Introduction

1. A Case of Scombroid Poisoning in the Emergency Department Janna Hoffman, MD, Steve Delis, MD Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois Introduction Case Presentation Discussion • A 50-year-old healthy female with no known food allergies ate tilapia at a family holiday celebration. The tilapia was purchased from a local supermarket earlier that afternoon and was prepared by the event hosts. The patient and other guests denied abnormal odor or taste to the fish. • Two hours after finishing her meal, she presented to the Emergency Department (ED) with acute-onset flushing, abdominal pain, nausea, and vomiting. • On initial exam, she was fearful with profound rigors. Her blood pressure was 110/70, heart rate was 93, and she was slightly tachypneic with a respiratory rate of 20. • She had diffuse abdominal tenderness without peritoneal signs. Her skin exam was significant for profound flushing, most pronounced on her upper chest and neck. She had perioral cyanosis and cyanosis of her distal upper and lower extremities, with 2+ peripheral pulses bilaterally. She had no angioedema and no signs of respiratory compromise. • Our differential diagnosis included food allergy, scombroid poisoning, with less likely considerations including viral gastroenteritis and anxiety attack. • Diagnostic testing ordered via the ED triage protocol included a CBC, CMP, Amylase/Lipase, Troponin, EKG and a urine dipstick. Abnormalities were consistent with mild dehydration and vomiting (Potassium 2.9, BUN 22, Creatinine 1.13; urine dip with +30 protein). EKG revealed normal sinus rhythm. • Her symptoms and exam abnormalities (including cyanosis, flushing, and abdominal tenderness) resolved completely with 50mg IV Benadryl, a 1L IV normal saline bolus, and 125mg IV Solu-medrol. Her potassium was repleted with 20meQ IV KCl and 40meq of oral KCl. • She remained normotensive (112/80) with a significant decrease in heart rate (63) and respiratory rate (14). • She was discharged from the ED with five days of scheduled Prednisone and Benadryl and a recommendation to follow up with her primary care physician for subsequent allergy testing. • Scombroid poisoning, a common seafood-associated disease in the United States, is vastly underreported due to its broad range of clinical presentations and self-limited nature. It has been reported as affecting both groups and individuals. • Symptoms, often mimicking fish allergy, result from ingestion of accumulated histamine in fish (20mg per 100g of fish). This is attributed to improper temperature control during fish handling or storage (>4ºC for 3-5 hours). • Commonly implicated fish include those of the Scombroidae family (i.e. tuna, mackerel) and other dark-fleshed fish, including mahi-mahi and bluefish. • Some patients report a peppery taste to contaminated fish. • We present a case of probable scombroid poisoning in a patient at the Christ Hospital Emergency Department. • Scombroid poisoning is often misdiagnosed as other conditions, even in cases where multiple people are affected. This can be attributed in part to lack of awareness of health care personnel, but also to the wide variety of presentations and to self-resolution before many patients ever seek medical attention. • While toxin accumulation may be prevented by individual consumers keeping fish refrigerated, most often contamination occurs during handling of the fish, both at sea and in transfer to commercial facilities. • Toxins are heat stable and not affected by cooking. • It is impossible to confirm a diagnosis of scombroid poisoning without an assay of the original fish ingested or an elevated patient blood histamine level (not supported by most laboratories). • However, this patient’s symptoms and their complete resolution with steroids and anti-histamines, no history of fish allergy and no subsequent reactions to fish, are supportive of this diagnosis. • Patients treated for scombroid should undergo subsequent allergy testing to rule out an IgE mediated response. On follow-up with this patient, she did not undergo subsequent allergy testing but denies further adverse reactions to fish. References • Attaran, RR, Probst, F. Histamine fish poisoning: a common but frequently misdiagnosed condition. Emerg Med J 2002; 19:474 • Chegini, S, Metcalfe, DD. Contemporary issues in food allergy: seafood toxin-induced disease in the differential diagnosis of allergic reactions. Allergy Asthma Proc 2005; 26:183. • Clark, RF, Williams, SR, Nordt, SP, Manoguerra, AS. A review of selected seafood poisonings. Undersea Hyperb Med 1999; 26:175. • Ferran, M, Yébenes, M. Flushing associated with scombroid fish poisoning. Dermatol Online J 2006; 12:15. • Hughes JM, Potter ME. Scombroid-fish poisoning. From pathogenesis to prevention. N Engl J Med 1991;324:766-8. • Mines, D, Stahmer, S, Shepherd, SM. Poisonings: food, fish, shellfish. Emerg Med Clin North Am 1997; 15:157. • McInerney J, Sahgal P, Vogel M, Rahn E, Jonas E. Scombroid poisoning.Ann Emerg Med 1996;28:235-8. • Morrow JD, Margolies GR, Rowland J, Roberts LJ II. Evidence that histamine is the causative toxin of scombroid-fish poisoning. N Engl J Med 1991;324:716-20. • Taylor SL, Stratton JE, Nordlee JA. Histamine poisoning (scombroid fish poisoning): an allergy-like intoxication. J Toxicol Clin Toxicol 1989;27:225-40. Acknowledgements We received no financial or other material support for this case study.