emDOCs Podcast – Episode 92: Marine Ingested Poisons and Infections

Today on the emDOCs cast, we have a special guest, Alexis Koda, core faculty at the Nazareth Emergency Medicine Residency program in Philadelphia, PA. Alexis takes us through marine ingested poisons and infections.


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
    • 1st 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

 

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