Shellfish and pufferfish poisoning syndromes

Poisoning syndrome	Affected seafood	Common geographic distribution	Primary toxin	Clinical findings	Management
Paralytic shellfish poisoning	Bivalve mollusks^* (Cockles, fresh- and salt-water mussels, little neck clams)	Worldwide, especially USA (Northeast, Pacific Northwest, and Alaska)	Saxitoxin	Perioral tingling Paresthesias Difficulty swallowing Dizziness Ataxia Paralysis	Supportive care Activated charcoal Mechanical ventilation for respiratory failure
Neurotoxic shellfish poisoning	Bivalve mollusks (eg, mussels or clams)	Southeast USA Mexico Caribbean New Zealand	Brevetoxin	Ingestion: Nausea Vomiting Diarrhea Abdominal pain Paresthesias Dizziness Ataxia Temperature-related dysesthesia Paralysis (rare) Coma (rare) Seizures (rare) Inhalation: Rhinorrhea Bronchoconstriction	Supportive care Ingestion: Activated charcoal Antiemetics (eg, ondansetron) Fluid repletion Treat seizures with benzodiazepines (eg, lorazepam) Mechanical ventilation for respiratory failure Inhalation: Inhaled bronchodilators (eg, albuterol) for bronchospasm
Diarrheic shellfish poisoning	Mussels	Japan Scandinavia France Belgium Spain Chile Uruguay Ireland Canada	Okadaic acid	Nausea Vomiting Diarrhea Abdominal pain	Supportive care Activated charcoal Antiemetics (eg, ondansetron) Fluid repletion
Amnestic shellfish poisoning	Mussels Razor clams Crustaceans	Canada Spain Portugal France Ireland United Kingdom Peru Chile Australia New Zealand	Domoic acid	Diarrhea Abdominal pain Headache Disorientation Retrograde and anterograde memory loss Ophthalmoplegia Coma Seizures	Supportive care Activated charcoal Treat seizures with benzodiazepines (eg, lorazepam)
Pufferfish poisoning	Pufferfish	Japan USA	Tetrodotoxin (liver) Saxitoxin (muscle)	Tetrodotoxin: Paresthesias Nausea Dizziness Paralysis Hypotension Saxitoxin: Same as paralytic shellfish poisoning above	Tetrodotoxin: Supportive care Gastric lavage Activated charcoal Give fluid therapy and vasopressors as for distributive shock in patients with hypotension Mechanical ventilation for respiratory failure Saxitoxin: As for paralytic shellfish poisoning

* Gastropod mollusks (eg, whelks, moon snails, and abalone), crustaceans (eg, Dungeness crab, shrimp, and lobster), pufferfish, and zooplanktivorous fish (eg, salmon, herring, or mackerel) can also become contaminated with saxitoxin and potentially cause paralytic shellfish poisoning although human disease has most commonly been described with bivalve mollusks.

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Shellfish and pufferfish poisoning syndromes