Severe Tetrodotoxin Poisoning after Consumption of Lagocephalus sceleratus (Pufferfish, Fugu) Fished in Mediterranean Sea, Treated with Cholinesterase Inhibitor

Lagocephalus sceleratus, or better known as the pufferfish, or fugu, is widespread in Asia and Indo-Pacific regions. It is a poisonous fish containing tetrodotoxin (TTX) which is a potent neurotoxin. In the Far East, fugu is considered a delicate dish, especially in Japan where it is prepared by experts. Nevertheless, poisoning from Lagocephalus sceleratus is not a rare event. Recent data from Japan indicate an incidence of 45 patients per year and a mortality rate of 11%. Mediterranean sea is not the natural habitat of Lagocephalus sceleratus. However, by now multiple reports have established a firm presence of Lagocephalus sceleratus in Mediterranean region as well. This phenomenon is explained by migration of pufferfish across the Suez Channel (lessepsian migration) (Eisenman et al., 2008, Bentur et al., 2008). With lessepsian migration came the first reports of TTX poisoning in the Mediterranean region. We report a patient with a particularly severe and life-threatening TTX poisoning caused by consumption of Lagocephalus sceleratus and treated by cholinesterase inhibitor to a complete and uneventful recovery.