Possible Estuary-Associated Syndrome: Symptoms, Vision, and Treatment

By Shoemaker, Ritchie C.; Hudnell, H. Kenneth | Environmental Health Perspectives, May 2001 | Go to article overview

Possible Estuary-Associated Syndrome: Symptoms, Vision, and Treatment


Shoemaker, Ritchie C., Hudnell, H. Kenneth, Environmental Health Perspectives


The human illness designated as possible estuarine-associated syndrome (PEAS) by the Centers for Disease Control and Prevention (CDC) has been associated with exposure to estuaries inhabited by toxin-forming dinoflagellates, including members of the fish-killing toxic Pfiesteria complex (TPC), Pfiesteria piscicida and Pfiesteria shumwayae. Humans may be exposed through direct contact with estuarine water or by inhalation of aerosolized or volatilized toxin(s). The five cases reported here demonstrate the full spectrum of symptoms experienced during acute and chronic stages of this suspected neurotoxin-mediated illness. The nonspecific symptoms most commonly reported are cough, secretory diarrhea, headache, fatigue, memory impairment, rash, difficulty in concentrating, light sensitivity, burning skin upon water contact, muscle ache, and abdominal pain. Less frequently encountered symptoms are upper airway obstruction, shortness of breath, confusion, red or tearing eyes, weakness, and vertigo. Some patients experience as few as four of these symptoms. The discovery that an indicator of visual pattern-detection ability, visual contrast sensitivity (VCS), is sharply reduced in affected individuals has provided an objective indicator that is useful in diagnosing and monitoring PEAS. VCS deficits are present in both acute and chronic PEAS, and VCS recovers during cholestyramine treatment coincident with symptom abatement. Although PEAS cannot yet be definitively associated with TPC exposure, resolution with cholestyramine treatment suggests a neurotoxin-mediated illness. Key words. cholestyramine, chronic neurotoxic illness, harmful algal blooms, Pfiesteria, possible estuary-associated syndrome, visual contrast sensitivity. [Online 14 May 2001]

http://ehpnet1.niehs.nih.gov/docs/2001 /109p539-545shoemaker/abstract.html

Case Presentation

Case 1

A 32-year-old male commercial fisherman worked on the Pocomoke River, a tributary of the Chesapeake Bay on the Eastern Shore of Maryland, since age 16 without any significant illness until October 1996. In association with harvesting multiple species of fish with deep, penetrating ulcers, the patient had initial onset of memory impairment, headache, hypersensitivity to bright light, fatigue, cough, muscle ache, skin rash, diarrhea, and anorexia. Subsequently, the patient was treated by several local physicians with antibiotics for recurrent pneumonia (seven episodes in 6 months). The diagnoses of pneumonia were based on clinical parameters alone, without additional confirmatory tests. The patient lost 40 pounds, became weak and lethargic, and continued to suffer from the symptoms listed above. He continued to work in the estuaries.

Table 1. Estuarine exposure and illness.

                 PEAS         Illness
                 condition    date

Case 1           Chronic(a)   Oct 1996-Sep 1997
                 Acute        Jun 1998
Case 2           Acute        Jul 1999
                 Acute        Oct 1999
                 Acute        Dec 1999
Case 3           Acute        Dec 1998
                 Acute        Feb 1999
Cases 4 and 5    Chronic      Sep 1998-Mar 1999
                 Acute        Jul 1999

                 Estuarine contact < 2 weeks        Dead or lesioned
                 before illness onset                  fish contact

Case 1           Pocomoke River, MD                         Y
                 Pocomoke River, MD                         Y
Case 2           Pocomoke River, MD                         Y
                   and Bulbeggar Creek, VA
                 Indian River, DE                           N
                 Rehoboth Bay and tributaries, DE           Y
Case 3           Chicamacomico River, MD                    Y
                 Chicamacomico River, MD                    Y
Cases 4 and 5    Back Creek, Manokin River, MD              Y
                 Back Creek, Manokin River, MD              N

                   Ever tested
                 positive for TPC   References

Case 1                  Y              (1)
                        Y              (1)
Case 2                  Y             (1,2)
                        Y              (3)
                        Y              (3)
Case 3                  Y              (4)
                        Y              (4)
Cases 4 and 5           Y             (4,5)
                        Y             (4,5)

(a) Chronic PEAS is defined as PEAS symptoms present > 1 month. … 

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