An Unusual Presentation of Severe Ciguatera Poisoning: Case Report.

BACKGROUND Ciguatera poisoning is presently estimated to afflict approximately 16 000 people in the United States each year. Ciguatera toxicity is due to the ingestion of warm-water reef fish that are known to consume dinoflagellates that contain ciguatoxins (CTXs). Historically, the diagnosis of ciguatera poisoning is confirmed in the emergency department when this ingestion is followed by manifestations of neurologic and gastrointestinal organ symptoms. Some individuals also manifest cardiac symptoms. These symptoms can vary within each organ system in type and duration. CASE REPORT In this report, 2 patients (husband and wife) are presented that consumed the same barracuda, resulting in severe ciguatera poisoning diagnosed in the emergency department. One had the complete triad of symptoms of gastrointestinal (GI), neurologic, and cardiac involvement. The other patient lacked neurological symptoms but did experience severe gastrointestinal and cardiac symptoms. It was assumed by the inpatient team, the consulted infectious disease specialist, and, initially, the in-house toxicologist that the lack of neurologic symptoms excluded the diagnosis of ciguatera. CONCLUSIONS If these patients had presented separately, only the former would have been considered to have ciguatera poisoning. These 2 cases demonstrate the misunderstanding among healthcare practitioners of the literature on the diagnostic criteria. Therefore, this article aims to analyze ciguatera diagnosis in the emergency department, which will ultimately guide prognostics and management, particularly for severe cardiac symptoms.

Establishing a Receptor Binding Assay for Ciguatoxins: Challenges, Assay Performance and Application.

Ciguatera, a global issue, lacks adequate capacity for ciguatoxin analysis in most affected countries. The Caribbean region, known for its endemic ciguatera and being home to a majority of the global small island developing states, particularly needs established methods for ciguatoxin detection in seafood and the environment. The radioligand receptor binding assay (r-RBA) is among the in vitro bioassays currently used for ciguatoxin analysis; however, similarly to the other chemical-based or bioassays that have been developed, it faces challenges due to limited standards and interlaboratory comparisons. This work presents a single laboratory validation of an r-RBA developed in a Cuban laboratory while characterizing the performance of the liquid scintillation counter instrument as a key external parameter. The results obtained show the assay is precise, accurate and robust, confirming its potential as a routine screening method for the detection and quantification of ciguatoxins. The new method will aid in identifying high-risk ciguatoxic fish in Cuba and the Caribbean region, supporting monitoring and scientific management of ciguatera and the development of early warning systems to enhance food safety and food security, and promote fair trade fisheries.

Outbreak of ciguatera poisoning in a commercial vessel: lessons learnt and prospects of early diagnosis, management, and prophylaxis.

An outbreak of food poisoning of unknown origin was notified to Central Queensland Public Health Unit on 9 December 2021. The bulk carrier sailing from Higashiharima, Japan to Gladstone, Australia reported an incident of sudden illness, with 19 out of 20 sailors on board reporting a combination of gastrointestinal and neurological symptoms. Central Queensland Public Health Unit started the outbreak investigation as per Queensland Health public health management guidelines. All 20 of the sailors consumed a self-caught barracuda and squid, prepared by the ship's cook, the day before. Unconsumed samples of the fish and squid were sent for testing. The affected sailors were triaged on arrival and were provided with medical care as required. The barracuda sample contained ciguatoxins (CTXs; P-CTX-1, P-CTX-2, P-CTX-3) with a total count of 3.40 ug/kg confirming the diagnosis. We propose the usage of the combination of gastrointestinal symptoms and paraesthesia in the light of a recent intoxication event for early detection of ciguatera poisoning (CP) in the eastern seaboard of Australia.

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.

A Curious Case of Ciguatera Fish Poisoning in the Midwest and a Review for Clinicians.

BACKGROUND: Ciguatera poisoning is one of the most prevalent types of fish poisoning, but it is often underreported, leading many health practitioners to be unfamiliar in correctly identifying and treating this toxicity. CASE REPORT: We present a case of ciguatera toxicity encountered in an emergency department in a Midwest community hospital setting. A 56-year-old woman presented to the ED with symptoms of perioral numbness, generalized pruritis, and hot/cold temperature reversal. Through careful history taking it was determined that the patient had recently returned from vacationing in the Caribbean and had been consuming meals containing various types of fish. A clinical diagnosis of ciguatera toxicity was made, and the patient was treated supportively. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This topic is important in the realm of emergency medicine because it presents a known toxicologic pathogen in an unsuspecting geographic location. This case highlights the importance of maintaining broad differentials and considering a patient's travel and exposure history to make the clinical diagnosis of ciguatoxin as well as the importance of preventative management to avoid recurrence of symptoms. We review the etiology of this fascinating toxin as well as the clinical implications in the diagnosis and management of this toxicity.

[Ciguatera fish poisoning while on vacation].

This case report presents a four-year-old Danish girl, who acquired ciguatera fish poisoning after eating a meal containing fish while being on vacation in Cuba. After returning to Denmark, her main complaint was pain in her lower legs and disrupted sleep. She was seen by her primary care physicians and at a paediatric department but was not diagnosed, until a specialist in tropical diseases saw her seven months after her return from Cuba. She was successfully treated with amitriptyline and dietary changes.

Ciguatera fish poisoning in Brazilian traveler to Caribbean.

Ciguatera poisoning is the most common form of non-bacterial food-poisoning from fish worldwide. The incidence among Brazilians returning from high-risk regions is unclear because it is not a mandatory reportable disease. We describe a previously healthy 53-year-old Brazilian woman developed Ciguatera fish poisoning while traveling to Havana, Cuba. Physicians and health care professionals should advise travelers to avoid eating ciguatoxic fish species and potentially toxic fish species in the Caribbean islands. Despite the prognosis for most cases is good with a short duration of self-limited symptoms, early recognition of the identifying clinical features of ciguatera can result in improved patient care.

Ciguatera fish poisoning in Brazilian traveler to Caribbean

ABSTRACT Ciguatera poisoning is the most common form of non-bacterial food-poisoning from fish worldwide. The incidence among Brazilians returning from high-risk regions is unclear because it is not a mandatory reportable disease. We describe a previously healthy 53-year-old Brazilian woman developed Ciguatera fish poisoning while traveling to Havana, Cuba. Physicians and health care professionals should advise travelers to avoid eating ciguatoxic fish species and potentially toxic fish species in the Caribbean islands. Despite the prognosis for most cases is good with a short duration of self-limited symptoms, early recognition of the identifying clinical features of ciguatera can result in improved patient care.

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.

Detection of pacific ciguatoxins using liquid chromatography coupled to either low or high resolution mass spectrometry (LC-MS/MS).

Ciguatera Fish Poisoning (CFP) is primarily caused by consumption of tropical and sub-tropical fish contaminated by Ciguatoxins (CTXs). These lipid-soluble, polyether neurotoxins are produced by dinoflagellates in the genera Gambierdiscus and Fukuyoa. While there is no regulatory level in Europe for CTXs, the European Food Safety Authority (EFSA) adopted the United States guidance level of 0.01 µg P-CTX1B eq.kg-1 of fish. This limit is extremely low and requires significant improvement in the detection of CTXs. In this study, we compared analytical protocols based on liquid chromatography coupled to tandem low or high resolution mass spectrometry (LC-LRMS or HRMS) to find the best conditions for sensitivity and/or selectivity. Different approaches such as LC conditions, ion choice and acquisition modes, were evaluated to detect the Pacific-ciguatoxins (P-CTXs) on a triple quadrupole (API4000 Qtrap, Sciex) or a quadrupole time of flight (QTOF 6550, Agilent Technologies) spectrometer. Moreover, matrix effects were calculated using matrix-matched calibration solutions of P-CTX1B and P-CTX3C prepared in purified fish extract. Subsequently, the method performance was assessed on naturally contaminated samples of seafood and phytoplankton. With LRMS, the ammoniated adduct ion used as a precursor ion showed an advantage for selectivity through confirmatory transitions, without affecting signal-to-noise ratios, and hence limits of detection (LODs). As also reported by some studies in the literature, methanol-based mobile phase gave better selectivity and sensitivity for the detection of P-CTXs. While the LOD for P-CTX1B and P-CTX3C met the EFSA recommendation level when using LRMS, the findings suggested careful evaluation of instrumental parameters for determination of CTXs. LODs were significantly higher for HRMS, which currently results in the need for a significantly higher sample intake. Nevertheless, HRMS allowed for the identification of artefacts and may allow for improved confirmation of the identity of P-CTXs analogues. Consequently, LRMS and HRMS are considered complementary to ensure adequate quantitation and identification of P-CTXs.

Consumption of barracuda in the Caribbean Sea linked to ciguatera fish poisoning among Filipino seafarers.

INTRODUCTION: Ciguatera fish poisoning (CFP) is common in tropical and subtropical waters. On 13 November 2015, eight Filipino seafarers from a cargo ship sailing in the Caribbean Sea experienced a range of symptoms after consuming a barracuda. Upon their return to the Philippines, an investigation was conducted to describe the cases. METHODS: A case-series was conducted. A CFP case was defined as a previously well individual on the ship who developed at least one gastrointestinal symptom and at least one neurologic manifestation after eating barracuda on 13 November 2015. All cases were admitted to hospital in Manila, Philippines and were interviewed using a standard questionnaire. Urine and serum samples of cases were collected for ciguatoxin (CTX) testing by radiological and receptor-binding assay. RESULTS: Eight of the 25 seafarers on the ship ate the barracuda; all eight met the CFP case definition. The age of cases ranged from 37 to 58 years (median: 47 years) and all were males. Onset of symptoms ranged from 1 to 3 hours (median: 2 hours) from the time of ingestion of the barracuda. All cases experienced gastrointestinal (nausea, vomiting, diarrhoea) and neurologic (temperature allodynia, itchiness) symptoms but no cardiovascular manifestations. Urine and serum specimens of all eight cases showed CTX below the detection limit. DISCUSSION: The Philippines Epidemiology Bureau recommended that the Philippine Maritime Authority include CTX poisoning and its health risks in seafarers' training to prevent future cases of CFP. The Event-based Surveillance and Response system will continue to provide a mechanism for the reporting and appropriate management of CFP cases.

[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.