References to non-CDC sites on the Internet are trailer 0000003486 00000 n The genetic analysis determined that all samples were Lagocephalus lunaris (Figure 2). Four cases ofpufferfish poisoning with one death in a family are described. In its native region, it has been confused with similar looking, nontoxic species, resulting in numerous illnesses (10). 0000000016 00000 n The patients said two friends who consumed the same fish had similar, although less pronounced, symptoms and had not sought care. H�lT]o�:}���cz�p������v˰~,q�0��&�ꡉ[;E�?J�c��֨t�sH�1ӂw�st�ӏ��z�]��z��Y�8���>g�Y8�(ұ�����>� {f�#� ���,�(z8�eƄS���A��5 P0T�X�:;�k�E�j��!n�����gor��6�,o���@_)=8.-3ހ,�e��r'���B���R{�\�1#�,�,_�h3��Ƃ��L��K[��8�{ЎO2�_/&9 ���Ѐ�b�P��\9n� S���rY�_�Pd?RM�Nu*#��)�pS���.9�Q XK�����=®G�uW��3��:)U�@��9?? Artificial ventilation is the single most effective therapeutic measure and should be considered in all severe cases. telephone: (202) 512-1800. Yang CC, Liao SC, Deng JF. of pages found at these sites. and/or the original MMWR paper copy for printable versions of official text, figures, and tables. Abdominal pain, nausea, vomiting, diarrhea and other symptoms related to the gastrointestinal tract start to occur rapidly.

How do I view different file formats (PDF, DOC, PPT, MPEG) on this site? Fish and fisheries products hazards and controls guidance. Thirty minutes after consumption, he experienced perioral and tongue numbn… After rehydration, tissues were homogenized, centrifuged, decanted, and samples were extracted a second time with an additional 9 mL of 1% acetic acid in water. Three patients (two children and one adult) were seriously affected. 2020-10-27T18:58:41-07:00 US Department of Health and Human Services, Food and Drug Administration; 2014. CDC is not responsible for the content A single laboratory validated method for the generation of DNA barcodes for the identification of fish for regulatory compliance. Apex PDFWriter Minnesota Department of Health; Minnesota Department of Agriculture; Roseville, Minnesota, Police Department. US Department of Health and Human Services, Food and Drug Administration. Government Printing Office (GPO), Washington, DC 20402-9371; All MMWR HTML versions of articles are electronic conversions from typeset documents. 0000008531 00000 n from Thailand. Analytic results of puffer fish toxin and species identification analyses in a tetrodotoxin poisoning outbreak — Minneapolis, Minnesota, 2014. No deaths were registered and the patients did not present sequelae after the episode. The progression of tetrodotoxin poisoning is classified asfollows.2 Grade1: paraesthesiaearoundthemouth,with mild gastrointestinal symptoms.

Genetic analysis* of dried puffer fish samples involved in a tetrodotoxin poisoning outbreak — Minneapolis, Minnesota, 2014. <<55BAF18205FE8649ACBE349BF80D01E5>]>> Regulatory authorities in the United States do not provide this training, nor is tetrodotoxin testing routinely conducted; therefore, only the frozen meat, skin, and male gonad from one species of puffer fish (Takifugu rubripes) from Japan, processed according to Japanese safety guidelines, is permitted to be imported into the United States a limited number of times per year, pursuant to an FDA/Japanese government agreement established in 1988 (6).

<> In this brief communication the authors report eleven cases of human poisoning caused by ingestion of pufferfish meat. endobj Patient 1. Deeds JR, White KD, Etheridge SM, Landsberg JH. 0 Physical examination was unremarkable; respiratory effort, mental status, and strength testing were normal.

Tetrodotoxin exerts its effects by blocking voltage-activated sodium channels, terminating nerve conduction and muscle action potentials, leading to progressive paralysis and, in extreme cases, to death from respiratory failure.

Cohen NJ, Deeds JR, Wong ES, et al. The patient stated that he had purchased dried fish described as globefish from a street vendor in New York City and transported the fish to Minnesota himself. All other imported puffer fish products are prohibited (7). 0000006103 00000 n Concentrations of saxitoxin and tetrodotoxin in three species of puffers from the Indian River Lagoon, Florida, the site of multiple cases of saxitoxin puffer fish poisoning from 2002–2004. Selected states have established additional requirements for controls for puffer fish from certain areas because of potential toxicity (8). Sequences for outbreak samples are available in GenBank at (accession no. The patient stated that he had purchased dried fish described as globefish from a street vendor in New York City and transported the fish to Minnesota himself. All seven samples were found to contain significant concentrations of tetrodotoxin with a mean of 19.8 ppm and a range of 5.7–72.3 ppm (Table). There was no labeling on the fish packaging, and all attempts to determine the source of the fish were unsuccessful. Department of Health and Human Services. 22 18 For domestic sources of puffer fish, only nontoxic species are recommended by FDA for consumption. Sequences for FDA reference standards are available at Mild cases may be observed in the emergency department and discharged with a telephone followup if the symptoms do not progress after 24 hours. 0000000972 00000 n At the ED, his temperature was 98.1°F (36.7°C), pulse 75 beats/min, respiratory rate 24 breaths/min, blood pressure 160/87 mmHg, and blood oxygen saturation 100% on room air. He noted that his two friends, who also consumed the fish but did not go to the ED, had similar symptoms that resolved over several hours. Samples were analyzed for tetrodotoxin by liquid chromatography-electrospray ionization-multiple reaction monitoring mass spectrometry (4). Seven of the dried, dressed fish (Figure 1) purchased by patient 1 were provided to the ED staff by the patients on arrival. The objective of the case report is to highlight recognition and management of puffer fish poisoning. He also complained that "my teeth can't feel themselves."

1Hennepin Regional Poison Center, Minneapolis, Minnesota; 2Hennepin County Medical Center, Minneapolis, Minnesota; 3Center for Food Safety and Applied Nutrition, Food and Drug Administration (Corresponding author: Jonathan R. Deeds,, 240-402-1474). Note: Javascript is disabled or is not supported by your browser. [a��~ ��d��c��b��5������I�����rq��m �I/6�1�4= " Ȯ]��Ss�R�F�����l�cB��1r �:���N)��0�/=>. Her physical examamination was unremarkable; respiratory effort, mental status, and strength testing were normal. Exchange of letters between Japan and the US Food and Drug Administration regarding puffer fish. Tetrodotoxin is a heat-stable and acid-stable, nonprotein, alkaloid toxin found in many species of the fish family Tetraodontidae (puffer fish) as well as in certain gobies, amphibians, invertebrates, and the blue-ringed octopus (2). 0000001378 00000 n KM236207-KM236215). Puffer fish poisoning may cause a constellation of symptoms, such as giddiness, numbness and tingling sensation of the mouth, paresthesia, and muscle weakness. application/pdf The amount of toxin in a fish varies by species, but in some cases one fish carries enough to kill up to 30 adult humans. Identification of tetrodotoxin and fish species in a dried dressed fish fillet implicated in food poisoning.

Public health response to puffer fish (tetrodotoxin) poisoning from mislabeled product. Available at, Food and Drug Administration. Alternate Text: The figure above is an unweighted pair-group method with arithmetic mean (UPGMA) tree showing the genetic analysis of dried puffer fish samples involved in a tetrodotoxin poisoning outbreak in Minneapolis, Minnesota, in 2014. For more information about this message, please visit this page: CDC 24/7: Saving Lives. Toxin analysis showed the product to be highly contaminated with tetrodotoxin, and a DNA analysis identified the fish as Lagocephalus lunaris, which is not allowed for import because naturally occurring toxin in its meat make safe preparation of this species impossible. J Food Prot 2009;72:810–7. 0000000656 00000 n <>/ProcSet[/PDF/Text/ImageB]/XObject<>>>/Type/Page>> Lagocephalus lunaris is an Indo-Pacific species of puffer fish and is one of the only species known to contain high concentrations of tetrodotoxin naturally in the meat, making safe preparation of this product impossible (9). startxref Severe cases may present with respiratory depression, circulatory failure, and death. Thirty minutes after consumption, he experienced perioral and tongue numbness, numbness and weakness in his extremities, extreme fatigue, and dyspnea. 4th ed. The puffer fish (sometimes called globefish, fugu, or blowfish) is highly prized in many Asian cultures and is consumed safely in some countries (e.g., Japan). Health care providers who work in emergency departments or with persons from countries with a tradition of puffer fish consumption should be aware of this potential public health threat and coordinate with local poison centers and health departments to investigate any suspected cases of puffer fish poisoning to determine the source of the fish, whether it was legally imported, and whether additional contaminated product needs to be removed from commerce. Noguchi T, Ebesu JSM. �t#�6��uq>��r��h��0��B{}��Z+x�-))�RH��:�_�S����E�͸�h[��=���o�'��8gi��u��)��� �o�z&j� )��a7��������4az5� F����[����*?�Ҥ3_'��9]? 0000000887 00000 n 4 0 obj '�u�Plꌜ{���^T�k.�0��{m�2�IiH0M�HK|��;�1�g D�Y�^/ݨ[���M+��L�7� ���|E��U�.5��4�{� 3��JE)b�ET�/����m�u��1�ʽ��aWw�aH(}V�k��%. 17 0 obj endobj

Samples of dried muscle (10 mg) were taken from each fish for genetic analysis. All cases visit to the physician within 30 min. Six hours before he came to the ED, he rehydrated some fish and consumed it with his sister and two friends. FDA has not established a guidance level for tetrodotoxin, but for comparison, the guidance level for the paralytic shellfish toxin saxitoxin, another alkaloid toxin with similar pharmacology and potency, is 0.8 ppm (5). FIGURE 1. The circumstances that precipitated the poisoning are discussed as well as the clinical aspects observed. H��W]��}�_� `͈�$R�[��~�v;@Q4E��i[�,����ɯ���I�,��X$��9����BfDn2�OHF��_���>g�?tO{������?نRB7χ�Bɲ�n6Ͽm���pA2��|�z��z8�~{������ Ǚ9��epvؔ%�J����͖2��tɥ�����c|�� ��PQU�t��$c8+�t��õsRd���r3?��l~)3R��Gj����Kݫ��_�GEN��g���A�͵���{� ��T�O��.������x1��Jwn��}��԰�6�O��X?�8TҪ| i�!Z[D{W�4�2���� 8)2�bF���!�4�6b O`��T�X�o9f��v�~�! 8 0 obj Laboratory results were as follows: hemoglobin, 14.4 g/dL (normal range = 13.1–17.5), white blood cell count, 6,080/µL (normal = 4,000–10,000), platelets 179,000/µL (normal = 150,000–400,000), sodium 141 mEq/L (normal = 135–148), potassium 3.6 mEq/L (normal = 3.5–5.3), chloride 105 mEq/L (normal = 100–108), carbon dioxide 29 mEq/L (normal = 22–30), creatinine 0.57 mg/dL (normal = 0.7–1.25), and ionized calcium, 4.9 mg/dL (normal = 4.4–5.2).

endorsement of these organizations or their programs by CDC or the U.S. Overnight observation was recommended but she also left against medical advice. J Toxicol Toxin Rev 2001;20:1–10. For the toxin analysis, samples of dried muscle (2 g) were taken from each fish and rehydrated overnight at 39.2°F (4.0°C) using 10 mL of 1% acetic acid in water.