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Fish Poisoning

Accidental Poisoning by a Fish

Fish poisoning can occur after ingestion of various fishes, such as reef fish, puffer fish, improperly processed or canned scombroid species (tuna), and shellfish. The clinical presentation almost universally involves some form of acute gastrointestinal irritation, whereas constitutional, cardiovascular, respiratory, and neurological symptoms arise depending on the type of fish poisoning. Symptoms appear within a few hours in most patients and can range from self-limiting to life-threatening. A properly obtained patient history is crucial for establishing the diagnosis.


Presentation

Numerous reports in the literature describe cases of fish poisoning occurring due to ingestion of several species, some of the most important being:

  • Shellfish - Poisoning from this fish stems from the effects of saxitoxin, a compound found in butter clams, geoducks, mussels, and other bivalve mollusks that are eaten by shellfish [1] [2] [3]. It is a very potent molecule capable of producing symptoms within several hours after being introduced into the gastrointestinal tract [2] [3]. Because saxitoxin blocks voltage-gated sodium channels, neurological symptoms are a constitutive feature of this type of fish poisoning; circumoral paresthesia, numbness and a tingling sensation of the extremities, ataxia, weakness, and altered consciousness are principal findings [2] [3]. In severe cases, hypertension and tachycardia may be accompanied by a severe muscular and respiratory paralysis, thus the term paralytic shellfish poisoning is often used [2] [3]. In rare cases, the effects of another toxin found in shellfish (brevetoxin) can cause temperature-related dysesthesia [1].
  • Pufferfish - Ingestion of pufferfish is a potentially life-threatening clinical entity and is known as fugu poisoning. Tetrodotoxin (TTX), similarly to saxitoxin, impairs the transmission of neuromuscular impulses [4] [5]. Lightheadedness, weakness, vomiting, and a rapidly ascending paralysis, eventually affecting respiratory muscles, may be fatal within 6-24 hours [5]. Diaphoresis, excessive salivation, dysphagia, convulsions, hypotension, bradycardia, and fixed dilated pupils are other notable symptoms of pufferfish poisoning [4] [5].
  • Scombroid species - Initially described from tuna, mackerel, and other fish belonging to the Scombridae family, and later with sardines and anchovies, scombroid fish poisoning arises in the setting of improper storage or processing, resulting in the accumulation of histamine [6] [7]. Thus, typical symptoms resemble an acute allergic reaction - disseminated erythema (without wheals) and flushing are accompanied by abdominal cramping, diarrhea, and vomiting [6] [7]. Headaches, palpitation, and dizziness are frequently reported [7]. Furthermore, bronchospasm and respiratory distress in conjunction with an unstable blood pressure can appear as well [6]. Symptoms develop shortly after consuming the fish (in the first hour and a half) and resolve within 36 hours [6].
  • Reef fish - Ciguatera fish poisoning (CFP), named after ciguatoxins that produce gastrointestinal (vomiting, diarrhea, abdominal pain), neurologic (paresthesias, pruritis), and musculoskeletal (myalgia, arthralgia, and weakness) symptoms in a period of hours, is primarily seen after consumption of fish species residing in coral reefs [1]. Dysesthesia is a constitutive feature of ciguatera fish poisoning as well, and it may be confused with shellfish poisoning [1].
Collapse
  • Author information 1 Environment and Resource Science/Studies, Trent University, 1600 West Bank Drive, Peterborough, ON, Canada K9J 7B8. karenemorrison@trentu.ca Abstract Following the collapse of the Cuban economy in the early 1990s, epidemiologists[ncbi.nlm.nih.gov]
  • Scombroid fish poisoning (tuna) At the same time as the rash, other symptoms may occur: Burning feeling in the mouth Pounding headache Raising heart Dizziness Difficulty breathing Abdominal pain Nausea Diarrhoea Collapse due to low blood pressure Symptoms[dermnetnz.org]
  • In severe cases, the poisoning can kill by slowing the heart and lowering the blood pressure to the point of circulatory collapse, shock and coma.[nytimes.com]
Gastric Lavage
  • All patients received symptomatic and supportive treatment and general supportive care, including gastric lavage and intravenous fluid. Intubation and mechanical ventilation was considered especially when paralysis was progressing rapidly.[ncbi.nlm.nih.gov]
Vomiting
  • Lightheadedness, weakness, vomiting, and a rapidly ascending paralysis, eventually affecting respiratory muscles, may be fatal within 6-24 hours.[symptoma.com]
  • The diagnosis usually is made by the presence of gastrointestinal symptoms, nausea, vomiting, and diarrhea, and of neurological symptoms such as paresthesias, paresis, and pruritus.[ncbi.nlm.nih.gov]
  • BACKGROUND: Ciguatera-fish poisoning (or ciguatera) is a common but underdiagnosed food-borne illness related to fish consumption that is characterized by nausea, vomiting and neurologic symptoms such as tingling in the fingers or toes.[ncbi.nlm.nih.gov]
  • Do not induce vomiting or give syrup of Ipecac. Ipecac was formerly used to induce vomiting in poisoned patients where there was a chance to get the toxin out of the body.[medicinenet.com]
  • Abstract Ciguatera fish poisoning is characterized by gastrointestinal symptoms such as nausea, vomiting, and diarrhea and neurologic symptoms such as weakness, tingling, and pruritus (itching).[ncbi.nlm.nih.gov]
Nausea
  • Symptoms of poisoning may include paralysis, respiratory failure, numbness, paraesthesia, nausea and ataxia. Health professionals should be aware of the condition so as to institute early and appropriate management.[ncbi.nlm.nih.gov]
  • The diagnosis usually is made by the presence of gastrointestinal symptoms, nausea, vomiting, and diarrhea, and of neurological symptoms such as paresthesias, paresis, and pruritus.[ncbi.nlm.nih.gov]
  • BACKGROUND: Ciguatera-fish poisoning (or ciguatera) is a common but underdiagnosed food-borne illness related to fish consumption that is characterized by nausea, vomiting and neurologic symptoms such as tingling in the fingers or toes.[ncbi.nlm.nih.gov]
  • Abstract Ciguatera fish poisoning is characterized by gastrointestinal symptoms such as nausea, vomiting, and diarrhea and neurologic symptoms such as weakness, tingling, and pruritus (itching).[ncbi.nlm.nih.gov]
  • CFP can cause gastrointestinal symptoms (nausea, vomiting, abdominal cramps, or diarrhea) within a few hours of eating contaminated fish.[ncbi.nlm.nih.gov]
Food Poisoning
  • What Is the Most Common Way to Get Food Poisoning From Fish? There are actually two ways in which you can get food poisoning from consuming fish.[healthguidance.org]
  • When consumed, this substance causes a food poisoning reaction similar to an allergic reaction. Food poisoning from raw fish can also occur as a result of contamination of the fish with infectious organisms.[livestrong.com]
  • Find out more in our viral food poisoning section.[medic8.com]
  • The treatment of this food poisoning is supportive, although intravenous mannitol is reported to be safe and effective. The prognosis is good and complete recovery is to be expected.[ncbi.nlm.nih.gov]
  • Avon Health Protection Team investigated food poisoning on a ship at Avonmouth, which was thought by the crew to be related to a white snapper fish from the Caribbean.[ncbi.nlm.nih.gov]
Abdominal Pain
  • OBJECTIVE: We describe the case of a young man who suffered from diarrhea and abdominal pain after eating raw fish and who also developed severe ataxia with spontaneous downbeat and perverted head-shaking nystagmus.[ncbi.nlm.nih.gov]
  • She developed abdominal pain, diarrhea and hypotension in the ED requiring admission to the hospital.[ncbi.nlm.nih.gov]
  • Symptoms of poisoning included perioral paraesthesia, tingling over the entire body, nausea and vomiting, dizziness, headache, abdominal pain and muscular paralysis of the limbs.[ncbi.nlm.nih.gov]
  • We defined CFP case-patients as persons with gastrointestinal symptoms (abdominal pain, vomiting, diarrhea, or nausea) and neurological symptoms (extremity paresthesia, arthralgia, myalgia, malaise, pruritus, headache, dizziness, metallic taste, visual[ncbi.nlm.nih.gov]
  • Reef fish - Ciguatera fish poisoning (CFP), named after ciguatoxins that produce gastrointestinal (vomiting, diarrhea, abdominal pain), neurologic (paresthesias, pruritis), and musculoskeletal (myalgia, arthralgia, and weakness) symptoms in a period of[symptoma.com]
Hypersalivation
  • 48 hours, while neurological symptoms–which develop later and can last for weeks or months after the initial exposure–include tingling, trouble with cold perception, headache, dental pain, metallic taste, vertigo, lack of coordination, itching, and hypersalivation[sea.edu]
Orthostatic Hypotension
  • PURPOSE: The purpose of this study was to investigate the pathophysiology of persistent orthostatic hypotension in a patient with ciguatera fish poisoning.[ncbi.nlm.nih.gov]
  • Orthostatic hypotension in ciguatera fish poisoning. Arch Intern Med 1992;152:2131-3. [ PUBMED ] [ FULLTEXT ] 5. Lewis R, Hoy A, McGiffin D. Action of ciguatoxin on human atrial trabeculae. Toxicon 1992;30:907-14. 6. Marquais M, Sauviat M.[heartviews.org]
Pruritic Rash
  • A 25-year-old woman presented to the emergency department (ED) with one hour of tongue and face swelling, an erythematous pruritic rash, and dyspnea with wheezing after consuming a tuna sandwich.[ncbi.nlm.nih.gov]
Suggestibility
  • Oculomotor findings suggested dysfunction of the vestibulocerebellum, especially the flocculus. CONCLUSION: These findings suggest that both the peripheral and the central nervous systems can be involved in ciguatera. Copyright 2012 Elsevier Inc.[ncbi.nlm.nih.gov]
  • The lack of abnormal needle EMG signs suggested axonal sparing.[ncbi.nlm.nih.gov]
  • Our findings suggest this could be related to respiratory muscles involvement.[ncbi.nlm.nih.gov]
  • It is suggested that intravenous mannitol may prove to be a useful treatment for mild to moderate ciguatera poisoning, and for patients who present late for treatment.[ncbi.nlm.nih.gov]
  • It is suggested that increased clinician awareness with early and appropriate treatment, and focussed public health intervention may help limit the potential public health impact of ciguatera poisoning in industrial ship crewmembers and other fish-consuming[ncbi.nlm.nih.gov]
Impulsivity
  • Tetrodotoxin (TTX), similarly to saxitoxin, impairs the transmission of neuromuscular impulses. Lightheadedness, weakness, vomiting, and a rapidly ascending paralysis, eventually affecting respiratory muscles, may be fatal within 6-24 hours.[symptoma.com]
Auditory Hallucination
  • A 40-year-old man experienced mild digestive troubles and terrifying visual and auditory hallucinations after eating a specimen of Sarpa salpa in a restaurant.[ncbi.nlm.nih.gov]
Headache
  • Amitriptyline demonstrated resolution of most symptoms except for heat/cold reversal in one patient and heat/cold reversal, pruritus and headache in the second patient.[ncbi.nlm.nih.gov]
  • Symptoms included a bright red rash, tightness of the chest, palpitations, anxiety, mild headache and dizziness, all of which resolved spontaneously within 2-3 h.[ncbi.nlm.nih.gov]
  • Although typically a benign syndrome, characterized by self-limited flushing, headache, and gastrointestinal symptoms, we describe a case unique in its severity and as a precipitant of an asthma exacerbation.[ncbi.nlm.nih.gov]
  • Symptoms of poisoning included perioral paraesthesia, tingling over the entire body, nausea and vomiting, dizziness, headache, abdominal pain and muscular paralysis of the limbs.[ncbi.nlm.nih.gov]
  • Signs and symptoms Symptoms include: tingling and burning around the mouth facial flushing and sweating nausea, vomiting and diarrhoea headache palpitations and dizziness rash.[sahealth.sa.gov.au]
Nystagmus
  • OBJECTIVE: We describe the case of a young man who suffered from diarrhea and abdominal pain after eating raw fish and who also developed severe ataxia with spontaneous downbeat and perverted head-shaking nystagmus.[ncbi.nlm.nih.gov]
Neurologic Manifestation
  • ., Serious neurological manifestations of ciguatera: is the delay unusually long? J Neurol Neurosurg Psychiatry. 1998;64:688-89.[rarediseases.org]

Workup

Because of the rapid onset of symptoms seen in the mentioned types of fish poisoning, a prompt diagnosis can be life-saving. A proper patient history is the single most important step in the workup. Data regarding recent consumption of fish, the development of similar symptoms in friends or other persons who ate the same food (or have been in the same restaurant) can be crucial for a presumptive diagnosis of intoxication [1] [5] [7]. The physical examination is an important component of the workup, during which the severity of complaints and their progression should be defined, mainly in order to consider the optimal therapeutic approach. Despite the scarce availability of commercial tests for specific toxins found in fish, recent introduction of novel biochemical tests might be useful for detecting the concentration of ciguatera toxin, histamine, tetrodotoxin, and saxitoxin in respective fish species; this confirming the presumed source [1] [2] [3] [5] [6]. An assessment of histamine concentration in blood or its metabolites in urine might also be a useful diagnostic tool [6].

Slow Nerve Conduction Velocities
  • However, intraperitoneal injection of ciguatoxin in rats increases neuronal refractory period and slows nerve conduction velocity. Treatment with mannitol fails to correct these effects.[ncbi.nlm.nih.gov]

Treatment

  • Treatment with mannitol fails to correct these effects.[ncbi.nlm.nih.gov]
  • IV mannitol), the appropriate treatment for CFP remains unclear to many physicians. We review the literature on the treatments for CFP, including randomized controlled studies and anecdotal reports.[ncbi.nlm.nih.gov]
  • Treatment was symptomatic and supportive and included vitamins B12 and BCO, folic acid, prostigmine, steroids and antihistamines as indicated.[ncbi.nlm.nih.gov]
  • Five patients sought medical attention; health care providers did not make a diagnosis of CFP or report the cases to public health authorities, and none of the patients received treatment.[ncbi.nlm.nih.gov]
  • Other plants used in CFP and the conventional treatment of CFP are also discussed briefly. Copyright 2011 John Wiley & Sons, Ltd.[ncbi.nlm.nih.gov]

Prognosis

  • The prognosis is good and complete recovery is to be expected. However, relapses can occur, especially on re-exposure to the toxin.[ncbi.nlm.nih.gov]
  • The prognosis for most cases is good with a short duration of self-limited symptoms, but for some cases neurological sequelae can become chronic.[ncbi.nlm.nih.gov]
  • Prognosis The prognosis for PSP is quite good, especially if the patient has passed the initial 12 hours of illness without needing breathing support. Most deaths occur during this period if breathing help is not available.[medical-dictionary.thefreedictionary.com]
  • During 2009-2015, 85 outbreaks of confirmed histamine fish poisoning involving 250 illnesses were reported to the CDC, with one hospitalizaiton and no deaths. [14] Prognosis Patients with histamine fish toxicity have a good prognosis.[emedicine.medscape.com]
  • Prognosis The prognosis is excellent.[emedicine.medscape.com]

Etiology

  • Other postulated second agents are cadaverine or putrescine. [9, 10] Etiology The fish species most commonly implicated in histamine toxicity are scombroid dark-meat fish (eg, tuna, mackerel, skipjack, bonito, marlin) and nonscombroid species, such as[emedicine.medscape.com]
  • Etiology Ingestion of sufficient quantities of fish that contain accumulated ciguatoxin produces this syndrome. Fish larger than 2 kg can contain significant amounts of toxin and readily produce toxic effects when ingested.[emedicine.medscape.com]

Epidemiology

  • In this review, we discuss the epidemiology, pathophysiology, evaluation, and treatment of scombroid disease.[ncbi.nlm.nih.gov]
  • The epidemiology, clinical manifestations, diagnosis, treatment and public health issues are discussed.[ncbi.nlm.nih.gov]
  • Abstract The objective of this study was to outline the epidemiology of Ciguatera fish poisoning as seen in a general practice serving two industrial seaports in Trinidad and Tobago, in order to highlight the potential public health implications.[ncbi.nlm.nih.gov]
  • Abstract In the present review, the main objective was to describe the epidemiology and clinical features of ciguatera fish poisoning in Hong Kong.[ncbi.nlm.nih.gov]
  • A ciguatera management plan that integrates epidemiology, treatment, and a simple method of detection is required to ensure the protection of consumers.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • PURPOSE: The purpose of this study was to investigate the pathophysiology of persistent orthostatic hypotension in a patient with ciguatera fish poisoning.[ncbi.nlm.nih.gov]
  • In this review, we discuss the epidemiology, pathophysiology, evaluation, and treatment of scombroid disease.[ncbi.nlm.nih.gov]
  • NO produced in large amounts is involved in a wide range of pathophysiological processes. Many traditional remedies are commonly used in the Pacific against CFP.[ncbi.nlm.nih.gov]
  • This paper is a general review of CFP including the human health effects of exposure to ciguatoxins (CTXs), diagnosis, human pathophysiology of CFP, treatment, detection of CTXs in fish, epidemiology of the illness, global dimensions, prevention, future[ncbi.nlm.nih.gov]

Prevention

  • To prevent ciguatera outbreaks, the public should be educated to avoid eating large coral reef fishes, especially the CTX-rich parts.[ncbi.nlm.nih.gov]
  • To prevent mass poisoning in gatherings and parties, the most ciguatoxic fish species and potentially toxic fish species must be avoided.[ncbi.nlm.nih.gov]
  • The frozen fish was secured for the prevention of further disease spreading and additional diagnostic tests. RESULTS: All but one sailor ate the fish.[ncbi.nlm.nih.gov]
  • Scombrotoxic fish poisoning is preventable by the correct handling and refrigeration of these fish.[ncbi.nlm.nih.gov]
  • Prevention Fish should be chilled and properly refrigerated as soon as possible after being caught to prevent histamine formation.[sahealth.sa.gov.au]

References

Article

  1. Friedman MA, Fleming LE, Fernandez M, et al. Ciguatera Fish Poisoning: Treatment, Prevention and Management. Mar Drugs. 2008;6(3):456-479.
  2. Hurley W, Wolterstorff C, MacDonald R, Schultz D. Paralytic Shellfish Poisoning: A Case Series. West J Emerg Med. 2014;15(4):378-381.
  3. Centers for Disease Control and Prevention (CDC). Paralytic shellfish poisoning - Southeast Alaska, May-June 2011. MMWR Morb Mortal Wkly Rep. 2011;60(45):1554–1556.
  4. Lago J, Rodríguez LP, Blanco L, Vieites JM, Cabado AG. Tetrodotoxin, an Extremely Potent Marine Neurotoxin: Distribution, Toxicity, Origin and Therapeutical Uses. Long P, ed. Mar Drugs. 2015;13(10):6384-6406.
  5. Centers for Disease Control and Prevention (CDC). Tetrodotoxin poisoning associated with eating puffer fish transported from Japan--California, 1996. MMWR Morb Mortal Wkly Rep. 1996;45(19):389-391.
  6. Stratta P, Badino G. Scombroid poisoning. CMAJ. 2012;184(6):674.
  7. Feldman KA, Werner SB, Cronan S, et al. A large outbreak of scombroid fish poisoning associated with eating escolar fish (Lepidocybium flavobrunneum). Epidemiol Infect. 2005;133(1):29-33.

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Last updated: 2019-07-11 22:00