Never eat an ugly fish: three cases of tetrodotoxin poisoning from Western Australia

Tetrodotoxin is a powerful axonal blocking agent found in a number of marine creatures, including puffer fish. Fatal and near fatal poisonings due to puffer fish ingestion have been described in the medical literature, but few reports are from Australia. Three adults from the same family (two men aged 40 and 24 years and one woman aged 47 years) presented to the Fremantle Hospital Emergency Department six hours after catching and eating an unknown fish. Two developed typical symptoms of tetrodotoxin poisoning including tongue and lip paraesthesiae, blurred vision, ataxia, vomiting and progressive muscular paralysis with inability to stand. They were admitted to the intensive care unit although neither required mechanical ventilation. The third had minimal signs and was observed in the emergency medicine observation ward overnight. All were discharged the next day with some residual ataxia. Clinically significant tetrodotoxin poisoning may culminate in respiratory failure and death if untreated. There is no specific antidote and treatment is supportive. The literature on this unusual poisoning is reviewed.