emDOCs Podcast – Episode 92: Marine Ingested Poisons and Infections

Scombroid

• Pathophysiology:
  • Fish from family Scombroidae
    • Tuna, mackerel, skipjack, bonito
  • Dark-meat fish
    • Herring, bluefish, anchovy, sardine, amberjack, black marlin, and mahi mahi
  • Histidine decarboxylase produces histamine and histamine like products
  • Improper preservation
• Presentation
  • Metallic, bitter or peppery taste, facial flushing, dizziness, GI symptoms, severe throbbing headache, palpitations, dry mouth, urticaria, paresthesia
  • Onset: 20-30 minutes
  • Duration: Up to 48 hours
• Treatment:
  • Parenteral antihistamine
  • IVF

Ciguatera

• Pathophysiology
  • Dinoflagellate with bacteria Gambierdiscus toxicus
  • Species: amberjack, barracuda, grouper, king mackerel, parrotfish, sea bass, snapper, sturgeon, surgeonfish, ulua
  • Anticholinesterase and Sodium channel blocker
• Presentation
  • Onset: 2-6 hours after ingestion
  • Duration: 1-2 weeks up to months
  • Presentation: perioral paresthesia, burning feet, loose/painful teeth, cold-hot temperature reversal with return of symptoms after alcohol, bradycardia, hypotension, GI symptoms
• Treatment
  • Supportive
  • Atropine or dopamine for hypotension and bradycardia
  • Antihistamine for pruritus

Neurotoxic shellfish poisoning

• Toxin: increased sodium channel permeability
• Species: mussels, clams, scallops, oysters
• Presentation:
  • Bronchospasm, temperature reversal, GI symptoms, paresthesia
  • Onset: 15 minutes to 18 hours
• Treatment: supportive and bronchodilators

Amnestic Shellfish Poisoning

• Toxin: excitatory neurotoxin
• Species: mussels, possibly other shellfish
• Presentation
  • Onset 15 min to 38 h
  • Duration: years
  • Amnesia, nausea, vomiting, diarrhea, paresthesias, respiratory depression
• Treatment: respiratory support

Paralytic Shellfish Poisoning

• Toxin: decreases sodium channel permeability
• Species: mussels, clams, scallops, oysters
• Presentation:
  • Onset 30 min
  • Duration: days
  • Respiratory depression, paresthesias, GI symptoms
• Treatment: supportive

Bacterial Infections

• Polymicrobial, halophilic, and gram negative
  • Staph, Strep, Aeromonas hydrophilia, E. coli, Pseudomonas, Erysipelothrix, Chromobacterium, Edwardsiella, Shewanella, Mycobacterium, Mycoplasma, Vibrio
  • Risk factors for severe disease from Vibrio
    • Liver disease
    • Immunosuppression
    • Diabetes
•  Vibrio parahemolyticus
  • Toxin: causes hemolysis
  • Pathophysiology: undercooked/raw fish or shellfish, seawater exposure
  • Presentation:
    • Cholera-like: water diarrhea, cramping, vomiting
    • OR Dysentery-like: mucoid or bloody stools
    • OR Wound infection
  • Treatment
    • Supportive Care
    • Antibiotics:
    • Cipro 500 mg PO BID or Bactrim DS PO BID,  or doxycycline 100 mg po bid for 3 dayor 3rd generation cephalosporin
•  Vibrio vulnificus
  • Pathophysiology: undercooked/raw fish or shellfish or seawater exposure
  • Presentation:
    • Vomiting, abdominal pain, diarrhea
    • Skin infection/hemorrhagic bullae
      • Erythematous patch>>ecchymosis>> vesicles and bullae>> necrosis and sloughing
    • Gastroenteritis in immunocompetent host
    • Can be fatal in liver disease, immunocompromised
    • Sepsis in hemochromatosis, alcoholics, or immunosuppressed
  • Treatment:
    • Doxycycline PLUS third generation cephalosporin OR fluoroquinolone
    • Necrosis: surgical debridement

Mycobacterium marinum

• Granulomatous skin infection
• Fish tank or aquarium granuloma
• Culture as may be antibiotic resistant

Antibiotics for Marine Wounds

• No antibiotic
  • Healthy
  • Received prompt wound care
  • No foreign body or bone/joint involvement
  • Superficial
• Prophylactic antibiotic
  • Late wound care
  • Large wound
  • Early or local inflammation
• Seawater
  • 1^st gen cephalosporin +/- MRSA coverage
  • Fluoroquinolone OR third generation cephalosporin if vibrio infection
• Freshwater
  • 1st generation cephalosporin +/-MRSA coverage OR
  • Fluoroquinolone OR trimethoprim/sulfamethoxazole OR carbapenem

References

1. Smith LM, Mahler SA. Food and Waterborne Illnesses. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. Accessed August 28, 2022. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=220292999
2. Zafren K, Thurman R, Jones ID. Marine Dermatitis. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 5e. McGraw Hill; 2021. Accessed August 25, 2022. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2969&sectionid=250461142
3. Fil LJ, Tunik MG. Food Poisoning. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank’s Toxicologic Emergencies, 11e. McGraw Hill; 2019. Accessed August 28, 2022. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2569&sectionid=210271206
4. Waldor MK, Ryan ET. Cholera and Other Vibrioses. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J. eds. Harrison’s Principles of Internal Medicine, 21e. McGraw Hill; 2022. Accessed August 27, 2022. https://accessmedicine.mhmedical.com/content.aspx?bookid=3095&sectionid=265422687