A fish tale: flushing and pruritis after tuna ingestion.

A 65-year-old woman presented with the sudden onset of feeling ‘‘hot,’’ accompanied by a diffuse, blanching red rash, conjunctival injection, and one episode of nonbloody diarrhea. It happened suddenly about 90 min after consuming a dinner that included fully cooked tuna. It was also associated with mild diffuse pruritus, and the patient reported feeling restless. The patient reported that her husband had similar but milder symptoms, including flushing and diarrhea. She denied any prior similar episodes, and had eaten tuna many times before without any adverse reactions. She denied shortness of breath, wheezing, itching in her throat, mouth, or eyes, or perioral paresthesias. The patient’s only medications were montelukast and mometasone nasal spray. The patient had drug allergies to penicillin and sulfa compounds. Due to the patient’s history of seasonal allergies, in the context of what she presumed was an allergic reaction, she immediately took 50 mg by mouth (PO) of diphenhydramine and 300 mg PO of cimetidine while at home right after the incident. On presentation, the patient was awake, alert, and comfortable. Her vital signs were: temperature 37.0 C, pulse 92 beats/min, respiration 20 breaths/min, blood pressure 150/74 mm Hg, and SpO2 99% on room air. The patient was not in distress. The patient’s skin had a diffuse erythematous, blanching rash of her arms, legs, back, chest, and feet. There were no noticeable focal lesions or discharge. No other rash was noted. The patient also had mild conjunctival injection bilaterally but no facial swelling. The patient’s cardiovascular examination was normal. The patient’s lungs were clear bilaterally and there were no upper airway sounds. The patient’s abdominal examination was benign. The patient remained stable throughout the Emergency Department (ED) visit. The patient was instructed to continue her self-treatment with diphenhydramine and cimetidine for her symptoms and to follow-up to the ED if she had any difficulty breathing, wheezing, or intractable diarrhea. Given the patient’s classic presentation in the context of recent ingestion of tuna, which also sickened her husband, the diagnosis of scombroid poisoning was made.