11

Seafood PoisoningSeafood Poisoning WhatWhat’’s in your sushi?s in your sushi?

Paul Van Caeseele MDPaul Van Caeseele MDApril 24, 2009April 24, 2009

Manitoba Travel Health ConferenceManitoba Travel Health Conference

22

Declaration:Declaration: Conflicts of InterestConflicts of Interest

••I have nothing against seafoodI have nothing against seafood

••I am not related to anybody with a seafood I am not related to anybody with a seafood restaurantrestaurant

••I have never received payment or honoraria I have never received payment or honoraria from fish or shellfishfrom fish or shellfish

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ObjectivesObjectives

••Know some of the statistics that compel us Know some of the statistics that compel us to discuss seafood poisoningto discuss seafood poisoning

••Know the basic types of food poisoning Know the basic types of food poisoning associated with seafoodassociated with seafood

••Know the basic syndromes of toxinKnow the basic syndromes of toxin-- associated seafood poisoningassociated seafood poisoning

••Know the basic syndromes of bacterial, Know the basic syndromes of bacterial, viral and parasitic seafood poisoningviral and parasitic seafood poisoning

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Seafood Poisoning Seafood Poisoning ––

why care?why care?

••19731973--1987 (CDC) only 2.8% of 1987 (CDC) only 2.8% of foodbornefoodborne illness was due to seafood.illness was due to seafood.

–– Recent figures estimate 1 in 6 due to seafood Recent figures estimate 1 in 6 due to seafood

••70% of population lives near seacoasts70% of population lives near seacoasts–– Seafood provides 40% of worldSeafood provides 40% of world’’s proteins protein–– Aquaculture production has tripled in the last Aquaculture production has tripled in the last

15 years, being a third of the seafood supply15 years, being a third of the seafood supply–– Tourists spend 2 billion personTourists spend 2 billion person--days/year at days/year at

coastal destinationscoastal destinationsDiaz, JH. Color Atlas of Human Poisoning and Envenoming. 2006: CRC Press.

Shuval, H. Estimating the global burden of thalassogenic

disease. J Water Health.

2003; 1: 53-64.

Sapkota, A, et al. Aquaculture practices and potential human health risks. Environ Int. 2008; 24: 1215-26.

55

66

Why care? Why care? continuedcontinued

•• Estimated impact of infectious disease Estimated impact of infectious disease attributable to pathogens from wastewater from attributable to pathogens from wastewater from land land –– 3 million 3 million DALYDALY’’ss

with est. economic loss of $12 with est. economic loss of $12

billion/yearbillion/year

•• In North America, major food safety issues areIn North America, major food safety issues are–– Bivalve mollusk consumptionBivalve mollusk consumption–– Ciguatera poisoningCiguatera poisoning–– Unregulated subsistence fishingUnregulated subsistence fishing

Diaz, JH. Color Atlas of Human Poisoning and Envenoming. 2006: CRC Press.

Shuval, H. Estimating the global burden of thalassogenic

disease. J Water Health.

2003; 1: 53-64.

77

Seafood Poisoning Seafood Poisoning --

TypesTypes

88

Marine intoxicationsMarine intoxications

: : icthyotoxismicthyotoxism

1.1.

ScombroidScombroid

fish poisoningfish poisoning

2.2.

Ciguatera fish poisoningCiguatera fish poisoning

3.3.

Shellfish poisoning syndromesShellfish poisoning syndromesdiarrheic, paralytic, amnesic, diarrheic, paralytic, amnesic, neurotoxicneurotoxic

4.4.

Mercury poisoningMercury poisoning

99

Distribution of Distribution of IcthyotoxismIcthyotoxism

Diaz, JH. Color Atlas of Human Poisoning and Envenoming. 2006: CRC Press.

1010

ScombroidScombroid

••Worldwide: Worldwide: estest’’dd

8000 cases/yr USA8000 cases/yr USA••Named for fish family Named for fish family ScomberidaeScomberidae

(tuna, (tuna,

mackerel, bonito, skipjack, etc.)mackerel, bonito, skipjack, etc.)–– Deep water, fast swimming fish with high Deep water, fast swimming fish with high

levels of levels of histidinehistidine

••Caused by bacterial breakdown of Caused by bacterial breakdown of unrefrigerated fish to heat resistant unrefrigerated fish to heat resistant vasoactivevasoactive

compoundscompounds

1111

1212

DiaminesDiamines

CadaverineCadaverine

HH

22

NN––CHCH

22

––CHCH

22

––CHCH

22

––CHCH

22

––CHCH

22

––NHNH

22

PutrescinePutrescineHH

22

NN––CHCH

22

––CHCH

22

––CHCH

22

––CHCH

22

––NHNH

22

1313

ScombroidScombroid

characteristicscharacteristics

••Onset: immediate to few hours (may taste Onset: immediate to few hours (may taste ““tinglytingly””))

••Symptoms [initial]: flushing, Symptoms [initial]: flushing, prurituspruritus, , burning, burning, urticariaurticaria, wheezing, headache, , wheezing, headache, hypotension hypotension ––

classic is classic is ““sunburn rashsunburn rash””

••Symptoms [later]: N/V, diarrheaSymptoms [later]: N/V, diarrhea

••Treatment: antihistamines, hydrationTreatment: antihistamines, hydration

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Ciguatera Fish PoisoningCiguatera Fish Poisoning

•• Due to Due to ciguatoxinciguatoxin, among others, among others•• Caused by bioaccumulation of toxins produced Caused by bioaccumulation of toxins produced

by by GambierdiscusGambierdiscus

toxicustoxicus

in large reef fish in large reef fish –– e.g. barracuda, grouper, snapper, sea basse.g. barracuda, grouper, snapper, sea bass

•• 2020--50,000 cases worldwide annually50,000 cases worldwide annually–– EstEst’’dd

1600/yr in USA1600/yr in USA

–– In some countries as high as 1200 per 100,000In some countries as high as 1200 per 100,000

•• Outbreaks associated with wholesale of imported Outbreaks associated with wholesale of imported fish (even in Canada)fish (even in Canada)

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CiguatoxinCiguatoxin

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CIGUATERA (3009 Cases)CIGUATERA (3009 Cases) Frequency of Signs and SymptomsFrequency of Signs and Symptoms

Sign or SymptomSign or Symptom

PercentagePercentage

Paresthesias (extremities)Paresthesias (extremities)

89.289.2Paresthesias (Paresthesias (circumoralcircumoral))

89.189.1Temperature reversalTemperature reversal

87.6+87.6+ArthalgiaArthalgia

87.587.5MyalgiaMyalgia

81.581.5

DiarrheaDiarrhea

70.670.6HeadacheHeadache

59.259.2Chills Chills 5959Abdominal PainAbdominal Pain

46.546.5PruritusPruritus

44.944.9NauseaNausea

42.942.9

VertigoVertigo

42.342.3AtaxiaAtaxia

37.737.7

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Ciguatera symptoms, cont.Ciguatera symptoms, cont.

•• Onset: 6Onset: 6--30 hours after ingestion30 hours after ingestion•• GI symptoms: 50GI symptoms: 50--70%, cardiovascular less 70%, cardiovascular less

frequentfrequent–– Both resolve in a few daysBoth resolve in a few days

•• Neurological symptoms may last for weeks Neurological symptoms may last for weeks and recur with:and recur with:–– StressStress–– Ingestion of alcohol, nuts, shellfish, fishIngestion of alcohol, nuts, shellfish, fish

•• Mortality = 1%Mortality = 1%•• Management: selfManagement: self--resolving, supportive resolving, supportive

treatment (no specific neurologic blockers treatment (no specific neurologic blockers reliably work)reliably work)

Paralytic Shellfish PoisoningParalytic Shellfish Poisoning

•• From ingestion of filterFrom ingestion of filter--feeding mollusks feeding mollusks (clams, cockles, mussels, scallops) (clams, cockles, mussels, scallops)

•• Tropical and temperate waters worldwideTropical and temperate waters worldwide•• Filtered Filtered dinoflagellatesdinoflagellates

AlexandriumAlexandrium

sp and sp and

Gymnodium breve Gymnodium breve introduce toxins introduce toxins ((saxitoxinsaxitoxin

derivatives) into the mollusk derivatives) into the mollusk

meatmeat–– SaxitoxinSaxitoxin

binds to sodium channels, blocking binds to sodium channels, blocking

nerve signal transmission. Affects neurons in nerve signal transmission. Affects neurons in autonomic and peripheral nervous systemsautonomic and peripheral nervous systems

–– Onset 30 minutes to 2 hOnset 30 minutes to 2 h

2121

SaxitoxinSaxitoxin

2222

PSP PSP --

symptomssymptoms

•• Initial: Initial: perioralperioral

paresthesiasparesthesias

spreading to face spreading to face and neckand neck

•• Then: Headache, N/V and diarrheaThen: Headache, N/V and diarrhea•• Followed by: (if enough toxin ingested)Followed by: (if enough toxin ingested)

–– dizziness, dizziness, dysmetriadysmetria, weakness, weakness–– DysarthriaDysarthria

and and dysphagiadysphagia

–– Respiratory paralysis (leading to death)Respiratory paralysis (leading to death)

•• Mechanical ventilation within 12 hours saves Mechanical ventilation within 12 hours saves lives. Mortality varies on availability of lives. Mortality varies on availability of services, but may be as high as 70%.services, but may be as high as 70%.

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““Glowing SeafoodGlowing Seafood””

••Several descriptions of Several descriptions of seafood that glows in seafood that glows in the darkthe dark

••Not radioactive, not Not radioactive, not fluorescent (stimulated fluorescent (stimulated by UV light), not alienby UV light), not alien

Sado, PN. Glowing Seafood? 1998: Food and Drug Administration.

Anonymous. Living Lights: A glowing compendium. 2008: Curious Expeditions.

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Example Example ––

““glowing seafoodglowing seafood””

““In Seattle, Washington cooked shrimp In Seattle, Washington cooked shrimp purchased from a grocery store in 1996 purchased from a grocery store in 1996 startled a consumer who opened her startled a consumer who opened her refrigerator door. The light bulb had refrigerator door. The light bulb had burned out in her refrigerator and the burned out in her refrigerator and the shrimp lit up its interior.shrimp lit up its interior.””

Sado, PN. Glowing Seafood? 1998: Food and Drug Administration.

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Knowing about glowingKnowing about glowing•• Caused by marine bacteria, mostlyCaused by marine bacteria, mostly

–– PhotobacteriumPhotobacterium phosphoreumphosphoreum/leiognathi/leiognathi

–– VibrioVibrio

fischeri/harveyi/splendidusfischeri/harveyi/splendidus/ / logeilogei

•• Can grow at low temperatures (~4 Can grow at low temperatures (~4 -- 2020ººC)C)

–– Require salt (grow well on shrimp, Require salt (grow well on shrimp, cooked crabmeat, imitation cooked crabmeat, imitation seafoodsseafoods))

•• Not toxic (2 exceptions : Not toxic (2 exceptions : V. cholera V. cholera btbt.. albensisalbensis

and and vulnificusvulnificus))

Sado, PN. Glowing Seafood? 1998: Food and Drug Administration.

Anonymous. Living Lights: A glowing compendium. 2008: Curious Expeditions.

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Mercury (Hg) In SeafoodMercury (Hg) In Seafood

••BioaccumulatesBioaccumulates

in large fishin large fish–– Especially albacore tuna, shark, swordfish, Especially albacore tuna, shark, swordfish,

marlin, tilefish, etc.marlin, tilefish, etc.–– Pike, bass, walleye (and marine mammals)Pike, bass, walleye (and marine mammals)

••Organic form of mercury (methyl mercury)Organic form of mercury (methyl mercury)–– Used as fungicide, commonly present due to Used as fungicide, commonly present due to

microbial breakdown of elemental Hgmicrobial breakdown of elemental Hg–– Uncommon to get toxic levels unless large Uncommon to get toxic levels unless large

amounts of fish are constantly consumedamounts of fish are constantly consumed

Anonymous. Mercury and human health. 2009. Health Canada.

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Methyl mercury (continued)Methyl mercury (continued)

••Absorbed across intestine, distributed Absorbed across intestine, distributed through body and concentrates in brainthrough body and concentrates in brain–– Can cross placenta and accumulate in fetusCan cross placenta and accumulate in fetus

••Causes Causes neurologicneurologic

diseasedisease–– Weakness, Weakness, paresthesiaparesthesia, visual and auditory , visual and auditory

defects, tremor, seizures, coma or deathdefects, tremor, seizures, coma or death

••Generally not at risk of toxicity, but famous Generally not at risk of toxicity, but famous cases exist, even in recent timescases exist, even in recent times

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MethyMethy

mercury (case report)mercury (case report)

•• Dec 2008: Actor/comic Jeremy Dec 2008: Actor/comic Jeremy PivenPiven

leaves Broadway show leaves Broadway show

““Speed the PlowSpeed the Plow””

d/td/t

mercury mercury poisoning poisoning ––

dizzy, trouble lifting dizzy, trouble lifting

arms and legs, fatiguearms and legs, fatigue

•• 20 years of sushi twice per day20 years of sushi twice per day

•• “…“…leaving show business to leaving show business to pursue a career as a pursue a career as a thermometerthermometer””

Hill, M. Piven’s

fish tale may hold water. Winnipeg Free Press (retrieved April 20, 2009).

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Viral Causes of Seafood FBIViral Causes of Seafood FBI

•• >110 viruses in human feces, >55% of cases>110 viruses in human feces, >55% of cases•• Viable in seawater, 17 Viable in seawater, 17 mosmos

in sedimentin sediment

•• Accumulate in mollusks:Accumulate in mollusks:–– Filter feeders: In digestive glands of oysters, clams, Filter feeders: In digestive glands of oysters, clams,

cockles, mussels, conchcockles, mussels, conch–– Carnivorous shellfish: In inedible portions of crab and Carnivorous shellfish: In inedible portions of crab and

lobsterlobster–– Survive well in Survive well in coliformcoliform--free waterfree water

•• Most viruses inactivated by 4Most viruses inactivated by 4--6 6 minsmins

steamingsteaming–– Main viral agents: HAV, Main viral agents: HAV, NorovirusNorovirus, (poliovirus), (poliovirus)

Anonymous. Seafood safety. 2007.Seafood Network Information Centre.

Ahmed, FE. Ed. Seafood safety. 1991. National Academy of Sciences Press.

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3131

Hepatitis A VirusHepatitis A Virus

•• Toughest viral offender: MC hepatitis due to Toughest viral offender: MC hepatitis due to seafoodseafood–– Est. 4 million cases/year due to shellfish, with est. Est. 4 million cases/year due to shellfish, with est.

40,000 deaths40,000 deaths

•• Takes 19 minutes steaming to inactivate, or at Takes 19 minutes steaming to inactivate, or at least 1 minute of rolling boil (~85least 1 minute of rolling boil (~85ººC)C)

•• HAV outbreaks have been associated with HAV outbreaks have been associated with consumption of oysters, clams and musselsconsumption of oysters, clams and mussels

Anonymous. Seafood safety. 2007.Seafood Network Information Centre.

Shuval, H. Estimating the global burden of thalassogenic

disease. J Water Health.

2003; 1: 53-64.

3232

3333

HAV HAV ––

the diseasethe disease

••Incubation: 2Incubation: 2--6 weeks after exposure6 weeks after exposure••Abrupt onset of weakness, fever, Abrupt onset of weakness, fever,

abdominal pain that may progress to abdominal pain that may progress to jaundice (fatal <0.1%)jaundice (fatal <0.1%)–– Usually asymptomatic in childrenUsually asymptomatic in children

••Diagnosis: standard with a blood test for Diagnosis: standard with a blood test for antibody to HAV (HAV antibody to HAV (HAV IgMIgM))

••Treatment: supportiveTreatment: supportive

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NorovirusNorovirus

(Norwalk virus)(Norwalk virus)

••RNA virus with many human and animal RNA virus with many human and animal strains strains ––

““Winter vomiting diseaseWinter vomiting disease””

••Higher attack rate than in Higher attack rate than in foodhandlerfoodhandler associated outbreaksassociated outbreaks

••Very common cause of outbreaks, Very common cause of outbreaks, including in Canadaincluding in Canada–– Described with oysters, clams, cocklesDescribed with oysters, clams, cockles

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NorovirusNorovirus

(Norwalk virus), (Norwalk virus), continuedcontinued

••Incubation: 40 hours (12Incubation: 40 hours (12--72 hours)72 hours)

••Nausea, vomiting, diarrhea, crampingNausea, vomiting, diarrhea, cramping

••Usually done in 48 hours (sometimes Usually done in 48 hours (sometimes longer)longer)

••Diagnosis: EM or PCR of stool specimens, Diagnosis: EM or PCR of stool specimens, PCR can be done on seafoodPCR can be done on seafood

••Treatment: Supportive (no vaccine)Treatment: Supportive (no vaccine)

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Bacterial seafood poisoningBacterial seafood poisoning

••Many possibilities, but only 8% of all casesMany possibilities, but only 8% of all cases–– Gram positive:Gram positive:

ListeriaListeria

monocytogenesmonocytogenes

–– GN:GN:

VibrioVibrio

parahemolyticusparahemolyticus, cholera, , cholera, vulnificusvulnificus–– Rarely Rarely Clostridium Clostridium botulinumbotulinum

(botulism)(botulism)

••Most are transient and harmlessMost are transient and harmless–– Except Except V. V. vulnificusvulnificus, as in , as in immunosuppressedimmunosuppressed

it can carry a >50% mortalityit can carry a >50% mortality

Ahmed, FE. Ed. Seafood safety. 1991. National Academy of Sciences Press.

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ListeriosisListeriosis

•• Due to Due to psychrophilicpsychrophilic

L. L. monocytogenesmonocytogenes•• Very common on surfaces of seafood, but often Very common on surfaces of seafood, but often

not virulentnot virulent•• Incubation: 4 Incubation: 4 --

21 days21 days

•• Usually causes mild and short diarrhea (if Usually causes mild and short diarrhea (if anything), but in anything), but in immunosuppressedimmunosuppressed

can cause can cause

sepsis, meningitis, abortionssepsis, meningitis, abortions•• Diagnosis: standard investigations of food, Diagnosis: standard investigations of food,

sometimes blood or CSF culturessometimes blood or CSF cultures•• Treatment: usually supportive, unless severeTreatment: usually supportive, unless severe

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Pathogenic Pathogenic VibriosVibrios

•• Principal concerns are Principal concerns are parahemolyticusparahemolyticus

and and vulnificusvulnificus

found in oysters and crabsfound in oysters and crabs

•• Marine (saltMarine (salt--requiring) Gramrequiring) Gram--negatives that like negatives that like warmer waters (counts go up in summer)warmer waters (counts go up in summer)

•• Accumulate mostly in mollusks, sometimes fishAccumulate mostly in mollusks, sometimes fish•• V. V. parahemolyticusparahemolyticus

is reported to cause up to is reported to cause up to

70% of FBI in Japan, and 35% in Taiwan70% of FBI in Japan, and 35% in Taiwan•• V. V. vulnificusvulnificus

accounts for 90% of seafood deaths accounts for 90% of seafood deaths

in the US, found in most oyster bedsin the US, found in most oyster beds

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Pathogenic Pathogenic VibriosVibrios, , continuedcontinued

•• Incubation: Vp~24 hours; Vv 1Incubation: Vp~24 hours; Vv 1--3 days3 days•• VpVp. causes acute onset explosive diarrhea with . causes acute onset explosive diarrhea with

cramping and pain. Fever, chills and headache cramping and pain. Fever, chills and headache are common.are common.

•• Vv. may cause diarrhea. It is best known for Vv. may cause diarrhea. It is best known for sepsis progressing to diffuse hemorrhagic sepsis progressing to diffuse hemorrhagic bullaebullae

in in immunosuppressedimmunosuppressed

persons, especially those persons, especially those with cirrhosis or iron overload syndromeswith cirrhosis or iron overload syndromes

•• Diagnosis: special culture techniques are best Diagnosis: special culture techniques are best for isolating these saltfor isolating these salt--loving sealoving sea--dogsdogs

•• Treatment: antimicrobials (tetracycline) and Treatment: antimicrobials (tetracycline) and perhaps drainage are required for Vv infectionsperhaps drainage are required for Vv infections

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Parasites in SeafoodParasites in Seafood

•• Nearly ALL marine animals are infected with Nearly ALL marine animals are infected with some sort of parasite (so are humans)some sort of parasite (so are humans)

•• 50 million infected worldwide with 50 million infected worldwide with trematodestrematodes from fish and shellfishfrom fish and shellfish

•• Dozens of possible contendersDozens of possible contenders–– E.g. E.g. GiardiaGiardia, , EustrongyloidesEustrongyloides, , ParagonimusParagonimus, ,

AngiostrongylusAngiostrongylus, , OpisthorchisOpisthorchis, , EchinostomaEchinostoma, , MetorchisMetorchis, , ClonorchisClonorchis, , NanophyetusNanophyetus, , etc.etc.

–– **AnisakisAnisakis, , DiphyllobothriumDiphyllobothrium, Cryptosporidium, Cryptosporidium**

Butt, AA, et al. Infections related to the ingestion of seafood Part II. Lancet Infect Dis. 2004; 4: 294-300.

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AnisakisAnisakis

simplexsimplex

(herring worm)(herring worm)

••Looks very similar to another occasional Looks very similar to another occasional parasite, parasite, PseudoterranovaPseudoterranova

decipiensdecipiens

••Parasite of dolphins, porpoises, whalesParasite of dolphins, porpoises, whales••33rdrd

stage larvae in fish accidentally infect stage larvae in fish accidentally infect

humans: herring, cod, salmon, squid, etc.humans: herring, cod, salmon, squid, etc.••Seen in areas where raw seafood Seen in areas where raw seafood

consumption common: Japan, SE Asia, consumption common: Japan, SE Asia, Netherlands and SpainNetherlands and Spain

Anonymous. Seafood safety. 2007.Seafood Network Information Centre.

Butt, AA, et al. Infections related to the ingestion of seafood Part II. Lancet Infect Dis. 2004; 4: 294-300.

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AnisakisAnisakis

continuedcontinued

•• Usually no symptomsUsually no symptoms•• 11--12 hours for gastric, 112 hours for gastric, 1--5 5

days for intestinaldays for intestinal•• Acute Acute epigastricepigastric

pain, fever pain, fever

and diarrheaand diarrhea•• Sometimes allergic reaction, Sometimes allergic reaction,

or or ““coughing a worm upcoughing a worm up””•• If penetrate intestinal If penetrate intestinal

mucosa, may need surgical mucosa, may need surgical removalremoval

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DiphyllobothriumDiphyllobothrium

(fish tapeworm)(fish tapeworm)

•• Most common Most common cestodecestode

infection from fishinfection from fish•• Endemic to Canada Endemic to Canada ––

can reach almost 10 can reach almost 10

metresmetres

long; 13 species can infect humanslong; 13 species can infect humans•• Infects most freshwater fish and salmon, and Infects most freshwater fish and salmon, and

found in gefilte fishfound in gefilte fish•• Usually asymptomatic, some may have diarrhea, Usually asymptomatic, some may have diarrhea,

abdominal pain and, if abdominal pain and, if D. D. latumlatum, vitamin B, vitamin B1212

deficiencydeficiency•• Easily treated with short course Easily treated with short course antihelmenthicsantihelmenthics

4646

DiphyllobothriumDiphyllobothrium

continuedcontinued

••Can grow Can grow quite rapidlyquite rapidly

••This one grew This one grew to 4.25 m in to 4.25 m in 18 days18 days

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General PreventionGeneral Prevention

••Eat within 1Eat within 1--2 days of catch or purchase2 days of catch or purchase

••Store as close as possible to ~0Store as close as possible to ~0--44ººCC

••Adhere to local advisoriesAdhere to local advisories

••Get HAV vaccination, the full seriesGet HAV vaccination, the full series

••““Clean, boil, peelClean, boil, peel””

(or cook) or walk away(or cook) or walk away

4949

Thank YouThank You