Introduction
Background
Scombroid fish poisoning (scombrotoxism, scombroid ichthyotoxicosis) is a food-related illness typically associated with the consumption of fish. Originally, the illness was associated with Scombroidea fish (eg, large dark meat marine tuna, albacore, mackerel); however, the Centers for Disease Control and Prevention (CDC) have identified the largest vector to be nonscombroid fish, such as mahi-mahi and amberjack. A case report documents a large outbreak related to escolar (rudderfish, oilfish) consumption, a species whose high waxy ester content can cause some gastrointestinal symptoms (keriorrhoea) that may overlap with those caused by scombroid poisoning.1 Epidemiologic data from the CDC suggest that scombroid poisoning is the principal chemical agent type of food-borne disease found in the United States; the second most common is ciguatera poisoning.2
Pathophysiology
Most of the published literature suggests that symptoms are related to the ingestion of biogenic amines, especially histamine; others, like putrescine and cadaverine, may potentiate toxicity.3 Histamine is produced via bacterial decarboxylation of histidine and is normally present at levels less than 0.1 mg per 100 g of fish. In contrast, samples of fish that produce poisoning contain histamine levels of at least 20-50 mg per 100 g of fish. Serum histamine levels and urinary histamine excretion are elevated in humans with acute illness. Antihistamines (H1- and H2-blockers) have been used with good efficacy and safety to abate or abolish the symptoms.
Frequency
United States
Scombroid poisoning is relatively uncommon (although likely highly underreported), making up 5% of food-borne disease outbreaks reported to the CDC. The American Association of Poison Control Centers does not maintain specific data on scombroid poisoning, as noted in its 1998 annual toxic surveillance report.
International
Although scombroid poisoning is more common in nations with a warm water fishing industry, the illness is worldwide in scope. The most commonly implicated fish species are scombroid dark meat fish (eg, tuna, mackerel, skipjack, bonito, marlin) and nonscombroid species, such as mahi-mahi (dolphinfish), sardine, yellowtail, herring, and bluefish. Although rare, cases of whitefish scombrotoxism also have been reported.
Clinical
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
- Nausea
- Diarrhea
- Sense of anxiety of unease
- Prostration or loss of vision (rare)
Physical
- Diffuse, macular, blanching erythema (most common); this is shown in the images below
An example of a typical scombroid rash, in this case from tuna. Image courtesy of Amanda Oakley, MBChB, FRACP.
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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.
- Tachycardia
- Wheezing (generally only in histamine-sensitive asthmatics)
- Hypotension or hypertension
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 cooled and refrigerated inadequately, 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.
- 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.
- 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 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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References
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Further Reading
Keywords
scombroid toxicity, scombroid fish poisoning, seafood poisoning, scombrotoxism, scombroid ichthyotoxicosis, scombroid food poisoning, food poisoning, histamine reaction, scombroid poisoning, food-related illness, keriorrhoea, Scombroidea fish, marine tuna, albacore, mackerel, nonscombroid fish, mahi-mahi, amberjack, food-borne disease, seafood toxicity
