A 45 year old man presents to your ED with facial flushing, an itchy rash, nausea and vomiting about 30 minutes after eating at a seafood restaurant in NYC. He says he ordered a peppery tasting fish. Vital signs are as follows: T: 99.8F, HR 105, BP 110/70. He is speaking in full sentences and you appreciate no wheezing on the exam. What is the treatment for the most likely cause of his symptoms?

A. Corticosteroids

B. Antihistamine and supportive care

C. Sodium Bicarbonate

D. Metronidazole

E. Intubate the patient prophylactically

F. Activated Charcoal

Answer: B. Antihistamine and Supportive Care

This patient is presenting with acute scombroid poisoning. This occurs when fish are improperly stored and bacterial overgrowth can occur which causes the conversion of histidine to histamine which accumulates in the fish tissue. Symptoms usually occur within one hour of ingestion and include cutaneous flushing, nausea/vomiting, diarrhea, urticarial rash, and  abdominal cramping. Symptoms usually resolve after 12-24 hours if untreated. Treatment includes antihistamines as well as supportive care (i.e. fluids if significant diarrhea/vomiting).

Dickinson G. Scombroid fish poisoning syndrome. Ann Emerg Med 1982; 11:487.

McMickle, R., et al. Seafood Poisoning and Toxidromes. February 24, 2021; http://www.emdocs.net/seafood-poisoning-and-toxidromes/

Nguyen, Thomas and Saadia Akhtar Walls R, Hockberger R, Gausche-Hill M. Rosen’s Emergency Medicine: Concepts and Clinical Practice, Ninth Edition Philadelphia, PA: Elsivier Inc; 2018.

Vickers, Jennifer. Scombroid Poisoning. N Engl J Med 3013; 356:e31. DOI: 10.1056/NEJMicm1300169