Coral Jack 51 2/5/1960 Author Chris Brooks Reviewer Sharon

coral, jack; 51 2/5/1960 author: chris brooks reviewer: sharon griswold case title: ciguatera toxin poisoning target audience:

Coral, Jack; 51
2/5/1960
Author: Chris Brooks Reviewer: Sharon Griswold
Case Title: Ciguatera Toxin Poisoning
Target Audience: medical students and residents
Primary Learning Objectives:
1. Learn to treat patient symptomatically during work-up
2. Learn about Ciguatera Poisoning
Critical actions checklist
1.
Provide symptomatic relief.
2.
Recognize ciguatera toxin poisoning.
3.
Provide specific therapy.
4.
Obtain EKG.
5.
Explain the diagnosis to the patient.
6.
Report the diagnosis to the local health authorities
For Examiner Only
Author: Chris Brooks Reviewer: Sharon Griswold
Case Title: Ciguatera Toxin Poisoning
CASE SUMMARY
CORE CONTENT AREA
Toxicology
SYNOPSIS OF HISTORY/ Scenario Background
The patient is a middle-aged male who contracts ciguatera toxin
poisoning from eating amberjack at a local restaurant. He went out to
dinner with friends and had raw oysters, salad, and the amberjack
special. The contaminated fish was taken from the Gulf of Mexico and
shipped to the restaurant by a local seafood supplier.
The patient’s symptoms include nausea, abdominal discomfort, diarrhea,
intense myalgias, and neurologic symptoms. Pt has burning and tingling
in the hands and feet. For example, the patient is unable to stand on
a tile floor with bare feet because of the discomfort.
SYNOPSIS OF PHYSICAL
Physical exam is essentially unremarkable.
For Examiner Only
CRITICAL ACTIONS
Scenario branch points/ PLAY OF CASE GUIDELINES
1.
Critical Action
Provide symptomatic relief. An IV should be started and fluids should
be administered. Normal saline by bolus infusion is preferred. Pain
medication including an anti-inflammatory and / or narcotic should be
given. Anti-emetics for nausea should be given.
Cueing Guideline: Patient asks, “Doctor, I really feel terrible. Is
there anything that you can do?”
2.
Critical Action
Recognize ciguatera toxin poisoning.
Cueing Guideline: If the examinee is unable to recognize that this is
ciguatera toxin poisoning, he may use the computer in the ED to “surf
the web”. The examinee must be able to know to search for marine
toxins and the CDC web page will be available. Patient asks, “Doctor,
what’s wrong with me? Was it something I ate last night?”
3.
Critical Action
Provide specific therapy. Give a mannitol infusion to the patient.
Dose should be approximately 1 gm / kg, typically a 100 gm infusion.
Tricyclic antidepressants or NSAID’s can also be prescribed when the
patient is discharged.
Cueing Guideline: Patient asks, “Doctor, is there an antidote that you
can give me?”
4.
Critical Action
Obtain EKG.
Cueing Guideline: Nurse says, “His heart rate seems slow to me.”
5.
Critical Action
Explain the diagnosis to the patient. The patient should be educated
that this is ciguatera poisoning. Patient education should include
nature of disease (toxin), prognosis (generally good but some patients
have persistent symptoms) and strategies to avoid reoccurrence in the
future.
Cueing Guideline: Patient says, “I’m going to sue that restaurant.
They should have known better than to serve that bad fish.”
6.
Critical Action
Report the outbreak to the local health authority.
It is important to notify public health departments about even one
person with marine toxin poisoning. Public health departments can then
investigate to determine if a restaurant, or fishing area has a
problem. This prevents other illnesses.
Cueing Guideline: The nurse taking care of the patient asks, “Are we
supposed to report this?.”
SCORING GUIDELINES
(Critical Action No.)
1. Score up for IV administration of fluids, pain medication and
anti-emetics.
2. Score up for knowledge of toxin. Also score up for rapid use of
on-line resources or consultation with toxicology service.
3. Score up for mannitol infusion. Score down for therapy directed at
other toxins.
4. Obtain EKG.
5. Score up for reassurance and details provided about prognosis and
epidemiology.
For Examiner Only
HISTORY
Onset of Symptoms: Symptoms began about 1 AM with nausea, diarrhea,
myalgias (primarily of the occipital & chest muscles), and burning /
tingling in the hands and feet.
Background Info: Patient went out to dinner last night with friends.
He developed symptoms during the night and presents at 7 AM after
being up all night. If asked a friend who ordered the same dinner is
also ill.
Chief Complaint: “I feel terrible.”
Past Medical Hx: Ulcerative Colitis
Migraine Headache
Medications: Verapamil SR 240 mg QD
Nortriptyline 50 mg QHS
Mesalamine 800 mg BID
Azothiaprine 100 mg QD
Allergies: Butalbital
Past Surgical Hx: Internal fixation of trimalleolar ankle fracture 2
years previously
Habits: Smoking: Quit smoking 20 years ago
ETOH: Social only (mixed drinks & single malt scotch)
Drugs: None
Family Medical Hx: Mother: Deceased, breast cancer
Father: Hypertension, diabetes, and coronary heart disease
Social Hx: Marital Status: Married
Children: 2
Education: PhD in chemical engineering
Employment: Manager for chemical company
ROS: Ulcerative Colitis well controlled on Mesalamine and Azothiaprine
Migraines well controlled on Verapamil and Nortriptyline
All other ROS items are non-contributory. No diarrhea, fever or
concern for sepsis.
For Examiner Only
PHYSICAL EXAM
Patient Name: Jack Coral Age & Sex: 51 year old male
General Appearance: Well-developed, well-nourished male in moderate
distress
Vital Signs: BP 116/72 P 58 R 16 T 37.2 C
Head: Normal Exam
Eyes: Normal Exam
Ears: Normal Exam
Mouth: Mucosa somewhat dry, otherwise normal
Neck: Without tenderness or rigidity
Skin: No rashes, some diaphoresis is present, skin color is normal
Chest: Tenderness over the pectoral muscles is present
Lungs: Clear to auscultation
Heart: Regular rhythm without murmurs, rubs, or gallops
Back: Normal Exam
Abdomen: Normal Exam
Extremities: Normal Exam
Rectal: Patient refuses
Pelvic: N/A
Neurological: Normal Exam
Mental Status: Normal
For Examiner Only
STIMULUS INVENTORY
#1 Emergency Admitting Form
#2 CBC
#3 BMP
#4 U/A
#5 Cardiac Enzymes
#6 Toxicology
#7 EKG
#8 CXR
#9 CDC Web Page: “Marine Toxins”
For Examiner Only
LAB DATA & IMAGING RESULTS
Stimulus #2
Complete Blood Count (CBC) Stimulus #5
WBC 14.6 /mm3 Cardiac Enzymes
Hgb 13.3 g/dL Myoglobin 52 ng/ml
Hct 40 % Troponin < 0.7 ng/ml
Platelets 365K /mm3
Differential
Segs 60 % Stimulus #6
Bands 0 % Toxicology
Lymphs 30 % Serum
Monos 10 % Salicylate Neg
Eos 0 % Acetaminophen Neg
Tricyclics Pos
Stimulus #3 ETOH Neg
Basic Metabolic Profile (BMP) Urine
Na+ 140 mEq/L Cocaine Neg
K+ 3.9 mEq/L Cannabinoids Neg
CO2 24 mEq/L PCP Neg
Cl- 112 mEq/L Amphetamines Neg
BUN 30 mg/dL Opiates Neg
Creatinine 1.2 mg/dL Barbiturates Neg
Glucose 110 mg/dL Benzodiazepines Neg
Stimulus #4 Stimulus #7
Urinalysis (U/A) EKG Sinus Bradycardia
Color yellow
Sp gravity 1.018 Stimulus #8
Glucose neg CXR Normal
Blood neg
Protein neg Stimulus #9
Ketone 1 + CDC Web Page
Leuk. Est. neg (“Marine Toxins”)
Nitrite neg
WBC 0-1 Verbal Reports Pulse Ox 98% (RA)
RBC 0-1
Learner Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name: Jack Coral
Age: 51 years
Sex: Male
Method of Transportation: Private car
Person giving information: Patient
Presenting complaint: “I feel terrible.”
Background: Patient went out to dinner last night with friends. He
developed symptoms during the night and presents at 7 AM after being
up all night.
Triage or Initial Vital Signs
BP: 116/72
P: 58
R: 16
T: 37.2 C
Learner Stimulus #2
Complete Blood Count (CBC)
WBC 14.6 /mm3
Hgb 13.3 g/dL
Hct 40 %
Platelets 365K /mm3
Differential
Segs 60 %
Bands 0 %
Lymphs 30 %
Monos 10 %
Eos 0 %
Learner Stimulus #3
Basic Metabolic Profile (BMP)
Na+ 140 mEq/L
K+ 3.9 mEq/L
CO2 24 mEq/L
Cl- 112 mEq/L
BUN 30 mg/dL
Creatinine 1.2 mg/dL
Glucose 110 mg/dL
Learner Stimulus #4
Urinalysis (U/A)
Color yellow
Sp gravity 1.018
Glucose neg
Blood neg
Protein neg
Ketone 1 +
Leuk. Est. neg
Nitrite neg
WBC 0-1
RBC 0-1
Learner Stimulus #5
Cardiac Enzymes
Myoglobin 52 ng/ml
Troponin < 0.7 ng/ml
Learner Stimulus #6
Toxicology
Serum
Salicylate Neg
Acetaminophen Neg
Tricyclics Pos
ETOH Neg
Urine
Cocaine Neg
Cannabinoids Neg
PCP Neg
Amphetamines Neg
Opiates Neg
Barbiturates Neg
Benzodiazepines Neg
Learner Stimulus #7
EKG

Learner Stimulus #8
CXR

For Examiner
Date: Examiner: Examinee(s):
Scoring: In accordance with the Standardized Direct Observational Tool
(SDOT)
The learner should be scored (based on level of training) for each
item above with one of the following:
NI = Needs Improvement
ME = Meets Expectations
AE = Above Expectations
NA= Not Assessed
Critical Actions
NI
ME
AE
NA
Category
Provide symptomatic relief.
PC, MK
Recognize ciguatera poisoning.
PC, MK, PBL
Obtain EKG
PC, MK, PBL
Provide specific therapy.
PC, MK, PBL
Explain diagnosis to the patient.
PC, MK, ICS, P, SBP
Report case to local authorities
SBP
The score sheet may be used for a variety of learners. For example, in
using the case for 4th year medical students, the key teaching points
of the case may be the recognition of shock and treatment with
appropriate fluid resuscitation. Other items may be marked N/A= not
assessed.
Category: One or more of the ACGME Core Competencies as defined in the
SDOT
PC= Patient Care
Compassionate, appropriate, and effective for the treatment of health
problems and the promotion of health
MK= Medical Knowledge
Residents are expected to formulate an appropriate differential
diagnosis with special attention to life-threatening conditions,
demonstrate the ability to utilize available medical resources
effectively, and apply this knowledge to clinical decision making
PBL= Practice Based Learning & Improvement
Involves investigation and evaluation of their own patient care,
appraisal and assimilation of scientific evidence, and improvements in
patient care
ICS= Interpersonal Communication Skills
Results in effective information exchange and teaming with patients,
their families, and other health professionals
P= Professionalism
Manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to
a diverse patient population
SBP= Systems Based Practice
Manifested by actions that demonstrate an awareness of and
responsiveness to the larger context and system of health care and the
ability to effectively call on system resources to provide care that
is of optimal value
Learner Stimulus #9 CDC Web Page: “Marine Toxins”

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/marinetoxins_g.htm.
Retrieved May 17, 2011
What can be done to prevent these diseases?
It is important to notify public health departments about even one
person with marine toxin poisoning. Public health departments can then
investigate to determine if a restaurant, oyster bed, or fishing area
has a problem. This prevents other illnesses. In any food poisoning
occurrence, consumers should note foods eaten and freeze any uneaten
portions in case they need to be tested. A commercial test has been
developed in Hawaii to allow persons to test sport caught fish for
ciguatoxins
Marine Toxins
What are marine toxins?
Marine toxins are naturally occurring chemicals that can contaminate
certain seafood. The seafood contaminated with these chemicals
frequently looks, smells, and tastes normal. When humans eat such
seafood, disease can result.
What sort of diseases do marine toxins cause? The most common diseases
caused by marine toxins in United States in order of incidence are
scombrotoxic fish poisoning, ciguatera poisoning, paralytic shellfish
poisoning, neurotoxic shellfish poisoning and amnesic shellfish
poisoning.
Scombrotoxic fish poisoning also known as scombroid or histamine fish
poisoning, is caused by bacterial spoilage of certain finfish such as
tuna, mackerel, bonito, and, rarely, other fish. As bacteria break
down fish proteins, byproducts such as histamine and other substances
that block histamine breakdown build up in fish. Eating spoiled fish
that have high levels of these histamines can cause in human disease.
Symptoms begin within 2 minutes to 2 hours after eating the fish. The
most common symptoms are rash, diarrhea, flushing, sweating, headache,
and vomiting. Burning or swelling of the mouth, abdominal pain, or a
metallic taste may also occur. The majority of patients have mild
symptoms that resolve within a few hours. Treatment is generally
unnecessary, but antihistamines or epinephrine may be needed in
certain instances. Symptoms may be more severe in patients taking
certain medications that slow the breakdown of histamine by their
liver, such as isoniazide and doxycycline.
Ciguatera poisoning or ciguatera is caused by eating contaminated
tropical reef fish. Ciguatoxins that cause ciguatera poisoning are
actually produced by microscopic sea plants called dinoflagellates.
These toxins become progressively concentrated as they move up the
food chain from small fish to large fish that eat them, and reach
particularly high concentrations in large predatory tropical reef
fish. Barracuda are commonly associated with ciguatoxin poisoning, but
eating grouper, sea bass, snapper, mullet, and a number of other fish
that live in oceans between latitude 35° N and 35° S has caused the
disease. These fish are typically caught by sport fishermen on reefs
in Hawaii, Guam and other South Pacific islands, the Virgin Islands,
and Puerto Rico. Ciguatoxin usually causes symptoms within a few
minutes to 30 hours after eating contaminated fish, and occasionally
it may take up to 6 hours. Common nonspecific symptoms include nausea,
vomiting, diarrhea, cramps, excessive sweating, headache, and muscle
aches. The sensation of burning or "pins-and-needles," weakness,
itching, and dizziness can occur. Patients may experience reversal of
temperature sensation in their mouth (hot surfaces feeling cold and
cold, hot), unusual taste sensations, nightmares, or hallucinations.
Ciguatera poisoning is rarely fatal. Symptoms usually clear in 1 to 4
weeks.
Paralytic shellfish poisoning is caused by a different dinoflagellate
with a different toxin, than that causing ciguatera poisoning. These
dinoflagellates have a red-brown color, and can grow to such numbers
that they cause red streaks to appear in the ocean called "red tides."
This toxin is known to concentrate within certain shellfish that
typically live in the colder coastal waters of the Pacific states and
New England, though the syndrome has been reported in Central America.
Shellfish that have caused this disease include mussels, cockles,
clams, scallops, oysters, crabs, and lobsters. Symptoms begin anywhere
from 15 minutes to 10 hours after eating the contaminated shellfish,
although usually within 2 hours. Symptoms are generally mild, and
begin with numbness or tingling of the face, arms, and legs. This is
followed by headache, dizziness, nausea, and muscular incoordination.
Patients sometimes describe a floating sensation. In cases of severe
poisoning, muscle paralysis and respiratory failure occur, and in
these cases death may occur in 2 to 25 hours.
Neurotoxic shellfish poisoning is caused by a third type of
dinoflagellate with another toxin that occasionally accumulates in
oysters, clams, and mussels from the Gulf of Mexico and the Atlantic
coast of the southern states. Symptoms begin 1 to 3 hours after eating
the contaminated shellfish and include numbness, tingling in the
mouth, arms and legs, incoordination, and gastrointestinal upset. As
in ciguatera poisoning, some patients report temperature reversal.
Death is rare. Recovery normally occurs in 2 to 3 days.
Amnesic shellfish poisoning is a rare syndrome caused by a toxin made
by a microscopic, red-brown, salt-water plant, or diatom called
Nitzchia pungens. The toxin produced by these diatoms is concentrated
in shellfish such as mussels and causes disease when the contaminated
shellfish are eaten. Patients first experience gastrointestinal
distress within 24 hours after eating the contaminated shellfish.
Other reported symptoms have included dizziness, headache,
disorientation, and permanent short-term memory loss. In severe
poisoning, seizures, focal weakness or paralysis, and death may occur.
How can these diseases be diagnosed? Diagnosis of marine toxin
poisoning is generally based on symptoms and a history of recently
eating a particular kind of seafood. Laboratory testing for the
specific toxin in patient samples is generally not necessary because
this requires special techniques and equipment available in only
specialized laboratories. If suspect, leftover fish or shellfish are
available, they can be tested for the presence of the toxin more
easily. Identification of the specific toxin is not usually necessary
for treating patients because there is no specific treatment.
How can these diseases be treated? Other than supportive care there
are few specific treatments for ciguatera poisoning, paralytic
shellfish poisoning, neurotoxic shellfish poisoning, or amnesic
shellfish poisoning. Antihistamines and epinephrine, however, may
sometimes be useful in treating the symptoms of scombrotoxic fish
poisoning. Intravenous mannitol has been suggested for the treatment
of severe ciguatera poisoning.
Are there long-term consequences to these diseases? Ciguatera
poisoning has resulted in some neurologic problems persisting for
weeks, and in rare cases, even years. Symptoms have sometimes returned
after eating contaminated fish a second time. Amnesic shellfish
poisoning has resulted in longterm problems with short-term memory.
Long-term consequences have not been associated with paralytic
shellfish poisoning, neurotoxic shellfish poisoning, and scombrotoxic
fish poisoning.
How common are these diseases? Every year, approximately 30 cases of
poisoning by marine toxins are reported in the United States. Because
healthcare providers are not required to report these illnesses and
because many milder cases are not diagnosed or reported, the actual
number of poisonings may be much greater. Toxic seafood poisonings are
more common in the summer than winter because dinoflagelates grow well
in warmer seasons. It is estimated from cases with available data that
one person dies every 4 years from toxic seafood poisonings.
Marine toxins, Ciguatera, foodborne illness
References
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/marinetoxins_g.htm.
Retrieved May 17, 2011
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