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Ichthyoallyeinotoxism is a rare kind of food poisoning contracted following the ingestion of fish. The responsible toxins are unknown, and the clinical feature is characterized by the development of CNS disturbances, especially hallucinations and nightmares. As the implicated fish species may be also related to ciguatera poisoning, there may be possible confusion between the two fish-borne intoxications. In order to clarify this, the literature pertaining to "dreamfish" was reviewed and two cases are presented. A 40-year-old man experienced mild digestive troubles and terrifying visual and auditory hallucinations after eating a specimen of Sarpa salpa in a restaurant. As he had severe behaviour troubles, he was managed in the hospital and recovered 36 h after the meal. He was unable to recall the hallucinatory period. Another man, 90-years-old and previously healthy, had auditory hallucinations 2 h after eating a specimen of Sarpa salpa. The two following nights, he had numerous nightmares and recovered spontaneously after a period of 3 days.
Keywords Ichthyoallyeinotoxism; Ichthyosarcotoxism; Hallucinatory Fish Poisoning; Dreamfish
Full Text :COPYRIGHT 2006 Taylor & Francis Ltd.
INTRODUCTION
Ichthyosarcotoxism is a type of food poisoning caused via the ingestion of fish. The most common and widely investigated form of ichthyosarcotoxism is ciguatera poisoning that affects the peripheral nervous system. It is due to contamination of fish flesh by various toxins produced by the benthic dinoflagellate Gambierdiscus toxicus. A less common form is ichthyoallyeinotoxism, characterized by development of central nervous system disturbances, especially hallucinations and nightmares. Ichthyoallyeinotoxism has been reported in many locations around the world (1,2). The purpose of this article is to describe two new cases of ichthyoallyeinotoxism that occurred in the Western Mediterranean after ingestion of Sarpa salpa, and to review the literature concerning this rare poisoning.
CASE 1
April 1994
A previously healthy 40-year-old executive began feeling weak and tired within 2 h after eating freshly caught baked sea bream (Sarpa salpa) for dinner while on vacation in Cannes on the French Riviera. Nausea and vomiting developed quickly during the night. The next day symptoms persisted and were accompanied by marked muscle weakness. He decided to shorten his vacation and drive home. At that point, he began to experience blurring of vision and hallucinations involving aggressive and screaming animals. Agitation and disorientation led him to seek medical assistance (he was not able to drive anymore as he was seeing giant arthropods around his car). Physical examination upon arrival at the hospital emergency room demonstrated no notable abnormalities: no fever, no sign of focalization or sensory-motor deficit, and normal hemodynamic status except for sinusal tachycardia linked directly to the mental disturbances. During hospitalization, the patient recovered rapidly with complete resolution of symptoms within 36 h post ingestion. He was unable to recall the hallucinatory period.
CASE 2
March 2002
A previously healthy 90-year-old retiree began experiencing auditory hallucinations 2 h after ingesting a sea bream (Sarpa salpa) that he had purchased from a professional fisherman in Saint Tropez on the French Riviera. He was used to eating this kind of fish, and had cleaned the fish after he had purchased it. Hallucinations were of a particularly terrifying nature (human screams and bird squealing), and he had numerous nightmares for the next two nights. Fearing that these symptoms might signal the beginning of a major mental illness, he did not tell his friends or attending physician. The manifestations abated three days after he had eaten the fish. Later, he recalled a warning that he had heard at the fish market concerning the hallucinogenic potential of sea bream and decided to contact the Poison Control Center in Marseille.
DISCUSSION
Clinical symptoms of ichthyoallyeinotoxism occur within a few minutes to 2 h after ingestion of toxic fish. The first symptoms resemble inebriety with loss of balance and coordination and generalized malaise (1-3). Sore throat and heartburn have also been reported in the initial phase. Within a few hours, specific signs of poisoning occur including delirium, visual and/or auditory hallucinations (often involving animals), depression, feelings of impending death with reactive tachycardia and hyperventilation, and disturbed behavior. If they are able to sleep, patients classically report terrifying nightmares (3). Gastrointestinal symptoms including nausea, abdominal pain, and diarrhea have been described in a few cases, but are usually low-grade (3). No specific treatment or antidote treatment is available. Appropriate management of transient behavioral disturbances (e.g., using benzodiazepine or neuroleptics), is important to prevent self-inflicted or other injury. Symptomatic treatment for gastrointestinal manifestation can enhance patient comfort. Symptoms generally abate within 24 to 36 h, but weakness may persist for several days (1-3).
Ichthyoallyeinotoxism is widespread in tropical and temperate areas of the Indian and Pacific Oceans as well as in the Mediterranean Sea. Toxic fish species belong to the 8 families detailed in Table 1. Most are herbivores or scavengers living in coastal areas. It should be noted that toxicity in all species varies according to fishing location, season, and way of preparing the fish (3). In the Mediterranean, most poisonings involving Sarpa salpa (eaten in Tunisia, France and Israel but considered as inedible in Italy and Spain), have been reported in spring and summer (4-7). A classically reported exacerbating factor is consumption of fish cooked without removing the head, and/or not immediately gutted after being caught (
. Although the toxic agents are still unknown, some authors have implicated toxic macroalgaes (caulerpaceae family) that are ingested and contaminate the flesh of fish (3,4). These toxins are probably heat stable since case reports have been described after ingestion of fried, boiled, steamed or raw fish (3,7). Most cases have been described anecdotally as unexpected, sporadic accidental food poisonings, usually occurring in endemic areas after consumption of fish considered as safe. However some cases of intentional consumption of "dreamfish" have been reported (810). Consumption of Sarpa salpa was reported for recreational purposes in the Mediterranean during the Roman Empire (1 1), and for ceremonial purposes particularly in Polynesian populations (8-10). The traditional names given to hallucinogenic species reflect their potentially toxic effect. Sarpa salpa is called "the fish that makes dreams" in Arab; Siganus spinus is called "the fish that inebriates" in Mascareignes (southwest coast of Reunion Island) (12,13); and Mulloidichthys samoensis is called "the chief of ghosts" in the Hawaiian Islands of Molokai, Kauai, and Oahu (8, 14, 15).
It should be emphasized that tropical fish species that cause ichthyoallyeinotoxism are also implicated in cases of ciguatera poisoning. In this regard, there has been some confusion concerning these two forms of ichthyosarcotoxism. Some cases of ichthyoallyeinotoxism reported in the western (11) and eastern Mediterranean (5-7,16) after ingestion of Sarpa salpa or Siganus luridus, have been described as ciguatera despite typical clinical signs of ichthyoallyeinotoxism, (i.e., hallucinations and nightmares lasting for a few hours). In this regard, it should be noted that the presence of Gambierdiscus toxicus, the dinoflagellate solely responsible for ciguatera, has not been formally documented in the Mediterranean. It should be emphasized that there are differences in clinical expression: ichthyoallyeinotoxism is characterized by central nervous system involvement, whereas ciguatera features peripheral nervous system involvement. The two diseases are also different with regard to potential severity and duration. Most patients with ichthyoallyeinotoxism recover within 36 h (1-3), while many patients with ciguatera die or present prolonged symptomatology for several months (17).
CONCLUSION
Ichthyoallyeinotoxism is a rare, poorly understood fish-borne intoxication. Its incidence is probably underestimated for several reasons. The first is that symptoms often occur at night and are short-lived. As a result, patients do not always seek medical advice, as was the case for our second patient. Another reason is that the disease occurs in remote geographical areas (islands and isolated archipelagoes), where there are few medical facilities able to document cases. Finally, voluntary ingestion by its very nature seldom leads to medical intervention. Great care is necessary to avoid confusing ichthyoallyeinotoxism and ciguatera that involve the same species in overlapping endemic areas.
als iemand ervaring heeft met dit zoort vissen of meer weet zou ik dat graag horen
Ichthyoallyeinotoxism is a rare kind of food poisoning contracted following the ingestion of fish. The responsible toxins are unknown, and the clinical feature is characterized by the development of CNS disturbances, especially hallucinations and nightmares. As the implicated fish species may be also related to ciguatera poisoning, there may be possible confusion between the two fish-borne intoxications. In order to clarify this, the literature pertaining to "dreamfish" was reviewed and two cases are presented. A 40-year-old man experienced mild digestive troubles and terrifying visual and auditory hallucinations after eating a specimen of Sarpa salpa in a restaurant. As he had severe behaviour troubles, he was managed in the hospital and recovered 36 h after the meal. He was unable to recall the hallucinatory period. Another man, 90-years-old and previously healthy, had auditory hallucinations 2 h after eating a specimen of Sarpa salpa. The two following nights, he had numerous nightmares and recovered spontaneously after a period of 3 days.
Keywords Ichthyoallyeinotoxism; Ichthyosarcotoxism; Hallucinatory Fish Poisoning; Dreamfish
Full Text :COPYRIGHT 2006 Taylor & Francis Ltd.
INTRODUCTION
Ichthyosarcotoxism is a type of food poisoning caused via the ingestion of fish. The most common and widely investigated form of ichthyosarcotoxism is ciguatera poisoning that affects the peripheral nervous system. It is due to contamination of fish flesh by various toxins produced by the benthic dinoflagellate Gambierdiscus toxicus. A less common form is ichthyoallyeinotoxism, characterized by development of central nervous system disturbances, especially hallucinations and nightmares. Ichthyoallyeinotoxism has been reported in many locations around the world (1,2). The purpose of this article is to describe two new cases of ichthyoallyeinotoxism that occurred in the Western Mediterranean after ingestion of Sarpa salpa, and to review the literature concerning this rare poisoning.
CASE 1
April 1994
A previously healthy 40-year-old executive began feeling weak and tired within 2 h after eating freshly caught baked sea bream (Sarpa salpa) for dinner while on vacation in Cannes on the French Riviera. Nausea and vomiting developed quickly during the night. The next day symptoms persisted and were accompanied by marked muscle weakness. He decided to shorten his vacation and drive home. At that point, he began to experience blurring of vision and hallucinations involving aggressive and screaming animals. Agitation and disorientation led him to seek medical assistance (he was not able to drive anymore as he was seeing giant arthropods around his car). Physical examination upon arrival at the hospital emergency room demonstrated no notable abnormalities: no fever, no sign of focalization or sensory-motor deficit, and normal hemodynamic status except for sinusal tachycardia linked directly to the mental disturbances. During hospitalization, the patient recovered rapidly with complete resolution of symptoms within 36 h post ingestion. He was unable to recall the hallucinatory period.
CASE 2
March 2002
A previously healthy 90-year-old retiree began experiencing auditory hallucinations 2 h after ingesting a sea bream (Sarpa salpa) that he had purchased from a professional fisherman in Saint Tropez on the French Riviera. He was used to eating this kind of fish, and had cleaned the fish after he had purchased it. Hallucinations were of a particularly terrifying nature (human screams and bird squealing), and he had numerous nightmares for the next two nights. Fearing that these symptoms might signal the beginning of a major mental illness, he did not tell his friends or attending physician. The manifestations abated three days after he had eaten the fish. Later, he recalled a warning that he had heard at the fish market concerning the hallucinogenic potential of sea bream and decided to contact the Poison Control Center in Marseille.
DISCUSSION
Clinical symptoms of ichthyoallyeinotoxism occur within a few minutes to 2 h after ingestion of toxic fish. The first symptoms resemble inebriety with loss of balance and coordination and generalized malaise (1-3). Sore throat and heartburn have also been reported in the initial phase. Within a few hours, specific signs of poisoning occur including delirium, visual and/or auditory hallucinations (often involving animals), depression, feelings of impending death with reactive tachycardia and hyperventilation, and disturbed behavior. If they are able to sleep, patients classically report terrifying nightmares (3). Gastrointestinal symptoms including nausea, abdominal pain, and diarrhea have been described in a few cases, but are usually low-grade (3). No specific treatment or antidote treatment is available. Appropriate management of transient behavioral disturbances (e.g., using benzodiazepine or neuroleptics), is important to prevent self-inflicted or other injury. Symptomatic treatment for gastrointestinal manifestation can enhance patient comfort. Symptoms generally abate within 24 to 36 h, but weakness may persist for several days (1-3).
Ichthyoallyeinotoxism is widespread in tropical and temperate areas of the Indian and Pacific Oceans as well as in the Mediterranean Sea. Toxic fish species belong to the 8 families detailed in Table 1. Most are herbivores or scavengers living in coastal areas. It should be noted that toxicity in all species varies according to fishing location, season, and way of preparing the fish (3). In the Mediterranean, most poisonings involving Sarpa salpa (eaten in Tunisia, France and Israel but considered as inedible in Italy and Spain), have been reported in spring and summer (4-7). A classically reported exacerbating factor is consumption of fish cooked without removing the head, and/or not immediately gutted after being caught (
. Although the toxic agents are still unknown, some authors have implicated toxic macroalgaes (caulerpaceae family) that are ingested and contaminate the flesh of fish (3,4). These toxins are probably heat stable since case reports have been described after ingestion of fried, boiled, steamed or raw fish (3,7). Most cases have been described anecdotally as unexpected, sporadic accidental food poisonings, usually occurring in endemic areas after consumption of fish considered as safe. However some cases of intentional consumption of "dreamfish" have been reported (810). Consumption of Sarpa salpa was reported for recreational purposes in the Mediterranean during the Roman Empire (1 1), and for ceremonial purposes particularly in Polynesian populations (8-10). The traditional names given to hallucinogenic species reflect their potentially toxic effect. Sarpa salpa is called "the fish that makes dreams" in Arab; Siganus spinus is called "the fish that inebriates" in Mascareignes (southwest coast of Reunion Island) (12,13); and Mulloidichthys samoensis is called "the chief of ghosts" in the Hawaiian Islands of Molokai, Kauai, and Oahu (8, 14, 15).It should be emphasized that tropical fish species that cause ichthyoallyeinotoxism are also implicated in cases of ciguatera poisoning. In this regard, there has been some confusion concerning these two forms of ichthyosarcotoxism. Some cases of ichthyoallyeinotoxism reported in the western (11) and eastern Mediterranean (5-7,16) after ingestion of Sarpa salpa or Siganus luridus, have been described as ciguatera despite typical clinical signs of ichthyoallyeinotoxism, (i.e., hallucinations and nightmares lasting for a few hours). In this regard, it should be noted that the presence of Gambierdiscus toxicus, the dinoflagellate solely responsible for ciguatera, has not been formally documented in the Mediterranean. It should be emphasized that there are differences in clinical expression: ichthyoallyeinotoxism is characterized by central nervous system involvement, whereas ciguatera features peripheral nervous system involvement. The two diseases are also different with regard to potential severity and duration. Most patients with ichthyoallyeinotoxism recover within 36 h (1-3), while many patients with ciguatera die or present prolonged symptomatology for several months (17).
CONCLUSION
Ichthyoallyeinotoxism is a rare, poorly understood fish-borne intoxication. Its incidence is probably underestimated for several reasons. The first is that symptoms often occur at night and are short-lived. As a result, patients do not always seek medical advice, as was the case for our second patient. Another reason is that the disease occurs in remote geographical areas (islands and isolated archipelagoes), where there are few medical facilities able to document cases. Finally, voluntary ingestion by its very nature seldom leads to medical intervention. Great care is necessary to avoid confusing ichthyoallyeinotoxism and ciguatera that involve the same species in overlapping endemic areas.
als iemand ervaring heeft met dit zoort vissen of meer weet zou ik dat graag horen
