285 M.E.J. ANESTH 20 (2), 2009
HUMAN POISONING AFTER INGESTION
OF PUFFER FISH CAUGHT
FROM MEDITERRANEAN SEA
- A Case Report -
suheIl ChuCrallah ChaManDI*, kaMal kallab**,
hanna Mattar*** anD elIe naDer****
Abstract
Puffer fish poisoning is due to a powerful neurotoxin produced by bacteria living in this kind
of fish. Though the sea of Lebanon (Mediterranean) is not endemic of puffer fish and incidence of
its serious poisoning is rare, yet occasional incidences do occur. The purpose of this presentation is
to raise the awareness of fishermen, fish-restaurant frequenters, public health organizations and the
Ministry of Health ,of its serious symptomology and to seek medical help as soon as possible.
Case Report
A 68 year-old woman, with hypertension and diabetes, was brought to the Emergency
Department of the Hopital Universitaire de Notre Dame De Secours, in January 2008 complaining
of proximal limb weakness and dyspnea.
Four hours prior to her arrival, the patient had eaten a half-cooked fish liver. Three hours and
thirty minutes later, she started feeling a tingling sensation in the perioral region and in the tip of
her fingers associated with blurred vision, head heaviness, nausea and one episode of vomiting.
Ten minutes later, she lost her ability to hold her head up and had developed weakness of
her upper and lower extremities. This was accompanied by mild abdominal distention and urinary
urgency. The patient then developed quadriplegia, hypophonia and dysarthria. She complained
of dyspnea, ophtalmoplegia and had an absent gag reflex. Subsequently, the patient underwent
endotracheal intubation.
After intubation, the neurological examination revealed normal consciousness and orientation,
bilateral third, fourth and sixth nerve palsies, normal pupillary reflexes, absent gag and cough
reflexes and the deep tendon reflexes. Computed Tomography (CT) scan of the brain did not show
any abnormalities.
Upon further questioning on the following day, the family reported that the fish was a blowfish
and identified it by picture comparisons, as Lagocephalus scleratus (Fig.1 & 2).
Affiliation to Holy Spirit University – USEK – Medical School-Kaslik, Lebanon and Lebanese University.
* MD, IC and Pain Clinic Director, Lebanese University-Medical Faculty-Beirut, Lebanon.
** MD, Dean of Medical Faculty.
*** MD,
Affiliation to Lebanese University Medical School-Beirut, Lebanon.
**** MD.
Corresponding author: Dr. Souheil C Chamandi, Holy Spirit University – USEK – Medical School, Kaslik, Lebanon.
Phone: +961 3 230071, Fax: 009619944099, E-mail: byblosmar@hotmail.com

286 SUHEIL CHUCRALLAH CHAMANDI ET. AL
Between 1974-1983, the incidence of puffer fish
intoxication was estimated to be as high as 200 cases
per year, with mortality approaching 50%. Puffer fish
poisoning is most commonly seen in Japan. Sporadic
cases have been reported in the United States.
The different bacteria living in puffer fish
liver, gonads, intestines and skin, are known to
synthesize a very potent heat stable neurotoxin called
“tetrodotoxin”.
Historically, the first recorded cases of
tetrodotoxin poisoning were from the logs of Captain
James Cook, the British explorer, navigator and
cartographer during his voyages to the Pacific Ocean,
late part of the 18th century. He recorded that his crew
were eating some local tropic fish (puffer fish), and
feeding the remains to the pigs kept on board. The crew
experienced numbness and shortness of breath, while
the pigs were all found dead the next morning. It is
clear that the crew received a mild dose of tetrodotoxin,
while the pigs ate the puffer fish body parts that
contained most of the toxin, thus killing them.
The toxin was first isolated and named in 1909
by Japanese scientist Yoshizumi Tahara: Tetrodotoxin
(anhydrotetrodotoxin 4-epitetrodotoxin, tetrodonic
acid, TTX) (Fig. 3 & 4).
Poisoning from tetrodotoxin is of particular
public health concern in Japan. “Fugu” is a traditional
delicacy, prepared and sold in special restaurants where
trained and licensed chefs carefully remove the viscera
to reduce the danger of poisoning.
Pathophysiology
The toxin blocks the action potentials in nerves by
binding to the pores of the voltage-gated, fast sodium
channels in nerve cell membranes. Tetrodotoxin binds
Four days later she was extubated and recovered
fully without any neurological sequelae.
Fig. 1
Dr. S. Chamandi holding a Puffer fish caught from our sea
Fig. 2
Puffer fish caught in the Mediterranean sea
Discussion
Puffer fish is the general name for fish of the
family Tetraodontidae, class Osteichthyes order
Tetraodontiformes. The Lagocephalus scleratus is
known to be one of the most dangerous puffer fish
species. These fish can swell their bellies to a shape
resembling a ball. They are geographically distributed
in waters surrouding Japan, the Indian and South
Pacific Oceans and North American waters (lesser
degree). The Mediterranean coasts is not known as an
endemic region.
Fig. 3 Fig. 4