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Prepared by the Disease Investigation Branch Revised January 2007

Scombroid Fish Poisoning Scombroid poisoning results from eating spoiled fish, primarily tuna, mahimahi, and related species. Imported mahimahi has been most often associated with scombroid poisoning in Hawai‘i. The disease is sometimes misdiagnosed as “fish allergy.” Inadequate or delayed refrigeration at sea results in the overgrowth of various bacteria normally found in these fishes. The natural action of these bacteria in the fish flesh produces histamine, saurine, and possibly other toxic substances. The fish may not have a foul odor, however, some victims have reported a sharp “metallic” or “peppery” taste while consuming the fish. This is believed to be due to the presence of histamine. Symptoms may appear within a few minutes to several hours, usually within an hour after eating a spoiled fish. Symptoms vary widely between individuals but may include the following: · flushing of the face, resembling sunburn, sometimes involving the neck, arms, and upper part of the trunk · severe throbbing headache · palpitations of the heart · abdominal cramps · diarrhea Other symptoms may include itching on the face or around the mouth, a burning sensation in the throat, dryness of the mouth, difficulty in swallowing and/or breathing, nausea, (rarely vomiting) and weakness. Symptoms usually last for eight to 12 hours, after which rapid recovery is expected. No fatalities have been recorded from scombroid poisoning to date in Hawai‘i and they appear to be extremely rare worldwide. Scombroid fish poisoning has been successfully treated with antihistamines. Other Types of Fish Poisoning Other types of fish poisoning occur less frequently than ciguatera or scombroid poisoning. These include intoxications usually associated with specific types of fish. “Hallucinogenic fish poisoning” is associated with mullet and a number of other species of fish including weke (goatfish), weke ‘ula, weke pueo, nenue (rudderfish), and manini (surgeon fish). It is seasonal, occurring usually in summer months. Symptoms reported of illness soon after ingestion may include the following: insomnia, intense dreaming, weakness, general malaise, dizziness, itching, burning of the throat, and other symptoms. Terrifying nightmares have been reported when the onset of symptoms occurs while asleep. Constrictive chest pains can also occur.

Ciguatera Poisoning
Ciguatera poisoning is thought to have been unknown to early Hawaiian fishermen. Until recently most cases of ciguatera fish poisoning involved fish from other areas of the Pacific, such as Midway or Johnson Island. Today, in Hawai‘i, ciguatera fish poisoning is a serious problem for recreational fishermen and the fishing industry. Many species of fish that are highly esteemed as food have been implicated in causing serious illness. Ulua (jack), kahala (amberjack), kole (surgeon fish), roi (grouper) and po‘ou (wrasse) have been most often responsible for ciguatera poisoning in Hawai‘i. Many other reef fish have been found to be toxic. The toxin(s) is produced by microscopic marine organism, a dinoflagellate called Gambierdiscus toxicus. This organism grows on the surface of marine algae and are eaten by herbivorous fish. Since the toxin accumulates in fish, any fish up the food chain can become toxic. The kole and palani (surgeon fish), uhu (parrotfish) and others that feed directly on the algae or coral reefs upon which the algae grows may be toxic. Fish that prey on these herbivores, ulua, kahala, uku (snapper) and eel may be even more toxic because of the cumulative effect. None of the deep sea fish, ‘ahi, aku (tuna), marlin, mahimahi, and ono (wahoo), have been found to be ciguatoxic in Hawai‘i to date. Unfortunately, there is no way of detecting a ciguatoxic fish from its appearance, smell or taste. The fish seem to be unaffected by ciguatoxin. The freshness of a fish has no relationship to its toxicity. Furthermore, the toxin is not altered by cooking, drying, salting, or freezing the fish. However, to minimize the risk of being poisoned, do not eat the roe (eggs), liver or guts of any reef fish. The toxin is concentrated up to 100 times more in these parts of the fish. In Hawai‘i, several deaths resulted from eating the viscera of toxic fish. For this reason it is recommended that all reef fish be promptly and thoroughly cleaned. Symptoms of ciguatera poisoning vary greatly from one individual to another, even when the same amounts of the same fish have been eaten. Illness usually occurs within two to six hours after eating a toxic fish. Common symptoms of illness may include the following: · general weakness · diarrhea · muscle pain, joint aches · numbness and tingling around the mouth, hands and feet · reversal of temperature sensation, where cold objects feel hot (a burning or tingling sensation may also be felt) and hot objects feel cold · others, such as nausea, vomiting, chills, itching, headache, sweating, and dizziness. The temperature reversal sensation phenomenon usually does not develop until two to five days after eating a toxin fish. Illness may last for weeks or months, rarely years. When ciguatera poisoning occurs, the affected individual should avoid consuming fish or shellfish products, alcoholic beverages and nut or seed products. These may increase the severity and/or duration of illness.

Puffer Fish Implicated in Seven Fatalitites in Hawai‘i
“Puffer fish” poisoning or “tetrodotoxication” may result from eating puffers, blowfish, balloon fish, ‘o‘opuhue, makimaki, keke, and others. Many species of puffer fish contain at least one very potent toxin, tetrodotoxin. Initial symptoms may occur within minutes and include sweating and tingling of the lips, tongue, and fingertips, followed by numbness that may spread throughout the body. Extreme weakness associated with nausea, vomiting, headache, profuse sweating and other symptoms have also been reported. In severe cases, respiratory and muscular paralysis may ensue and may be followed by death. The most common puffer fish or “fugu” (Arothron hispidus), has been implicated in at least seven fatalities in Hawai‘i. If the fish poisoning is suspected: · CALL YOUR PHYSICIAN IMMEDIATELY FOR TRATMENT. If your physician is unavailable, call Hawai‘i Poison Center at 941-4411. A physician’s care is needed to remove unabsorbed toxins from gastrointestinal tract and to treat the manifestations of illness. · Do not take any drug or medication without your physician’s advice. · Do not eat any remaining fish that could be toxic. · Save the remainder of the fish (including the head and guts) in your refrigerator or freezer to be given later to the Department of Health. The Department of Health can assist in arranging for laboratory confirmation of suspected fish poisoning cases. · Call the DEPARTMENT OF HEALTH to report a case of suspected fish poisoning. On O‘ahu, call the Disease Investigation Branch...............586-4586 On the neighbor islands, call Maui District Health Office.......................................984-8213 Hawai‘i District Health Office...................................933-0912 Kona Health Office....................................................322-4877 Kauai District Health Office......................................241-3563

Gambierdiscus toxicus
(magnifies 450 times)

Fish poisoning can result from eating spoiled fish or from eating fresh fish containing toxic substances. There are various types of fish poisoning. Some types are associated with specific fish, for example hallucinogenic fish poisoning (mullet, manini, nenue, or weke) and puffer fish poisoning (puffer fish or makua). Scombroid fish poisoning occurs when certain fish (mahimahi, ‘ahi or aku) are eaten after they have spoiled, usually because of improper refrigeration or storage. Ciguatera fish poisoning is a natural occurrence still not well understood.