Agent: Endogenous toxin. Toxin: Endogenous toxin production by endo-symbiotic gut bacteria (Bacillus, Micrococcus, Acinetobacter, Altermonas, Vibrio, and other enterobacterial species). LD50 (IV in mice): 9 mcg/kg. Mechanism: Reversible binding to the outer pore of the Na channel, with decreased Na influx, preventing depolarization and subsequent nerve action potentials (NAPs).
Vectors: All pufferfish (balloonfish, blowfish, fugu fish, globefish, swellfish, toadfish), porcupine fish, marine sunfish; xanthid crabs, marine worms; blue-ringed octopus bites; skin secretions of some newts, frogs, and toads. Incubation: 10-20 minutes. Symptoms: Initial paresthesias, perioral burning, then salivation, headache, nausea and vomiting (diarrhea rare), sweating, glove and stocking paresthesias then numbness, tremor, ataxia, dysarthria, dysphagia, respiratory depression then paralysis, cardiovascular instability, stupor, and coma. Diagnosis: Mouse bioassay, TLC, HPLC, gas chromatography/mass spectrometry. Treatment: Supportive = protect airway, gastric lavage then AC-MDAC, IV fluids, vasopressors, and mechanical ventilation. Prognosis: CFR = 62%; survivors will recover within 1 week of ICU care (not universally available, especially in developing world).
Prevention: Avoid eating all pufferfish; travelers may consume fugu only in Japan, prepared by commercially licensed fugu chefs. Ban importation of all fugu fish and other pufferfish.
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