A 51‐year‐old man with a medical history of gastroesophageal reflux disease, herpetic whitlow, and nephrolithiasis presented to the emergency room (ER) with cough and headache after a zoanthoid coral from his home aquarium was cleaned. Hours prior to admission, he and a worker had soaked it and then used a pressure washer on it in the driveway. The patient experienced bouts of coughing and headache for 7 hours before coming to the ER. He was tachycardic, febrile, retching, and complained that he had burning in his lungs and concomitant cough with deep inspiration. He also complained of metallogeusia. He had a fever of 103.5°F. The physical examination yielded no abnormalities. An EKG revealed sinus tachycardia. The chest x‐ray was clear. His labs revealed a leukocytosis of 21.8 K/μL, a lactic dehydrogenase (LDH) of 292 U/L, a creatine kinase (CK) of 187 U/L, CK‐MB of 2.95 ng/mL, and a lactic acid of 2.9 mmol/L The patient was admitted for palytoxin poisoning. Normal saline at 100 cc/hour was initiated, along with ondansetron, acetaminophen, and albuterol nebulizer. He responded well to treatment and his symptoms improved. Subsequent labs revealed a decline in LDH, CK, and lactate to normal limits with a persistent leukocytosis. On day of discharge, the patient felt substantially improved.
Palytoxin is a highly potent marine toxin originally isolated from the Palythoa species that exists in a number of aquatic organisms. The burgeoning coral trade has resulted in increased poisonings by palytoxin. The toxin disrupts the Na+/K+ pump after binding to its external domain. It can be introduced through multiple routes of exposure but rarely by inhalation. It is postulated that while cleaning coral, aerosolization of the toxin occurs and is unknowingly inhaled. Palytoxin confirmation is achieved by methods that are impractical in the emergency setting. Therefore, a case definition has been generated. It is applied to individuals seeking care that have a risk factor of: a recent visit to an area with current algal bloom or historical Ostreopsis presence, inhalation of steam from cleaning aquaria, or occupational exposure to algae. This must be accompanied by at least 2 of the following: fever > 100.4°F, dyspnea, cough, sore throat, headache, nausea, vomiting, diarrhea, arrhythmia, rhinorrhea, ocular lacrimation, paresthesias, myalgias, and numbness or weakness of extremities. Treatment is symptomatic since no antidote exists. Aggressive hydration is utilized to prevent potentially dangerous consequences like rhabdomyolysis. The patient should be monitored on telemetry due to arrhythmia concerns. Hemolysis risk warrants serial CBC and LDH levels. Life threatening bronchospasms can occur so patients should begin nebulizer treatments immediately.
More clinicians should be aware of palytoxin poisonings, as there is an increasing trend to bring this beautiful but dangerous marine life into our homes.
To cite this abstract:Decastro G, Hasan F. A Subtle Suburban Poisoning: Palytoxin. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 383. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-subtle-suburban-poisoning-palytoxin/. Accessed January 21, 2020.