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Toxicity, Tetrodotoxin: Differential Diagnoses & Workup

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
Contributor Information and Disclosures

Updated: Oct 2, 2009

Differential Diagnoses

CBRNE - Botulism
Lambert-Eaton Myasthenic Syndrome
Gastroenteritis
Myasthenia Gravis
Guillain-Barré Syndrome
Octopus Envenomations
Heart Block, First Degree
Toxicity, Ciguatera
Heart Block, Second Degree
Toxicity, Scombroid
Heart Block, Third Degree
Toxicity, Shellfish
Hypocalcemia

Workup

Laboratory Studies

  • No specific laboratory test that confirms tetrodotoxin ingestion exists; thus, dietary history is key for diagnosis.
  • Mouse bioassays for paralytic shellfish toxin (ie, saxitoxin) exist that are positive with tetrodotoxin. There are research chromatography techniques for tetrodotoxin as well, but neither is available in the acute clinical situation. Tetrodotoxin also may be detected by fluorescent spectrometry.
  • Measure routine serum electrolytes, calcium, magnesium, and ABGs to rule out metabolic causes of diffuse sensory and motor neuron dysfunction.

Imaging Studies

  • Patients with evidence of cyanosis or respiratory insufficiency should have a chest x-ray to exclude local lung pathology (eg, aspiration pneumonia).
  • Obtain a plain film and upright x-ray of the abdomen in patients with persistent vomiting or severe abdominal pain to exclude obstruction or hollow viscus perforation.
  • Perform a CT scan of the brain if the patient exhibits any focal neurologic dysfunction or seizures.

More on Toxicity, Tetrodotoxin

Overview: Toxicity, Tetrodotoxin
Differential Diagnoses & Workup: Toxicity, Tetrodotoxin
Treatment & Medication: Toxicity, Tetrodotoxin
Follow-up: Toxicity, Tetrodotoxin
Multimedia: Toxicity, Tetrodotoxin
References
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References

  1. Padera RF, Tse JY, Bellas E, Kohane DS. Tetrodotoxin for prolonged local anesthesia with minimal myotoxicity. Muscle Nerve. Dec 2006;34(6):747-53. [Medline].

  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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Further Reading

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Keywords

TTX, Japanese puffer fish, fugu, tetrodotoxin, tetrodotoxin toxicity, tetrodotoxin exposure, tetrodotoxin poisoning, tetrodotoxin ingestion, neurotoxin

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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.

Medical Editor

Robert L Norris, MD, Associate 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.

Pharmacy Editor

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.

Managing Editor

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.

CME Editor

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.

 
 
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