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].

• Chills

  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]

  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]

  Other less common symptoms include chills, itching, sweating, headache, and taste disturbances. Gastrointestinal symptoms last for about 1 or 2 days. Other symptoms may last for up to 1 week. [sailorgirl.com]

  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 with alcohol ingestion, chills [medical-dictionary.thefreedictionary.com]

• Swelling

  The ciguatoxins are a family of heat stable, lipid soluble cyclic polyether compounds that bind to and open voltage-sensitive Na(+) channels at resting membrane potential, resulting in neural hyperexcitability, as well as swelling of the nodes of Ranvier [ncbi.nlm.nih.gov]

  The ciguatoxins are a family of heat stable, lipid soluble cyclic polyether compounds that bind to and open voltage-sensitive Na + channels at resting membrane potential, resulting in neural hyperexcitability, as well as swelling of the nodes of Ranvier [pn.bmj.com]

  More serious symptoms of breathing trouble, swelling of the tongue and mouth, and blurred vision, require treatment in an emergency room with antihistamines, such as diphenhydramine (Benadryl®) and perhaps other drugs. [poison.org]

  Although the pathology of this poison is still not well understood, current thinking is that the toxin damages the protective sheath covering the nerves, causing the sheath to swell and compress the delicate tissue it’s supposed to protect. [nytimes.com]

• Burning Pain

  RESULTS: 1) 19 years female presented with nausea, vomiting, diarrhea, myalgia and burning pain all over her body few hours after ingesting Amberjack fish. Later she progressed to have numbness on the left side of her body and severe headache. [neurology.org]

  "Ciguatoxins activate specific cold pain pathways to elicit burning pain from cooling". The EMBO Journal. 31 (19): 3795–808. doi : 10.1038/emboj.2012.207. PMC 3463840. PMID 22850668. ^ Patel R, Brice NL, Lewis RJ, Dickenson AH (December 2015). [en.wikipedia.org]

  For example, ciguatera sufferers have reported that a refreshing dive in the ocean actually caused burning pain, or that drinking cool beer felt like too hot coffee. [nutritionfacts.org]

  […] sensation is altered such that cold is experienced as a burning pain The mechanism for this is obscure DIFFERENTIAL DIAGNOSIS Sometimes mistaken for multiple sclerosis chronic fatigue syndrome chronic dermatitis INVESTIGATION primarily a clinical diagnosis [lifeinthefastlane.com]

• Camping

  Camp. Biochem. Physiol. 1993.106(3):615-628. Lewis RJ. The changing face of ciguatera. Toxicon. 2001; 39: 97-106. Dickey R, Plakas S. Ciguatera: A public health perspective. Toxicon.2001;56:123-136. Instituto Nacional de la Salud de Colombia. [revistas.unicartagena.edu.co]

• Dyspnea

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

• Vomiting

  She reported she had eaten eel at 7:00pm with friends the previous evening and had started vomiting soon after. Case 2 One hour later, a 67 year-old man self-presented with vomiting and diarrhoea. [nzma.org.nz]

  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]

  Gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and cramping are common. Neurologic symptoms might include paresthesias, ataxia, and headache. [first10em.com]

  We “support” the patient while he/she has nausea, vomiting, tingling, numbness, bradycardia, hypotension, muscle cramps, and tooth pain — and thinks that cold things are hot and hot things cold. No anti-toxin, no antibiotic, sorry. [blogs.jwatch.org]

• Nausea

  Gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and cramping are common. Neurologic symptoms might include paresthesias, ataxia, and headache. [first10em.com]

  We “support” the patient while he/she has nausea, vomiting, tingling, numbness, bradycardia, hypotension, muscle cramps, and tooth pain — and thinks that cold things are hot and hot things cold. No anti-toxin, no antibiotic, sorry. [blogs.jwatch.org]

  They can range from abdominal pain, nausea, diarrhea and vomiting to a painful defecation process. [symptoma.com]

• Food Poisoning

  Ciguatera is a type of food poisoning. The ciguatera toxin may be found in large reef fish, most commonly barracuda, grouper, red snapper, eel, amberjack, sea bass, and Spanish mackerel. [tripadvisor.com]

  This food poisoning results from eating fish or giant clams contaminated by marine toxins, the ciguatoxins, produced by a microscopic alga ( Gamberdiscus spp). [en.ird.fr]

  This is the third outbreak of ciguatera food poisoning in the Canary Islands in 2012. We describe the epidemiology of this outbreak. [eurosurveillance.org]

  This was probably food poisoning, a doctor told the exhausted patient. Most food poisoning is caused by ingested bacteria — E. coli, salmonella or staphylococcus aureus. [nytimes.com]

  Ciguatera field reference guide by Dominique Laurent, Being Yeeting and Jean-Paul Gaudechoux Ciguatera is a form of food poisoning caused by eating fish containing toxins called ciguatoxins which come from micro-algae living on coral reefs. [spc.int]

• Abdominal Pain

  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 onset of symptoms vary with the amount of toxin eaten from half an hour to up to two days and include: •nausea •vomiting •diarrhea •muscle pain •numbness •tingling •abdominal pain •dizziness •vertigo •Hot and cold sensations How is ciguatera treated [thebermudian.com]

  Initial gastrointestinal symptoms include nausea, vomiting, diarrhea and abdominal pain. These symptoms may last several days. [travel.gc.ca]

  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]

• 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]

• Hypotension

  Less often, patients develop cardiovascular complications such as heart blocks and hypotension. What is the timing of the disease? There is usually a delay of about 6-24 hours between ingestion of the contaminated fish and symptom onset. [first10em.com]

  We “support” the patient while he/she has nausea, vomiting, tingling, numbness, bradycardia, hypotension, muscle cramps, and tooth pain — and thinks that cold things are hot and hot things cold. No anti-toxin, no antibiotic, sorry. [blogs.jwatch.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]

  He was found to be profoundly bradycardic (HR 30 bpm) and hypotensive (BP 72/35 mm Hg). His vital signs improved with atropine. [nzma.org.nz]

• 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]

  Gut symptoms of nausea, vomiting, pain in tummy, cramps, abnormal metallic taste, aching of the teeth and a watery diarrhoea may occur. Tightness in the jaw and face muscles have been described. [fishingcairns.com.au]

  This is followed by neurological complications appearing 3 to 72 hours later, including a tingling sensation, temperature reversal (cold items feel hot and hot items feel cold), itching, metallic taste in the mouth, feeling like teeth are loosening, blurred [iamat.org]

  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]

• Arthralgia

  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]

  […] 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, reversal of temperature sense, arthralgias [medical-dictionary.thefreedictionary.com]

  […] abdominal discomfort, nausea) within 24 hours, and/or neurological symptoms (temperature dysesthesia [i.e. touch cold/hot objects and feel opposite temperature], paresthesia [numbness] in extremities, generalized pruritis, blurry vison, headache, myalgia, arthralgia [bccdc.ca]

  Neurologic symptoms may include the following: Lingual and circumoral paresthesias Painful paresthesias of the extremities Paradoxical temperature reversal (eg, cold objects feel hot and hot objects feel cold) Dental pain (teeth feel loose) Pruritus Arthralgias [emedicine.medscape.com]

• 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]

• 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 symptoms may include the following: Lingual and circumoral paresthesias Painful paresthesias of the extremities Paradoxical temperature reversal (eg, cold objects feel hot and hot objects feel cold) Dental pain (teeth feel loose) Pruritus Arthralgias [emedicine.medscape.com]

• Headache

  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]

  Neurologic symptoms might include paresthesias, ataxia, and headache. Patients might also report myalgias, arthralgias, fatigue, dizziness, or generalized pruritus. [first10em.com]

  Other less common symptoms include chills, itching, sweating, headache, and taste disturbances. Gastrointestinal symptoms last for about 1 or 2 days. Other symptoms may last for up to 1 week. [sailorgirl.com]

  Ciguatera poisoning, the food-borne disease that can come from eating large, carnivorous reef fish, causes vomiting, headaches, and a burning sensation upon contact with cold surfaces. [sciencedaily.com]

  Neurological symptoms develop after the initial symptoms, and include: tingling and numbness around the mouth, lips, throat, arms and legs sore muscles and tooth pain temperature reversal (hot things feel cold and cold things feel hot) feeling tired, headaches [travel.gc.ca]

• Dizziness

  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]

  Non-specific dizziness may be psychiatric in origin. [en.wikipedia.org]

  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 onset of symptoms vary with the amount of toxin eaten from half an hour to up to two days and include: •nausea •vomiting •diarrhea •muscle pain •numbness •tingling •abdominal pain •dizziness •vertigo •Hot and cold sensations How is ciguatera treated [thebermudian.com]

• 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 symptoms might include paresthesias, ataxia, and headache. Patients might also report myalgias, arthralgias, fatigue, dizziness, or generalized pruritus. [first10em.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]

  […] 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]

• Burning Sensation

  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]

  Ciguatera poisoning, the food-borne disease that can come from eating large, carnivorous reef fish, causes vomiting, headaches, and a burning sensation upon contact with cold surfaces. [sciencedaily.com]

  Within 24 hours symptoms emerge including numbness around the fingers, toes and mouth, a burning sensation when in contact with cold, joint pain, nausea, itchiness and for people with high sensitivity, breathing difficulties. [foodsafety.asn.au]

  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]

• Dysesthesia

  Sequelae include chronic dysesthesia, which may be relieved by amitriptyline. [pmj.bmj.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]

  […] like a standard case of gastroenteritis — nausea and vomiting — but since ciguatera is a neurotoxin, here’s some of the weird stuff that follows : tingling, numbness, bradycardia, hypotension, muscle cramps, tooth pain, and most famously, “paradoxical dysesthesias [blogs.jwatch.org]

  […] 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]

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 The treatment is mainly supportive. It is recommended to avoid eating fish, fish sauces, shellfish, alcohol, and nuts for several months after the incident. Immunity You do not develop immunity to Ciguatera. [health.hawaii.gov]

What is the treatment? There is no specific treatment. Management is watchful waiting. [first10em.com]

This compound, well known for its antiviral, antibacterial, antioxidant and anti-inflammatory properties but had not hitherto been described for its beneficial effects in the treatment of food poisoning like ciguatera. [en.ird.fr]

Ciguatera fish poisoning: treatment, prevention and management. Mar Drugs. 2008; 6 (3):456–479. [ PMC free article ] [ PubMed ] [ Google Scholar ] [ncbi.nlm.nih.gov]

No specific treatment has been developed. [medical-dictionary.thefreedictionary.com]

Prognosis The prognosis is excellent. [emedicine.medscape.com]

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. [phac-aspc.gc.ca]

Ciguatera can be mistaken for organophosphate toxicity, botulism, multiple sclerosis, Guillain-Barre syndrome, and a wide range of other food poisonings. [2][4] Prognosis The toxicity of ciguatera is generally self-limiting, with symptoms only lasting [ncbi.nlm.nih.gov]

This activity reviews the etiology, presentation, evaluation, and management/prevention of Ciguatera toxicity, and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition. [ncbi.nlm.nih.gov]

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

Etiology Ingestion of sufficient quantities of fish that contain accumulated ciguatoxin produces this syndrome. Fish larger than 2 kg can contain significant amounts of toxin and readily produce toxic effects when ingested. [emedicine.medscape.com]

The workshop will cover ecological, epidemiological and toxicological aspects of ciguatera fish poisoning to inform the later prioritisation of Australian research objectives. [eventbrite.com.au]

Prompt reporting of CFP makes it easier for the Epidemiology and Surveillance Unit to track down the source and can help prevent further cases. Printer-friendly version Back to Newsroom [gov.bm]

European scientists have combined their expertise in the EuroCigua project on the "determination of the incidence and epidemiological characteristics of ciquatera cases in Europe." [sciencedaily.com]

We describe the epidemiology of this outbreak. [eurosurveillance.org]

Epidemiological data and reports View communicable diseases data for notifiable conditions in Queensland. Find OzFoodNet annual and quarterly reports. [disease-control.health.qld.gov.au]

Clinical aspects of ciguatera toxicity, its pathophysiology, diagnostic difficulties and epidemiology are discussed. [journals.lww.com]

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]

Based upon this research on ‘The pathophysiological mechanism of ciguatera’, Dr. Vetter won the prestigious Dr. Edouard Delcroix Award 2016. [vliz.be]

“Ciguatera Fish Poisoning: Treatment, Prevention and Management.” Marine Drugs 6.3 (2008): 456–479. PMC. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579736/ ↑ 3.0 3.1 "Ciguatera." Centers for Disease Control and Prevention. [coraldigest.org]

Prevention Do not eat the head, guts, liver or roe (eggs) of any reef fish. Cooking, drying, salting, or freezing does not kill the poison causing Ciguatera fish poisoning. [health.hawaii.gov]

Neither can be prevented by cooking or freezing the fish. Fish can also be contaminated with chemicals or heavy metals. [poison.org]

Ciguatera fish poisoning: treatment, prevention and management. Mar Drugs. 2008; 6 (3):456–479. [ PMC free article ] [ PubMed ] [ Google Scholar ] [ncbi.nlm.nih.gov]

Can it be prevented? The toxin cannot be destroyed by any food preparation techniques. Symptoms are proportional to the amount of toxin ingested. [first10em.com]

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10. Tsumuraya T, Fujii I, Hirama M. Production of monoclonal antibodies for sandwich immunoassay detection of Pacific ciguatoxins. Toxicon. 2010;56(5):797-803.