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  3. Clinical entry: Scombroid fish poisoning

Clinic: Scombroid fish poisoning

Examine for venom effects

Direct pharmacological effects of exogenous histamine

  • Nausea, vomiting, diarrhoea, abdominal pain,
  • skin rash (erythema),  pruritus, angio-oedema,  
  • burning sensation (mouth), peppery taste, 
  • flushing, sweating,
  • headache, fever,
  • palpitations (tachycardia), arterial hypotension.

Laboratory method and physical investigation

See reviews Bian et al. (2024), Feng et al. (2016), Hungerford (2021), Ridolo et al. (2016).
Feng et al. (2016) suggest the following tests:

  • Fish histamine level >50 mg/100 kg, 
  • “Skin prick testing may help rule out IgE-mediated food allergies. Prick-to-prick testing should be performed on the sample of the fish that caused the reaction and samples obtained from different sources that are as fresh as possible and on ice or frozen. If the test is positive for the same type of fish from different sources, then an IgE-mediated fish allergy is highly likely. However, if the skin test is only positive for the implicated fish sample, then HFP or an alternative food used in the cooking or preparation is the likely suspect. One can also consider repeating the same tests in a normal control to validate the results” (Patel et al. 2023, citing Feng et al. 2016), 
  • Normal tryptase level (serum tryptase levels may be elevated in true IgE-mediated anaphylaxis and should not be elevated in scombroid); 
  • Negative 5-HIAA, metanephrines, 
  • Urinary PGD2.

Electrophysiological investigations

  • Tachycardia, supraventricular arrhythmias (atrial flutter) (Borysiewicz and Krikler 1981).

Species-specific envenoming pattern

  

Direct pharmacological effects of exogenous histamine1

Scombrotoxin fish poisoning; histamine fish poisoning

  

Differential diagnosis 
see also
Emergency flowchart: Poisonous animals

Skin rash (erythema), flushing and burning in the mouth, combined with a short incubation period of 10 min–2 h, distinguish scombroid poisoning clinically from other types of food poisoning. Several criteria support the differential diagnostic distinction between scombroid poisoning and "true" seafood allergies. Scombroid poisoning generally occurs in "small epidemics", i.e. there are usually other ill persons besides the index patient. High concentrations of histamine are found in the consumed fish. The patient has no history of allergies.

See Friedman et al. (2017)
See also Anagnostou and Abrams (2023), Patel et al. (2023)

1Effects due to exogenous histamine with a direct pharmacological effect
Skin rash (erythema), flushing, sweating, pruritus, angio-oedema, nausea, vomiting, diarrhoea, abdominal pain, burning sensation (mouth), peppery taste, palpitations (tachycardia), arterial hypotension, headache, fever (see Table in Section ‘Studies’ below).

Time between ingestion and onset of symptoms

10 min–2 h (Bartholomew et al. 1987).

See also reviews Feng et al. (2016); Ridolo et al. (2016).

Diagnosis

  • The diagnosis of scombroid poisoning is primarily based on patient history and clinical criteria. 
  • The detection of increased clearance of histamine and its metabolite in urine with normal PGD-M levels (Morrow et al. 1991) and the detection of histamine in remaining tissue from the consumed fish support the diagnosis.
  • Correlation of signs and symptoms with the histamine concentration in the consumed fish gives the following picture (Bartholomew et al. 1987): 
    • If the samples investigated contained >20 mg% histamine, there was close agreement (94%) with clinically manifest scombroid poisoning (skin rash, flushing, burning in the mouth, short incubation period). 
    • If the samples contained 5–20 mg% histamine, this agreement was only 38%. However, also in cases where the consumed fish caused symptoms and in which the samples contained <5 mg% histamine, 39% of the observed symptom complexes were characteristic for scombroid poisoning in terms of the symptoms listed above.

Differential diagnosis

  • Skin rash (erythema), flushing and burning in the mouth, combined with a short incubation period of 10 min–2 h, distinguish scombroid poisoning clinically from other types of food poisoning. Several criteria support the differential diagnostic distinction between scombroid poisoning and "true" seafood allergies. Scombroid poisoning generally occurs in "small epidemics", i.e. there are usually other ill persons besides the index patient. High concentrations of histamine are found in the consumed fish. The patient has no history of allergies.
  • The clinical picture of scombroid poisoning appears to be very uniform, according to all of the existing clinical data, which are, however, almost invariably retrospective. Differences between individuals can almost always be explained by the dose-effect relationship.

Morbidity

Without treatment the symptoms disappear after 12–24 h with no lasting effects.

Case fatality rate

Generally, not directly associated with fatalities, as opposed to potentially fatal anaphylaxis associated with allergies.

Species-specific publications 
see ‘References’ at the end of the file.

Clinical management

See also Clinical Management: poisonous animals

for advice on diagnosis (clinical, laboratory) and treatment (supportive).

First Aid

Gastric evacuation, if this has not occurred spontaneously. However, there has been no study to prove the value of this method.

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

Obey Scombroid Fish Poisoning - specific features

see 'Species-specific envenoming pattern' above.

Key issues

Supportive treatment for mild to moderate and severe scombroid poisoning

Mild to moderate symptoms

  • Oral or iv H1 blockers and H2 blockers
  • Intravenous fluids
  • Promethazine for nausea

Severe symptoms

  • Epinephrine IM or IV epinephrine or dopamine titrated to effect
  • Methylprednisolone
  • Intravenous fluids

(Blakesley 1983, Feng et al. 2016, Morrow et al. 1991).

Tuberculosis patients on isoniazid

  • Isoniazid is a histamine inhibitor. Tuberculosis patients on isoniazid develop the typical signs of scombroid fish poisoning at much lower concentrations of histamine in fish than persons not taking this medication. If the interval between taking isoniazid and consumption of the poisonous fish is sufficiently long, the levels of isoniazid may already be so low that this reaction does not occur (Uragoda 1980, Uragoda and Kottegoda 1977).

Specific treatment (Antidote)

Antidotes are not available.
H1 blockers and H2 blockers are not "antidotes" in the strict sense.

References

Reviews

  • Anagnostou A, Abrams E. Is it food poisoning or allergy?: A diagnostic challenge revisited.Ann Allergy Asthma Immunol. 2023 Apr;130(4):403-404. PMID: 37005046. https://doi.org/10.1016/j.anai.2022.12.019
  • Bian Y, Zhang Y, Feng XS, Gao HY.Marine toxins in seafood: Recent updates on sample pretreatment and determination techniques. Food Chem. 2024 Apr 16;438:137995. Epub 2023 Nov 20. PMID: 38029684. https://doi.org/10.1016/j.foodchem.2023.137995
  • Feng C, Teuber S, Gershwin ME. Histamine (Scombroid) Fish Poisoning: a Comprehensive Review. Clin Rev Allergy Immunol. 2016 Feb;50(1):64-9. PMID: 25876709. https://doi.org/10.1007/s12016-015-8467-x
  • Hungerford JM. Histamine and Scombrotoxins. Toxicon. 2021 Oct 15;201:115-126. Epub 2021 Aug 20. PMID: 34419509. https://doi.org/10.1016/j.toxicon.2021.08.013
  • Patel P, Komorowski AS, Mack DP. An allergist's approach to food poisoning. Ann Allergy Asthma Immunol. 2023 Apr;130(4):444-451. Epub 2022 Nov 2. PMID: 36334721. https://doi.org/10.1016/j.anai.2022.10.021
  • Ridolo E, Martignago I, Senna G, Ricci G. Scombroid syndrome: it seems to be fish allergy but... it isn't. Curr Opin Allergy Clin Immunol. 2016 Oct;16(5):516-21. PMID: 27466827. https://doi.org/10.1097/aci.0000000000000297

Original publications

  • Bartholomew BA, Berry PR, Rodhouse JC, Gilbert RJ, Murray CK. Scombrotoxic fish poisoning in Britain: features of over 250 suspected incidents from 1976 to 1986. Epidemiol Infect. 1987 Dec;99(3):775-82. PMID: 3428380; PMCID: PMC2249252. https://doi.org/10.1017/s0950268800066632
  • Blakesley ML. Scombroid poisoning: prompt resolution of symptoms with cimetidine. Ann Emerg Med. 1983 Feb;12(2):104-6. PMID: 6824204. https://doi.org/10.1016/s0196-0644(83)80386-2
  • Borysiewicz L, Krikler D. Scombrotoxic atrial flutter. Br Med J (Clin Res Ed). 1981 May 2;282(6274):1434. doi: 10.1136/bmj.282.6274.1434. PMID: 6784855; PMCID: PMC1505159. https://doi.org/10.1136/bmj.282.6274.1434
  • Morrow JD, Margolies GR, Rowland J, Roberts LJ 2nd. Evidence that histamine is the causative toxin of scombroid-fish poisoning. N Engl J Med. 1991 Mar 14;324(11):716-20. PMID: 1997836. https://doi.org/10.1056/nejm199103143241102
  • Uragoda CG. Histamine poisoning in tuberculous patients after ingestion of tuna fish. Am Rev Respir Dis. 1980 Jan;121(1):157-9. PMID: 7188722. https://doi.org/10.1164/arrd.1980.121.1.157
  • Uragoda CG, Kottegoda SR. Adverse reactions to isoniazid on ingestion of fish with a high histamine content. Tubercle. 1977 Jun;58(2):83-9. PMID: 406701. https://doi.org/10.1016/0041-3879(77)90034-4

Systemic supportive treatment

  • WHO ABCDE Approach. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
  • WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured. https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2

Internet links providing specific information

Species-specific evidence

Studies

  • Bartholomew BA, Berry PR, Rodhouse JC, Gilbert RJ, Murray CK. Scombrotoxic fish poisoning in Britain: features of over 250 suspected incidents from 1976 to 1986. Epidemiol Infect. 1987 Dec;99(3):775-82. PMID: 3428380; PMCID: PMC2249252. https://doi.org/10.1017/s0950268800066632
    Retrospective study. 638 cases in 258 outbreaks. The 94 outbreaks in which the consumed fish contained >5 mg% are histamine are described. The results for signs and symptoms are based on the number of outbreaks, with the argument that the symptoms within a single outbreak are always very uniform. Determination of histamine from fish samples in 240/258 outbreaks.
  • Gilbert RJ, Hobbs G, Murray CK, Cruickshank JG, Young SE. Scombrotoxic fish poisoning: features of the first 50 incidents to be reported in Britain (1976-9). Br Med J. 1980 Jul 5;281(6232):71-2. PMID: 7190856; PMCID: PMC1713701.
    Retrospective study. 196 cases in 50 outbreaks. The 30 outbreaks (= 150 cases) for which there were sufficient clinical data are described. The results for signs and symptoms are based on the number of outbreaks, with the argument that the symptoms within a single outbreak are always very uniform. Determination of histamine from fish samples in 37/50 outbreaks.
  • Chen Kow-Tong, Malison MD. Outbreak of scombroid fish poisoning, Taiwan. Am J Public Health. 1987 Oct;77(10):1335-6. PMID: 3631369; PMCID: PMC1647154. https://doi.org/10.2105/ajph.77.10.1335
    Retrospective study, N = 115. Determination of histamine from fish samples.
  • Maire R, Dreiding K, Wyss PA. Inzidenz und Klinik der Scombroid-Fischvergiftung [Incidence and clinical aspects of scombroid fish poisoning]. Schweiz Med Wochenschr. 1992 Dec 12;122(50):1933-5. German.PMID: 1465598. 
    Retrospective study, N = 31.
    Murray CK, Hobbs G, Gilbert RJ. Scombrotoxin and scombrotoxin-like poisoning from canned fish. J Hyg (Lond). 1982 Apr;88(2):215-20. PMID: 7061836; PMCID: PMC2133850. https://doi.org/10.1017/s002217240007008x
    Retrospective study. 71 cases in 26 outbreaks. The results for signs and symptoms are based on the number of outbreaks, with the argument that the symptoms within a single outbreak are always veryuniform. Determination of histamine from fish samples.

Signs and symptoms of scombroid poisoning: comparison of various studies (see above)

(Review T. Junghanss)



Case reports

  • Borysiewicz L, Krikler D. Scombrotoxic atrial flutter. Br Med J (Clin Res Ed). 1981 May 2;282(6274):1434. doi: 10.1136/bmj.282.6274.1434. PMID: 6784855; PMCID: PMC1505159. https://doi.org/10.1136/bmj.282.6274.1434
  • Kasha EE Jr, Norins AL. Scombroid fish poisoning with facial flushing. J Am Acad Dermatol. 1988 Jun;18(6):1363-5. PMID: 3385050. https://doi.org/10.1016/s0190-9622(88)80119-1
  • Morrow JD, Margolies GR, Rowland J, Roberts LJ 2nd. Evidence that histamine is the causative toxin of scombroid-fish poisoning.N Engl J Med. 1991 Mar 14;324(11):716-20. PMID: 1997836. https://doi.org/10.1056/nejm199103143241102