Chronic Ciguatera Poisoning: A Case Report.

Ciguatera is a common marine, toxin-borne illness caused by the consumption of fish that contain toxins that activate voltage-sensitive sodium channels. The clinical manifestations of ciguatera are typically self-limited, but chronic symptoms may occur in a minority of patients. This report describes a case of ciguatera poisoning with chronic symptoms, including pruritus and paresthesias. A 40-y-old man was diagnosed with ciguatera poisoning after consuming amberjack while vacationing in the US Virgin Islands. His initial symptoms, including diarrhea, cold allodynia, and extremity paresthesias, evolved into chronic, fluctuating paresthesias and pruritus that became worse after the consumption of alcohol, fish, nuts, and chocolate. After a comprehensive neurologic evaluation failed to reveal another cause for his symptoms, he was diagnosed with chronic ciguatera poisoning. His neuropathic symptoms were treated with duloxetine and pregabalin, and he was counseled to avoid foods that triggered his symptoms. Chronic ciguatera is a clinical diagnosis. Signs and symptoms of chronic ciguatera can include fatigue, myalgias, headache, and pruritus. The pathophysiology of chronic ciguatera is incompletely understood but may involve genetic factors or immune dysregulation. Treatment involves supportive care and avoidance of foods and environmental conditions that may exacerbate symptoms.

Ciguatera poisoning and confirmation of ciguatoxins in fish imported into New Zealand.

Ciguatera poisoning has caused illnesses in New Zealand through the consumption of contaminated reef fish imported from Pacific Islands. In May 2020 five people became ill and one was hospitalised following the consumption of Fiji Kawakawa (camouflage grouper; Epinephelus polyphekadion). The fish was purchased in New Zealand but imported from Fiji. The meal remnants were analysed for ciguatoxins, the causative compounds of ciguatera poisoning, and showed the presence of the three main toxic fish metabolites. Other fish tested from the same shipment did not contain detectable levels of ciguatoxins, indicating they were likely not toxic.

Neurological Disturbances of Ciguatera Poisoning: Clinical Features and Pathophysiological Basis.

Ciguatera fish poisoning (CFP), the most prevalent seafood poisoning worldwide, is caused by the consumption of tropical and subtropical fish contaminated with potent neurotoxins called ciguatoxins (CTXs). Ciguatera is a complex clinical syndrome in which peripheral neurological signs predominate in the acute phase of the intoxication but also persist or reoccur long afterward. Their recognition is of particular importance in establishing the diagnosis, which is clinically-based and can be a challenge for physicians unfamiliar with CFP. To date, no specific treatment exists. Physiopathologically, the primary targets of CTXs are well identified, as are the secondary events that may contribute to CFP symptomatology. This review describes the clinical features, focusing on the sensory disturbances, and then reports on the neuronal targets and effects of CTXs, as well as the neurophysiological and histological studies that have contributed to existing knowledge of CFP neuropathophysiology at the molecular, neurocellular and nerve levels.

Junctional bradycardia caused by ciguatera intoxication.

Ciguatera is a common but underreported tropical disease caused by the consumption of coral reef fish contaminated by ciguatoxins. Gastrointestinal and neurological symptoms predominate, but may be accompanied by cardiovascular features such as hypotension and sinus bradycardia. Here, we report an unusual case of junctional bradycardia caused by ciguatera in the Caribbean; to our knowledge, the first such report from the region. An increase in global sea temperatures is predicted to lead to the spread of ciguatera beyond traditional endemic areas, and the globalisation of trade in coral reef fish has resulted in sporadic cases occurring in developed countries far away from endemic areas. This case serves as a reminder to consider environmental intoxications such as ciguatera within the differential diagnosis of bradycardias.

[Ciguatera or why you should enquire about fish consumption in cases of cold allodynia]. / Ciguatera oder wieso bei der Kälteallodynie nach dem Fischverzehr gefragt werden sollte.

Ciguatoxine sind potente, von Mikroalgen produzierte, marine Biotoxine, die sich in tropischen Raubfischen, lokal und saisonal unterschiedlich stark, anreichern können. Kurze Zeit nach dem Fischverzehr treten gastrointestinale, neurologische und/oder kardiovaskuläre Vergiftungssymptome auf. Durch die hohe Affinität der Toxine zu neuronalen Natriumkanälen sind neurologische Symptome für Ciguatera-Vergiftungen charakteristisch. Nahezu pathognomonisch ist dabei die Kälteallodynie, bei der kalte Oberflächen als heiß, schmerzhaft oder extrem unangenehm empfunden werden. Durch Importe von Tropenfisch tritt Ciguatera zunehmend auch in gemäßigten Klimazonen auf. Wir erläutern anhand zweier Fälle die Besonderheiten dieser Fischvergiftung.

Ciguatera fish poisoning in Hawai'i and the Pacific.

Ciguatera fish poisoning (CFP) is a foodborne illness caused by fish containing ciguatoxin (CTX). The toxin is produced by the microalgae Gambierdiscus spp. which are then eaten by reef fish; humans contract the illness when eating either fish that have eaten the algae, or carnivorous fish that have eaten those fish. CTX is an odorless, tasteless, and colorless neurotoxin that blocks voltage-sensitive Na(+) channels and accumulates in many tissues of the fish, especially the viscera. The illness is typically mild to moderate in severity with gastrointestinal (diarrhea, cramping, nausea, vomiting) and neurological (paraesthesias, cold allodynia, fatigue, pruritis) manifestations. Rarely, the disease can be more severe with significant neuropathic or cardiac effects such as bradycardia and hypotension. Endemic to Hawai'i and islands throughout the Caribbean and Pacific, CFP incidence rates range from several to thousands of cases per 100,000 per year. Since fishing is important for local food supply, exportation, and recreation throughout the Pacific, CFP is medically and economically significant in these areas. We present a case of CFP from Hawai'i to illustrate the disease, demonstrating that the diagnosis is primarily clinical, with confirmatory tests from fish samples available in some cases. Treatment is supportive and symptomatic with no disease specific remedy. The prognosis for most cases is good with a short duration of self-limited symptoms, but for some cases neurological sequelae can become chronic. With no effective treatment, education on which species of reef fish and which body parts to avoid eating is essential in the prevention of CFP.

Ciguatera fish poisoning: a first epidemic in Germany highlights an increasing risk for European countries.

Toxin-producing microalgae are thriving worldwide due to coral reef destruction and global warming with major consequences on ecosystems, international trade and human health. Microalgae belonging to the family of flagellate protists, in particular dinoflagellates, secrete a variety of high-molecular-weight polyether toxins that accumulate through the marine food chain to cause disease in humans by acting as sodium channel activator toxins; ciguatera is the most frequent seafood-borne illness worldwide with 50,000 to 500,000 global incidences per annum and is usually limited to endemic areas located between 35° northern and 35° southern latitude. The rising global incidence frequency renders it a major human health problem, because no curative treatment is available yet and reliable detection assays are lacking. During the last decade ciguatera has increasingly become endemic in previously unaffected areas for two reasons: first global warming has contributed to the emergence of dinoflagellate species in subtropical and even temperate regions that previously had been constrained to tropical areas and second: in Europe globalization of fishing industry and tourism has led to a progressive increase in the number of ciguatera cases and a lack of awareness among medical personnel contributes to under-reporting. We review, through a recent ciguatera outbreak in Germany, the risk for ciguatera poisoning in Europe and highlight characteristic symptoms, current knowledge about disease pathomechanisms and treatment options.

Caso de intoxicación por ciguatera en paciente pediátrico / A case of ciguatera poisoning in a paediatric patient

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[Ciguatera fish poisoning]. / La ciguatéra.

Ciguatera, an ichtyosarcotoxism linked to the consumption of usually healthy coral fish is a common poisoning in the Pacific, Caribbean and Indian Ocean where it is endemic. However, increased tourism and commercial transportation of tropical fish for consumption make it an unexceptional intoxication in countries away from its endemic area. Environmental stresses such as climate changes also contribute to the expansion of its geographical area. The non-specific clinical symptomatology is characterized by the occurrence of gastrointestinal, cardiovascular, nervous and general signs few hours after eating a ciguatoxic fish. The diagnosis is clinical and relatively easy in endemic areas but much less for physicians who are rarely confronted with, which is a source of prolonged diagnostic delays and a significant increase in spending. Treatment of ciguatera is symptomatic but new treatments, still experimental, give a real hope for the future.

Severe bradycardia and prolonged hypotension in ciguatera.

Ciguatera results when ciguatoxin-contaminated coral reef fish from tropical or subtropical waters are consumed. The clinical features that present in affected persons are mainly gastrointestinal, neurological, general, and much less commonly, cardiovascular. We report the case of a 50-year-old man who developed the characteristic combination of acute gastrointestinal and neurological symptoms after the consumption of an unidentified coral reef fish head. In addition to those symptoms, he developed dizziness, severe bradycardia (46 bpm) and prolonged hypotension, which required the administration of intravenous atropine and over three days of intravenous fluid replacement with dopamine infusion. Patients with ciguatera can develop severe bradycardia and prolonged hypotension. Physicians should recognise the possible cardiovascular complications of ciguatera and promptly initiate treatment with intravenous atropine, intravenous fluid replacement and inotropic therapy if such complications are observed.

Hypnosis to alleviate the symptoms of ciguatera toxicity: a case study.

Ciguatera toxicity is a poisoning from consuming reef fish that had fed on dinoflagellates such as Gambierdiscus toxicus found along coral reefs. The toxin is oil soluble, odorless, colorless, tasteless, heat stable, and is concentrated in larger carnivorous fish such as amberjack, barracuda, eel, grouper, red snapper, sea bass, and Spanish mackerel. Onset of symptoms is usually within 6-12 hours after ingestion. Gastrointestinal symptoms lasting 1-2 days include abdominal pain, nausea, vomiting, and diarrhea. Neurological symptoms may persist for weeks or several months or--rarely--years and include circumoral and extremity paresthesias, temperature sensation reversal, itching, weakness, ataxia, and others. A patient with burning hands and feet who had not found relief using other methods had diagnosis of ciguatera toxicity assisted by hypnotically refreshed memory followed by rapid relief with hypnotic suggestions in 1 session and remained free of symptoms.

Ciguatera: a public health perspective.

Ciguatera fish poisoning is a seafood-borne illness caused by consumption of fish that have accumulated lipid-soluble ciguatoxins. In the United States, ciguatera is responsible for the highest reported incidence of food-borne illness outbreaks attributed to finfish, and it is reported to hold this distinction globally. Ciguatoxins traverse the marine food web from primary producers, Gambierdiscus spp., to commonly consumed fish in tropical and subtropical regions of the world. Ciguatoxins comprise 12 known congeners among Caribbean and tropical Atlantic fish and 29 reported congeners among Pacific fish. Expanding trade in fisheries from ciguatera-endemic regions contributes to wider distribution and increasing frequency of disease among seafood consumers in non-endemic regions. Ciguatoxins produce a complex array of gastrointestinal, neurological and cardiological symptoms. Treatment options are very limited and supportive in nature. Information derived from the study of ciguatera outbreaks has improved clinical recognition, confirmation, and timely treatment. Such studies are equally important for the differentiation of ciguatoxin profiles in fish from one region to the next, the determination of toxicity thresholds in humans, and the formulation of safety limits. Analytical information from case and outbreak investigations was used to derive Pacific and Caribbean ciguatoxin threshold contamination rates for adverse effects in seafood consumers. To these threshold estimates 10-fold safety factors were applied to address individual human risk factors; uncertainty in the amount of fish consumed; and analytical accuracy. The studies may serve as the basis for industry and consumer advisory levels of 0.10ppb C-CTX-1 equivalent toxicity in fish from the tropical Atlantic, Gulf of Mexico, Caribbean, and 0.01ppb P-CTX-1 equivalent toxicity in fish from Pacific regions.

Ciguatera fish poisoning: treatment, prevention and management.

Ciguatera Fish Poisoning (CFP) is the most frequently reported seafood-toxin illness in the world, and it causes substantial physical and functional impact. It produces a myriad of gastrointestinal, neurologic and/or cardiovascular symptoms which last days to weeks, or even months. Although there are reports of symptom amelioration with some interventions (e.g. IV mannitol), the appropriate treatment for CFP remains unclear to many physicians. We review the literature on the treatments for CFP, including randomized controlled studies and anecdotal reports. The article is intended to clarify treatment options, and provide information about management and prevention of CFP, for emergency room physicians, poison control information providers, other health care providers, and patients.