| Possible Estuary-Associated Syndrome: Symptoms, Vision, and Treatment Ritchie C. Shoemaker1 and H. Kenneth Hudnell2 1McCready Outpatient Services Center, Pocomoke City, Maryland, USA; 2U.S. Environmental Protection Agency, National Health and Environmental Effects Research Laboratory, Neurotoxicology Division, Research Triangle Park, North Carolina, USA Abstract
 McCready Outpatient Services Center
U.S. Environmental Protection Agency The human illness designated as possible estuarine-associated syndrome (PEAS) by the Centers for Disease Control and Prevention (CDC) has been associated with exposure to estuaries inhabited by toxin-forming dinoflagellates, including members of the fish-killing toxic Pfiesteria complex (TPC) , Pfiesteria piscicida and Pfiesteria shumwayae. Humans may be exposed through direct contact with estuarine water or by inhalation of aerosolized or volatilized toxin(s) . The five cases reported here demonstrate the full spectrum of symptoms experienced during acute and chronic stages of this suspected neurotoxin-mediated illness. The nonspecific symptoms most commonly reported are cough, secretory diarrhea, headache, fatigue, memory impairment, rash, difficulty in concentrating, light sensitivity, burning skin upon water contact, muscle ache, and abdominal pain. Less frequently encountered symptoms are upper airway obstruction, shortness of breath, confusion, red or tearing eyes, weakness, and vertigo. Some patients experience as few as four of these symptoms. The discovery that an indicator of visual pattern-detection ability, visual contrast sensitivity (VCS) , is sharply reduced in affected individuals has provided an objective indicator that is useful in diagnosing and monitoring PEAS. VCS deficits are present in both acute and chronic PEAS, and VCS recovers during cholestyramine treatment coincident with symptom abatement. Although PEAS cannot yet be definitively associated with TPC exposure, resolution with cholestyramine treatment suggests a neurotoxin-mediated illness. Key words: cholestyramine, chronic neurotoxic illness, harmful algal blooms, Pfiesteria, possible estuary-associated syndrome, visual contrast sensitivity. Environ Health Perspect 109:539-545 (2001) . [Online 14 May 2001] http://ehpnet1.niehs.nih.gov/docs/2001/109p539-545shoemaker/ abstract.html Address correspondence to H.K. Hudnell, U.S. Environmental Protection Agency, National Health and Environmental Effects Research Laboratory, Neurotoxicology Division, MD-74B, Research Triangle Park, NC 27711 USA. Telephone: (919) 541-7866. Fax: (919) 541-4849. E-mail: hudnell.ken@epamail.epa.gov We thank J. Shoemaker for assistance in preparation of this manuscript. No grants were involved in this work. This manuscript was reviewed by the National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, and approved for publication. Approval does not signify that the contents necessarily reflect the views and policies of the agency, nor does mention of trade names or commercial products constitute endorsement or recommendation. Received 21 December 2000 ; accepted 1 February 2001.
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