Scombroid Toxicity Clinical Presentation

  • Author: John D Patrick, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Apr 4, 2012
 

History

Scombroid toxicity is usually self-limited but may cause significant discomfort. The onset of symptoms is usually 10-30 minutes after ingestion of the implicated fish, which is said to have a characteristic peppery bitter taste. The symptoms are nonspecific and may include the following:

  • Flushing
  • Palpitations
  • Headache
  • Numbness, tingling, burning sensations of the mouth
  • Abdominal pain, nausea, diarrhea
  • Sense of anxiety of unease
  • Prostration or loss of vision (rare)
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Physical

Physical examination findings may include the following:

  • Diffuse, macular, blanching erythema (most common); this is shown in the images below:An example of a typical scombroid rash, in this caAn example of a typical scombroid rash, in this case from tuna. Image courtesy of Amanda Oakley, MBChB, FRACP. An example of a typical scombroid rash, in this caAn example of a typical scombroid rash, in this case from tuna. Posterior view of the same patient as in the image above. Image courtesy of Amanda Oakley, MBChB, FRACP.
  • Tachycardia
  • Wheezing (generally only in histamine-sensitive asthmatics)
  • Hypotension or hypertension
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Causes

  • The bacterial decarboxylation of histidine usually present in fish tissue requires time and moderate temperatures. Thus, the most common causes of clinical illness are the consumption of spoiled fish, consumption of caught fish that has been inadequately cooled and refrigerated, or consumption of frozen fish that has been allowed to sit at room air temperature for a prolonged time after thawing. The most effective preventive measure is the maintenance of chilled temperatures (< 40°F [< 4.4°C]) from the time of catch until cooking or consumption.[7]
  • Generally, consumption of larger amounts of scombrotoxic fish produces more symptoms. Eating a portion of fish closer to the outside of a previously frozen mass of fish also causes more toxicity. Taste is a relatively insensitive measure of toxicity, since the lowest levels of histamine sufficient to cause symptoms cannot be tasted. Occasionally patients can experience peppery taste when ingesting fish with higher histamine concentrations.
  • Cooking does notinactivate the toxin.
  • The degree of symptoms in individuals consuming the same meal may be quite variable. Magnitude of symptoms may be related to the following:
    • Individual differences in sensitivity to or metabolism of histamine (eg, symptoms may be markedly worse in persons taking isoniazid because of blockade of GI tract histaminase)
    • Size of the portion consumed
    • Whether the portion was from the same fish
    • How cold the fish was before cooking (ie, more thawing may have taken place at the surface, and a fish portion from this area may contain more histamine)
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Contributor Information and Disclosures
Author

John D Patrick, MD  Assistant Professor of Medicine, Division of Emergency Medicine, Harvard Medical School; Staff, Walk-In Center, Mount Auburn Hospital

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

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.

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

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

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.

References

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An example of a typical scombroid rash, in this case from tuna. Image courtesy of Amanda Oakley, MBChB, FRACP.
An example of a typical scombroid rash, in this case from tuna. Posterior view of the same patient as in the image above. Image courtesy of Amanda Oakley, MBChB, FRACP.
 
 
 
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