Like many characters in the third season of “The White Lotus,” the pong pong tree spends a lot of its air time hanging by the pool — but it ended up being quite the star of the show.
In the introductory episode of the third season of “The White Lotus,” which aired its season finale Sunday, a receptionist at the namesake hotel, Pam (played by Morgana O'Reilly), warns the Ratliff family that a poisonous fruit tree is growing in the middle of their habitation — planting a seed of suspense that grows throughout the season.
That suspense culminated in the finale episode after Pam inadvertently gives instructions on how to prepare and eat the deadly plant to Timothy Ratliff, who has been contemplating suicide throughout the season after learning his family will lose their wealth after their vacation in Thailand ends.
Known as the “suicide tree” in Southeast Asia and Australia where it grows, the pong pong tree (Cerbera odollam) has been linked to thousands of deaths. In fact, it may be even more toxic than the show depicts, according to Dr. Ryan Misek, an emergency medicine physician and clinical associate professor at Midwestern University who co-authored a case report involving a 22-year-old patient who consumed the pong pong’s seeds.
Although one study reported that it was once responsible for half of plant poisoning cases in Kerala, India, relatively little research has been published about it in the West. Misek said he published the case report to raise awareness about this deadly toxin in the U.S.
“This was a situation where this was a toxin that was not very well publicized,” Misek told Salon in a phone interview. “By publishing this case report, the hope was that we would increase awareness among doctors and toxicologists and people on the front lines, so that if the next victim came in, there would be some knowledge and we would be able to … save more of these patients.”
"Although we lack high-quality data determining the exact amount of takes to be lethal, just one kernel seems to be enough to cause significant toxicity and even death."
The fruits of the tree contain one or two bitter seeds containing cerberin, a toxin the plant evolved to prevent animals from eating it. Although Misek’s patient consumed an unknown amount of pong pong seeds, there have been deaths reported with people who ate just one of its seeds, he said.
“The kernels are definitely deadly,” said Dr. Josh Trebach, an emergency physician and medical toxicologist at the University of Iowa Health Care who said he is not speaking on behalf of his institution or giving medical advice. “Although we lack high-quality data determining the exact amount it takes to be lethal, just one kernel seems to be enough to cause significant toxicity and even death.”
Cerberin, which is found in a handful of other plants, is a cardiac glycoside, which disrupts the electrical signaling in the heart.
Specifically, when ingested, the toxin targets the electrolyte pumps in the wall of the heart called the sodium potassium ATPase pump. In a healthy body, this pump helps shift electrolytes around in the heart and pump blood throughout the body. But cerberin poisons this pump, which can cause the heart's electrical system to fail. There can also be an associated increase in potassium found in the blood stream, which further poisons the heart. This leads the heart to slow down and can lead to a fatal arrhythmia, Misek said.
"The heart's electrical system ultimately stops conducting electricity and muscle cells lose their ability to contract in a normal, organized fashion," he said. "This ultimately leads to cardiac arrest."
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Eating these seeds can lower a person’s heart rate and cause nausea, vomiting and stomach pain. When Timothy Ratcliff’s son, Lochlan, accidentally drinks the leftover toxic mixture he prepared in the blender in the season finale of “The White Lotus,” he displays some of these same symptoms before passing out, seeing some spiritual stuff and waking back up.
But what is displayed is a Hollywood version of the process, chopped and edited to fit into a 90-minute episode. In reality, it typically takes at least a few hours before a person would start to feel the effects of the cerberin. The patient involved in Misek’s case report ate the seeds seven hours before coming in to treat their symptoms.
"Deaths reported from pong pong seeds are generally not as quick as depicted on television," Misek said. "Case reports of fatal overdoses often describe suffering during the hours after ingestion before the patient loses consciousness and ultimately dies."
Trebach emphasized how dangerous these seeds were and that it was important to seek medical care or call poison control if any ingestion is suspected. Treating someone who has ingested pong pong seeds usually involves treating the symptoms they are experiencing, Misek said. Doctors may also administer a digoxin immune fab antidote, which is used to treat a similar toxin.
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After ingesting the seeds, Lochlan presumably fights for his life while unconscious, entering a dream-like state where he finds himself struggling to swim to the surface of a pool of water. On his way, he sees four monk-shaped silhouettes. In the moment he lets go, he wakes up, rolling over to tell his father he “saw God.”
The portrayal of Lochlan’s near-death experience might have been more realistic than his poisoning. Many people report leaving their bodies and other transcendental experiences after near-fatal accidents.
But based on the amount of pong pong seeds he consumed, it would have been more realistic if Lochlan had died, Trebach told Salon in an email.
“Lochlan’s symptoms came on so fast (even before he finished drinking the entire thing) that I worry he was exposed to a consequential amount,” Trebach said. “Without medical treatment, I think it is extremely unlikely that Lochlan would've survived ‘The White Lotus’ season three finale.”
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