Ciguatera: Difference between revisions
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==Background== | ==Background== | ||
*Caused by eating fish contaminated with a heat-stable toxin, which is obtained | *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 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 | *Most common fish include barracuda, moray eel, amberjack, and certain types of grouper, mackerel, parrotfish, and red snapper | ||
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==Clinical Features== | ==Clinical Features== | ||
*GI symptoms | *GI symptoms (~3-30 hours after consumption) | ||
**vomiting, diarrhea, and abdominal cramping | **vomiting, diarrhea, and abdominal cramping | ||
*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, nerve palsies, and hot/cold temperature reversal | ||
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==Management== | ==Management== | ||
*Symptomatic | *Symptomatic therapies are the mainstay of treatment | ||
**Antiemetics and IVF | |||
**Antiemetics and IVF | |||
**Atropine for bradycardia | **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 that many patients may be hypovolemic 2/2 GI symptoms 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== | ==Disposition== |
Revision as of 04:14, 4 April 2016
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, nerve palsies, and hot/cold temperature reversal
- Cardiovascular symptoms
- Bradycardia, heart block, and hypotension.
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
Diagnosis
- Clinical diagnosis
Management
- Symptomatic therapies are the mainstay of treatment
- Antiemetics and IVF
- Atropine for bradycardia
- 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
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.