Acute Hepatitis and Renal Failure Following Ingestion of Raw Carp
Gallbladders -- Maryland and Pennsylvania, 1991 and 1994
In some cultures, eating gallbladders from certain species of
snakes, birds, or fish is believed to improve health. A syndrome of
acute hepatitis and renal failure following the ingestion of raw
carp gallbladders has been described previously among persons
living in Asia (1-4). This report summarizes two cases of this
syndrome that occurred in residents of Pennsylvania who had eaten
the raw bile and gallbladders of carp caught in Maryland.
Patient 1. On July 11, 1991, a 59-year-old man who had
immigrated from Korea ate the uncooked gallbladder of a carp he had
caught in Maryland from a tributary of the Susquehanna River. Six
hours after eating the gallbladder, he developed diarrhea and
abdominal pain. On July 14, he was admitted to a hospital with mild
jaundice and persistent nausea and vomiting. Laboratory testing
revealed elevated levels of serum creatinine (10 mg/dL {normal:
0.7-1.5 mg/dL}), total bilirubin (3.5 mg/dL {normal: 0.1-1.2
mg/dL}), and transaminases (aspartate aminotransferase {AST} 171
U/L {normal: less than 54 U/L} and alanine aminotransferase {ALT}
1043 U/L {normal: less than 52 U/L}). Renal ultrasound detected no
evidence of hydronephrosis. Despite transient progression of his
renal failure, the patient did not require dialysis. He was
discharged from the hospital after 6 days with normal urine output,
a serum creatinine of 4 mg/dL and normal liver function.
Patient 2. On October 30, 1994, a 41-year-old man who had
immigrated from Cambodia ate the raw gallbladders from three carp
he had caught at a reservoir near Cowonigo, Maryland. Two hours
after eating the gallbladders, he developed transient right upper
quadrant abdominal pain, nausea, vomiting, and diarrhea. On
November 3, he consulted his physician because of recurrent nausea,
abdominal pain, and decreased urinary output. Laboratory findings
were consistent with acute hepatitis (AST 1032 U/L, ALT 2028 U/L,
and total bilirubin 4.8 mg/dL) and acute renal failure (serum
creatinine 6.0 mg/dL). Abdominal ultrasound revealed normal-sized
kidneys; there was no evidence of urinary or biliary tract
obstruction. The patient was hospitalized for hemodialysis when, 5
days after his exposure, his serum creatinine increased to 12.6
mg/dL. The patient's renal and hepatic function gradually improved,
and he was discharged on November 16 with a serum creatinine of 8
mg/dL and markedly improved liver function.
Reported by: SJ Goldstein, MD, RM Raja, MD, M Kramer, MD, W Hirsch,
MD, Div of Nephrology, Albert Einstein Medical Center,
Philadelphia, Pennsylvania. EB May, PhD, Div of Fisheries, Maryland
Dept of Natural Resources, Oxford. Foodborne and Diarrheal Diseases
Br, Div of Bacterial and Mycotic Diseases, National Center for
Infectious Diseases, CDC.
Editorial Note
Editorial Note: Despite the widespread use of basic public health
food safety and hygiene measures, clinicians and public health
practitioners have encountered an increasing diversity of foodborne
illnesses. Factors contributing to this trend include changes in
the technology of food production, greater importation of food from
other countries, and a diversification of food preparation and
eating habits.
Although acute hepatitis and renal failure following ingestion
of raw carp gallbladders have not been reported previously in
persons in the United States, such cases have been recognized in
persons in Taiwan (1,2), Hong Kong (3), and South Korea (4).
Clinical manifestations of this syndrome include acute
gastrointestinal symptoms followed several days later by jaundice
and oliguria. Histologic studies of kidney and liver tissue
specimens from patients demonstrate acute tubular necrosis and
focal hepatitis (4). Although the bile component(s) responsible for
this syndrome have not been characterized fully (5), cyprinol, a
C27 alcohol found in the bile of cyprinid fish, may have a direct
toxic affect on the kidneys (1). No specific treatment has been
identified; renal and hepatic impairment generally resolve within
3 weeks with supportive care.
Five species of fish belonging to the order Cypriniformes have
been associated with bile-induced hepatitis and renal failure (4).
Two of these species are found in the United States: the common
carp (Cyprinus carpio), which is abundant and widely distributed in
North America, and the grass carp (Ctenopharyngodon idellus), which
has been introduced in many areas in the eastern United States (J.
Sheferland, Chesapeake Bay Field Station, U.S. Fish and Wildlife
Service, personal communication, 1995). Because they can be caught
without limit, carp are an inexpensive food source used extensively
by some populations.
The syndrome of bile-induced hepatitis and renal failure
described in this report, in addition to previous reports of
foodborne illnesses (e.g., trichinosis {6} and mushroom poisoning
{7}), suggest that clinicians should be aware of eating habits and
food exposures that may pose a risk for their patients. The cases
described in this report also underscore the importance of
obtaining careful food histories from patients, including those
whose illness may not initially appear to be food-related.
References
Chen WY, Yen TS, Cheng JT, Hsieh BS, Hsu HC. Acute renal failure
due to ingestion of raw bile of Grass Carp (Ctenopharyngodon
idellus). J Formosan Med Assoc 1976;75:149-57.
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;15:639-44.
Chan DWS, Yeung CK, Chan MK. Acute renal failure after eating
raw fish gall bladder. BMJ 1985;290:897.
Park SK, Kim DG, Kang SK, et al. Toxic acute renal failure and
hepatitis after ingestion of raw carp bile. Nephron 1990;56:188-93.
Yip LL, Chow CL, Yung KH, Chiu KW. Toxic material from the
gallbladder of the grass carp (Ctenopharyngodon idellus). Toxicon
1981;19:567-9.
CDC. Trichinella spiralis infection -- United States, 1990. MMWR
1991;40:57-60.
CDC. Mushroom poisoning among Laotian refugees -- 1981. MMWR
1982;31:287-8.
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