Outbreak of Type E Botulism Associated with an Uneviscerated, Salt-Cured Fish Product -- New Jersey, 1992

In May 1992, the New Jersey Department of Health (NJDH) received a report of a man admitted to a hospital with a preliminary diagnosis of botulism. Subsequently, three family members of the man were diagnosed with botulism. This report summarizes the epidemiologic investigation of these cases that linked illness to consumption of an uneviscerated, salt-cured fish product.

During May 4-5, a man of Egyptian descent aged 32 years made three visits to a hospital emergency department because of rapidly progressive problems including dizziness, ptosis, facial drooping, dry mouth, weakness, and respiratory failure requiring mechanical ventilation. On the third visit, myasthenia gravis was diagnosed on the basis of a positive Tensilon * test. On May 6, the patient was transferred to another hospital for treatment of suspected mayasthenia gravis; on arrival, he was admitted to intensive care and continued on mechanical ventilation for respiratory failure. Plasmapheresis was performed without improvement in symptoms.

Also on May 6, three family members developed blurred vision, ptosis, and dry mouth. A diagnosis of botulism was considered, and the three family members were hospitalized. All four patients received trivalent (types A, B, and E) botulinal antitoxin.

NJDH traced the source of botulism to an ethnic preparation of fish known as moloha, an uneviscerated, salt-cured fish product. On May 3, the family consumed moloha reported to have been purchased that day from a local retail fish market. They consumed the moloha without cooking or heating it. Botulinal toxin type E was detected in leftover fish and in a stool specimen from the index patient. A family friend who also ate some of the fish but did not develop symptoms was treated with antitoxin as a prophylactic measure.

On May 6, no moloha or similar fish products were found at the market, and the owner denied selling this type of fish. The fish distributors serving this market were contacted, but no source of the fish could be identified.

On May 7, NJDH notified all New Jersey acute-care hospitals, public health departments in the New Jersey and New York City areas, and the New Jersey Poison Information and Education System of the outbreak and signs and symptoms of botulism. On May 8, the public was alerted through the news media to avoid consumption of moloha and to seek medical care if symptoms of botulism developed. CDC notified state epidemiologists of nearby states of the outbreak. No additional cases were identified.

Reported by: G French, MD, A Pavlick, DO, A Felsen, MD, P Gross, MD, Hackensack Medical Center, Hackensack; J Brook, MD, S Paul, MD, C Genese, MBA, K Kolano, G Wolf, KC Spitalny, MD, State Epidemiologist, New Jersey Dept of Health. Div of Emergency and Epidemiological Operations and Newark District Office, Office of Regional Operations, Food and Drug Administration. Enteric Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Foodborne botulism is a paralytic illness caused by ingestion of a preformed neurotoxin in contaminated food. Patients typically develop cranial nerve palsies followed by descending paralysis that can lead to respiratory failure and death. Of the seven toxin types, three (A, B, and E) account for virtually all cases of botulism in humans. Type E is associated with preserved or fermented fish and marine mammals, and ethnic preparations of uneviscerated fish pickled in brine have previously been associated with type E botulism (1-3).

Treatment for botulism usually requires intensive care, including mechanical ventilation; the early administration of antitoxin is recommended. Physicians who suspect botulism should contact their state health departments immediately for assistance with diagnosis and treatment. State health departments can contact CDC to obtain antitoxin and further assistance.

References

1. Shaffer N, Wainwright RB, Middaugh JP, Tauxe RV. Botulism among Alaska Natives: the role of changing food preparation and consumption practices. West J Med 1990;153:390-3.

2. Slater PE, Addiss DG, Cohen A, et al. Foodborne botulism: an international outbreak. Int J Epidemiol 1989;18:693-6.

3. Telzak EE, Bell EP, Kautter DA, et al. An international outbreak of type E botulism due to uneviscerated fish. J Infect Dis 1990;161:340-2.

• Use of trade names is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services.

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