sushi parasites & fish poisoning
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
Sushi Parasites & Fish Sushi Parasites & Fish PoisoningPoisoning
Part 1Part 1Killer SashimiKiller 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.Most cases in Japan3 cases reported in San Francisco after eating sushi (1988)By 1988, about 50 cases in US had been reportedNew England Journal of Medicine (319:1128-29, 1988
Gastric and Intestinal Anisakiasis
Larva in cross-section, burrowed into intestinal wallPatient 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?
Anisakiasis
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 fishEndoscopic removal is treatment of choiceOccurs in sensitized individuals
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
My oh Moi!
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 priorPleuritic chest pain and pink sputumParagonimiasisWorm inflammatory response allows eggs to migrate into bronchus & sputum
Pulmonary manifestations of Paragonimus westermani
Ingested Paragoniumus metacercaria migrate to pleural cavity Cause pneumothorax, pleural effusionsCommon 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 ovaIn Japan, river crabs are placed next to raw fish 2cm long, they carry P. miyazakiiShould 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 tapewormPatient may vomit or pass worm2% symptomatic anemiaworm has affinity for vitamin B12
Freshwater & Andromous Fish
AKA Scandinavian or Jewish Housewife’s diseaseHomemade Gefiltefish or Fish BallsAbsent Great Lakes1980 outbreak involved 4 physicians in LA, who ate salmon sushi (CDC)
Diphyllobothrium latumDiagnosis: 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
Nematode larva Spirurina
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.
Part 2Now we’re cookin’
Grilled Walu (Yum!)
Ichthyosarcotoxism
AKA poisoning by fish fleshExcludes shellfish poisoningExcludes bacterially contaminated fishOften misdiagnosed as gastroenteritisA 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 FeaturesDelayed 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 toxicusReef fish can concentrate the toxin in fleshToxins are stable, resistant to cooking.Ciguatoxin alters membrane properties of cellsActivates 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 snapper3 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/h250 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 Mannitol50 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!
Probably this one’s ok
FuguToxic 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.
Internal Medicine Applicant Dinner at Season’s Restaurant
3 IM attendings ate tuna
1 applicant from Florida ate steak
Dr. Magrep developed diarrhea, flushing and subjective fever, mild pruritis.
Comparing notes the next am, 2 colleagues reported same symptoms
Applicant survived process.
ScromboidScromboidae Family - Tuna Mackerel
Dark fleshed migratory species of pelagic fish.
Mackerel, tuna, bonito, mahi-mahi
Humans ingest canned tuna, smoked mackerel, tinned sardines - most cases
Also “ripe” fresh fish
Scromboid
Rapid onset of symptoms – within 10 minutes
Maximal symptoms within 2 hours
Like others, causes acute GI distress – vomiting, cramps, diarrhea.
Skin: erythema, urticarial patches, edema, facial swelling
Often confused with allergic reaction
Very seldom fatal
Pathogenesis
Histidine in fish flesh.Histidine is converted to histamine in gutWidespread activation of mast cellsTreatment antihistamines!H2 blocker provides superior relief than H1 blocker, but no reason to not give bothIV cimetidine produces rapid resolution of sx
Questions?