Four cases of puffer fish poisoning with one death in a family are described. Acute respiratory cessation probably resulted from both depression of the medullary centres and muscular paralysis by the neurotoxin. Artificial ventilation is the single most effective therapeutic measure and should be considered in all severe cases. Delay in treatment may result in death. Anticholinesterases are not known to confer any benefit. Medical staff in coastal hospitals should familiarise themselves with the management of puffer fish poisoning.
Tetrodotoxin poisoning has been commonly reported in Japan due to consumption of contaminated fugu (puffer fish). Poisoning is possible when the fish is not cleansed and dressed properly. Puffer fish is considered a delicacy by the Japanese as the fish meat is very tender and tasty. A certified chef trained in ways of preparing this poisonous fish should only be allowed to serve this fish. Despite careful preparation, this fish remains a deadly meal for many as 50 deaths are reported annually1 . An outbreak of 34 cases of tetrodotoxin occurred in Johor in May 2008. Here, we would like to report three cases of tetrodotoxin poisoning in a family who consumed this deadly fish and was admitted to Hospital Sultanah Aminah Johor Bahru (HSAJB).
A 69-year-old lady who was referred by her general practitioner with a diagnosis of food poisoning developed cardiorespiratory arrest shortly after arriving at the Casualty Department. Cardiac output was successfully restored with resuscitation but she had to be mechanically ventilated due to the absence of any spontaneous respiratory effort. Assessment 24 hours after admission, showed fixed and dilated pupils with brain stem areflexia. Her family was told that the prognosis was hopeless. Surprisingly, her condition rapidly improved a day later and she eventually had a good recovery. Her condition was actually due to severe tetrodotoxin poisoning after eating roe of the puffer fish and it was fortunate that appropriate aggressive resuscitation was instituted to revive the patient from her critical state.
The horseshoe crab (Carcinoscorpius rotundicauda) is consumed by those residing near the coastal areas of Kota Marudu District in Malaysia, as it is considered a delicacy. During June to August, 2011 thirty cases of tetrodotoxin poisoning were reported from Kota Marudu District following ingestion of horseshoe crabs caught in Kota Marudu Bay. The purpose of this study is to describe this case series in order to determine risk factors to prevent further outbreaks. There were six confirmed and 24 probable cases of tetrodotoxin poisoning identified in the study area during the study period as diagnosed by clinical presentation and laboratory findings. Symptoms included dizziness (80%), circumoral and lingual numbness (80%), hand and feet numbness (63.3%), nausea and vomiting (30%) and weakness and difficulty in breathing (26.6%). Three cases (10%) died while 27 cases recovered. Forty-seven percent of the cases had onset of symptoms within 30 minutes of ingestion and 14% 31-60 minutes after ingestion of horseshoe crab meat. Urine samples were collected from the cases, while horseshoe crabs, cockles and sea water from the epidemic area were also taken for analysis. Tetrodotoxin was detected in the urine of six cases; the highest concentrations recorded were among the three cases who died. High tetrodotoxin concentrations were found in the hepatic cecum and eggs of the tested horseshoe crabs. Dinoflagellates were not detected in the sea water or cockle samples. Intensive health education was initiated quickly to stop other members of the Marudu Bay community from consuming the horseshoe crabs. This is the first documented epidemic of tetrodotoxin poisoning in Sabah.
The puffer fish belongs to the family Tetraodontidae and has one identifying characteristic which is the ability to inflate itself by gulping in large quantities of air or water. They are commonly found in estuarine and inshore water. The viscera (ovaries, testes and liver) of puffer fish contain varying amounts of extremely potent toxins [tetraodontoxin). The most violent form of fish poisoning is produced by ingestion of tetraodontoid or puffer-like fishes and this has been reported. The putftoad, Tetradon maculatum, has caused fatal poisoning? Despite the high toxicity of this group of fish, the meat is commonly consumed by some fisherman in Sabah without much morbidity. In Japan, puffer fish, called "fuqu" commands the highest prices in food fish and are prepared and sold in special restaurants where specially trained cooks are employed to prepare the "fuqu". Nevertheless it is still the primary cause of food poisoning in Japan especially among the lower socio-economic classes who fail to take the necessary precautions. In Sabah, four cases of puffer fish poisoning resulting in one death have been documented." We report herewith another incidence of puffer fish poisoning in which 18 persons from seven families were affected with nine deaths from two families.