Thread by @BIDMC_IDFellows, 1/A 40F and her 10 yo son present with flushing of neck/face, [...]

BIDMC Infectious Diseases Fellowship

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1/
A 40F and her 10 yo son present with flushing of neck/face, headache, and diarrhea about 45 min after eating mackerel, rice, and some fruit (mango, cantaloupe).

#IDTwitter #IDMedEd #MedTwitter #FOAMed

1/A 40F and her 10 yo son present with flushing of neck/face, headache, and diarrhea about 45 min after eating mackerel, rice, and some fruit (mango, cantaloupe). #IDTwitter #IDMedEd #MedTwitter #FOAMed

1/A 40F and her 10 yo son present with flushing of neck/face, headache, and diarrhea about 45 min after eating mackerel, rice, and some fruit (mango, cantaloupe). #IDTwitter #IDMedEd #MedTwitter #FOAMed

2/
What do you think is cause of their sxs? #IDTwitter #IDMedEd #MedTwitter #FOAMed

Pic credits:
https://bit.ly/39Nvx1O
https://bit.ly/339lKSj

3/Dx: Scombroid (histamine) poisoning

After ingestion of contaminated

(tuna, mackerel, bonito, swordfish, mahi-mahi, and more)

Did you know it can occur after w/contaminated cheese too?

Freq misdiagnosed as seafood allergy

Usu fresh fish but can occur with canned fish

4/
Improperly stored

bactl overgrowth (ex: E.coli, Vibrio, Proteus, etc)

histidine in fish converted to histamine/other amines

toxic levels in as short as 2-3h

Toxins not broken down by cooking, freezing, or refrigeration

Fish seems fresh but tastes "peppery/spicy"

5/

hist sxs w/i 1 hr of eating:

Rapid-onset flushing face/neck

Erythematous/urticarial rash

Diarrhea

HA

Rarely severe bronchospasm/cardiac/shock in those with predisposing conditions

Can use H1/H2 blockers. Tx anaphylaxis if necessary

6/
Next, let's cover Ciguatera poisoning

Ingest reeffish (barracuda, amberjack, moray eel, 400+ diff

spp)

Contaminated w/toxins fr dinoflagellates (Gambierdiscus toxicus, single cell orgs on coral reefs)

Fish consume, concentrate toxin in organs/flesh (but not affected)

7/

Fish taste/smell nl

Cooking/marinating/freezing does not destroy toxin

Sxs:

Gastroenteritis w/i 3-6h (but can be delayed)

Neuro w/i 3-72h: peri-oral paresthesias, pruritis (w/o rash), HA

CV: brady, heart block w/i hrs

8/

Types of sxs vary according to geography (likely due to diff in toxins + local food habits)

Pacific Ocean regions: early neuro+GI+CV sxs with neuro sxs/AMS predominant

Caribbean: usu gastroenteritis 1st, then neuro (but no AMS), not life threatening

9/

One more ID+food association: Alpha-gal allergy or red meat allergy

Alpha-gal (galactose-alpha-1,3-galactose) = carb in all mammal meat except humans/apes/Old World monkeys

In susceptible indls, mult tick bites resulted in IgE Ab to alpha-gal and recurrent anaphylaxis

10/

Typically allergic rxn with 5-30min of eating

Most often implicated is Amblyomma americanum (lone star tick), mostly in SE US (but alpha-gal meat allergy reported in other parts of world)

Ref: CDC
https://jamanetwork.com/journals/jama/fullarticle/2670238
https://pubmed.ncbi.nlm.nih.gov/23743512/

10/Typically allergic rxn with 5-30min of eatingMost often implicated is Amblyomma americanum (lone star tick), mostly in SE US (but alpha-gal meat allergy reported in other parts of world)Ref: CDC https://jamanetwork.com/journals/jama/fullarticle/2670238 https://pubmed.ncbi.nlm.nih.gov/23743512/

10/Typically allergic rxn with 5-30min of eatingMost often implicated is Amblyomma americanum (lone star tick), mostly in SE US (but alpha-gal meat allergy reported in other parts of world)Ref: CDC https://jamanetwork.com/journals/jama/fullarticle/2670238 https://pubmed.ncbi.nlm.nih.gov/23743512/

11/
Three useful illnesses (ciguatera poisoning, scombroid poisoning, alpha-gal meat allergy) to be aware of that are commonly misdiagnosed! (also might be used in various test/board exams

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