A Case Report of Puffer Fish Poisoning in Singapore

Although many Asians regard puffer fish as a delicacy since ancient times, puffer fish (Lageocephalus scitalleratus) is also a well-known source of possibly lethal food poisoning. The fish is gaining popularity in Singapore and can be found in quite a few restaurants now. Puffer fish contains tetrodotoxin (TTX), a potent poison affecting the neural pathway. Puffer fish poisoning may cause a constellation of symptoms, such as giddiness, numbness and tingling sensation of the mouth, paresthesia, and muscle weakness. Severe cases may present with respiratory depression, circulatory failure, and death. TTX poisonings have been reported in Japan, Taiwan, Hong Kong, Bangladesh, and the United States (Haque et al. 2008). We report a case of mild poisoning and suggest observation for such cases. 1. Introduction TTX is one of the most potent and oldest known neurotoxins, and puffer fish poisoning is common along the coasts of Asian countries [1–4]. TTX poisonings have been reported in Japan, Taiwan, Hong Kong, Cambodia [3], Bangladesh [4], and the United States. Also referred to as Fugu (meaning “river pig” in Japanese), balloonfish, blowfish, bubblefish, globefish, Patka fish, swellfish, toadfish, toadies, honey toads, sugar toads, and sea squab, the puffer fish [5] is commonly found in coastal regions of the tropics such as the Indian Ocean and in the South Pacific. They are relatively uncommon in the temperate zone and completely absent from cold waters [6]. Even with its long history of toxic effects, the fish is considered a delicacy in Japan especially and is prepared by licensed puffer fish cooks only in Japan. Despite this, reports of up to 50 deaths annually occur in Japan from puffer fish poisoning [7, 8]. In Taiwan, more than 100 cases were reported from 1998 to 2008, and the mortality rate was about 10% [9]. Ingestion of the flesh, viscera, or skin of toxic tetraodontiform fishes can cause poisoning. There are reports of a distinct relationship between gonadal activity of the fish and its toxicity, the fish being most lethal for consumption immediately prior to and during their reproductive periods [10, 11]. The highest concentration of the toxins is found in the viscera (gonads, especially the ovaries; liver; and intestine) and skin. The body musculature is usually free of poison [1]. To date, there is no known antidote available. Management remains supportive; hence people should be made aware of the potential risks of eating puffer fish, understand the symptoms and signs of poisoning, and quickly seek medical attention when such symptoms occur. 2.