On October 25, 2018, at 2:15 a.m., a woman aged 30 years and her mother, aged 55 years, both of Egyptian descent, arrived at an emergency department in New Jersey in hypotensive shock after 16 hours of abdominal pain, vomiting, and diarrhea. The daughter also reported blurry vision and double vision (diplopia), shortness of breath, chest pain, and difficulty speaking. She appeared lethargic and had ophthalmoplegia and bilateral ptosis. Both women were admitted to the hospital. The mother improved after fluid resuscitation, but the daughter required vasopressor support in the intensive care unit. Although the mother did not have evidence of cranial nerve involvement on admission, during the next 24 hours, she developed dysphagia and autonomic dysfunction with syncope and orthostasis and was transferred to the intensive care unit as her symptoms progressively worsened similar to those of her daughter.
Two days before admission, both women had eaten fesikh, a traditional Egyptian fish dish of uneviscerated gray mullet that is fermented and salt-cured. Fesikh has been linked to foodborne botulism, including a large type E outbreak in Egypt in 1993 (1). The Egyptian Ministry of Health has since issued public health warnings regarding fesikh before Sham el-Nessim, the Egyptian holiday commemorating the beginning of spring, during which fesikh is commonly prepared and eaten.* Foodborne botulism outbreaks associated with fesikh and similar uneviscerated salt-cured fish have also occurred in North America (2); two outbreaks occurred among persons of Egyptian descent in New Jersey in 1992 (3) and 2005 (4).