II. Epidemiology

  1. Most common reported fish ingestion related Poisoning in U.S.
  2. Reaction occurs in up to 90% of Ciguatoxin ingestions
  3. Most common outbreaks
    1. Florida
    2. Hawaii
    3. West Indies
    4. Puerto Rico
    5. U.S. Virgin Islands

III. Pathophysiology

  1. Dinoflagellates (unicellular protozoa)
    1. Gambierdiscus toxicus bioaccumulates in carnivorous reef fish
  2. Reef fish ingestion results in reaction (>500 individual species have been associated)
    1. Amberjack
    2. Grouper
    3. Snapper
    4. Sturgeon
    5. King Mackerel
    6. Barracuda
    7. Moray eel
  3. Toxin
    1. Ciguatoxin is a tasteless, odorless, lipid soluble toxin
    2. Ciguatoxin is heat stable and acid-stable
    3. Ciguatoxin may be transferred via Breastmilk and placenta as well as via semen
  4. Mechanism
    1. Ciguatoxin binds to open Sodium channels on Neurons (depolarized Neurons)
    2. Results in Sodium influx into Neurons, resulting in Neuronal edema

IV. Symptoms: Anticholinergic Reaction

  1. Onset of symptoms at 2 to 6 hours after ingestion (up to 24 hours)
  2. Gastrointestinal (duration 24-48 hours)
    1. Nausea or Vomiting
    2. Voluminous, watery Diarrhea
    3. Abdominal Pain and cramping
  3. Neurologic (duration days to weeks)
    1. Cold-hot Sensation reversal (Cold Allodynia)
      1. Hot feels cold and cold feels hot
      2. Occurs in 80% of cases
      3. Pathognomonic for Ciguatera Toxin
    2. Numbness or Paresthesias of hands, feet and face (Tongue, lips, throat, perioral region)
    3. Vertigo or Ataxia
    4. Weakness
    5. Myalgias
    6. Headache
    7. Seizures
    8. Vision Changes
  4. Cardiopulmonary changes (duration days to weeks)
    1. Bradycardia
    2. Orthostatic Hypotension
  5. Miscellaneous
    1. Diaphoresis
    2. Sensation of loose or painful teeth
    3. Post-coital symptoms in women (Dysuria, Dyspareunia, Pelvic Pain)

V. Labs

  1. See Unknown Ingestion
  2. Serum Electrolytes
    1. Evaluate for Electrolyte losses (related to Diarrhea)
  3. Ciguatoxin Testing (ELISA or HPLC)
    1. Confirms diagnosis, but typically delayed results
    2. Ciguatera Poisoning is a clinical diagnosis

VI. Diagnostics

VII. Imaging

  1. As indicated based on presentation and differential diagnosis

VIII. Course

  1. Anticholinergic Symptoms within 2-6 hours after ingestion
    1. Reactions delayed up to 24 hours in some cases
  2. Symptom duration: 7 to 14 days
  3. More severe cases with prior Ciguatoxin reactions
  4. Paresthesias may persist for months

IX. Management

  1. See Unknown Ingestion
  2. Consider Activated Charcoal (1 mg/kg)
    1. Consider if ingestion within prior 1-2 hours and patient alert
  3. Supportive care
  4. Antiemetics (e.g. Zofran IV)
  5. Electrolyte replacement and intravenous hydration as needed
  6. May require Vasopressors for Hypotension
  7. May require Unstable Bradycardia management
  8. Avoid Alcohol
  9. Mannitol does not appear effective in shortening course
    1. Has been used at 1 g/kg over 30-240 min
    2. Schnorf (2002) Neurology 58:873-80 [PubMed]
  10. Admission Criteria
    1. Unclear diagnosis (See Unknown Ingestion)
    2. Significant neurologic or cardiac symptoms
    3. Significant Dehydration or Electrolyte abnormalities

X. Complication

  1. Stocking-Glove distribution neuropathic pain
    1. Peripheral Neuropathy symptoms may persist for weeks after onset
    2. Medications to consider
      1. Amitriptyline 25 mg orally once to twice daily
      2. Gabapentin 300-400 mg orally three times daily (start with bedtime dosing)
      3. Pregabalin 150 mg orally twice daily

XI. Prevention

  1. Avoid ingestion of large warm-water reef fish
  2. Limit intakes to small quantities
  3. Avoid ingesting internal organs of fish
  4. No food preparation method deactivate Ciguatoxin

XII. References

  1. Koch and Tomaszewski (2021) Crit Dec Emerg Med 35(8): 28
  2. Perkins (2004) Am Fam Physician 69(4):885-90 [PubMed]

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Related Studies

Ontology: Ciguatera Poisoning (C0008775)

Definition (MSH) Poisoning caused by ingestion of SEAFOOD containing microgram levels of CIGUATOXINS. The poisoning is characterized by gastrointestinal, neurological and cardiovascular disturbances.
Concepts Injury or Poisoning (T037)
MSH D036841
ICD10 T61.0
SnomedCT 212865008, 61614000, 240346005, 241774007
English Ciguatera, Ciguatera fish poisoning, Ciguatoxin causng toxic effect, Toxic eff/ciguatera fish poisn, ciguatera fish poisoning, ciguatera poisoning (diagnosis), ciguatera poisoning, Ciguatera Poisoning [Disease/Finding], Ciguatera Fish Poisoning, Poisoning, Ciguatera Fish, Ciguatera Fish Poisonings, Poisonings, Ciguatera Fish, ciguatera, poisoning fish, fish poisoning, ciguatera poison, Fish poisoning (disorder), Ciguatera (disorder), Fish poisoning, Ciguatoxin causing toxic effect (event), Ciguatera Poisonings, Poisoning, Ciguatera, Poisonings, Ciguatera, Ciguatoxin causing toxic effect, Toxic effect of ciguatera fish poisoning, Ciguatoxin causing toxic effect (disorder), Ciguatera Poisoning, ciguatera fish; ichthyotoxism, ciguatera fish; poisoning, ichthyotoxism; ciguatera fish, poisoning; ciguatera fish, Fish poisoning, NOS, Ichthyosarcotoxism, NOS, Poisoning by eating contaminated fish, Fish poisoning (disorder) [Ambiguous], Ichthyosarcotoxism, Poisoning;ciguatera
Swedish Ciguateraförgiftning
Czech ciguatera
Finnish Ciguatera-myrkytys
Italian Ciguatera, Avvelenamento da ciguatera
German Ciguatera-Fischvergiftung, Ciguatera, Ciguatera-Vergiftung
Japanese シグワテラ, 中毒-シガテラ, 食中毒-シガテラ, シガテラ, シガテラ中毒
Korean 시구아테라 물고기 중독
Spanish ciguatoxina que causa efectos tóxicos (trastorno), ciguatoxina que causa efectos tóxicos, efecto tóxico causado por ciguatoxina (trastorno), efecto tóxico causado por ciguatoxina, intoxicación por pescado (trastorno), ciguatera, intoxicación por pescado, ictiosarcotoxicosis, intoxicación por ingestión de pescado contaminado, Envenenamiento por Ciguatera, intoxicación por pescado (concepto no activo), Ciguatera, Intoxicación por Ciguatera
Polish Zatrucie toksyną cigua
Norwegian Ciguatera-forgiftning, Ciguatera
Portuguese Envenenamento Alimentar por Ciguatera, Intoxicação Alimentar por Ciguatera, Envenenamento por Ciguatera, Ciguatera, Intoxicação por Ciguatera
Dutch ciguateravis; ichthyotoxisme, ciguateravis; vergiftiging, ichthyotoxisme; ciguateravis, vergiftiging; ciguateravis, Vergiftiging door ciguateravis, Ciguatera, Ciguateravergiftiging
French Ciguatera, Intoxication à la ciguatoxine

Ontology: Ciguatoxins (C0008776)

Definition (MSH) Polycyclic ethers produced by Gambierdiscus (DINOFLAGELLATES) from gambiertoxins, which are ingested by fish which in turn may be ingested by humans who are susceptible to the CIGUATERA POISONING.
Concepts Biologically Active Substance (T123) , Hazardous or Poisonous Substance (T131)
MSH D002922
SnomedCT 26426004
English Ciguatoxin, ciguatoxin, Ciguatoxins [Chemical/Ingredient], Ciguatoxins, Ciguatoxin (substance)
Swedish Ciguatoxiner
Czech ciguatoxin, ciguatoxiny
Finnish Siguatoksiinit
Japanese シグアトキシン
French Ciguatoxine, Ciguatoxines
Italian Ciguatossina, Ciguatossine
Polish Toksyny cigua
Spanish ciguatoxina (sustancia), ciguatoxina, Ciguatoxina, Ciguatoxinas
German Ciguatoxin, Ciguatoxine
Portuguese Ciguatoxina, Ciguatoxinas