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Acute Hepatitis and Renal Failure Following Ingestion of Raw Carp Gallbladders -- Maryland and Pennsylvania, 1991 and 1994

In some cultures, eating gallbladders from certain species of snakes, birds, or fish is believed to improve health. A syndrome of acute hepatitis and renal failure following the ingestion of raw carp gallbladders has been described previously among persons living in Asia (1-4). This report summarizes two cases of this syndrome that occurred in residents of Pennsylvania who had eaten the raw bile and gallbladders of carp caught in Maryland.

Patient 1. On July 11, 1991, a 59-year-old man who had immigrated from Korea ate the uncooked gallbladder of a carp he had caught in Maryland from a tributary of the Susquehanna River. Six hours after eating the gallbladder, he developed diarrhea and abdominal pain. On July 14, he was admitted to a hospital with mild jaundice and persistent nausea and vomiting. Laboratory testing revealed elevated levels of serum creatinine (10 mg/dL {normal: 0.7-1.5 mg/dL}), total bilirubin (3.5 mg/dL {normal: 0.1-1.2 mg/dL}), and transaminases (aspartate aminotransferase {AST} 171 U/L {normal: less than 54 U/L} and alanine aminotransferase {ALT} 1043 U/L {normal: less than 52 U/L}). Renal ultrasound detected no evidence of hydronephrosis. Despite transient progression of his renal failure, the patient did not require dialysis. He was discharged from the hospital after 6 days with normal urine output, a serum creatinine of 4 mg/dL and normal liver function.

Patient 2. On October 30, 1994, a 41-year-old man who had immigrated from Cambodia ate the raw gallbladders from three carp he had caught at a reservoir near Cowonigo, Maryland. Two hours after eating the gallbladders, he developed transient right upper quadrant abdominal pain, nausea, vomiting, and diarrhea. On November 3, he consulted his physician because of recurrent nausea, abdominal pain, and decreased urinary output. Laboratory findings were consistent with acute hepatitis (AST 1032 U/L, ALT 2028 U/L, and total bilirubin 4.8 mg/dL) and acute renal failure (serum creatinine 6.0 mg/dL). Abdominal ultrasound revealed normal-sized kidneys; there was no evidence of urinary or biliary tract obstruction. The patient was hospitalized for hemodialysis when, 5 days after his exposure, his serum creatinine increased to 12.6 mg/dL. The patient's renal and hepatic function gradually improved, and he was discharged on November 16 with a serum creatinine of 8 mg/dL and markedly improved liver function. Reported by: SJ Goldstein, MD, RM Raja, MD, M Kramer, MD, W Hirsch, MD, Div of Nephrology, Albert Einstein Medical Center, Philadelphia, Pennsylvania. EB May, PhD, Div of Fisheries, Maryland Dept of Natural Resources, Oxford. Foodborne and Diarrheal Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Despite the widespread use of basic public health food safety and hygiene measures, clinicians and public health practitioners have encountered an increasing diversity of foodborne illnesses. Factors contributing to this trend include changes in the technology of food production, greater importation of food from other countries, and a diversification of food preparation and eating habits.

Although acute hepatitis and renal failure following ingestion of raw carp gallbladders have not been reported previously in persons in the United States, such cases have been recognized in persons in Taiwan (1,2), Hong Kong (3), and South Korea (4). Clinical manifestations of this syndrome include acute gastrointestinal symptoms followed several days later by jaundice and oliguria. Histologic studies of kidney and liver tissue specimens from patients demonstrate acute tubular necrosis and focal hepatitis (4). Although the bile component(s) responsible for this syndrome have not been characterized fully (5), cyprinol, a C27 alcohol found in the bile of cyprinid fish, may have a direct toxic affect on the kidneys (1). No specific treatment has been identified; renal and hepatic impairment generally resolve within 3 weeks with supportive care.

Five species of fish belonging to the order Cypriniformes have been associated with bile-induced hepatitis and renal failure (4). Two of these species are found in the United States: the common carp (Cyprinus carpio), which is abundant and widely distributed in North America, and the grass carp (Ctenopharyngodon idellus), which has been introduced in many areas in the eastern United States (J. Sheferland, Chesapeake Bay Field Station, U.S. Fish and Wildlife Service, personal communication, 1995). Because they can be caught without limit, carp are an inexpensive food source used extensively by some populations.

The syndrome of bile-induced hepatitis and renal failure described in this report, in addition to previous reports of foodborne illnesses (e.g., trichinosis {6} and mushroom poisoning {7}), suggest that clinicians should be aware of eating habits and food exposures that may pose a risk for their patients. The cases described in this report also underscore the importance of obtaining careful food histories from patients, including those whose illness may not initially appear to be food-related.

References

  1. Chen WY, Yen TS, Cheng JT, Hsieh BS, Hsu HC. Acute renal failure due to ingestion of raw bile of Grass Carp (Ctenopharyngodon idellus). J Formosan Med Assoc 1976;75:149-57.

  2. Lim PS, Lin JL, Hu SA, Huang CC. Acute renal failure due to ingestion of the gallbladder of grass carp: report of 3 cases with review of the literature. Renal Failure 1993;15:639-44.

  3. Chan DWS, Yeung CK, Chan MK. Acute renal failure after eating raw fish gall bladder. BMJ 1985;290:897.

  4. Park SK, Kim DG, Kang SK, et al. Toxic acute renal failure and hepatitis after ingestion of raw carp bile. Nephron 1990;56:188-93.

  5. Yip LL, Chow CL, Yung KH, Chiu KW. Toxic material from the gallbladder of the grass carp (Ctenopharyngodon idellus). Toxicon 1981;19:567-9.

  6. CDC. Trichinella spiralis infection -- United States, 1990. MMWR 1991;40:57-60.

  7. CDC. Mushroom poisoning among Laotian refugees -- 1981. MMWR 1982;31:287-8.


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