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A fishy cause of sudden near fatal hypotension
Resuscitation (2007) 72, 158—160
CASE REPORT
A fishy cause of sudden near fatal hypotension夽 P.S. Borade ∗, C.C. Ballary, D.K.C. Lee Department of Internal Medicine, Ipswich Hospital, Heath Road, Ipswich, IP4 5PD Suffolk, United Kingdom Received 28 October 2005 ; received in revised form 10 May 2006; accepted 30 May 2006 KEYWORDS Seafood-borne illness; Mackerel fish; Histamine; Scombroid poisoning
Summary Seafood-borne illnesses are a common but under recognised source of morbidity. We report the case of an 80-year-old woman who presented to hospital after collapsing in a restaurant following lunch consisting of mackerel fish. A detailed food history and clinical exclusion helped diagnose the condition as scombroid poisoning. The patient made a complete recovery following antihistamine therapy. © 2006 Elsevier Ireland Ltd. All rights reserved.
Introduction Scombroid or histamine food poisoning is a worldwide problem associated with significant morbidity. It is probably one of the more common causes of fish poisoning. Scombroid poisoning is a distinctive clinical syndrome resulting from consumption of foods, typically certain types of fish and cheeses that contain unusually high levels of histamine. Contaminated fish belonging to the Scombroidae and Scomberesocidae family (tuna, mackerel, skipjack, bonito)1 as well as certain non-scombroid fish (mahi-mahi, bluefish, herring, anchovies, sardines)2,3 are commonly implicated. Bacterial decomposition of the amino acid histidine results in formation of a heatstable toxin (scombrotoxin) which in turn liberates bioactive amines such as histamine. 夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/ j.resuscitation.2006.05.021. ∗ Corresponding author. E-mail address: [email protected] (P.S. Borade).
The clinical presentation is similar to histamine toxicity, typically with urticaria, flushing, headache, abdominal cramps, diarrhoea and vomiting. The onset of symptoms usually occurs within a few minutes after ingestion of the implicated food, but the effects of poisoning can last for up to a day. The course is usually mild and self-limiting. Antihistamines can be used effectively to treat this intoxication.
Case report An 80-year-old woman presented to hospital after collapsing in a restaurant. She had consumed mackerel fish for lunch. She felt generally unwell with dizziness and complained of severe nausea and vomiting after finishing her meal. She subsequently collapsed and loss consciousness while having tea. There was no history of chest pain, palpitations, breathlessness, headache, diarrhoea or abdominal pain. Apart from hypertension, which was well controlled on medication, she was relatively fit
0300-9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2006.05.021
Scombroid poisoning and healthy. She had no known drug or food allergies. On examination, she was found to have significant hypotension with a blood pressure of 60/40 mmHg respectively. Her pulse was regular at 90 beats a minute with a normal character. A localized erythematous rash was found on the anterior aspect of her neck. She did not complain of any itching or pain from the rash. Cardiovascular examination revealed normal heart sounds with no murmur, rub or gallop heard on auscultation. Neurological examination was normal. Examination of the respiratory and abdominal systems was unremarkable. Blood biochemistry and haematology were within normal limits. Electrocardiography was unremarkable and there were no significant abnormalities noted on the chest X-ray. D-dimer and 24-h cardiac troponin I were normal. There was an initial lack of complete response to therapy following emergency resuscitation with intravenous fluids. It was not until intravenous cyclizine was administered for her severe nausea and vomiting that her vital signs began to significantly improve and her neck rash started to fade. Suspecting food allergy or scombroid poisoning, oral chlorpheniramine was administered and the local public health department was notified. She continued to improve with antihistamine therapy and remained haemodynamically stable overnight. She was subsequently discharged home after 24 h of observation.
Discussion In view of the patient’s age, previous history of hypertension, and current presentation, we considered antihypertensive medication overdose, neurological or cardiac disorder, or allergic reaction as the possible cause of sudden hypotension. However, a detailed history coupled with a rapid clinical improvement following antihistamine therapy suggested scombroid poisoning as the likely cause. Normal laboratory results aided by normal electrocardiography and radiography further affirmed the diagnosis by exclusion. The pathogenesis of scombroid poisoning has not been clearly elucidated, however, it is generally associated with high histamine levels of greater than 50 mg/100 g in bacterially contaminated fish.4 cis-Urocanic acid has recently been recognised as a mast cell degranulator, and endogenous histamine from mast cell degranulation may augment the exogenous histamine consumed in spoiled fish. Histamine is an important chemical mediator of inflammation, vasodilation, increased vas-
159 cular permeability, decreased peripheral resistance, airway smooth muscle contraction, and pruritus through sensory nerve stimulation. Acting at H1 - and H2 -receptors, histamine induces the vascular endothelium to release nitric oxide, which stimulates guanylyl cyclase and increases cyclic guanosine monophosphate in the vascular endothelial cells, leading to vasodilation, erythema, increased vascular permeability, and oedema.5 Vasodilation is further enhanced by an axonal reflex resulting from the release of substance P by antidromic conduction on afferent C fibres. Vasodilation and reduced peripheral resistance may contribute to a significant fall in blood pressure. Our case serves to highlight a relatively rare, but nonetheless, serious presentation of scombroid poisoning. Current literature suggests that the illness typically runs a mild, self-limiting course with common clinical presentations of urticaria, pruritus, headache, nausea, vomiting, abdominal pain and diarrhoea. There are few isolated reports of adverse effects of scombroid poisoning such as hypotension, bronchospasm, anaphylactic shock, arrhythmias and visual loss.6—8 The risk of grave harm is further augmented in certain patient populations, namely the elderly and those with underlying asthma or cardiac disease. Our patient was fortunate to have responded well to antihistamine therapy as scombroid poisoning can potentially cause severe hypotension requiring inotropic support with dopamine infusion and intravenous adrenaline (epinephrine). Scombroid poisoning is often misdiagnosed and as a result, under reported. Nevertheless, the condition still accounted for 32% of reported illnesses associated with fish or shellfish in the United Kingdom9 and 50% in the United States of America10 in the 1990s. Diagnosis is clinical. It is based on taking a good history and having a high index of suspicion. Although not performed routinely, blood sampling within 4 h of ingestion of contaminated fish may yield a high plasma histamine concentration11 and analysis of the fish flesh may confirm the presence of toxin. Despite the paucity of data from clinical trials, H1 -antihistamines are effective in ameliorating the symptoms of scombroid poisoning. H2 antihistamines may also shorten the course of illness. Supportive measures include adequate rehydration and appropriate antiemetic therapy. Major toxicity may require the same aggressive management as acute anaphylaxis. Scombroid poisoning can be prevented by keeping dark-fleshed fish refrigerated below 15 ◦ C and
160 by ensuring that fish that has been kept in opened cans for several days is not consumed.1
Conclusions • Scombroid fish poisoning can easily be misdiagnosed as food allergy or bacterial food poisoning. • The non-specific but characteristic presentation of histamine food poisoning and previous consumption of fish should alert physicians to the possibility of scombroid poisoning. • A correct diagnosis not only helps in creating awareness of the illness, but is also important from a public health perspective, as prompt identification and reporting will assist officials in preventing additional cases and outbreaks.
References 1. Mines D, Stahmer S, Shepherd SM. Poisonings: food, fish, shellfish. Emerg Med Clin North Am 1997;15:157—77. 2. Taylor SL. Histamine food poisoning: toxicology and clinical aspects. Crit Rev Toxicol 1986;17:91—128.
P.S. Borade et al. 3. Etkind P, Wilson ME, Gallagher K, Cournoyer J. Bluefishassociated scombroid poisoning. An example of the expanding spectrum of food poisoning from seafood. JAMA 1987;258:3409—10. 4. Lehane L, Olley J. Histamine fish poisoning revisited. Int J Food Microbiol 2000;58:1—37. 5. Simons FE. H1-antihistamines: more relevant than ever in the treatment of allergic disorders. J Allergy Clin Immunol 2003;112:S42—52. 6. McInerney J, Sahgal P, Vogel M, Rahn E, Jonas E. Scombroid poisoning. Ann Emerg Med 1996;28:235—8. 7. Hall M. Something fishy: six patients with an unusual cause of food poisoning! Emerg Med (Fremantle) 2003;15: 293—5. 8. Tursi A, Modeo ME, Cascella AM, Cuccorese G, Spinazzola AM, Miglietta A. Scombroid syndrome with severe and prolonged cardiovascular involvement. Recenti Prog Med 2001;92:537—9. 9. Gillespie IA, Adak GK, O’Brien SJ, Brett MM, Bolton FJ. General outbreaks of infectious intestinal disease associated with fish and shellfish, England and Wales, 1992—1999. Commun Dis Public Health 2001;4:117—23. 10. Lipp EK, Rose JB. The role of seafood in foodborne diseases in the United States of America. Rev Sci Technol 1997;16:620—40. 11. Bedry R, Gabinski C, Paty MC. Diagnosis of scombroid poisoning by measurement of plasma histamine. N Engl J Med 2000;342:520—1.
CASE REPORT
A fishy cause of sudden near fatal hypotension夽 P.S. Borade ∗, C.C. Ballary, D.K.C. Lee Department of Internal Medicine, Ipswich Hospital, Heath Road, Ipswich, IP4 5PD Suffolk, United Kingdom Received 28 October 2005 ; received in revised form 10 May 2006; accepted 30 May 2006 KEYWORDS Seafood-borne illness; Mackerel fish; Histamine; Scombroid poisoning
Summary Seafood-borne illnesses are a common but under recognised source of morbidity. We report the case of an 80-year-old woman who presented to hospital after collapsing in a restaurant following lunch consisting of mackerel fish. A detailed food history and clinical exclusion helped diagnose the condition as scombroid poisoning. The patient made a complete recovery following antihistamine therapy. © 2006 Elsevier Ireland Ltd. All rights reserved.
Introduction Scombroid or histamine food poisoning is a worldwide problem associated with significant morbidity. It is probably one of the more common causes of fish poisoning. Scombroid poisoning is a distinctive clinical syndrome resulting from consumption of foods, typically certain types of fish and cheeses that contain unusually high levels of histamine. Contaminated fish belonging to the Scombroidae and Scomberesocidae family (tuna, mackerel, skipjack, bonito)1 as well as certain non-scombroid fish (mahi-mahi, bluefish, herring, anchovies, sardines)2,3 are commonly implicated. Bacterial decomposition of the amino acid histidine results in formation of a heatstable toxin (scombrotoxin) which in turn liberates bioactive amines such as histamine. 夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/ j.resuscitation.2006.05.021. ∗ Corresponding author. E-mail address: [email protected] (P.S. Borade).
The clinical presentation is similar to histamine toxicity, typically with urticaria, flushing, headache, abdominal cramps, diarrhoea and vomiting. The onset of symptoms usually occurs within a few minutes after ingestion of the implicated food, but the effects of poisoning can last for up to a day. The course is usually mild and self-limiting. Antihistamines can be used effectively to treat this intoxication.
Case report An 80-year-old woman presented to hospital after collapsing in a restaurant. She had consumed mackerel fish for lunch. She felt generally unwell with dizziness and complained of severe nausea and vomiting after finishing her meal. She subsequently collapsed and loss consciousness while having tea. There was no history of chest pain, palpitations, breathlessness, headache, diarrhoea or abdominal pain. Apart from hypertension, which was well controlled on medication, she was relatively fit
0300-9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2006.05.021
Scombroid poisoning and healthy. She had no known drug or food allergies. On examination, she was found to have significant hypotension with a blood pressure of 60/40 mmHg respectively. Her pulse was regular at 90 beats a minute with a normal character. A localized erythematous rash was found on the anterior aspect of her neck. She did not complain of any itching or pain from the rash. Cardiovascular examination revealed normal heart sounds with no murmur, rub or gallop heard on auscultation. Neurological examination was normal. Examination of the respiratory and abdominal systems was unremarkable. Blood biochemistry and haematology were within normal limits. Electrocardiography was unremarkable and there were no significant abnormalities noted on the chest X-ray. D-dimer and 24-h cardiac troponin I were normal. There was an initial lack of complete response to therapy following emergency resuscitation with intravenous fluids. It was not until intravenous cyclizine was administered for her severe nausea and vomiting that her vital signs began to significantly improve and her neck rash started to fade. Suspecting food allergy or scombroid poisoning, oral chlorpheniramine was administered and the local public health department was notified. She continued to improve with antihistamine therapy and remained haemodynamically stable overnight. She was subsequently discharged home after 24 h of observation.
Discussion In view of the patient’s age, previous history of hypertension, and current presentation, we considered antihypertensive medication overdose, neurological or cardiac disorder, or allergic reaction as the possible cause of sudden hypotension. However, a detailed history coupled with a rapid clinical improvement following antihistamine therapy suggested scombroid poisoning as the likely cause. Normal laboratory results aided by normal electrocardiography and radiography further affirmed the diagnosis by exclusion. The pathogenesis of scombroid poisoning has not been clearly elucidated, however, it is generally associated with high histamine levels of greater than 50 mg/100 g in bacterially contaminated fish.4 cis-Urocanic acid has recently been recognised as a mast cell degranulator, and endogenous histamine from mast cell degranulation may augment the exogenous histamine consumed in spoiled fish. Histamine is an important chemical mediator of inflammation, vasodilation, increased vas-
159 cular permeability, decreased peripheral resistance, airway smooth muscle contraction, and pruritus through sensory nerve stimulation. Acting at H1 - and H2 -receptors, histamine induces the vascular endothelium to release nitric oxide, which stimulates guanylyl cyclase and increases cyclic guanosine monophosphate in the vascular endothelial cells, leading to vasodilation, erythema, increased vascular permeability, and oedema.5 Vasodilation is further enhanced by an axonal reflex resulting from the release of substance P by antidromic conduction on afferent C fibres. Vasodilation and reduced peripheral resistance may contribute to a significant fall in blood pressure. Our case serves to highlight a relatively rare, but nonetheless, serious presentation of scombroid poisoning. Current literature suggests that the illness typically runs a mild, self-limiting course with common clinical presentations of urticaria, pruritus, headache, nausea, vomiting, abdominal pain and diarrhoea. There are few isolated reports of adverse effects of scombroid poisoning such as hypotension, bronchospasm, anaphylactic shock, arrhythmias and visual loss.6—8 The risk of grave harm is further augmented in certain patient populations, namely the elderly and those with underlying asthma or cardiac disease. Our patient was fortunate to have responded well to antihistamine therapy as scombroid poisoning can potentially cause severe hypotension requiring inotropic support with dopamine infusion and intravenous adrenaline (epinephrine). Scombroid poisoning is often misdiagnosed and as a result, under reported. Nevertheless, the condition still accounted for 32% of reported illnesses associated with fish or shellfish in the United Kingdom9 and 50% in the United States of America10 in the 1990s. Diagnosis is clinical. It is based on taking a good history and having a high index of suspicion. Although not performed routinely, blood sampling within 4 h of ingestion of contaminated fish may yield a high plasma histamine concentration11 and analysis of the fish flesh may confirm the presence of toxin. Despite the paucity of data from clinical trials, H1 -antihistamines are effective in ameliorating the symptoms of scombroid poisoning. H2 antihistamines may also shorten the course of illness. Supportive measures include adequate rehydration and appropriate antiemetic therapy. Major toxicity may require the same aggressive management as acute anaphylaxis. Scombroid poisoning can be prevented by keeping dark-fleshed fish refrigerated below 15 ◦ C and
160 by ensuring that fish that has been kept in opened cans for several days is not consumed.1
Conclusions • Scombroid fish poisoning can easily be misdiagnosed as food allergy or bacterial food poisoning. • The non-specific but characteristic presentation of histamine food poisoning and previous consumption of fish should alert physicians to the possibility of scombroid poisoning. • A correct diagnosis not only helps in creating awareness of the illness, but is also important from a public health perspective, as prompt identification and reporting will assist officials in preventing additional cases and outbreaks.
References 1. Mines D, Stahmer S, Shepherd SM. Poisonings: food, fish, shellfish. Emerg Med Clin North Am 1997;15:157—77. 2. Taylor SL. Histamine food poisoning: toxicology and clinical aspects. Crit Rev Toxicol 1986;17:91—128.
P.S. Borade et al. 3. Etkind P, Wilson ME, Gallagher K, Cournoyer J. Bluefishassociated scombroid poisoning. An example of the expanding spectrum of food poisoning from seafood. JAMA 1987;258:3409—10. 4. Lehane L, Olley J. Histamine fish poisoning revisited. Int J Food Microbiol 2000;58:1—37. 5. Simons FE. H1-antihistamines: more relevant than ever in the treatment of allergic disorders. J Allergy Clin Immunol 2003;112:S42—52. 6. McInerney J, Sahgal P, Vogel M, Rahn E, Jonas E. Scombroid poisoning. Ann Emerg Med 1996;28:235—8. 7. Hall M. Something fishy: six patients with an unusual cause of food poisoning! Emerg Med (Fremantle) 2003;15: 293—5. 8. Tursi A, Modeo ME, Cascella AM, Cuccorese G, Spinazzola AM, Miglietta A. Scombroid syndrome with severe and prolonged cardiovascular involvement. Recenti Prog Med 2001;92:537—9. 9. Gillespie IA, Adak GK, O’Brien SJ, Brett MM, Bolton FJ. General outbreaks of infectious intestinal disease associated with fish and shellfish, England and Wales, 1992—1999. Commun Dis Public Health 2001;4:117—23. 10. Lipp EK, Rose JB. The role of seafood in foodborne diseases in the United States of America. Rev Sci Technol 1997;16:620—40. 11. Bedry R, Gabinski C, Paty MC. Diagnosis of scombroid poisoning by measurement of plasma histamine. N Engl J Med 2000;342:520—1.