Brief Reports
Tetrodotoxin poisoning,☆☆

https://doi.org/10.1053/ajem.2003.50008Get rights and content

Abstract

Tetrodotoxin (TTX) poisoning, although uncommon, is frequently seen in Taiwan, Japan, and Southeast Asia. It is rare but significant in the United States as well. Only three cases have been reported in the EM literature. We report an outbreak of six cases of TTX poisoning from eating puffer fish. On April 17, 2001, an outbreak of TTX poisoning occurred among Mainland Chinese fishermen who shared puffer fish on their boat in the Taiwan Strait. All six cases were middle-aged men (aged 32-49 yr). Onset of symptoms began approximately 2 to 3 hours after ingestion; symptoms included orolingual numbness, acroparesthesia, and breathlessness. As a result of delayed transportation and initial resuscitation, one patient presented in full cardiac arrest, with recovery of spontaneous circulation after successful cardiopulmonary resuscitation. With the exception of this patient, the initial acid-base abnormalities were inconsistent with severity of illness and mild hypercapnia was common (4 out of 5). The patient who presented in full arrest died 1 day after admission as a result of intractable bradycardia (complete atrioventricular block), a finding rarely mentioned in the literature, despite intravenous atropine and dopamine infusion. The remaining patients survived without significant sequelae and were discharged after short-term observation and supportive care, although some had neurologic and cardiopulmonary manifestations (muscle weakness, hypotension, hypoxemia, and hypercapnia). Some mildly hypoventilated patients recovered well without endotracheal intubation and ventilatory support. Favorable outcomes in most patients can be obtained if aggressive supportive treatment is provided in time. Thus, appropriate prehospital and ED ventilatory support (the implementation of a bag-valve mask or endotracheal intubation with good ventilatory support) is mandatory for those patients with respiratory failure. Most patients experience onset of symptoms within 6 hours of ingestion, but a few have a delayed onset up to 20 hours. Therefore, for those TTX-intoxicated patients without immediate prominent respiratory insufficiency, at least 24 hours of intensive monitoring of their respiratory state is necessary because of the different susceptibility and unpredictability of an individual course. (Am J Emerg Med 2003;21:51-54. Copyright 2003, Elsevier Science (USA). All rights reserved.)

Section snippets

Case reports

On April 17, 2001, six Chinese fishermen ingested puffer fish (later identified as Lagocephalus lunaris [Bloch & Schneider] by photography) on their boat in the Taiwan Strait. They experienced orolingual numbness, acroparesthesia, and breathlessness approximately 2 to 3 hours after ingestion. They were evacuated by helicopter and were dispatched to three hospitals in the Chiayi area, the southern part of Taiwan. All six patients were middle-aged men. The clinical presentations of these patients

Discussion

In this study, six cases of TTX poisoning with a variety of clinical presentations is reported. All were middle-aged men. One patient was dead on arrival because of delay in transportation and initial resuscitation. After successful resuscitation, he regained his spontaneous circulation but developed a complete atrioventricular block soon after initial stabilization. This patient died 1 day after admission as a result of intractable bradycardia and multiple organ failure despite intravenous

Conclusion

TTX poisoning, although uncommon, is frequently seen in Taiwan, Japan, and Southeast Asia. It is rare but significant in the United States. A favorable outcome can be obtained if aggressive supportive treatment is provided in time in most patients. Thus, appropriate prehospital and ED ventilatory support (the implementation of a bag-valve mask or endotracheal intubation with good ventilatory support) are mandatory for those patients with respiratory failure. Most patients have their symptom

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  • Cited by (0)

    Address reprint requests to Chii-Hwa Chern, MD, Emergency Department, Veterans General Hospital-Taipei, Taiwan, R.O.C, E-mail: [email protected]

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    0735-6757/03/2101-0012$35.00/0

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