II. Epidemiology

  1. More common in Hawaii and California

III. Pathophysiology

  1. Improper handling of fish (delay to refrigeration, poorly refrigerated or inadequately frozen)
    1. Scombridae family or dark meat fish such as Tuna, Mahi-mahi,or mackerel
    2. Food typically tastes atypical
  2. Histidine from fish Muscle is decarboxylated to histamine by marine Bacteria
    1. Bacteria containing Histidine decarboxylase include Escherichia, Klebsiella, Proteus, Vibrio, Pseudomonas
  3. Isoniazid potentiates this reaction

IV. Causes: Scombridae Family Fish

  1. Mackerel
  2. Marlin
  3. Bonito Fish
  4. Yellowfin Tuna
  5. Albacore Tuna
  6. Skipjack Tuna

V. Symptoms (Related to histamine release)

  1. Typical histamine related response
    1. Severe Flushing including facial Flushing
    2. Diarrhea
    3. Palpitations
    4. Abdominal Pain
    5. Urticaria
    6. Bronchospasm with Wheezing
    7. Orthostatic Hypotension
    8. Bitter, pepper or Metallic Taste (Dysgeusia)
  2. Histamine-3 (H3) activity related symptoms
    1. Nausea
    2. Vomiting
    3. Severe Headache

VI. Labs

  1. Avoid histamine level (not useful)
  2. Tryptase level
    1. May differentiate from Allergic Reactions

VII. Differential Diagnosis

VIII. Course

  1. Onset within 10-60 min (on average 20-30 min) of ingestion
  2. Resolves within 6-8 hours, up to 24 hours (rarely more)

IX. Management

  1. Avoid Gastric Decontamination in most cases
  2. Antihistamine
    1. Diphenhydramine (Benadryl) 50 mg IV/IM}PO
    2. Consider H2 Receptor Blocker (Ranitidine, Cimetidine)
  3. Nebulized Albuterol
    1. Indicated for bronchospasm
  4. Other symptomatic management
    1. Antiemetics

X. References

  1. Koch and Tomaszewski (2018) Crit Dec Emerg Med 32(1): 24
  2. Stratta (2012) Scombroid Poisoning 184(6):674 +PMID:22231690 [PubMed]

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