Tetrodotoxin Toxicity Clinical Presentation

  • Author: Theodore I Benzer, MD, PhD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Apr 14, 2011
 

History

  • The first symptoms occur 15 minutes to several hours postingestion of tetrodotoxin-containing food. A recent report on toxicity found that initial symptoms may occur up to 20 hours after ingestion.
  • Initial symptoms include lip and tongue paresthesias, followed by facial and extremity paresthesias and numbness.
  • Salivation, nausea, vomiting, and diarrhea with abdominal pain develop early.
  • Motor dysfunction with weakness, hypoventilation (may be from dysfunction of central and peripheral nervous systems), and speech difficulties then develop. A rapid ascending paralysis occurs over 4-24 hours. Extremity paralysis precedes bulbar paralysis, which is followed by respiratory muscle paralysis. Deep tendon reflexes are preserved early in the course of paralysis.
  • Finally, cardiac dysfunction with hypotension and dysrhythmias (bradycardia), central nervous system (CNS) dysfunction (eg, coma), and seizures develop. Patients with severe toxicity may have deep coma, fixed nonreactive pupils, apnea, and loss of all brain stem reflexes.
  • Death can occur within 4-6 hours. Typically, death occurs from respiratory muscle paralysis and respiratory failure.
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Physical

  • Loss of sensory and motor neuron function is a prominent finding.
  • Ascending paralysis with respiratory depression.
  • Cyanosis occurs with respiratory failure.
  • Hypotension can occur with myocardial dysfunction.
  • Cardiac rhythm disturbances, especially bradycardia, atrioventricular (AV)–nodal block, and bundle-branch block, can be life threatening.
  • GI effects are not prominent, but vomiting and abdominal tenderness can occur.
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Causes

  • Ingestion of tetrodotoxin causes the syndrome.
  • Almost all toxicity is caused by the ingestion of fugu, but other species of animals have been shown to produce tetrodotoxin (eg, California newt, parrot fish, blue-ringed octopus). A death from ingestion of tetrodotoxin from a California newt has been documented.
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Contributor Information and Disclosures
Author

Theodore I Benzer, MD, PhD  Assistant Professor in Medicine, Harvard Medical School; Director of Clinical Operations, Director of Toxicology, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital

Theodore I Benzer, MD, PhD is a member of the following medical societies: Alpha Omega Alpha and American College of Emergency Physicians

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 & 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.

Michael J Burns, MD  Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

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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  2. San Diego Department of Environmental Health, FDA. Tetrodotoxin poisoning associated with eating puffer fish transported from Japan--California, 1996. MMWR Morb Mortal Wkly Rep. May 17 1996;45(19):389-91. [Medline].

  3. Rivera VR, Poli MA, Bignami GS. Prophylaxis and treatment with a monoclonal antibody of tetrodotoxin poisoning in mice. Toxicon. Sep 1995;33(9):1231-7. [Medline].

  4. Chang FC, Spriggs DL, Benton BJ, et al. 4-Aminopyridine reverses saxitoxin (STX)- and tetrodotoxin (TTX)-induced cardiorespiratory depression in chronically instrumented guinea pigs. Fundam Appl Toxicol. Jul 1997;38(1):75-88. [Medline].

  5. Ahasan HA, Mamun AA, Karim SR, et al. Paralytic complications of puffer fish (tetrodotoxin) poisoning. Singapore Med J. Feb 2004;45(2):73-4. [Medline].

  6. FDA/CFSAN resources page. Pufferfish poisoning. Food and Drug Administration Web site. Available at: http://vm.cfsan.fda.gov/~mow/chap39.html. Accessed January 20, 2005. [Full Text].

  7. How CK, Chern CH, Huang YC, et al. Tetrodotoxin poisoning. Am J Emerg Med. Jan 2003;21(1):51-4. [Medline].

  8. Karalliedde L. Animal toxins. Br J Anaesth. Mar 1995;74(3):319-27. [Medline].

  9. Lange WR. Puffer fish poisoning. Am Fam Physician. Oct 1990;42(4):1029-33. [Medline].

  10. Mills AR, Passmore R. Pelagic paralysis. Lancet. Jan 23 1988;1(8578):161-4. [Medline].

  11. Sims JK, Ostman DC. Pufferfish poisoning: emergency diagnosis and management of mild human tetrodotoxication. Ann Emerg Med. Sep 1986;15(9):1094-8. [Medline].

  12. Sun KO. Management of puffer fish poisoning. Br J Anaesth. Oct 1995;75(4):500. [Medline].

  13. Xu QH, Zhao XN, Wei CH, Rong KT. Immunologic protection of anti-tetrodotoxin vaccines against lethal activities of oral tetrodotoxin challenge in mice. Int Immunopharmacol. Jul 2005;5(7-8):1213-24. [Medline].

 
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Puffer fish.
Chemical structure of tetrodotoxin.
 
 
 
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