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%

GI symptoms (~3-30 hours after consumption)
- vomiting, diarrhea, and abdominal cramping
Neurologic symptoms
- Paresthesias, painful teeth, painful urination, blurred vision, nerve palsies, respiratory paralysis, ataxia, vertigo, and hot/cold temperature reversal (cold allodynia)
Cardiovascular symptoms
- Bradycardia, heart block, pulmonary edema, and hypotension.

Toxins
- Ciguatera
- Neurotoxic shellfish poisoning
- Paralytic shellfish poisoning
- Scombroid
- Tetrodotoxin (e.g. pufferfish)
Stingers
- Stingray injury
Venomous fish (catfish, zebrafish, scorpion fish, stonefish)
- Cone shells
- Lionfish
- Sea urchins
Nematocysts
- Coral reef
- Fire coral
- Jellyfish (Cnidaria)
  - Box jellyfish
  - Sea wasp
- Portuguese man-of-war
- Sea anemones
Phylum porifera (sponges)
Bites

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

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

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.

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