Fatal pufferfish poisoning 1000 km inland: a case series from eastern Turkey

We report the first tetrodotoxin (TTX) poisoning cases from Van, Eastern Turkey, a city located more than 1000 km inland. Three male patients presented in December 2020 after eating Lagocephalus sceleratus, which a local vendor mistook for an edible fish. One patient, a 41-year-old man who consumed the fish liver, rapidly developed severe signs of poisoning (adverse event grade 4) with complete paralysis and respiratory failure. Arterial blood gas analysis showed severe acidosis (pH 7.179) and high lactate levels (5.3 mmol/L). Despite intensive care, including mechanical ventilation and high-dose vasopressors, the patient died on the fourth day of hospitalisation due to refractory cardiac arrest. The other two patients, who consumed less fish and no liver, had only mild symptoms (adverse event grades 1 and 2) and recovered completely within 24 h. This incident illustrates the extreme danger of consuming pufferfish and particularly its visceral organs, which typically contain substantially higher tetrodotoxin levels. Finding these cases so far inland reveals serious gaps in the Turkish food distribution system. The fish likely travelled from Mediterranean ports to Van in mixed fish crates without having been identified. Fish vendors need proper training to identify toxic species, and supply chains require better oversight to prevent such tragedies.