Oona I'a Ciguatera (Suiga o le Tempera vevela-Malili, Bradycardia) vs. Scombroid Histamine Fufulu I'a ma A'ai A'ai.¶

O le atia'e fa'afuase'i o le ma'i o le gutu, mu le pa'u pe a pa'i i le vai malulu, mumu mumu o mata, niniva, po'o le faigata ona manava i se taimi e le'i leva ona 'ai i'a a'au, pelagic steaks, po'o figota bivalve e mana'omia ai le va'aiga vave o falema'i i biotoxins tetele o le gataifale. Valaau lau numera faʻafuaseʻi i le lotoifale (911 i le Iunaite Setete ma Kanata, 112 i le isi itu o le Iuni a Europa, 999 i Peretania) pe faʻafesoʻotaʻi la matou fa'atonu numera fa'afuase'i fa'avaomalo i le taimi lava lea pe a fa'aalia e le faleaiga lemu le tata o le fatu, maualalo le toto toto, uigi, fenumiai, po'o le vaivai o maso. Aua o le Scombroid fish poisoning e fa'ata'ita'i fa'atusaina se fa'alavelave fa'afefe IgE fa'ama'i po'o anaphylaxis, ae o le Ciguatera, Domoic Acid, ma le Brevetoxin e fa'amalieina lo tatou lautele lautele. botulism ma supa figota neurotoxin taiala faataitai, e tatau foi i tagata tali mai ona faʻavasegaina nei mea vevela vevela mai siama mea'ai ma le ma'i gastroenteritis.

Kuka, falai, falai, tao, ulaula, fa'aisa, po'o le fa'afefeteina o i'a i le sua o le lime (ceviche) e le fa'aumatia ai so'o se mea oona o le gataifale. E le gata i lea, o i'a oona ma figota e foliga, sogisogi, ma tofo e matua masani lava (ae na'o le na'o le u mai o le pepe pe u'amea i le i'a scombroid). E tatau i foma'i fa'alavelave fa'afuase'i ma tagata femalagaa'i ona va'ava'ai vave i le va o ma'i tetele e fa o le gataifale: 1. Ciguatera Fish Poisoning (CFP): Mafua mai i le 'aina o i'a a'au fe'ai tetele (barracuda, grouper, red snapper, amberjack, moray eel, hogfish, Spanish mackerel, coral trout) o loo iai ciguatoxins (CTX) bioaccumulated mai le benthic dinoflagellate Gambierdiscus toxicus. E maua i le ma'i ma'i gastroenteritis (2 to 12 hours), e lamatia ai le ola ** sinus bradycardia ma le maualuga o le toto**, ma pathognomonic alodynia malulu (hot-cold temperature reversal), togafitia i totonu 48 to 72 hours fa'atasi ai ma le tui toto 20% Mannitol (1.0 g/kg) fa'atasi ai ma le fa'ama'i 6-masina fa'aoso-alo'ese taumafa. 2. Scombroid (Histamine) Oona I'a: Mafua mai i le 'aina o i'a aano o manuuliuli e le'i fa'a'aisa (tuna, mahi-mahi [dorado], bluefish, mackerel, bonito, marlin, sardines, anchovies) lea e faaliliu ai e siama i luga le maso L-histidine i ni aofaiga tele o le histamine. Tuuina atu i totonu 10 to 60 minutes e pei o se mea mata'ina ** "pei o le la" o le histamine flush**, tiga o le ulu, tatavale, ma le bronchospasm, togafitia vave i H1 ma H2 antihistamines (not permanent fish allergy). 3. Amnesic Shellfish Poisoning (ASP - Domoic Acid): Mafua mai i le Pseudo-nitzschia fuga mai o le diatom i mussels, silvi, scallops, ma Dungeness crab viscera; fa'aosoina tele hippocampal AMPA/kainate glutamate receptors, e mafua ai le tulaga epilepticus ma le maua'i manatuaga puupuu anterograde tumau. 4. Neurotoxic Shellfish Poisoning (NSP - Brevetoxin): Mafua mai i le Karenia brevis ("Florida / Gulf of Mexico red tide") dinoflagelates i faisua ma pipi; fa'agaoioi ala o le sodium (pei o le ciguatoxin) e maua ai le cold allodynia, paresthesia, ma le aerosolized beach bronchospasm e aunoa ma le pe.

+-------------------------------------------------------------------------+
|            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  |
+-------------------------------------------------------------------------+

Fai nei loa¶

1. ** Iloilo vave le mānava, fatu, ma le toto maualuga, ma valaʻau i auaunaga faʻafuaseʻi.** Telefoni le 911 (US ma Kanata), 112 (Iuni a Europa), 999 (United Kingdom), 000 (Australia), poʻo le 111 (Niu Sila).
2. Afai na 'ai le tagata tuna po'o mahi-mahi 15 minutes ua mavae ma o le taimi nei o lo'o i ai le uila, malo le fa'a'i, po'o le fula o le laulaufaiva (Scombroid matuia), fa'aaoga se epinephrine auto-injector (EpiPen) i totonu o le ogavae pito i fafo pe a maua, ma tuu tuugutu le diphenhydramine (Benadryl, 25 to 50 mg) poʻo cetirizine (10 mg) faaopoopo famotidine (Pepcid, 20 mg) pe a mafai ona folo saogalemu.
3. Afai na 'ai e le tagata le ** barracuda, grouper, red snapper, po'o le amberjack** 2 to 8 hours ua mavae ma ua niniva pe matapogia ma le telegese le tata (below 50 beats per minute) (Ciguatera), fa'ata'oto i luga o latou tua ma fa'ae'e vae 30 centimeters (12 inches) ia faatumauina le tafe toto i le faiʻai aʻo faʻatali mo fomaʻi faʻatasi ma le **atropine ** ma le saline masani.
4. Fa'ata'ita'i le moega "Cold Object Test" mo Ciguatera po'o Brevetoxin. Fai i le tagata ma'i e pa'i i se apa vai malulu, se pusa aisa, po'o se vai paipa malulu. Afai e lagona le mea malulu e pei o se *afi mu tiga, aisa mago, po'o te'i eletise (cold allodynia / hot-cold temperature reversal)**, o le su'esu'ega e toetoe lava a mautinoa Ciguatera Fish Poisoning (pe a 'aina i'a aau) po'o Neurotoxic Shellfish Poisoning (Brevetoxin) (pe a 'aina le Fagaloa o Mekisikō / subtropical shellfish). (Gulf of Mexico)
5. Aua ne'i inu vai aisa pe ta'ele malulu pe a masalomia le Ciguatera. O le inuina o vai malulu e fa'atupu ai le tiga tele o le mu i lalo o le fa'a'i ma le esophagus, ma o le vai malulu i luga o le pa'u e mafua ai le pa'u tiga. Tu'u atu na'o suavai fa'asuavai ile potu-vevela po'o sua mafanafana ole fa'asuavai ile sips laiti.
6. Ia mautinoa e toe fa'ainu atoatoa le vai a'o le'i tu'uina atu le Intravenous Mannitol mo Ciguatera. Ta'u i le foma'i fa'afuase'i o lo'o maua e le ma'i le ma'i Ciguatera Fish Poisoning i totonu o le 48 to 72 hour faamalama mo ** Intravenous 20% Mannitol (1.0 gram/kg). Ae ui i lea, talu ai o le mannitol o se vailaʻau malosi osmotic ma o le Ciguatera e mafua ai le vave puaʻi ma le manava, ** e tatau ona faʻafefe le manitol pe a uma ona faʻasaʻo atoatoa le hypovolemia ma le faʻamaʻaina. 1 to 2 liters o crystalloids tui toto (isotropic intravenous crystalloids)0.9% saline masani po'o le Lactated Ringer's).
7. Faasao ma fa'a'aisa le toega o i'a po'o figota ma lapata'i isi tagata 'ai uma. Afīfī so'o se toega e le'i vela pe vela o le taumafataga i pepa pepa po'o se taga palasitika ma fa'aisa mo su'ega biotoxin a le matagaluega o le soifua maloloina (FDA / state marine lab liquid chromatography-mass spectrometry). Fa'afeso'ota'i vave tagata uma na fa'asoa le i'a.

La'au fa'ai'uga: Fa'ata'ita'iga oona o i'a ma figota¶

flowchart TD
    A["Ma'i Tu'i pe a uma ona 'ai i'a po'o figota"] --> B{"O le a le Ituaiga o Mea'ai Sami na 'aina?"}
    B -->|"I'a Pelagic Meat Pouliuli (Tuna, Mahi-Mahi, Mackerel, Bluefish, Sardines)"| C{"Amata ile 10-60 Minu ile Mumu Mumu Fa'aliga/Ua Fufulu & Tachycardia?"}
    B -->|"Teropika/A'au I'a (Barracuda, Grouper, Snapper, Amberjack, Tuna)"| D{"Gastroenteritis (2-12h) + Allodynia Cold, Tiga o Nifo, po'o Bradycardia?"}
    B -->|"Pivalve Shellfish (Mussels, Clams, Oysters, Scallops) poʻo Crab Viscera"| E{"Fa'ailoga le ma'i o Shellfish e ala ile Neurological Signs"}
    C -->|"Ioe"| F["SCOMBROID (HISTAMINE) I'A OONA: Tu'u IV/PO H1 Blocker (Diphenhydramine 25-50 mg) + H2 Blocker (Famotidine 20 mg IV); Albuterol/Epi pe a Uō"]
    D -->|"Ioe"| G["ONA I'A I'A CIGUATERA (CFP): Toe fa'ao'o muamua ile 1-2 L IV 0.9% Saline + IV Atropine (0.5-1 mg) mo Bradycardia/Mata'ilalo."]
    G --> H["I le taimi e tasi Euvolemic (ma totonu ole 48-72h): Fa'ainu 20% IV Mannitol (1.0 g/kg i luga ole 30-45 min); Fa'amalosia le 6-Masina Fa'aoso Mea'ai Aloese"]
    E -->|"Le fenumia'i, Fa'aletonu, Faoa faamalosi, Ga'imau Manatu Pu'upu'u"| I["AMNESIC SHELLFISH POISONING (Domoic Acid): ICU Airway Protection + IV Benzodiazepines/Phenobarbital mo Tulaga Epilepticus"]
    E -->|"Allodynia malulu + Tingling Perioral + Bronchospasm (LEAI Supa)"| J["NEUROTOXIC SHELLFISH POISONING (Brevetoxin - Red Tide): Lagolago IV Suavai + Albuterol mo Bronchospasm"]
    E -->|"Fa'aoso Fa'aa'e Vave Fa'aliga/Va'ava Numbness + Diaphragmatic Paralysis"| K["FA'A'ONA A'E FA'ALI'I SU'E (Saxitoxin): Fa'agata Fa'ato'a Fa'a'au'au & Fa'a'ave'ese Fa'ainisinia."]

Fa'atusatusaga fa'apitoa o le 4 marine biotoxin syndromes¶

Fa'a'ai 1: Ciguatera Fish Poisoning (CFP): Pathophysiology, Mannitol Protocol, ma le 6-Month Diet¶

Ciguatera Fish Poisoning o le ma'i sili ona taatele o le oona i le sami e le o ni siama i le lalolagi, e aafia ai. 50,000 to 500,000 tagata i tausaga ta'itasi i le va o latitu 35 degrees North ma 35 degrees South (le Caribbean, South Florida, Gulf of Mexico, Hawaii, French Polynesia, Australia's Great Barrier Reef, le Pasefika i Saute, ma le Vasa Initia). Talu ai ona o fela'ua'iga fa'ava-o-malo o lo'o fa'asalalau atu ai i'a fou i le lalolagi atoa, o fa'ama'i Ciguatera e masani ona o'o mai i potu fa'afuase'i i Niu Ioka, Lonetona, Toronto, Paris, ma Tokyo.

1. Mea'ai-Chain Bioaccumulation: Aisea e Sili Ona Mata'utia ai Manufe'ai Lautele¶

• Pe a faaleagaina amu amu i afā, pa'u, su'e, po'o tafega i le gataifale, o le a fa'atupuina a'a mamate e le microscopic benthic dinoflagellates o le ituaiga Gambierdiscus (G. toxicus, G. polynesiensis).
• O tama'i i'a a'au e tata'a i le macroalgae o lo'o ufiufi ai 'amu ma 'ai le gambiertoxins. Ona o tama'i i'a e 'aina e i'a feololo, ma i'a feololo e 'aina e pex reef predators (barracuda, grouper lapopoa, red snapper, amberjack, kingfish, moray eel), o le lipid-soluble toxins e fa'ama'iina e enzymes ate i'a i ** ciguatoxins (P-CTX-1, C-CTX-1, I-CTX)** ma faalautele le filifili meaai.
• Aua e le afaina le ciguatoxin i le i'a lava ia, a 10-kilogram (22-pound) Barracuda po'o grouper e foliga maloloina a'o tauaveina se fa'ama'i mata'utia o tagata i lona aano ma totoga.

2. Pathophysiology: Aisea e pei ai o le afi mu le vai malulu (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. Le 3 Clinical Systems A'afia e Ciguatera¶

1. Fa'a'ai Fa'a'ai (Onset 2 to 12 hours, tumau 24 to 48 hours): Fa'afuase'i le manava manava, faufau, pua'i, afu tele, ma manava manava.
2. Vaega Tuto'atasi Cardiovascular (Onset 2 to 24 hours, tumau 2 to 5 days): O le Ciguatoxin e fa'aosofia ai alava ga'o fatu ma alavai sodium tuto'atasi, e mafua ai ** sinus bradycardia e lamatia ai le ola (heart rate 30 to 45 bpm)**, poloka fatu AV, ma tetele le toto (systolic BP < 70 to 80 mmHg).
3. ** Pathognomonic Neurological Phase (Onset 3 to 72 hours, tumau weeks to months):**
4. Circumoral and Acral Paresthesia: Ma'i ma'i fa'atete ma fa'atete i laugutu, laulaufaiva, fa'a'i, tamatamai lima, ma tamatama'ivae.
5. ** Allodynia malulu (Hot-Cold Temperature Reversal):** Va'aia i 70% to 90% o mataupu. O le pa'i atu i se kopa malulu o le faitoto'a, laa i luga o se fola malūlū, po'o le inuina o se vai malulu e mafua ai le mu, mu, po'o le te'i eletise.
6. ** Fa'a'ese'ese Nifo (Odontalgia):** O se lagona masani o le fofo ua matala i o latou faavae pe tiga tiga pe a u i lalo.
7. Pruritus ("La Gratte"): Magese lautele lautele i luga o alofilima, alofivae, ma ogalaau e faateteleina i le po, faatasi ai ma le vaivai vaivai (asthenia), myalgias, arthralgias, dysuria, ma dyspareunia.

4. Laasaga-ma-Laasaga Falemai Polokalama: Sua, Atropine, ma Intravenous 20% Mannitol¶

1. Laasaga 1: Fa'asa'o le Fa'amama ma le Bradycardia MUAMUA (Mandatory Pre-Mannitol Stabilization):
2. tui 1 to 2 liters o 0.9% masima masani po'o le Lactated Ringer's i totonu o le toto seia o'o ina vave le alu o le mimi (> 0.5 to 1.0 mL/kg/hour) ma mucous membrane e susu.
3. Mo fa'ailoga bradycardia (HR < 50 bpm) po'o le toto maualuga, tu'u le ** Intravenous Atropine (0.5 to 1.0 mg IV tulei uma 5 minutes, e oo atu i 3 mg)** ma fa'aopoopo i ai se fa'asusu o le dopamine po'o le norepinephrine pe a fa'aauau pea le toto maualuga pe a uma ona toe fa'atumu le vai.
4. Laasaga 2: Infusion 20% Mannitol Infusion (Within 48 to 72 Hours of Ingestion):
5. Aisea e afaina ai le taimi ma le faʻamamaina: E sili ona aoga le mannitol i totonu o le toto pe a tuʻuina i totonu o le muamua 24 to 48 hours (up to 72 hours) o le amataga o faailoga. 'A'E LE tu'uina le mannitol i se tagata ma'i ua fa'amama le vai po'o le ma'i ma'i ma'i'a, ona o le fa'ama'i o le osmotic o le a fa'atupu ai le te'i tu'i o le hypovolemic ma le necrosis tubular.
6. Sa'o Tulaga Fa'ata'ita'iga: A uma loa le ma'i e euvolemic ma masani, fa'ainu 1.0 gram per kilogram (1.0 g/kg, pe 5 mL/kg o a 20% vaifofo o le mannitol) tui i luga ole toto 30 to 45 minutes.
7. Toe Fa'asuavai: Afai e soso'o ai le neurosensory toomaga ma se vaega toe fa'afo'i i le aso e soso'o ai, lona lua. 1.0 g/kg fua ole 20% e mafai ona tuʻuina atu le mannitol 12 to 24 hours mulimuli ane faatasi ai ma le tausiga o le crystalloid sui.
8. Laasaga 3: Fa'ailoga Fa'ailoga mo le Neuropathy Fa'aletonu/Taimi (Weeks 1 to 12):
9. Afai e sili atu nai lo 72 hours pe a uma le taumafataga, fa'atonu le gutu Gabapentin (300 to 600 mg faatolu i aso taitasi), Pregabalin (75 to 150 mg faalua i aso taitasi), poo Amitriptyline (25 to 50 mg i le taimi e momoe ai) e faʻamama ai le allodynia malulu ma le pruritus.

5. Le Fa'atonu 6-Month Ciguatera Trigger-Avoidance Diet¶

Talu ai ona o le lipophilic ciguatoxin o loʻo tumau pea ona tuʻuina i totonu o paʻu o le nerve peripheral ma aano o meaʻai mo le tele o masina, o meaʻai ma meainu e faʻateleina ai le tafe toto, faʻasaʻo le histamine, poʻo le suia o gaʻo gaʻo o le nerve o le a ** toe faʻaosoina ai le toe faʻafoʻi mai o le Ciguatera mageso atoa, paresthesia mu, ma le vaivai** 3 to 6 months ina ua lagona e le ma'i ua toe malosi. Soʻo se maʻi Ciguatera e tatau ona matua aloese mai mea nei mo 3 to 6 months: * I'a uma, figota, ma mea'ai o le sami (e o'o lava i i'a vai malulu, samani fa'ato'aga, po'o tuna tuna e leai se ciguatoxin, 'ai so'o se polotini i'a e fa'atupu fa'afuase'i fa'ailoga). * O meainu malosi uma (pia, uaina, ava malosi, o le mea e tasi e sili ona malosi e mafua ai le toe foi mai o le Ciguatera ma le maualuga o le toto maualuga/bradycardia). * Nati, pinati, ma suauu fatu (e aofia ai le pata pinati, almonds, walnuts, ma sesame). * Kafeina ma mea'ai e maualuga le histamine (kofe, meainu malosi, sukalati pogisa, ma aano o manufa'amālōlō).

Ma'i 2: Scombroid (Histamine) Oona I'a: O le Anaphylaxis Mimic¶

Scombroid fish oona (histamine fish poisoning) ose fa'ama'i fa'ama'i, e le ose fa'ama'i i'a i le olaga atoa, e mafua mai i le 'aina o i'a na mafatia sauaina o le vevela (stored above 4.4 degrees Celsius [40 degrees Fahrenheit] for more than 3 to 4 hours) i le va o le pueina ma le kuka.

Patophysiology: Bacterial Histidine Decarboxylase¶

I'a pelagic aano-pogisa mai aiga Scombridae (tuna, mackerel, bonito, skipjack, albacore) ma Scombresocidae, faapea foi ma ituaiga e le-scombroid (mahi-mahi / dorado [Coryphaena hippurus], bluefish, amberjack, marlin, swordfish, escolar, sardines, anchovies, ma herring), e masani ona iai le maualuga maualuga o le amino acid free L-histidine (> 1,000 mg/100 g) i totonu o latou tino maso. * Afai e tu'u le i'a i luga o se fata va'a mafanafana, fa'afefeteina i luga o se fale'aiga, pe teu i totonu o se pusaaisa mafanafana, o siama kalama-negative enteric i luga o gills ma gut (Morganella morganii, Klebsiella pneumoniae, Hafnia alvei, Photobacterium phosphoreum) faatele ma maua ai le enzyme histidine. * I totonu o itula, e faaliliu e le histidine decarboxylase le muso L-histidine i ni vaega tetele o le histamine (often > 50 to 500 milligrams per 100 grams o i'a; i'a fou masani ei ai < 1 mg/100 g), fa'atasi ai ma biogenic diamines (putrescine ma cadaverine) e fa'agata ai histaminases intestinases (diamine oxidase [DAO] ma histamine N-methyltransferase) ma fa'amalosia le tele o le histamine i totonu o le toto. * Tusa lava pe fa'a'aisa mulimuli ane e le fale'aiga le i'a ma mu pe fa'avela i le vevela tele, pete le siama, ae tumau pea le 100% o le histamine na mua'i faia ma ola.

+-------------------------------------------------------------------------+
|       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    |
+-------------------------------------------------------------------------+

Laasaga-ma-Laasaga Scombroid Togafitiga Protocol¶

1. Talua H1 + H2 Antihistamine Blockade (The Definitive Cure):
2. Fa'atonu se H1 fa'afeagai fa'afeagai: Diphenhydramine (Benadryl, 25 to 50 mg IV pe tautala; 1 mg/kg i tamaiti) po'o se fa'agata H1 tupulaga lona lua e le fa'afilemu (Cetirizine 10 mg IV/PO).
3. Tu'u i le taimi lava e tasi se H2 fa'afeagai fa'afeagai: Famotidine (Pepcid, 20 mg IV pe tautala; 0.5 mg/kg i tamaiti) poʻo Cimetidine (300 mg IV) / Ranitidine. Talu ai ona o alātoto paʻu ma le myocardium e faʻaalia uma le H1 ma le H2 histamine receptors, o le tuʻufaʻatasia o le H1 ma le H2 poloka e foia ai le mulumulu o mata, tiga o le ulu, tachycardia, ma le manava manava i totonu 15 to 30 minutes.
4. O afea e Tuuina atu ai le Epinephrine ma le Bronchodilators: O le tele o ma'i scombroid e fa'agata (resolving in 6 to 12 hours) ma e le manaʻomia le epinephrine. Peitaʻi, i tagata mamaʻi e maua i lalo o le sthma, tagata matutua e maua i le fatu fatu, poʻo tagata mamaʻi o loʻo ave ** Isoniazid (INH)** po o Monoamine Oxidase Inhibitors (MAOIs) (lea e poloka ai le malepelepe o le histamine i totonu ma mafua ai le te'i fulminant scombroid te'i), o le histamine mai fafo e mafai ona faaosofia ai le bronchospasm (wheezing) po o le vasoplegic hypotension. Tu'u le nebulized albuterol (salbutamol, 2.5 to 5 mg), vai inu toto, ma epinephrine intramuscular (0.3 to 0.5 mg o 1 mg/mL [1:1,000] i totonu o le suilapalapa pito i luma) i le taimi lava lea pe a iai le manava manava po o le toto maualuga.
5. A'oa'oga a le Ma'i A'o Le'i Fa'ate'a: Fa'amautinoa le ma'i (ma fa'amaonia manino i le latou siata fa'afoma'i) na maua i le Scombroid (histamine) mea'ai oona mai i'a le fa'a'aisa, e le ose i'a fou e allergy, ina ia aua ne'i fa'ailogaina e afīfī i i'a po'o vali fa'afeagai.

A'ai 3 & 4: Shellfish Neurotoxins: Amnesic (Domoic Acid) vs. Neurotoxic (Brevetoxin) vs. Supa (Saxitoxin)¶

1. Amnesic Shellfish Poisoning (ASP: Domoic Acid)¶

• Mafuaaga ma Mechanism: Na gaosia e diatoms o le gataifale o le ituaiga Pseudo-nitzschia i luga o le Pasefika i Matusisifo, Kalefonia, Atlantic Canada (Prince Edward Island, lea na tupu ai le faamai muamua o tagata i totonu. 1987), Europa, ma Niu Sila. Domoic acid o se fa'atusa fa'atulagaina o kainic acid ma le excitatory neurotransmitter L-glutamate. E fusifusia ma le maualuga o fesoʻotaʻiga i AMPA ma kainate glutamate receptors e matua faʻapipiʻi i le ** CA1 ma CA3 itulagi o le hippocampus o le tagata ** ma amygdala, e mafua ai le faʻavaivaia o le calcium (Ca2+) lolofi ma necrosis excitotoxic neuronal.
• Clinical Course: I totonu 15 minutes to 24 hours o le 'aina o mussel ua pisia, pipi, po'o le Dungeness crab viscera, o tagata ua afaina e maua ai le faufau, pua'i, ma le manava manava. I totonu 4 to 48 hours (aemaise lava i tagata matutua po o tagata gasegase e maua i le fatuga'o faaumiumi, talu ai o le domoic acid e kilia fatu), ogaoga oona oona: ** fenumiai, le mautonu, mutism, lamu/grimacing automatisms, toto le mautu, myoclonus, refractory status epilepticus, ma koma**. O i latou e sao e masani ona pagatia ** tumau i le anterograde taimi pupuu manatua leiloa** (le mafai ona fausia ni manatuaga fou pe a uma le taumafataga, e tutusa ma Korsakoff psychosis poʻo le lua o le hippocampal resection).
• Togafitiga: E leai se vaifofo. Tu'u vave ** malala ola** (within 1 to 2 hours), fa'amalosi fa'amama le toto e fa'atele ai le fa'amamaina o fatu o le domoic acid e mafai ona solu i le vai, ma fa'agata maualuga GABA-A agonists (IV lorazepam, midazolam, phenobarbital, ma propofol) e taofiofia le tulaga epilepticus excitotoxic hippocampal (phenytoin is ineffective against domoic acid seizures).

2. Neurotoxic Shellfish Poisoning (NSP: Brevetoxin)¶

• Mafuaaga ma Mechanism: Na faia e le dinoflagellate e le'i ofutau Karenia brevis (formerly Gymnodinium breve), o le tino e nafa ma Florida ma Fagaloa o Mekisiko "Red Tides" (ma fuga faapena i Niu Sila). Brevetoxins ( (Gulf of Mexico)PbTx) fusifusia i le Site 5 i luga o alavai sodium-gated voltage, o le nofoaga tonu lava e maua ai le Ciguatoxin.
• Ala e Lua o Fa'aaliga:
• Oral Shellfish Ingestion: O le aiina o faisua, pipi, po'o coquinas ua afaina ai laugutu, laulaufaiva, ma le fa'ai i totonu. 30 minutes to 3 hours, sosoo ai ma le pua'i, manava manava, niniva, ataxia, ** Cold Allodynia (hot-cold temperature reversal)**, fa'atetele tamaiti, ma le bradycardia vaivai. E le pei o le Su'e Shellfish Poisoning (Saxitoxin), NSP E LE fa'atupuina le manava o le manava, ma toe malosi atoatoa tagata mama'i i totonu 2 to 3 days fa'atasi ai ma vai IV lagolago.
• Beach Surf Aerosol Inhalation ("Red Tide Cough"): Talu ai o Karenia brevis sela e ma'ale'ale ma e leai se atigi malo, o galu pa'u o le sami e liu limu ma fa'aulu ai le lipid-soluble brevetoxin i le suasami aerosol. O tagata tafafao ma tagata i le gataifale o lo'o manavaina le puao e vave ona tupu (within 5 to 15 minutes) mu mata, rhinorrhea, tale ta'i e le'o fua mai, ma fa'ama'i ogaoga i tagata e maua i le sela po'o le COPD. Si'i i totonu o le fale i se fale ea malulu ma fa'aaoga le agonist beta-2 inhaled (albuterol) vave fo'ia fa'ailoga.

Tulaga fa'aitulagi fa'alavelave fa'afuase'i ma fa'asalalauga fa'asao¶

• Amerika ma Kanata: Valaau 911 mo fa'alavelave fa'afuase'i o le manava, fatu, po'o le neura, ma fa'afeso'ota'i le Poison Control (1-800-222-1222 i le US; 1-844-POISON-X i Kanata). I Florida, le Fagaloa o Mekisiko, Puerto Rico, le US Virgin Islands, ma Hawaii, fa'asoa matagaluega fa'afuase'i (Gulf of Mexico) 20% Mannitol mo le fa'ainu vave o le Ciguatera, ma le setete o le soifua maloloina e talosagaina toega o mea'ai aisa mo le FDA Center for Food Safety and Applied Nutrition (CFSAN) su'ega.
• United Kingdom ma Europa Iuni: Valaau 999 (UK) poʻo 112 (EU). E fa'afeso'ota'i e foma'i le NPIS / TOXBASE (UK) po'o nofoaga oona a le EU (CAPTV i Farani, lea e faamaopoopoina foi teritori Farani i fafo i le Atu Karipiane [Guadeloupe, Martinique] ma le Pasefika [French Polynesia, New Caledonia] lea o le Ciguatera e hyper-endemic). E le gata i lea, o le amberjack (Seriola) ma le barracuda na maua i le lotoifale i le Canary Islands, Madeira, ma le Metitirani i sasa'e ua mafua ai le autochthonous European Ciguatera outbreaks.
• Ausetalia, Niu Sila, ma Atumotu o le Pasefika: Valaau 000 (Ausetalia) po o 111 (Niu Sila), ma faafesoota'i le Poisons Information Center (13 11 26 i Ausetalia; 0800 764 766 i Niu Sila). I Kuiniselani, Teritori i Matu, Fiti, Samoa, Toga, ma Vanuatu, Ciguatera mai i'amu, mackerel Spanish, mūmū, ma i'a chinaman ose fa'ata'ita'iga fa'apitoa fa'afoma'i e fa'atautaia i IV crystalloids, atropine, ma vave. 20% manitol (1.0 g/kg).
• Asia (Hong Kong, Iapani, Filipaina, Asia i Sautesasae): Fefa'ataua'iga mea'ai amu ola ma i'a (grouper, humphead wrasse, snapper) e mafua ai fuifui Ciguatera soo i Hong Kong, Saina i saute, ma Asia i Sautesasae; nofoaga autu oona fa'aitulagi fa'amalosia le 48-to-72-hour IV mannitol faʻamalama ma le 6-masina e aloese mai iʻa, ava malosi, ma nati.

Fesili e fai soo¶

O le a le "cold allodynia" (vevela-malulu suiga) ma o a mea'ai oona e mafua ai?¶

Cold allodynia (e masani ona taʻua o le vevela ma le malulu o le vevela) o se faʻamaʻi o le neurological pathognomonic lea e paʻi ai i le vai malulu, uuina se vai aisa, poʻo le laa i luga o se fola malulu e maua ai se lagona mu tiga, mu, poʻo le eletise-teʻi i luga o le paʻu ma le faʻaʻi. E tupu ona o le Ciguatoxin (mai i'a a'au e pei o le barracuda, grouper, ma le snapper) ma le Brevetoxin (mai figota mumu-mumu) e lokaina alavai o le sodium i totonu o alava o neura pito i luga e lagona ai le malulu, ma mafua ai ona latou afi malosi i soo se taimi e malulu i lalo ole 24 i le 26 tikeri Celsius.

Aisea e tatau ai ona maua e le tagata ma'i le sua o le masima tui a'o le'i maua le IV Mannitol mo Ciguatera?¶

Intravenous 20% Mannitol (1.0 g/kg infued over 30 i 45 minute i totonu o le 48 i le 72 itula) e galue e ala i le tosoina mai o le tele o le vai mai sela fulafula Schwann o loʻo siomia ai neura oona oona, vave faʻamalolo Ciguatera numbness ma tiga. Ae ui i lea, talu ai ona o le Ciguatera e amata i le malosi o le puaʻi, manava manava, ma le toto maualalo o le vagal, ma o le mannitol o se vailaʻau malosi osmotic e toso le vai i totonu o le urine, tuʻuina atu le mannitol aʻo leʻi faʻamamaina atoatoa le tagata maʻi i le 1 i le 2 lita o le saline masani e mafai ona faʻaalia ai le mataʻutia o le hypovolemic ma faʻaleagaina fatugaʻo.

Aisea e le mafai ai e se tasi ona toe malosi mai Ciguatera ona inu le ava malosi pe 'ai soo se i'a poo nati mo le 6 masina?¶

O le Ciguatoxin e malosi tele le ga'o ma e tumau pea ona fusifusia i neura peripheral ma ga'o o le tino mo ni masina pe a mae'a le amataga o le gastroenteritis. O le taumafaina o le ava malosi, so'o se ituaiga i'a po'o figota (e o'o lava i i'a malulu po'o samani tu'u apa), pinati, nati laau, caffeine, po'o sukalati i totonu o le 3 i le 6 masina e fa'afuase'i ai ona toe oso fa'afuase'i le tiga o le neura mu, ma'i leaga, toto maualalo, ma le vaivai tele.

E fa'afefea ona e iloa le mea oona i'a Scombroid e ese mai ise mea'ai sami mo le olaga atoa?¶

O le scombroid poisoning ma se fa'a'a'i e mafua ai le fulafula o mata, hives, tatavale, ma le uigi i totonu o le 10 i le 60 minute o le 'aina o i'a, ma tali uma i antihistamines (ma epinephrine pe a ogaoga). Ae ui i lea, o le Scombroid e tupu mai i le 'aina o iʻa uliuli (tuna, mahi-mahi, mackerel, bluefish) e leʻi faʻafefeteina, e mafai ai e siama ona liua maso histidine i le histamine: e masani ona tofo le iʻa i le meaʻai poʻo le uʻamea, o le toʻatele o tagata e fefaʻasoaaʻi le ipu e mamaʻi faʻatasi, ma e le maua e le tagata maʻi se faʻamaʻi moni IgE ma e mafai ona toe 'ai ma le saogalemu i le iʻa fou.

Aisea e matua'i a'afia ai tagata mama'i e ave Isoniazid (INH) mo le mamapala mai i'a Scombroid?¶

Isoniazid (INH) ma monoamine oxidase inhibitors (MAOIs) e matua taofia le diamine oxidase (DAO, poʻo le histaminase), o le enzyme masani i totonu o le pa o le intestinal o le tagata e talepeina ai le histamine meaʻai aʻo leʻi ulu atu i le toto. Afai e 'ai e se tagata ma'i e ave le isoniazid le tuna, mahi-mahi, po'o le mackerel o lo'o iai le maualuga o le histamine, o le histamine e le-metabolized e lolovaia lo latou ta'amilosaga, ma mafua ai le pa'u, tu'i le ulu, tigaina o le bronchospasm, ma le fa'ate'ia o le toto.

Pe fa'aisa i'a po'o le fa'ainu i le sua o le lime mo le ceviche e fa'amateina ai le Ciguatera po'o le Scombroid toxins?¶

Leai, e le o le Ciguatoxin, Scombroid histamine, po o figota biotoxins (Domoic acid, Brevetoxin, Saxitoxin) e faʻaumatia e ala i le faʻamaisaina, faʻafefe, falai, taoina, ulaula, poʻo vai suamalie suamalie suamalie. A'o fa'amalieina le tuna fou po'o le mahi-mahi i luga ole aisa i lalo ole 4.4 tikeri Celsius (40 tikeri Fahrenheit) mai le taimi na maua ai e taofia ai siama mai le gaosia o histamine fou, pe'ā iai le histamine po'o le ciguatoxin i totonu o le fillet, e leai se auala kuka e mafai ona saogalemu ai.

Ina ia sauniuni mo faʻalavelave faʻafuaseʻi faʻafomaʻi e mafua mai meaʻai, faʻamaʻi, ma femalagaaʻi, mafaufau e ave se fesoasoani muamua ma le CPR mai le Koluse Mumu, St John Ambulance, poʻo se tagata e tuʻuina atu aʻoaʻoga faʻapitonuʻu.

Taiala fa'atatau¶

• Botulism, Ciguatera, Scombroid, ma Shellfish Neurotoxin Vaaiga Aoaoga oona
• Fa'afitauli Fa'ama'i ma Anaphylaxis Fesoasoani Muamua
• Rebound Anaphylaxis, Biphasic Allergic Reaction, ma le Taimi EpiPen Lona Lua
• Oona o Mea'ai, Ma'i Gastroenteritis, ma le Fa'agata
• Oona Lautele Fesoasoani Muamua ma le Fa'amama

Punavai ma ta'iala aloa'ia¶

• U.S. Nofoaga Autu mo le Puipuia ma le Puipuia o Fa'ama'i (CDC): CDC Yellow Book (Faamatalaga Soifua Maloloina mo Femalagaaiga Fa'avaomalo): Oona o Mea'ai mai Toxin o le Gataifale (Ciguatera, Scombroid, ma Shellfish Poisoning) (United States).
• U.S. Pulea o Mea'ai ma Fualaau Fa'asaina (FDA): Bad Bug Book (Foodborne Pathogenic Microorganisms and Natural Toxins, 2^nd Edition): Scombrotoxin (Histamine), Ciguatoxin, Domoic Acid (ASP), Brevetoxin (NSP), ma Saxitoxin (PSP) (United States).
• Faalapotopotoga o le Soifua Maloloina a le Lalolagi (WHO) & Faalapotopotoga o Mea Taumafa ma Faatoaga (FAO): Lipoti a le Fonotaga a le Tofa i le Ciguatera Poisoning ma Marine Biotoxins i Bivalve Molluscs (Roma / Geneva).
• ** 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.: * Ciguatera fish poisoning: togafitiga, puipuiga ma le puleaina * (Marine Drugs / Palafox NA intravenous mannitol studies).