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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A and B&#44; Generalized erythematous rash mainly affecting the face &#40;not shown in the image&#41; and the trunk of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> C&#44; Detailed view of the upper thorax&#46; Note the absence of whealing&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reproduced with permission from Jantschitsch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p>"
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although because the condition is mild and self-limiting&#44; it is probably safe to assume that a considerable proportion of patients do not visit a doctor&#46; Accordingly&#44; and also because scombroid poisoning is frequently confused with a food allergy&#44; many cases are not reported and it is probably underdiagnosed&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> The aim of this article is to provide a practical overview of scombroid poisoning and to guide dermatologists in its diagnosis and treatment&#44; as it is not unusual for us to be called on to evaluate the skin lesions seen with this syndrome&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Scombroid poisoning exists around the world&#46; Its incidence is unknown&#44; and reported rates vary enormously from one area to the next depending on fish consumption habits&#46; An estimated annual incidence of between 2 and 5 cases per 1 million inhabitants has been reported for Denmark&#44; New Zealand&#44; France&#44; and Finland&#44; while rates for Hawaii have been as high as 31 cases per 1 million inhabitants a year&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> The largest numbers of cases have been reported in Japan&#44; the United Kingdom&#44; the United States&#44; and Australia&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> In the United States and Europe&#44; scombroid poisoning accounts for up to 40&#37; of all food poisoning outbreaks&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Scombroid poisoning typically affects groups of diners who have eaten contaminated oily fish&#46; It has traditionally been linked to the consumption of fish from the Scombroidae and Scomberesocidae family&#44; 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although there have been cases attributed to bacteria from the species <span class="elsevierStyleItalic">Vibrio</span>&#44; <span class="elsevierStyleItalic">Proteus</span>&#44; <span class="elsevierStyleItalic">Serratia</span>&#44; <span class="elsevierStyleItalic">Enterobacter</span>&#44; <span class="elsevierStyleItalic">Klebsiella</span>&#44; <span class="elsevierStyleItalic">Clostridium</span>&#44; <span class="elsevierStyleItalic">Salmonella</span>&#44; and <span class="elsevierStyleItalic">Shigella</span>&#46; Histamine poisoning generally affects fresh fish rather than canned fish&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> as the latter is typically subject to more quality controls and cans generally contain different specimens of fish&#44; meaning that the toxic effect of a single contaminated specimen would be minimized&#46; Although the canning process can destroy the bacteria&#44; it cannot destroy histamine that has already formed&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical Presentation</span><p id="par0030" class="elsevierStylePara elsevierViewall">The clinical manifestations of scombroid poisoning appear within minutes to hours of eating contaminated fish and are the result of histamine poisoning&#46; Histamine is an endogenous amine with numerous biological effects&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> including vasodilation&#44; an immediate allergic response following activation of H<span class="elsevierStyleInf">1</span> receptors&#44; and neurotransmission due to the activation of H<span class="elsevierStyleInf">3</span> receptors&#46; The amount of histamine required to produce manifestations varies from one person to the next&#46; Scombroid poisoning symptoms tend to be mild and typically start with a burning or tingling sensation on the tongue&#44; accompanied or not by a peppery and&#47;or metallic taste&#46; This is gradually followed by flushing in the head and neck area&#44; with a considerable burning sensation&#44; and a downward-spreading erythematous urticarial rash on the face and upper trunk<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Other common symptoms are a burning sensation&#44; pruritus&#44; and swelling around the mouth&#46; Gastrointestinal symptoms are also common and include stomach cramps&#44; nausea&#44; vomiting&#44; and diarrhea&#46; A throbbing headache and palpitations are other hallmark symptoms&#46; Because of the similarity with allergic reaction symptoms&#44; scombroid poisoning is frequently mistaken for immunoglobulin E &#40;IgE&#41;&#8211;mediated fish allergy&#46; Although rare&#44; there have been reports of hypotension with distributive shock&#44; bronchospasm&#44; respiratory distress&#44; and cardiac arrhythmias&#59; these complications tend to occur in patients with an underlying condition &#40;e&#46;g&#46;&#44; asthma or heart disease&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8&#8211;10</span></a> explaining why some authors have described scombroid poisoning as a dermatologic emergency&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Symptoms typically disappear within 12 to 48<span class="elsevierStyleHsp" style=""></span>hours without treatment and leave no short-term or long-term sequelae&#46; Patients under treatment with isoniazid or monoamine oxidase inhibitors &#40;MAOIs&#41; are more vulnerable to histamine fish poisoning<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> and develop more severe and lasting symptoms&#44; as these drugs inhibit the metabolism of histamine&#46; Patients under treatment with antihistamines&#44; by contrast&#44; are somewhat protected against scombroid poisoning as these block the effect of histamine&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diagnosis</span><p id="par0040" class="elsevierStylePara elsevierViewall">There are no specific diagnostic tests for scombroid poisoning in humans&#46; The condition is generally diagnosed on clinical grounds and a recent history of fish ingestion&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> A thorough history is thus very important for the correct diagnosis of scombroid poisoning &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The following findings can also help to raise suspicion&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Onset of symptoms within 1 hour of eating scombroid fish</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Histamine-mediated symptoms&#44; such as flushing&#44; rash&#44; headache&#44; diarrhea&#44; etc&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Epidemiological data&#58; similar symptoms in other diners</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Rapid resolution of symptoms following the administration of antihistamines</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Once scombroid poisoning is suspected&#44; a definitive diagnosis can be established by measuring histamine levels in the fish implicated in the episode&#46; Levels of over 50<span class="elsevierStyleHsp" style=""></span>mg per 100<span class="elsevierStyleHsp" style=""></span>g of fish are considered toxic&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> In Europe&#44; histamine levels must not exceed 10<span class="elsevierStyleHsp" style=""></span>mg per 100<span class="elsevierStyleHsp" style=""></span>g&#46; Levels are determined by sending samples of the suspect fish to the laboratory&#44; accompanied&#44; where appropriate&#44; by other products from the same lot&#46; It is important to ensure that the samples are shipped in a frozen state to prevent the formation of histamine during shipment&#46; Furthermore&#44; because histamine levels can vary enormously from one part of the fish to another&#44; different sections should be sent&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is also useful to measure plasma histamine levels in the patient<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a>&#59; a 2- to 4-fold increase above normal is suggestive of poisoning&#46; This test must be performed within 24<span class="elsevierStyleHsp" style=""></span>hours&#44; as levels return to normal after this time&#46; High plasma histamine levels within the first 4<span class="elsevierStyleHsp" style=""></span>hours have been proposed as a specific finding for scombroid poisoning&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Differential Diagnosis</span><p id="par0075" class="elsevierStylePara elsevierViewall">The following conditions should be contemplated in the differential diagnosis<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><p id="par0080" class="elsevierStylePara elsevierViewall">Allergic reaction to fish&#46; This is the most common condition with which scombroid poisoning is confused&#46; De novo fish allergy is rare in adults&#44; with a prevalence of just 0&#46;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> However&#44; the absence of known allergies&#44; similar symptoms in other diners&#44; and&#44; where possible&#44; the detection of toxic histamine levels in fish&#44; all help to establish a diagnosis of scombroid poisoning&#46; If the suspicion of an allergic reaction persists&#44; specific IgE levels should be measured or the patient referred to an allergologist&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><p id="par0085" class="elsevierStylePara elsevierViewall">Acute myocardial infarction&#46; This condition is distinguishable from scombroid poisoning in that its main manifestation is intense&#44; oppressive chest pain&#44; accompanied by symptoms such as profuse sweating&#44; dizziness&#44; nausea&#44; vomiting&#44; etc&#46; Serial electrocardiograms and normal cardiac markers help to rule out infarction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><p id="par0090" class="elsevierStylePara elsevierViewall">Staphylococcal food poisoning&#46; Unlike scombroid food poisoning&#44; staphylococcal food poisoning is generally characterized by fever and does not cause flushing or rash&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Treatment</span><p id="par0095" class="elsevierStylePara elsevierViewall">Given the benign nature of scombroid poisoning and its tendency to spontaneously resolve&#44; many patients do not require treatment&#46; In the case of mild symptoms &#40;flushing&#44; burning&#44; rash&#44; or swelling around the mouth&#41;&#44; the only effective treatment is the prompt administration of oral antihistamines for 1 to 2 days&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> H<span class="elsevierStyleInf">1</span> antihistamines&#44; including cetirizine&#44; are preferable as they are nonsedating&#46; They can be combined with an H<span class="elsevierStyleInf">2</span> antihistamine&#44; such as cimetidine&#44; famotidine&#44; or ranitidine&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> With this treatment&#44; symptoms should resolve within 6 to 8<span class="elsevierStyleHsp" style=""></span>hours&#46; It is unnecessary to prolong treatment for longer than 2 days&#44; as this is the time it takes for the toxin to be completely absorbed or eliminated and consequently for the clinical manifestations to disappear&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Intravenous antihistamines can be administered to patients with very bothersome symptoms or patients who do not tolerate oral antihistamines&#46; The drugs of choice in such cases are diphenhydramine&#44; famotidine&#44; and ranitidine&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Patients who experience hypertension or dehydration should be administered fluids&#44; and vomiting can be treated with intravenous promethazine&#46; The use of epinephrine or other vasoconstrictors should be considered in patients with severe symptoms&#44; although these situations are extremely rare &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Corticosteroids<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> and epinephrine are not indicated in mild cases&#44; as their action is independent of the pathogenesis of scombroid poisoning&#46; In other words&#44; they do not reduce histamine levels and as such are ineffective&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The prophylactic use of antihistamines is not justified either&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> although it could be indicated in a patient about to eat fish who is being treated with isoniazid and&#47;or MAOIs and has had a prior episode of scombroid poisoning&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">It is important to educate patients on the origin of the condition and remind them that it is not a fish allergy and they can therefore eat fish without fear of a reaction&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Prognosis</span><p id="par0125" class="elsevierStylePara elsevierViewall">Scombroid poisoning is generally a benign&#44; self-limiting condition&#46; However&#44; because there have been reports of distributive shock&#44; bronchospasm&#44; and cardiac arrhythmias&#44; early diagnosis and treatment is important&#46; There has just been 1 reported death due to scombroid poisoning worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Prevention</span><p id="par0130" class="elsevierStylePara elsevierViewall">The most important consideration is that scombroid poisoning can be prevented by rapidly refrigerating fish for consumption&#46; Fish should be ideally be stored at a temperature of 0<span class="elsevierStyleHsp" style=""></span>&#176;C or less to prevent both the growth of bacteria and the activation of histidine decarboxylase&#46; It is important to recall that while cooking or freezing contaminated fish can destroy the bacteria&#44; it will not destroy the toxin&#44; which is stable in heat and cold&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Finally&#44; outbreaks of scombroid poisoning should always be reported to the health department to prevent other cases&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">Scombroid poisoning is a common cause of fish poisoning and is very probably underdiagnosed&#46; It typically presents with cutaneous lesions and is treated with oral antihistamines for 1 to 2 days&#46; Complications are rare&#46; Prevention is unquestionably the best &#8220;cure&#8221;&#44; as once histamine has formed&#44; reactions cannot be prevented by cooking&#44; freezing&#44; or canning&#46; Familiarity with this condition among dermatologists will help to prevent confusion with allergic reactions to fish&#46; As scombroid poisoning presents with skin lesions&#44; it is likely that at some point in our career&#44; we will be called on by the emergency department to evaluate a case of scombroid poisoning&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of Interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            2 => "Fish"
            3 => "Food poisoning"
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            0 => "Intoxicaci&#243;n histam&#237;nica"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Scombroid poisoning is a common cause of food poisoning worldwide&#46; It is caused by ingestion of oily fish contaminated with bacteria that trigger the formation of high concentrations of histamine&#46; Scombroid poisoning manifests mainly as a skin complaint &#40;flushing that spreads downward and&#47;or an erythematous urticarial rash affecting the face and upper trunk&#41;&#46; Although the clinical course is usually self-limiting and benign&#44; vascular compromise&#44; bronchospasm&#44; and arrhythmias have been described&#46; It is important to establish a differential diagnosis that includes conditions such as fish allergy&#46; Oral antihistamines are the mainstay of treatment&#46; Scombroid poisoning is best prevented by refrigerating fish properly&#46; The practical review of scombroid poisoning provided here is intended for dermatologists&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La escombroidosis es una causa frecuente de intoxicaci&#243;n alimentaria a nivel mundial que se debe a la ingesta de pescado azul contaminado con bacterias que inducen la formaci&#243;n de grandes cantidades de histamina&#46; Cl&#237;nicamente se manifiesta sobre todo a nivel cut&#225;neo&#44; en forma de <span class="elsevierStyleItalic">flushing</span> descendente y&#47;o <span class="elsevierStyleItalic">rash</span> eritemato-urticariforme facial y en el tronco superior&#46; Aunque habitualmente tiene un curso autolimitado y benigno&#44; pueden existir casos de compromiso vascular&#44; broncoespasmo y arritmias&#46; Es importante hacer un correcto diagn&#243;stico diferencial&#44; entre otros con la alergia al pescado&#46; El tratamiento se basa en la administraci&#243;n de antihistam&#237;nicos orales&#46; Lo m&#225;s importante es su prevenci&#243;n mediante una correcta refrigeraci&#243;n del pescado&#46; Este trabajo es una revisi&#243;n pr&#225;ctica de la escombroidosis orientada para su uso por el dermat&#243;logo&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guergu&#233;-D&#237;az de Cerio O&#44; Barrutia-Borque A&#44; Gardeazabal-Garc&#237;a J&#46; Escombroidosis&#58; abordaje pr&#225;ctico&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;567&#8211;571&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A and B&#44; Generalized erythematous rash mainly affecting the face &#40;not shown in the image&#41; and the trunk of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> C&#44; Detailed view of the upper thorax&#46; Note the absence of whealing&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reproduced with permission from Jantschitsch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type of fish ingested&#63; Cooked&#47;raw&#63; Smell and appearance&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Any other food eaten before the onset of symptoms&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">First episode&#63; Have there been similar episodes&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">How long between ingestion of the fish and the appearance of symptoms&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Comorbidities&#63; Particularly asthma or other chest conditions and heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Usual treatment&#63; Particularly antihistamines&#44; isoniazid or monoamine oxidase inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Where did it happen &#40;home&#44; restaurant&#44; etc&#46;&#41;&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Any other diners affected&#63;&nbsp;\t\t\t\t\t\t\n
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    "bibliografia" => array:2 [
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      "seccion" => array:1 [
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                    0 => array:2 [
                      "titulo" => "Scombrotoxic fish poisoning&#58; Features of the first 50 incidents to be reported in Britain &#40;1976-9&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46;J&#46; Gilbert"
                            1 => "G&#46; Hobbs"
                            2 => "C&#46;K&#46; Murray"
                            3 => "J&#46;G&#46; Cruickshank"
                            4 => "S&#46; Young"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br Med J"
                        "fecha" => "1980"
                        "volumen" => "281"
                        "paginaInicial" => "71"
                        "paginaFinal" => "72"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7190856"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
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Practical Dermatology
Scombroid Poisoning: A Practical Approach
Escombroidosis: abordaje práctico
O. Guergué-Díaz de Cerio
Autor para correspondencia
, A. Barrutia-Borque, J. Gardeazabal-García
Servicio de Dermatología, Hospital Universitario Cruces, Vizcaya, Spain
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A and B&#44; Generalized erythematous rash mainly affecting the face &#40;not shown in the image&#41; and the trunk of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> C&#44; Detailed view of the upper thorax&#46; Note the absence of whealing&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reproduced with permission from Jantschitsch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p>"
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although because the condition is mild and self-limiting&#44; it is probably safe to assume that a considerable proportion of patients do not visit a doctor&#46; Accordingly&#44; and also because scombroid poisoning is frequently confused with a food allergy&#44; many cases are not reported and it is probably underdiagnosed&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> The aim of this article is to provide a practical overview of scombroid poisoning and to guide dermatologists in its diagnosis and treatment&#44; as it is not unusual for us to be called on to evaluate the skin lesions seen with this syndrome&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Scombroid poisoning exists around the world&#46; Its incidence is unknown&#44; and reported rates vary enormously from one area to the next depending on fish consumption habits&#46; An estimated annual incidence of between 2 and 5 cases per 1 million inhabitants has been reported for Denmark&#44; New Zealand&#44; France&#44; and Finland&#44; while rates for Hawaii have been as high as 31 cases per 1 million inhabitants a year&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> The largest numbers of cases have been reported in Japan&#44; the United Kingdom&#44; the United States&#44; and Australia&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> In the United States and Europe&#44; scombroid poisoning accounts for up to 40&#37; of all food poisoning outbreaks&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Scombroid poisoning typically affects groups of diners who have eaten contaminated oily fish&#46; It has traditionally been linked to the consumption of fish from the Scombroidae and Scomberesocidae family&#44; such as tuna fish &#40;responsible for over 80&#37; of cases&#41;&#44; mackerel&#44; and bonito&#46; Cases&#44; however&#44; have also been linked to other types of fish&#44; such as anchovies&#44; greater amberjack fish&#44; swordfish&#44; herring&#44; sardines&#44; salmon&#44; trout&#44; and even dolphin and Swiss cheese&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Pathogenesis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Scombroid&#44; or histamine fish&#44; poisoning&#44; is caused by the ingestion of poorly conserved fish&#44; i&#46;e&#46;&#44; fish that has generally been stored at a temperature of above 4<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; These conditions favor the growth of different bacteria&#44; triggering the conversion of histidine &#40;present in the meat of oily fish&#41; to histamine by bacterial enzymes&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;4</span></a> namely histidine decarboxylase&#46; The conversion takes place in a matter of hours&#44; such that fish stored at 20<span class="elsevierStyleHsp" style=""></span>&#176;C can accumulate toxic levels of histamine in just 2<span class="elsevierStyleHsp" style=""></span>hours&#46; Levels of over 50<span class="elsevierStyleHsp" style=""></span>mg of histamine per 100<span class="elsevierStyleHsp" style=""></span>g of fish are necessary to trigger the clinical manifestations of scombroid poisoning&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> &#40;Histamine levels in fresh fish are less than 0&#46;01<span class="elsevierStyleHsp" style=""></span>mg&#47;100<span class="elsevierStyleHsp" style=""></span> g&#46;&#41; The most commonly implicated bacterial agent is <span class="elsevierStyleItalic">Escherichia coli</span>&#44; although there have been cases attributed to bacteria from the species <span class="elsevierStyleItalic">Vibrio</span>&#44; <span class="elsevierStyleItalic">Proteus</span>&#44; <span class="elsevierStyleItalic">Serratia</span>&#44; <span class="elsevierStyleItalic">Enterobacter</span>&#44; <span class="elsevierStyleItalic">Klebsiella</span>&#44; <span class="elsevierStyleItalic">Clostridium</span>&#44; <span class="elsevierStyleItalic">Salmonella</span>&#44; and <span class="elsevierStyleItalic">Shigella</span>&#46; Histamine poisoning generally affects fresh fish rather than canned fish&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> as the latter is typically subject to more quality controls and cans generally contain different specimens of fish&#44; meaning that the toxic effect of a single contaminated specimen would be minimized&#46; Although the canning process can destroy the bacteria&#44; it cannot destroy histamine that has already formed&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical Presentation</span><p id="par0030" class="elsevierStylePara elsevierViewall">The clinical manifestations of scombroid poisoning appear within minutes to hours of eating contaminated fish and are the result of histamine poisoning&#46; Histamine is an endogenous amine with numerous biological effects&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> including vasodilation&#44; an immediate allergic response following activation of H<span class="elsevierStyleInf">1</span> receptors&#44; and neurotransmission due to the activation of H<span class="elsevierStyleInf">3</span> receptors&#46; The amount of histamine required to produce manifestations varies from one person to the next&#46; Scombroid poisoning symptoms tend to be mild and typically start with a burning or tingling sensation on the tongue&#44; accompanied or not by a peppery and&#47;or metallic taste&#46; This is gradually followed by flushing in the head and neck area&#44; with a considerable burning sensation&#44; and a downward-spreading erythematous urticarial rash on the face and upper trunk<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Other common symptoms are a burning sensation&#44; pruritus&#44; and swelling around the mouth&#46; Gastrointestinal symptoms are also common and include stomach cramps&#44; nausea&#44; vomiting&#44; and diarrhea&#46; A throbbing headache and palpitations are other hallmark symptoms&#46; Because of the similarity with allergic reaction symptoms&#44; scombroid poisoning is frequently mistaken for immunoglobulin E &#40;IgE&#41;&#8211;mediated fish allergy&#46; Although rare&#44; there have been reports of hypotension with distributive shock&#44; bronchospasm&#44; respiratory distress&#44; and cardiac arrhythmias&#59; these complications tend to occur in patients with an underlying condition &#40;e&#46;g&#46;&#44; asthma or heart disease&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8&#8211;10</span></a> explaining why some authors have described scombroid poisoning as a dermatologic emergency&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Symptoms typically disappear within 12 to 48<span class="elsevierStyleHsp" style=""></span>hours without treatment and leave no short-term or long-term sequelae&#46; Patients under treatment with isoniazid or monoamine oxidase inhibitors &#40;MAOIs&#41; are more vulnerable to histamine fish poisoning<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> and develop more severe and lasting symptoms&#44; as these drugs inhibit the metabolism of histamine&#46; Patients under treatment with antihistamines&#44; by contrast&#44; are somewhat protected against scombroid poisoning as these block the effect of histamine&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diagnosis</span><p id="par0040" class="elsevierStylePara elsevierViewall">There are no specific diagnostic tests for scombroid poisoning in humans&#46; The condition is generally diagnosed on clinical grounds and a recent history of fish ingestion&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> A thorough history is thus very important for the correct diagnosis of scombroid poisoning &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The following findings can also help to raise suspicion&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Onset of symptoms within 1 hour of eating scombroid fish</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Histamine-mediated symptoms&#44; such as flushing&#44; rash&#44; headache&#44; diarrhea&#44; etc&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Epidemiological data&#58; similar symptoms in other diners</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Rapid resolution of symptoms following the administration of antihistamines</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Once scombroid poisoning is suspected&#44; a definitive diagnosis can be established by measuring histamine levels in the fish implicated in the episode&#46; Levels of over 50<span class="elsevierStyleHsp" style=""></span>mg per 100<span class="elsevierStyleHsp" style=""></span>g of fish are considered toxic&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> In Europe&#44; histamine levels must not exceed 10<span class="elsevierStyleHsp" style=""></span>mg per 100<span class="elsevierStyleHsp" style=""></span>g&#46; Levels are determined by sending samples of the suspect fish to the laboratory&#44; accompanied&#44; where appropriate&#44; by other products from the same lot&#46; It is important to ensure that the samples are shipped in a frozen state to prevent the formation of histamine during shipment&#46; Furthermore&#44; because histamine levels can vary enormously from one part of the fish to another&#44; different sections should be sent&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is also useful to measure plasma histamine levels in the patient<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a>&#59; a 2- to 4-fold increase above normal is suggestive of poisoning&#46; This test must be performed within 24<span class="elsevierStyleHsp" style=""></span>hours&#44; as levels return to normal after this time&#46; High plasma histamine levels within the first 4<span class="elsevierStyleHsp" style=""></span>hours have been proposed as a specific finding for scombroid poisoning&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Differential Diagnosis</span><p id="par0075" class="elsevierStylePara elsevierViewall">The following conditions should be contemplated in the differential diagnosis<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><p id="par0080" class="elsevierStylePara elsevierViewall">Allergic reaction to fish&#46; This is the most common condition with which scombroid poisoning is confused&#46; De novo fish allergy is rare in adults&#44; with a prevalence of just 0&#46;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> However&#44; the absence of known allergies&#44; similar symptoms in other diners&#44; and&#44; where possible&#44; the detection of toxic histamine levels in fish&#44; all help to establish a diagnosis of scombroid poisoning&#46; If the suspicion of an allergic reaction persists&#44; specific IgE levels should be measured or the patient referred to an allergologist&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><p id="par0085" class="elsevierStylePara elsevierViewall">Acute myocardial infarction&#46; This condition is distinguishable from scombroid poisoning in that its main manifestation is intense&#44; oppressive chest pain&#44; accompanied by symptoms such as profuse sweating&#44; dizziness&#44; nausea&#44; vomiting&#44; etc&#46; Serial electrocardiograms and normal cardiac markers help to rule out infarction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><p id="par0090" class="elsevierStylePara elsevierViewall">Staphylococcal food poisoning&#46; Unlike scombroid food poisoning&#44; staphylococcal food poisoning is generally characterized by fever and does not cause flushing or rash&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Treatment</span><p id="par0095" class="elsevierStylePara elsevierViewall">Given the benign nature of scombroid poisoning and its tendency to spontaneously resolve&#44; many patients do not require treatment&#46; In the case of mild symptoms &#40;flushing&#44; burning&#44; rash&#44; or swelling around the mouth&#41;&#44; the only effective treatment is the prompt administration of oral antihistamines for 1 to 2 days&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> H<span class="elsevierStyleInf">1</span> antihistamines&#44; including cetirizine&#44; are preferable as they are nonsedating&#46; They can be combined with an H<span class="elsevierStyleInf">2</span> antihistamine&#44; such as cimetidine&#44; famotidine&#44; or ranitidine&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> With this treatment&#44; symptoms should resolve within 6 to 8<span class="elsevierStyleHsp" style=""></span>hours&#46; It is unnecessary to prolong treatment for longer than 2 days&#44; as this is the time it takes for the toxin to be completely absorbed or eliminated and consequently for the clinical manifestations to disappear&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Intravenous antihistamines can be administered to patients with very bothersome symptoms or patients who do not tolerate oral antihistamines&#46; The drugs of choice in such cases are diphenhydramine&#44; famotidine&#44; and ranitidine&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Patients who experience hypertension or dehydration should be administered fluids&#44; and vomiting can be treated with intravenous promethazine&#46; The use of epinephrine or other vasoconstrictors should be considered in patients with severe symptoms&#44; although these situations are extremely rare &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Corticosteroids<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> and epinephrine are not indicated in mild cases&#44; as their action is independent of the pathogenesis of scombroid poisoning&#46; In other words&#44; they do not reduce histamine levels and as such are ineffective&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The prophylactic use of antihistamines is not justified either&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> although it could be indicated in a patient about to eat fish who is being treated with isoniazid and&#47;or MAOIs and has had a prior episode of scombroid poisoning&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">It is important to educate patients on the origin of the condition and remind them that it is not a fish allergy and they can therefore eat fish without fear of a reaction&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Prognosis</span><p id="par0125" class="elsevierStylePara elsevierViewall">Scombroid poisoning is generally a benign&#44; self-limiting condition&#46; However&#44; because there have been reports of distributive shock&#44; bronchospasm&#44; and cardiac arrhythmias&#44; early diagnosis and treatment is important&#46; There has just been 1 reported death due to scombroid poisoning worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Prevention</span><p id="par0130" class="elsevierStylePara elsevierViewall">The most important consideration is that scombroid poisoning can be prevented by rapidly refrigerating fish for consumption&#46; Fish should be ideally be stored at a temperature of 0<span class="elsevierStyleHsp" style=""></span>&#176;C or less to prevent both the growth of bacteria and the activation of histidine decarboxylase&#46; It is important to recall that while cooking or freezing contaminated fish can destroy the bacteria&#44; it will not destroy the toxin&#44; which is stable in heat and cold&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Finally&#44; outbreaks of scombroid poisoning should always be reported to the health department to prevent other cases&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">Scombroid poisoning is a common cause of fish poisoning and is very probably underdiagnosed&#46; It typically presents with cutaneous lesions and is treated with oral antihistamines for 1 to 2 days&#46; Complications are rare&#46; Prevention is unquestionably the best &#8220;cure&#8221;&#44; as once histamine has formed&#44; reactions cannot be prevented by cooking&#44; freezing&#44; or canning&#46; Familiarity with this condition among dermatologists will help to prevent confusion with allergic reactions to fish&#46; As scombroid poisoning presents with skin lesions&#44; it is likely that at some point in our career&#44; we will be called on by the emergency department to evaluate a case of scombroid poisoning&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of Interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            2 => "Fish"
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            0 => "Intoxicaci&#243;n histam&#237;nica"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Scombroid poisoning is a common cause of food poisoning worldwide&#46; It is caused by ingestion of oily fish contaminated with bacteria that trigger the formation of high concentrations of histamine&#46; Scombroid poisoning manifests mainly as a skin complaint &#40;flushing that spreads downward and&#47;or an erythematous urticarial rash affecting the face and upper trunk&#41;&#46; Although the clinical course is usually self-limiting and benign&#44; vascular compromise&#44; bronchospasm&#44; and arrhythmias have been described&#46; It is important to establish a differential diagnosis that includes conditions such as fish allergy&#46; Oral antihistamines are the mainstay of treatment&#46; Scombroid poisoning is best prevented by refrigerating fish properly&#46; The practical review of scombroid poisoning provided here is intended for dermatologists&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La escombroidosis es una causa frecuente de intoxicaci&#243;n alimentaria a nivel mundial que se debe a la ingesta de pescado azul contaminado con bacterias que inducen la formaci&#243;n de grandes cantidades de histamina&#46; Cl&#237;nicamente se manifiesta sobre todo a nivel cut&#225;neo&#44; en forma de <span class="elsevierStyleItalic">flushing</span> descendente y&#47;o <span class="elsevierStyleItalic">rash</span> eritemato-urticariforme facial y en el tronco superior&#46; Aunque habitualmente tiene un curso autolimitado y benigno&#44; pueden existir casos de compromiso vascular&#44; broncoespasmo y arritmias&#46; Es importante hacer un correcto diagn&#243;stico diferencial&#44; entre otros con la alergia al pescado&#46; El tratamiento se basa en la administraci&#243;n de antihistam&#237;nicos orales&#46; Lo m&#225;s importante es su prevenci&#243;n mediante una correcta refrigeraci&#243;n del pescado&#46; Este trabajo es una revisi&#243;n pr&#225;ctica de la escombroidosis orientada para su uso por el dermat&#243;logo&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guergu&#233;-D&#237;az de Cerio O&#44; Barrutia-Borque A&#44; Gardeazabal-Garc&#237;a J&#46; Escombroidosis&#58; abordaje pr&#225;ctico&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;567&#8211;571&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A and B&#44; Generalized erythematous rash mainly affecting the face &#40;not shown in the image&#41; and the trunk of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> C&#44; Detailed view of the upper thorax&#46; Note the absence of whealing&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reproduced with permission from Jantschitsch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type of fish ingested&#63; Cooked&#47;raw&#63; Smell and appearance&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Any other food eaten before the onset of symptoms&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">First episode&#63; Have there been similar episodes&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">How long between ingestion of the fish and the appearance of symptoms&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Comorbidities&#63; Particularly asthma or other chest conditions and heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Usual treatment&#63; Particularly antihistamines&#44; isoniazid or monoamine oxidase inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Where did it happen &#40;home&#44; restaurant&#44; etc&#46;&#41;&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Any other diners affected&#63;&nbsp;\t\t\t\t\t\t\n
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Scombrotoxic fish poisoning&#58; Features of the first 50 incidents to be reported in Britain &#40;1976-9&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46;J&#46; Gilbert"
                            1 => "G&#46; Hobbs"
                            2 => "C&#46;K&#46; Murray"
                            3 => "J&#46;G&#46; Cruickshank"
                            4 => "S&#46; Young"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br Med J"
                        "fecha" => "1980"
                        "volumen" => "281"
                        "paginaInicial" => "71"
                        "paginaFinal" => "72"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7190856"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Histamine fish poisoning&#58; A common but frequently misdiagnosed condition"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;R&#46; Attaran"
                            1 => "F&#46; Probst"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Emerg Med J"
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                        "volumen" => "19"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12205017"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Scombroid &#40;histamine&#41; poisoning&#46; UpToDate&#46; &#91;accessed 2 Nov 2015&#93;&#46; Available from&#58; <a href="http://www.uptodate.com/contents/scombroid-histamine-poisoning">http&#58;&#47;&#47;www&#46;uptodate&#46;com&#47;contents&#47;scombroid-histamine-poisoning</a>"
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Histamine &#40;scombroid&#41; fish poisoning&#58; A comprehensive review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46; Feng"
                            1 => "S&#46; Teuber"
                            2 => "M&#46;E&#46; Gershwin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s12016-015-8467-x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Rev Allergy Immunol&#46;"
                        "fecha" => "2016"
                        "volumen" => "50"
                        "paginaInicial" => "64"
                        "paginaFinal" => "69"
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