JA Shulman, MJ Lynch, Pizon AF

Suspected Tetrodotoxin Ingestion in a Family Causing Neurologic
Symptoms and Generating an Interstate Public Health Investigation
JA Shulman, MJ Lynch, Pizon AF
University of Pittsburgh Medical Center, Division of Medical Toxicology, Department of Emergency Medicine, Pittsburgh, PA
Background
•  Tetrodotoxin is a potent neurotoxin found in the tissues of certain species of
pufferfish
•  Ingestion has been associated with nausea, emesis, paresthesias, paralysis,
cardiac conduction abnormalities, and death through sodium channel blockade
Hypothesis
•  Five patients from one family likely suffered tetrodotoxin toxicity following
ingestion of varying quantities of pufferfish.
•  Poison center and toxicologist recognition of a potential public health hazard
can contribute to an effective intervention.
Case report
•  The patriarch, a healthy 45-year-old male Chinese restaurateur, prepared a meal
consisting of an unknown species of dried pufferfish that was consumed by his
wife and three children, ages 21, 13 and 11.
•  Pufferfish was purchased at a market in New York City, NY by his wife, who
transported the fish across state lines via charter bus.
•  The man consumed the largest portion. Thirty minutes later, all five diners
developed perioral paresthesias, and both the man and his wife developed
nausea and emesis.
•  All family members were evaluated in a community emergency department.
•  The children’s symptoms resolved without intervention and they were
discharged home.
•  The man progressed to respiratory failure requiring intubation.
•  The woman had vertigo and nausea but did not require ventilation. (Table 1)
•  Both the regional poison center and medical toxicology service were consulted
and the pair was transferred for tertiary care.
Patient
Age
Gender
Perioral
Paresthesia
Nausea/
Emesis
Vertigo
1
45
Male
++
++
++
2
43
Female
++
++
+++
3
21
Female
+
4
13
Female
+
5
11
Male
+
Extremity Respiratory
Paresthesia Depression
+
+
Table 1: Age, Gender, and symptoms in family members who reportedly consumed pufferfish
Results:
•  On hospital day 2, the man was extubated.
•  Both patients continued to complain of
severe vertigo that improved with oral
meclizine and intravenous
prochlorperazine.
•  No fish remained uneaten for analysis.
•  The 23 year old daughter was able to
identify a picture of the type of fish
consumed (Figure 1)
Key
6
Source
Market
1
NY Department
of Agriculture
NEW YORK
Patient Transfer
Consultation/
Communication
PENNSYLVANIA
Index
cases
Food and Drug
Administration
4
2
Tertiary
Referral
Center
Investigation
By Government
Agency
Movement of
Toxic Product
5
Community ED
PA
Department of
Health
Regional
Poison
Center
Medical
Toxicology
Service
Medical
Affiliation
3
Figure 2: Flowchart depicting the multiple medical, public health, and governmental agencies involved in responding
to this public health crisis. Potentially toxic product was purchased in New York City, was transported to
Pennsylvania by bus (1) and consumed in Pennsylvania; patients presented to community ED (2), consultation made
to poison center and medical toxicology (3), patient transferred to tertiary facility (4), collaboration with several
government departments (5), and investigation made into market across state lines (6).
Figure 1: Representative fish identified independently by daughter
as the
Courtesy: National Geographic
species of marine wildlife consumed by the family, likely pufferfish
(Lagocephalus genus). Courtesey National Geographic
•  The toxicology group and poison
center collaborated with the
Pennsylvania Department of
Health, the New York Department
of Agriculture, and the FDA to
investigate and identify the
retailer illegally supplying the
puffer fish. (Figure 2)
•  Unfortunately, the sample
obtained from the shop was
identified through genotyping as
dried monkfish, and no
tetrodotoxin was isolated from
the sample
Discussion
•  Myriad neurologic symptoms after pufferfish ingestion have been well documented.
•  These cases illustrate a dose-response relationship among individuals who consumed
different amounts of pufferfish.
•  Since no fish remained for testing, and no tetrodotoxin was identified during
investigation, cannot exclude other seafood toxins (e.g. saxitoxin) or psychogenic
illness.
•  Also demonstrates a robust, coordinated effort by public health officials in multiple
jurisdictions to attempt to identify the source of a food-based toxin.
Conclusion
•  Toxicologists and poison centers can play a pivotal role in the identification and
investigation of potential public health threats across state lines.