Ackee Fruit Toxicity Clinical Presentation

  • Author: Dave A Holson, MD, MBBS, MPH; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Aug 19, 2011
 

History

The clinical syndrome induced by the consumption of the unripe ackee fruit is known in Jamaica as "Jamaican vomiting sickness" or "ackee poisoning." The symptoms are similar to Reye syndrome. Jamaican vomiting sickness is characterized by a sudden onset of vomiting that is preceded by generalized epigastric discomfort starting 2-6 hours after the ingestion of a meal containing ackee. Once the sickness begins, symptom progression is rapid. Patients experience pronounced diaphoresis, tachypnea, tachycardia, headache, generalized weakness, paresthesia, and disturbed mental states. After a period of prostration, which may last as long as 18 hours, a second bout of vomiting may occur. Unless treatment is given, this episode is usually followed by convulsions, coma, and death. Death is more common in children than in adults.

  • Tonic-clonic convulsions occur in 25% of the patients.
  • Seizures occur in 85% of all fatal cases.
  • Fatty degeneration of the liver similar to Reye syndrome also occurs.
  • The average time to death is 12.5 hours.
  • Symptoms of the disease do not include fever or diarrhea.

Guidelines for the diagnosis and management of other foodborne illnesses have been established by the American Medical Association, American Nurses Association, American Nurses Foundation, Centers for Disease Control and Prevention, Center for Food Safety and Applied Nutrition, US Food and Drug Administration, Food Safety and Inspection Service, and US Department of Agriculture.[5]

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Physical

The general physical examination is important in deciding how aggressively to resuscitate the patient. Observed clinical manifestations, listed by degree of severity, are as follows:

  • I - Asymptomatic with normal vital signs
  • II -Dehydration and hypotension as a result of the intense vomiting
  • III - Delirium or coma
  • IV - Seizure (an ominous sign)
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Causes

  • Potential risk behaviors for ackee poisoning include the following:
    • Consumption of unripe ackee fruit
    • Consumption of ackee that has been forcibly opened
    • Reuse of the water in which an unripe ackee has been cooked
  • Undernutrition is also thought to be associated with individualized susceptibility to Jamaican vomiting sickness and the severity of the disease.
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Contributor Information and Disclosures
Author

Dave A Holson, MD, MBBS, MPH  Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine; Director, Department of Emergency Medicine, Queens Hospital Center

Dave A Holson, MD, MBBS, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael E Mullins  MD, Assistant Professor, Division of Emergency Medicine, Washington University School of Medicine, Emergency Department, Barnes Jewish Hospital, St Louis, Missouri

Michael E Mullins is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians

Disclosure: Johnson & Johnson stock ownership None; Savient Pharmaceuticals stock ownership None

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD  Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Glendon C Henry, MD, and Sekuleo Gathers, MD, to the original writing and development of this article.

References

  1. Sharma S, Yacavone MM, Cao X, Samuda PM, Cade J, Cruickshank K. Nutritional composition of commonly consumed composite dishes for Afro-Caribbeans (mainly Jamaicans) in the United Kingdom. Int J Food Sci Nutr. Apr 1 2009;1-11. [Medline].

  2. Joskow R, Belson M, Vesper H, et al. Ackee fruit poisoning: an outbreak investigation in Haiti 2000-2001 and review of the literature. Clin Toxicol (Phila). 2006;44 (3):267-73.

  3. Moya J. Ackee (Blighia sapida) poisoning in the Nothern Province, Haiti, 2001. Epidemiol Bull. June 2006;22 (2):8-9.

  4. Gaillard Y, Carlier J, Berscht M, et al. Fatal intoxication due to ackee (Blighia sapida) in Suriname and French Guyana. GC-MS detection and quantification of hypoglycin-A. Forensic Sci Int. Mar 20 2011;206(1-3):e103-7. [Medline].

  5. American Medical Association; American Nurses Association-American Nurses Foundation; Centers for Disease Control and Prevention; Center for Food Safety and Applied Nutrition, Food and Drug Administration; Food Safety and Inspection Service, US Department of Agriculture. Diagnosis and management of foodborne illnesses: a primer for physicians and other health care professionals. MMWR Recomm Rep. Apr 16 2004;53:1-33. [Medline].

  6. [Best Evidence] Vlasselaers D, Milants I, Desmet L, et al. Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised controlled study. Lancet. Feb 14 2009;373(9663):547-56. [Medline].

  7. Addae JI, Melville GN. A re-examination of the mechanism of ackee-induced vomiting sickness. West Indian Med J. Mar 1988;37(1):6-8. [Medline].

  8. [Best Evidence] [Guideline] Barceloux DG. Akee fruit and Jamaican vomiting sickness (Blighia sapida Koenig). Dis Mon. Jun 2001;55 (6):318-26.

  9. Barennes, H, Valea, I, Boudat AM, et al. Early glucose and methylene blue are effective against unripe ackee apple poisoning in mice. Food and Chemical Toxicology. 2004;42(5):809-815. [Medline].

  10. Bressler R, Corredor C, Brendel K. Hypoglycin and hypoglycin-like compounds. Pharmacol Rev. Jun 1969;21(2):105-30. [Medline].

  11. CDC. Toxic hypoglycemic syndrome--Jamaica, 1989-1991. MMWR Morb Mortal Wkly Rep. Jan 31 1992;41(4):53-5. [Medline].

  12. Eddleston M, Persson H. Acute plant poisoning and antitoxin antibodies. J Toxicol Clin Toxicol. 2003;41(3):309-15. [Medline].

  13. Kean EA. Commentary on a review on the mechanism of ackee-induced vomiting sickness. West Indian Med J. Sep 1988;37(3):139-42. [Medline].

  14. Larson J, Vender R, Camuto P. Cholestatic jaundice due to ackee fruit poisoning. Am J Gastroenterol. Sep 1994;89(9):1577-8. [Medline].

  15. McTague JA, Forney R Jr. Jamaican vomiting sickness in Toledo, Ohio. Ann Emerg Med. May 1994;23(5):1116-8. [Medline].

  16. Mills J, Melville GN, Bennett C, et al. Effect of hypoglycin A on insulin release. Biochem Pharmacol. Feb 15 1987;36(4):495-7. [Medline].

  17. Tanaka K, Kean EA, Johnson B. Jamaican vomiting sickness. Biochemical investigation of two cases. N Engl J Med. Aug 26 1976;295(9):461-7. [Medline].

 
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Freshly picked Ackee fruit
Black seeds surrounded by a thick, oily, yellow aril (edible portion).
 
 
 
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