Presented Presented

ByBy

Dr / Said Said ElshamaDr / Said Said Elshama

IntroductionIntroductionMarine toxins is a vague area for physicians Marine toxins is a vague area for physicians

and clinical toxicologist in Egypt.and clinical toxicologist in Egypt.Puffer fish contains one of the most potent Puffer fish contains one of the most potent

marine toxins which is called tetrodotoxin . marine toxins which is called tetrodotoxin . Tetrodotoxin is a neurotoxin and has a Tetrodotoxin is a neurotoxin and has a

severe dangerous effect for the life .severe dangerous effect for the life .In Japan In Japan , puffer fish poisoning is the most , puffer fish poisoning is the most

common cause of fatal food poisoning .common cause of fatal food poisoning .In EgyptIn Egypt, many physicians observed , many physicians observed

sporadic cases of puffer fish poisoning .sporadic cases of puffer fish poisoning .

In the last ten years , the rate of In the last ten years , the rate of these cases was progressive these cases was progressive increased and made many troubles increased and made many troubles for physicians and people because for physicians and people because

of wide extreme of different clinical of wide extreme of different clinical pictures and prognosis.pictures and prognosis.

In Suez city, In Suez city, many people eat puffer many people eat puffer fish without appearance any toxic fish without appearance any toxic manifestations, but some of them manifestations, but some of them complain of different toxic signs and complain of different toxic signs and symptoms without any residual symptoms without any residual affection and the others die . affection and the others die .

Aim of the workAim of the work

Attraction of health professional Attraction of health professional attention to importance of toxicity attention to importance of toxicity puffer fish which is a common form of puffer fish which is a common form of poisoning in Egyptian coastal cities poisoning in Egyptian coastal cities such as Suez city . such as Suez city .

Determination of factors affecting Determination of factors affecting the clinical picture and outcome of the clinical picture and outcome of puffer fish poisoning for early and puffer fish poisoning for early and clear diagnosis. clear diagnosis.

Patients and Methods Patients and Methods The study was carried out in General Suez The study was carried out in General Suez

Hospital. Hospital. Nine patients from different families with Nine patients from different families with

different ages and sex were admitted with different ages and sex were admitted with history of puffer fish ingestion. history of puffer fish ingestion.

Source of contamination was puffer fish which Source of contamination was puffer fish which was caught from the red sea, especially the Suez was caught from the red sea, especially the Suez Gulf .Gulf .

Suez gulf was free from any contamination Suez gulf was free from any contamination (microbial contamination and water pollution). (microbial contamination and water pollution).

Researchers of National Institute of Researchers of National Institute of Oceanography and Fishery (Suez branch) proved Oceanography and Fishery (Suez branch) proved that Suez Gulf was free from any pollution that Suez Gulf was free from any pollution during the same period of the research after during the same period of the research after investigation of multiple and frequent samples investigation of multiple and frequent samples of water and fish of water and fish

Puffer fish poisoning was diagnosed on the Puffer fish poisoning was diagnosed on the basis of recent dietary history and clinical basis of recent dietary history and clinical picture. picture.

All patients ate one fish and average amount All patients ate one fish and average amount of boiled rice .of boiled rice .

No any medication was taken before the No any medication was taken before the admission. admission.

All cases were clinically examined, All cases were clinically examined, investigated and observed from admission to investigated and observed from admission to discharge for the following parameters : discharge for the following parameters :

Onset of symptoms.Onset of symptoms. Clinical manifestations.Clinical manifestations. Complete blood picture . Complete blood picture . Renal functions ,(SGPT), (SGOT).Renal functions ,(SGPT), (SGOT). Blood glucose, Electrolytes (Na, K, Ca, P ).Blood glucose, Electrolytes (Na, K, Ca, P ).

Clinical picture was divided into gradingClinical picture was divided into grading

according to clinical grading system according to clinical grading system (Wan et al.,

2007) .

Grade I : Grade I : Perioral numbness and paraesthesia.Perioral numbness and paraesthesia.

Grade II : Grade II : Numbness of tongue, face and other Numbness of tongue, face and other areas,areas,

in-coordination and slurred speech . in-coordination and slurred speech .

Grade III: Grade III: Flaccid paralysis, dyspnoea and aphonia .Flaccid paralysis, dyspnoea and aphonia .

Grade IV: Grade IV: Respiratory failure and coma . Respiratory failure and coma . ● All patients treated with :-All patients treated with :-

- - Gastric lavageGastric lavage for one time in emergency room. for one time in emergency room.

- - Multiple doses of activated charcoalMultiple doses of activated charcoal for the first for the first

two days of admission. two days of admission.

- - SymptomaticSymptomatic treatment . treatment .

ResultsResults Table (1) : The relationship between the grade of Table (1) : The relationship between the grade of

severityseverityof puffer fish poisoning and number of of puffer fish poisoning and number of

intoxicated intoxicated patients .patients .

Total number of the patients was nineninethree patients had grade Igrade Ithree had grade II grade II three fatal cases had grade IIIgrade III later on, their condition was deteriorated and had grade IV grade IV .

Grade Grade II IIII IIIIII IVIV

N. N. Patients Patients

33 33 -- 33

Table {2}: Vital signs and system affection of Table {2}: Vital signs and system affection of all puffer fishall puffer fish

intoxicated patients during admission in the intoxicated patients during admission in the hospital.hospital.

VV

CC

Blood Blood pressurepressure

PulsePulse Respiratory rateRespiratory rate TemperatureTemperature ◦◦ System affectionSystem affection

11 120/70 85 25 37.8 CNS Paraesthesia

22 130/90 90 24 37.5 CNS Numbness of tongue

33 100/60 85 19 36.8 CNS Incoordination

44 110/75 75 20 37.2 CNS Slurred speech

55 150/95 90 21 37.4CNS Paralysis

CVS Hypertension

66 120/85 70 22 37.2 CNS Perioral numbness

77 140/90 90 22 37.5CNS Paraesthesia CVS Dyspnoea

88 110/60 80 18 37.3 CNS Coma

99 110/70 90 20 36.3 CNS Coma

Table (3): Relationship between clinical Table (3): Relationship between clinical grading system grading system

of puffer fish poisoning, onset of symptoms, of puffer fish poisoning, onset of symptoms, eaten part ofeaten part of

fish and outcome of all intoxicated patients .fish and outcome of all intoxicated patients .PatientPatient Onset of Onset of

symptoms symptoms (Minutes)(Minutes)

GradeGradeof of

poisoningpoisoning

Eaten part of Eaten part of fishfish

OutcomeOutcome Cause of Cause of deathdeath

1 >30 4 Gonads + Flesh Death R.F

2 >30 1 Flesh Recovery -

3 >30 2 Flesh Recovery -

4 <30 1 Flesh Recovery -

5 30-60 4 Head + Flesh Death R.F

6 30-60 2 Soup + Flesh Recovery -

7 30-60 2 Flesh Recovery -

8 <30 4 Head + Flesh Death RF

9 <30 1 Flesh Recovery -

Table (4): The relationship between number of fatal Table (4): The relationship between number of fatal casescases

and method of cooking of puffer fish.and method of cooking of puffer fish.

Out of six patients who ate fried fish only two patients died, while out of three patients who ate the boiled fish only one died. Method of cooking had not any effect on the prognosis. Method of cooking of high degree temperature had not any effect on

efficacy of tetrodotoxin because it is a heat stable .

Total number of Total number of patientspatients

Method of Method of cookingcooking

Number of fatal Number of fatal casescases

66 FryingFrying 2233 BoilingBoiling 11

Table (5): Renal functions of all puffer fish Table (5): Renal functions of all puffer fish intoxicatedintoxicated

patients .patients .

Table (6): Liver functions of all puffer fish Table (6): Liver functions of all puffer fish intoxicatedintoxicated

patients .patients .

CC

R.FR.F ReferenceReference

rangerange11 22 33 44 55 66 77 88 99

S.Creatinine o.6 - 1.4o.6 - 1.4 0.60.6 0.70.7 0.80.8 0.90.9 0.90.9 0.90.9 1.11.1 1.21.2 11

S.Urea 4545 --1515 2525 3333 2929 3232 3838 2727 3939 3535 3030

CC

L.FL.F

ReferenceReferenceRangeRange 11 22 33 44 55 66 77 88 99

S.G.P.TS.G.P.T Up to 49Up to 49 1212 1818 1717 1515 1717 1313 4040 4242 2020

S.G.O.TS.G.O.T Up to 49Up to 49 1414 3030 2020 1717 2222 2020 3535 3838 1313

Table (7) : Parameters of complete blood pictures Table (7) : Parameters of complete blood pictures of allof all

puffer fish intoxicated patients .puffer fish intoxicated patients . CC

PP

11 22 33 44 55 66 77 88 99 ReferenceReferencerangerange

WBCs WBCs (10/mm)(10/mm)

88 9.49.4 9.79.7 5.55.5 5.35.3 1010 8.18.1 66 88 ))4-114-11((

Hb (g/dl)Hb (g/dl) 1111 13.213.2 13.513.5 12.512.5 12.612.6 11.511.5 14.114.1 1313 1414 M (14-18)M (14-18)F ( 12-16)F ( 12-16)

RBCs RBCs (10/mm)(10/mm)

4.14.1 4.54.5 4.44.4 4.64.6 4.24.2 4.24.2 4.94.9 4.84.8 4.94.9 ))F (4.5-5.5F (4.5-5.5M (4.5- 6)M (4.5- 6)

HCTHCT% % 3333 38.638.6 38.838.8 3636 3737 3434 44.644.6 4343 4545 4646 - -3333

MCV(fl)MCV(fl) 81.381.3 84.984.9 85.285.2 83.983.9 86.286.2 8282 91.291.2 9090 9292 9696--8080

MCH (pg)MCH (pg) 2828 29.929.9 31.731.7 31.231.2 31.431.4 3030 32.232.2 3030 3131 3434--2727

MCHC MCHC (g/dl)(g/dl)

3030 3333 33.333.3 33.833.8 33.233.2 3131 35.435.4 3434 3535 3636--3030

PLT PLT (10/mm)(10/mm)

220220 294294 259259 240240 286286 260260 185185 190190 249249 400400--150150

Table (8): Serum electrolytes (sodium, potassium, Table (8): Serum electrolytes (sodium, potassium, calciumcalcium

and phosphorous) and blood glucose levels of all and phosphorous) and blood glucose levels of all pufferpuffer

fish intoxicated patients .fish intoxicated patients .

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Electrolytes Electrolytes

Reference Reference rangerange

11 22 33 44 55 66 77 88 99

R. glucose R. glucose (mg/dl)(mg/dl)

200200>> 100100 110110 102102 9696 8484 156156 110110 100100 116116

Ca (mg/dl)Ca (mg/dl) 10.510.5--8.58.5 9.29.2 9.49.4 8.78.7 8.88.8 9.29.2 9.19.1 99 9.29.2 8.88.8

PP 2.5-52.5-5 5.65.6 4.34.3 3.43.4 3.33.3 2.82.8 3.73.7 44 3.53.5 3.23.2

Na (mEq/L)Na (mEq/L) 155155--135135 150150 160160 140140 164164 139139 140140 145145 150150 142142

K (mEq/L)K (mEq/L) 5.35.3--3.43.4 3.43.4 3.63.6 3.53.5 3.93.9 3.33.3 4.54.5 4.64.6 4.24.2 3.83.8

ConclusionConclusion Diagnosis of puffer fish poisoning depends onDiagnosis of puffer fish poisoning depends on

clinical picture and history of ingestion . clinical picture and history of ingestion . Clinical picture of intoxication is mainlyClinical picture of intoxication is mainly

neurological, especially sensory. neurological, especially sensory. Git and cardiovascular manifestations are notGit and cardiovascular manifestations are not

common in the most patients . common in the most patients . Factors affecting severity and prognosis of Factors affecting severity and prognosis of

puffer puffer

fish toxicity are the mode of preparation and fish toxicity are the mode of preparation and the the

eaten part of the fish . eaten part of the fish . The best method of preparation of puffer fish The best method of preparation of puffer fish

mealmeal

depends on the removal of viscera and skin .depends on the removal of viscera and skin .

Thank you