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  • Caused by eating fish which have been improperly stored/refrigerated
    • Bacteria grow and produce heat-stable toxin that causes histamine release when consumed[1]
    • Patient may complain that the fish tasted like pepper, metallic, or bitter
  • Commonly associated fish include: tuna, bluefish, mahi-mahi, herring, mackerel, skip-jack, sardine, and bonito
  • Frequently misdiagnosed as seafood allergy

Clinical Features

  • Symptoms generally start within one hour of ingestion, and usually resolves within 12 hours (if untreated)
  • Flushing, warmth, erythematous rash, palpitations, dizziness, diarrhea
  • May also see severe throbbing headache, blurred vision, tachycardia, and respiratory distress

Differential Diagnosis

  • Ciguatera - similar clinical presentation, different fish

Acute allergic reaction

Erythematous rash


  • Generally clinical diagnosis


  • Antihistamines - give both H1 and H2 antagonists
  • Consider epinephrine, albuterol if symptoms of respiratory distress


  • Generally may be discharged

See Also


  1. Craig SA, Zich DK: Gastroenteritis, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 92:p 1211-1222