History
Most patients present within 10-60 minutes of toxin ingestion. [1] The patient may have noted a sharp, metallic, bitter, or peppery taste to the fish and describe its appearance as honeycombed.
In situations where several people have eaten portions of a fish that was contaminated with histamine, their presentations may vary. Uneven distribution of histamine in the fish’s tissues, differences in the amount consumed, and individual susceptibility to histamine all can affect the severity of the episode. For example, patients taking isoniazid (INH) or monoamine oxidase inhibitors (MAOIs) may have more significant reactions because of histaminase blockade in the gastrointestinal (GI) tract.
Manifestations of histamine fish poisoning include the following:
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Erythema of the face, neck, and upper torso
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Headache (severe and throbbing)
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Dysphagia
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Nausea and vomiting
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Abdominal cramps or epigastric pain
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Diarrhea
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Palpitations
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Pruritus
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Dizziness
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Dry mouth
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Angioedema
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Sense of anxiety or unease
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Respiratory distress and chest tightness (rare)
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Loss of vision (rare)
Physical Examination
The initial physical presentation easily can be mistaken for an allergic reaction if the history of fish ingestion is not obtained. Physical signs include the following:
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Diffuse erythematous rash, well demarcated and typically on the head, neck, and upper trunk (see the images below)
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Conjunctival injection
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Tachycardia
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Bronchospasm
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Hypotension
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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Mackerel.
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An example of a typical histamine toxicity rash, in this case from tuna. Image courtesy of Amanda Oakley, MBChB, FRACP.
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An example of a typical histamine toxicity rash, in this case from tuna. Image courtesy of Amanda Oakley, MBChB, FRACP.
