2. PresentedBy Dr / Said Said Elshama

3. Introduction Marine toxins is a vague area for physicians and clinical toxicologist in Egypt. Marine toxins is a vague area for physicians and clinical toxicologist in Egypt. Puffer fish contains one of the most potent marine toxins which is called tetrodotoxin. Puffer fish contains one of the most potent marine toxins which is called tetrodotoxin. Tetrodotoxin is a neurotoxin and has a severe dangerous effect for the life. Tetrodotoxin is a neurotoxin and has a severe dangerous effect for the life. In Japan, puffer fish poisoning is the most common cause of fatal food poisoning. In Japan, puffer fish poisoning is the most common cause of fatal food poisoning. In Egypt, many physicians observed sporadic cases of puffer fish poisoning. In Egypt, many physicians observed sporadic cases of puffer fish poisoning.

4. In the last ten years, the rate of these cases was progressive increased and made many troubles for physicians and people because In the last ten years, the rate of these cases was progressive increased and made many troubles for physicians and people because of wide extreme of different clinical pictures and prognosis. of wide extreme of different clinical pictures and prognosis. In Suez city, many people eat puffer fish without appearance any toxic manifestations, but some of them complain of different toxic signs and symptoms without any residual affection and the others die. In Suez city, many people eat puffer fish without appearance any toxic manifestations, but some of them complain of different toxic signs and symptoms without any residual affection and the others die.

5. Aim of the work Attraction of health professional attention to importance of toxicity puffer fish which is a common form of poisoning in Egyptian coastal cities such as Suez city. Attraction of health professional attention to importance of toxicity puffer fish which is a common form of poisoning in Egyptian coastal cities such as Suez city. Determination of factors affecting the clinical picture and outcome of puffer fish poisoning for early and clear diagnosis. Determination of factors affecting the clinical picture and outcome of puffer fish poisoning for early and clear diagnosis.

6. Patients and Methods The study was carried out in General Suez Hospital. The study was carried out in General Suez Hospital. Nine patients from different families with different ages and sex were admitted with history of puffer fish ingestion. Nine patients from different families with different ages and sex were admitted with history of puffer fish ingestion. Source of contamination was puffer fish which was caught from the red sea, especially the Suez Gulf. Source of contamination was puffer fish which was caught from the red sea, especially the Suez Gulf. Suez gulf was free from any contamination (microbial contamination and water pollution). Suez gulf was free from any contamination (microbial contamination and water pollution). Researchers of National Institute of Oceanography and Fishery (Suez branch) proved that Suez Gulf was free from any pollution during the same period of the research after investigation of multiple and frequent samples of water and fish Researchers of National Institute of Oceanography and Fishery (Suez branch) proved that Suez Gulf was free from any pollution during the same period of the research after investigation of multiple and frequent samples of water and fish

7. Puffer fish poisoning was diagnosed on the basis of recent dietary history and clinical picture. Puffer fish poisoning was diagnosed on the basis of recent dietary history and clinical picture. All patients ate one fish and average amount of boiled rice. All patients ate one fish and average amount of boiled rice. No any medication was taken before the admission. No any medication was taken before the admission. All cases were clinically examined, investigated and observed from admission to discharge for the following parameters : All cases were clinically examined, investigated and observed from admission to discharge for the following parameters :  Onset of symptoms.  Clinical manifestations.  Complete blood picture.  Renal functions,(SGPT), (SGOT).  Blood glucose, Electrolytes (Na, K, Ca, P ).

8. Clinical picture was divided into grading according to clinical grading system according to clinical grading system (Wan et al., 2007). Grade I : Perioral numbness and paraesthesia. Grade II : Numbness of tongue, face and other areas, in-coordination and slurred speech. Grade III: Flaccid paralysis, dyspnoea and aphonia. Grade IV: Respiratory failure and coma. All patients treated with :- ● All patients treated with :- - Gastric lavage for one time in emergency room. - Gastric lavage for one time in emergency room. - Multiple doses of activated charcoal for the first - Multiple doses of activated charcoal for the first two days of admission. two days of admission. - Symptomatic treatment. - Symptomatic treatment.

9. Results Table (1) : The relationship between the grade of severity of puffer fish poisoning and number of intoxicated patients. nine Total number of the patients was nine grade I three patients had grade I grade II three had grade II grade III three fatal cases had grade III grade IV later on, their condition was deteriorated and had grade IV. GradeIIIIIIIV N. Patients 33-3

10. Table {2}: Vital signs and system affection of all puffer fish intoxicated patients during admission in the hospital. intoxicated patients during admission in the hospital. System affection Temperature ◦ Respiratory rate Pulse Blood pressure V V C CNS Paraesthesia37.82585120/701 CNS Numbness of tongue37.52490130/902 CNS Incoordination36.81985100/603 CNS Slurred speech37.22075110/754 CNS Paralysis CVS Hypertension37.42190150/955 CNS Perioral numbness37.22270120/856 CNS Paraesthesia CVS Dyspnoea37.52290140/907 CNS Coma37.31880110/608 CNS Coma36.32090110/709

11. Table (3): Relationship between clinical grading system of puffer fish poisoning, onset of symptoms, eaten part of fish and outcome of all intoxicated patients. Cause of death Outcome Eaten part of fish Grade of poisoning Onset of symptoms (Minutes) Patient R.FDeathGonads + Flesh4>301 -RecoveryFlesh1>302 -RecoveryFlesh2>303 -RecoveryFlesh1<304 R.FDeathHead + Flesh430-605 -RecoverySoup + Flesh230-606 -RecoveryFlesh230-607 RFDeathHead + Flesh4<308 -RecoveryFlesh1<309

12. Table (4): The relationship between number of fatal cases and method of cooking of puffer fish. and method of cooking of puffer fish.  Out of six patients who ate fried fish only two patients died, while out of three patients who ate the boiled fish only one died.  Method of cooking had not any effect on the prognosis.  Method of cooking of high degree temperature had not any effect on efficacy of tetrodotoxin because it is a heat stable. Number of fatal cases Method of cooking Total number of patients 2Frying6 1Boiling3

13. Table (5): Renal functions of all puffer fish intoxicated patients. patients. Table (6): Liver functions of all puffer fish intoxicated patients. patients.987654321Referencerange CR.F11.21.10.90.90.90.80.70.6 o.6 - 1.4 S.Creatinine 303539273832293325 45 -15 S.Urea 987654321ReferenceRange CL.F204240131715171812 Up to 49 S.G.P.T 133835202217203014 S.G.O.T

14. Table (7) : Parameters of complete blood pictures of all puffer fish intoxicated patients. puffer fish intoxicated patients.Referencerange987654321 CP(4-11)868.1105.35.59.79.48 WBCs (10/mm) M (14-18) F ( 12-16) 141314.111.512.612.513.513.211 Hb (g/dl) ( F (4.5-5.5 M (4.5- 6) 4.94.84.94.24.24.64.44.54.1 RBCs (10/mm) 46- 33 454344.634373638.838.633 HCT % 96-80 929091.28286.283.985.284.981.3MCV(fl) 34-27 313032.23031.431.231.729.928 MCH (pg) 36-30 353435.43133.233.833.33330 MCHC (g/dl) 400-150 249190185260286240259294220 PLT (10/mm)

15. Table (8): Serum electrolytes (sodium, potassium, calcium and phosphorous) and blood glucose levels of all puffer and phosphorous) and blood glucose levels of all puffer fish intoxicated patients. fish intoxicated patients. 987654321 Reference range CElectrolytes1161001101568496102110100 200> R. glucose (mg/dl) 8.89.299.19.28.88.79.49.2 10.5-8.5 Ca (mg/dl) 3.23.543.72.83.33.44.35.62.5-5P 142150145140139164140160150 155-135 Na (mEq/L) 3.84.24.64.53.33.93.53.63.4 5.3-3.4 K (mEq/L)

16. Conclusion  Diagnosis of puffer fish poisoning depends on clinical picture and history of ingestion. clinical picture and history of ingestion.  Clinical picture of intoxication is mainly neurological, especially sensory. neurological, especially sensory.  Git and cardiovascular manifestations are not common in the most patients. common in the most patients.  Factors affecting severity and prognosis of puffer fish toxicity are the mode of preparation and the fish toxicity are the mode of preparation and the eaten part of the fish. eaten part of the fish.  The best method of preparation of puffer fish meal depends on the removal of viscera and skin. depends on the removal of viscera and skin.

17. Thank you