When a middle-aged man showed up at a Florida hospital with high blood pressure and facial paralysis, doctors barely knew where to begin. Almost like an episode of House, there were so many things that could have been wrong with him. In the end, doctors wrote in BMJ recently, a bizarre combination of factors turned out to be to blame. Most notably, pufferfish and cocaine — a recipe for a very bad night out.
"This case exemplifies the classic manifestations of tetrodotoxin poisoning with some unique overlapping features, in the setting of an interesting social history."
The 43-year-old man’s doctors documented his case in a paper published June 7 in which they explain that tetrodotoxin from a pufferfish liver was likely to blame for his near-death experience. The toxic effects of this exotic food were complicated by his history of kidney disease and high blood pressure, his regular consumption of canned foods, and his cocaine use. Even the doctors on the case expressed amazement at how strange the situation was.
“This case exemplifies the classic manifestations of tetrodotoxin poisoning with some unique overlapping features, in the setting of an interesting social history,” they wrote.
When the unnamed patient arrived at the hospital, he told doctors he had eaten pufferfish liver a few hours before. Pufferfish, known as fugu in Japan, is sought after for its unique-tasting flesh, but eating it is risky because it also secretes a deadly toxin in almost all its other body parts. Its liver, intestines, gonads, and skin all contain tetrodotoxin, which is 1,200 times more toxic than cyanide. Just 2 to 3 milligrams of the substance can kill an adult human.
Even though fugu is only allowed to be processed by licensed handlers in Japan, a few dozen cases of fugu poisoning still occur there each year, usually due to human error in preparing or packaging the fish.
In this case, it’s not clear where the man got pufferfish in Florida. Since there are some native species there, it’s possible he fished for it himself or got it from a friend. The doctors note in the case report that there’s an “underground market” for the fish.
Shortly after the man arrived at the hospital and doctors began treating his extremely elevated blood pressure (268/164), he crashed. At that point, doctors had to intubate him to keep him from suffocating. They also gave him activated charcoal to absorb any of the remaining toxin in his stomach and treated him for possible botulism, since he also reported eating canned goods over the previous days. Canned goods are a known source of Botulinum, the bacteria that causes the illness.
Tetrodotoxin has no existing antidote, so treating a patient for exposure involves dealing with their symptoms until the body clears the toxin naturally. The patient had to be hooked up to a ventilator and treated for pneumonia.
As tetrodotoxin spreads through the body, it causes paralysis that begins at the face and spreads downward. Usually, it kills by paralyzing the diaphragm, at which point the victim suffocates. Putting the patient on a ventilator and treating his other complications, including aspirated vomit and kidney damage, ensured his survival. He remains on dialysis because of damage to his kidneys that he sustained during his ICU stay, but he’s alive.
The cocaine added a particularly interesting twist to the case. Tetrodotoxin usually lowers blood pressure, but the doctors note that the cocaine in the man’s system seemed to counteract the toxin’s effects and even cause his blood pressure to skyrocket.
Dangerous as it is, the toxin has the potential to be used therapeutically. It paralyzes its victims by inhibiting voltage-gated sodium channels, the proteins that allow nerve cells to fire correctly, and as these tiny channels are blocked by the toxin, cells become paralyzed. Recently, scientists have suggested that this paralytic action might actually help in the development of new, non-addictive, pain-relieving drugs.
The doctors, for their part, recommend avoiding pufferfish altogether:
“For now, we will forewarn the public to refrain from consuming the deadly delicacy known as ‘fugu.’”