Raw salmon or red herring: ascending paralysis with suspected seafood poisoning

A 16-year-old boy presented with rapidly progressive ascending paralysis 1 hour after eating raw salmon. Seafood poisoning was initially considered. Although salmon is not a common cause of toxic seafood poisoning, cases have been reported in the Pacific region. The patient rapidly developed acute left heart and respiratory failure, and investigations revealed a rare tracking intramedullary haematoma of the spinal cord. Structural abnormalities of the central nervous system may present with acute paralysis and spinal shock, mimicking toxicological syndromes.

A 16-year-old boy presented to the emergency department with severe epigastric pain, headache and ascending lower limb weakness 1 hour after eating raw salmon. The weakness ascended rapidly over the next hour to involve the upper limbs. In hospital, he was alert, but was soft-voiced and in obvious respiratory distress. He had tachycardia (heart rate, 110 beats per min), hypertension (blood pressure, 205/128 mmHg), tachypnoea (22 breaths per min) and oxygen saturation of 89% (using a non-rebreathing oxygen mask). Although his sensation and mental state appeared normal, he had profound quadriparesis. Pupils were 3 mm in diameter, equal and sluggishly reactive to light. Because of a rapid deterioration in his respiratory status, the patient was intubated, ventilated, and sedated with a propofol infusion before a more complete neurological examination could be completed.