Marine Marine Poisoning and Poisoning and Envenomation Envenomation

Jennifer HughesJennifer HughesDr. David JohnsonDr. David JohnsonFebruary 16, 2006February 16, 2006

Le grand planLe grand plan• Marine Marine envenomationenvenomation

– Toxic animals that live in the oceanToxic animals that live in the ocean– Mechanisms of envenomationMechanisms of envenomation– Learn a little about venomLearn a little about venom– TreatmentTreatment

• Marine Marine poisoningpoisoning– Foods and food preparation to avoidFoods and food preparation to avoid– Recognize the dangerous causesRecognize the dangerous causes– Learn a little about the toxinsLearn a little about the toxins

• Prepare for your next beach holidayPrepare for your next beach holiday• Not covering botulism, food poisoningNot covering botulism, food poisoning

Poisoning vs EnvenomationPoisoning vs Envenomation

• Marine envenomationMarine envenomation– glands that produce venomglands that produce venom– applied or injected parenterallyapplied or injected parenterally– painfulpainful– CV effectsCV effects

• Marine poisoningMarine poisoning– animals accumulate toxins from environmentanimals accumulate toxins from environment– do not produce themdo not produce them– must ingest for toxic effectmust ingest for toxic effect– GI and neuro clinical effects GI and neuro clinical effects

Venom and Anti-venomVenom and Anti-venom

• ““mosaic of antigens”mosaic of antigens”

• Circulating and tissue-fixedCirculating and tissue-fixed

• Can be deeper than typical snake bitesCan be deeper than typical snake bites

• Circulating venom neutralized by specific Circulating venom neutralized by specific immunoglobulins (anti-venom)immunoglobulins (anti-venom)

• Anti-venom rarely reverses pathology at Anti-venom rarely reverses pathology at site of envenomationsite of envenomation

Marine EnvenomationsMarine Envenomations

• Worldwide 40,000-50,000 Worldwide 40,000-50,000 envenomations each yearenvenomations each year

• Significant risk for swimmers in open-Significant risk for swimmers in open-water athletic eventswater athletic events

• Typically divide into vertebrates and Typically divide into vertebrates and invertebratesinvertebrates

Stingray wounds are often Stingray wounds are often complicated by complicated by infections with:infections with:

a.a. Staph aureusStaph aureusb.b. StreptococcusStreptococcusc.c. Vibrio vulnificansVibrio vulnificansd.d. Pasteurella multocidaPasteurella multocida

Pain relief in Stonefish stings Pain relief in Stonefish stings can be provided by:can be provided by:

a.a. Peeing on the woundPeeing on the woundb.b. Vinegar Vinegar c.c. Immersion in hot waterImmersion in hot waterd.d. Scraping the wound with a Scraping the wound with a

credit cardcredit card

Anti-venoms exist for:Anti-venoms exist for:

a.a. Sea snakesSea snakesb.b. Sting raysSting raysc.c. StonefishStonefishd.d. A and CA and Ce.e. A and B A and B

VertebratesVertebrates

• StingraysStingrays

• Scorpaenidae (Stonefish, lionfish, Scorpaenidae (Stonefish, lionfish, scorpionfish, tigerfish, zebrafish, scorpionfish, tigerfish, zebrafish, turkeyfish)turkeyfish)

• Sea snakesSea snakes

StingraysStingrays

• 11 species in US coastal 11 species in US coastal waterswaters

• Burrow in shallow sandBurrow in shallow sand

• Tail barb reflexively Tail barb reflexively firesfires

• Most common injury = Most common injury = secondary bacterial infxsecondary bacterial infx

• Venom = Venom = phophodiesterase, phophodiesterase, serotoninserotonin

• HEAT LABILEHEAT LABILE

StingraysStingrays• Symptoms: Symptoms:

– Severe pain and burning locallySevere pain and burning locally– Intensifies for several hoursIntensifies for several hours– Systemic effects: muscle cramping, weakness, Systemic effects: muscle cramping, weakness,

tremor, syncope, cv collapse, seizurestremor, syncope, cv collapse, seizures

• Fatality rare (chest injuries, bleeding, tetanus)Fatality rare (chest injuries, bleeding, tetanus)

• Mx:Mx:– Clean and debride wound, td proph, tx of infectionClean and debride wound, td proph, tx of infection– Vibrio vulnificus (Ancef)Vibrio vulnificus (Ancef)– Pain control by immersing in hot water (45 C)Pain control by immersing in hot water (45 C)

Scorpaenidae Scorpaenidae (stonefish/lionfish)(stonefish/lionfish)

• Scorpaenidae most common Scorpaenidae most common vertebrate to sting humansvertebrate to sting humans

• Gulf of Mexico, Pacific and Indian Gulf of Mexico, Pacific and Indian OceanOcean

StonefishStonefish• Can be fatal!!Can be fatal!!

• Will attack humans if Will attack humans if threatenedthreatened

• Venom glands at tip of Venom glands at tip of spinesspines

• Verrucatoxin, nor-epi, Verrucatoxin, nor-epi, dopamine, tryptaphandopamine, tryptaphan

• Stonustoxin (activates Stonustoxin (activates nitric oxide pathway) nitric oxide pathway)

StonefishStonefish

• Clinical signs and symptoms:Clinical signs and symptoms:– Excrutiating pain (LOC)Excrutiating pain (LOC)– Induration, ecchymosis, hyperesthesia, Induration, ecchymosis, hyperesthesia,

dyesthesia or anesthesia of affected limbdyesthesia or anesthesia of affected limb– N/V, diaphoresis, dyspnea, hypotension, N/V, diaphoresis, dyspnea, hypotension,

syncopesyncope– Cardiac dysrhythmias, conduction abn, Cardiac dysrhythmias, conduction abn,

ischemia, pulmonary edema, sz, paralysisischemia, pulmonary edema, sz, paralysis

LionfishLionfish

• Don’t normally attackDon’t normally attack• Smaller venom Smaller venom

glandsglands• Venom = PGE2, Venom = PGE2,

Thromboxane B2, Thromboxane B2, PGF2PGF2

• Severe burning and Severe burning and swellingswelling

• Rare CV or neuro Rare CV or neuro effectseffects

Treatment of All Treatment of All ScorpaenidaeScorpaenidae• Soak limb in hot waterSoak limb in hot water

• Oral analgesic, local blockOral analgesic, local block

• Remove barbs/spinesRemove barbs/spines

• Excise blisters (full of venom)Excise blisters (full of venom)

• TetanusTetanus

• AntibioticsAntibiotics

• ANTI-VENOM (usually used for stonefish)ANTI-VENOM (usually used for stonefish)

Sea SnakesSea Snakes

• 50 species50 species

• Pacific and Indian Pacific and Indian OceanOcean

• NONE in Atlantic or NONE in Atlantic or CaribbeanCaribbean

• All are toxic, seven All are toxic, seven species fatal to species fatal to humanshumans

• Most bites harmless Most bites harmless fangs too short! fangs too short!

Sea SnakesSea Snakes

• Venom:Venom:– Peripheral neurotoxinPeripheral neurotoxin– Alters Na+, Cl- permeability without Alters Na+, Cl- permeability without

changing Na-K-ATPase pumpchanging Na-K-ATPase pump

• Symptoms occur with no local rxnSymptoms occur with no local rxn– 3-6 hrs cranial and peripheral neuropathies3-6 hrs cranial and peripheral neuropathies– Paralysis, resp failure, myonecrosis, Paralysis, resp failure, myonecrosis,

myoglobinuria, renal failuremyoglobinuria, renal failure

Management of Sea Snake Management of Sea Snake bitesbites• Stabilize vitalsStabilize vitals

• Polyvalent sea Polyvalent sea snake snake anti-venomanti-venom

InvertebratesInvertebrates

• Jellyfish (box jellyfish, Portuguese Jellyfish (box jellyfish, Portuguese man-of-war)man-of-war)

• SpongesSponges

• Cone shellsCone shells

• OctopiOctopi

• Sea anenomesSea anenomes

• CoralCoral

• Sea urchinsSea urchins

QuizQuiz

A group of jellyfish traveling together A group of jellyfish traveling together is called a: is called a:

a.a. SchoolSchool

b.b. SmuckSmuck

c.c. FleetFleet

d.d. GaggleGaggle

JellyfishJellyfish

• Venom: bradykinin, serotonin, Venom: bradykinin, serotonin, histamine, PGs, adenosine, histamine, PGs, adenosine, phosphodiesterase, fibrinolysin, phosphodiesterase, fibrinolysin, hemolysin…hemolysin…

• All have long tentacles hanging from All have long tentacles hanging from pneumatophorepneumatophore

• Venom injected by nematocystsVenom injected by nematocysts

• Most result in local reaction, stinging, Most result in local reaction, stinging, ulceration, anaphylactoid rxnulceration, anaphylactoid rxn

What is a Nematocyst?What is a Nematocyst?

• Nematocyst = spring - loaded venom Nematocyst = spring - loaded venom gland that suddenly everts and gland that suddenly everts and delivers venomdelivers venom

• Located on tentacles, spicules, etcLocated on tentacles, spicules, etc• Continue to fire after animal’s deathContinue to fire after animal’s death• May still be “loaded” when in skinMay still be “loaded” when in skin• Local reaction, allergic reaction, toxic Local reaction, allergic reaction, toxic

reaction (N/V/D, CP, cramps, SOB, reaction (N/V/D, CP, cramps, SOB, paralysis, cardiorespiratory collapse)paralysis, cardiorespiratory collapse)

Portugese Man-of-Portugese Man-of-WarWar

• FloridaFlorida• July-Sept after tropical July-Sept after tropical

stormstorm• Excrutiating pain, welts, Excrutiating pain, welts,

myalgias, HA, resp myalgias, HA, resp distress, CV collapsedistress, CV collapse

• multiple stings multiple stings death death• Mx: ABCs, remove Mx: ABCs, remove

tentacles, vinegar, tentacles, vinegar, credit card scrape, NO credit card scrape, NO antivenom existsantivenom exists

Box jellyfish (sea wasp)Box jellyfish (sea wasp)

• Most deadly of all Most deadly of all stinging marine lifestinging marine life

• Australia, Southeast Australia, Southeast AsiaAsia

• Enough venom to kill Enough venom to kill 10 adults10 adults

• Fatality rate of 20%Fatality rate of 20%• Hypotension, muscle Hypotension, muscle

spasm, resp paralysis, spasm, resp paralysis, cardiac arrestcardiac arrest

• Death can occur within Death can occur within 30 sec30 sec

Mx of Jellyfish Mx of Jellyfish envenomationsenvenomations• INACTIVATE nematocysts (convince INACTIVATE nematocysts (convince

someone to pee on you, vinegar)someone to pee on you, vinegar)• REMOVE tentacles and nematocysts by REMOVE tentacles and nematocysts by

shaving or scraping credit cardshaving or scraping credit card• Don’t use fresh waterDon’t use fresh water• TdTd• Antibiotic prophylaxis prnAntibiotic prophylaxis prn• ANTI-VENOM for box jellyfish (Chironex)ANTI-VENOM for box jellyfish (Chironex)

Other invertebratesOther invertebrates• Fire coralFire coral

– nematocysts, local rxnnematocysts, local rxn

• SpongesSponges – inject venom with spicules inject venom with spicules local rxn local rxn

• Cone shellsCone shells – snails inject venom through long toothsnails inject venom through long tooth– typically local rxn but can get CV collapsetypically local rxn but can get CV collapse

• Blue-ringed octopusBlue-ringed octopus – bites rare bites rare tetrodotoxin tetrodotoxin– mx supportivemx supportive

• Sea urchinSea urchin – venom gland on spiculevenom gland on spicule– local rxn, embedded spine can be problematiclocal rxn, embedded spine can be problematic

To sum it all up…To sum it all up…• Really bad (+/- fatal)Really bad (+/- fatal)

– Stonefish (ANTIVENOM)Stonefish (ANTIVENOM)– Sea snakes (ANTIVENOM)Sea snakes (ANTIVENOM)– Box jellyfish (ANTIVENOM)Box jellyfish (ANTIVENOM)– Man-of-war jellyfish (with multiple stings)Man-of-war jellyfish (with multiple stings)– Blue-ringed octopus Blue-ringed octopus

• Not quite as badNot quite as bad– StingrayStingray– Many sea snakesMany sea snakes– LionfishLionfish– Corals, sponges, sea urchins, cone shellsCorals, sponges, sea urchins, cone shells

To sum it all up…To sum it all up…

L o o k b u t D O N 'T to u ch

L o ca l w ou n d ca reA n tive n om fo r sna kes

B IT E So c to p i

se a sna kes

R e m o ve te n ta c lesV IN E G A R

C re d it ca rd sc ra peA n tive n om fo r sea w a sps

N E M A T O C Y S T Sje llyf ish , se a w a sp

m a n - o f - w ar

R e m ove stin g erIrrig a te

H O T W A T E RA n tive no m fo r sto ne fish

S T IN G Ss ta rf ish , u rch ins

s tin g ra y, b on yfish

M a na ge m e nt

Thanks Rob!

QuizQuiz

What is the definition of What is the definition of ichthyosarcotoxic?ichthyosarcotoxic?

a.a. Toxins causing pruritis as main symptomToxins causing pruritis as main symptom

b.b. Fish-borne toxins that specifically target Fish-borne toxins that specifically target muscle of victimmuscle of victim

c.c. Toxins from muscle, viscera and gonads Toxins from muscle, viscera and gonads of fishof fish

Marine PoisoningsMarine Poisonings

• Affect voltage gated Na channelsAffect voltage gated Na channels

• Myelinated and unmyelinated nervesMyelinated and unmyelinated nerves

• Typically peripheral neuropathiesTypically peripheral neuropathies

• Can get flaccid paralysisCan get flaccid paralysis

Mr and Mrs ScubaMr and Mrs Scuba

A young healthy couple on their honeymoon in A young healthy couple on their honeymoon in Nicauragua had a local dinner of rice, beans, Nicauragua had a local dinner of rice, beans, a large red snapper, canned fruit and wine. a large red snapper, canned fruit and wine.

Five hours after dinner, both developed abdo Five hours after dinner, both developed abdo pain, diarrhea, vomiting, then headache, pain, diarrhea, vomiting, then headache, numbness in arms and legs, and bone and numbness in arms and legs, and bone and tooth pain. When the woman reached for a tooth pain. When the woman reached for a hot washcloth to rub on her “freezing skin”, hot washcloth to rub on her “freezing skin”, the washcloth felt cold. This sensation lasted the washcloth felt cold. This sensation lasted for 3 days. Within 4 days, their symptoms for 3 days. Within 4 days, their symptoms completely resolved. completely resolved.

ApproachApproach

• What did they eat?What did they eat?

• Where was it caught?Where was it caught?

• If not eating, other activities?If not eating, other activities?

• Pattern of neurological symptoms?Pattern of neurological symptoms?

• Onset of symptoms?Onset of symptoms?

• Can you make the diagnosis?Can you make the diagnosis?

• Management?Management?

Ciguatera PoisoningCiguatera Poisoning

• Most common fishborne poisoningMost common fishborne poisoning• Endemic to warm-water, bottom-Endemic to warm-water, bottom-

dwelling shore dwelling shore reefreef fish fish• 35 degrees north – 35 degrees south35 degrees north – 35 degrees south• MAY-AUGUSTMAY-AUGUST• 500 fish species involved: barracuda, 500 fish species involved: barracuda,

sea bass, parrot fish, red snapper, sea bass, parrot fish, red snapper, grouper, sturgeongrouper, sturgeon

CiguateraCiguatera

• Dinoflagellates (plankton protozoa) Dinoflagellates (plankton protozoa) contain contain ciguatoxinciguatoxin

• Small fish eat dinoflagellatesSmall fish eat dinoflagellates• Bigger fish eat small fish Bigger fish eat small fish • Really big fish (>5 lbs) eat bigger fishReally big fish (>5 lbs) eat bigger fish• People eat really big fishPeople eat really big fish• Ciguatoxin increasingly concentrated Ciguatoxin increasingly concentrated

in flesh, fat and viscera of larger fishin flesh, fat and viscera of larger fish

CiguatoxinCiguatoxin• Lipid solubleLipid soluble

• Acid stableAcid stable

• Heat stableHeat stable

• Odorless/tastelessOdorless/tasteless

• Fresh and frozen fishFresh and frozen fish

• Prolonged opening of Prolonged opening of voltage gated voltage gated sodium channels in sodium channels in nerves and muscle nerves and muscle tissuestissues

Ciguatoxin signs and Ciguatoxin signs and symptomssymptoms

• 2-6 hours after ingestion2-6 hours after ingestion

• 75% within 12 hours75% within 12 hours

• 96% within 24 hours96% within 24 hours

• Clinical diagnosisClinical diagnosis

1.1. GastrointestinalGastrointestinal– N/V/DN/V/D

2.2. Neurological Neurological – Paresthesias, dysesthesiasParesthesias, dysesthesias– Sensation of loose, painful teethSensation of loose, painful teeth– Cold allodynia (pathognomic)Cold allodynia (pathognomic)– AtaxiaAtaxia– Vertigo, seizures, visual disturbancesVertigo, seizures, visual disturbances

3.3. CardiovascularCardiovascular– BradycardiaBradycardia– HypotensionHypotension

4.4. Diffuse Pain SyndromesDiffuse Pain Syndromes– HeadacheHeadache– MyalgiasMyalgias– ArthralgiasArthralgias

Natural History of DiseaseNatural History of Disease

• MortalityMortality– 0.5%0.5%– Usually patients with comorbiditiesUsually patients with comorbidities

• Duration of symptomsDuration of symptoms– GIGI

•24-48 hours24-48 hours

– Bradycardia & NeuropathyBradycardia & Neuropathy•Days to weeksDays to weeks

ManagementManagement

• Inducing vomiting likely unhelpfulInducing vomiting likely unhelpful

• SupportiveSupportive

• Activated charcoal (acc to Goldfrank)Activated charcoal (acc to Goldfrank)

• CatharticsCathartics

• IV MannitolIV Mannitol

MannitolMannitol

• Though to decrease neuro and Though to decrease neuro and muscular symptomsmuscular symptoms– Evidence fromEvidence from

•Single casesSingle cases

•case seriescase series

•Uncontrolled trialsUncontrolled trials

•Non-randomized trialsNon-randomized trials

• Animal studiesAnimal studies

• RCT – N=50RCT – N=50InclusionInclusion

•Consumed local reef fishConsumed local reef fish

•Neurological and GI symptoms within 48 Neurological and GI symptoms within 48 hourshours

TreatmentTreatment•Mannitol 20% - 500ml bolusMannitol 20% - 500ml bolus

•NS – 500ml bolusNS – 500ml bolus

Primary OutcomesPrimary Outcomes

1.1. Evolution of 13 items (5 Evolution of 13 items (5 point Likert scale) over point Likert scale) over 24 hours24 hours

• Unvalidated scaleItemsUnvalidated scaleItems

• GI symptomsGI symptoms– N/V, diarrhea, crampingN/V, diarrhea, cramping

• Neurological symptomsNeurological symptoms– Numbness, dysesthesia, Numbness, dysesthesia,

cold allodyniacold allodynia

• Diffuse pain symdromesDiffuse pain symdromes– myalgias, arthralgias, HAmyalgias, arthralgias, HA

• Other Other – Pruritus, dizziness, Pruritus, dizziness,

general weakness, general weakness, dysuriadysuria

2.2. Evolution of Evolution of neurologic status at neurologic status at baseline and 24 baseline and 24 hourshours

Secondary OutcomesSecondary Outcomes1.1. Need for additional medicationNeed for additional medication

- acetaminophen, scopolamine, butylbromide, - acetaminophen, scopolamine, butylbromide, promethazine, NS, atropinepromethazine, NS, atropine

2.2. Frequency of poor respondersFrequency of poor responders– Hospitalization >24 hoursHospitalization >24 hours– Administration of open label mannitolAdministration of open label mannitol– RehospitalizationRehospitalization

3.3. Subjective treatment satisfactionSubjective treatment satisfaction

ResultsResults• Improvement of symptomsImprovement of symptoms

– Mannitol - 96%Mannitol - 96%– NS - 92%NS - 92%

• p-value = 1.0p-value = 1.0

• Asymptomatic patients at 24 hoursAsymptomatic patients at 24 hours– Mannitol -12%Mannitol -12%– NS – 24%NS – 24%

• p-value 0.46p-value 0.46

• Asymptomatic patients at 1 week follow up (70%)Asymptomatic patients at 1 week follow up (70%)– Mannitol – 28%Mannitol – 28%– NS – 28%NS – 28%

• Discomfort caused by treatmentDiscomfort caused by treatment– Mannitol - 84%Mannitol - 84%– NS – 36%NS – 36%

• p-value = 0.0015p-value = 0.0015

ConclusionsConclusions

• Mannitol equivalent to NS in relieving Mannitol equivalent to NS in relieving SSx of ciguatera poisoningSSx of ciguatera poisoning

• Mannitol has more side effectsMannitol has more side effects

• NS unlikely to have treatment effect, NS unlikely to have treatment effect, so don’t use eitherso don’t use either

Treatment of Chronic Treatment of Chronic Neurological Effects of Neurological Effects of Ciguatera PoisoningCiguatera Poisoning• Multiple case reportsMultiple case reports

– GabapentinGabapentin– AmitryptillineAmitryptilline– NifedipineNifedipine– FluoxetineFluoxetine– TocainideTocainide

• No real evidenceNo real evidence

Mr. FlushMr. Flush

54 yo M back from a week-long sport fishing 54 yo M back from a week-long sport fishing trip in Hawaii. He brought some fish back trip in Hawaii. He brought some fish back with him (didn’t declare it to customs) and with him (didn’t declare it to customs) and cooked some up tonight for dinner washed cooked some up tonight for dinner washed down with several glasses of Chilean wine. down with several glasses of Chilean wine.

15 minutes after eating, he developed 15 minutes after eating, he developed burning in his mouth, generalized pruritis, burning in his mouth, generalized pruritis, dysphagia, headache, followed by dysphagia, headache, followed by vomiting and diarrhea. On exam in the vomiting and diarrhea. On exam in the emergency department, his BP was normal emergency department, his BP was normal and his face and torso were bright red. and his face and torso were bright red.

ApproachApproach

• What did they eat?What did they eat?

• Where was it caught?Where was it caught?

• If not eating, other activities?If not eating, other activities?

• Pattern of neurological symptoms?Pattern of neurological symptoms?

• Onset of symptoms?Onset of symptoms?

• Can you make the diagnosis?Can you make the diagnosis?

• Management?Management?

DifferentialDifferential

• Anaphylaxis/anaphylactoid reactionAnaphylaxis/anaphylactoid reaction

• Tyramine (wine, cheese)Tyramine (wine, cheese)

• MSGMSG

• Metabisulfites (wine, fruit, shrimp Metabisulfites (wine, fruit, shrimp preserv)preserv)

• Tartrazine (yellow colouring food Tartrazine (yellow colouring food additive)additive)

Scromboid poisoningScromboid poisoning

• Eating cooked, smoked, canned or Eating cooked, smoked, canned or raw fishraw fish

• Mahi mahi and amber jack most Mahi mahi and amber jack most common (CDC)common (CDC)

• PREVENTABLEPREVENTABLE

Remember scromboid = Remember scromboid = histaminehistamine• Histidine found in dark meatHistidine found in dark meat• Morganella morganii, E.Coli, Klebsiella Morganella morganii, E.Coli, Klebsiella

pneumoniae contain histidine decarboxylase pneumoniae contain histidine decarboxylase enzymeenzyme

• Converts histidine to histamine and saurine in Converts histidine to histamine and saurine in WARMWARM fish fish

• Healthy fish < 0.1 mg/100 g of fishHealthy fish < 0.1 mg/100 g of fish• 12 hours at room temp = 100mg/100g of fish12 hours at room temp = 100mg/100g of fish• Toxic = 50 mg/100g Toxic = 50 mg/100g • Normal appearance, taste and smellNormal appearance, taste and smell• Rarely “honeycombing” and peppery tasteRarely “honeycombing” and peppery taste

What Scromboid looks likeWhat Scromboid looks like

• Symptoms begin in minutes to hoursSymptoms begin in minutes to hours

• Numbness, tingling, burning of mouthNumbness, tingling, burning of mouth

• DysphagiaDysphagia

• Flush (face, neck, torso)Flush (face, neck, torso)

• GI symptomsGI symptoms

• Rare: pruritis, angioedema, Rare: pruritis, angioedema, bronchospasmbronchospasm

ManagementManagement

• Activated charcoal Activated charcoal

• Supportive (fluids)Supportive (fluids)

• AntihistaminesAntihistamines

• H2 receptor antagonist*H2 receptor antagonist*

• B2 adrenergics/epiB2 adrenergics/epi

• Excellent prognosisExcellent prognosis

Blasely ML. Scombroid poisoning: prompt resolution of symptoms with cimetidine. Ann Blasely ML. Scombroid poisoning: prompt resolution of symptoms with cimetidine. Ann Emerg Med 1983, 12: 104-106.Emerg Med 1983, 12: 104-106.

Ms. OyMs. Oy

A 23 yo female eats out at an local A 23 yo female eats out at an local oyster bar in Charlottetown in oyster bar in Charlottetown in celebration of finishing university for celebration of finishing university for the summer.the summer.

Later that evening she starts vomiting. Later that evening she starts vomiting. 2 days later her friends notice that 2 days later her friends notice that she is not remembering simple she is not remembering simple things in their conversation. things in their conversation.

ApproachApproach

• What did they eat?What did they eat?

• Where was it caught?Where was it caught?

• If not eating, other activities?If not eating, other activities?

• Pattern of neurological symptoms?Pattern of neurological symptoms?

• Onset of symptoms?Onset of symptoms?

• Can you make the diagnosis?Can you make the diagnosis?

• Management?Management?

Shellfish poisoningShellfish poisoning

• Mollusks eat Mollusks eat dinoflagellates dinoflagellates May-AugustMay-August

• Oysters, clams, Oysters, clams, mussels, scallopsmussels, scallops

• 3 categories:3 categories:– Paralytic shellfish Paralytic shellfish

poisoning (PSP)poisoning (PSP)– Neurotoxic shellfish Neurotoxic shellfish

poisoning (NSP)poisoning (NSP)– Amnestic shellfish Amnestic shellfish

poisoning (ASP)poisoning (ASP)

Paralytic Shellfish Poisoning Paralytic Shellfish Poisoning (PSP)(PSP)

• Onset 1 hour Onset 1 hour • Saxitoxin : blocks Saxitoxin : blocks

voltage gated voltage gated sodium channelssodium channels

• Dose-related toxinDose-related toxin• Fatality from resp Fatality from resp

failurefailure• Mortality 6%Mortality 6%• Mx: lavage, Mx: lavage,

supportive, supportive, intubationintubation

• NumbnessNumbness• Sensation of Sensation of

floatingfloating• AtaxiaAtaxia• Muscle weaknessMuscle weakness• Cranial nerve Cranial nerve

dysfunctiondysfunction• ParalysisParalysis

Neurotoxic Shellfish Poisoning Neurotoxic Shellfish Poisoning (NSP)(NSP)

• Onset mean 3 hoursOnset mean 3 hours

• Brevetoxin (P.brevis)Brevetoxin (P.brevis)

• Just like ciguatera poisoning but Just like ciguatera poisoning but NO PARALYSIS NO PARALYSIS

• Not fatalNot fatal

• Mx: supportive, ? Ventolin Mx: supportive, ? Ventolin (Goldfrank)(Goldfrank)

Amnestic Shellfish Poisoning Amnestic Shellfish Poisoning (ASP)(ASP)

• Onset mean 5 hoursOnset mean 5 hours

• Domoic acid Domoic acid

• Only documented Only documented outbreak Canada 1987 outbreak Canada 1987 from mussels in PEIfrom mussels in PEI

• Mortality 2%Mortality 2%

• 10% longterm memory 10% longterm memory loss, neuropathyloss, neuropathy

• Mx: decontamination, Mx: decontamination, supportivesupportive

• SymptomsSymptoms– GI: N/V/D/crampsGI: N/V/D/cramps– Neuro: MEMORY LOSS Neuro: MEMORY LOSS

(damage to amygdala (damage to amygdala and hippocampus)and hippocampus)

– sz, grimacing, chewing, sz, grimacing, chewing, opthalmoplegia less opthalmoplegia less commoncommon

– CV: hypotension and CV: hypotension and arrythmiasarrythmias

Miss FuguMiss Fugu

A 23 yo F is teaching English in Japan. She A 23 yo F is teaching English in Japan. She presents to the hospital complaining of presents to the hospital complaining of sudden onset of headache, numbness in sudden onset of headache, numbness in her lips, tongue, face and feet after eating her lips, tongue, face and feet after eating Fugu, a local delicacy.Fugu, a local delicacy.

When you check on her in 5 minutes, her When you check on her in 5 minutes, her mouth has developed bullae, she is mouth has developed bullae, she is drooling, cannot walk any longer, and is drooling, cannot walk any longer, and is now in severe respiratory distress. now in severe respiratory distress.

Killer Fugu!Killer Fugu!

• Tetrodotoxin PoisoningTetrodotoxin Poisoning• Mortality 50% in some Mortality 50% in some

studiesstudies• Only Tetraodontiformes Only Tetraodontiformes

OrderOrder• Japan, California, Africa, Japan, California, Africa,

SA, AustraliaSA, Australia• 100 species:globefish, 100 species:globefish,

balloonfish, blowfish, balloonfish, blowfish, toadfish, blueringed toadfish, blueringed octupus.octupus.

• 2 newts in Oregon, 2 newts in Oregon, California and Alaska can California and Alaska can be fatalbe fatal

Sims et al. Pufferfish poisoning: emergency diagnosis and management Sims et al. Pufferfish poisoning: emergency diagnosis and management of mild human tetrodotoxication. Ann Emerg Med 1986, 15: 1094-of mild human tetrodotoxication. Ann Emerg Med 1986, 15: 1094-10981098

TetrodotoxinTetrodotoxin

• Found in liver, Found in liver, ovary, intestines, ovary, intestines, skinskin

• Heat stableHeat stable

• Water solubleWater soluble

• Dose-dependentDose-dependent

• Inhibits Na-K pump Inhibits Na-K pump and blockade of and blockade of neuromuscular neuromuscular transmissiontransmission

TetrodotoxicationTetrodotoxication

• Onset within minutesOnset within minutes• Neuro: HA, diaphoresis, dysesthesias, Neuro: HA, diaphoresis, dysesthesias,

paresthesias (lips, tongue, face, paresthesias (lips, tongue, face, fingers, toes), dysphagia, weakness, fingers, toes), dysphagia, weakness, ascending paralysis ascending paralysis in 2-4 hoursin 2-4 hours

• Skin: Buccal bullae, salivationSkin: Buccal bullae, salivation• GI: N/V/abdo painGI: N/V/abdo pain• CV: hypotensionCV: hypotension

Clinical grading for Clinical grading for tetrodotoxintetrodotoxin

DiagnosisDiagnosis

• ClinicalClinical

• Tetrodotoxin detected in urine up to Tetrodotoxin detected in urine up to 5 days post-ingestion5 days post-ingestion

• 24 hour urine collection 24 hour urine collection

ManagementManagement

• Decontamination (charcoal, GL, Decontamination (charcoal, GL, cathartic?)cathartic?)

• Airway protectionAirway protection

• SupportiveSupportive

Summary of shellfish Summary of shellfish ingestioningestion

C la m , m u sc le s , o ys te rs , sca llo ps

P a ra lyt icS h e llf ish

P o iso n ing

N e u ro log ic o n ly

N e u ro to x icP o iso n ing

p a res th ,a tax ia ,ve rt ig o ,n o p ara lys is

A m n es tic S h e llf ishP o iso n ing

m e m o ry lo ssp re do m ina tes

N e u ro lo g ic +G I

C o n s id e r sym p tom /s ignp re se n ta tion

Thanks Rob!

In summaryIn summary

IN G E S T IO N O F F IS H

C IG U A T E R A

L a rge fishN o t te tro do to xic f ish

O n se t w /i h o u rsG I + N eu ro lo g ic

S C O M B R O ID

L a rge fishN o t te tro d o to x icO n se t w /i h o u rs

? a lle rg ic rxn (f lu sh e tc)

T e tro d o to x in

T e trod o to xic f ish(p u ffe r, b lo w , e tc)O n se t w /i m in u tes

A sce nd in g pa ra lys is ,e tc

W h at k ind o f f ish?O n se t o f sym p tom s?

S ym p tom pa tte rn?

Thanks Rob!

ReferencesReferences

Isbister et al. Neurotoxic marine poisoning. Lancet Neurology 2005; 2: 219-28. Isbister et al. Neurotoxic marine poisoning. Lancet Neurology 2005; 2: 219-28.

Schnorf, et al. Ciguatera fish poisoning: a double blind, randomized trial of mannitol Schnorf, et al. Ciguatera fish poisoning: a double blind, randomized trial of mannitol therapy. Neurology 2002; 58:873-880.therapy. Neurology 2002; 58:873-880.

Sims et al. Pufferfish poisoning: emergency diagnosis and management of mild human Sims et al. Pufferfish poisoning: emergency diagnosis and management of mild human tetrodotoxication. Ann Emerg Med 1986, 15: 1094-1098tetrodotoxication. Ann Emerg Med 1986, 15: 1094-1098

Tunik, M and L. Goldfrank. Food poisoning. In: Goldfrank’s toxicologic emergencies, Tunik, M and L. Goldfrank. Food poisoning. In: Goldfrank’s toxicologic emergencies, seventh edition. 2002; pp.1085-1099.seventh edition. 2002; pp.1085-1099.

Weisman R. Marine envenomations. In: Goldfrank’s toxicologic emergencies, seventh Weisman R. Marine envenomations. In: Goldfrank’s toxicologic emergencies, seventh edition. 2002; pp.1592-1598.edition. 2002; pp.1592-1598.