurant, this guy decided to eat a spoonful of lime-mango pickle. He tried to be cool about it, but was clearly in some pain. I tried to tell him to start mild, and ramp it up gradually, but he just wanted to go for it.

perhaps stuffy nose, takes big avocado slice sized scoops of wasabi to put on sandwich. Big bite to be sure of getting full slice of avocado and not having to bite it in half.

I recently suffered three weeks of anosmia (loss of smell, taste) due to an acute sinus infection, and had some wasabi one evening. I could not taste it at all, and further, I did not get the eye watering, nose burning sensation I normally get that restricts me to a quarter teaspoon at most. If this woman had a similar issue, then yes, I can see how one could eat cups of wasabi and not notice.

What kind of person would get emotionally distressed to the point of chest pains requiring an emergency department because they didn't get some avocado?

> because they didn't get some avocado?

If you drink a shot of liquid LSD thinking it was vodka you don't die because "you didn't get some vodka?". She died because of the effect of wasabi, not because of the lack of avocado.

I think you've misunderstood - it was a response to the parent comment, which you seem to have missed.

She didn’t die

Millennials. (I’m a millennial, so I can say it!)

I’m curious with something as poorly understood as takotsubo, how they are so confident to rush to the conclusion that the wasabi must have triggered. I actually read the full text and I dont see any discussion on eliminating confounders, and this is just one case.

At best this suggests further research is in order, but I’m not convinced anything can be definitively concluded here about the cardiotoxicity of wasabi.

Case report or not, what passes for medical research makes me shake my head.

As a cardiologist, this is also my perception (that you can’t assign causality to wasabi here).

Not bad to put out a case report, since if there is truth here, this could spur future knowledge. But it seems unlikely that wasabi was causal compared to, say, the wedding itself.

Doctors are not trained scientists but I imagine the authors took the inductive position that many people at the wedding did not get the heart attack and the woman who ate the wasabi was triggered by it.

Come to think of it, triggers are not necessarily the underlying causes, so this particular diction in the abstract and title may be fully apt.

Yeah, I have no complaints about any part of this publication. This is typical of case reports.

If we lived in a world where we could go back and see the true causes, I would bet that the true cause was not the wasabi. If historical evidence says that P(takotsubo|wedding) is low but nonzero and P(takotsubo|wasabi) is virtually zero, then my money is still on the wedding being the cause, even if nobody else at the wedding got takotsubo. (It's not thought to be transmissible as if it were an infectious disease.) Happy to be wrong here.

But, like any case report, this case report is interesting (which is why it was published). And if more evidence accumulates that wasabi can lead to stress cardiomyopathy, that would, indeed, be interesting.

Aside: now does a cardiologist become a member of Hacker News?

Your question prompted me to realize that I’ve been on HN for over a decade...

There are a bunch of physicians of different specialties in this community. It’s not uncommon.

Hear, hear: neurosurgical anesthesiologist (retired) here

Yeah, how can we get more experts from various fields.

It's right in the domain name: ycombinator

Since no one has mentioned it yet, the etymology of the phrase:

The name "takotsubo syndrome" comes from the Japanese word takotsubo "octopus trap", because the left ventricle of the heart takes on a shape resembling an octopus trap when affected by this condition.

This is very reminiscent of something which happened to a friend of mine a couple of years ago. She'd never eaten Japanese food before and I took her to a local sushi joint. She mistook wasabi for guacamole and ended up putting a large lump of it in her mouth. Fortunately, I noticed it immediately and asked her to spit it out, and by then her eyes were already teary and her breathing was quite labored. She didn't at first, perhaps because she was concerned about the embarrassment it'd cause. I had to repeat again, this time adding that she shouldn't be worried about anything and just spit it out and she did. Finally, rinsing the mouth with a jug full of cold water and eating some Gari (the pickled sweet ginger that's served with Sushi) alleviated her symptoms.

I texted her the link to this hinting that I might have saved her life that day. Evidently, she still avoids Japanese food, thanks to that incident.

My parents are both very healthy; my dad's 80 and my mom is in her early 70s. They're typically mistaken for much (10-20 years) younger.

So it was quite a shock to hear my mom was in the hospital for a heart issue a couple years back.

She was ultimately diagnosed with Takotsubo.

They had been watching a play at an outdoor theater, and during a very stressful/dramatic/revealing moment in the play (I think with loud drums, etc), she had these chest pains and was rushed to the hospital.

Very interesting to learn about this condition I hadn't heard of. The "good news" is that, if you recover, and go a few weeks (I want to say 6+) without a recurrence, the heart re-strengthens and you're not any more likely to have heart issues again than anyone else.


I don't have access to the full article, but my only real question is - HOW? I don't know how you'd mistake a mouthful of wasabi for anything, except maybe trying to swallow a flamethrower. I can't imagine getting through the first mouthful and then moving on to the "eating a large amount" stage.

If I know anything about trending, there's going to be a few new Youtube channels now dedicated to wasabi ingestion, hopefully complete with medical personnel available if something should go wrong.

Cardiologist takotsubo wasn't real.

I can't read the full article and I'm not a physician: Doubly handicapped. Why do you say it wasn't real?

sorry I sadly forgot a verb. "cardiologist said takotsubo wasn't real" (not my opinion)

What rationale did they give for that? There is a fair body of literature that they'd be overturning if they can show that stress cardiomyopathy, which we see often, is not real.

I didn't ask more I was already too frustrated.

I just assume everything has some small chance of killing me and try not to let it bother me too much.

Every time boulevardesque stuff like this gets too prominent on the HN frontpage, I go do a deep dive into daily politics to see if there is anything that is being buried.

As a hacker, Im struggling to see how this is relevant to me?

I thought wasabi was a hacker-friendly food.

Just don't upvote it and it'll go away.

don't you eat when you hack ?

No. But even so, a rare fringe case of someone mistaking wasabi and avocado.... I have a feeling I'll make it to 80 years of age without that happening.

You will now that you've got the benefit of reading about this case

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