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)
- Neurologic symptoms
- Paresthesias, painful teeth, painful urination, blurred vision, nerve palsies, respiratory paralysis, ataxia, vertigo, and hot/cold temperature reversal (cold allodynia)
- Cardiovascular symptoms
Differential Diagnosis
Marine toxins, envenomations, and bites
- Toxins
- Ciguatera
- Scombroid
- Tetrodotoxin (e.g. pufferfish)
- Shellfish poisoning
- Amnesic shellfish poisoning
- Diarrheal shellfish poisoning
- Neurotoxic shellfish poisoning
- Paralytic shellfish poisoning
- Stingers
- Venomous fish
- Cone shell
- Lionfish
- Sea urchins
- Crown-of-Thorns Starfish
- Stonefish
- Other: Catfish, zebrafish, scorpion fish
- Nematocysts
- Coral reef
- Fire coral
- Jellyfish (Cnidaria)
- Portuguese man-of-war
- Sea anemones
- Seabather's eruption
- Phylum porifera (sponges)
- Bites
- Infections
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 [1]. However, no benefit over normal saline in RCT[2]
- 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[3] [4]
- Gabapentin[5] and Pregabalin [6] 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
References
- ↑ Friedman MA et al. Ciguatera Fish Poisoning: Treatment, Prevention, and Management. Marine Drugs 2008; 6:456-479
- ↑ Schnorf H et al. Ciguatera Fish Poisoning. A double-blind randomized trial of mannitol therapy. Neurology 2002; 58(6):873
- ↑ Lange W et al. Travel and ciguatera fish poisoning. Arch. Int. Med. 1992; 152:2049-2052
- ↑ Davis RT and Villar LA. Symptomatic improvement with amitriptyline in ciguatera fish poisoning. N Engl J Med 1986; 315:65
- ↑ Perez CM et al. Treatment of ciguatera poisoning with gabapentin. N Engl J Med 2001; 344:692
- ↑ Brett J and Murnion B. Pregabalin to treat ciguatera fish poisoning. Clinical toxicology 2015; 53(6):588.