FATAL FISH: A RARE CASE OF BOTULISM AFTER INGESTION OF FERMENTED FISH

Abstract

SESSION TITLE: Case Report Semifinalists 10 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Botulism is a rare, life-threatening neuromuscular syndrome caused be the ingestion of Clostridium botulinum neurotoxin. C botulinum is a spore-forming gram-positive rod that is known to inhabit surfaces of seafood. We discuss the cases of a mother and daughter who presented with variable symptoms of botulism two days after ingesting Fesikh; a traditional Egyptian dish consisting of raw uneviscerated mullet fish fermented in salt water. CASE PRESENTATION: A 30-year-old female and her mother presented to the emergency department with vomiting, diarrhea, and abdominal pain two days after eating Fesikh. The daughter’s symptoms appeared more severe on presentation as she also complained of blurry vision and difficulty speaking. On examination, the daughter was lethargic in appearance and demonstrated difficulty with horizontal eye movements past midline and bilateral Ptosis. Although the patient’s muscle strength in her tongue was intact, her speech was muffled and she complained of difficulty swallowing. Both patients presented hypotensive on admission, however the mother’s blood pressure improved after intravenous fluid resuscitation. The daughter remained hypotensive requiring vasopressor support and was subsequently admitted to the intensive care unit. Although the mother did not demonstrate any symptoms suggestive of cranial nerve involvement on admission, during her hospital stay she began to experience dysphagia and evidence of autonomic dysfunction with dizziness and orthostatic hypotension. Poison Control was contacted and initially suspected Ciguatera toxin poisoning. As our suspicion for botulism remained high given the patient’s cranial nerve abnormalities and recent ingestion of Fesikh, the Center of Disease Control (CDC) was contacted and the decision was made to treat both patients for presumed botulism with heptavalent botulinum antitoxin. After administration of antitoxin, both patients demonstrated significant clinical improvement in their symptoms. Botulism was later confirmed by the CDC after stool, blood and specimens of the fish ingested were analyzed and tested for C botulinum and its neurotoxin. DISCUSSION: Although uncommon, outbreaks of foodborne botulism have occurred after the consumption of fermented fish. Clinical manifestations of botulism vary however, descending flaccid paralysis affecting cranial nerves remains the classic presentation. Common presenting symptoms include blurry vision, diplopia, ptosis, and difficulty speaking and swallowing. When not recognized and treated promptly, botulism can be potentially fatal leading to respiratory collapse. The importance of a thorough history and physical exam are of utmost importance in early recognition of botulism. CONCLUSIONS: When there is a high clinical suspicion, the threshold for treating botulism should be low as delay in treatment can result in increased mortality and worsened overall outcomes. Reference #1: From the Centers for Disease Control. Outbreak of type E botulism associated with an uneviscerated, salt-cured fish product--New Jersey, 1992. (1992). JAMA: The Journal of the American Medical Association, 268(8). https://doi.org/10.1001/jama.268.8.963b DISCLOSURES: No relevant relationships by Pavan Ganapathiaju, source=Web Response No relevant relationships by Pavan Ganapathiaju, source=Web Response No relevant relationships by Daniel Gurrieri, source=Web Response Speaker/Speaker's Bureau relationship with Allergan Please note: $5001 - $20000 Added 03/20/2019 by Frances Loftus, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boerhyinger ingelheim Please note: $1001 - $5000 Added 03/20/2019 by Frances Loftus, source=Web Response, value=Honoraria No relevant relationships by Natalie Millet, source=Web Response