August 13, 2012

Sea water Fish Poisoning

Notes: This is an informal writing and based on experience and postulation. Therefore, there might be a mistake in this writing. The purpose of i’m writing this case is as a sharing basis.

A 45 years old lady who was previously healthy presented with spasm of bilateral hand, perioral and fingertips numbness, twitching of the facial muscle and lethargy 4 hours after eating a freshly caught fish cook by her neighbor. Her medical history was not significant except for allergy to amoxycillin and prawn. Apart from that, she denied any shortness of breath, increase in salivation, vomiting, diarrhea, headache, increase in salivation, palpitation, chest pain, wheezing, eczema, pruritic skin, loss of consciousness and fitting. Her neighbour also presented with the same complaint but with a milder presentation.

The fish was describe as a long, thin body, covered with smooth scales and prominent sharp-edged fang-like teeth. According to the patient, she used to eat the same fish previously but never having similar problem.

On examination, she was fully alert and conscious. Vital signs were stable except for the heart rate which was slightly tachycardic. There were carpopedal spasm of the hand with positive chvostek's sign. Trousseau's sign was not checked. Examination of the other system was un remarkable.

A diagnosis of symptomatic hypocalcaemia secondary to food poisoning was made based on clinical finding as the calcium level was not ready and she was treated with Slow infusion of calcium gluconate 10%, 20cc over 10 minutes. After the infusion, patient clinically improve with no more spasm and muscle twitching but still lethargy. She was then supported with IV drip maintenance. In view of patient also have history of allergy, she was also covered with IV Dihydropherenamine maleate and Hydrocortisone.

Retrospectively, all the blood investigation result come back normal and the calcium was also within the normal range. The only abnormality was a slightly low phosphate level.

I try to search in the internet regarding the phenomena and one explanation fit with this patient which is Ciguatera Fish Poisoning. Therefore i think that the presentation was due to ciguatera toxin and not because of hypocalcaemia.

Image from Wikipedia [link]
Image from Wikipedia [link]

Ciguatera is a type of food poisoning. The ciguatera toxin may be found in large reef fish, most commonly barracuda, grouper, red snapper, eel, amberjack, sea bass, and Spanish mackerel[John F.C  & Melissa C.S]

 Ciguatera toxin tends to accumulate in predator fish, such as the barracuda and other carnivorous reef fish, because they eat other fish that consume toxin-producing algae (dinoflagellates) that live in coral reef waters. [John F.C  & Melissa C.S]

Ciguatera toxin is harmless to fish but poisonous to humans. The toxin is odorless and tasteless, and it is heat-resistant, so cooking does not destroy the toxin. Eating ciguatera-contaminated tropical or subtropical fish poisons the person who eats it. [John F.C  & Melissa C.S]

The symptoms consist of nausea, vomiting, diarrhea, muscle pain, numbness, tingling, abdominal pain, dizziness and vertigo can appear six to eight hours. Severe form of ciguatera poisoning may result in shortness of breath, salivation, tearing of the eyes, chills, rashes, itching and paralysis. death may occur in rare case due to heart or respiratory failure.

The treatment is supportive and no antidote available for this condition.

1)  John P. Cunha & Melissa Conrad Stöpple, " Ciguatera Fish Poisoning (Ciguatera Toxin)

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