‘Bad Fish’ Gets Even Worse

Published on March 6, 2013
Working in an ED in the Caribbean, an unusual case of fish poisoning turns quickly into an emergency.

I try to get paid for my vacations, and I have found locums positions in exotic locations are a good way to accomplish this. Like you, I love the Caribbean, and sipping an umbrella drink at the end of a long day watching a sunset sounds just about right. Especially after the day I had. I usually get off work, go scuba diving, take an afternoon nap, and then go down to where the fishermen are selling their catch of the day off the ponga boats. I pick out a grouper and go grill it before the next night shift. It’s frustrating when I must see them in the emergency department, and they are sick as dogs from what they ate. It also makes me a bit nervous as I might be next.

So when he came in with a heart rate of thirty and hypotensive, I knew there was trouble out at sea. He was a Haitian in his mid-thirties, but years of sun damage and poverty made him appear a lot older than his stated age. His GCS was 10/15, and he was stuporous. His wife was panicked rac- ing around the gurney and jabbering patois. We hooked him up to monitors and were amazed by the readouts. I prepared him for intubation, as the cold chill ran down my spine. Dropping into ACLS mode, I gave him Atropine 0.5 mg, and the response was dramatic. His heart rate rose into the 80’s and his blood pressure normalized, and he woke up, sat up in bed, and wondered how he got to the ED. His wife fell silent and looked at me with awe. It was like a miracle. He looked at me and said, ‘Bad Fish.’

He had known fish poisoning before, but not like this. The Haitians have found a way to test for Ciguatera that is quite ingenious. They lay the fish out, and if the flies stay off, they know the fish is toxic and throw it out. Ciguatera toxin accumulates in predator fish such as red snapper, grouper, Spanish mackerel, and sea bass that eat reef fish. The reef fish graze on the coral and pick up dinoflagellates that are toxin produc- ing most often during spring and fall. Once a human eats the infected predator fish they fall ill in a matter of hours. The toxin is essentially undetectable being odorless, tasteless, and heat resistant, and is there- fore impervious to most cooking. The typical and most common symptoms are nausea, vomiting, diarrhea, muscle pain, numbness and tingling. However, in the severe cases, like in our fisherman, the toxin affects the sodium channels in the cardiac and skeletal muscles, as well as the vasculature causing serious sinus bradycardia and hypo- tension, with resulting paralysis, heart, and respiratory failure.

Mild symptoms are treated with IV fluids, diphenhydramine, and other supportive measures. Severe symptoms, in addition to the above, are treated with Atropine. In his case, the patient was given Atropine as often as every 30 minutes to alleviate the toxic effects on the heart and vasculature, while his liver metabolized and eliminated it. He required frequent doses, usually hourly, which decreased over the next three days. He left the Hospital smiling, and as a bonus I didn’t have to pay for my fish for the rest of the time I was in the Caribbean!

SHARE YOUR CURIOUS CASES: When you come upon a case that grabs your attention – be it bizarre, rare or humorous – share it here. Cases should be 500 words or less, and photos are encouraged. Email cases to Logan@EPIJournal.com.

From the Fall 2012 issue of Emergency Physicians International

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