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Sushi Parasites & Fish Poisoning. Part 1 Killer Sashimi. The Good. The Bad. Jejunum resected for acute abdomen one day after eating sashimi. Anisakiasis. Anisikid Nematodes. Anisakis simplex (herring worm), and related worms Pseudoterranova spp. Contraceacum spp.
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Jejunum resected for acute abdomen one day after eating sashimi
Anisikid Nematodes Anisakis simplex (herring worm), and related worms Pseudoterranova spp. Contraceacum spp. • Most cases in Japan • 3 cases reported in San Francisco after eating sushi (1988) • By 1988, about 50 cases in US had been reported New England Journal of Medicine (319:1128-29, 1988
Gastric and Intestinal Anisakiasis • Larva in cross-section, burrowed into intestinal wall • Patient may feel tickling in throat & cough up worm • Anisakiasis most commonly affects stomach
Related HelminthNecator Americanus • Hookworm • Bloodsucker • Huge cause of anemia, decreased economic productivity, infertility. • Cost South Civil War?
Larvae of A.simplex Final hosts are dolphins & whales 1st intermediate host is krill 2nd host is fish/squid 150 spp. Acute gastric disease, occurs 1 to 2 h after eating raw fish Endoscopic removal is treatment of choice Occurs in sensitized individuals Anisakiasis
Intestinal Anisakiasis • Presents as Acute Abdomen • Confused with appendicitis, Chron’s, Gastrointestinal Cancer. • Diagnosis made after surgery • Extragastrointestinal involvement is possible • Omentum, liver, abdominal wall
Risky Fishes • Larvae occur frequently in: cod, haddock, fluke, pacific salmon, herring, flounder, and monkfish • Illuminating filets of fish (candling) mostly ineffective
Bilateral Hydro-pneumothorax • 21 yo M ate pickled crabs 3 weeks prior • Pleuritic chest pain and pink sputum • Paragonimiasis • Worm inflammatory response allows eggs to migrate into bronchus & sputum
Pulmonary manifestations of Paragonimus westermani • Ingested Paragoniumus metacercaria migrate to pleural cavity • Cause pneumothorax, pleural effusions • Common cause hemoptysis in SE Asia
TB or Parasite? • Cystic findings in lung • TB common in these locales. Misdiagnosis in 50% • Loffler syndrome - eosinophilic infiltrates migrate side to side
Soap bubble sign • Pt ate raw Japanese mitten crab • Paragonimuswestermani • Calcified “bubbly” frontal lobe lesion
Cerebral Paragonimus Disease • Encapsulated cerebral ova • In Japan, river crabs are placed next to raw fish • 2cm long, they carry P. miyazakii • Should not be eaten even if cooked!
Albuquerque Sushi Case • 40 yo male presents to ED at Albuquerque VA • He has passed a pale 1 meter long parasite • No symptoms • Only exposure to fish, he states, is homemade sushi made from salmon
Diphyllobothrium latum • Full grown worm from 1 to 15 meters! • Longest human tapeworm • Patient may vomit or pass worm • 2% symptomatic anemia • worm has affinity for vitamin B12
Freshwater & Andromous Fish • AKA Scandinavian or Jewish Housewife’s disease • Homemade Gefiltefish or Fish Balls • Absent Great Lakes • 1980 outbreak involved 4 physicians in LA, who ate salmon sushi (CDC)
Diphyllobothrium latum • Diagnosis: worm, operculate eggs in stool. • Adult may produce 1 million eggs per day. • Treat with Praziquantel or Niclosamide • Available from CDC
D. latum • Proglottid contain gravid uterus and several eggs. • Prevented by avoiding raw or pickled fish
Superficial larva migrans • 38 yo M who developed abdominal rash after eating firefly squid! • More commonly larva migrans appears after going barefoot in tropics Br J Derm Aug 1998(139) 2: 315
FDA recommendations • All fish and shellfish intended for raw (or semiraw such as marinated or partly cooked) consumption be: • 1) Blast frozen to -35°C (-31°F) or below for 15 hours, • 2) Or, regularly frozen to -20°C (-4°F) or below for 7 days.
Ichthyosarcotoxism • AKA poisoning by fish flesh • Excludes shellfish poisoning • Excludes bacterially contaminated fish • Often misdiagnosed as gastroenteritis • A wide variety of fish are implicated
Ciguatera • Most prevalent Ichthyosarcotoxism • Over 400 fish species are implicated • Mainly large, carnivorous fish • Grouper, Snapper, Barracuda, Surgeon Fish, and Moray Eel.
CDC case report • 17 crew members of cargo ship fell ill in Freeport TX, in 1997 with nausea, weakness, and paresthesias • All had eaten barracuda - later found to be ciguatoxin positive • All recovered • 120 cases reported to CDC in decade prior in US
Crew Member’s Symptoms • Diarrhea (100%) • Abdominal Cramps (82%) • Nausea/Vomiting (76%) • Muscle Weakness (88%) • Itching/Numbness of mouth (65%) • Temperature reversal (65%) • Acroparesthesias (65%) • Dizziness (59%)
Ciguatera Clinical Features • Delayed Onset: 4-10 hours post ingestion • Initially: GI, nausea, vomiting, and diarrhea • Later: Neuro, paresthesias, temperature reversal – Hot objects feel cold on skin or in mouth • Heart block may occur
Ciguatera pathogenesis • Ciguatoxin is produced by dinoflagellate protozoan – Gambierdiscus toxicus • Reef fish can concentrate the toxin in flesh • Toxins are stable, resistant to cooking. • Ciguatoxin alters membrane properties of cells • Activates voltage dependent sodium channels in nerve and muscle
Ciguatera Treatment • Activated Charcoal • Supportive care • Correction of dehydration • Mannitol and Calcium have been reported to have benefits anecdotally • Neurologic symptoms may last months • Mortality is low < 1:1000
Ciguatera case report • Two Marshallese men (30 and 31 y.o.) developed circumoral numbness and tingling in fingers two hours after eating fresh-caught cooked snapper • 3 hours: burning sensation on drinking or touching water; marked weakness, then joint pains & lethargy. • 6 hours: unconscious, responded only to pain, with flaccid paralysis. JAMA, May 13, 1988 - Vol 259, No. 18
JAMA, May 13, 1988 - Vol 259, No. 18 • 72 hours: LR was given at a rate of 125 mL/h • 250 mL of 20% Mannitol solution administered IV at a rate of 500 mL/h while they were evacuated by aircraft. • One patient stood up ten minutes after mannitol therapy was started; the other patient, confused, sat up after five minutes. • Both discharged, fully recovered 48 hours after treatment.
Randomized Trial Mannitol • 50 patients: after 24 hours, 96% mannitol-treated patients vs. 92% saline-treated patients had improved (p = 1.0) • 12% and 24% of patients in each group were asymptomatic (p = 0.46). • Infusion pain: mannitol group (84%) > NS group (36%) (p = 0.0015). • Mannitol was not superior to NS in relieving symptoms and signs of CP but had more side effects. • Ciguatera fish poisoning: a double-blind randomized trial of mannitol therapy. Schnorf H - Neurology - 26-MAR-2002; 58(6): 873-80
Ciguatera Prevention • Avoid eating the biggest specimens of reef fish • Avoid eating scaleless fish (eels) • Avoid viscera – makes sense to me!
Fugu • Toxic Pufferfish • Known in sushi bars as Fugu • Fugu is prepared by specially trained chefs in Japan. • Several tens of cases each year in Japan • Mortality exceeds 50%!
Fugu/Tetrodotoxin poisoning • Most powerful emetic known • Causes severe GI upset with profound vomiting, pain. • GI symptoms are often accompanied by paresthesias, ataxia, respiratory depression. • Victims proceed to coma, convulsions, and death within hours
Tetrodotoxin • Axonal blocking agent, interferes with cytochrome system • Often causes bradycardia, heart block, circulatory failure, seizures, hypothermia. • Treatment is supportive, ICU, pressors, fluids, AC charcoal probably doesn’t hurt.