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Histamine Toxicity from Fish Treatment & Management

  • Author: Alexei Birkun, III, MD, PhD; Chief Editor: Timothy E Corden, MD  more...
Updated: Apr 22, 2016

Approach Considerations

Most cases of histamine fish poisoning are self-limited; duration is less than 6 hours. However, comorbid atopic conditions (ie, asthma) have been reported to extend course duration and severity.[13]

In most instances, illness severity can be well controlled with oral or intravenous (IV) antihistamines (ie, histamine 1 [H1] and histamine 2 [H2] blockers). Corticosteroids may occasionally be appropriate.

Bronchospasm is treated with oxygen and beta-adrenergic agents. Hypotension is treated with IV fluids and, rarely, pressors. Administration of epinephrine, because of the mistaken belief that the patient is experiencing an acute allergic reaction, will also result in rapid resolution of symptoms.[14]

Hospital admission is required only under exceptional circumstances. Criteria for admission are severe comorbidity or refractory toxicity that mandates respiratory or pressor support.

Most cases require no consultation for medical management. Consultation may be requested from the local health department to help confirm diagnosis. Contact the regional poison control center or a local medical toxicologist for additional information and patient care recommendations.

Remember public health issues. Notify the local health department of any case of histamine fish poisoning, especially if the source was public, in order to help prevent additional cases.


Prehospital and Emergency Department Care

Prehospital care is primarily supportive. Emergency personnel may provide oxygen and monitor cardiac function as needed. Advanced life support personnel may use antihistamines and bronchodilators as appropriate.

In the emergency department (ED), if the patient has only minimal symptoms of histamine toxicity, reassurance and observation may be the only treatment necessary. If clinically necessary, obtain an ECG and institute intravenous access, oxygen, and cardiac monitoring. H1 and H2 blockers can provide symptom relief.

Serum histamine levels and urinary histamine excretion are elevated in persons with acute illness. However, they are usually not available in a timely manner and do not have practical value for acute treatment of these cases.

Consider use of activated charcoal only if the patient ate a large amount of fish, presents very early after the meal (within 1 hour), and can adequately protect his or her airway. Use of ipecac or gastric lavage is not recommended, as these can result in complications.

Bronchospasm is a rare manifestation of histamine toxicity. If it occurs, use standard treatment, as follows:

  • Inhaled beta2-adrenergic agonists
  • Inhaled ipratropium bromide (may be particularly useful for the treatment of histamine-induced bronchospasm)
  • Epinephrine
  • Corticosteroids

Extremely rare reported cases of myocardial dysfunction, ischemia, or infarction related to histamine fish poisoning exist[15] ; standard treatment for these complications should be used. One reported case documents successful treatment of a 36-year-old woman with severe myocardial dysfunction refractory to pressor support by using a biventricular assist device for 8 days.[16]

The vast majority of patients may be discharged from the ED with oral H1- and H2-blockers for the next 3-5 days. Headache often responds H2 blocker treatment. The patient may return to normal activity as tolerated.

Patients may express concern about future allergic reactions to fish and seafood. Reassure patients that their illness resulted from improper fish handling and storage, not from an allergic reaction.

Contributor Information and Disclosures

Alexei Birkun, III, MD, PhD Assistant Professor of the Chair of Emergency Medicine and Anesthesiology, Medical Academy named after SI Georgievsky of VI Vernadsky Crimean Federal University; Critical Care Physician, Anesthesiologist, Department of Laparoscopic Surgery and New Medical Technologies, Crimea State Medical University Clinic

Alexei Birkun, III, MD, PhD is a member of the following medical societies: European Respiratory Society, International Society for Infectious Diseases, The Aerosol Society

Disclosure: Nothing to disclose.


John D Patrick, MD Corresponding Member of the Faculty in Emergency Medicine, Harvard Medical School; Emeritus Staff Physician, Emergency Department, Mount Auburn Hospital

John D Patrick, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Daniel Noltkamper, MD, FACEP EMS Medical Director, Department of Emergency Medicine, Naval Hospital of Camp Lejeune

Daniel Noltkamper, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

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, Wisconsin Medical Society

Disclosure: Nothing to disclose.


Fred Harchelroad, MD, FACMT, FAAEM, FACEP Director of Medical Toxicology, Allegheny General Hospital

Disclosure: Nothing to disclose.

Robert L Norris, MD Professor, Department of Surgery, Chief, Division of Emergency Medicine, Stanford University Medical Center

Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, California Medical Association, International Society of Toxinology, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

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

Disclosure: Merck Salary Employment

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

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.

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An example of a typical histamine toxicity rash, in this case from tuna. Image courtesy of Amanda Oakley, MBChB, FRACP.
An example of a typical histamine toxicity rash, in this case from tuna. Image courtesy of Amanda Oakley, MBChB, FRACP.
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