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Histamine Toxicity from Fish Workup

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

Approach Considerations

Generally, the diagnosis of histamine toxicity from fish is made on clinical grounds; no laboratory tests are necessary. If proof is required for epidemiologic or other reasons, uneaten portions of the fish may be tested for histamine levels. In addition, affected patients have increased histamine levels in plasma and high levels of histamine methabolites (N- methylhistidine) in urine.[3, 10] Although these findings support the diagnosis, these measurements are poorly correlated to clinical manifestations and do not affect clinical decisions.[6]

A patient with respiratory complaints may require chest radiography to exclude foreign body aspiration or other respiratory pathology. A patient with cardiac complaints may need an electrocardiogram (ECG) to exclude other causes of palpitations or chest tightness.

Histamine toxicity can sometimes be difficult to distinguish from true food allergy, especially in isolated cases. The absence of any history of allergic reactions to the same food, especially if combined with a cluster of cases associated with eating the same meal, can be helpful in making this distinction, since these would suggest a diagnosis of histamine toxicity.

One study has suggested that serum tryptase levels, if obtained very early (1-2 h) after symptom onset, may also help to make this distinction. If tryptase levels are elevated, an allergic reaction is more likely, since the tryptase level is usually within the normal range in histamine food poisoning.[12]

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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