RealCases
14 JULY 2023 ausdoc . com . au
Did listeriosis kill King Henry I ?
The wonders of clinical hindsight
King Henry I of England .
General medicine
Heather Saxena Medical reporter for Australian Doctor .
A doctor has challenged the long-held belief that the monarch died from poisoning after overindulging on lampreys .
FOR nearly 900 years , the sudden death of King Henry I of England has been attributed to accidental poisoning after dining on a large dish of lampreys , which some have described as the ugliest fish on the planet .
But now a US-based doctor has challenged this centuries-old diagnosis , claiming the monarch most likely died of acute meningitis secondary to Listeria monocytogenes .
The king — who was in his late 60s at the time — famously retained the “ tremendous energy ” of his youth until his fatal illness , writes Dr Matthew Turner from the Madigan Army Medical Center in Washington .
On 25 November 1135 , Henry had spent a long day hunting in the forest of Lyons in France , and that evening , the king dined on a large dish of lampreys “ against the advice of his physicians ”, Dr Turner wrote in Cureus .
“ He fell ill during the night , quickly developing a chill , convulsions , fever and ‘ heavy sweating ’.”
Henry subsequently died on 1 December before he could confirm whether his estranged daughter Matilda or nephew Stephen would succeed him .
As for the fish that supposedly dispatched him , Dr Turner explained it was a popular delicacy among the wealthy at the time , with a taste and texture closer to beef short ribs or venison .
King Henry I also had a history of gastrointestinal disturbances from the dish he loved , which renowned doctors and scholars of the time considered to be a “ dangerous meal ”.
“ Based on the humoural theories of the time , physicians thought that lampreys were ‘ cold and moist in the fourth degree ’ and posed a ‘ humoural threat ’ that could only be countered with spices ,” Dr Turner said .
‘ There ’ s a wide variety of other potentially lethal abdominal pathologies .’
“ They were also considered poisonous due to their resemblance to snakes .”
In support of the longstanding theory , more contemporary evidence has shown that failure to properly wash lamprey meat or remove the mucous covering can lead to poisoning within hours of ingestion .
But the associated illness — nausea , vomiting , diarrhoea , abdominal pain and weakness — is self-limiting and usually resolves after several days .
“ There are no reports of death via lamprey poisoning in modern literature ,” Dr Turner said .
Yes , food poisoning was commonplace during the medieval times given the “ abhorrent ” hygienic conditions involved in food preparation .
Although Staphylococcus aureus poisoning was highly suspect , the death rate is “ miniscule ”, with approximately six deaths per 242,000 cases in the US each year , the author explained .
Therefore , he reasoned that the most likely culprit would have been L . monocytogenes poisoning .
“ This bacterium is foodborne and , as the causative agent of listeriosis , can have a mortality rate of up to 20-30 %, with complications that include meningitis , gastroenteritis and septicaemia ,” he said .
“ The stone fortress of Lyons-la-Forêt was likely cold and damp in November 1135 , providing optimal conditions for listeria growth .
Dr Turner noted that between 24 % and 37 % of patients with listeriosis have no preexisting conditions , which fits with what was known about the king ’ s health at the time .
He also said that none of the king ’ s hunting companions became ill , which suits the typically sporadic manifestation of the illness .
Additionally , Henry ’ s belief that his end was near was suggestive of CNS listeriosis infection .
“ While the description of Henry I ’ s death due to overeating a large meal of lampreys makes for an interesting historical anecdote , the tale does not appear to have any firm basis in reality ,” Dr Turner concluded .
“ If the king suffered from food poisoning , we believe that an acute meningitis secondary to [ L . monocytogenes ] is the most likely culprit for the king ’ s strange symptoms and sudden passing .
“ However , the wide variety of other potentially lethal abdominal pathologies — including pancreatitis , appendicitis [ and ] biliary disease — should also be considered in this interesting historical case .” Cureus 2023 ; 21 May .
Anonymous GP MARK , 34 , was having a rough trot . His father was diagnosed with pancreatic cancer , and despite everyone ’ s best efforts , Mark and his family watched helplessly as he faded to nothing and then passed . Then Mark ’ s mother died suddenly . As his marriage collapsed , his previously undiagnosed PTSD roared into life , and his career crumbled . To top it all off , a minor shoulder injury flared , he was taken to theatre and then completely failed to recover , leaving Mark — a young man with two young daughters — with a useless , painful frozen shoulder . And then his gut symptoms started . Mark came in for a review in January with severe abdominal cramping , diarrhoea , nausea , vomiting and weight loss that had started before Christmas .
We looked at each other wild-eyed and immediately set about making sure it was not pancreatic cancer . Bloods — normal . Ultrasound — normal . Followed up by further investigations : stool culture , CT scan , gastroscopy , colonoscopy — all normal .
The gastroenterologist kept in touch , but we suspected that perhaps his symptoms were being driven by his ongoing significant PTSD and subsequent major depression , for which the mirtazapine — started in October — was only just knocking off the edges .
Mark required several trips to theatre for drainage of golf ball – sized abscesses in his armpits . Mark had lost 8kg . None of the prn medications were easing his gut symptoms , and recurrent antibiotic treatment was only making them worse . His mental health was not turning a corner . We discussed the option of psychiatric hospital admission , but then his new psychiatrist suggested a change of SSRI .
Now some of you might have already spotted the happy ending here .
I know , I am kicking myself for not spotting it sooner : mirtazapine . It is not my first choice in antidepressants , but I have used it often for depression , especially for its benefit in the management of insomnia .
Mark reported an improvement in his sleep when his specialist started it — even if his mood never did lift .
With regard to other side effects , I generally warn my patients that they are likely to gain weight and to expect a possible transient disturbance in gut function .
The disconnect of several months between starting mirtazapine and the development of severe abdominal symptoms was a complete surprise .
But his improvement off the medication was almost instant . His nausea lifted , his pain ceased and his appetite returned .
He put on weight , his energy spiked and his mood improved .
Mark is delighted with the outcome and forgiving about the delay in getting him well .
He has also given me his blessing to share this cautionary tale — a gentle reminder to first do no harm .