What Is This Eruption?
A 35-year-old otherwise healthy man was referred for evaluation of a sudden, pruritic, erythematous patch covering a well-demarcated area of the upper back and shoulders (Figure). He noted a sense of extreme heat, itching, and flushing approximately 45 minutes after consuming a tuna fish sandwich. He reported diarrhea but no nausea or vomiting. He did not take any prescription or over-the-counter medications and denied prior allergic reactions to any medications or food. Additionally, there was no recent sun exposure to yield a photosensitive eruption. Examination revealed a sharply demarcated erythematous patch covering the upper back, shoulders, and neck. The patches were slightly warm to touch (blanchable) but were not tender. Vital signs were normal with blood pressure, 120/80 mm Hg and pulse, 75 beats per/min (reportedly elevated from normal 60 beats per/min). The eruption completely resolved within approximately 2 hours. There was no recurrence with subsequent consumption of any type of fish or other seafood.
What is Your Diagnosis?
Go to page 2 for an answer and more details.
Diagnosis: Scombroid Food Poisoning
Scombroid food poisoning results from the consumption of histamine-contaminated (spoiled) fish in the Scombroidae and Scomberesocidae families (tuna, mackerel, bonito, albacore, skipjack).1-6 Consuming fish outside of the Scombroidae family (sardine, bluefish, salmon [rarely]) can also lead to symptoms; therefore, this condition is often referred to as histamine fish poisoning.1-6 The most common culprits in the United States include tuna and mahi-mahi (>80%).1
It is not a true allergy and thus not immune-mediated, but instead results from histamine release from spoiled fish. The spoiling occurs when the fish are not properly cared for and marine bacteria enzymatically break down histidine in the fish muscle.5 Specifically, this improper care includes when fish are not frozen adequately with resultant bacterial overgrowth and conversion from histidine to histamine.1 Histidine decarboxylase is the primary enzyme involved, which converts histidine into histamine.5 Numerous bacteria with histidine decarboxylase include Proteus, Enterobacter, Serratia, Citrobacteer, Escherichia coli, Clostridium, Vibrio, Acinetobacter, Pseudomonas, and Photobacterium.1
Other by-products of histidine metabolism may be involved; for instance, urocanic acid is thought to be involved in mast cell degranulation.4 Both fresh and canned fish may be affected, and spoilage can occur at any stage in food production.6 Neither cooking nor the canning process will prevent contamination because toxins are heat stable. Histamine that has already formed is not destroyed during these processes.2,4,6 Scombroid fish poisoning is underrecognized but may account for approximately 5% of foodborne disease outbreaks and 39% of all seafood-associated outbreaks in the United States.1,2,4
Clinical Features
Symptoms are histamine-mediated, resemble that of an allergic reaction, are usually mild, of short duration, and typically self-limited.1 These may include rash, flushing, nausea, diarrhea, sweating, headache, dizziness, palpitations, respiratory distress, facial swelling, burning sensation in the mouth, and a peppery or metallic taste.1,2,4 Onset usually occurs within a few minutes to hours of eating the contaminated fish, but symptoms often resolve within 8 hours unless the patient has a condition such as asthma. This may prolong the course for up to 24 hours.1-4,6 Because symptoms are self-limited and resolve quickly, many cases are never reported.6
The pathophysiology of histamine fish poisoning is defined by its activity on its 4 receptor subtypes, with activation of H1 and H3 receptors accounting for the majority of symptom-related activity.1
Differential Diagnosis
Diagnosis is usually dependent on physical exam and history. The differential diagnosis of this presentation is wide and accurate diagnosis mandates ruling out other potential causes (Table). Taking note of what the patient consumed leading up to the onset of symptoms is important in ruling out other potential diagnoses.4 This must be asked as patients may not associate illness with consumption of any food type. Patients taking isoniazid and/or monoamine oxidase inhibitors (inhibit histamine metabolism) may be at increased risk for histamine fish poisoning.1 Scombroid poisoning is likely if allergy tests are negative and the patient has no previous history of allergies to fish. If multiple unrelated patients present with symptoms at the same time after consuming fish, scombroid poisoning is also likely.1,2 Bacterial food poisoning differs in that histamine levels in fish will be normal and patients will present primarily with gastrointestinal symptoms.1,2 While seldom examined, histamine levels in the patient or in the fish can be checked to confirm the diagnosis.3
Studies indicate that histamine levels ranging from 20 to 100 mg per 100 g of fish are usually needed for toxicity; however, the FDA indicates that histamine levels of at least 50 mg per 100 g of fish are toxic.1,3,5,6 US food regulations mandate that histamine levels do not exceed 5 mg/100 g.1 Definitive diagnosis can be achieved by testing the fish itself, although this is likely not a practical or logistically easy task.1 Such methods may include the use of reverse-phase high-performance liquid chromatography, although this is primarily utilized in the laboratory setting.1 Flow injection analysis and quantitative enzyme-linked immunosorbent assay testing kits have been utilized for real-time diagnoses when required.1 Skin prick testing has been utilized for diagnosis as well.1
Treatment
Treatment of scombroid food poisoning is simple once the diagnosis is established. Treatment focuses on managing symptoms and antihistamines (diphenhydramine, cetirizine, chlorpheniramine) are typically given as primary therapy.1 Corticosteroids are not an effective treatment.2 Locating the source of the contamination as well as reporting cases to public health officials are important steps to follow to prevent the occurrence of new cases.5
Our Patient
Our patient was diagnosed quickly based on the known recent history of consumption of seafood within the Scombroidae family and clinical symptoms consistent with a histamine-type reaction (Figure). While additional diagnostic testing was possible, early treatment with antihistamine and quick resolution of the symptoms and clinical findings did not necessitate further diagnostic testing or treatment. While it is important to be aware of the potential additional testing well by Feng and colleagues,1 we believe it is also important to rely on traditional clinical medical findings and treat accordingly.
Ms Kamensky is with the department of medicine at Mercer University School of Medicine in Macon, GA.
Dr Joshua Lane is with the departments of medicine and surgery at Mercer University School of Medicine in Macon, GA, and the department of dermatology at Emory University School of Medicine in Atlanta, GA.
Dr Tanda Lane is with the department of dermatology at Emory University School of Medicine in Atlanta, GA.
Disclosure: The authors report no relevant financial relationships.
References
1. Feng C, Teuber S, Gershwin ME. Histamine (scombroid) fish poisoning: a comprehensive review. Clin Rev Allergy Immunol. 2016;50(1):64-69.
2. Jantschitsch C, Kinaciyan T, Manafi M, Safer M, Tanew A. Severe scromboid fish poisoning: an underrecognized dermatologic emergency. J Am Acad Dermatol. 2011;65(1):246-247.
3. Kasha EE, Norins, AL. Scombroid fish poisoning with facial flushing. J Am Acad Dermatol. 1988;18(6):1363-1365.
4. Predy G, Honish L, Hohn W, Jones S. Was it something she ate? Case report and discussion of scombroid poisoning. CMAJ. 2003;168(5):587-588.
5. Tortorella V, Masciari P, Pezzi M, et al. Histamine poisoning from ingestion of fish or scombroid syndrome. Case Rep Emerg Med. 2014;2014:482531. doi:10.1155/2014/482531
6. Wilson BJ, Musto RJ, Ghali WA. A case of histamine fish poisoning in a young atopic woman. J Gen Int Med. 2012;27(7):878-881.
What Is This Eruption?
A 35-year-old otherwise healthy man was referred for evaluation of a sudden, pruritic, erythematous patch covering a well-demarcated area of the upper back and shoulders (Figure). He noted a sense of extreme heat, itching, and flushing approximately 45 minutes after consuming a tuna fish sandwich. He reported diarrhea but no nausea or vomiting. He did not take any prescription or over-the-counter medications and denied prior allergic reactions to any medications or food. Additionally, there was no recent sun exposure to yield a photosensitive eruption. Examination revealed a sharply demarcated erythematous patch covering the upper back, shoulders, and neck. The patches were slightly warm to touch (blanchable) but were not tender. Vital signs were normal with blood pressure, 120/80 mm Hg and pulse, 75 beats per/min (reportedly elevated from normal 60 beats per/min). The eruption completely resolved within approximately 2 hours. There was no recurrence with subsequent consumption of any type of fish or other seafood.
What is Your Diagnosis?
Go to page 2 for an answer and more details.
Diagnosis: Scombroid Food Poisoning
Scombroid food poisoning results from the consumption of histamine-contaminated (spoiled) fish in the Scombroidae and Scomberesocidae families (tuna, mackerel, bonito, albacore, skipjack).1-6 Consuming fish outside of the Scombroidae family (sardine, bluefish, salmon [rarely]) can also lead to symptoms; therefore, this condition is often referred to as histamine fish poisoning.1-6 The most common culprits in the United States include tuna and mahi-mahi (>80%).1
It is not a true allergy and thus not immune-mediated, but instead results from histamine release from spoiled fish. The spoiling occurs when the fish are not properly cared for and marine bacteria enzymatically break down histidine in the fish muscle.5 Specifically, this improper care includes when fish are not frozen adequately with resultant bacterial overgrowth and conversion from histidine to histamine.1 Histidine decarboxylase is the primary enzyme involved, which converts histidine into histamine.5 Numerous bacteria with histidine decarboxylase include Proteus, Enterobacter, Serratia, Citrobacteer, Escherichia coli, Clostridium, Vibrio, Acinetobacter, Pseudomonas, and Photobacterium.1
Other by-products of histidine metabolism may be involved; for instance, urocanic acid is thought to be involved in mast cell degranulation.4 Both fresh and canned fish may be affected, and spoilage can occur at any stage in food production.6 Neither cooking nor the canning process will prevent contamination because toxins are heat stable. Histamine that has already formed is not destroyed during these processes.2,4,6 Scombroid fish poisoning is underrecognized but may account for approximately 5% of foodborne disease outbreaks and 39% of all seafood-associated outbreaks in the United States.1,2,4
Clinical Features
Symptoms are histamine-mediated, resemble that of an allergic reaction, are usually mild, of short duration, and typically self-limited.1 These may include rash, flushing, nausea, diarrhea, sweating, headache, dizziness, palpitations, respiratory distress, facial swelling, burning sensation in the mouth, and a peppery or metallic taste.1,2,4 Onset usually occurs within a few minutes to hours of eating the contaminated fish, but symptoms often resolve within 8 hours unless the patient has a condition such as asthma. This may prolong the course for up to 24 hours.1-4,6 Because symptoms are self-limited and resolve quickly, many cases are never reported.6
The pathophysiology of histamine fish poisoning is defined by its activity on its 4 receptor subtypes, with activation of H1 and H3 receptors accounting for the majority of symptom-related activity.1
Differential Diagnosis
Diagnosis is usually dependent on physical exam and history. The differential diagnosis of this presentation is wide and accurate diagnosis mandates ruling out other potential causes (Table). Taking note of what the patient consumed leading up to the onset of symptoms is important in ruling out other potential diagnoses.4 This must be asked as patients may not associate illness with consumption of any food type. Patients taking isoniazid and/or monoamine oxidase inhibitors (inhibit histamine metabolism) may be at increased risk for histamine fish poisoning.1 Scombroid poisoning is likely if allergy tests are negative and the patient has no previous history of allergies to fish. If multiple unrelated patients present with symptoms at the same time after consuming fish, scombroid poisoning is also likely.1,2 Bacterial food poisoning differs in that histamine levels in fish will be normal and patients will present primarily with gastrointestinal symptoms.1,2 While seldom examined, histamine levels in the patient or in the fish can be checked to confirm the diagnosis.3
Studies indicate that histamine levels ranging from 20 to 100 mg per 100 g of fish are usually needed for toxicity; however, the FDA indicates that histamine levels of at least 50 mg per 100 g of fish are toxic.1,3,5,6 US food regulations mandate that histamine levels do not exceed 5 mg/100 g.1 Definitive diagnosis can be achieved by testing the fish itself, although this is likely not a practical or logistically easy task.1 Such methods may include the use of reverse-phase high-performance liquid chromatography, although this is primarily utilized in the laboratory setting.1 Flow injection analysis and quantitative enzyme-linked immunosorbent assay testing kits have been utilized for real-time diagnoses when required.1 Skin prick testing has been utilized for diagnosis as well.1
Treatment
Treatment of scombroid food poisoning is simple once the diagnosis is established. Treatment focuses on managing symptoms and antihistamines (diphenhydramine, cetirizine, chlorpheniramine) are typically given as primary therapy.1 Corticosteroids are not an effective treatment.2 Locating the source of the contamination as well as reporting cases to public health officials are important steps to follow to prevent the occurrence of new cases.5
Our Patient
Our patient was diagnosed quickly based on the known recent history of consumption of seafood within the Scombroidae family and clinical symptoms consistent with a histamine-type reaction (Figure). While additional diagnostic testing was possible, early treatment with antihistamine and quick resolution of the symptoms and clinical findings did not necessitate further diagnostic testing or treatment. While it is important to be aware of the potential additional testing well by Feng and colleagues,1 we believe it is also important to rely on traditional clinical medical findings and treat accordingly.
Ms Kamensky is with the department of medicine at Mercer University School of Medicine in Macon, GA.
Dr Joshua Lane is with the departments of medicine and surgery at Mercer University School of Medicine in Macon, GA, and the department of dermatology at Emory University School of Medicine in Atlanta, GA.
Dr Tanda Lane is with the department of dermatology at Emory University School of Medicine in Atlanta, GA.
Disclosure: The authors report no relevant financial relationships.
References
1. Feng C, Teuber S, Gershwin ME. Histamine (scombroid) fish poisoning: a comprehensive review. Clin Rev Allergy Immunol. 2016;50(1):64-69.
2. Jantschitsch C, Kinaciyan T, Manafi M, Safer M, Tanew A. Severe scromboid fish poisoning: an underrecognized dermatologic emergency. J Am Acad Dermatol. 2011;65(1):246-247.
3. Kasha EE, Norins, AL. Scombroid fish poisoning with facial flushing. J Am Acad Dermatol. 1988;18(6):1363-1365.
4. Predy G, Honish L, Hohn W, Jones S. Was it something she ate? Case report and discussion of scombroid poisoning. CMAJ. 2003;168(5):587-588.
5. Tortorella V, Masciari P, Pezzi M, et al. Histamine poisoning from ingestion of fish or scombroid syndrome. Case Rep Emerg Med. 2014;2014:482531. doi:10.1155/2014/482531
6. Wilson BJ, Musto RJ, Ghali WA. A case of histamine fish poisoning in a young atopic woman. J Gen Int Med. 2012;27(7):878-881.
What Is This Eruption?
A 35-year-old otherwise healthy man was referred for evaluation of a sudden, pruritic, erythematous patch covering a well-demarcated area of the upper back and shoulders (Figure). He noted a sense of extreme heat, itching, and flushing approximately 45 minutes after consuming a tuna fish sandwich. He reported diarrhea but no nausea or vomiting. He did not take any prescription or over-the-counter medications and denied prior allergic reactions to any medications or food. Additionally, there was no recent sun exposure to yield a photosensitive eruption. Examination revealed a sharply demarcated erythematous patch covering the upper back, shoulders, and neck. The patches were slightly warm to touch (blanchable) but were not tender. Vital signs were normal with blood pressure, 120/80 mm Hg and pulse, 75 beats per/min (reportedly elevated from normal 60 beats per/min). The eruption completely resolved within approximately 2 hours. There was no recurrence with subsequent consumption of any type of fish or other seafood.
What is Your Diagnosis?
Go to page 2 for an answer and more details.
Diagnosis: Scombroid Food Poisoning
Scombroid food poisoning results from the consumption of histamine-contaminated (spoiled) fish in the Scombroidae and Scomberesocidae families (tuna, mackerel, bonito, albacore, skipjack).1-6 Consuming fish outside of the Scombroidae family (sardine, bluefish, salmon [rarely]) can also lead to symptoms; therefore, this condition is often referred to as histamine fish poisoning.1-6 The most common culprits in the United States include tuna and mahi-mahi (>80%).1
It is not a true allergy and thus not immune-mediated, but instead results from histamine release from spoiled fish. The spoiling occurs when the fish are not properly cared for and marine bacteria enzymatically break down histidine in the fish muscle.5 Specifically, this improper care includes when fish are not frozen adequately with resultant bacterial overgrowth and conversion from histidine to histamine.1 Histidine decarboxylase is the primary enzyme involved, which converts histidine into histamine.5 Numerous bacteria with histidine decarboxylase include Proteus, Enterobacter, Serratia, Citrobacteer, Escherichia coli, Clostridium, Vibrio, Acinetobacter, Pseudomonas, and Photobacterium.1
Other by-products of histidine metabolism may be involved; for instance, urocanic acid is thought to be involved in mast cell degranulation.4 Both fresh and canned fish may be affected, and spoilage can occur at any stage in food production.6 Neither cooking nor the canning process will prevent contamination because toxins are heat stable. Histamine that has already formed is not destroyed during these processes.2,4,6 Scombroid fish poisoning is underrecognized but may account for approximately 5% of foodborne disease outbreaks and 39% of all seafood-associated outbreaks in the United States.1,2,4
Clinical Features
Symptoms are histamine-mediated, resemble that of an allergic reaction, are usually mild, of short duration, and typically self-limited.1 These may include rash, flushing, nausea, diarrhea, sweating, headache, dizziness, palpitations, respiratory distress, facial swelling, burning sensation in the mouth, and a peppery or metallic taste.1,2,4 Onset usually occurs within a few minutes to hours of eating the contaminated fish, but symptoms often resolve within 8 hours unless the patient has a condition such as asthma. This may prolong the course for up to 24 hours.1-4,6 Because symptoms are self-limited and resolve quickly, many cases are never reported.6
The pathophysiology of histamine fish poisoning is defined by its activity on its 4 receptor subtypes, with activation of H1 and H3 receptors accounting for the majority of symptom-related activity.1
Differential Diagnosis
Diagnosis is usually dependent on physical exam and history. The differential diagnosis of this presentation is wide and accurate diagnosis mandates ruling out other potential causes (Table). Taking note of what the patient consumed leading up to the onset of symptoms is important in ruling out other potential diagnoses.4 This must be asked as patients may not associate illness with consumption of any food type. Patients taking isoniazid and/or monoamine oxidase inhibitors (inhibit histamine metabolism) may be at increased risk for histamine fish poisoning.1 Scombroid poisoning is likely if allergy tests are negative and the patient has no previous history of allergies to fish. If multiple unrelated patients present with symptoms at the same time after consuming fish, scombroid poisoning is also likely.1,2 Bacterial food poisoning differs in that histamine levels in fish will be normal and patients will present primarily with gastrointestinal symptoms.1,2 While seldom examined, histamine levels in the patient or in the fish can be checked to confirm the diagnosis.3
Studies indicate that histamine levels ranging from 20 to 100 mg per 100 g of fish are usually needed for toxicity; however, the FDA indicates that histamine levels of at least 50 mg per 100 g of fish are toxic.1,3,5,6 US food regulations mandate that histamine levels do not exceed 5 mg/100 g.1 Definitive diagnosis can be achieved by testing the fish itself, although this is likely not a practical or logistically easy task.1 Such methods may include the use of reverse-phase high-performance liquid chromatography, although this is primarily utilized in the laboratory setting.1 Flow injection analysis and quantitative enzyme-linked immunosorbent assay testing kits have been utilized for real-time diagnoses when required.1 Skin prick testing has been utilized for diagnosis as well.1
Treatment
Treatment of scombroid food poisoning is simple once the diagnosis is established. Treatment focuses on managing symptoms and antihistamines (diphenhydramine, cetirizine, chlorpheniramine) are typically given as primary therapy.1 Corticosteroids are not an effective treatment.2 Locating the source of the contamination as well as reporting cases to public health officials are important steps to follow to prevent the occurrence of new cases.5
Our Patient
Our patient was diagnosed quickly based on the known recent history of consumption of seafood within the Scombroidae family and clinical symptoms consistent with a histamine-type reaction (Figure). While additional diagnostic testing was possible, early treatment with antihistamine and quick resolution of the symptoms and clinical findings did not necessitate further diagnostic testing or treatment. While it is important to be aware of the potential additional testing well by Feng and colleagues,1 we believe it is also important to rely on traditional clinical medical findings and treat accordingly.
Ms Kamensky is with the department of medicine at Mercer University School of Medicine in Macon, GA.
Dr Joshua Lane is with the departments of medicine and surgery at Mercer University School of Medicine in Macon, GA, and the department of dermatology at Emory University School of Medicine in Atlanta, GA.
Dr Tanda Lane is with the department of dermatology at Emory University School of Medicine in Atlanta, GA.
Disclosure: The authors report no relevant financial relationships.
References
1. Feng C, Teuber S, Gershwin ME. Histamine (scombroid) fish poisoning: a comprehensive review. Clin Rev Allergy Immunol. 2016;50(1):64-69.
2. Jantschitsch C, Kinaciyan T, Manafi M, Safer M, Tanew A. Severe scromboid fish poisoning: an underrecognized dermatologic emergency. J Am Acad Dermatol. 2011;65(1):246-247.
3. Kasha EE, Norins, AL. Scombroid fish poisoning with facial flushing. J Am Acad Dermatol. 1988;18(6):1363-1365.
4. Predy G, Honish L, Hohn W, Jones S. Was it something she ate? Case report and discussion of scombroid poisoning. CMAJ. 2003;168(5):587-588.
5. Tortorella V, Masciari P, Pezzi M, et al. Histamine poisoning from ingestion of fish or scombroid syndrome. Case Rep Emerg Med. 2014;2014:482531. doi:10.1155/2014/482531
6. Wilson BJ, Musto RJ, Ghali WA. A case of histamine fish poisoning in a young atopic woman. J Gen Int Med. 2012;27(7):878-881.
