A student buys sushi from the gas station for breakfast. Is this what sent him to the hospital — or was it his penchant toward garbage picking for food? Watch the analysis of this fishy case.

Read the transcript below:

TB is a 22-year-old man, presenting to the emergency room with facial swelling, shortness of breath, and hives.

He tells the admitting nurse that he had had severe, right-sided, lower abdominal pain for at least the last 3 days.

You see, TB was a college student.

During his freshman year, he found out the grocery would toss out their expired food, and he could pick it from the waste bin, to eat.

He wasn’t picky. If it was edible, he took it.

The grocery would throw away a bag of apples if even just one was rotten. But to TB, the other apples were just fine.

On the internet, he read that over 1 billion tons of food every year is thrown away. Clearly, this was bad for the environment, so picking that disposed food and eating it was doing his part. His reward for saving the earth was eating for free.

As TB became more experienced in finding his food, he became more relaxed in what qualified as edible.

Instead of tossing the rotten apples, he eventually just ate around it. If bread was moldy, cut out the bad part — it’s fine, he thought.

This got to the point where he’d pick pizza, hot dogs, and sushi from the back of the gas station, at night.

TB’s favorite was Monday because that was when the gas station threw away their weekend sushi.

Yeah, it’s a couple of days old, he thought, but it’s refrigerated. And sealed. No reason anything could be wrong with it, he thought.

So every Tuesday morning, TB had gas station sushi for breakfast. He did this for months, and he was fine.

One Monday night, TB was heating up a suspicious gas station pizza for dinner.

If you heat it up for a really long time in the microwave, you clean off the bacteria so then it’s no longer suspicious, he thought.

Earlier that morning, he had his normal sushi breakfast before class and was feeling great.

But immediately after finishing his expired gas station pizza, TB felt like he couldn’t breathe. He could feel his tongue expanding.

His stomach started to cramp. His face, started to swell.

A sensation rippled through his cheeks, as he was brought down to the floor.

As the hours go by, TB laid down in a bathroom, with minimal relief.

He felt his stomach folding over itself over the next few days. He woke up every night, sweating. His friends made fun of him saying he clearly had been getting Botox because his lips were so swollen.

He couldn’t take it anymore as he brought himself to the emergency room where we are now.

At examination, TB’s abdomen was a little swollen. There was tenderness in the right lower quadrant. There was nothing suspicious about his stool, but his blood test was borderline. Counts of his white blood cells were near the upper limit of normal. Could be a problem. Maybe not.

TB told the doctors about his food habits. He had been garbage picking for so long and had so many successes that he was proud of all the money he saved himself. He told them he was sure that whatever he picked out the garbage wasn’t rotten, hadn’t come into contact with flies or rats, and that he always physically examined it himself, visually, and by smell.

He told the doctors that the expired gas station pizza he last ate was suspect. He knew beforehand that it was sketchy. Maybe he didn’t microwave it long enough. But, he also forgot to mention anything about sushi because he didn’t think anything of it. It was definitely the pizza.

Over the next 6 hours, TB was observed and the physical exam was repeated. Abdominal tenderness, guarding, and rebound tenderness were found in the right lower quadrant. If you look at an anatomical model, this right lower region of the abdomen is where the appendix is. A CT scan showed inflammation in the area and other features pointing to appendicitis.

TB was sent in for an appendectomy, the removal of his appendix.

Appendicitis is caused by a blockage of the appendiceal lumen, or hole. The blockage could be from undigested food, from some inflammation, or maybe that twisting and turning he felt in his stomach was actually his appendix, doing just that. But the reality was, after it was removed, TB’s appendix didn’t really look that inflamed. It was kind of normal and unremarkable. The region around it also looked ok. The surgeon told TB afterwards that they had seen worse.

The doctors advised TB to stop scavenging his food. To just get a meal plan from the cafeteria, or something that didn’t involve garbage. TB argued back that cafeteria food was the real garbage as he was wheeled off.

And his surgical recovery was uncomplicated. At the end, he felt, a little better.

At home now, TB started picking expired food again, but this time, no more pizza.

In a few weeks after his surgery, he started creeping back to his old foods.

During this period, TB would start to experience crampy abdominal pain. Sometimes, he’d sit in the bathroom and struggle for a movement.

Every day, he’d feel exhausted, and tired. (Students, what are you thinking here? Crohn’s? IBD? How about UC?)

The next day, TB went to the gas station. For the first time, he bought the sushi that he had been picking from the garbage all these months.

He was going to have a legitimate breakfast this time.

Immediately after finishing this raw fish, a rash quickly developed all over TB’s body. His face started swelling, and he became short of breath. His stomach started cramping. As he got down to the floor, his roommates called for an ambulance, and he’s brought to the emergency room, again.

On examination this time, TB’s blood pressure was 60/30. He was in anaphylactic shock. Epinephrine, also known as adrenaline, was administered to him with fluid resuscitation, to increase his blood pressure. This is so that oxygen can get to his organs. Over the next several hours, TB was managed as he was admitted into the hospital.

This sudden onset abdominal pain and nausea with a history of constipation could mean something is blocking his intestines, and TB would likely need surgery, again.

An abdominal radiograph showed markedly dilated loops of bowel, strongly suggesting that there is some kind of blockage going on.

A blood test revealed a high count of white blood cells, meaning TB might have some sort of infection. This was confirmed because at surgery, parts of his intestines by where his appendix used to be were removed. The finding showed that the inside walls of those removed parts were thickened, and accompanied by inflammation, meaning white blood cells swelled up the region with fluid, causing the blockage.

But why would those white cells be there?

Looking at samples of that tissue under a microscope, clumps of immune cells were gathered all around multiple worm-like larva that had embedded in the tissue, meaning that a parasite, had been living and crawling around this whole time.

In the recovery room, doctors asked TB what his last meal was, and when he answered gas station sushi, they confirmed, this nematode parasite is named Anisakis simplex, a common roundworm found in raw fish.

The problem with a parasite found in raw fish sushi, that causes severe illness, is that it may be more common than you might think.

In Japan, at a wholesale fish market, 98% of its mackerel and 94% of its cod, was found to carry Anisakis simplex; 40% of fish sold at a market in Spain were also found to contain the worms.

And in the United States, one study found a 1 in 13 chance of consuming an Anisakis larva in salmon sushi, meaning if you’ve ever had that delicious fish, it’s likely you’ve had contact in some form, with the parasite.

This isn’t by chance. Almost all of us have been warned at some point in time about eating raw fish, and this parasite’s lifecycle tells us everything about its prevalence.

The Anisakis parasite’s primary hosts are whales and dolphins, animals called cetaceans. Primary host, meaning that Anisakis lives as adults in the stomach of these animals. This is important because during the Anisakis adult life, they lay eggs in their hosts’ stomach. The host then passes these eggs in their feces, which is spread all over the sea. Those eggs develop into embryos in water, as they hatch into larvae, where they’re eaten by crustaceans like krill.

Inside the krill, the larva mature. Krill can then be eaten by larger fish and squid, who accumulate the parasite. Anisakis grows into an adult inside fish, and as fish eat other fish, the parasite gets passed on to one another, as the big ones accumulate a lot of these nematodes.

Normally, a whale, or porpoise will eat those fish and complete the Anisakis lifecycle. But somewhere in this pathway, humans come in to play.

Humans that eat infected uncooked fish that hasn’t been previously frozen. Me included. Anisakis enters our GI tract. It’s not supposed to be there. It’s not meant to be in an environment like a human stomach, so it tries to burrow into the mucosa, or the inner lining, where it wreaks havoc as it damages tissue by digging deeper, to get out. The immune system immediately reacts by sending huge amounts of white blood cells, and inducing what looks like an allergic reaction, just like in TB.

The story isn’t over for him. After recovering from the surgery, he still had epigastric pain and nausea. A CT scan showed thickened stomach mucosa. He was sent in for endoscopy, and another set of roundworms, Anisakis again, was found and extracted, meaning TB was probably exposed to it, more than once.

The normal-appearing appendix after appendectomy meant that he probably didn’t have appendicitis but instead already had Anisakis around the ileocecal region right by it. The unnecessary operation was suspected by the first surgeon, but it wasn’t clear at that time what was going on because TB never told anyone about eating raw fish.

They didn’t know what they were looking for.

Anisakidosis is a rare infection and can be mistaken for Crohn’s disease, appendicitis, and many others. And without him mentioning eating raw fish, the doctors missed that possibility altogether.

The leftover pizza that TB kept talking about at that first hospital admission could have caused food poisoning. But abdominal pain in the right lower quadrant, of his severity, is not typically something you’d get from spoiled pizza.

It was only at the second hospital admission that an Anisakis larva was found in the walls of his intestine. His immune system had been reacting to this by sending an inflammatory response and white blood cells to the region causing it to swell and form a structure that eventually obstructed his bowels.

Anisakis can’t live inside human stomachs or intestines for very long, but in some rare cases, they can be absorbed into the liver, the pancreas, and cause massive damage there that would look like tumors on radiographic imaging. These parasitic lesions have been mistaken for metastatic carcinomas in literature.

TB’s second infection came after he bought his gas station sushi. In this case, the Anisakis larva stopped short in his GI tract and burrowed into the lining of his stomach, causing acute abdominal pain, and nausea. The rash and swollen face looked like an allergic reaction and was again, a response by the immune system to a foreign pathogen, as his body detected something damaging his stomach.

All of this from raw fish sushi that was likely not handled well, because while Anisakis is relatively prevalent in fish, we have measures to prevent this from happening.

Do you remember that 1 in 13 chance of eating Anisakis in salmon sushi? Well, the study specified that those larvae weren’t alive when found. Anisakis needs to be living to cause problems, because it causes that damage by burrowing into mucosa, and it can’t do that if it’s not alive. And in the United States, most salmon served raw is frozen first, which would kill the nematode, but also means that you would still have eaten a deceased worm anyways. That 8% is kind of unsettling if you think about it.

There’s really no way to prevent what happened to TB, other than to just not eat any raw fish at all, cause unless you do it yourself, you may never know who prepared the food, or how it was prepared. It’s no surprise that of all the Anisakis cases reported, the majority of them come from coastal Japan. Although there’s been an increase of reports from coastal regions of Europe, notably Spain and Italy, as well as from South America. If you’re in the United States, eating sushi from a well-known restaurant, that has a good track record is probably going to be ok. But for sushi packaged from an unknown place, and put on a shelf, where it’s left for a couple of days, and then discarded because it’s past its sell-by date, well I hope you’re now aware of the risks if you’re thinking of eating that.

Having learned a valuable lesson in food caution, through permanently losing parts of his GI tract, TB was able to make a recovery.

Please don’t let this video make you be scared of sushi. I still eat it once a week. That study that said 1 in 13, well they were all dead larva, and this study was written in 1990. I would at least hope it’s a little better today. But I can’t say for sure. So if you have any medical friends who refuse to eat sushi, it’s because they’ve heard of cases like this one. It’s still a rare occurrence here in the U.S. because we’re pretty good at handling our food. Just be careful of what you eat. Take care of yourself. And be well!

“Dr. Bernard” is a licensed physician and clinical adjunct professor at the University of Illinois. See more of his videos on his “Chubbyemu” YouTube channel.

last updated 02.20.2020