Though the neurology team suspected HPP in our patient, it is unlikely that this would have a first-time onset at 34 years of age. HPP begins in the teenage years and may manifest as several attacks per week. It may be precipitated by rest after exercise, stress, or a high-carbohydrate meal. Our patient was healthy and exercised regularly. It was unlikely for him to suddenly develop HPP if there were no changes to his routine. The only change was the exposure to the coral.

Conclusion

It is easy in a busy emergency department to attribute a patient’s symptoms to more common diagnoses. However, it is important to develop a broad differential and to obtain a detailed history. In our case, asking about the patient’s pets revealed his exposure to zoanthid coral. There are no current guidelines on proper handling to avoid exposure to palytoxin. Warning signs may help with educating the general public about the corals. However, proper handling techniques need to be established to prevent future exposure.

Dr. Zhao is an emergency medicine resident at Wright State University in Dayton, Ohio.

Dr. Ballester is program director and assistant professor of emergency medicine at Wright State University in Dayton, Ohio.

References

1. Hilgemann DW. From a pump to a pore: how palytoxin opens the gates. Proc Natl Acad Sci U S A. 2003;100(2):386-388.
2. Hamade AK, Deglin SE, McLaughlin JB, et al. Suspected palytoxin inhalation exposures associated with zoanthid corals in aquarium shops and homes–Alaska, 2012-2014. MMWR Morb Mortal Wkly Rep. 2015;64(31):852-855.
3. Nordt SP, Wu J, Zahller S, et al. Palytoxin poisoning after dermal contact with zoanthid coral. J Emerg Med. 2011;40(4):397-399.
4. Hoffmann K, Hermanns-Clausen M, Buhl C, et al. A case of palytoxin poisoning due to contact with zoanthid corals through a skin injury. Toxicon. 2008;51(8):1535-1537.