View source for Ciguatera

==Background==
*Caused by eating fish contaminated with a heat-stable toxin, which is obtained when the fish consumes dinoflagellates that grow on and around coral reefs
*Most cases occur in the tropics and subtropics, between 35 degrees north and south latitudes
*Most common fish include barracuda, moray eel, amberjack, and certain types of grouper, mackerel, parrotfish, and red snapper
*Suspected cases should be reported to local department of health
*Neurologic symptoms typically resolve within days to weeks
**Persist for months in 20%, and years in up to 2%

==Clinical Features==
*GI symptoms (~3-30 hours after consumption)
**[[vomiting]], [[diarrhea]], and [[abdominal cramping]]
*Neurologic symptoms
**[[Paresthesias]], painful teeth, [[painful urination]], [[blurred vision]], [[focal neuro deficit|nerve palsies]], [[respiratory failure|respiratory paralysis]], [[ataxia]], [[vertigo]], and '''hot/cold temperature reversal''' (cold allodynia)
*Cardiovascular symptoms 
**[[Bradycardia]], [[heart block]], [[pulmonary edema]], and [[hypotension]].

==Differential Diagnosis==
{{Marine envenomation DDX}}

==Evaluation==
*Clinical diagnosis

==Management==
*Symptomatic therapies are the mainstay of treatment
**[[Antiemetics]] and [[IVF]]
**[[Atropine]] for bradycardia
*[[Mannitol]] - Recommended by several experts for neurologic symptoms if given within 24-48 hours of onset <ref>Friedman MA et al. Ciguatera Fish Poisoning: Treatment, Prevention, and Management. Marine Drugs 2008; 6:456-479 </ref>. However, no benefit over normal saline in RCT<ref>Schnorf H et al. Ciguatera Fish Poisoning. A double-blind randomized trial of mannitol therapy. Neurology 2002; 58(6):873</ref>
**Caution: patients may be hypovolemic due to vomiting/diarrhea and should be appropriately volume resuscitated prior to considering mannitol
*[[Amitriptyline]] reported effective for neuropathic pain in several case series<ref>Lange W et al. Travel and ciguatera fish poisoning. Arch. Int. Med. 1992; 152:2049-2052</ref> <ref> Davis RT and Villar LA. Symptomatic improvement with amitriptyline in ciguatera fish poisoning. N Engl J Med 1986; 315:65</ref>
*[[Gabapentin]]<ref> Perez CM et al. Treatment of ciguatera poisoning with gabapentin. N Engl J Med 2001; 344:692 </ref> and [[Pregabalin]] <ref> Brett J and Murnion B. Pregabalin to treat ciguatera fish poisoning. Clinical toxicology 2015; 53(6):588. </ref> also reported to control neurologic symptoms
*Prevent recurrences - instruct patient to not ingest alcohol, caffeine, nuts or fish for 6 months

==Disposition==
*Generally may be discharged
*Advise caution that patients should avoid consumption of similar fish for six months as it could trigger a recurrence. 

==See Also==
*[[Marine toxins and envenomations]]

==References==
<references/>

[[Category:Environmental]]
[[Category:Toxicology]]