Simultaneous acute renal and hepatic failure after ingesting raw carp gall bladder

Yuh-Feng Lin and Shih-Hua Lin

Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China

Correspondence and offprint requests to: Yuh-Feng Lin, MD, Division of Nephrology, Department of Medicine, Tri-Service General Hospital, Number 8, Section 3, Ting-Chow Road, 100, Taipei, Taiwan, Republic of China.

Keywords: acute renal failure; acute hepatitis; toxin; raw carp bile



   Introduction
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 Introduction
 Case
 Discussion
 References
 
There has been a custom in some cultures in Asia to ingest raw bile of the grass carp with the belief that it improves visual acuity, rheumatism and health [1]. Although a syndrome of acute hepatitis and acute renal failure following the ingestion of raw carp gall bladders have been reported previously among persons living in Asia such as in Taiwan [2], Hong Kong [3], Japan [4] and Korea [5], two cases of this syndrome has been described recently in the US [6]. Since more and more people who have emigrated from Asia reside in Western countries and physicians are often less aware of its toxic effects on liver and kidney, we present a case to illustrate the typical clinical course.



   Case
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 Introduction
 Case
 Discussion
 References
 
On January 20, 1997, a 50-year-old male allegedly took two pills of raw carp gall bladder for improving health and visual acuity when he caught the two grass carps (see Figure 1Go) in the river. Six hours after eating the raw gall bladders, he suffered from diffuse abdominal crampy pain, nausea, vomiting and watery diarrhoea. Despite medication and intravenous fluid supplement at local medical clinics, he developed excruciating abdominal tenderness simulating acute abdomen with peritonitis 1 day later. He underwent an exploratory laparotomy, but no organic lesion was identified. Two days later, biochemical studies revealed serum creatinine 5.6 mg/dl, blood urea nitrogen 70 mg/dl, SGPT 1032 IU/l, SGOT 586 IU/l and creatine phosphokinase 276 IU/l. In addition, two episodes of generalized tonic and clonic seizure, lasting for 1 min, and oligouria were observed. He was transferred to our hospital for further management.



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Fig. 1. The grass carp (Ctenopharyngodon idellus).

 
On admission, he was in a delirious state. BP was 140/80 mmHg, pulse rate 88/min, respiratory rate 22/min and body temperature 37.3°C. Cardiopulmonary examination was unremarkable. There was no lymphadenopathy and hepatosplenomegaly, but abdominal tenderness without rebounding pain was noted. Neurological examination was normal except for unclear mentality. Blood examination revealed haemoglobin 13.5 g/dl, leukocyte count 13 500/mm3 with neutrophils predominant and platelet count 217 000/mm3. Urine examination showed abundant granular casts without red blood cells or white cell casts. Biochemical investigations revealed abnormal liver function with SGPT 725 IU/l, SGOT 451 IU/l, bilirubin 1.4 mg/dl, albumin 3.0 g/dl, rGT 68 IU/l, creatine phosphokinase 322 IU/l, alkaline phosphatase 146 IU/l, creatinine 9.3 mg/dl and blood urea nitrogen 85 mg/dl. Serum Na+ 142 mmol/l, K+ 4.8 mmol/l, Cl- 106 mmol/l, ionized calcium 1.24 mmol/l, inorganic phosphate 1.04 mmol/l and magnesium 0.8 mmol/l were normal. Arterial blood gas indicated metabolic acidosis with pH 7.37, PCO2 24.8 mmHg, PO2 90.2 mmHg, and HCO3 14.2 mmHg. Chest X-ray and supine plain film were normal. Abdominal sonography demonstrated liver dense and normal renal images. CT of his brain showed no abnormalities. Seizure ceased and mentation became clear 2 days after haemodialysis was initiated. His liver function returned to normal a week later whereas his daily urine became non-oliguric 2 weeks later. He refused a renal biopsy. His renal function recovered gradually and became normal 1 month after discharge.



   Discussion
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 Introduction
 Case
 Discussion
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Among fish poisoning, ciguatera and scombroid poisoning are the most commonly recognized. However, the raw gall bladder of the grass carp (Ctenopharyngodon idellus) with both nephrotoxic and hepatotoxic properties is less known. After ingestion, most patients present initially with gastrointestinal upset including abdominal pain, nausea, vomiting and watery diarrhoea several hours later, followed by the manifestations of the central nervous system and oliguria. The hepatic picture usually precedes the impairment of renal function, but may be concomitant with nephrotoxicity [2]. Spontaneous resolution of hepatic dysfunction within a few days is usual. More serious is the nephrotoxicity, which culminates in oliguric or non-oliguric acute renal failure, usually within 48–72 h after ingestion while hepatic dysfunction is resolving. Deaths following ingestion of raw carp gall bladder have been described [4]. Although the clinical presentation was typical of intoxication due to raw carp gall bladder in this case, unnecessary surgery was performed on account of severe abdominal pain mimicking acute peritonitis.

Various causes have been implicated in the pathogenesis of acute renal failure after the ingestion of raw carp gall bladder. These include direct nephrotoxicity of the bile, bradycardia and systemic hypotension secondary to the accumulation of the bile, and volume depletion either due to initial natriuresis and diuresis, or protracted diarrhoea. Based on no evidence of hypotension, bradycardia, pre-renal azotaemia and rhabdomyolysis in this case, acute tubular necrosis with abundant urinary granular casts due to direct nephrotoxicity is the most plausible explanation.

Histological studies of kidney and live tissue specimens from patients usually demonstrate acute tubular necrosis and focal hepatitis. These pathological findings may be attributed to toxin with both nephrotoxic and hepatotoxic properties rather than to an infective agent in the raw bile [7]. Although the bile components responsible for these pictures have not been characterized fully, cyprinol, a C27 bile alcohol found to be present in bile of the family represented by the common carp may have a direct effect on the kidneys and liver [8]. When it was administrated to rats, their livers showed multiple focal necrosis and their kidney showed congestion and cloudy swelling of tubular epithelium. Interestingly, this poisonous constituent in bile is present mainly in the freshwater carp and not in the marine carp.

Simultaneous renal and hepatic damage may occur following exposure to a variety of toxins, including carbon tetrachloride, trichloroethylene, chloroform, amantita phalloides (mushroom poisoning), copper sulfate and chromium, and drugs including paracetamol overdose and fluorinated anaesthetic agents such as methoxyfluorane and fluoxene. When the patient with acute renal failure and hepatitis denies exposure to such toxins and drugs, the possibility of ingestion of raw carp gall bladder should be raised. In the light of these toxic effects, clinicians should not only be alert to these toxic complications after the ingestion of raw carp gall bladder, but also aware of eating habits and food exposure that may pose a risk for their patients.



   References
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 Introduction
 Case
 Discussion
 References
 

  1. Chen WY, Yen TS, Chen JT, Hsieh BS, Hsu HC. Acute renal failure due to ingestion of raw bile of grass carp (Ctenopharyngodon idellus). J Formosan Med Assoc 1976; 75: 149–157
  2. Lim PS, Lin JL, Hu SA, Huang CC. Acute renal failure due to ingestion of the gallbladder of grass carp: report of 3 cases with review of the literature. Renal Failure 1993; 15: 639–644[ISI][Medline]
  3. Chan DWS, Yeung CK, Chan MK. Acute renal failure after eating raw fish gallbladder. Br Med J 1985; 290: 897
  4. Yamamoyo Y, Wakisaka O, Fujimoto S et al. Acute renal failure caused by ingestion of carp gall bladder—a case report of 3 cases in Japan. Nippon Naika Gakkai Zasshi 1988; 77: 1268–1273[Medline]
  5. Park SK, Kim DG, Kang SK et al. Toxic acute renal failure and hepatitis after ingestion of raw carp bile. Nephron 1990; 56: 188–193[ISI][Medline]
  6. Goldstein SJ, Raja RM, Kramer M, Hirsch W. Acute hepatitis and renal failure following ingestion of raw carp gall bladder—Maryland and Pennsylvania, 1991 and 1994. J Am Med Assoc 1995; 274: 604[ISI][Medline]
  7. Chen CF, Chen WY, Yen TS. The effect of raw bile of grass carp (Ctenopharyngodon idellus) on renal function in the conscious rat. J Formosan Med Assoc 1983; 82: 1203–1209
  8. Yip LL, Chow CI, Yung KH, Chiu KW. Toxic material from the gall bladder of the grass carp (Ctenopharyngodon idellus). Toxicology 1981; 19: 567–569
Received for publication: 10. 2.99
Accepted in revised form: 1. 4.99





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