Food poisoning

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  • 1. Food POISONING
  • 2. Food-borne Poisoning
    • With Neurologic symptoms ***
    • With Gastroenteritis, anemia, thrombocytopenia and azotemia (HUS)
    • With Diarrhea and fever
    • And Bioterrorism
  • 3. Ciguatera Poisoning
  • 4. Ciguatera Poisoning
    • One of the most common vertebrate fish-borne poisoning
    • Indian ocean, Caribbean, South Pacific
    • May - August
    • > 500 fish species involved
      • Baracuda, parrot fish, red snapper, kingfish, sturgeon
    • Common factor
      • Large size of fish involved
  • 5. Figure. Worldwide distribution of ciguatera. Gray indicates coral reef regions located between 35° north and 35° south latitudes; darker gray indicates disease-endemic areas of ciguatera; black circle indicates Canary Islands (latitude 28°06′ north, longitude 15°24′ west. Source: refs. 4 and 5.
  • 6.  
  • 7. Ciguatera Fish Poisoning
    • Photosynthetic Benthic dinoflagellate
      • Gambierdiscus toxicus
    • Coral reef fish:
      • ปลาสาก , ปลากะพง , ปลากะรัง
      • ปลานกแก้ว , ปลาหมอทะเล
  • 8.  
  • 9. Ciguatoxin
    • Can be found in blue-green algae, protozoa, free algae dinoflagellate
    • Main nutritional source for small herbivorous fish  larger carnivorous fish
    • ↑ concentration in flesh, adipose tissue, viscera of larger fish
  • 10. Ciguatoxin
    • Heat stable
    • Lipid soluble, acid stable
    • Odorless, tasteless
    • MW 1100 D
    • Binds to Sodium channel
    • ↑ sodium permeability
  • 11. Figure 1. Saltatory conduction, with the action potential jumping from one node of Ranvier to the nextDifferent channels are distributed unevenly along the axonal membrane: Na + and K + s are in high concentrations at the node and K + f are almost exclusively paranodal. I h (permeable to both K + and Na + ) limits axonal hyperpolarisation, whereas the Na + /K + pump reverses iconic fluxes that may be generated through activity. 8 Na + =Na channels; K + f =fast K channels; K + s =slow K channels; I h =inward rectifier channels.
  • 12.  
  • 13. Clinical Manifestation
    • Symptoms begin 2-6 hrs after ingestion
    • Acute onset of diaphoresis , abd pain, N/V/D
    • Neurologic symptoms
      • Headache, paresthesia, dysesthesia
      • Watery eye, tingling of tongue, lip, throat
    • Myalgia, arthralgia
    • Dysuria, dyspareunia
    • Bradycardia, orthostatic hypotension
  • 14. Clinical effects of ciguatera poisoning
    • Gastrointestinal
      • Diarrhoea
      • Abdominal pain
      • Vomiting
      • Nausea
    • Neurological
      • Myalgia
      • Paresthesia (mouth, hands, feet)
      • Arthralgia
      • Cold allodynia (burning on contact with cold)
      • Headache
      • Ataxia
      • Dizziness or vertigo
    • Other
      • Asthenia
      • Pruritus
      • Perspiration
      • Mood disorders
      • Bradycardia
      • Eye pain
      • Dental pain
      • Dysuria
      • Skin rash
  • 15.  
  • 16. Treatment
    • Standard supportive care for toxic ingestion
    • Cathartic
    • Amitryptyline 25 mg Bid
  • 17. Ciguatera Poisoning
    • Sources
      • Sea fish (large fish)
      • Blue-green algae, dinoflagellate
    • Toxin
      • Ciguatoxin
    • Clinical
      • Sweating, abd pain, N/V/D
      • Paresthesia, dysesthesia
      • Myalgia, arthralgia
      • Bradycardia, hypotension
    • Management
      • Supportive care
      • Amitryptyline
  • 18. Ciguatera-like Poisoning
    • Sources
      • Moray, conger, anquilid eels
    • Toxin
      • Ichthyohemotoxin
    • Clinical
      • Like ciguatoxin
      • Cholinergic toxicity
      • Shortness of breath, mucosal erythema, skin eruption
    • Management
      • Supportive
  • 19.  
  • 20. Scombroid Poisoning
  • 21. Scombroid Poisoning
    • Sources
      • Scombroidae fish: tuna, mackerel, skipjack
      • Non-scombroidae: mahi mahi, amberjack
      • Cooked, smoked, canned, raw fish
    • Toxin
      • Histidine in dark meat
      • Histidine Histamine, Saurine
    Histidine decarboxylase
  • 22. Scombroid Poisoning
    • Clinical
      • Usually within minutes to hours after eating
      • Flush : intense erythema of face, neck, upper torso
      • Numbness , tingling, burning sensation of mouth
      • Dysphagia, headache
      • Pruritus, urticaria, angioedema, bronchospasm
      • Dizziness, N/V/D, palpitation, abdominal pain
  • 23. Scombroid Poisoning
    • Management
      • Supportive
      • Food allergy?
  • 24. Shellfish Poisoning
    • Paralytis Shellfish Poisoning
    • Neurotoxic Shellfish Poisoning
    • Amnestic Shellfish Poisoning
  • 25. Shellfish
    • Oyster หอยนางรม
    • Clam หอยกาบ
    • Mussel หอยสองฝา
    • Scallop หอยแครง
  • 26. Shellfish Poisoning
    • Ingestion of shellfish
    • Contaminated by dinoflagellates or algae
  • 27. Paralytic Shellfish Poisoning (PSP)
    • Source
      • Clams, oysters, mussels, scallops
    • Toxin
      • Saxitoxin
    • Effect
      • Blocks voltage-sensitive sodium channel
      • Like tetradotoxin
  • 28. Paralytic Shellfish Poisoning
    • Clinical manifestation
      • Symptoms occur within 30 min of ingestion
      • Neurologic symptoms
        • Paresthesia, numbness of mouth, extremities
        • Floating, headache, ataxia, vertigo, weakness
        • CN palsy: dysphagia, dysarthria, dysphonia
      • GI symptoms
        • Less common, N/V/D, abd pain
      • Fatalities within 12 hrs
      • Muscle weakness may persist for weeks
  • 29. Paralytic Shellfish Poisoning (PSP)
    • Treatment
      • Supportive
      • Orogastric lavage
      • Cathartic
      • Saxitoxin antibody (in animal)
  • 30. Neurotoxic Shellfish Poisoning (NSP)
    • Source
      • Same
    • Toxin
      • Brevetoxin
    • Effect
      • Lipid soluble, heat stable ~ ciguatoxin
      • Stimulate sodium channel of nerve, muscle
  • 31. Neurotoxic Shellfish Poisoning
    • Clinical manifestation
      • Incubation period: 3 hours (15 mins-18 hrs)
      • Duration: 17 hrs (1-72 hrs)
      • Neurologic symptoms
        • Paresthesia, reversal hot-cold temp
        • Myalgia, vertigo, ataxia, headache, tremor
        • NO PARALYSIS
      • GI symptoms
        • Abdominal pain, N/V/D, Rectal burning
      • Dysphagia, bradycardia, dilated pupil
  • 32. Neurotoxic Shellfish Poisoning (NSP)
    • Treatment
      • Supportive
    • Fatality
      • Not fatal
      • Severe respiratory depression : rare
  • 33. Amnestic Shellfish Poisoning (ASP)
    • Source
      • Mussels
    • Toxin
      • Domoic acid produced by diatom
    • Outbreak
  • 34. Amnestic Shellfish Poisoning
    • Clinical manifestation
      • Onset of symptoms : 5 hrs (15 mins-38 hrs)
      • Neurologic symptoms
        • Memory loss
        • Coma, seizure, hemiparesis
        • Ophthalmoplegia, chewing, grimace
      • GI symptoms
        • Less common
      • Unstable BP, arrhythmia
  • 35. Tetradon Poisoning
  • 36. Tetradon Poisoning
    • Source
      • Pufferlike fish: globe fish, balloon fish, toad fish
      • Fugu
    • Toxin
      • Tetradotoxin
    • Effect
      • Heat-stable, water-soluble,
      • Skin, liver, OVARY, intestine and muscle
      • Inhibit Na-K pump activity,block NM transmission
  • 37.
    • Clinical manifestation
      • Symptoms within minutes
      • Headache, diaphoresis, paresthesia of lips, tongue, mouth, face, fingers and toes
      • Buccal bullae, salivation
      • Dysphagia, dysarthria, N/V/D
      • Malaise, loss of co-ordination, fasciculation
      • Ascending paralysis (with risk of respiratory paralysis) occurs in 4-24 hrs
  • 38. Tetradon Poisoning
    • Treatment
      • Supportive
      • Removal of toxin
      • Prevention of absorption
  • 39. พิษจากแมงดาทะเล
    • แมงดาทะเลในประเทศไทย
      • แมงดาจาน
      • แมงดาถ้วย หรือ แมงดาไฟ ( ตัวเล็กไม่เกิน 6 นิ้ว หางกลม มีพิษ )
    • อาการเกิดขึ้นภายหลังรับประทานแมงดาถ้วย ประมาณครึ่งชม .
    • อาการชาบริเวณปาก ลิ้น ปลายมือปลายเท้า
    • เวียนศีรษะ คลื่นไส้ อาเจียน มึนงง เดินเซ
    • กล้ามเนื้อไม่มีแรง พูดไม่ชัด อัมพาต หมดสติ
    • เสียชีวิตอย่างรวดเร็วภายใน 2-4 ชม . จากกล้ามเนื้อหายใจเป็นอัมพาต
  • 40. พิษจากคางคก
    • มีต่อมน้ำเมือกใกล้หู ขับเมือกที่มีสารพิษ bufotoxin , aglucones, bufagins, bufotalins... “ digitaloids ”
    • อาการเกิดช้า ภายในหลายชม . ได้
    • อาการคลื่นไส้ อาเจียน ปวดท้อง ท้องเสีย
    • สับสน วิงเวียน เห็นภาพเป็นสีเหลือง
    • สับสน เพ้อ ง่วงซึม ชัก หมดสติ
    • หัวใจเต้นช้าและผิดจังหวะ
    • เสียชีวิตจากระบบไหลเวียนโลหิตล้มเหลว
  • 41. Monosodium Glutamate
    • “ Chinese restaurant syndrome”
    • Clinical manifestation
      • Burning (back-neck-shoulder-abdomen)
      • Facial pressure, flushing, headache
      • Chest pain
      • N/V/D
      • Bronchospasm , angioedema
    • Duration
      • Usually 1 hour
    • Treatment
      • Supportive
  • 42. Botulism
  • 43. Clostridium botilinum
    • Anaerobic Gram Positive Bacilli
    • Spore-forming
    • Toxin
      • Type A: poorly process meats & vegetables
      • Type B: poorly process meats & vegetables
      • Type E: fish products
  • 44. Clostridium botilinum
    • Spore
      • Dormant, highly resistance
      • 100 °C for hours
      • Germination promoted by
        • pH > 4.5
        • NaCl content< 3.5%
        • Low nitrite level
    • Prevent spore germination
      • Acidifying agents: phosphoric acid, citric acid
  • 45. Clostridium botilinum
    • Toxin
      • Heat-labile
      • Can be destroyed by heating
        • 80 °C for 30 mins
        • 100°C for 10 mins
  • 46. Pathophysiology
    • Toxin in single polypeptide chain
    • Proteolytic Cleavage to dichain form
    • Bind to cell membrane (rapid, irreversible)
    • Endocytosis
    • Prevent acetylcholine release
    • Impaired cholinergic transmission at all Ach-dependent synapse in peripheral nervous system
    • NOT affect CNS
  • 47. Clinical Manifestation
    • Food-borne Botulism***
    • Wound Botulism
    • Infant Botulism (in vivo intestinal colonization)
    • Adult Infectious Botulism (in vivo intestinal colonization)
  • 48. Botulism
    • CDC criteria
      • Patient presents with “ DESCENDING PARALYSIS ”
      • and AT LEAST ONE of the following
        • EMG finding
        • C. botulinum in stool or wound
        • Botulinum toxin in serum, stool or food sample
        • Compatible clinical illness in a person who is epidemiologically linked to confirmed case
  • 49. Foodborne Botulism
  • 50. Clinical Manifestation
    • General
      • Dizziness
      • Fatigue
      • Normal mental status
    • GI
      • Abdominal distress
      • Diarrhea (early)
      • Constipation (late)
      • Ileus
      • N/V
  • 51. Neurologic Manifestation
    • Symptoms
      • Blurred vision
      • Difficult urination
      • Diplopia
      • Dry mouth
      • Dysarthria
      • Dysphagia
      • Dyspnea
      • Weakness
    • Signs
      • Descending Paralysis
      • Ataxia, CN palsy
      • Decreased gag reflex
      • Facial paresis
      • Lingual weakness
      • Ptosis, Nystagmus
      • Hyporeflexia
      • Ophthalmoplegia
      • Urinary retention
  • 52. Botulism GBS Miller Fisher Fever - +/- +/- Pupils Dilated or unreactive Normal Normal Ophthalmoplegia Early Late Present Paralysis Descending Ascending Descending DTR - + + Ataxia - + + Paresthesia - + + CSF protein Normal Elevated Elevated
  • 53. Treatment
    • Supportive care
    • Gastric decontamination
    • Botulinum antitoxin
      • Type specific anti-toxin to A, E are beneficial
      • Anti-toxin can prevent paralysis
      • NOT affect already paralyzed muscle
      • Trivalent Anti-toxin (A,B,E) given immediately in both symptomatic and asymptomatic exposed person
  • 54. Mushroom Poisoning
    • Cyclopeptides
    • Monomethylhydrazine
    • Muscarine
    • Ibotenic acid and Muscimol
    • Coprine
    • Psilocybin and Psilocin
    • Gastrointestinal poisoning
  • 55. Nephrotoxicity
    • Cyclopeptide group
    • Amatoxins and Phallotoxins
    • Mushroom
      • Aminita phalloides (Death Cap)
      • Amanita verna (Spring Amanita)
      • Amanita virosa (Destroy Angle)
    • Toxin
      • 3 amatoxins : α -, β -, γ - amanitin
      • 2 phallotoxins : phalloidin, phalloin
  • 56. Amanita phalloides (Death Cap)
  • 57. เห็ดที่มีพิษต่อไตในประเทศไทย
    • Amanita verna (Spring Amanita)
      • เห็ดระโงกหิน , เห็ดไข่ตายซาก
      • สีขาวล้วน มีเปลือกหุ้มสีขาวคล้ายเปลือกไข่
      • ด้านบนฉีกขาดออกเมื่อโตขึ้น
    • Amanita virosa (Destroy Angle)
      • เห็ดระโงกหิน , เห็ดไข่ตายซาก
      • มีขนหยาบกร้าน
      • สปอร์กลม
      • พบได้มากกว่า
  • 58. Toxic Effect
    • Amatoxins inhibit RNA polymerase
    • Fragmentation and segregation of nuclear component
    • Necrosis of liver and kidney
  • 59. Clinical Manifestation
    • Depend on alpha-amanitin
    • Appearance of symptoms delayed for 6-12 or up to 24 hrs
    • 2 Phase
      • Acute phase
      • Relapse phase
  • 60. Clinical Manifestation
    • Acute phase (6-12 hr)
      • Severe vomiting
      • Diarrhea
      • Dehydration
      • Hypotension
      • Muscle cramp
      • Azotemia
      • Hypokalemia
      • Leukocytosis
    • Relapse phase (36-48 hr)
      • Hepatomegaly
      • Cramp
      • Drowsiness
      • Pupil dilatation
      • Albuminuria
      • Hemoglobinuria
      • Oliguria or anuria
      • Coma and death within 3-5 days
  • 61. Treatment
    • Decontamination
    • Fluid replacement up to 3 L/day
    • Reduce enterohepatic circulation
    • Forced diuresis
    • Hemodialysis and hemoperfusion
    • No proven specific antidote for Amanita toxin