Authors: Dr Jhon Drexler Arellano Legaspi , Dr Karlo Marciano Orencio Venida Hermo

Abstract

Seafood forms a major part of the Filipino diet. In the absence of an adequate cold chain, histamine toxicity may occur causing scombroid poisoning. Conversely, cerebrovascular accidents remain among the top five causes of mortality in the Philippines. Recognizing distinct clinical presentations—and the rare instance in which both conditions coexist—requires careful history-taking and high clinical suspicion.

This is a case of a 72/M, coming in for angioedema presenting with initial vital signs of 160/80mmHg, 90bpm, 20cpm, 36.8℃, 99% O2. Patient has no known comorbidities and allergies. The night prior to consult, after eating “tulingan” (Katsuwonus pelamis), a deep-sea fish, the patient developed periorbital edema but slept through it. Upon waking up, still with angioedema now with generalized pruritic rash. Patient then noticed right sided body weakness. On physical exam, generalized rash with noted angioedema. The patient is GCS 15 but with noted right facial asymmetry and right tongue deviation, 4/5 motor strength and 60% sensory on the right side.           

Initial impression was acute ischemic stroke, scombroid poisoning. Patient was managed with 50mg Diphenhydramine IM, and 50mg Ranitidine and 300mg Hydrocortisone IV. Initial oral doses of 80mg Aspirin PO and 80mg Atorvastatin PO was also given. The patient was referred to Toxicology Service and Neurology Service for the following problems respectively.

In our case, the patient’s scombroid poisoning from the ingestion of the deep-sea fish could have resulted in an acute ischemic stroke. This could be likened to the rare Kounis Syndrome, where an acute coronary syndrome develops from an anaphylactoid reaction. This pan-arterial hypersensitivity-associated disorder affects not only the coronary arteries, but also the cerebral arteries. The human brain is very sensitive and susceptible to ischemia, and in this specific scenario, vasospastic reactions from the anaphylactoid reaction could have caused the ischemic stroke. This case highlights the challenge in Emergency Medicine, of recognizing rare presentations like scombroid poisoning alongside acute ischemic stroke --- emphasizing the need for swift identification and simultaneous management of multiple emergent conditions.

Keywords: SCOMBROID POISONING; ACUTE ISCHEMIC STROKE; TOXICOLOGY; NEUROLOGY