Ciguatoxin-like toxicity distribution in flesh of amberjack (Seriola spp.) and dusky grouper (Epinephelus marginatus).

Ciguatoxins (CTXs) are marine neurotoxins that cause ciguatera poisoning (CP), mainly through the consumption of fish. The distribution of CTXs in fish is known to be unequal. Studies have shown that viscera accumulate more toxins than muscle, but little has been conducted on toxicity distribution in the flesh, which is the main edible part of fish, and the caudal muscle is also most commonly targeted for the monitoring of CTXs in the Canary Islands. At present, whether this sample is representative of the toxicity of an individual is undisclosed. This study aims to assess the distribution of CTXs in fish, considering different muscle samples, the liver, and gonads. To this end, tissues from four amberjacks (Seriola spp.) and four dusky groupers (Epinephelus marginatus), over 16.5 kg and captured in the Canary Islands, were analyzed by neuroblastoma-2a cell-based assay. Flesh samples were collected from the extraocular region (EM), head (HM), and different areas from the fillet (A-D). In the amberjack, the EM was the most toxic muscle (1.510 CTX1B Eq·g-1), followed by far for the caudal section of the fillet (D) (0.906 CTX1B Eq·g-1). In the dusky grouper flesh samples, D and EM showed the highest toxicity (0.279 and 0.273 CTX1B Eq·g-1). In both species, HM was one of the least toxic samples (0.421 and 0.166 CTX1B Eq·g-1). The liver stood out for its high CTX concentration (3.643 and 2.718 CTX1B Eq·g-1), as were the gonads (1.620 and 0.992 CTX1B Eq·g-1). According to these results, the caudal muscle next to the tail is a reliable part for use in determining the toxicity of fish flesh to guarantee its safe consumption. Additionally, the analysis of the liver and gonads could provide further information on doubtful specimens, and be used for CTX monitoring in areas with an unknown prevalence of ciguatera.

Ciguatoxin in Hawai'i: Fisheries forecasting using geospatial and environmental analyses for the invasive Cephalopholis argus (Epinephelidae).

Invasive species can precede far-reaching environmental and economic consequences. In the Hawai'ian Archipelago Cephalopholis argus (family Serranidae) is an established invasive species, now recognized as the dominant local reef predator, negatively impacting the native ecosystem and local fishery. In this region, no official C. argus fishery exists, due to its association with Ciguatera seafood poisoning (CP); a severe intoxication in humans occurring after eating (primarily) fish contaminated with ciguatoxins (CTXs). Pre-harvest prediction of CP is currently not possible; partly due to the ubiquitous nature of the microalgae producing CTXs and the diverse bioaccumulation pathways of the toxins. This study investigated the perceived risk of CP in two geographically discrete regions (Leeward and Windward) around the main island of Hawai'i, guided by local fishers. C. argus was collected and investigated for CTXs using the U.S. Food and Drug Administration (FDA) CTX testing protocol (in vitro neuroblastoma N2a-assay and LC-MS/MS). Overall, 76% of fish (87/113) exceeded the FDA guidance value for CTX1B (0.01 ng g-1 tissue equivalents); determined by the N2a-assay. Maximum CTX levels were ≅2× higher at the Leeward vs Windward location and, respectively, 95% (64/67) and 54% (25/46) of fish were positive for CTX-like activity. Fisher persons and environmental understandings, regarding the existence of a geographic predictor (Leeward vs Windward) for harvest, were found to be (mostly) accurate as CTXs were detected in both locations and the local designation of C. argus as a risk for CP was confirmed. This study provides additional evidence that supports the previous conclusions that this species is a severe CP risk in the coastal food web of Hawai'i, and that ocean exposure (wave power) may be a prominent factor influencing the CTX content in fish within a hyperendemic region for CP.

An Updated Review of Tetrodotoxin and Its Peculiarities.

Tetrodotoxin (TTX) is a crystalline, weakly basic, colorless organic substance and is one of the most potent marine toxins known. Although TTX was first isolated from pufferfish, it has been found in numerous other marine organisms and a few terrestrial species. Moreover, tetrodotoxication is still an important health problem today, as TTX has no known antidote. TTX poisonings were most commonly reported from Japan, Thailand, and China, but today the risk of TTX poisoning is spreading around the world. Recent studies have shown that TTX-containing fish are being found in other regions of the Pacific and in the Indian Ocean, as well as the Mediterranean Sea. This review aims to summarize pertinent information available to date on the structure, origin, distribution, mechanism of action of TTX and analytical methods used for the detection of TTX, as well as on TTX-containing organisms, symptoms of TTX poisoning, and incidence worldwide.

[Analysis of Ciguatoxins in the Spotted Knifejaw, Oplegnathus punctatus from the Waters of Japan].

Ciguatera fish poisoning (CFP) is recognized as the most frequent seafood poisoning due to the consumption of fish containing the principal toxins, ciguatoxins (CTXs). In Japan, CFP events have been reported annually from Okinawa and Amami Islands, locating subtropical regions. In addition, there have been reported several outbreaks due to consumption of the fish caught from the Pacific coast of the Mainland and they were often caused by the matured spotted knifejaw, Oplegnathus punctatus. As part of our research on CFP in Japan, we investigated CTXs analysis by LC-MS/MS on 176 individuals of O. punctatus (weight: 100-6,350 g, standard length: 13-60 cm) from the coast of the Mainland (Honshu, Shikoku, and Kyushu), Amami, Okinawa, and Ogasawara (Bonin) Islands. CTXs were detected from only two specimens collected from Okinawa. Total CTXs levels of the two specimens were at 0.014 and 0.040 µg/kg, respectively, exceeding FDA guidance level at 0.01 µg CTX1B equivalent/kg. However, they might be little risk of CFP because consuming over 1.5 kg of flesh is needed to develop intoxication. The toxins consisted of CTX1B analogs including CTX1B, 52-epi-54-deoxyCTX1B, CTX4A, and CTX4B, and no CTX3C analogs, supporting the finding that ciguatoxic fishes in Okinawan Waters containing only CTX1B analogs.

[Analysis of Ciguatoxins in Variola louti Captured off the Ogasawara (Bonin) Islands].

Ciguatera poisoning (CP) is one of the most abundant seafood poisonings in the world. CP frequently occurred in the tropical and subtropical Indo-Pacific Ocean and the Caribbean Sea. In Japan, CP cases have been reported annually, from the subtropical regions, including Okinawa Prefecture and Amami Islands, Kagoshima Prefecture. The principal toxins, named ciguatoxins (CTXs), are bio-synthesized by benthic dinoflagellate of genera Gambierdiscus and Fukuyoa. They are bio-transferred herbivorous animals to carnivorous fishes via the food chain.The Ogasawara Islands comprise more than 30 islands, Mukojima Islands, Chichijima (Bonin) Islands, Hahajima Islands, Iwo Islands, Nishinoshima, Minamitorishima, and Okinotorishima, which locate in the tropical to subtropical regions. The Mukojima Islands, Chichijima Islands, and Hahajima Islands locate approximately the same latitude as Okinawa. The distance from Tokyo is approximately 1,000 km for Chichijima, 1,700 km for Okinotorishima (the southernmost tip of Japan), and 1,900 km for Minamitorishima (the easternmost tip of Japan). These islands exist in a wide range of waters, latitudes from 20°25' to 27°44' North and longitudes from 136°04' to 153° 59' East. We collected 65 specimens of a grouper, Variola louti, the most frequent species implicated in CP in Japan, from the waters around the Chichijima, Mukojima, and Hahajima islands. The fish flesh specimens were analyzed CTXs using the liquid chromatography-tandem mass spectrometer (LC-MS/MS). While the peak whose retention time is almost identical to that of CTX1B was detected in all specimens on our routine protocol, no 52-epi-54-deoxyCTX1B nor 54-deoxyCTX1B was detected. The peak retention time was quite different from that of CTX1B when re-analyzing by changing the analytical column. Thus, the CTXs in the specimens in the waters of these islands seemed to be undetectable levels.

[Detection of Ciguatoxins from Fish Introduced into a Wholesale Market in Japan].

Ciguatera fish poisoning (CFP), one of the most frequently occurring seafood poisonings due to marine finfish consumption, mainly affects the tropical and subtropical Indo-Pacific region and the Caribbean Sea. The principal class of toxins, ciguatoxins (CTXs) from the Pacific, includes more than 20 derivatives and are classified into two groups, CTX1B and CTX3C congeners, based on their skeletal structures. As part of risk management of CFP by the Japanese government, the import of certain species of fish into Japan is prohibited. Additionally, local governments recommend rejecting certain fish species caught in Japan. In this study, we used LC-MS/MS to analyze CTXs from 18 fish specimens belonging to 7 species that had been brought to a wholesale market but were disapproved for sale because of their potential danger of CFP. CTXs were detected in four specimens of Lutjanus bohar and one specimen of Variola louti. It was estimated that the two most poisonous specimens (no. 5: 0.348 µg/kg, no. 8: 0.362 µg/kg) had a toxicity of 0.05 MU/g. Consumption of 200 g of flesh from these fish could cause CFP. Thus, the guidance of the local government to disallow the sale of these fish species in the market contributed to the prevention of CFP.Only CTX1B congeners were detected in L. bohar (specimen no. 5), which had no record of the area where it captured from. It is presumed that the origin of specimen no. 5 was the same as that of the Okinawan L. bohar because the CTX compositions were similar. In two specimens (nos. 6 and 8) from Wakayama, both CTX1B and CTX3C congeners were detected. This is the first report to reveal the CTX profile in fish collected off the Honshu island in Japan.

Epidemiology and Toxicology of Ciguatera Poisoning in the Colombian Caribbean.

Ciguatera is a food intoxication caused by the consumption of primarily coral fish; these species exist in large numbers in the seas that surround the Colombian territory. The underreported diagnosis of this clinical entity has been widely highlighted due to multiple factors, such as, among others, ignorance by the primary care practitioner consulted for this condition as well as clinical similarity to secondary gastroenteric symptoms and common food poisonings of bacterial, parasitic or viral etiology. Eventually, it was found that people affected by ciguatoxins had trips to coastal areas hours before the onset of symptoms. Thanks to multiple studies over the years, it has been possible to identify the relation between toxigenic dinoflagellates and seagrasses, as well as its incorporation into the food chain, starting by fish primarily inhabiting reef ecosystems and culminating in the intake of these by humans. Identifying the epidemiological link, its cardinal symptoms and affected systems, such as gastrointestinal, the peripheral nervous system and, fortunately with a low frequency, the cardiovascular system, leads to a purely clinical diagnostic impression without necessitating further complementary studies; in addition, what would also help fight ciguatera poisoning is performing an adequate treatment of the symptoms right from the start, without underestimating or overlooking any associated complications.

Ciguatera fish poisoning: First reported case in Sabah, Malaysia.

Ciguatera fish poisoning (CFP) is the most common natural marine toxin poisoning worldwide and yet under recognised in Malaysia. We report the first confirmed case of CFP in Sabah with severe neurological, cardiovascular and gastrointestinal manifestations after consumption of emperor snapper. Early recognition of CFP is important because it will result in improved patient care and public health intervention.

Ciguatera in Mexico (1984⁻2013).

Historical records of ciguatera in Mexico date back to 1862. This review, including references and epidemiological reports, documents 464 cases during 25 events from 1984 to 2013: 240 (51.72%) in Baja California Sur, 163 (35.12%) in Quintana Roo, 45 (9.69%) in Yucatan, and 16 (3.44%) cases of Mexican tourists intoxicated in Cuba. Carnivorous fish, such as snapper (Lutjanus) and grouper (Epinephelus and Mycteroperca) in the Pacific Ocean, and great barracuda (Sphyraena barracuda) and snapper (Lutjanus) in the Atlantic (Gulf of Mexico and Caribbean Sea), were involved in all cases. In the Mexican Caribbean, a sub-record of ciguatera cases that occurred before 1984 exists. However, the number of intoxications has increased in recent years, and this food poisoning is poorly studied in the region. Current records suggest that ciguatera fish poisoning in humans is the second most prevalent form of seafood poisoning in Mexico, only exceeded by paralytic shellfish poisoning (505 cases, 21 fatalities in the same 34-year period). In this study, the status of ciguatera in Mexico (epidemiological and treatment), and the fish vectors are reviewed. Dinoflagellate species Gambierdiscus, Ostreopsis, and Prorocentrum are related with the reported outbreaks, marine toxins, ecological risk, and the potential toxicological impact.

Toxicological Investigations on the Sea Urchin Tripneustes gratilla (Toxopneustidae, Echinoid) from Anaho Bay (Nuku Hiva, French Polynesia): Evidence for the Presence of Pacific Ciguatoxins.

The sea urchin Tripneustes gratilla (Toxopneustidae, Echinoids) is a source of protein for many islanders in the Indo-West Pacific. It was previously reported to occasionally cause ciguatera-like poisoning; however, the exact nature of the causative agent was not confirmed. In April and July 2015, ciguatera poisonings were reported following the consumption of T.gratilla in Anaho Bay (Nuku Hiva Island, Marquesas archipelago, French Polynesia). Patient symptomatology was recorded and sea urchin samples were collected from Anaho Bay in July 2015 and November 2016. Toxicity analysis using the neuroblastoma cell-based assay (CBA-N2a) detected the presence of ciguatoxins (CTXs) in T.gratilla samples. Gambierdiscus species were predominant in the benthic assemblages of Anaho Bay, and G.polynesiensis was highly prevalent in in vitro cultures according to qPCR results. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) analyses revealed that P-CTX-3B was the major ciguatoxin congener in toxic sea urchin samples, followed by 51-OH-P-CTX-3C, P-CTX-3C, P-CTX-4A, and P-CTX-4B. Between July 2015 and November 2016, the toxin content in T.gratilla decreased, but was consistently above the safety limit allowed for human consumption. This study provides evidence of CTX bioaccumulation in T.gratilla as a cause of ciguatera-like poisoning associated with a documented symptomatology.

An Updated Review of Ciguatera Fish Poisoning: Clinical, Epidemiological, Environmental, and Public Health Management.

Ciguatera Fish Poisoning (CFP) is the most frequently reported seafood-toxin illness in the world. It causes substantial human health, social, and economic impacts. The illness produces a complex array of gastrointestinal, neurological and neuropsychological, and cardiovascular symptoms, which may last days, weeks, or months. This paper is a general review of CFP including the human health effects of exposure to ciguatoxins (CTXs), diagnosis, human pathophysiology of CFP, treatment, detection of CTXs in fish, epidemiology of the illness, global dimensions, prevention, future directions, and recommendations for clinicians and patients. It updates and expands upon the previous review of CFP published by Friedman et al. (2008) and addresses new insights and relevant emerging global themes such as climate and environmental change, international market issues, and socioeconomic impacts of CFP. It also provides a proposed universal case definition for CFP designed to account for the variability in symptom presentation across different geographic regions. Information that is important but unchanged since the previous review has been reiterated. This article is intended for a broad audience, including resource and fishery managers, commercial and recreational fishers, public health officials, medical professionals, and other interested parties.

Ciguatoxins and Maitotoxins in Extracts of Sixteen Gambierdiscus Isolates and One Fukuyoa Isolate from the South Pacific and Their Toxicity to Mice by Intraperitoneal and Oral Administration.

Ciguatoxins (CTXs), and possibly maitotoxins (MTXs), are responsible for Ciguatera Fish Poisoning, an important health problem for consumers of reef fish (such as inhabitants of islands in the South Pacific Ocean). The habitational range of the Gambierdiscus species is expanding, and new species are being discovered. In order to provide information on the potential health risk of the Gambierdiscus species, and one Fukuyoa species (found in the Cook Islands, the Kermadec Islands, mainland New Zealand, and New South Wales, Australia), 17 microalgae isolates were collected from these areas. Unialgal cultures were grown and extracts of the culture isolates were analysed for CTXs and MTXs by liquid chromatography tandem mass spectrometry (LC-MS/MS), and their toxicity to mice was determined by intraperitoneal and oral administration. An isolate of G. carpenteri contained neither CTXs nor MTXs, while 15 other isolates (including G. australes, G. cheloniae, G. pacificus, G.honu, and F. paulensis) contained only MTX-1 and/or MTX-3. An isolate of G. polynesiensis contained both CTXs and MTX-3. All the extracts were toxic to mice by intraperitoneal injection, but those containing only MTX-1 and/or -3 were much less toxic by oral administration. The extract of G. polynesiensis was highly toxic by both routes of administration.

Clinical diagnosis and chemical confirmation of ciguatera fish poisoning in New South Wales, Australia.

Ciguatera fish poisoning is common in tropical and sub-tropical areas and larger fish (> 10 kg) are more susceptible to toxin accumulation with age. Although the coastal climate of northern New South Wales is considered sub-tropical, prior to 2014 there has only been 1 documented outbreak of ciguatera fish poisoning from fish caught in the region. During February and March 2014, 2 outbreaks of ciguatera fish poisoning involved 4 and 9 individuals, respectively, both following consumption of Spanish mackerel from northern New South Wales coastal waters (Evans Head and Scotts Head). Affected individuals suffered a combination of gastrointestinal and neurological symptoms requiring hospital treatment. At least 1 individual was symptomatic up to 7 months later. Liquid chromatography-tandem mass spectrometry detected the compound Pacific ciguatoxin-1B at levels up to 1.0 µg kg(-1) in fish tissue from both outbreaks. During April 2015, another outbreak of ciguatera fish poisoning was reported in 4 individuals. The fish implicated in the outbreak was caught further south than the 2014 outbreaks (South West Rocks). Fish tissue was unavailable for analysis; however, symptoms were consistent with ciguatera fish poisoning. To our knowledge, these cases are the southernmost confirmed sources of ciguatera fish poisoning in Australia. Educational outreach to the fishing community, in particular recreational fishers was undertaken after the Evans Head outbreak. This highlighted the outbreak, species of fish involved and the range of symptoms associated with ciguatera fish poisoning. Further assessment of the potential for ciguatoxins to occur in previously unaffected locations need to be considered in terms of food safety.

[First ciguatera outbreak in Germany in 2012]. / Erster Ciguatera-Ausbruch in Deutschland 2012.

In November 2012, 23 cases of ciguatera with typical combinations of gastrointestinal and neurological symptoms occurred in Germany after consumption of imported tropical fish (Lutjanus spp.). A questionnaire was used to gather information on the disease course and fish consumption. All patients suffered from pathognomonic cold allodynia. Aside from two severe courses of illness, all other cases showed symptoms of moderate intensity. During a three-year follow-up, seven patients reported prolonged paresthesia for more than one year. Two of them reported further neuropathies over almost three years. This is the first time that long-term persistence of symptoms has been documented in detail. Outbreak cases were allocated to eight clusters in seven German cities. A further cluster was prevented by the successful recall of ciguatoxic fish. Three clusters were confirmed by the detection of ciguatoxin in samples of suspicious and recalled fish. An extrapolation on the basis of ciguatoxic samples revealed twenty prevented cases of ciguatera. Further officially unknown cases should be assumed. During the outbreak investigations, inadvertently falsely labelled fish species and fishing capture areas on import and retail level documents were observed. The ascertainment of cases and the outbreak investigations proved to be difficult due to inconsistent case reports to poisons centers, local health and veterinary authorities. In Germany, many physicians are unaware of the disease pattern of ciguatera and the risks caused by tropical fish. The occurrence of further outbreaks during the following years emphasizes the increasing significance of ciguatera in Germany.

Use of Surveillance Systems in Detection of a Ciguatera Fish Poisoning Outbreak - Orange County, Florida, 2014.

What is already known on this topic? Ciguatera fish poisoning (CFP), caused by the ingestion of predatory reef-dwelling fish harboring ciguatoxins is one of the most commonly reported fish-associated marine intoxications. Ciguatoxin retains toxicity regardless of freezing or cooking. Prompt treatment can reduce debilitating neurologic symptoms that are associated with CFP.What is added by this report? Syndromic surveillance systems in Florida identified six adults with CFP following consumption of black grouper. Five patients sought medical attention; health care providers did not make a diagnosis of CFP or report the cases to public health authorities, and none of the patients received treatment. Close collaboration among several investigating agencies allowed traceback efforts to link black grouper consumed by all patients to a common international distributor.What are the implications for public health practice? Syndromic surveillance systems capable of detecting CFP are essential public health tools to identify outbreaks and enhance investigations. Medical and public health practitioners should be educated to inquire about recent fish consumption when evaluating patients with clinically compatible signs and symptoms to allow for prompt treatment, and report suspected CFP cases to public health authorities to facilitate source-food traceback efforts. Public education on avoidance of consumption of relatively large predatory reef fish species known to be from ciguatoxic-endemic areas might reduce the risk for CFP.

Contribution to the risk characterization of ciguatoxins: LOAEL estimated from eight ciguatera fish poisoning events in Guadeloupe (French West Indies).

From 2010 to 2012, 35 ciguatera fish poisoning (CFP) events involving 87 individuals who consumed locally-caught fish were reported in Guadeloupe (French West Indies). For 12 of these events, the presence of ciguatoxins (CTXs) was indicated in meal remnants and in uncooked fish by the mouse bioassay (MBA). Caribbean ciguatoxins (C-CTXs) were confirmed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis. Using a cell-based assay (CBA), and the only available standard Pacific ciguatoxin-1 (P-CTX-1), the lowest toxins level detected in fish samples causing CFP was 0.022 µg P-CTX-1 equivalent (eq.)·kg(-1) fish. Epidemiological and consumption data were compiled for most of the individuals afflicted, and complete data for establishing the lowest observable adverse effects level (LOAEL) were obtained from 8 CFP events involving 21 individuals. Based on toxin intakes, the LOAEL was estimated at 4.2 ng P-CTX-1 eq./individual corresponding to 48. 4 pg P-CTX-1 eq.kg(-1) body weight (bw). Although based on limited data, these results are consistent with the conclusions of the European Food Safety Authority (EFSA) opinion which indicates that a level of 0.01 µg P-CTX-1 eq.kg(-1) fish, regardless of source, should not exert effects in sensitive individuals when consuming a single meal. The calculated LOAEL is also consistent with the U.S. Food and Drug Administration guidance levels for CTXs (0.1 µg C-CTX-1 eq.kg(-1) and 0.01 µg P-CTX-1 eq.kg(-1) fish).

Emergence and epidemiology of ciguatera in the coastal cities of southern China.

In the present review of 23 published case studies, the main objective is to report the emergence and epidemiology of ciguatera in the coastal cities of southern China. There was a sudden surge in ciguatera outbreaks in 2004. Ciguatera mostly occurred in the Guangdong Province. In Shenzhen, the incidence of ciguatera in 2004 was estimated to be over 7.5 per million people. In Foshan and Zhongshan, three large outbreaks each affecting over 100-200 subjects (caused by tiger grouper served at banquets) accounted for the much higher incidence of ciguatera in 2004 (>48.7 and >129.9 per million people). Humphead wrasse and areolated coral grouper were the other important ciguatoxic fish. In some subjects, risk factors for increased likelihood of (severe) ciguatera were present, namely concomitant alcohol consumption and ingestion of large reef fishes and CTX-rich fish parts. To prevent large outbreaks and severe illness, large apex predators from coral reefs should never be served at banquets and the public should realize the increased risk of severe symptoms due to ingestion of CTX-rich fish parts with alcohol. The systematic collection of accurate details, implementation of risk assessment process and continuing education for the public on prevention are of obvious importance.

Ciguatera fish poisoning in East Asia and southeast Asia.

In the coastal countries of East Asia and Southeast Asia, ciguatera should be common because of the extensive tropical and subtropical coral reefs along the coasts and in the neighboring seas with ciguatoxic fishes. An extensive search of journal databases, the Internet and the government websites was performed to identify all reports of ciguatera from the regions. Based on the official data and large published case series, the incidence of ciguatera was higher in the coastal cities (Hong Kong, Foshan, Zhongshan) of southern China than in Japan (Okinawa Prefecture). In Singapore, ciguatera appeared to be almost unknown. In other countries, only isolated cases or small case series were reported, but under-reporting was assumed to be common. Ciguatera may cause severe acute illness and prolonged neurological symptoms. Ciguatera represents an important public health issue for endemic regions, with significant socio-economic impact. Coordinated strategies to improve risk assessment, risk management and risk communication are required. The systematic collection of accurate data on the incidence and epidemiology of ciguatera should enable better assessment and management of its risk. Much more work needs to be done to define the size threshold for important coral reef fish species from different regions, above which the risk of ciguatera significantly increases.

Clinicoepidemiological Profile of Ciguatera Cardiotoxicity: A Systematic Review.

Patients with ciguatera poisoning commonly present with gastrointestinal and neurologic symptoms, but its cardiotoxicity has been largely unrecognized. This systematic review is the first to summarize the evidence regarding clinical characteristics of cardiotoxicity from ciguatera poisoning to provide the illness script and pertinent knowledge for clinicians. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement, we searched MEDLINE and EMBASE for all peer-reviewed articles using keywords including "ciguatera" and "cardiotoxicity" from their inception to January 2024. We included 20 articles, including 148 cases, in this systematic review. Among the included cases, the median age was 54 years with male predominance (62.2%). Based on the WHO designation, 68.5% were reported from the Western Pacific Region. Common symptoms included hypotension (75.0%) and bradycardia (67.6%), and chest pain or syncope were less commonly reported (2.7% and 1.4%, respectively). Sinus bradycardia was the most common electrocardiogram abnormality (35.9%), followed by atrioventricular blocks (15.4%). Symptomatic treatments such as atropine, dopamine, and epinephrine were commonly used, and only 4.1% required intensive care unit admission. None expired due to cardiotoxicity from ciguatera. This review summarizes the current evidence and the characteristics of cardiotoxicity from ciguatera. Although ciguatera cardiotoxicity is currently underrecognized, increased awareness of the condition in clinicians is crucial because the clinical outcomes of the patients could be benign as long as it is identified and intervened early.