Difference between revisions of "Ciguatera"

(See Also)
(References)
 
(16 intermediate revisions by 10 users not shown)
Line 1: Line 1:
 
==Background==
 
==Background==
*Most cases tropics and subtropics, between 35 degrees north and south latitudes
+
*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 common fish are barracuda, moray eel, amberjack, and certain types of grouper, mackerel, parrotfish, and red snapper
+
*Most cases occur in the tropics and subtropics, between 35 degrees north and south latitudes
*Caused by fish eating dinoflagellates that grow on and around coral reefs and contain a heat-stable toxin
+
*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%
  
==Diagnosis==
+
==Clinical Features==
*GI symptoms
+
*GI symptoms (~3-30 hours after consumption)
**vomiting, diarrhea, and abdominal cramping
+
**[[vomiting]], [[diarrhea]], and [[abdominal cramping]]
**3-30hrs after eating contaminated fish
 
 
*Neurologic symptoms
 
*Neurologic symptoms
**Paresthesias, painful teeth, painful urination, blurred vision, nerve palsies, and hot/cold temperature reversal
+
**[[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  
 
*Cardiovascular symptoms  
**Bradycardia, heart block, and hypotension.
+
**[[Bradycardia]], [[heart block]], [[pulmonary edema]], and [[hypotension]].
  
^Diagnosis based on history and physical only
+
==Differential Diagnosis==
 +
{{Marine envenomation DDX}}
  
==Treatment==
+
==Evaluation==
*Symptomatic
+
*Clinical diagnosis
*Prevent recurrances
 
**Do not injest alcohol, caffeine, nuts or fish for 6 months
 
  
==Prognosis==
+
==Management==
*Neurologic symptoms typically persist from a few days to several weeks
+
*Symptomatic therapies are the mainstay of treatment
*~20% of patients have symptoms that persist for months
+
**[[Antiemetics]] and [[IVF]]
*<2% have symptoms that last for years
+
**[[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==
 
==See Also==
*[[Diarrhea]]
 
*[[Weakness]]
 
 
*[[Marine toxins and envenomations]]
 
*[[Marine toxins and envenomations]]
  
==Source==
+
==References==
UpToDate
+
<references/>
  
[[Category:Environ]]
+
[[Category:Environmental]]
 +
[[Category:Toxicology]]

Latest revision as of 17:19, 28 September 2019

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

Differential Diagnosis

Marine toxins, envenomations, and bites

Evaluation

  • Clinical diagnosis

Management

  • Symptomatic therapies are the mainstay of treatment
  • 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

  1. Friedman MA et al. Ciguatera Fish Poisoning: Treatment, Prevention, and Management. Marine Drugs 2008; 6:456-479
  2. Schnorf H et al. Ciguatera Fish Poisoning. A double-blind randomized trial of mannitol therapy. Neurology 2002; 58(6):873
  3. Lange W et al. Travel and ciguatera fish poisoning. Arch. Int. Med. 1992; 152:2049-2052
  4. Davis RT and Villar LA. Symptomatic improvement with amitriptyline in ciguatera fish poisoning. N Engl J Med 1986; 315:65
  5. Perez CM et al. Treatment of ciguatera poisoning with gabapentin. N Engl J Med 2001; 344:692
  6. Brett J and Murnion B. Pregabalin to treat ciguatera fish poisoning. Clinical toxicology 2015; 53(6):588.