Ingestion of pufferfish (called fugu or "river pig" in Japanese), considered to be one of the most delicious fish in Japan, can lead to life-threatening intoxication that is often described in the literature as fugu poisoning [1] [2] [3]. The pathogenesis stems from the presence of tetrodotoxin (TTX) in the internal organs of the fugu (the liver, the intestines, and gonads, but also the skin), a powerful heat-stable neurotoxin that blocks sodium channel action, thus diminishing neuronal activity [1] [4]. In most cases, the onset of symptoms appears shortly after ingestion of the toxin (<30 minutes) [1], with initial signs being gastrointestinal complaints (nausea, vomiting) and mild paresthesia of the perioral area [2] [3]. As the activity of TTX increases, paresthesia and weakness spread to the chest and both upper and lower extremities, whereas headaches, vertigo, ataxia, and blurred vision also appear [2] [3] [4]. Other common complaints are diaphoresis, dysphagia, excessive salivation, seizures, and muscle spasms, whereas hypotension, bradycardia, and fixed dilated pupils are markers of severe poisoning [2] [4]. Respiratory difficulties, arising from progressive paralysis of the breathing muscles, develop in advanced stages, and can be fatal within 24 hours [3] [4]. In fact, fatality rates of severe fugu poisoning are estimated at 60% according to certain reports [4].

• Dyspnea

  […] activity and include (in order of appearance): numbness of lips and tongue dizziness tingling increasing paraesthesias gastrointestinal symptoms such as nausea, vomiting and diarrhea (often severe) impaired heart rate paralysis: impaired speech, increasing dyspnea [flipper.diff.org]

• Food Poisoning

  How to spot food poisoning The symptoms of fugu poisoning are slightly different from the typical food poisoning symptoms. [es.favy-jp.com]

  Nationwide, there were 338 food poisoning cases in Japan related to fugu consumption that killed 23 people from 2000 to 2009. [japantimes.co.jp]

  The men, whose names were not released because of medical confidentiality laws, were lucky: They survived severe food poisoning from a notorious source--fugu. [articles.latimes.com]

  Puffer fish account for the majority of Japan's food poisoning deaths but the delicacy shows no sign of dying out, although it is heavily regulated. [dailymail.co.uk]

  Food poisoning: fish and shellfish. In: Olson KR, ed. Poisoning and drug overdose. 2nd ed. Norwalk, Connecticut: Appleton and Lange, 1994. Gellert GA, Ralls J, Brown C, Huston J, Merryman R. [cdc.gov]

• Numbness of the Tongue

  A lethal dose of tetrodotoxin will first reveal itself as a slight numbness in the tongue and lips. Then difficulty breathing and headaches will set in. Death could occur anywhere from 20 minutes to 8 hours of the onset of symptoms. [en.rocketnews24.com]

  Numbness of the tongue, lips and fingertips come first. Next are headaches, fatigue, lassitude, speech impediment and difficulty to breathe. Gradual paralysis of the breathing muscles follows, with coma and death within 24 hours of eating a blowfish. [poisonousnature.biodiversityexhibition.com]

  Properly prepared, thinly sliced fugu may give a slight tingling or numbing sensation on the mouth and tongue. [naturespoisons.com]

  Some professional chefs prepare the fish so that there is a minute amount of poison in the meat, giving a prickling feeling and numbness on the tongue and the lips.. [podolsky.ca]

  Some professional chefs prepare the fish so that there is a minute amount of poison in the meat, giving a prickling feeling and numbness on the tongue and the lips. [cs.mcgill.ca]

• Hypotension

  Patients initially present with paresthesias and gastrointestinal irritation, followed by progressive paralysis, hypotension, loss of consciousness and cardiac arrest with respiratory muscle paralysis. [symptoma.com]

  Other steps include administration of oxygen, assisted breathing, intravenous atropine for bradycardia (slow heartbeat) and intravenous fluids, along with dopamine, to manage hypotension. [encyclopedia.com]

  Administration of alfa-adrenoreceptor agonists and hydration is strongly recommended in order to prevent hypotension. Administration of anti-colesterasis drugs have been reported to have no evidence of improving. [flipper.diff.org]

  In severe poisoning, dysrhythmia, hypotension, and even death might occur. [lamag.com]

• Flushing

  Approximately 10-15 minutes later, he had onset of tingling in his mouth and lips followed by dizziness, fatigue, headache, a constricting feeling in his throat, difficulty speaking, tightness in his upper chest, facial flushing, shaking, nausea, and [cdc.gov]

• Paresthesia

  As the activity of TTX increases, paresthesia and weakness spread to the chest and both upper and lower extremities, whereas headaches, vertigo, ataxia, and blurred vision also appear. [symptoma.com]

  Paresthesias begin 10-45 minutes after ingestion, usually as tingling of the tongue and inner surface of the mouth. Other common symptoms include vomiting, lightheadedness, dizziness, feelings of doom, and weakness. [cdc.gov]

  Toxic manifestations start with perioral paresthesias, quickly followed by generalized weakness, ascending paralysis, and respiratory failure. To read my Emergency Medicine News column on fugu, click here. [thepoisonreview.com]

  If a rapid onset of one of the following neurologic and gastrointestinal signs or symptoms occurs, the clinical description for tetrodotoxin poisoning has been met: 1) oral paresthesias (might progress to include the arms and legs), 2) cranial nerve dysfunction [lamag.com]

  Initial symptoms include lip and tongue paresthesias, followed by facial and extremity paresthesias and numbness. Salivation, nausea, vomiting, and diarrhea with abdominal pain develop early. [podolsky.ca]

• Confusion

  “In its native region, it has been confused with similar looking, nontoxic species, resulting in numerous illnesses. This is the same species that was illegally imported and responsible for illnesses in California, Illinois, and New Jersey in 2007.” [nbcnews.com]

  The highest number of fatalities occurs in domestic preparation rather than in restaurants: this is likely to result from improper methods as well as confusion between types of Puffers. [flipper.diff.org]

  They are not to be confused with the porcupinefish, which belong to a different family. Fact 2: They can grow up to nearly four feet long. Portrait of a Starry Puffer, also known as Stellate pufferfish (Arothron stellatus). [ipfactly.com]

  […] average fatality rate of 6.8%. [15] Of the 23 incidents reported in Tokyo from 1993 through 2006, only one took place in a restaurant; all others involved people catching and eating the fish. [15] Poisonings through amateur preparation can result from confusion [ipfs.io]

  […] average fatality rate of 6.8%. [26] Of the 23 incidents reported in Tokyo from 1993 through 2006, only one took place in a restaurant; all others involved people catching and eating the fish. [26] Poisonings through amateur preparation can result from confusion [en.wikipedia.org]

• Flaccid Paralysis

  […] and general body flaccid paralysis” – and unable to speak, but your head is weirdly clear. [ranker.com]

Because of the high fatality rate of fugu poisoning, a prompt diagnosis could be life-saving. For this reason, the physician must conduct a thorough physical examination, and most importantly, obtain a detailed patient history, which is perhaps the vital step in the workup [3] [4]. Fugu poisoning has been reported mainly in countries of Southeast Asia (Bangladesh, Taiwan, Cambodia, Hong Kong), but cases in the United States were also described in the literature [3] [4] [5] [6]. Very recent ingestion of pufferfish should be disclosed during the interview, whereas a complete neurological assessment provides sufficient clues to make a presumptive diagnosis of a sudden and progressive paralysis. Since several outbreaks have occurred in association with TTX from fugu [1], physicians must check if similar symptoms are present in friends or persons who ate the same food. The diagnosis of fugu poisoning rests on clinical grounds, but when possible, levels of TTX can be measured in the patient's serum or urine (or in leftover food, if available) [3] [4] [6] [7]. Mass spectrometry (MS) is able to detect tetrodotoxin in these samples and confirm the diagnosis [7].

Tetrodotoxin levels are affected by preparation (removal of most toxic materials, treatments such as curing and pickling, see below); it is, however, reportedly not significantly affected by cooking. [13] Treatment The symptoms from ingesting a lethal [ipfs.io]

Alternative treatment There is no alternative medicine treatment for fugu poisoning. KEY TERMS Ataxia— A lack of muscle control. Arrhythmia— An irregularity in the normal rhythm or force of the heartbeat. [encyclopedia.com]

Treatment There is no antidote for fugu poisoning, therefore treatment is limited to supportive measures and the removal of the unabsorbed toxin. If spontaneous vomiting does not occur, it should be induced. [medical-dictionary.thefreedictionary.com]

Treatment for scombroid poisoning Treatment for scombroid poisoning is generally unnecessary. Symptoms usually resolve within 12 hours and scombroid poisoning is rarely life-threatening. [hopkinsmedicine.org]

When to Seek Medical Care Seek medical treatment as soon as possible. [emedicinehealth.com]

Hibbert's prognosis, Homer wouldn't feel any pain until his heart suddenly exploded. That won't happen with actual fugu poisoning, nor will you spend your final minutes sitting in a chair listening to Larry King's audiobook of the Bible. [civilized.life]

Prognosis The mortality rate may be as high as 60%. Epidemiologic evidence suggests that recovery can be expected if an affected person survives beyond 24 hours. After 24 hours, a person with fugu poisoning usually makes a full recovery. [encyclopedia.com]

Div of Environmental Hazards and Health Effects, National Center for Environmental Health; Div of Field Epidemiology, Epidemiology Program Office, CDC. [cdc.gov]

Epidemiologic evidence suggests that recovery can be expected if an affected person survives beyond 24 hours. After 24 hours, a person with fugu poisoning usually makes a full recovery. [encyclopedia.com]

Epidemiology: Anyone who consumes this kind of edibles is susceptible of disease. [flipper.diff.org]

Epidemiology Frequency United States Reports of tetrodotoxin poisoning are rare in the United States. [emedicine.medscape.com]

[…] some species of salamanders [1] Detection of tetrodotoxins in European bivalve shellfish in the United Kingdom along the English Channel has been reported, although concentrations were low in comparison to published minimum lethal doses for humans. [2] Pathophysiology [emedicine.medscape.com]

الصفحة 1607 - Centers for Disease Control and Prevention: 1994 Revised Classification System for Human Immunodeficiency Virus Infection in Children Less Than 13 Years of Age, MMWR, 43, 1-19, No. ‏ [books.google.com]

The poison can paralyse the nerves and prevent the lungs working. There is no known antidote and death occurs within minutes - with the first indication being numbness of the lips - if the concentration is strong enough. [telegraph.co.uk]

Prevention The only prevention is not to eat any of the species of fugu that contain toxins. Resources BOOKS Olson, Kent R. Poisoning & Drug Overdose New York City: McGraw-Hill, 2003. PERIODICALS Currie, Bart J. "Marine Antivenoms." [encyclopedia.com]

Prevention The only prevention is not to eat any of the species of fugu that contain toxins. Resources Books Olson, Kent R. Poisoning & Drug Overdose New York City: McGraw-Hill, 2003. Periodicals Currie, Bart J. "Marine Antivenoms." [medical-dictionary.thefreedictionary.com]

A mixture called akar bangun (a root from North Borneo which is said to possess the property of preventing intoxication) was administered in water then they hoisted Private Unong on to the kitchen shelf ( para ) and lit a good big fire under him (which [leminhkhai.wordpress.com]

1. 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.
2. Ahasan HA, Mamun AA, Karim SR, Bakar MA, Gazi EA, Bala CS. Paralytic complications of puffer fish (tetrodotoxin) poisoning. Singap Med J. 2004;45:73–74
3. Yong YS, Quek LS, Lim EK, Ngo A. A Case Report of Puffer Fish Poisoning in Singapore. Case Reports in Medicine. 2013;2013:206971.
4. 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.
5. Ngy L, Taniyama S, Shibano K, Yu C-F, Takatani T, Arakawa O. Distribution of tetrodotoxin in puffer fish collected from coastal waters of Sihanouk Ville, Cambodia. Journal of the Food Hygienic Society of Japan. 2008;49(5):361–365.
6. Homaira N, Rahman M, Luby SP, et al. Multiple outbreaks of puffer fish intoxication in Bangladesh, 2008. American Journal of Tropical Medicine and Hygiene. 2010;83(2):440–444.
7. Leung KSY, Fong BMW, Tsoi YK. Analytical challenges: determination of tetrodotoxin in human urine and plasma by LC-MS/MS. Mar Drugs. 2011;9(11):2291–2303.