Histamine Toxicity from Fish Differential Diagnoses

Updated: Oct 05, 2021
  • Author: Alexei Birkun, III, MD, PhD; Chief Editor: Timothy E Corden, MD  more...
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Diagnostic Considerations

Histamine toxicity can be difficult to distinguish from true food allergy, especially in isolated cases. The absence of any history of allergic reactions to the same food, especially if combined with a cluster of cases associated with eating the same meal, can be helpful in making this distinction, since these would suggest a diagnosis of histamine toxicity. [1]

Staphylococcus aureus causes very similar symptoms with sudden onset nausea, vomiting, and abdominal pain within 2 hours after eating contaminated food. These patients, however, may develop fever, while patients with histamine toxicity do not. Also, patients with histamine toxicity typically have flushing or rash, while patients with Staphylococcus food poisoning do not. [6]

In patients who have been drinking alcohol, other problems to be considered in the differential diagnosis of histamine toxicity from fish include the following:

  • Chloral hydrate interaction (Mickey Finn)

  • Tyramine and monoamine oxidase inhibitor (MAOI) interaction

  • Disulfiram-type reaction

  • Ethanol flush

Considerations not related to alcohol ingestion include the following:

  • Chinese restaurant syndrome

  • Niacin flush

  • Acute allergic reaction

  • Mastocytosis

  • Migraine or cluster headache

Consumption of escolar (rudderfish, oilfish) can cause keriorrhoea, an oily diarrhea, because of the high waxy ester content of these fish. However, escolar consumption can also result in histamine toxicity, as was documented in a case report of a large outbreak. [17]

Differential Diagnoses