ʻO ka iʻa ʻawaʻawa ʻo Ciguatera (Ke hoʻohuli ʻana i ke anuanu wela, Bradycardia) vs. Scombroid Histamine Fish Flush and Shellfish Toxins¶

ʻO ka hoʻoulu ʻana i ka ʻūhū koke ʻana a puni ka waha, ka ʻili ʻā i ka wā e hoʻopā ai i ka wai anuanu, ka ʻulaʻula ʻulaʻula o ka maka, ka ʻūlū, a i ʻole ka pilikia hanu ma hope koke o ka ʻai ʻana i ka iʻa ʻāʻī, nā steak pelagic, a i ʻole nā ​​​​iʻa bivalve e pono ai ka hoʻokaʻawale wikiwiki ʻana i waena o nā biotoxins moana nui. Kāhea i kāu helu ulia pōpilikia kūloko (911 ma ʻAmelika Hui Pū ʻIa a me Kanada, 112 ma waena o ka European Union, 999 ma United Kingdom) a i ʻole e nīnau i kā mākou papa kuhikuhi helu ulia pōpilikia honua inā hōʻike koke ka hale ʻaina i ka lohi o ka puʻuwai, ke koko haʻahaʻa, ka haʻalulu, ka huikau, a i ʻole ka nāwaliwali o ka ʻiʻo. No ka mea ʻo Scombroid fish poisoning pili loa i ka IgE-mediated maʻi maʻi a i ʻole anaphylaxis, ʻoiai ʻo Ciguatera, Domoic Acid, a me Brevetoxin e hoʻokō i kā mākou ākea ākea. ʻO ka botulism a me ka paralytic shellfish neurotoxin triage guide, Pono nā mea pane e hoʻokaʻawale i kēia mau mea hoʻopaʻa wela mai ka bacteria ka ʻai ʻana a me ka maʻi gastroenteritis.

ʻO ka kuke ʻana, ka paila ʻana, ka palai ʻana, ka puhi ʻana, ka puhi ʻana, ka hau, a i ʻole ka hoʻomoʻa ʻana i ka iʻa i loko o ka wai lime (ceviche) ʻAʻole e luku i kekahi o kēia mau meaʻawaʻawa moana. Eia kekahi, ʻo ka iʻa ʻawaʻawa a me ka iʻa iʻa ke nānā aku, honi, a me ka ʻono maʻamau loa (koe wale nō ka ʻai ʻana i ka peppery a i ʻole ka nahu metala i ka iʻa scombroid). Pono e hoʻokaʻawale koke nā kauka lapaʻau a me nā huakaʻi ma waena o ʻehā mau maʻi marine nui: 1. ** ʻO ka ʻona iʻa Ciguatera (CFP):** Ma muli o ka ʻai ʻana i nā iʻa ʻāwīwī nui (barracuda, grouper, red snapper, amberjack, moray eel, hogfish, Spanish mackerel, coral trout) loaʻa nā ciguatoxins (CTX) bioaccumulated mai ka dinoflagellate benthic Gambierdiscus toxicus. Loaʻa me ka gastroenteritis acute (2 to 12 hours), hiki i ke ola ** sinus bradycardia a me ka hypotension**, a me ka pathognomonic ** alodynia anu (hot-cold temperature reversal), mālama ʻia i loko 48 to 72 hours me ka hoʻohana ʻana i ke koko 20% Mannitol (1.0 g/kg) me ka ʻai paʻa 6 mau mahina e pale i ka hoʻomaka ʻana. 2. Scombroid (Histamine) Ka ʻona iʻa: Ma muli o ka ʻai ʻana i ka iʻa ʻeleʻele i hoʻopaʻa ʻia i ka pahu hau (tuna, mahi-mahi [dorado], bluefish, mackerel, bonito, marlin, sardines, anchovies) kahi e hoʻololi ai ka bacteria o ka ʻili i ka ʻiʻo L-histidine i mau nui o histamine. Hāʻawi i loko 10 to 60 minutes ma ke ʻano he ** "like me ka lā" histamine flush, ka ʻūhā ʻana o ke poʻo, palpitations, a me ka bronchospasm, mālama wikiwiki ʻia me H1 a me H2 antihistamines (not permanent fish allergy). 3. Amnesic Shellfish Poisoning (ASP - Domoic Acid): Hoʻokumu ʻia e Pseudo-nitzschia ka pua ʻana o ka diatom i loko o nā ʻiʻo, nā ʻili pahi, nā scallops, a me Dungeness crab viscera; hoʻoulu nui ʻia hippocampal AMPA/kainate glutamate receptors, e hoʻoulu ai i ke kūlana epilepticus a me ka ka pohō hoʻomanaʻo no ka wā pōkole anterograde. 4. Neurotoxic Shellfish Poisoning (NSP - Brevetoxin): Hoʻokumu ʻia e Karenia brevis ("Florida / Gulf of Mexico red tide") nā dinoflagelates i loko o nā ʻoʻo a me nā pāpaʻi; hoʻāla i nā ala sodium i hoʻopaʻa ʻia i ka uila (e like me ka ciguatoxin) e hana i ** allodynia anuanu**, paresthesia, a me ka bronchospasm kahakai aerosolized me ka ʻole o ka lolo.

+-------------------------------------------------------------------------+
|            MARINE SEAFOOD TOXIN RAPID DIFFERENTIATION MATRIX            |
+-------------------------------------------------------------------------+
|  1. CIGUATERA FISH POISONING (Barracuda, Grouper, Snapper, Amberjack)   |
|     * Toxin: Ciguatoxin (Locks open Na+ channels) -> Onset 2 to 12 hrs  |
|     * Hallmarks: Cold Allodynia (Ice feels like burning fire), Tooth    |
|       ache/loose-tooth sensation, Severe Bradycardia (HR < 45) & Low BP |
|     * Treatment: IV Atropine + Fluids; IV 20% Mannitol (1 g/kg over     |
|       30-45m AFTER full rehydration, within 48-72h) + 6-Month Diet      |
+-------------------------------------------------------------------------+
|  2. SCOMBROID HISTAMINE POISONING (Tuna, Mahi-Mahi, Mackerel, Bluefish) |
|     * Toxin: Bacterial Histamine (from warm storage) -> Onset 10-60 min |
|     * Hallmarks: Peppery/metallic taste, Bright Red Face/Neck Flush,    |
|       throbbing headache, tachycardia, diarrhea (NOT a true allergy)    |
|     * Treatment: IV/PO H1 Blocker (Diphenhydramine/Cetirizine) + H2     |
|       Blocker (Famotidine 20 mg IV); Epinephrine only if bronchospasm   |
+-------------------------------------------------------------------------+
|  3. AMNESIC SHELLFISH POISONING (Mussels, Razor Clams, Crab Viscera)    |
|     * Toxin: Domoic Acid (Glutamate excitotoxin) -> Onset 15m to 38 hrs |
|     * Hallmarks: Vomiting -> Confusion, Status Epilepticus, Permanent   |
|       loss of short-term memory (Hippocampal necrosis)                  |
+-------------------------------------------------------------------------+
|  4. NEUROTOXIC vs. PARALYTIC SHELLFISH POISONING (Oysters, Clams)       |
|     * NSP (Brevetoxin): Na+ channel opener -> Cold allodynia, NO apnea  |
|     * PSP (Saxitoxin): Na+ channel blocker -> Rapid respiratory arrest  |
+-------------------------------------------------------------------------+

E hana i kēia i kēia manawa¶

1. E loiloi koke i ka hanu, ka nui o ka naʻau, a me ke koko, a kāhea aku i nā lawelawe pilikia. Kāhea i ka 911 (US a me Kanada), 112 (European Union), 999 (United Kingdom), 000 (Australia), a i ʻole 111 (New Zealand).
2. Ina ua ai ke kanaka tuna a mahi-mahi 15 minutes i hala aku nei a i kēia manawa he ʻūhū, ʻāʻī ʻāʻī, a pehu paha ke alelo (Scombroid koʻikoʻi), hoʻohana i kahi epinephrine auto-injector (EpiPen) i loko o ka ʻūhā waho inā loaʻa, a hāʻawi i ka diphenhydramine waha (Benadryl, 25 to 50 mg) aiʻole cetirizine (10 mg) me famotidine (Pepcid, 20 mg) inā hiki iā lākou ke moni pono.
3. Inā ʻai ke kanaka i ka barracuda, grouper, ʻulaʻula, a i ʻole amberjack 2 to 8 hours i ka wā i hala a ʻeha ʻia a ʻeha paha me ka ** puʻuwai lohi (below 50 beats per minute)** (Ciguatera), e hoomoe ia lakou ma ke kua me ke kiekie o na wawae 30 centimeters (12 inches) e mālama i ke kahe o ke koko i ka lolo i ka wā e kali ana i nā mea lapaʻau me ka atropine a me ka paʻakai maʻamau.
4. E hana i ka ʻaoʻao moe "Cold Object Test" no Ciguatera a i ʻole Brevetoxin. E hoʻopā i ka mea maʻi i ke kini wai anuanu, kahi pahu hau, a i ʻole ka wai piʻi anuanu. Inā manaʻo ka mea anu e like me ke ahi ʻeha, ka hau maloʻo, a i ʻole nā ​​haʻalulu uila (cold allodynia / hot-cold temperature reversal), ʻaneʻane maopopo loa ka hōʻike ʻana ʻo Ciguatera Fish Poisoning (inā ʻai ʻia ka iʻa ʻāʻu) a i ʻole Neurotoxic Shellfish Poisoning (Brevetoxin) (inā ʻai ʻia ke kahawai ʻo Mexico / subtropical shellfish). (Gulf of Mexico)
5. Mai inu i ka wai hau a i ʻole ʻauʻau anuanu inā manaʻo ʻia ʻo Ciguatera. ʻO ka inu ʻana i ka wai anuanu e hoʻoulu ai i ka ʻeha wela ma lalo o ka ʻāʻī a me ka esophagus, a ʻo ka wai anuanu ma ka ʻili ke kumu o ka paresthesia ʻeha. Hāʻawi wale ** i ka wai wela o ka lumi a i ʻole ka wai hoʻomaʻemaʻe waha** i nā sips liʻiliʻi.
6. E hōʻoia i ka hoʻomaʻemaʻe hou ʻana o ka wai i loko o ke koko ma mua o ka hāʻawi ʻana i ka Mannitol Intravenous no Ciguatera. E haʻi aku i ke kauka ulia pōpilikia ua loaʻa ka maʻi maʻi Ciguatera Fish Poisoning i loko o ka 48 to 72 hour pukaaniani no ** Intravenous 20% Mannitol (1.0 gram/kg). Eia nō naʻe, no ka mea he mana osmotic diuretic ikaika ka mannitol a ʻo Ciguatera ke kumu o ka luaʻi mua ʻana a me ka maʻi maʻi, ** pono e hoʻokomo wale ʻia ka mannitol ma hope o ka hoʻoponopono ʻana o ka hypovolemia a me ka dehydration. 1 to 2 liters ʻO nā crystalloids intravenous isotropic (0.9% saline maʻamau a i ʻole Lactated Ringer's).
7. **E mālama a hoʻokuʻu i ka iʻa a i ʻole ka iʻa a e ʻōlelo aku i nā mea ʻai ʻē aʻe a pau.FDA / state marine lab liquid chromatography-mass spectrometry). E hoʻokaʻaʻike koke aku i nā mea a pau i kaʻana like i ka iʻa.

Ka lāʻau hoʻoholo: Ka hoʻāʻo ʻana i ka iʻa moana a me ka iʻa ʻawaʻawa¶

flowchart TD
    A["ʻO ka maʻi koʻikoʻi ma hope o ka ʻai ʻana i ka iʻa a i ʻole ka iʻa"] --> B{"He aha ke ʻano o ka iʻa i ʻai ʻia?"}
    B -->|"ʻO ka iʻa pelagic ʻeleʻele (Tuna, Mahi-Mahi, Mackerel, Bluefish, Sardines)"| C{"Hoʻomaka i ka 10-60 min me ka ʻulaʻula ʻulaʻula a me ka ʻāʻī a me ka tachycardia?"}
    B -->|"ʻO nā iʻa ʻaʻahu ʻāʻī (Barracuda, Grouper, Snapper, Amberjack, Eel)"| D{"ʻO ka maʻi ʻeha (2-12h) + Allodynia Cold, ʻEha niho, a i ʻole Bradycardia?"}
    B -->|"ʻO ka iʻa Bivalve (Mussels, Clams, Oysters, Scallops) a i ʻole Crab Viscera"| E{"Hoʻokaʻawale i ka Shellfish Syndrome e nā hōʻailona Neurological"}
    C -->|"ʻAe"| F["SCOMBROID (HISTAMINE) FISH POISONING: Hāʻawi IV / PO H1 Blocker (Diphenhydramine 25-50 mg) + H2 Blocker (Famotidine 20 mg IV); Albuterol/Epi inā ʻo Wheezing"]
    D -->|"ʻAe"| G["KA LUNA I'A CIGUATERA (CFP): Ho'ola Mua me 1-2 L IV 0.9% Saline + IV Atropine (0.5-1 mg) no Bradycardia/Hypotension"]
    G --> H["Once Euvolemic (a i loko o 48-72h): Infuse 20% IV Mannitol (1.0 g / kg ma luna o 30-45 min); E hoʻokō i ka meaʻai ʻaʻai ʻana i nā mahina 6 mahina"]
    E -->|"Pioloke, Hoʻohaunaele, Hoʻopaʻa ʻia, Pohō hoʻomanaʻo no ka wā pōkole"| I["AMNESIC SHELLFISH POISONING (Domoic Acid): ICU Airway Protection + IV Benzodiazepines/Phenobarbital for Status Epilepticus"]
    E -->|"Allodynia anu + ʻuʻuku maʻamau"| J["NEUROTOXIC SHELLFISH POISONING (Brevetoxin - Red Tide): Nā wai kōkua IV + Albuterol no ka Bronchospasm"]
    E -->|"ʻO ka piʻi wikiwiki ʻana o ka Maka/Lamb Numbness + Diaphragmatic Paralysis"| K["KA POISONING SHELLFISH PARALYTIC (Saxitoxin): Hoʻokomo koke i ka Endotracheal Intubation & Mechanical Ventilation"]

Hoʻohālikelike piha o nā maʻi biotoxin 4 moana¶

ʻO ka maʻi maʻi 1: ʻona iʻa Ciguatera (CFP): Pathophysiology, Mannitol Protocol, a me ka ʻai 6-Mahina¶

** ʻO Ciguatera Fish Poisoning** ʻo ia ka maʻi ʻawaʻawa iʻa iʻa ʻole bacteria maʻamau i ka honua, e pili ana 50,000 to 500,000 kanaka i kēlā me kēia makahiki ma nā ʻāpana kāʻei endemic ma waena o nā latitu 35 degrees North a 35 degrees South (ka Caribbean, South Florida, ke Kaikuono o Mekiko, Hawaii, French Polynesia, Australia's Great Barrier Reef, South Pacific, and the Indian Ocean). Ma muli o ka hoʻouna ʻana o ka mokulele mokulele honua i nā iʻa hou i ka honua holoʻokoʻa, hōʻike pinepine ʻia nā maʻi maʻi Ciguatera i nā keʻena pilikia ma New York, London, Toronto, Paris, a me Tokyo. (Gulf of Mexico)

1. ʻO ka meaʻai-Chain Bioaccumulation: No ke aha ka mea ʻoi loa ka pōʻino o nā mea ʻaihue nui¶

• Ke hoʻopōʻino ʻia nā ʻākoʻakoʻa e ka ʻino, ka bleaching, dredging, a i ʻole ka holo ʻana o ke kahakai, lilo nā ʻili koʻakoʻa make i colonized e nā microscopic benthic dinoflagellates o ka genus Gambierdiscus (G. toxicus, G. polynesiensis).
• ʻAi nā iʻa liʻiliʻi herbivorous i ka macroalgae e uhi ana i ke koʻa a ʻai i gambiertoxins. No ka mea, ʻai ʻia nā iʻa liʻiliʻi e nā iʻa kai ʻai, a ʻai ʻia nā iʻa waena e nā pex reef predators (barracuda, grouper nui, ʻulaʻula, amberjack, kingfish, moray eel), ua hoʻoheheʻe ʻia nā toxins hiki ke hoʻoheheʻe ʻia i ka lipid e nā enzyme ate iʻa i loko o ciguatoxins (P-CTX-1, C-CTX-1, I-CTX) a hoʻonui i ke kaulahao meaʻai.
• No ka mea, he mea ino ole ka ciguatoxin i ka i'a ponoi, a 10-kilogram (22-pound) ʻo ka barracuda a i ʻole grouper ke nānā aku i ke olakino ʻoiai e lawe ana i kahi maʻi kanaka make i loko o kona ʻiʻo a me kona mau kino.

2. ʻO ka maʻi maʻi: No ke aha e like ai ka wai anuanu e like me ke ahi ʻā (Cold Allodynia)¶

+-------------------------------------------------------------------------+
|     MECHANISM OF CIGUATOXIN COLD ALLODYNIA & MANNITOL RESCUE            |
+-------------------------------------------------------------------------+
|  1. Ciguatoxin (CTX) binds Site 5 on Voltage-Gated Sodium Channels      |
|     (Nav1.6 / Nav1.8) in peripheral C-polymodal nociceptors & A-delta   |
|     cold-sensing nerve fibers                                           |
|  2. Shifts activation voltage to resting potential -> Spontaneous,      |
|     repetitive nerve depolarization whenever skin cools below 24-26 C   |
|     -> Brain interprets cold input as intense BURNING HEAT (Allodynia)  |
|  3. Continuous Na+ influx draws water osmotically into axons and        |
|     myelinating Schwann cells -> Acute Paranodal Schwann Cell Edema     |
+-------------------------------------------------------------------------+
|  HOW INTRAVENOUS 20% MANNITOL (1.0 g/kg) REVERSES ACUTE CIGUATERA:      |
|  * Creates an intravascular osmotic gradient that pulls trapped water   |
|    OUT of swollen Schwann cells and nerve axons at the nodes of Ranvier |
|  * Competitively displaces Ciguatoxin from sodium channel membranes     |
|    and scavenges free hydroxyl radicals generated by nerve ischemia     |
+-------------------------------------------------------------------------+

3. ʻO ka 3 Clinical Systems i hoʻopili ʻia e Ciguatera¶

1. ** ʻĀpana ʻōpū (Onset 2 to 12 hours, mau loa 24 to 48 hours):** ʻO ka maʻi maʻi wai hikiwawe, nausea, luaʻi, hoʻohuhū nui, a me ka ʻōpū o ka ʻōpū.
2. ** ʻĀpana Autonomic Cardiovascular (Onset 2 to 24 hours, mau loa 2 to 5 days):** Hoʻoulu ʻo Ciguatoxin i nā fiber vagal cardiac a me nā ala sodium autonomic, e hoʻoulu ai i ** sinus bradycardia weliweli i ke ola (heart rate 30 to 45 bpm)**, poloka naʻau AV, a me ke kuhiakau koʻikoʻi (systolic BP < 70 to 80 mmHg).
3. Pathognomonic Neurological Phase (Onset 3 to 72 hours, mau loa weeks to months:
4. Circumoral and Acral Paresthesia: ʻO ka ʻeha nui a me ke kani ʻana a puni nā lehelehe, ke alelo, ka ʻāʻī, nā manamana lima, a me nā manamana wāwae.
5. ** Allodynia anu (Hot-Cold Temperature Reversal):** ʻIke ʻia ma 70% to 90% o na hihia. ʻO ka hoʻopā ʻana i kahi puʻupuʻu puka anu, ka piʻi ʻana ma luna o ka papahele ʻili maloʻo, a i ʻole ka inu ʻana i ka wai anuanu ke kumu o ka ʻeha, ʻā, a i ʻole ka ʻeha ulia.
6. ** ʻO ka ʻeha niho (Odontalgia):** He manaʻo maʻamau ʻo ka niho ua hemo i ko lākou kumu a i ʻole e ʻeha ʻeha ke nahu i lalo.
7. Pruritus ("La Gratte"): ʻO ka ʻeha maʻamau ma luna o nā poho lima, nā kapuaʻi, a me ke kumu e ʻoi aʻe ana i ka pō, me ka luhi hoʻi.asthenia), myalgias, arthralgias, dysuria, a me dyspareunia.

4. Kaʻina Haukapila i kēlā me kēia ʻanuʻu: Nā wai, Atropine, a me Intravenous 20% Mannitol¶

1. ** KaʻAnuʻu 1: Hoʻoponopono i ka Dehydration a me Bradycardia FIRST (Mandatory Pre-Mannitol Stabilization:**
2. Infuse 1 to 2 liters o 0.9% paʻakai maʻamau a i ʻole Lactated Ringer's i loko o ke koko a hiki i ka wikiwiki o ka puka ʻana o ka mimi (> 0.5 to 1.0 mL/kg/hour) a me ka mucous membrane ua pulu.
3. No ka hōʻailona bradycardia (HR < 50 bpm) a i ʻole hypotension, hāʻawi ** Intravenous Atropine (0.5 to 1.0 mg IV pana i kēlā me kēia 5 minutes, a hiki i 3 mg)** a hoʻohui i kahi haʻahaʻa haʻahaʻa dopamine a i ʻole norepinephrine infusion inā mau ka hypotension ma hope o ka hoʻopiha ʻana i ka wai.
4. ** KaʻAnuʻu 2: Infusion 20% Mannitol Infusion (Within 48 to 72 Hours of Ingestion:**
5. No ke aha he mea nui ka manawa a me ka wai: ʻOi aku ka maikaʻi o ka mannitol intravenous ke hāʻawi ʻia i loko o ka mua 24 to 48 hours (up to 72 hours) o ka hoʻomaka ʻana o ka hōʻailona. ** MAI hoʻokomo i ka mannitol i loko o ka mea maʻi dehydrated a hypotensive paha**, no ka mea, e hoʻoneʻe ka diuresis osmotic i ka haʻalulu hypovolemic a me ka necrosis tubular acute.
6. Polokia Dosing Pono: I ka wā e hoʻomaʻamaʻa ʻia ai ka mea maʻi a normotensive, hoʻokomo 1.0 gram per kilogram (1.0 g/kg, a i ʻole 5 mL/kg o a 20% Mannitol solution) i loko o ke koko ma luna o 30 to 45 minutes.
7. E hana hou i ka Dosing: Inā hahai ʻia ka hōʻoluʻolu neurosensory e kahi hoʻihoʻi hapa i ka lā aʻe, kahi lua 1.0 g/kg kaʻina o 20% Hiki ke hoʻohana ʻia ka mannitol 12 to 24 hours ma hope me ka mālama ʻana i ka crystalloid pani.
8. ** KaʻAnuʻu 3: Hōʻailona hōʻailona no Subacute/Chronic Neuropathy (Weeks 1 to 12:**
9. Inā hōʻike ka mea maʻi ma mua o 72 hours ma hope o ka ʻai ʻana, kuhikuhi waha Gabapentin (300 to 600 mg ʻekolu manawa i kēlā me kēia lā), Pregabalin (75 to 150 mg ʻelua manawa i kēlā me kēia lā), a i ʻole Amitriptyline (25 to 50 mg i ka wā e moe ai) e hoʻopau i ke anu allodynia a me ka pruritus.

5. ʻO ke koi ʻana o 6 mau mahina Ciguatera Trigger-Avoidance Diet¶

Ma muli o ka lipophilic ciguatoxin i hoʻopaʻa ʻia i loko o nā membrane nerve peripheral a me ka ʻiʻo adipose no nā mahina, ʻo nā meaʻai a me nā mea inu e hoʻonui ai i ke kahe o ke koko, hoʻokuʻu i ka histamine, a hoʻololi paha i nā lipid membrane nerve ** e hoʻoulu hou i ka hoʻihoʻi hou ʻana o ka Ciguatera piha piha, paresthesia wela, a me ka luhi** 3 to 6 months ma hope o ka manaʻo o ka mea maʻi. Pono kēlā me kēia maʻi Ciguatera e pale pono i kēia mau mea no 3 to 6 months: * ʻO nā iʻa a pau, ka iʻa iʻa, a me ka iʻa (ʻo ia hoʻi ka iʻa wai anuanu, ka salmon mahiʻai, a i ʻole ka tuna hiki ke loaʻa ʻole ciguatoxin, ʻo ka ʻai ʻana i nā pūmua iʻa e hoʻomaka koke ka hōʻailona). * ** ʻO nā mea inu ʻawaʻawa a pau** (beer, waina, ʻawaʻawa, waiʻona ka mea hoʻokahi e hoʻomaka ai ka hoʻihoʻi hou ʻana o Ciguatera a me ka hypotension koʻikoʻi/bradycardia). * Nati, pīkī, a me nā aila hua (me ka pīkī pīkī, nā ʻalemona, nā wōnati, a me ka sesame). * Kafeina a me nā meaʻai histamine kiʻekiʻe (kofe, mea inu ikaika, kokoleka ʻeleʻele, a me nā ʻiʻo i hoʻōla ʻia).

ʻO ka maʻi maʻi 2: Scombroid (Histamine) Ka ʻona iʻa: The Anaphylaxis Mimic¶

Ka ʻona iʻa Scombroid (histamine fish poisoning) he mea ʻona kemika nui, ʻaʻole he maʻi maʻi iʻa i ke ola holoʻokoʻa, ma muli o ka ʻai ʻana i nā iʻa i loaʻa ** ka hoʻomāinoino ʻana i ka wela o ka manawa** (stored above 4.4 degrees Celsius [40 degrees Fahrenheit] for more than 3 to 4 hours) ma waena o ka hopu a me ka kuke ʻana.

ʻO ka maʻi maʻi: Bacterial Histidine Decarboxylase¶

ʻO nā iʻa pelagic ʻeleʻele mai nā ʻohana Scombridae (tuna, mackerel, bonito, skipjack, albacore) a me Scombresocidae, a me nā ʻano mea ʻole-scombroid (mahi-mahi / dorado [Coryphaena hippurus], bluefish, amberjack, marlin, swordfish, escolar, sardines, anchovies, and herring), loaʻa maoli nā pae kiʻekiʻe loa o ka ʻakika amino manuahi L-histidine (> 1,000 mg/100 g) i loko o ko lākou ʻiʻo ʻiʻo. * Inā waiho ʻia ka iʻa ma luna o ka papa moku mehana, hoʻoheheʻe ʻia ma ka pā hale ʻaina, a mālama ʻia paha i loko o ka pahu hau mahana, e hoʻonui ʻia nā bacteria gram-negative enteric ma nā gills a me ka ʻōpū (Morganella morganii, Klebsiella pneumoniae, Hafnia alvei, Photobacterium phosphoreum) e hoʻonui a hana i ka enzyme histidine. * I loko o nā hola, hoʻohuli ʻo histidine decarboxylase i ka ʻiʻo L-histidine i loko o ka nui o ka ** histamine** (often > 50 to 500 milligrams per 100 grams o ka i'a; loaʻa nā iʻa hou maʻamau < 1 mg/100 g), me ka biogenic diamines (putrescine a me cadaverine) e pale ana i ka histaminases intestinal kanaka (diamine oxidase [DAO] a histamine N-methyltransferase) a hoʻoikaika i ka histamine absorption nui i loko o ke kahe koko. * ʻOiai inā e hoʻokuʻu ka iʻa ma hope o ka hale ʻaina a ʻā a hoʻolapalapa paha i ka wela nui, ** make ka bacteria, akā mau ka histamine i hana mua ʻia he 100% paʻa a paʻa **.

+-------------------------------------------------------------------------+
|       SCOMBROID POISONING vs. TRUE IgE SEAFOOD ALLERGY TRIAGE           |
+-------------------------------------------------------------------------+
|  SCOMBROID (HISTAMINE) POISONING:                                       |
|  * Fish had a "peppery," "metallic," or "fizzy" bite on the tongue      |
|  * Multiple diners at the same table eating the tuna/mahi get sick      |
|  * Bright red "sunburn" flush on face, neck, and upper chest (often     |
|    WITHOUT raised wheals/hives) + throbbing histamine headache          |
|  * Patient has eaten the exact same fish species safely in the past     |
|    and CAN safely eat properly refrigerated fish again in the future    |
+-------------------------------------------------------------------------+
|  TRUE IgE-MEDIATED SEAFOOD ALLERGY (ANAPHYLAXIS):                       |
|  * Only the allergic individual reacts; other diners are unaffected     |
|  * Prominent raised pruritic urticaria (hives), angioedema of lips/     |
|    tongue, laryngeal stridor, and hypotensive anaphylactic shock        |
|  * Requires lifelong fish avoidance and an Epinephrine Auto-Injector    |
+-------------------------------------------------------------------------+

ʻAʻai-ma-Step Scombroid Lapaʻau Protocol¶

1. Palua H1 + H2 Antihistamine Blockade (The Definitive Cure:
2. Hāʻawi i kahi H1 receptor antagonist: Diphenhydramine (Benadryl, 25 to 50 mg IV a ma ka waha paha; 1 mg/kg i nā kamaliʻi) a i ʻole ka mea hoʻopaʻa H1 hanauna lua ʻole (Cetirizine 10 mg IV/PO).
3. Hoʻohana like i ka H2 receptor antagonist: Famotidine (Pepcid, 20 mg IV a ma ka waha paha; 0.5 mg/kg i nā keiki) a i ʻole Cimetidine (300 mg IV) / Ranitidine. Ma muli o ka hōʻike ʻana o nā kīʻaha koko a me ka myocardium i ka H1 a me ka H2 histamine receptors, ʻo ka hui pū ʻana i ka H1 a me H2 blocker e hoʻonā i ka ʻili o ka maka, ka ʻeha ʻeha, ka tachycardia, a me ka ʻōpū o ka ʻōpū i loko o 15 to 30 minutes.
4. ** ʻO ka manawa e hāʻawi ai i ka Epinephrine a me nā Bronchodilators:** ʻO ka hapa nui o nā maʻi scombroid e hoʻopau iā ia iho (resolving in 6 to 12 hours) a ʻaʻole koi i ka epinephrine. Eia nō naʻe, i nā poʻe maʻi me ka ** hānō** lalo, nā poʻe maʻi ʻelemakule me ka maʻi aʻa coronary, a i ʻole nā ​​mea maʻi e lawe ana i ka ** Isoniazid (INH)** aiʻole Monoamine Oxidase Inhibitors (MAOIs) (ʻo ia ka mea e ālai ai i ka haʻihaʻi ʻana o ka histamine endogenous a hoʻoulu i ka fulminant scombroid shock), hiki i ka histamine exogenous ke hoʻoulu bronchospasm koʻikoʻi (wheezing) aiʻole vasoplegic hypotension. Hāʻawi i ka nebulized albuterol (salbutamol, 2.5 to 5 mg), nā wai i loko o ke koko, a me ka intramuscular epinephrine (0.3 to 0.5 mg o 1 mg/mL [1:1,000] i loko o ka ʻūhā anterolateral) inā pilikia ka hanu a i ʻole ka hypotension.
5. Hoʻonaʻauao ma mua o ka hoʻokuʻu ʻia ʻana: E hōʻoiaʻiʻo i ka mea maʻi (a palapala maopopo i kā lākou palapala lapaʻau) ua loaʻa iā lākou Scombroid (histamine) meaʻai ʻona mai ka iʻa i hoʻopaʻa ʻole ʻia, ʻaʻole he maʻi iʻa hou, no laila ʻaʻole pono lākou e hōʻailona ʻia i ka maʻi i ka iʻa a i ʻole ke kala like ʻole.

ʻO Syndrome 3 & 4: Nā Neurotoxins Shellfish: Amnesic (Domoic Acid) vs. Neurotoxic (Brevetoxin) vs. Paralytic (Saxitoxin)¶

1. ʻAi ʻAna ʻAmnesic Shellfish (ASP: Domoic Acid)¶

• Source and Mechanism: Hana ʻia e nā diatoms moana o ka genus Pseudo-nitzschia ma ka Pākīpika Northwest, Kaleponi, ʻAkelanika Kanada (Prince Edward Island, kahi i puka mai ai ka laha kanaka mua ma 1987), ʻEulopa, a me New Zealand. ʻO Domoic acid he mea hoʻohālikelike o ka kainic acid a me ka excitatory neurotransmitter L-glutamate. Hoʻopili ia me ka pili kiʻekiʻe i AMPA a me kainate glutamate receptors i hoʻopaʻa nui ʻia i ka ** CA1 a me CA3 ʻāpana o ka hippocampus kanaka ** a me amygdala, e hoʻoulu ai i ka calcium mau loa (Ca2+) influx a me neuronal excitotoxic necrosis.
• Ka Papa Hana Ola: Iloko 15 minutes to 24 hours ʻO ka ʻai ʻana i nā ʻū i hoʻohaumia ʻia, ka pahi pahi, a i ʻole Dungeness crab viscera, e ulu ana nā mea i loaʻa i ka nausea, ka luaʻi, a me ka ʻōpū o ka ʻōpū. Iloko 4 to 48 hours (ʻoi loa i ka poʻe ʻelemakule a i ʻole nā ​​maʻi me ka maʻi maʻi maʻi maʻi, ʻoiai ua holoi ʻia ka ʻakika domoic ma ka renal), hiki ke loaʻa nā mea ʻawaʻawa neurological: ** huikau, disorientation, mutism, chewing/grimacing automatisms, unstable blood pressure, myoclonus, refractory status epilepticus, and coma**. Loaʻa pinepine ka poʻe i ola ** nalo hoʻomanaʻo no ka wā pōkole anterograde** (hiki ʻole ke hana i nā mea hoʻomanaʻo hou ma hope o ka ʻai ʻana, e like me Korsakoff psychosis a i ʻole bilateral hippocampal resection).
• Lapaʻau: ʻAʻohe lāʻau lapaʻau. Hāʻawi mua i ka lāhuhi hoʻōla (within 1 to 2 hours), ikaika intravenous hydration e hoʻonui i ka hoʻomaʻemaʻe renal o ka wai-soluble domoic acid, a me GABA-A agonists kiʻekiʻe (IV lorazepam, midazolam, phenobarbital, a propofol) e hoʻopau i ke kūlana epilepticus excitotoxic hippocampal (phenytoin is ineffective against domoic acid seizures).

2. ʻO ka lāʻau ʻawaʻawa neurotoxic (NSP: Brevetoxin)¶

• Kumu a me Mechanism: Hana ʻia e ka dinoflagellate ʻaʻohe mea kaua Karenia brevis (formerly Gymnodinium breve), ka mea ola nona ke kuleana o Florida a me ke Kaikuono o Mekiko "Red Tides" (a me na pua like ma New Zealand). Brevetoxins ( (Gulf of Mexico)PbTx) hoʻopaʻa iā Site 5 ma nā kahawai sodium-gated voltage, ka pūnaewele hoʻokipa like me Ciguatoxin.
• ʻElua Alanui o ka Hōʻike:
• Oral Shellfish Ingestion: ʻO ka ʻai ʻana i nā ʻo, nā pāpaʻi, a i ʻole nā coquinas i hoʻopōʻino ʻia ke kumu o ke kani ʻana o nā lehelehe, ke alelo, a me ka ʻāʻī i loko. 30 minutes to 3 hours, ukali ʻia e ka luaʻi, ka maʻi ʻaʻai, ka noʻonoʻo, ataxia, ** Cold Allodynia (hot-cold temperature reversal), nā haumāna i hoʻopaʻa ʻia, a me ka bradycardia māmā. 'A'ole like me ka Poisoning Shellfish Paralytic (Saxitoxin), ** ʻAʻole ʻo NSP e hoʻoulu i ka maʻi hanu, a hoʻōla loa nā maʻi i loko 2 to 3 days me nā wai kōkua IV.
• Hōʻai Aerosol Beach Surf ("Red Tide Cough"): Ma muli o ka palupalu a me ka ʻole o nā pūnaewele ʻo Karenia brevis ʻaʻole i paʻa, hoʻoheheʻe nā nalu moana i ka limu a hoʻolele i ka brevetoxin hiki ke hoʻoheheʻe ʻia i loko o ke kai. Hoʻomaka koke ka poʻe hele kahakai a me ka poʻe kamaʻāina kahakai e hanu ana i ka noe (within 5 to 15 minutes) ka ʻā ʻana o ka maka, ka rhinorrhea, ka ʻāʻī hoʻomake ʻole, a me ka ** bronchospasm koʻikoʻi ** i ka poʻe me ka hānō a i ʻole COPD. Ke neʻe nei i loko o ka hale i kahi hale hoʻonanea i ka ea a me ka lawelawe ʻana i ** inhaled beta-2 agonists (albuterol)** hoʻoponopono koke i nā hōʻailona.

Nā protocols hōʻike hōʻike ʻāina a me ka hōʻike moana¶

• ** ʻAmelika Hui Pū ʻIa a me Kanada:** Kāhea iā 911 no nā pilikia o ka hanu, naʻau, a i ʻole neurological, a e hoʻopili iā Poison Control (1-800-222-1222 ma US; 1-844-POISON-X ma Kanada). Ma Florida, ke Kaiwa o Mekiko, Puerto Rico, ka US Virgin Islands, a me Hawaii, nā waihona o nā keʻena pilikia (Gulf of Mexico) 20% ʻO Mannitol no ka infusion Ciguatera koke, a noi nā keʻena olakino o ka mokuʻāina i nā koena meaʻai hau hau no ka FDA Center for Food Safety and Applied Nutrition (CFSAN) hoʻāʻo.
• United Kingdom a me ʻEulopa: Kāhea iā 999 (UK) a i ʻole 112 (EU). Kūkākūkā nā kauka lapaʻau iā NPIS / TOXBASE (UK) a i ʻole nā kikowaena ʻona o EU (CAPTV ma Farani, ka mea e hoʻonohonoho pū ana i nā ʻāina ʻē aʻe o Farani ma ka Caribbean [Guadeloupe, Martinique] a me ka Pākīpika [French Polynesia, New Caledonia] kahi o Ciguatera he hyper-endemic). Eia kekahi, ʻo ka amberjack (Seriola) a me ka barracuda ma ka Canary Islands, Madeira, a me ke Kaiwaenahonua hikina hikina ke hoʻoulu nei i nā maʻi maʻi autochthonous European Ciguatera.
• Australia, New Zealand, a me nā mokupuni o ka Pākīpika: E kelepona iā 000 (Australia) a i ʻole 111 (New Zealand), a e nīnau i ka Poisons Information Center (13 11 26 ma Australia; 0800 764 766 ma Aotearoa). Ma Queensland, ka Northern Territory, Fiji, Samoa, Tonga, a me Vanuatu, ʻo Ciguatera mai ka ʻaʻa koʻa, Spanish mackerel, ʻulaʻula, a me ka iʻa chinaman kahi hōʻike lapaʻau nui i mālama ʻia me IV crystalloids, atropine, a me ka mua. 20% mannitol (1.0 g/kg).
• Asia (Hong Kong, Iapana, Pilipine, Asia Hikina Hikina): Kaʻai ʻai-ʻaʻa ʻaʻa ola (grouper, humphead wrasse, snapper) ke kumu o nā hui Ciguatera ma waena o Hong Kong, Kina hema, a me Asia Hikina Hema; hoʻokō nā kikowaena toxicology āpau i ka 48-to-72-hour ʻO ka puka aniani IV mannitol a me ka pale ʻana i ka iʻa, ka waiʻona, a me nā nati no 6 mau mahina.

Nīnau pinepine¶

He aha ka "cold allodynia" (wela-anu hoʻohuli) a he aha nā mea ʻawaʻawa iʻa iʻa ke kumu?¶

ʻO Cold allodynia (i kapa pinepine ʻia ʻo ka hoʻohuli ʻana i ka mahana wela) he hōʻailona neurological pathognomonic e pili ana i ka wai anuanu, e paʻa ana i ka wai hau, a i ʻole ka heʻe ʻana i kahi papahele maloʻo e loaʻa ai kahi ʻeha ʻeha, ʻā, a i ʻole ka puʻu uila ma ka ʻili a me ka puʻu. Loaʻa ia ma muli o ka laka ʻana o Ciguatoxin (mai nā iʻa ʻākau e like me barracuda, grouper, a me Brevetoxin (mai ka iʻa red-tide shellfish) i ka wehe ʻana i nā kahawai sodium i hoʻopaʻa ʻia i ke anuanu i nā aʻalolo peripheral ʻike anu.

No ke aha e loaʻa ai i ka mea maʻi nā wai paʻakai ma mua o ka loaʻa ʻana o IV Mannitol no Ciguatera?¶

Hana ʻia ʻo Intravenous 20% Mannitol (1.0 g/kg ma luna o 30 a 45 mau minuke i loko o 48 a 72 mau hola) ma ka huki ʻana i ka wai nui mai loko mai o nā pūnaewele Schwann pehu e hoʻopuni ana i nā aʻalolo peripheral ʻona, e hoʻomaha koke i ka ʻeha a me ka ʻeha o Ciguatera. Eia naʻe, no ka mea, hoʻomaka ʻo Ciguatera me ka luaʻi nui, ka maʻi maʻi wai, a me ke koko haʻahaʻa vagal, a ʻo ka mannitol he diuretic osmotic potent e huki ai i ka wai i loko o ka mimi, hāʻawi i ka mannitol ma mua o ka hoʻomaʻemaʻe ʻana i ka mea maʻi me 1 a 2 mau lita o ka paʻakai maʻamau hiki ke hoʻoulu i ka pōʻino hypovolemic a me ka pōʻino o ka puʻupaʻa.

No ke aha e hiki ʻole ai i kekahi ke hoʻōla mai Ciguatera ke inu i ka waiʻona a ʻai paha i kekahi iʻa a i ʻole nati no 6 mahina?¶

ʻO ka Ciguatoxin ka mea hiki ke hoʻoheheʻe i ka momona a paʻa mau i nā membrane nerve peripheral a me ka momona o ke kino no nā mahina ma hope o ka hoʻoholo ʻana o ka gastroenteritis mua. ʻO ka ʻai ʻana i ka waiʻona, kēlā me kēia ʻano iʻa a iʻa paha (ʻo ia hoʻi ka iʻa wai maʻemaʻe a i ʻole ka salmon canned), nā pīni, nā hua lāʻau, caffeine, a i ʻole ke kokoleka i loko o 3 a 6 mau mahina e hoʻomaka ai ka hoʻihoʻi hou ʻana o ka ʻeha aʻa o ke aʻalolo, ka ʻeha ʻeha, ke koko haʻahaʻa, a me ka luhi nui.

Pehea e hiki ai iā ʻoe ke haʻi aku i ka make ʻana o ka iʻa Scombroid ma kahi ʻokoʻa o ka maʻi iʻa iʻa a pau?¶

ʻO ka make ʻana o Scombroid a me ka hopena maʻi e hoʻoulu ai i ka maka, nā hives, palpitations, a me ka wīwī i loko o 10 a 60 mau minuke o ka ʻai ʻana i ka iʻa, a pane lāua ʻelua i nā antihistamines (a me ka epinephrine inā paʻakikī). Eia nō naʻe, loaʻa mai ka Scombroid ma muli o ka ʻai ʻana i ka iʻa ʻeleʻele (tuna, mahi-mahi, mackerel, bluefish) i waiho ʻole ʻia i loko o ka pahu hau, e ʻae ana i ka bacteria e hoʻololi i ka histidine muscle i histamine: ʻono pinepine ka iʻa i ka peppery a i ʻole metala, nui ka poʻe i hui pū i ke kīʻaha e maʻi pū ʻia, a ʻaʻole loaʻa ka maʻi maʻi IgE maoli a hiki ke ʻai hou i ka iʻa hou.

No ke aha e lawe ai nā poʻe maʻi iā Isoniazid (INH) no ka maʻi maʻi maʻi me ka pilikia loa mai ka iʻa Scombroid?¶

ʻO Isoniazid (INH) a me ka monoamine oxidase inhibitors (MAOIs) ke kāohi ikaika i ka diamine oxidase (DAO, a i ʻole histaminase), ka enzyme kūlohelohe i loko o ka pā ʻōpū o ke kanaka e wāwahi i ka histamine meaʻai ma mua o ke komo ʻana i ke kahe koko. Inā ʻai ka mea maʻi i ka isoniazid i ka tuna, mahi-mahi, a i ʻole mackerel i loaʻa i nā pae haʻahaʻa o ka histamine, kahe ka histamine un-metabolized i ko lākou holo ʻana i ka ʻōnaehana, e hoʻoulu ai i ka pahū, ke kuʻi poʻo, ka bronchospasm koʻikoʻi, a me ka haʻalulu hypotensive.

ʻO ka hoʻoinu ʻana i ka iʻa a i ʻole ka hoʻopaʻa ʻana i ka wai lime no ka ceviche e pepehi iā Ciguatera a i ʻole Scombroid toxins?¶

ʻAʻole, ʻaʻole hoʻopau ʻia ʻo Ciguatoxin, Scombroid histamine, a me nā biotoxins shellfish (Domoic acid, Brevetoxin, Saxitoxin) ma ka maloʻo, ka paila, ka palai, ka kuke ʻana, ka puhi ʻana, a me ka wai lime wai marinades. ʻOiai ka mālama ʻana i ka tuna hou a i ʻole ka mahi-mahi i ka hau ma lalo o 4.4 degere Celsius (40 degere Fahrenheit) mai ka manawa i loaʻa ai e pale i ka bacteria mai ka hana ʻana i ka histamine hou, ke komo ka histamine a i ʻole ciguatoxin i loko o ka ʻōpala, ʻaʻohe ala kuke e hiki ke palekana.

No ka hoʻomākaukau ʻana no nā pilikia olakino e lawe ʻia i ka meaʻai, maʻi a me ka huakaʻi, e noʻonoʻo e lawe i kahi kōkua mua a me ka papa CPR mai ke Keʻa ʻulaʻula, St John Ambulance, a i ʻole kahi mea hoʻolako aʻo kūloko.

Nā alakaʻi pili¶

• ʻO Botulism, Ciguatera, Scombroid, a me Shellfish Neurotoxin Poisoning Overview
• ʻO nā maʻi maʻi a me ke kōkua mua anaphylaxis
• Rebound Anaphylaxis, Biphasic Allergic Reaction, and Second EpiPen Timeing
• ʻAi ʻAi ʻAi, ʻAi ʻAi ʻAi ʻAi, a me ka Dehydration
• Kokua Mua a me ka Ho'oma'ema'e 'ana i ka 'ona

Nā kumu a me ke alakaʻi kūhelu¶

• U.S. Nā Center for Disease Control and Prevention (CDC): CDC Yellow Book (Health Information for International Travel): ʻAi ʻAi ʻAi mai nā Toxins Moana (Ciguatera, Scombroid, and Shellfish Poisoning) (United States).
• U.S. Hoʻoponopono Meaʻai a Laʻau Laau (FDA): Buke Kino ʻino (Foodborne Pathogenic Microorganisms and Natural Toxins, 2^nd Edition): Scombrotoxin (Histamine), Ciguatoxin, Domoic Acid (ASP), Brevetoxin (NSP), a me Saxitoxin (PSP) (United States).
• World Health Organization (WHO) & Food and Agriculture Organization (FAO): Hōʻike o ka hālāwai loea e pili ana i ka lāʻau ʻawaʻawa Ciguatera a me nā Biotoxins moana ma Bivalve Molluscs (Rome / Geneva).
• ** ʻO UK National Poisons Information Service (NPIS) / TOXBASE:** Clinical Management of Ciguatera Fish Poisoning (Mannitol Protocol), Scombroid Fish Poisoning, and Shellfish Neurotoxins (United Kingdom).
• Friedman MA, Fleming LE, Fernandez M, Bienfang P, et al.: * Ka lāʻau ʻawaʻawa o ka iʻa Ciguatera: ka mālama ʻana, ka pale ʻana a me ka mālama ʻana * (Marine Drugs / Palafox NA intravenous mannitol study).