DISEASE OUTBREAK CONTROL DIVISION

After hours/emergency phone numbers:

Mainland and Neighbor Islands.........1-800-360-2575

After hours on O‘ahu...........................(808) 566-5049

**We provide access to our activities without regard to race,

color, national origin (including language), age, sex, religion,
or disability. Write or call our Affirmative Action Officer at Box
3378, Honolulu, HI 96801-3378 or at (808) 586-4616 (voice)
within 180 days of a problem.

Prepared by the Disease Investigation Branch

Revised January 2007
 Scombroid Fish Poisoning
Scombroid poisoning results from eating spoiled fish, primarily
tuna, mahimahi, and related species. Imported mahimahi has been
most often associated with scombroid poisoning in Hawai‘i. The
disease is sometimes misdiagnosed as “fish allergy.”
Inadequate or delayed refrigeration at sea results in the overgrowth of
various bacteria normally found in these fishes. The natural action of
these bacteria in the fish flesh produces histamine, saurine, and
possibly other toxic substances. The fish may not have a foul odor,
however, some victims have reported a sharp “metallic” or “peppery”
taste while consuming the fish. This is believed to be due to the
presence of histamine.
Symptoms may appear within a few minutes to several hours,
usually within an hour after eating a spoiled fish. Symptoms vary
widely between individuals but may include the following:
· flushing of the face, resembling sunburn, sometimes
involving the neck, arms, and upper part of the trunk
· severe throbbing headache
· palpitations of the heart
· abdominal cramps
· diarrhea
Other symptoms may include itching on the face or around the mouth,
a burning sensation in the throat, dryness of the mouth, difficulty in
swallowing and/or breathing, nausea, (rarely vomiting) and weakness.
Symptoms usually last for eight to 12 hours, after which rapid
recovery is expected. No fatalities have been recorded from
scombroid poisoning to date in Hawai‘i and they appear to be
extremely rare worldwide. Scombroid fish poisoning has been
successfully treated with antihistamines.
Other Types of Fish Poisoning
Other types of fish poisoning occur less frequently than
ciguatera or scombroid poisoning. These include intoxications usually
associated with specific types of fish.
“Hallucinogenic fish poisoning” is associated with mullet and a
number of other species of fish including weke (goatfish), weke ‘ula,
weke pueo, nenue (rudderfish), and manini (surgeon fish). It is
seasonal, occurring usually in summer months. Symptoms reported of
illness soon after ingestion may include the following: insomnia,
intense dreaming, weakness, general malaise, dizziness, itching,
burning of the throat, and other symptoms. Terrifying nightmares have
been reported when the onset of symptoms occurs while asleep.
Constrictive chest pains can also occur.
Ciguatera Poisoning
Ciguatera poisoning is thought to have been unknown to early Hawaiian
fishermen. Until recently most cases of ciguatera fish poisoning involved fish from
other areas of the Pacific, such as Midway or Johnson Island. Today, in Hawai‘i,
ciguatera fish poisoning is a serious problem for recreational fishermen and the
fishing industry.
Many species of fish that are highly esteemed as food have been
implicated in causing serious illness. Ulua (jack), kahala (amberjack), kole
(surgeon fish), roi (grouper) and po‘ou (wrasse) have been most often responsible
for ciguatera poisoning in Hawai‘i. Many other reef fish have been found to be toxic.
The toxin(s) is produced by microscopic marine organism, a dinoflagellate
called Gambierdiscus toxicus. This organism grows on the surface of marine algae
and are eaten by herbivorous fish. Since the toxin accumulates in fish, any fish up
the food chain can become toxic. The kole and palani (surgeon fish), uhu
(parrotfish) and others that feed directly on the algae or coral reefs upon which the
algae grows may be toxic. Fish that prey on these herbivores, ulua, kahala, uku
(snapper) and eel may be even more toxic because of the cumulative effect. None
of the deep sea fish, ‘ahi, aku (tuna), marlin, mahimahi, and ono (wahoo), have
been found to be ciguatoxic in Hawai‘i to date.
Unfortunately, there is no way of detecting a ciguatoxic fish from its
appearance, smell or taste. The fish seem to be unaffected by ciguatoxin. The
freshness of a fish has no relationship to its toxicity. Furthermore, the toxin is not
altered by cooking, drying, salting, or freezing the fish.
However, to minimize the risk of being poisoned, do not eat the roe
(eggs), liver or guts of any reef fish. The toxin is concentrated up to 100 times
more in these parts of the fish. In Hawai‘i, several deaths resulted from eating the
viscera of toxic fish. For this reason it is recommended that all reef fish be promptly
and thoroughly cleaned.
Symptoms of ciguatera poisoning vary greatly from one individual to
another, even when the same amounts of the same fish have been eaten. Illness
usually occurs within two to six hours after eating a toxic fish.
Common symptoms of illness may include the following:
· general weakness
· diarrhea
· muscle pain, joint aches
· numbness and tingling around the mouth, hands and feet
· reversal of temperature sensation, where cold objects feel hot
(a burning or tingling sensation may also be felt) and hot objects feel
cold
· others, such as nausea, vomiting, chills, itching, headache, sweating,
and dizziness.
The temperature reversal sensation phenomenon usually does not develop until two
to five days after eating a toxin fish. Illness may last for weeks or months, rarely
years.
When ciguatera poisoning occurs, the affected individual should avoid
consuming fish or shellfish products, alcoholic beverages and nut or seed products.
These may increase the severity and/or duration of illness.

Gambierdiscus toxicus
(magnifies 450 times)
Fish poisoning can result from eating spoiled
fish or from eating fresh fish containing toxic
substances. There are various types of fish
poisoning. Some types are associated with
specific fish, for example hallucinogenic fish
poisoning (mullet, manini, nenue, or weke)
and puffer fish poisoning (puffer fish or
makua). Scombroid fish poisoning occurs
when certain fish (mahimahi, ‘ahi or aku) are
eaten after they have spoiled, usually because
of improper refrigeration or storage.
Ciguatera fish poisoning is a natural
occurrence still not well understood.
Puffer Fish Implicated in Seven Fatalitites in Hawai‘i
“Puffer fish” poisoning or “tetrodotoxication” may result from eating puffers,
blowfish, balloon fish, ‘o‘opuhue, makimaki, keke, and others. Many
species of puffer fish contain at least one very potent toxin,
tetrodotoxin. Initial symptoms may occur within minutes and include
sweating and tingling of the lips, tongue, and fingertips, followed by
numbness that may spread throughout the body. Extreme weakness
associated with nausea, vomiting, headache, profuse sweating and
other symptoms have also been reported. In severe cases,
respiratory and muscular paralysis may ensue and may be followed by
death. The most common puffer fish or “fugu” (Arothron hispidus),
has been implicated in at least seven fatalities in Hawai‘i.
If the fish poisoning is suspected:
· CALL YOUR PHYSICIAN IMMEDIATELY FOR TRATMENT.
If your physician is unavailable, call Hawai‘i Poison Center
at 941-4411. A physician’s care is needed to remove
unabsorbed toxins from gastrointestinal tract and to treat
the manifestations of illness.
· Do not take any drug or medication without your physician’s
advice.
· Do not eat any remaining fish that could be toxic.
· Save the remainder of the fish (including the head and guts) in
your refrigerator or freezer to be given later to the
Department of Health. The Department of Health can
assist in arranging for laboratory confirmation of
suspected fish poisoning cases.
· Call the DEPARTMENT OF HEALTH to report a case of
suspected fish poisoning.
On O‘ahu, call the Disease Investigation Branch...............586-4586
On the neighbor islands, call
Maui District Health Office.......................................984-8213
Hawai‘i District Health Office...................................933-0912
Kona Health Office....................................................322-4877
Kauai District Health Office......................................241-3563