Epidemiology

History

• Palytoxin Poisoning was Originally Reported in Hawaii

Incidence

• Difficult to Estimate the True Incidence of Palytoxin, Given the Co-Occurrence of Palytoxin with Other Marine Toxins (Ciguatoxins, Saxitoxins, and Tetrodotoxin) (Toxicon, 2010) [MEDLINE]
  • Approximately 171 Cases (Inhalational or Dermal Toxicity) were Reported in the US Via the National Poison Data System Between 2000-2014 (Environ Toxicol Pharmacol, 2017) [MEDLINE]

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Exposures

• Dermal Exposure
  • Skin Contact with Corals Which Elaborate the Toxin
    • Cases Have Been Reported (Environ Toxicol Pharmacol, 2017) [MEDLINE]
• Ingestion-Related Exposure
  • Ingestion of Fish/Crabs/Shellfish Which Have Fed on Palytoxin-Containing Algae or Coral
    • Clinical Symptoms Following the Ingestion of Fish/Crabs/Shellfish Have Been Described (Toxicon, 2010) [MEDLINE]
• Inhalational Exposure
  • Inhalation of Aerosols from the Cleaning of Home Aquariums Containing Soft Corals
    • Cases Have Been Reported in Association with Zoanthid Corals in Aquariums in Alaska (MMWR Morb Mortal Wkly Rep, 2015) [MEDLINE]
  • Inhalation of Sea Air
    • Cases Have Been Reported Following Algal Blooms in Italy (Anal Chem, 2006) [MEDLINE]
• Ocular Exposure
  • Ocular Contact with Hands After Touching Corals Which Elaborate the Toxin
    • Ocular Manifestations Due to Exposure Have Been Described (Arch Ophthalmol, 2010) [MEDLINE]

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Physiology

Palytoxin

• Palytoxin is Formed by the Microalgae (Ostreopsis Ovate, Ostreopsis Siamensis), Corals, and Sea Anemones
  • Palytoxin was First Isolated from the Zoanthid Coral, Palythoa Toxica
  • Palytoxin is One of the Most Potent Toxins Known (Environ Toxicol Pharmacol, 2017) [MEDLINE]
  • In Animal Models, Palytoxin Has Been Found to Be Most Toxic Via Intravenous, Intraperitoneal, and Intratracheal Exposures and of Lesser Toxicity Via Dermal and Ocular Exposures
• Palytoxin Binds to and Disables the Sodium/Potassium ATPase Pump
  • Efflux of Potassium
  • Influx of Calcium
  • Membrane Depolarization

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Diagnosis

• Predominantly Historical

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Clinical Manifestations

Cardiovascular Manifestations

• Chest Pain (see Chest Pain, Chest Pain)

Dermatologic Manifestations

• Diaphoresis (see Diaphoresis, Diaphoresis)

Gastrointestinal Manifestations

• Abdominal Cramps/Pain (see Abdominal Pain, Abdominal Pain)
• Diarrhea (see Diarrhea, Diarrhea)
• Nausea/Vomiting (see Nausea and Vomiting, Nausea and Vomiting)

Hematologic Manifestations

• Hemolysis (see Hemolytic Anemia, [[Hemolytic Anemia])

Neurologic Manifestations

• Hot-Cold Reversal
• Parasthesias (see Parasthesias, Parasthesias)
• Weakness (see Weakness, Weakness)

Ophthalmologic Manifestations

• Conjunctivitis (see Conjunctivitis, Conjunctivitis)

Pulmonary Manifestations

• Acute Pneumonitis
  • Epidemiology: cases have been reported (Respiration, 2012) [MEDLINE]
• Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome, Acute Respiratory Distress Syndrome)
  • Epidemiology: cases have been reported in association with inhalational exposure (Respir Med Case Rep, 2017) [MEDLINE]
• Acute Respiratory Failure (see Respiratory Failure, Respiratory Failure)
  • Epidemiology: may occur in some cases
• Bronchospasm (see Obstructive Lung Disease, Obstructive Lung Disease)
  • Epidemiology: common
  • Clinical
    • Dyspnea (see Dyspnea, Dyspnea)
    • Wheezing (see Wheezing, Wheezing)

Rheumatologic Manifestations

• Muscle Cramps (see Muscle Cramps, Muscle Cramps)
  • Clinical: may be severe and uncontrollable
• Rhabdomyolysis (see Rhabdomyolysis, Rhabdomyolysis)
  • Epidemiology: may occur in some cases

Other Manifestations

• Low-Grade Fever (see Fever, Fever)

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Treatment

Supportive Care

• Antihistamines (see H1-Histamine Receptor Antagonists, H1-Histamine Receptor Antagonists)
• Bronchodilators
• Corticosteroids (see Corticosteroids, Corticosteroids)
• Mechanical Ventilation (see Mechanical Ventilation, Mechanical Ventilation)

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Prognosis

• Mortality Rate: may be as high as 10% (Toxicon, 2010) [MEDLINE]

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References

• The Genoa 2005 outbreak. Determination of putative palytoxin in Mediterranean Ostreopsis ovata by a new liquid chromatography tandem mass spectrometry method. Anal Chem. 2006;78(17):6153 [MEDLINE]
• Ostreopsis ovata and human health: epidemiological and clinical features of respiratory syndrome outbreaks from a two-year syndromic surveillance, 2005-06, in north-west Italy. Euro Surveill. 2007;12(6):E070607.1. Epub 2007 Jun 7 [MEDLINE]
• Human risk associated with palytoxin exposure. Toxicon. 2010;56(2):150. Epub 2009 Jun 6 [MEDLINE]
• Aquarium coral keratoconjunctivitis. Arch Ophthalmol. 2010;128(10):1360 [MEDLINE]
• Palytoxin poisoning after dermal contact with zoanthid coral. J Emerg Med. 2011;40(4):397. Epub 2009 Jul 9 [MEDLINE]
• Aquarism: an innocent leisure activity? Palytoxin-induced acute pneumonitis. Respiration. 2012;84(5):436. Epub 2012 Jun 29 [MEDLINE]
• Case series: inhaled coral vapor–toxicity in a tank. J Med Toxicol. 2013;9(3):282 [MEDLINE]
• Suspected Palytoxin Inhalation Exposures Associated with Zoanthid Corals in Aquarium Shops and Homes – Alaska, 2012-2014. MMWR Morb Mortal Wkly Rep. 2015;64(31):852 [MEDLINE]
• Prevalence and characteristics of inhalational and dermal palytoxin exposures reported to the National Poison Data System in the U.S. Environ Toxicol Pharmacol. 2017;55:107. Epub 2017 Aug 18 [MEDLINE]
• Corneal Toxicity Associated With Aquarium Coral Palytoxin. Am J Ophthalmol. 2017;174:119. Epub 2016 Oct 25 [MEDLINE]
• Palytoxin-induced acute respiratory failure. Respir Med Case Rep. 2017;20:4. Epub 2016 Oct 21 [MEDLINE]