Received: 22 November 2020 

|  Revised: 12 April 2021 

|  Accepted: 14 April 2021

DOI: 10.1002/ccr3.4222

CASE REPORT

A novel case of food poisoning caused by the consumption of

Pacific bluefin tuna infected with Kudoa hexapunctata

Takayuki Tachibana1  | Takashi Watari2

1
Faculty of Medicine, Shimane University,
Shimane, Japan
Abstract
2
General Medicine Center, Shimane Consumption of Japanese cuisine, such as sushi and sashimi, is accompanied by the
University Hospital, Shimane, Japan risk of food poisoning through various pathogens. Kudoa hexapunctata, detected in
both adult and juvenile Pacific bluefin tuna, causes foodborne diseases. Here, we
Correspondence
Takashi Watari, 89-­1, Enya-­cho, Izumo report cases of food poisoning after Kudoa hexapunctata-­infected PBT consumption.
shi, General Medicine Center, Shimane We suggest that medical history about the fish used in sashimi and sushi preparation is used
University Hospital, Shimane 693-­8501,
to assist in making the diagnosis as Kudoa infection.
Japan.
Email: [email protected]
KEYWORDS
food poisoning, gastroenterology, infectious disease, Kudoa hexapunctata, tuna

1  |   IN T RO D U C T ION and potential to cause myoliquefaction, which is absent in K

hexapunctata. Although previous in vitro study suggested
Consumption of Japanese cuisine, such as sushi and sashimi, that K hexapunctata causes food poisoning,4 currently it is
is accompanied by the risk of food poisoning through vari- not listed as a food poisoning–­related pathogen in Japan.
ous pathogens. Kudoa hexapunctata, detected in both adult Here, we report food poisoning in 10 patients after con-
and juvenile Pacific bluefin tuna, causes foodborne dis- sumption of juvenile PBT infected with K hexapunctata.
eases. Here, we report cases of food poisoning after Kudoa
hexapunctata–­infected PBT consumption.
The Kudoa genus comprises more than 90 myxospor- 2  |  CASE REPORT/CASE HISTORY
ean parasitic species capable of infecting various marine
fish.1 In Japan, K  septempunctata was recently associated A 28-­year-­old man with severe diarrhea and nausea visited
with food poisoning caused by the consumption of infected our emergency room after consuming food at a restaurant,
raw olive flounder.2,3 Until recently, infection potential along with 31 colleagues; as per the survey of the staff at
of other members of the genus Kudoa in humans was un- the Izumo Health Center, 10 out of 32 individuals developed
known. However, in the past decade, Japanese researchers acute gastrointestinal symptoms several hours after the meal
have reported foodborne diseases after the consumption of (attack rate, 31.3%; incubation period ≈ 7 hours; incubation
K  hexapunctata–­infected adult or juvenile Pacific bluefin distribution, 2-­12 hours) with diarrhea and nausea being the
tuna (PBT) (Thunnus orientalis).4 Until recently, K  hexa- most common symptoms (60.0%), followed by abdominal
punctata was classified as an intraspecific variant of K pain (50.0%) and fever (40.0%); the average number of bowel
neothunni, but it has now been established as a separate movements per day was approximately six (range: 4-­8), and
species 5,6; it differs in spore shape, 28S rDNA sequences, mean temperature was 37.4°C (range: 37.0-­37.8°C).

We suggest that medical history about the fish used in sashimi and sushi preparation is used to assist in making the diagnosis as Kudoa infection.

This is an open access article under the terms of the Creative Commons Attribution NonCommercial NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non commercial and no modifications or adaptations are made.
© 2021 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.

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As all the patients had consumed sashimi prepared using performed to assess K hexapunctata toxicity in vitro. These
juvenile PBT, food poisoning was suspected, and meal left- results correlated with the incubation period reported in an
overs and stool specimens from the patients were submitted epidemiological survey.4 Rapid reduction in TER in an assay
to the Shimane Prefectural Institute of Public Health and using the Caco-­2 cell line, which has been widely used as an
Environmental Science, Japan. PCR analysis revealed that in vitro model for intestinal transport and enterotoxin studies,
four of the seven stool (three samples were missing) samples indicates the loss of human intestinal epithelial monolayer
and leftover sashimi samples harbored Kudoa hexapunctata. integrity, which is believed to cause diarrhea.7 The incuba-
In addition, Kudoa hexapunctata was observed microscopi- tion period and primary symptom (diarrhea) observed herein
cally in two samples collected from the leftover (Figure 1). are consistent with those reported previously.4 K hexapunc-
No suspected food poisoning–­related pathogens other than K tata does not cause gastrointestinal inflammatory symptoms,
hexapunctata were detected in the stool samples. This diag- unless it is abundantly present in the raw fish consumed.4
nosis was made as all patients presented with transient diar- Hence, in the current study, some patients may not have de-
rhea and vomiting, within a few hours of consuming sashimi veloped gastrointestinal symptoms despite consuming the
containing juvenile PBT. sashimi. It was also reported that TER of freeze-­thawed K
hexapunctata was not decreased in Caco-­2 cell assays, which
indicates the possibility to prevent food poisoning caused by
3  |   D IS C U S S ION K hexapunctata. In addition, previous study showed that the
K hexapunctata–­positive rate and number in tuna other than
In the present study, PCR analysis of the stool samples of juvenile PBT were low and no K hexapunctata was detected
seven patients and leftover sashimi (prepared from juvenile in the residual food of clinical diarrhea cases by ingestion
PBT) samples indicated K hexapunctata infection. Previous of tunas.4 However, few studies have evaluated the cases of
studies have confirmed the presence of K hexapunctata in food poisoning that are thought to be caused by K hexapunc-
both Japanese bluefin and yellowfin tuna, especially in PBT, tata. Therefore, it is necessary to investigate the suspected
with a higher rate of infection in juvenile than in adult fish. food poisoning cases caused by the ingestion of adult or ju-
The K  hexapunctata positivity rate in juvenile PBT from venile PBT.
Japanese waters is generally high from May to July.4 More Symptoms of the patients were resolved within a few
than 70% of clinical diarrhea cases also caused by tuna inges- days without specific treatments. However, in case of pa-
tion occurred between June and September.4 In the current tients with severe symptoms, supportive care (infusion flu-
study, juvenile PBT consumed by the patients were caught in ids, antiemetics, and antifebrile treatment) may be required.
early August, which is proximal to the aforementioned time Currently, Japanese cuisine is the second-­most popular cui-
frame. Therefore, concurrent with the previous reports, we sine worldwide.8 Moreover, a patient's history and physical
considered the K hexapunctata positivity rate in juvenile PBT examination usually form the basis of diagnosis for acute
consumed by the patients to be high.4 Surveys of the clinical gastroenteritis, as culture or blood tests are rarely performed.
diarrhea due to tuna ingestion in Tokyo indicated a 5-­to 7-­h This increases the chances of underdiagnosis or misdiagno-
incubation period until symptom onset.4 In vitro studies have sis of acute gastroenteritis due to parasites, including K sep-
reported that the time lag until transepithelial electrical re- tempunctata, and the condition is more commonly diagnosed
sistance (TER) across the Caco-­2 cell monolayer decreases as acute viral gastroenteritis. Acute gastroenteritis due to
by 80% in cell monolayer permeability assays, which are parasites, including K septempunctata, might be associated
with autoimmune disease such as Guillain-­Barre syndrome
caused by Campylobacter; therefore, further experimen-
tal and epidemiological studies are required to elucidate
the pathogenicity of K hexapunctata. Thus, it is important
to acquire information about the fish used in sashimi and
sushi preparation (raw flounder and adult or juvenile PBT)
from the patients for clarifying whether their gastrointestinal
symptoms (eg, vomiting and diarrhea) are associated with a
Kudoa infection.

ACKNOWLEDGMENTS
The authors would like to thank the staff of the Izumo Health
F I G U R E 1   Kudoa hexapunctata spores. K hexapunctata spores Center for their kind help and Professor Kazumichi Onigata,
harvested from juvenile Pacific bluefin tuna muscles from the sashimi Dean of Shimane University, Faculty of Medicine, for his
leftovers. Scale bar: 10 μm valuable advice. Published with written consent of the patient.
TACHIBANA and WATARI   
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CONFLICT OF INTEREST 3. Tachibana T, Watari T Kudoa septempunctata infection: an un-

None declared. derdiagnosed pathogen of acute gastrointestinal symptoms. QJM.
2020;113:43-­44. https://doi.org/10.1093/qjmed/​hcz227
4. Suzuki J, Murata R, Yokoyama H, Sadamasu K, Kai A. Detection
AUTHOR CONTRIBUTIONS rate of diarrhoea-­causing Kudoa hexapunctata in Pacific bluefin
T.T and T.W: almost equally contributed, collected, ana- tuna Thunnus orientalis from Japanese waters. Int J Food Microbiol.
lyzed, and interpreted data; drafted the article; and critically 2015;194:1-­6. https://doi.org/10.1016/j.ijfoo​dmicro.2014.11.001
revised the article. 5. Abe N, Maehara T. Molecular characterization of kudoid para-
sites (Myxozoa: Multivalvulida) from somatic muscles of Pacific
CONSENT TO PARTICIPATE bluefin (Thunnus orientalis) and yellowfin (T albacores) tuna.
Acta Parasitol. 2013;58:226-­ 230. https://doi.org/10.2478/s1168​
Patient consent was obtained prior to this study.
6-­013-­0130-­1
6. Yokoyama H, Suzuki J, Shirakashi S Kudoa hexapunctata n. sp.
CONSENT FOR PUBLICATION (Myxozoa: Multivalvulida) from the somatic muscle of Pacific blue-
Patient consent was obtained prior to this study. fin tuna Thunnus orientalis and re-­description of K neothunni in yel-
lowfin tuna T albacares. Parasitol Int. 2014;63:571-­579. https://doi.
DATA AVAILABILIT Y STATEMENT org/10.1016/j.parint.2014.03.006
Not applicable. 7. Guarino A, Canani RB, Casola A, et al. Human intestinal crypto-
sporidiosis: secretory diarrhoea and enterotoxic activity in Caco-­2
cells. J Infect Dis. 1995;171:976-­983. https://doi.org/10.1093/infdi​
ORCID
s/171.4.976
Takashi Watari  https://orcid.org/0000-0002-9322-8455 8. Waldfogel J. Dining out as cultural trade. J Cult Econ. 2020;44:309-­
338. https://doi.org/10.1007/s1082​4-­019-­09360​-­5
R E F E R E NC E S
1. Yokoyama H, Grabner D, Shirakashi S. Transmission biology of the
myxozoa. In: Carvalho ED, David GS, Silva RJ, eds. Health and How to cite this article: Tachibana T, Watari T.
Environment in Aquaculture. Croatia: InTech; 2012. https://doi. A novel case of food poisoning caused by the
org/10.5772/29571
consumption of Pacific bluefin tuna infected with
2. Kawai T, Sekizuka T, Yahata Y, et al. Identification of Kudoa sep-
Kudoa hexapunctata. Clin Case Rep. 2021;9:e04222.
tempunctata as the causative agent of novel food poisoning out-
breaks in Japan by consumption of Paralichthys olivaceus in raw https://doi.org/10.1002/ccr3.4222
fish. Clin Infect Dis. 2012;54:1046-­1052. https://doi.org/10.1093/
cid/cir1040