Scombroid pancreatitis from mahi-mahi consumption

Abstract

A 61-year-old woman with no significant previous medical history presented to an urgent care facility with generalised rash, flushing and abdominal pain after eating mahi-mahi. She was diagnosed with an allergic reaction and discharged home. Later she experienced severe acute abdominal pain and multiple episodes of vomiting, which prompted her to go to the hospital. On admission, the patient had an elevated white count, lipase, amylase and C reactive protein with normal liver enzymes and bilirubin. Imaging showed acute pancreatitis that was suspected to be secondary to scombroid poisoning. This was confirmed by elevated immunoglobulin E and histamine levels. The acute pancreatitis was treated with pain management and supportive treatment. Scombroid poisoning is a well-recognised disease, however, acute pancreatitis secondary to this is rare as only two cases have been reported in the literature, one with codfish and the second an unknown type of fish.

Scombroid Poisoning

“…Bacteria that form above 3.3 °C, 38 °F allows for the production of an enzyme that converts histidine into histamine (York & Castaneda-Guarderas, 2022). Thoroughly cooking or freezing the fish does not remove the histamine formed in the flesh, causing toxicity to the individual once ingested (Hernandez Garcilazo et al, 2021). The ENPs need to identify and treat patients with scombroid poisoning correctly.…”

“…When fish is stored in temperatures above 3.3 °C or 38 °F, it allows for the bacteria-derived enzyme histidine decarboxylase to form, which converts histidine to histamine (York & Castaneda-Guarderas, 2022). After histamine levels have formed, it remains stable despite later freezing or thoroughly cooking (Hernandez Garcilazo, Prasad, Varghese, & Kemnic, 2021). It is important to note that histidine is already present in the flesh of the fish before the enzymatic conversion to histamine.…”

“…It is important to note that histidine is already present in the flesh of the fish before the enzymatic conversion to histamine. Bacteria associated with scombroid are Escherichia coli , Serratia , Citrobacter , Klebsiella , Clostridium , Vibrio , Acinetobacter , Pseudomonas , Morganella , and Photobacterium (Hernandez Garcilazo et al, 2021). Once the patient consumes the fish, the histamine from the flesh is released, causing symptoms (Gonzalez et al, 2021).…”

“…In severe cases, patients may develop respiratory symptoms such as wheezing, angioedema, bronchospasm, hypotension, and respiratory distress (Guergué-Díaz de Cerio et al, 2016; Nordt & Pomeranz, 2015). There have been reports of pancreatitis supported by elevated lipase and computed tomographic findings in some cases (Hernandez Garcilazo et al, 2021). In addition, although not common, some patients may develop acute coronary syndrome and arrhythmias due to histamine toxicity and transient vasospasm (Ferrazzo, Andò, Cerrito, & de Gregorio, 2019).…”

Two Case Reports of Scombroid in Singapore: A Literature Review

“…While mostly self-limiting and mild, there have been reports of life-threatening scombroid poisoning. A previously healthy young woman developed hypotension needing vasopressors with ST depressions [ 9 ] while another scombroid poisoning was complicated by acute pancreatitis [ 10 ]. Some cases were severe enough to need ICU admissions.…”