Ciguatera

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Background

  • Most cases tropics and subtropics, between 35 degrees north and south latitudes
  • Most common fish are barracuda, moray eel, amberjack, and certain types of grouper, mackerel, parrotfish, and red snapper
  • Caused by fish eating dinoflagellates that grow on and around coral reefs and contain a heat-stable toxin
  • Suspected cases should be reported to local department of health

Clinical Features

  • GI symptoms
    • vomiting, diarrhea, and abdominal cramping
    • 3-30hrs after eating contaminated fish
  • 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

Diagnosis

  • Clinical diagnosis

Management

  • Symptomatic
    • 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 that many patients may be hypovolemic 2/2 GI symptoms and should be appropriately volume resuscitated prior to considering mannitol
    • Neuropathic pain
    • Antiemetics and IVF for hypotension
    • Atropine for bradycardia
  • Prevent recurrances
    • Do not ingest alcohol, caffeine, nuts or fish for 6 months

Disposition

  • Generally may be discharged

Prognosis

  • Neurologic symptoms typically persist from a few days to several weeks
  • ~20% of patients have symptoms that persist for months
  • <2% have symptoms that last for years

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.