Cardiac Arrests after Eating Raw Grass Carp Gall Bladders: A Case Report

BACKGROUND: Cases of poisoning by eating raw sh gallbladder occur mainly in Asia. These cases have been reported mainly with acute liver and kidney damage. We found that the ingestion of carp gallbladder also caused myocardial damage and lead to frequent cardiac arrest in patients with subclinical long QT interval syndrome. Patient concerns: We report a 57-year-old woman with an unexplained Long QT syndrome history who developed arrhythmia sudden death two times following ingestion of raw sh gall bladder.Fish bile poisoning, toxic hepatitis, acute renal failure, cardiac arrest, postoperative cardiopulmonary resuscitation, long QT syndrome were diagnosed. As in this case, myocardial injury caused by sh bile poisoning further leads to cardiac arrest related to LQTS.The patient underwent continued renal replacement therapy (CRRT) and other supportive treatments to manage symptoms, promote detoxing, protect liver and myocardium in our hospital. Then she completed a cardiac pacemaker placement in local hospital.Her liver enzymes prole returned to normal after 18 days, and kidney injury index returned to normal after more than one month. On follow up after three months, her renal as well as the liver parameters were found normal and she never attack malignant arrhythmia again. Conclusion: Eating sh bile can lead to MODS, not merely to liver and kidney damage. Some of the LQTS patients usually have no clinical symptoms. Clinicians should be aware of changes in low-risk LQTS patients when something special happens to them. report a woman with sh heart muscle asymptomatic long QT interval subclinical long QT sudden from severe


Introduction
In some countries and regions of Southeast Asia, local residents believe that eating raw sh gall bladder can cure their chronic diseases and boost immunity and it is also a signi cation of courage. Some research shows that a kind of toxin bile salt which is called 5 alpha-cyprinol sulphate with hepatotoxic and nephrotoxic is contained in sh gall bladder especially in carp [1] .
Long QT syndrome (LQTS) is a syndrome of unknown etiology which characterized by prolonged QT interval in the electrocardiogram and accompanied by abnormal T wave and/or U wave. Some of the LQTS patients have no clinical symptoms when it does not occur. Congenital LQTS is usually genetically related and these patients are more likely to experience syncope and even sudden death than others [2] .

Case Presentation
Chief complaints A 57-year-old woman came to the emergency department in our hospital after taking sh gallbladder for six hours.

History of present illness
She ate 4 fresh grass carp gall bladders as a folk remedy for stomachache. Her husband took her to hospital at once, while she has no speci c clinical symptoms or signs. As she strongly refused to get a gastric lavage and any other inspection or treatment, the doctor let them go. After 6 hours of ingestion of gall bladder, she developed dizziness accompanied by visual rotation, nausea and vomiting. She also had diarrhea three times during this period. So she came to our emergency department at the second time.

History of past illness
The patient did not provide any previous medical history except a stomachache without clinical diagnosed.
History of family illness She and her family had a free family history.

Physical examination
The patient characteristics, measured vitals on admission are depicted in Table 1. All physical examinations about cardiopulmonary revealed no abnormality. There was neither lymphadenopathy nor hepatosplenomegaly. Neurological examinations were normal too.

Course records and treatment
As she still refused to get neither nether gastric lavage nor hemodialysis, doctors adopted other supportive treatments to manage symptoms, protect liver and promote detoxing at that night.
Her indicators of liver enzymes and kidney damage increased signi cantly and her urine output decreased since the next day. Continued renal replacement therapy (CRRT) was received on the second to fourth days then urination improved and renal function got normalized. Drugs such as glutathione continue to be used for liver protection. Symptoms and indicators gradually improvedAfter seven days, she consulted with her family to stop hemodialysis. After that, the biomarkers of kidney damage increased, but urine volume was almost normal. Liver enzymes pro le returned to normal after 18 days, and kidney injury index returned to normal after more than one month.
On day 8, the patient developed chest distress and asthma, and computerized tomography showed massive pleural effusion on both sides. She underwent bilateral thoracic close drainage. In the early hours of the 23rd day, her relatives found her gasping for breath and unconscious. She was asphygmia when doctors arrived. We quickly gave her cardiopulmonary resuscitation and endotracheal intubation. She regained her autonomic rhythm in about half an hour. On day 25, her ECG monitor recorded a brief ventricular brillation and then return to sinus rhythm rapidly. Metoprolol and lidocaine were used to control the arrhythmia. She recovered well and on day 26 she had the endotracheal tube removed and was transferred to the observation ward. At this time, the ECG showed that a QT interval of 550 ms was accompanied by abnormal T waves. On the 43rd day, the patient had another sudden cardiac arrest when talking with others in the morning. After cardiopulmonary resuscitation for about 10 minutes, she regained consciousness and was hospitalized for observation. Considering her long QT interval, the possibility of arrhythmia or even sudden death can happen at any time, we suggests the installation of a pacemaker. After consultation with her family, she decided to return to the local hospital to complete the cardiac pacemaker placement. On follow up after three months, her renal as well as the liver parameters were found normal.