Notes: This is an informal writing and based on
experience and postulation. Therefore, there might be a mistake in this
writing. The purpose of i’m writing this case is as a sharing basis.
A 45 years old lady who was previously healthy
presented with spasm of bilateral hand, perioral and fingertips numbness, twitching
of the facial muscle and lethargy 4 hours after eating a freshly caught fish
cook by her neighbor. Her medical history was not significant except for
allergy to amoxycillin and prawn. Apart from that, she denied any shortness of
breath, increase in salivation, vomiting, diarrhea, headache, increase in
salivation, palpitation, chest pain, wheezing, eczema, pruritic skin, loss of
consciousness and fitting. Her neighbour also presented with the same complaint
but with a milder presentation.
The fish was describe as a long, thin body, covered
with smooth scales and prominent sharp-edged fang-like teeth. According to the
patient, she used to eat the same fish previously but never having similar
problem.
On examination, she was fully alert and conscious.
Vital signs were stable except for the heart rate which was slightly
tachycardic. There were carpopedal spasm of the hand with positive chvostek's sign. Trousseau's
sign was not checked. Examination of the other system was un remarkable.
A diagnosis of symptomatic hypocalcaemia secondary
to food poisoning was made based on clinical finding as the calcium level was
not ready and she was treated with Slow infusion of calcium gluconate 10%, 20cc
over 10 minutes. After the infusion, patient clinically improve with no more
spasm and muscle twitching but still lethargy. She was then supported with IV
drip maintenance. In view of patient also have history of allergy, she was also
covered with IV Dihydropherenamine maleate and Hydrocortisone.
Retrospectively, all the blood investigation result
come back normal and the calcium was also within the normal range. The only
abnormality was a slightly low phosphate level.
I try to search in the internet regarding the
phenomena and one explanation fit with this patient which is Ciguatera Fish
Poisoning. Therefore i think that the presentation was due to ciguatera toxin
and not because of hypocalcaemia.
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| Image from Wikipedia [link] |
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| Image from Wikipedia [link] |
Ciguatera is a type of food poisoning. The ciguatera
toxin may be found in large reef fish, most commonly barracuda, grouper, red
snapper, eel, amberjack, sea bass, and Spanish mackerel[John F.C & Melissa C.S]
Ciguatera
toxin tends to accumulate in predator fish, such as the barracuda and other
carnivorous reef fish, because they eat other fish that consume toxin-producing
algae (dinoflagellates) that live in coral reef waters. [John F.C & Melissa C.S]
Ciguatera toxin is harmless to fish but poisonous to
humans. The toxin is odorless and tasteless, and it is heat-resistant, so
cooking does not destroy the toxin. Eating ciguatera-contaminated tropical or
subtropical fish poisons the person who eats it. [John F.C & Melissa C.S]
The symptoms consist of nausea, vomiting, diarrhea,
muscle pain, numbness, tingling, abdominal pain, dizziness and vertigo can
appear six to eight hours. Severe form of ciguatera poisoning may result in
shortness of breath, salivation, tearing of the eyes, chills, rashes, itching
and paralysis. death may occur in rare case due to heart or respiratory
failure.
The treatment is supportive and no antidote available
for this condition.
Reference:
1) John P. Cunha
& Melissa Conrad Stöpple, " Ciguatera Fish Poisoning (Ciguatera Toxin)
http://www.emedicinehealth.com/wilderness_ciguatera_toxin/article_em.htm
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