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Ciguatera Poisoning

Ciguatera poisoning (CP) is a rare condition occurring after the ingestion of presumably edible tropical or subtropical fish. CP is caused by ciguatoxin, a poisonous substance produced by the marine organism Gamabierdiscus toxicus, which will accumulate in the organs of edible fish. Gastric lavage is the method of choice for an efficient cure.

Presentation

Ciguatera poisoning (CP) occurs after the ingestion of contaminated fish and is the most common non-bacterial fish-related poisoning in the world. Currently, five variations of the causative poisonous agent ciguatoxin are known [1].

CP presents with a combination of gastrointestinal, neurologic and cardiovascular symptoms. Gastrointestinal symptoms often start within the first day after ingestion and typically last for one to two days. They can range from abdominal pain, nausea, diarrhea and vomiting to a painful defecation process. Neurologic symptoms can show at any time between three hours and three days after the ingestion of contaminated fish and last for weeks or even several months. There are lingual or circumoral paresthesias, painful paresthesias, reversed temperature sensation (i.e. hot objects feel cold and vice versa), dental pain, pruritus, arthralgias, myalgias, ataxia, respiratory paralysis and coma [2] [3]. Cardiovascular symptoms appear in the acute phase and should wear off within five days after ingestion. Bradycardia, hypotension and pulmonary edema have been reported frequently. Generic symptoms of CP are dysuria, chills, sweating, polymyositis, a metallic taste in the mouth and painful ejaculation [4].

Both genders and all age groups can acquire CP. The symptoms are usually milder in children and most severe in seniors. Notably, neurologic symptoms may worsen as a consequence of alcohol consumption, physical exercise, dietary changes or sexual intercourse. Ciguatoxin is present in semen and breast milk. Sexual intercourse and breastfeeding can, therefore, transmit CP [5].

Entire Body System

Nightmare

Two families complained of a sensation of "electrical currents," tremors, muscle cramps, nightmares, hallucinations, agitation, anxiety and nausea of varying severity several hours after consuming rabbitfish ("aras").[ncbi.nlm.nih.gov]
Literally, it can cause nightmares; about 1 in 6 may experience signs of hallucinatory poisoning: lack of coordination, hallucinations, depression and nightmares.[nutritionfacts.org]
[…] tingling, or a burning sensation around mouth, hands, or feet; joint or muscle pains with weakness or cramps; vomiting, diarrhea, chills, itching, headache, sweating, and dizziness; reversal of temperature sensation in the mouth, unusual taste sensations; nightmares[mauinow.com]
[…] tingling, or a burning sensation around mouth, hands, or feet; Joint or muscle pains with weakness or cramps; Vomiting, diarrhea, chills, itching, headache, sweating, and dizziness; Reversal of temperature sensation in the mouth, unusual taste sensations; nightmares[health.hawaii.gov]
., Pfiesteria, “the cell from hell,” and other toxic algal nightmares. Clin Infect Dis. 1999;28:1197-98. Sierra-Beltran AP, et al., An overview of marine food poisoning in Mexico. Toxicon. 1998;36:1493-502.[rarediseases.org]

Sepsis

In addition to a lack of response to mannitol, clinical and laboratory indices of sepsis were present in this patient.[ncbi.nlm.nih.gov]

Constitutional Symptom

Constitutional symptoms may be misdiagnosed as chronic fatigue syndrome. A common source outbreak is easier to recognize and therefore notify to public health organizations.[ncbi.nlm.nih.gov]

Rigor

The patient also had significant functional decline that responded to rigorous inpatient rehabilitation not previously described in literature.[ncbi.nlm.nih.gov]

Respiratoric

Dyspnea

In severe cases, there may be rapid progression to breathing difficulties (dyspnea) and muscular paralysis.[rarediseases.org]

Gastrointestinal

Vomiting

Do not induce vomiting or give syrup of Ipecac. Ipecac was formerly used to induce vomiting in poisoned patients where there was a chance to get the toxin out of the body.[rxlist.com]
Some investigators have suggested vomiting should be induced if the victim is awake and alert and has eaten ciguatera toxin-containing fish within the last 3 to 4 hours.[emedicinehealth.com]

Nausea

Two families complained of a sensation of "electrical currents," tremors, muscle cramps, nightmares, hallucinations, agitation, anxiety and nausea of varying severity several hours after consuming rabbitfish ("aras").[ncbi.nlm.nih.gov]
A 12-year-old Tongan female presented to our Emergency Department with mid-abdominal pain, nausea, change in mental status, and new-onset movement disorder after ingestion of jellyfish imported from American Samoa.[ncbi.nlm.nih.gov]
Symptoms include: nausea , vomiting , diarrhea , muscle pain, numbness, tingling, abdominal pain , dizziness , and vertigo . Hot and cold sensation may be reversed.[rxlist.com]
Symptoms include: nausea, vomiting, diarrhea, muscle pain, numbness, tingling, abdominal pain, dizziness, and vertigo. Hot and cold sensation may be reversed.[medicinenet.com]

Food Poisoning

Abstract Ciguatera is a specific type of food poisoning associated with the ingestion of tropical fish, which, although normally safe for consumption, may at times contain high amounts of ciguatoxin, as well as other chemically related toxins.[ncbi.nlm.nih.gov]
Another similar type of food poisoning is scombroid poisoning which is discussed separately. The symptoms of this are very similar to food poisoning but can last for a long period of time.[medic8.com]
Red Bass Ciguatera food poisoning is an unusual form of food poisoning most typically caused by larger and older fish that live in warm ocean waters. However smaller warm ocean water finfish may also be implicated.[foodsafety.asn.au]
It's the most common form of fish-related food poisoning in the world, and according to a new study published online in the American Journal of Tropical Medicine and Hygiene, it just became even more common in the state of Florida.[fox13news.com]
More Information Food Poisoning from Marine Toxins[wwwnc.cdc.gov]

Abdominal Pain

A 12-year-old Tongan female presented to our Emergency Department with mid-abdominal pain, nausea, change in mental status, and new-onset movement disorder after ingestion of jellyfish imported from American Samoa.[ncbi.nlm.nih.gov]
They can range from abdominal pain, nausea, diarrhea and vomiting to a painful defecation process.[symptoma.com]
The symptoms from ingesting Ciguatera toxin are similar to other types of food poisoning and may consist of nausea, vomiting, diarrhea, muscle pain, numbness, tingling, abdominal pain, dizziness, and vertigo.[intlfieldstudies.org]
The illness is characterized by abdominal pain, nausea, vomiting, and diarrhea.[iamat.org]
Symptoms include: nausea , vomiting , diarrhea , muscle pain, numbness, tingling, abdominal pain , dizziness , and vertigo . Hot and cold sensation may be reversed.[rxlist.com]

Abdominal Cramps

Individuals, who have come in contact with Ciguatera poisoning can “experience many symptoms including tingling and numbness in fingers, toes, around lips, tongue, mouth and throat; nausea, vomiting, diarrhea or abdominal cramps, joint pains, headache[edition.channel5belize.com]
Common CFP symptoms include gastrointestinal problems like abdominal cramps, diarrhea, nausea, and vomiting followed by neurological symptoms.[www2.fgcu.edu]
Most people experience some combination of flushing and rash on the face and upper body, sweating, diarrhea, and abdominal cramps. Sometimes, there is a burning, peppery taste in the mouth. Most people recover quickly without treatment.[poison.org]
The most common gastrointestinal symptoms reported are abdominal cramps, nausea, vomiting and diarrhea with these events occurring early in the disease process [ 7, 9 ].[headache.imedpub.com]

Jaw & Teeth

Metallic Taste

Generic symptoms of CP are dysuria, chills, sweating, polymyositis, a metallic taste in the mouth and painful ejaculation. Both genders and all age groups can acquire CP. The symptoms are usually milder in children and most severe in seniors.[symptoma.com]
Headaches, muscle aches, and numbness are common; other symptoms may include strange sensations, such as the feeling of loose teeth, confusion between hot and cold temperatures, or a metallic taste in the mouth.[www2.fgcu.edu]
CFP symptoms include: Nausea Stomach Cramps Diarrhea General Weakness Dizziness Itching Increased or Decreased Heart Rate Rarely - Paralysis & Coma Headache Muscular Pain Metallic Taste in the Mouth Tooth Pain Numbness Temperature Reversal (hot feels[bareboatsbvi.com]
Some people may have neurologic symptoms, such as a tingling sensation, tooth pain or feeling as if the teeth are loose, itching, a metallic taste in the mouth, and blurred vision.[wwwnc.cdc.gov]

Cardiovascular

Hypotension

We report two patients with persistent bradycardia and hypotension after eating mackerel fish.[heartviews.org]
Bradycardia, hypotension and pulmonary edema have been reported frequently. Generic symptoms of CP are dysuria, chills, sweating, polymyositis, a metallic taste in the mouth and painful ejaculation. Both genders and all age groups can acquire CP.[symptoma.com]
[…] cause morbidity regardless of the form of preparation Clinical Onset 6-12 hrs after ingestion; N&V, cramping, diarrhea, paresthesias, reversal of temperature sense, arthralgias, myalgias, cranial nerve palsies, pruritus with alcohol ingestion, chills, hypotension[medical-dictionary.thefreedictionary.com]
[…] symptoms include: Nausea Stomach Cramps Diarrhea General Weakness Dizziness Itching Increased or Decreased Heart Rate Rarely - Paralysis & Coma Headache Muscular Pain Metallic Taste in the Mouth Tooth Pain Numbness Temperature Reversal (hot feels cold) Hypotension[bareboatsbvi.com]
In patient-2, despite fluid replacement, she continued to have hypotension and bradycardia which improved after Atropine and Dopamine infusion suggest patient had autonomic dysfunction.[neurology.org]

Skin

Pruritus

Physical urticaria is a stress-related disorder exhibiting pruritus as well as skin lesions in addition to CP symptoms. Ciguatoxin has been implicated in a patient's ability to discern between black, gray and white colors.[symptoma.com]
Twenty-four hours after the ingestion of black grouper, lower-extremity paresthesias, left retrobulbar pain, pruritus, diarrhea, and urinary frequency developed in a 57-year-old woman.[ncbi.nlm.nih.gov]
This was followed by neurological symptoms 24-48 hours later, including temperature reversal (paradoxical dysaesthesia), intense pruritus and increased nociception as a result of a small fibre peripheral neuropathy.[ncbi.nlm.nih.gov]
This was followed by neurological symptoms 24–48 hours later, including temperature reversal (paradoxical dysaesthesia), intense pruritus and increased nociception as a result of a small fibre peripheral neuropathy.[pn.bmj.com]
[…] bass and–unlike scombroid poisoning, may cause morbidity regardless of the form of preparation Clinical Onset 6-12 hrs after ingestion; N&V, cramping, diarrhea, paresthesias, reversal of temperature sense, arthralgias, myalgias, cranial nerve palsies, pruritus[medical-dictionary.thefreedictionary.com]

Skin Lesion

Physical urticaria is a stress-related disorder exhibiting pruritus as well as skin lesions in addition to CP symptoms. Ciguatoxin has been implicated in a patient's ability to discern between black, gray and white colors.[symptoma.com]

Face, Head & Neck

Circumoral Paresthesia

There are lingual or circumoral paresthesias, painful paresthesias, reversed temperature sensation (i.e. hot objects feel cold and vice versa), dental pain, pruritus, arthralgias, myalgias, ataxia, respiratory paralysis and coma.[symptoma.com]

Circumoral Paresthesia

There are lingual or circumoral paresthesias, painful paresthesias, reversed temperature sensation (i.e. hot objects feel cold and vice versa), dental pain, pruritus, arthralgias, myalgias, ataxia, respiratory paralysis and coma.[symptoma.com]

Neurologic

Headache

Complications include long term fatigue, persistent headaches and difficulty with balance and co-ordination. Treatment for ciguatera poisoning Ciguatera poisoning cannot be cured.[medic8.com]
Individuals, who have come in contact with Ciguatera poisoning can “experience many symptoms including tingling and numbness in fingers, toes, around lips, tongue, mouth and throat; nausea, vomiting, diarrhea or abdominal cramps, joint pains, headache[edition.channel5belize.com]
Symptoms can include numbness, tingling, or a burning sensation around mouth, hands, or feet; joint or muscle pains with weakness or cramps; vomiting, diarrhea, chills, itching, headache, sweating, and dizziness; reversal of temperature sensation in the[mauinow.com]
Headaches, muscle aches, and numbness are common; other symptoms may include strange sensations, such as the feeling of loose teeth, confusion between hot and cold temperatures, or a metallic taste in the mouth.[www2.fgcu.edu]

Dizziness

They include a very slow heart rate and high blood pressure which can cause dizziness and physical weakness. Sweating, chills and a stiff neck are other symptoms of ciguatera poisoning.[medic8.com]
Symptoms include vomiting, itching, dizziness, and a burning sensation around the mouth, hands and feet. People who have ciguatera may also find that cold things feel hot and hot things feel cold. Ciguatera has no cure.[khon2.com]
The symptoms from ingesting Ciguatera toxin are similar to other types of food poisoning and may consist of nausea, vomiting, diarrhea, muscle pain, numbness, tingling, abdominal pain, dizziness, and vertigo.[intlfieldstudies.org]
Symptoms can include numbness, tingling, or a burning sensation around mouth, hands, or feet; joint or muscle pains with weakness or cramps; vomiting, diarrhea, chills, itching, headache, sweating, and dizziness; reversal of temperature sensation in the[mauinow.com]
Signs and Symptoms Numbness, tingling, or a burning sensation around mouth, hands, or feet; Joint or muscle pains with weakness or cramps; Vomiting, diarrhea, chills, itching, headache, sweating, and dizziness; Reversal of temperature sensation in the[health.hawaii.gov]

Paresthesia

Twenty-four hours after the ingestion of black grouper, lower-extremity paresthesias, left retrobulbar pain, pruritus, diarrhea, and urinary frequency developed in a 57-year-old woman.[ncbi.nlm.nih.gov]
However, symptoms of peripheral neuropathy with paresthesias and paradoxical disturbance of thermal sensation are the hallmark. Electrophysiological studies are often normal, except in severe cases.[ncbi.nlm.nih.gov]
There are lingual or circumoral paresthesias, painful paresthesias, reversed temperature sensation (i.e. hot objects feel cold and vice versa), dental pain, pruritus, arthralgias, myalgias, ataxia, respiratory paralysis and coma.[symptoma.com]
[…] of fish are implicated–eg, barracuda, grouper, red snapper, amberjack, surgeonfish, sea bass and–unlike scombroid poisoning, may cause morbidity regardless of the form of preparation Clinical Onset 6-12 hrs after ingestion; N&V, cramping, diarrhea, paresthesias[medical-dictionary.thefreedictionary.com]
Patient was given trial of Mannitol on day 3 without immediate improvement but gradually her symptoms improved over a month. 2) Her mother, 51 years presented with nausea, vomiting, diarrhea, perioral paresthesia few hours after ingesting amberjack-fish[neurology.org]

Dysesthesia

[…] symptoms Typical presentation GI symptoms initially: diarrhea, nausea, and vomiting These symptoms typically last just a few days followed by weakness and fatigue, with occasional hypotension or bradycardia Features of peripheral neuropathy including dysesthesia[lifeinthefastlane.com]
Neurologically, patients commonly experience paranesthesia of the hands and feet, perioral numbness, headache, pain, weakness, dysesthesia, itching, shakiness, fatigue, hot/cold reversal, and lack of muscle strength [ 3, 5, 8, 10 - 12 ].[headache.imedpub.com]
Notes Clinical illness defined as: gastrointestinal symptoms (vomiting, diarrhea, abdominal discomfort, nausea) within 24 hours, and/or neurological symptoms (temperature dysesthesia [i.e. touch cold/hot objects and feel opposite temperature], paresthesia[bccdc.ca]
Temperature-related dysesthesia has also been reported in neurotoxic shellfish poisoning (NSP) from consumption of shellfish contaminated with brevetoxin. Therefore, NSP should be considered in the differential diagnosis.[calpoison.org]

Peripheral Neuropathy

However, symptoms of peripheral neuropathy with paresthesias and paradoxical disturbance of thermal sensation are the hallmark. Electrophysiological studies are often normal, except in severe cases.[ncbi.nlm.nih.gov]
This was followed by neurological symptoms 24-48 hours later, including temperature reversal (paradoxical dysaesthesia), intense pruritus and increased nociception as a result of a small fibre peripheral neuropathy.[ncbi.nlm.nih.gov]
This was followed by neurological symptoms 24–48 hours later, including temperature reversal (paradoxical dysaesthesia), intense pruritus and increased nociception as a result of a small fibre peripheral neuropathy.[pn.bmj.com]
neuropathy including dysesthesia, dental pain, and paradoxical disturbance of thermal sensation, are the hallmarks and may last up to 6 months or longer Ataxia and seizures have also been described Hot-cold reversal better termed cold allodynia considered[lifeinthefastlane.com]

Workup

Diagnosis is based on the patient's recent history. Ingestion of fish, in particular in warm coastal regions, is a key criterion to look out for. To date, barracuda, greater amberjack, black grouper, blackfin snapper, cubera snapper, dog snapper, horse-eye jack, hogfish, king mackerel, red grouper and yellowfin grouper have been identified as potential carriers of ciguatoxin. Generally speaking, fish from constantly warm regions preferentially inhabiting coral reefs are most likely to accumulate ciguatoxin [6] [7].

A few disorders, some of which are food-related, show similar symptoms to CP and should be taken into consideration for diagnosis. Tetraodon poisoning, Scombroid fish poisoning, and physical urticaria are most likely to be mistaken with CP. Tetraodon poisoning additionally presents with pruritus after ingestion of puffer fish; scombroid fish poisoning is related to bacterial toxin production in insufficiently refrigerated tuna, skipjack, mackerel, bonito, and mahi-mahi. Physical urticaria is a stress-related disorder exhibiting pruritus as well as skin lesions in addition to CP symptoms [8].

Ciguatoxin has been implicated in a patient's ability to discern between black, gray and white colors. Therefore, it is advisable to carry out a visual contrast sensitivity test [9].

Since chemists have successfully synthesized monoclonal antibodies for ciguatoxin, it is possible to set up an enzyme-linked immunosorbent assay (ELISA) for the toxin, if a tissue sample of the ingested fish species is available [10].

Treatment

Because no symptomatic treatment has been totally satisfactory, folk remedies remain of great interest.[ncbi.nlm.nih.gov]
No specific treatment has been developed.[medical-dictionary.thefreedictionary.com]
Supportive therapy is the mainstay of treatment.[ncbi.nlm.nih.gov]
Ciguatera pathophysiology, clinical presentation, differential diagnosis (including consideration of palytoxin poisoning), and treatment are briefly reviewed. We emphasize the growing incidence of ciguatera fish poisoning outside "high-risk" areas.[ncbi.nlm.nih.gov]

Prognosis

A letter to crew members, outlining the cause and prevention of ciguatera fish poisoning as well as prognosis and post-illness advice was also distributed to the crew on April 14, 2015.[canada.ca]

Etiology

They are also required to report unusual illness (not expected to occur in NB or unknown etiology) within 24 hours.[canada.ca]

Epidemiology

In the face of increases in both tourism and in the global trade in tropical and exotic fish, physicians in both endemic and non-endemic areas should be familiar with the epidemiology and clinical features of this important condition.[ncbi.nlm.nih.gov]
Clinical aspects of ciguatera toxicity, its pathophysiology, diagnostic difficulties and epidemiology are discussed.[ncbi.nlm.nih.gov]
She received a Ph.D. in epidemiology from the University of Florida and an M.P.H. in epidemiology from the University of Pittsburgh. References 1. Friedman, MA, et al. 2008. Ciguatera fish poisoning: Treatment, prevention and management.[foodsafetymagazine.com]
The IPHAB urges that the relevant Member State agencies develop the capacity to monitor for Ciguatera-causing organisms, toxins, contaminated seafood and the epidemiology to reduce the risk associated with benthic HABs; The IOC is cooperating with the[hab.ioc-unesco.org]

Sex distribution

Age distribution

Pathophysiology

Ciguatera pathophysiology, clinical presentation, differential diagnosis (including consideration of palytoxin poisoning), and treatment are briefly reviewed. We emphasize the growing incidence of ciguatera fish poisoning outside "high-risk" areas.[ncbi.nlm.nih.gov]
Clinical aspects of ciguatera toxicity, its pathophysiology, diagnostic difficulties and epidemiology are discussed.[ncbi.nlm.nih.gov]
Based upon this research on ‘The pathophysiological mechanism of ciguatera’, Dr. Vetter won the prestigious Dr. Edouard Delcroix Award 2016.[vliz.be]
Diarrhea in ciguatera fish poisoning: Preliminary evaluation of pathophysiological mechanisms. Gastroenterology 1991;100:471-6. [ PUBMED ] 3. Bidard J, Vijverberg H, Frelin C, Chungue E, Legrand AM, Bagnis R, et al.[heartviews.org]

Prevention

Neither can be prevented by cooking or freezing the fish. Fish can also be contaminated with chemicals or heavy metals.[poison.org]
So how can you prevent getting this potentially serious toxin? Prevention can be difficult since the toxin in the fish cannot be killed by cooking and there is no offensive odor or appearance to the fish.[outbreaknewstoday.com]
Food Security GetCheckedOnline Harm Reduction Services Healthy Built Environment Healthy Eating Hepatitis Prevention & Care I Boost Immunity Injury Prevention Kids Boost Immunity Naloxone Programs Outreach Overdose Response Peer Engagement Population[bccdc.ca]
Ciguatera toxin is not destroyed by cooking or freezing and is odorless, so the only prevention is to avoid eating fish from warm-water areas where ciguatera is known to occur.[jamanetwork.com]

References

Article

Radke EG, Reich A, Morris JG. Epidemiology of Ciguatera in Florida. Am J Trop Med Hyg. 2015;93(2):425-432.
Beadle A. Ciguatera fish poisoning. Mil Med. 1997;162(5):319-322.
Cameron J, Capra MF. The basis of the paradoxical disturbance of temperature perception in ciguatera poisoning. J Toxicol Clin Toxicol. 1993;31(4):571-579.
Isbister GK, Kiernan MC. Neurotoxic marine poisoning. Lancet Neurol. 2005;4(4):219-228.
Lange WR, Lipkin KM, Yang GC. Can ciguatera be a sexually transmitted disease?. J Toxicol Clin Toxicol. 1989;27(3):193-197.
Hsieh CH, Hwang KL, Lee MM, Lan CH, Lin WF, Hwang DF. Species identification of ciguatoxin-carrying grouper implicated in food poisoning. J Food Prot. 2009;72(11):2375-2379.
Tester PA, Feldman RL, Nau AW, et al. Ciguatera fish poisoning and sea surface temperatures in the Caribbean Sea and the West Indies. Toxicon. 2010;56(5):698-710.
Clark RF, Williams SR, Nordt SP, Manoguerra AS. A review of selected seafood poisonings. Undersea Hyperb Med. 1999;26(3):175-184.
Shoemaker RC, House D, Ryan JC. Defining the neurotoxin derived illness chronic ciguatera using markers of chronic systemic inflammatory disturbances: a case/control study. Neurotoxicol Teratol. 2010; 32(6):633-639.
Tsumuraya T, Fujii I, Hirama M. Production of monoclonal antibodies for sandwich immunoassay detection of Pacific ciguatoxins. Toxicon. 2010;56(5):797-803.

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Last updated: 2018-06-22 04:08