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Poisoning by Edible Fish

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Poisoning by Edible Fish 246 JAccid Emerg Med 1997;14:246-251 REVIEW J Accid Emerg Med: first published as 10.1136/emj.14.4.246 on 1 July 1997. Downloaded from Ichthyosarcotoxism: poisoning by edible fish Iain C Grant The term ichthyosarcotoxism describes a variety cause different syndromes, and even within a of conditions arising as the result of poisoning recognised single disease entity there may be by fish flesh. Poisoning by shellfish and other wide variation in symptoms depending on the invertebrates is excluded, as is bacterial food fish eaten or the geographical area. All of this poisoning from contaminated fish. Although makes classification very difficult and conse- most of the conditions are experienced mainly quently no recognised classification exists. in warmer climates than Britain's, one form of Table 1 shows an attempt to classify the condi- fish poisoning is relatively common here, and tions by the type of clinical features and symp- others may be imported, either through toms usually seen. This arrangement is simpli- imported fish or by travellers. The conditions fied and there is some overlap between could present to any accident and emergency conditions, but for the physician faced with a (A&E) department, and increased awareness patient with likely fish poisoning it gives some of these disease entities may improve diagnosis guidance towards a specific diagnosis. and management. It has been suggested that the features of It has long been known that some normally ciguatera, tetraodon, and paralytic shellfish edible fish species may from time to time cause poisoning are similar and that these should be poisoning. Many of the early records of these considered as a single disease, pelagic paraly- conditions come from the Royal Navy. Both sis.4 However, each of these syndromes pro- Captain Blighl and Captain Cook2 described duces a recognisable clinical picture, the toxins illness among their crews after eating fish causing the conditions have been shown to be which were known usually to be safe. The first different, the fish species implicated vary, the detailed medical treatise on fish poisoning in morbidity and mortality are differ greatly, and the West Indies was written by the Surgeon on there are differences in recommended manage- a frigate.3 Since the beginning of this century, ment. For these reasons most authorities agree interest in the conditions and awareness of the that the conditions should be considered as http://emj.bmj.com/ considerable morbidity they produce has in- distinct entities.57 creased. Most of these conditions are found mainly in Several different clinical syndromes have tropical and subtropical regions, but scom- been described with a variety of gastrointesti- broid is well known and endemic in the United nal, neurotoxic, and cardiotoxic features. Kingdom,8 9 ciguatera has been described in The syndromes are not specific to any one West Indians returning to Britain and in British species of fish-some species may at times servicemen,' 1' "exotic" fish are increasingly on October 10, 2021 by guest. Protected copyright. Table 1 Classification of ichthyosarcotoxisms Group 1 Mild gastrointestinal symptoms only Cyclostome (lampreys and hagfish). Probably from slime. Severe but self limiting symptoms. Elasmobranch (shark flesh usually from Greenland sleeper shark). Relatively mild. Gempylid (snake mackerel, castor oil fish, skilfish). Strongly purgative. Group 2 Gastrointestinal and neurological symptoms Tetraodon (puffer and porcupine fish). See text. Elasmobranch (liver) (shark liver from most sharks). Possibly related to hypervitaminosis A but probably also some toxin involved. Ichthyootoxism (roe or caviar poisoning). Often freshwater fish including sturgeon and salmon. ?Related to saxitoxin, the cause of paralytic shellfish poisoning. Accident and Group 3 Gastrointestinal and cardiac symptoms Emergency Clupeotoxin (sardines, anchovies, herring). Episodic outbreaks. Department, Group 4 Derriford Hospital, Gastrointestinal, neurological, cardiac, joints, etc Plymouth, Devon Ciguatera (many fish and symptoms). See text. PL6 8DH Gymothorax (Moray eel). Probably severe ciguatera. I C Grant Group 5 Anaphylactoid Scombroid (See text) Correspondence to: Group 6 Mr I C Grant, consultant in Hallucinogenic A&E medicine. Chimera (ratfish and elephant fish). Very poorly understood. Avoid these fish! Haliucinogenic fish poisoning (HFP) (mainly mullet). See text. Accepted for publication Surgeon fish. Possibly related to one of ciguateric toxins (maitotoxin) but more likely to be indole induced. 10 April 1997 Fish poisoning 247 available in British supermarkets, and inter- as herring, sardines, anchovies, and salmon.'5- national cuisine gains popularity making it Perhaps therefore the alternative name of possible that tetradotoxication will soon be "anaphylactoid fish poisoning" should be used. J Accid Emerg Med: first published as 10.1136/emj.14.4.246 on 1 July 1997. Downloaded from seen in Europe. These three conditions are certainly the most important ichthyosarcotox- CLINICAL FEATURES isms worldwide, but before discussing these in The clinical picture starts with rapid onset of more detail, two ofthe less common are worthy symptoms, sometimes within 10 minutes of of particular mention. beginning to eat the fish. Symptoms are usually maximal at about two hours after ingestion. An Sardine poisoning acute gastrointestinal upset with vomiting, Sardine poisoning occurs infrequently and epi- abdominal cramps, and sometimes diarrhoea is sodically in the tropics and as far north as the associated with erythema, urticarial patches, Mediterranean. For some uncertain reason, and oedema. Although much of the swelling is suddenly many of the sardines in a local area, often facial, airway compromise is rare. There usually those caught close to shore, appear to can be tachycardia and palpitations, although be toxic at the same time. Sometimes ancho- these are uncommon. The disease is frighten- vies and sprats many also be affected. ing and distressing but is very seldom if ever fatal. Spontaneous recovery within 24 hours is CLINICAL FEATURES usual without treatment, but appropriate man- A violent gastrointestinal illness precedes agement can dramatically curtail the attacks.'7 paraesthesiae, progressive paresis, fits, and tetanic spasms. Cardiovascular effects are often AETIOLOGY marked, with arrhythmias and even cardiac Smoked Mackerel used to account for most of arrest. Behavioural changes with anxiety and the outbreaks of this condition in the United bizarre behaviour are also frequent. Desqua- Kingdom," but tinned products, mainly tuna mation and other skin problems are reported in and sardines, now appear to cause more prob- those who survive the acute episode. Mortality lems. 7 is about 40%. In 1993 thirty two incidents were reported in the first eight months of the year. Seven of PATHOGENESIS these were traced to two batches of imported It has been suggested that the occurrence of fresh tuna from Indonesia and Sri Lanka, and sardine poisoning may be associated with algal 10 were from canned products.8 blooms such as the red tides which cause saxi- There is probably considerable under- toxin problems in shellfish, but this has not reporting of scombroid for several reasons. The been established. A hypothetical toxin involv- disease is self limiting and may not come to ing the conversion of eicosapentaeonic acids to medical attention. Even if it does it may not be a toxin akin to thromboxane A2 has been recognised, the symptoms being easily con- postulated. 12 fused with allergy. There is no legal require- Given that all the fish involved feed on ment to report the condition, although the plankton, it seems likely that a protozoon is the Food Hygiene Laboratory at PHLS (Public http://emj.bmj.com/ origin of the toxin (as in ciguatera and paralytic Health Laboratory Service) would welcome shellfish poisoning), but the exact organism has reports. yet to be identified.'3 PATHOGENESIS TREATMENT The pathogenesis of scombroid remains a mat- No effective treatment has been described, and ter of some dispute. The flesh of the implicated work is to try fish is rich in and organisms such as given the high mortality, required histidine, on October 10, 2021 by guest. Protected copyright. to produce an effective prevention strategy or klebsiella and morganella in gut and bile treatment. 12 produce a decarboxylase which converts this to histamine, and possibly other amines such as Hallucinogenic fish poisoning saurine. Since the symptoms produced are While sardine poisoning causes bizarre behav- those usually associated with histamine release, ioural changes, another interesting group of it is considered by many that histamine is the ichthyotoxins is known to produce hallucina- principal toxin.'2'7-20 Some investigators, how- tions without gastrointestinal or other toxicity. ever, have suggested that since histamine can Various toxins including indoles akin to LSD be taken by mouth without ill effect, and since have been implicated, with sources in algae and the symptoms are not necessarily related to the plankton eaten by the fish.'2 There is some evi- amount of histamine in the fish, a more dence that a combination of these toxins with complex mechanism involving the activation of plant and perhaps fungal toxins is the basis for mast cells by the toxin may be involved.2'22 the "zombies" of Haiti.7 TREATMENT Scombroid In the past treatment relied on adrenaline and The only indigenous British ichthyosarcotox- histamine (HI) antagonists
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