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Epidemiologic Notes and Reports Restaurant-Associated Scombroid Fish Poisoning -- Alabama, Tennessee

Between December 31, 1985, and January 4, 1986, three restaurants in Alabama and Tennessee received complaints of illness from nine customers and one employee who ate Pacific amberjack fish (also called yellowtail or kahala). Detailed information was obtained on four of the 10 persons. Illness onset occurred 10-90 minutes after eating (median 23 minutes). Symptoms included red facial rash (4/4), body rash (2/4), severe headache (2/4), oral paresthesias (1/4), shortness of breath (2/4), vomiting (1/4), and diarrhea (3/4). Of the three persons who sought medical evaluation, one had diastolic hypotension, and one had bronchospasm. All three were diagnosed as having food or fish allergy and were treated with an antihistamine. Rash persisted for 2-5 hours (median 3 hours), and all other symptoms resolved in 3-36 hours (median 14 hours). One restaurant cook, who did not eat the fish, reported a transient red rash on the hands shortly after handling the fish.

Ill persons reported no other menu items in common. The fish meals were prepared by grilling or frying, and none of the restaurants reported using food preservatives or monosodium glutamate (MSG) on the fish.

In November 1985, a Florida seafood company procured 1,100 pounds of fresh amberjack from southern California. A 120-pound portion was resold December 30 to a distributor that in turn supplied the fish to nine restaurants in Alabama, Kentucky, and Tennessee. After receiving complaints from three of the restaurants, the distributor promptly notified all recipient restaurants and collected 20 pounds of amberjack. Analysis of the leftover fish by the U.S. Food and Drug Administration (FDA) showed 19 of 20 subsamples had markedly elevated levels of histamine (257-430 mg%). (Fresh fish normally contains less than 1 mg% of histamine.) The remaining fish, which had not been distributed, was destroyed under FDA supervision. Reported by JFE Shaw, MPA, Jefferson County Health Dept, Birmingham, WE Birch, DVM, State Epidemiologist, Alabama State Dept of Public Health; RH Hutcheson, MD, State Epidemiologist, Tennessee Dept of Health and Environment; Investigations Br, Nashville District Office, W Staruszkiewicz, Div of Food Technology, Center for Food Safety and Applied Nutrition, US Food and Drug Administration; Div of Field Svcs, Epidemiology Program Office, Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The symptoms of scombroid fish poisoning resemble those of a histamine reaction; the illness is characterized by flushing, headache, dizziness, burning of the mouth and throat, abdominal cramps, nausea, vomiting, and diarrhea. Urticaria and generalized pruritus often occur (1). In severe cases, bronchospasm and respiratory distress may develop (2). Some victims complain that the toxic food has a sharp or peppery taste. Typical incubation periods are less than 1 hour, although wide variations can occur among individuals (1).

Scombroid means mackerel-like; mackerel, tuna, and bonito are related species that are often implicated in outbreaks of scombroid poisoning. However, nonscombroid species, such as the amberjack reported here, have also been implicated in scombroid poisoning (2,3). Of the 73 outbreaks of scombroid poisoning reported to CDC during the 5-year period 1978-1982, 31 (42%) implicated mahi-mahi (dolphin fish), a nonscombroid fish (4).

Poisoning is caused by the ingestion of spoiled fish. Histamine and probably other toxic byproducts are produced by bacterial action on histidine, a normal muscle constituent of dark-meat fishes (5). Scombroid poisoning is a response to toxic by-products--not an allergic reaction to fish. Once formed, the toxins are heat-stable, so the best defense against poisoning is prompt storage of freshly caught fish at 0 C (32 F) or below (6). Laboratory confirmation of scombroid fish poisoning is based on demonstrating elevated histamine levels in incriminated fish (1). Public health authorities should be notified when this or other fish-related illness is suspected so that the distribution of the implicated food can be determined.

References

  1. Hughes JM, Merson MH. Fish and shellfish poisoning. N Engl J Med 1976; 295:1117-20.

  2. Halstead BW. Class osteichthyes: poisonous scombrotoxic fishes. In: Halstead BW. Poisonous and venomous marine animals of the world. Princeton: Darwin Press, Inc., 1978:417-35.

  3. CDC. Foodborne and waterborne disease outbreaks, annual summary 1977.

  4. CDC. Foodborne disease surveillance, annual summary reports, 1978 to 1982.

  5. Arnold SH, Brown WD. Histamine toxicity from fish products. Adv in Food Res 1978;23:113-54.

  6. Behling AR, Taylor SL. Bacterial histamine production as a function of temperature and time of incubation. J Food Sci 1982;47:1311-4.

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