![]() ![]() In 2013, in Reunion Island (surrounded by the Indian Ocean), a family of 12 was hospitalised after pufferfish intoxication. 8 Although most reported cases of pufferfish poisoning have occurred in Asia, cases have been noted in other temperate areas of the world, as pufferfish thrive in warm waters. One of the most notable outbreaks occurred in Bangladesh in 2008, where 95 people in three different districts consumed pufferfish and 14 of them died. Previous outbreaks of pufferfish intoxication have been documented, primarily in countries where resources are scarce and the knowledge about pufferfish consumption is limited. 5 7 If intoxication does not result in death, symptoms usually recover within 24 hours, as was the case with our patient. 4 6 Prior case studies have reported the use of neostigmine to reverse paralytic effects, which we administered to our patient however, the current literature is insufficient to provide evidence for or against its use. 2 4 Activated charcoal can be administered and gastric lavage may be performed, but these practices are only effective within 60 min of ingestion. 2 4 The toxin is heat-stable and has no antidote, therefore, management of intoxication is symptomatic. TTX is dose-dependent, as was evident with our patient and his grandmother. 2 4 Paradoxically, our patient presented with hypertensive emergency, which can be attributed to concomitant cocaine ingestion, in the setting of a history of underlying HTN. The typical haemodynamic presentation is that of hypotension and bradycardia. 2–4 Naturally, aspiration of gastric contents due to compromised airway protection is a common complication, as was the likely case with our patient. 2 4 The most common manifestations of intoxication are tingling sensation, perioral numbness, dizziness, limb weakness, nausea and vomiting, however, respiratory failure and death may occur. ![]() 2 3 The onset of symptoms is typically 30 min to 6 hours after ingestion. 2 3 TTX exerts its paralytic effects by inhibiting voltage-gated sodium channels. 2 TTX is 1200 times more toxic than cyanide, with the minimal lethal dose in humans being only 2–3 mg. 1 The lethality of pufferfish is attributed to TTX, which is primarily concentrated in the liver and gonads. In Japan, where pufferfish or ‘fugu’ is a food delicacy, approximately 50 cases of pufferfish intoxication result in death each year. The patient’s grandmother endured a much more benign clinical course and did not require ICU management. Eventually, the patient’s respiratory failure resolved, however, renal function did not recover and the patient remains dialysis-dependent today. The patient’s kidney function continued to worsen and he eventually became anuric, necessitating the initiation of intermittent haemodialysis. pneumoniae in the sputum may have represented a coloniser, the patient was empirically treated, given his severity of illness. Although the patient’s initial clinical picture was not consistent with community acquired pneumonia, and the isolation of S. Sputum cultures obtained on admission were positive for pan-sensitive Streptococcus pneumoniae, for which intravenous ceftriaxone was initiated. Hospital course was complicated by the development of acute respiratory distress syndrome, in the setting of a possible aspiration event during the episode of bulbar paralysis and subsequent intubation, resulting in the use of prolonged mechanical ventilation and paralytics. Repeat CT chest was consistent with multi-lobar pneumonia and air bronchograms ( figure 2). Repeat chest radiograph revealed bilateral alveolar infiltrates ( figure 1). However, over the proceeding 24 hours, the patient acutely decompensated and had to be re-intubated. Physical exam was pertinent for confusion and somnolence, as well as garbled speech, decreased muscle strength on all extremities and absent reflexes bilaterally.Īfter approximately 24 hours, the patient regained muscle strength and was successfully extubated. Vital signs were notable for an elevated blood pressure of 268/164 mm Hg, with no fever or tachycardia. Social history was notable for occasional cocaine ingestion, however, he denied alcohol or tobacco use. His home medications were nifedipine and hydralazine. The patient’s grandmother, who consumed a smaller portion of the same pufferfish, also presented to our institution with dizziness and lower extremity weakness. He reported ingesting canned food and cocaine 3 days prior. Four hours prior to presentation, he ingested pufferfish liver. He had associated chest pain, which was tearing in nature. A 43-year-old African American man with history of hypertension (HTN) and chronic kidney disease presented with vomiting, abdominal pain, bilateral leg numbness, difficulty speaking and weakness. ![]()
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