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| {{short description|Foodborne illness}} | | {{short description|Foodborne illness}} |
| {{Infobox medical condition (new) | | {{Infobox medical condition (new) |
| | name = Ciguatera fish poisoning | | | name = Ciguatera fish poisoning |
| | synonyms = Ciguatera, ciguatera food poisoning | | | synonyms = Ciguatera, ciguatera food poisoning |
| | image = Ciguatoxin.svg | | | image = Ciguatoxin.svg |
| | width =
| | | caption = Chemical structure of [[ciguatoxin]] |
| | alt =
| | | symptoms = [[Diarrhea]], vomiting, numbness, itchiness, sensitivity to hot and cold, [[dizziness]], weakness |
| | caption = Chemical structure of [[ciguatoxin]] | | | complications = |
| | pronounce =
| | | onset = 30 minutes to 2 days |
| | field =
| | | duration = Few weeks to months |
| | symptoms = [[Diarrhea]], vomiting, numbness, itchiness, sensitivity to hot and cold, [[dizziness]], weakness<ref name=Fri2017/><ref name=Yellow2018/> | | | causes = [[Ciguatoxin]] and [[maitotoxin]] within certain [[reef fish]] |
| | complications = | | | risks = [[Barracuda]], [[grouper]], [[moray eel]], [[amberjack]], [[sea bass]], [[surgeonfish]] |
| | onset = 30 min to 2 days<ref name=FAO2004/> | | | diagnosis = Based on symptoms and recently eating fish |
| | duration = Few weeks to months<ref name=FAO2004/> | | | differential = [[Paralytic shellfish poisoning]], [[neurotoxic shellfish poisoning]], [[scombroid food poisoning]], [[pufferfish poisoning]] |
| | types =
| | | prevention = Avoiding reef fish and high-risk species |
| | causes = [[Ciguatoxin]] and [[maitotoxin]] within certain [[reef fish]]<ref name=Yellow2018/> | | | treatment = [[Mannitol]], [[gabapentin]], [[amitriptyline]] |
| | risks = [[Barracuda]], [[grouper]], [[moray eel]], [[amberjack]], [[sea bass]], [[surgeon fish]].<ref name=Yellow2018/> | | | medication = |
| | diagnosis = Based on symptoms and recently eating fish<ref name=Fri2017/> | | | prognosis = Risk of death < 0.1% |
| | differential = [[Paralytic shellfish poisoning]], [[neurotoxic shellfish poisoning]], [[scombroid food poisoning]], [[pufferfish poisoning]]<ref name=Fri2017/> | | | frequency = ≈50,000 per year |
| | prevention = | |
| | treatment = [[Mannitol]], [[gabapentin]], [[amitriptyline]]<ref name=Fri2017/><ref name=Yellow2018/> | |
| | medication = | |
| | prognosis = Risk of death < 0.1%<ref name=Yellow2018/> | |
| | frequency = ≈50,000 per year<ref name=Yellow2018/> | |
| | deaths =
| |
| }} | | }} |
| | '''Ciguatera fish poisoning''' ('''CFP'''), also known as '''ciguatera''', is a [[foodborne illness]] caused by consuming certain [[reef fish]] contaminated with [[ciguatoxin]] or [[maitotoxin]]. Symptoms typically include [[diarrhea]], vomiting, numbness, sensitivity to hot and cold, and [[neurological]] disturbances such as [[dizziness]] and weakness. Symptoms may appear within 30 minutes to two days after ingestion and can last for weeks to months. Severe cases may include cardiovascular symptoms like [[bradycardia]] or [[hypotension]]. |
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| | == Causes == |
| title='''{{PAGENAME}}'''
| | The primary toxins involved, ciguatoxin and maitotoxin, originate from the marine [[dinoflagellate]] ''[[Gambierdiscus toxicus]]'', which thrives in [[coral reef]] environments. These toxins bioaccumulate as they move up the [[food chain]] from [[herbivorous]] fish to larger [[carnivorous]] species like [[barracuda]], [[grouper]], and [[moray eel]]. Cooking does not neutralize ciguatoxin, and it has no discernible taste or odor, making it challenging to detect. |
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| <!-- Definition and symptoms -->
| | == Symptoms == |
| '''Ciguatera fish poisoning''' ('''CFP'''), also known simply as '''ciguatera''', is a [[foodborne illness]] caused by eating [[reef fish]] whose flesh is contaminated with certain [[toxin]]s.<ref name=Yellow2018/> Symptoms may include [[diarrhea]], vomiting, numbness, itchiness, sensitivity to hot and cold, [[dizziness]], and weakness.<ref name=Fri2017/><ref name=Yellow2018/> The onset of symptoms varies with the amount of toxin eaten from half an hour to up to two days.<ref name=FAO2004/> The diarrhea may last for up to four days.<ref name=Fri2017/> Some symptoms typically remain for a few weeks to months.<ref name=FAO2004/> Heart difficulties such as [[bradycardia|slow heart rate]] and [[low blood pressure]] may also occur.<ref name=Yellow2018/> | | Symptoms of CFP are diverse and include: |
| | * '''Gastrointestinal''': [[Nausea]], [[vomiting]], [[diarrhea]] |
| | * '''Neurological''': [[Headache]], muscle aches, numbness, [[paresthesia]], and [[allodynia]] (burning sensation on contact with cold) |
| | * '''Cardiovascular''': [[Bradycardia]], [[tachycardia]], [[hypotension]] |
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| <!-- Cause and diagnosis -->
| | In rare cases, neurological symptoms such as hallucinations and [[ataxia]] may persist for years. |
| The specific toxins involved are [[ciguatoxin]] and [[maitotoxin]].<ref name=Yellow2018/> They are originally made by a small [[marine organism]], ''[[Gambierdiscus toxicus]]'', that grow on and around [[coral reefs]] in [[tropical]] and [[subtropical]] waters.<ref name=Yellow2018/> These are eaten by [[herbivorous]] fish which in turn are eaten by larger [[carnivorous]] fish.<ref name=Yellow2018/> The toxins become [[Bioaccumulation|more concentrated]] as they move up the [[food chain]].<ref name=FAO2004>{{cite book |title=Marine biotoxins |date=2004 |publisher=Food and Agriculture Organization |isbn=978-92-5-105129-0|page=Chapter 7 |chapter-url=http://www.fao.org/docrep/007/y5486e/y5486e0q.htm |chapter=Ciguatera Fish Poisoning (CFP)}}</ref> The fish most often implicated include [[barracuda]], [[grouper]], [[moray eel]], [[amberjack]], [[sea bass]], and [[sturgeon]].<ref name=Yellow2018/> Diagnosis is based on a person's symptoms together with having recently eaten fish.<ref name=Fri2017/> If a number of those who eat the same fish develop symptoms the diagnosis becomes more likely.<ref name=Fri2017/> If some of the fish they had previously eaten is available this can also be tested to confirm the diagnosis.<ref name=Fri2017/>
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| <!-- Prevention and treatment -->
| | == Diagnosis == |
| Preventive efforts include not eating [[reef fish]], not eating high-risk fish such as barracuda, and not eating fish liver, [[roe]], or fish heads.<ref name=Yellow2018/> [[Ciguatoxin]] has no taste or smell, and cannot be destroyed by conventional [[cooking]].<ref name=Yellow2018/> There is no specific treatment for ciguatera fish poisoning once it occurs.<ref name=Yellow2018>{{cite web |title=Food Poisoning from Marine Toxins - Chapter 2 - 2018 Yellow Book |url=https://wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/food-poisoning-from-marine-toxins |website=CDC |accessdate=1 June 2018 |language=en-us |date=2017}}{{PD-notice}}</ref> [[Mannitol]] may be considered, but the evidence supporting its use is not very strong.<ref name=Fri2017>{{cite journal |last1=Friedman |first1=MA |last2=Fernandez |first2=M |last3=Backer |first3=LC |last4=Dickey |first4=RW |last5=Bernstein |first5=J |last6=Schrank |first6=K |last7=Kibler |first7=S |last8=Stephan |first8=W |last9=Gribble |first9=MO |last10=Bienfang |first10=P |last11=Bowen |first11=RE |last12=Degrasse |first12=S |last13=Flores Quintana |first13=HA |last14=Loeffler |first14=CR |last15=Weisman |first15=R |last16=Blythe |first16=D |last17=Berdalet |first17=E |last18=Ayyar |first18=R |last19=Clarkson-Townsend |first19=D |last20=Swajian |first20=K |last21=Benner |first21=R |last22=Brewer |first22=T |last23=Fleming |first23=LE |title=An Updated Review of Ciguatera Fish Poisoning: Clinical, Epidemiological, Environmental, and Public Health Management. |journal=Marine Drugs |date=14 March 2017 |volume=15 |issue=3 |page=72 |doi=10.3390/md15030072 |pmid=28335428|pmc=5367029}}</ref> [[Gabapentin]] or [[amitriptyline]] may be used to treat some of the symptoms.<ref name=Yellow2018/>
| | Diagnosis is based on a combination of recent consumption of reef fish and the presence of typical symptoms. [[Differential diagnosis]] includes conditions like [[paralytic shellfish poisoning]] and [[scombroid poisoning]]. Testing fish samples can confirm the presence of toxins. |
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| <!-- Epidemiology and history -->
| | == Treatment == |
| The [[Centers for Disease Control]] estimates that around 50,000 cases occur globally each year.<ref name=Yellow2018/> Other estimates suggest up to 500,000 cases per year.<ref name=Fri2017/> It is the most frequent [[seafood poisoning]].<ref name=FAO2004/> It occurs most commonly in the [[Pacific Ocean]], [[Indian Ocean]], and the [[Caribbean Sea]] between the [[latitudes]] of 35°N and 35°S.<ref name=Yellow2018/> The risk of the condition appears to be increasing due to coral reef deterioration and increasing trade in seafood.<ref name=Yellow2018/> The risk of death from poisoning is less than 1 in 1,000.<ref name=Yellow2018/> Descriptions of the condition date back to at least 1511.<ref name=FAO2004/> The current name came into use in 1787.<ref name=FAO2004/>
| | There is no specific cure for CFP. Treatment is symptomatic and may include: |
| | * '''Medications''': [[Mannitol]] for acute symptoms, [[gabapentin]] or [[amitriptyline]] for neurological discomfort. |
| | * '''Supportive care''': Management of dehydration and monitoring of cardiovascular health. |
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| | == Prevention == |
| | Preventive measures include: |
| | * Avoiding high-risk reef fish such as [[barracuda]] and [[amberjack]] |
| | * Avoiding consumption of fish liver, [[roe]], and heads, which may contain higher toxin concentrations |
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| <youtube>
| | == Epidemiology == |
| title='''{{PAGENAME}}'''
| | Ciguatera is the most common [[seafood poisoning]] worldwide, with approximately 50,000 cases reported annually. It is prevalent in tropical and subtropical regions, particularly the [[Pacific Ocean]], [[Indian Ocean]], and the [[Caribbean Sea]]. |
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| ==Signs and symptoms== | | == Historical Context == |
| Hallmark symptoms of ciguatera in humans include [[gastrointestinal]], cardiovascular, and [[neurological]] effects.<ref name=Isbister-2005>{{cite journal |vauthors=Isbister G, Kiernan M |title=Neurotoxic marine poisoning |journal=The Lancet Neurology |volume=4 |issue=4 |pages=219–28 |year=2005 |pmid=15778101 |doi=10.1016/S1474-4422(05)70041-7}}</ref><ref name=uhm>{{cite journal |vauthors=Clark RF, Williams SR, Nordt SP, Manoguerra AS |title=A review of selected seafood poisonings |journal=Undersea Hyperb Med |volume=26 |issue=3 |pages=175–84 |year=1999 |pmid=10485519 |doi= |url=http://archive.rubicon-foundation.org/2314 |accessdate=2008-08-12}}</ref> Gastrointestinal symptoms include [[nausea]], [[vomiting]], and [[diarrhea]], usually followed by neurological symptoms such as [[headache]]s, muscle aches, [[paresthesia]], numbness of extremities, mouth and lips, reversal of hot and cold sensation,<ref>{{Cite journal|last=Patel|first=Ryan|last2=Brice|first2=Nicola L.|last3=Lewis|first3=Richard J.|last4=Dickenson|first4=Anthony H.|date=December 2015|title=Ionic mechanisms of spinal neuronal cold hypersensitivity in ciguatera|journal=The European Journal of Neuroscience|volume=42|issue=11|pages=3004–3011|doi=10.1111/ejn.13098|issn=0953-816X|pmc=4744673|pmid=26454262}}</ref><ref>{{Cite journal|last=Vetter|first=Irina|last2=Touska|first2=Filip|last3=Hess|first3=Andreas|last4=Hinsbey|first4=Rachel|last5=Sattler|first5=Simon|last6=Lampert|first6=Angelika|last7=Sergejeva|first7=Marina|last8=Sharov|first8=Anastasia|last9=Collins|first9=Lindon S|date=2012-10-03|title=Ciguatoxins activate specific cold pain pathways to elicit burning pain from cooling|journal=The EMBO Journal|volume=31|issue=19|pages=3795–3808|doi=10.1038/emboj.2012.207|issn=0261-4189|pmc=3463840|pmid=22850668}}</ref> [[ataxia]], [[vertigo]], and [[hallucination]]s.<ref name=Swift-1993>{{cite journal |vauthors=Swift A, Swift T |title=Ciguatera |journal=J. Toxicol. Clin. Toxicol. |volume=31 |issue=1 |pages=1–29 |year=1993 |pmid=8433404 |doi=10.3109/15563659309000371}}</ref><ref name=uhm /> Severe cases of ciguatera can also result in cold [[allodynia]], which is a burning sensation on contact with cold.<ref name=Isbister-2005 /> Neurological symptoms can persist and ciguatera poisoning is occasionally misdiagnosed as [[multiple sclerosis]].<ref>{{cite journal |vauthors=Ting J, Brown A |title=Ciguatera poisoning: a global issue with common management problems |journal=Eur. J. Emerg. Med. |volume=8 |issue=4 |pages=295–300 |year=2001 |pmid=11785597 |doi=10.1097/00063110-200112000-00009|url=http://espace.library.uq.edu.au/view/UQ:10391/CiguateraEjem.pdf }}</ref> Cardiovascular symptoms include [[bradycardia]], [[tachycardia]], hypotension, hypertension, orthostatic tachycardia, exercise intolerance, and rhythm disorders.<ref>{{Cite journal|last=Hokama|first=Y.|date=1988-01-01|title=Ciguatera fish poisoning|journal=Journal of Clinical Laboratory Analysis|volume=2|issue=1|pages=44–50|doi=10.1002/jcla.1860020110|issn=1098-2825}}</ref> Death from the condition can occur, but is very rare.<ref name=Telegraph-2016-10-13 />
| | Ciguatera has been recognized since at least the 18th century, with the term first used in 1787. It has been a known health concern for indigenous populations in tropical regions and remains a challenge due to increased global seafood trade and [[coral reef]] degradation. |
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| [[Dyspareunia]] and other ciguatera symptoms have developed in otherwise healthy males and females following [[sexual intercourse]] with partners suffering ciguatera poisoning, signifying that the toxin may be sexually transmitted.<ref>{{cite journal |vauthors=Lange W, Lipkin K, Yang G |title=Can ciguatera be a sexually transmitted disease? |journal=J. Toxicol. Clin. Toxicol. |volume=27 |issue=3 |pages=193–7 |year=1989 |pmid=2810444 |doi=10.3109/15563658909038583}}</ref> Diarrhea and facial rashes have been reported in breastfed infants of poisoned mothers, suggesting that ciguatera toxins migrate into breast milk.<ref>{{cite journal |vauthors=Blythe D, de Sylva D |title=Mother's milk turns toxic following fish feast |journal=JAMA |volume=264 |issue=16 |page=2074 |year=1990 |pmid=2214071 |doi=10.1001/jama.264.16.2074b}}</ref> | | == See Also == |
| | * [[Marine biotoxins]] |
| | * [[Reef fish]] |
| | * [[Tropical diseases]] |
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| The symptoms can last from weeks to years, and in extreme cases as long as 20 years, often leading to long-term disability.<ref>{{cite journal |vauthors=Gillespie N, Lewis R, Pearn J, Bourke A, Holmes M, Bourke J, Shields W |title=Ciguatera in Australia. Occurrence, clinical features, pathophysiology and management |journal=Med. J. Aust. |volume=145 |issue=11–12 |pages=584–90 |year=1986 |pmid=2432386}}</ref> Most people do recover slowly over time.<ref>{{cite journal |author=Pearn J |title=Neurology of ciguatera |journal=J. Neurol. Neurosurg. Psychiatry |volume=70 |issue=1 |pages=4–8 |year=2001 |pmid=11118239 |doi=10.1136/jnnp.70.1.4 |pmc=1763481}}</ref>
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| ==Cause==
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| ''[[Gambierdiscus toxicus]]'' is the primary [[dinoflagellate]] responsible for the production of a number of similar [[polyether]] toxins, including [[ciguatoxin]], [[maitotoxin]], [[gambieric acid]] and [[scaritoxin]], as well as the [[Fatty alcohol|long-chain alcohol]] [[palytoxin]].<ref name=Identifying>Faust, MA and Gulledge RA. [http://botany.si.edu/references/dinoflag/Taxa/Gtoxicus.htm Identifying Harmful Marine Dynoflagellates.] Smithsonian Institution, Contributions from the United States National Herbarium. Volume 42:1-144. 2002.</ref><ref name=WHOI>National Office for Harmful Algal Blooms, [http://www.whoi.edu/redtide/page.do?pid=9679&tid=523&cid=27687 Ciguatera Fish Poisoning]. Woods Hole Oceanographic Institution.</ref> Other dinoflagellates that may cause ciguatera include ''[[Prorocentrum]]'' spp., ''[[Ostreopsis]]'' spp., ''[[Coolia monotis]]'', ''[[Thecadinium]]'' spp. and ''[[Amphidinium carterae]]''.<ref>National Office for Harmful Algal Blooms, [http://www.whoi.edu/redtide/human-health/ciguatera-fish-poisoning Ciguatera Fish Poisoning: Causative organisms:]. Woods Hole Oceanographic Institution.</ref>
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| ==Diagnosis==
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| Diagnosis is based on a person's symptoms together with having recently eaten fish.<ref name=Fri2017 /> If a number of those who eat the same fish have symptoms the diagnosis becomes more likely.<ref name=Fri2017 /> If some of the fish they had previously eaten is available this can also be tested to confirm the diagnosis.<ref name=Fri2017 /> Other potential causes such as [[paralytic shellfish poisoning]] (PSP), [[neurotoxic shellfish poisoning]] (NSP), [[scombrotoxin fish poisoning]], and [[pufferfish poisoning]] should be excluded.<ref name=Fri2017 />
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| The reversal of hot and cold sensations is an occasional symptom of CFP that may help differentiate it from [[viral gastroenteritis|intestinal "flu"]].<ref>{{cite journal |last1=Lehane |first1=Leigh |last2=Lewis |first2=Richard J |title=Ciguatera: recent advances but the risk remains |journal=International Journal of Food Microbiology |date=November 2000 |volume=61 |issue=2–3 |pages=91–125 |doi=10.1016/S0168-1605(00)00382-2|pmid=11078162 }}</ref>
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| ==Treatment==
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| There is no effective treatment or antidote for ciguatera poisoning. The mainstay of treatment is supportive care. There is some evidence that [[calcium channel blockers]] like [[nifedipine]] and [[verapamil]] are effective in treating some of the symptoms that remain after the initial sickness passes, such as poor circulation and shooting pains through the chest. These symptoms are due to [[vasoconstriction]] caused by [[maitotoxin]].<ref name=uhm /><ref>{{cite book |vauthors=Attaway D, Zaborsky O |title=Marine Biotechnology |page=8 |year=1993 }}</ref><ref>{{cite web |author=Fleming L |title=Ciguatera Fish Poisoning |url=http://www.whoi.edu/redtide/page.do?pid=9679&tid=523&cid=27687 |publisher=Woods Hole Oceanographic Institution}}</ref><ref>{{cite book |author=Schlossberg D |title=Infections of leisure |page=13 |year=1999 |isbn=978-3-540-94069-2}}</ref> Ciguatoxin lowers the threshold for opening [[voltage-gated sodium channel]]s in [[synapse]]s of the [[nervous system]]. Opening a sodium channel causes depolarization, which could sequentially cause paralysis, heart contraction, and changing the senses of hot and cold. Some medications such as [[amitriptyline]] may reduce some symptoms, such as [[fatigue (medical)|fatigue]] and [[paresthesia]],<ref>{{cite journal |doi=10.1056/NEJM198607033150115 |vauthors=Davis R, Villar L |title=Symptomatic improvement with amitriptyline in ciguatera fish poisoning |journal=N. Engl. J. Med. |volume=315 |issue=1 |page=65 |year=1986 |pmid=3713788}}</ref> although benefit does not occur in every case.<ref>{{cite journal |vauthors=Hampton M, Hampton A |title=Ciguatera fish poisoning |journal=J. Am. Acad. Dermatol. |volume=20 |issue=3 |pages=510–1 |year=1989 |pmid=2918120 |doi=10.1016/S0190-9622(89)80094-5}}</ref>
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| ===Mannitol===
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| [[Mannitol]] was once used for poisoning after one study reported symptom reversal.<ref name=uhm /><ref>{{cite journal |vauthors=Palafox N, Jain L, Pinano A, Gulick T, Williams R, Schatz I |title=Successful treatment of ciguatera fish poisoning with intravenous mannitol |journal=JAMA |volume=259 |issue=18 |pages=2740–2 |year=1988 |pmid=3128666 |doi=10.1001/jama.259.18.2740}}</ref> Follow-up studies in animals<ref>{{cite journal |vauthors=Mattei C, Molgó J, Marquais M, Vernoux J, Benoit E |title=Hyperosmolar D-mannitol reverses the increased membrane excitability and the nodal swelling caused by Caribbean ciguatoxin-1 in single frog myelinated axons |journal=Brain Res. |volume=847 |issue=1 |pages=50–8 |year=1999 |pmid=10564735 |doi=10.1016/S0006-8993(99)02032-6}}</ref> and case reports in humans<ref>{{cite journal |author=Williamson J |title=Ciguatera and mannitol: a successful treatment |journal=Med. J. Aust. |volume=153 |issue=5 |pages=306–7 |year=1990 |pmid=2118229}}</ref> also found benefit from mannitol. However, a randomized, [[double-blind]] [[clinical trial]] found no difference between mannitol and normal [[Saline (medicine)|saline]].<ref>{{cite journal |vauthors=Schnorf H, Taurarii M, Cundy T |title=Ciguatera fish poisoning: a double-blind randomized trial of mannitol therapy |journal=Neurology |volume=58 |issue=6 |pages=873–80 |year=2002 |pmid=11914401 |doi=10.1212/WNL.58.6.873}}</ref> Despite this its use may still be considered.<ref name=Fri2017 />
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| ==Epidemiology==
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| The current estimated global incidence annually is 20,000 to 50,000 people, though a large number of cases are believed to go unreported.<ref name="UpToDate 06-04-2015">{{Citation |last=Marcus |first=Erin N. |title=Ciguatera fish poisoning |url=http://www.uptodate.com/contents/ciguatera-fish-poisoning?source=related_link |accessdate=6 April 2015 }}</ref>
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| Due to the limited habitats of ciguatoxin-producing microorganisms, ciguatera is common only in [[subtropical]] and [[tropics|tropical waters]], particularly the Pacific and Caribbean, and usually is associated with fish caught in tropical reef waters.<ref name=Isbister-2005 /> Exportation of reef fish, as well as tourism, often account for cases that develop in other regions.<ref name="UpToDate 06-04-2015"/>
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| Ciguatoxin is found in over 400 species of reef fish. Avoiding consumption of all reef fish is the only sure way to avoid exposure.<ref name=Schep>{{cite journal |vauthors=Schep LJ, Slaughter RJ, Temple WA, Beasley DM |title=Ciguatera poisoning: an increasing occurrence in New Zealand |journal=N. Z. Med. J. |volume=123 |issue=1308 |pages=100–102 |year=2010 |pmid=20173810 |url=}}</ref> Imported fish served in restaurants may contain the toxin and produce illness which often goes unexplained by physicians unfamiliar with the symptoms of a tropical toxin.<ref name=Schep /><ref>{{cite journal |vauthors=Geller R, Olson K, Senécal P |title=Ciguatera fish poisoning in San Francisco, California, caused by imported barracuda |journal=West. J. Med. |volume=155 |issue=6 |pages=639–642 |year=1991 |pmid=1812639 |pmc=1003121}}</ref> Ciguatoxin can also occur in [[aquaculture|farm-raised]] [[salmon]].<ref>{{cite journal |vauthors=DiNubile M, Hokama Y |title=The ciguatera poisoning syndrome from farm-raised salmon |journal=Annals of Internal Medicine |volume=122 |issue=2 |pages=113–114 |year=1995 |pmid=7992985 |doi=10.7326/0003-4819-122-2-199501150-00006}}</ref> Furthermore, [[Seafood mislabelling#Seafood substitution|species substitution]], labeling a reef fish as a non-reef fish at restaurants and retail, can complicate efforts by consumers to avoid ciguatera.
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| ===20th and 21st centuries===
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| *In 1994, Nobel Prize winning novelist [[Saul Bellow]] nearly died from Ciguatera after eating red snapper on vacation in St. Martin, fictionalized in his last novel [[Ravelstein]].<ref>Leader, Zachary, ''The Life of Saul Bellow: Love and Strife 1965-2005'', p. 528.</ref>
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| *In 2007, ten people in [[St. Louis, Missouri]] developed the disease after eating imported fish.<ref>{{cite web|url=http://www.nbcnews.com/id/29392319 |title=Bizarre fish poisoning sparks alarm |publisher=NBC News |date=2019-05-01 |accessdate=2019-05-07}}</ref>
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| *In February 2008, the [[Food and Drug Administration (United States)|U.S. Food and Drug Administration]] (FDA) traced several outbreaks to the [[Flower Garden Banks National Marine Sanctuary]] in the northern [[Gulf of Mexico]], near the [[Texas]]–[[Louisiana]] shoreline. The FDA advised seafood processors that ciguatera poisoning was reasonably likely to occur from eating several species of fish caught as far as {{convert|50|mi|km}} from the sanctuary.<ref>{{cite press release | title = FDA Advises Seafood Processors About Ciguatera Fish Poisoning in the Northern Gulf of Mexico Near the Flower Garden Banks National Marine Sanctuary | publisher = [[Food and Drug Administration (United States)|U.S. Food and Drug Administration]] | date = 2008-02-05 | url = https://www.fda.gov/bbs/topics/NEWS/2008/NEW01790.html | accessdate = 2008-02-07}}</ref>
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| *From August 2010 to July 2011, there were eight outbreaks of Ciguatera fish poisoning in New York City. Outbreaks were linked to barracuda and grouper purchased at a fish market in Queens, New York.<ref>{{cite journal |pmid=23364271 |pmc=4604878 |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6204a1.htm |year=2013 |author1=Centers for Disease Control and Prevention (CDC) |title=Ciguatera fish poisoning - New York City, 2010-2011 |volume=62 |issue=4 |pages=61–5 |journal=MMWR. Morbidity and Mortality Weekly Report}}</ref>
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| *In the first quarter of 2012, two restaurants in [[Lanzarote]], [[Canary Islands]] are thought to have been the source of ciguatera poisoning, leading to new fishing regulations issued 18 April 2012. The first outbreak was reported in February 2012. Diners suffered with vomiting, diarrhoea and abdominal pain several hours after eating amberjack. The second case was in early April affecting six people who live in Lanzarote and had all eaten amberjack at a local restaurant.<ref>{{cite news|last1=Cliffe-Jones|first1=Mike Jules|title=Isolated Cases of Ciguatera Poisoning in Lanzarote|url=http://www.lanzaroteinformation.com/content/isolated-cases-ciguatera-poisoning-lanzarote|accessdate=31 October 2015|work=Information Lanzarote|publisher=Information Lanzarote|date=April 17, 2012}}</ref>
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| *In March 2014, nine people were hospitalised near Macksville, New South Wales, Australia after a recreational fisherman caught a 55 lb Spanish Mackerel (Scomberomorus commerson) off Scott's Head (NSW) and then shared it among his friends and family.<ref>{{Cite news|url=http://www.abc.net.au/news/2014-03-04/nine-victims-of-ciguatera-poisoning-from-fish-caught-off-scotts/5296808|title=Ciguatera poisoning from Spanish Mackerel caught off Scotts Head|date=2014-03-04|work=ABC News|access-date=2017-10-16}}</ref>
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| *In April 2015, fourteen crew members of a potash ship were hospitalized in Saint John, New Brunswick, Canada after consuming tropical fish obtained from international waters.<ref>{{cite news |title=Balsa 85 ID'd as ship in Saint John whose crew was hit by food poisoning |url=https://www.cbc.ca/news/canada/new-brunswick/balsa-85-id-d-as-ship-in-saint-john-whose-crew-was-hit-by-food-poisoning-1.3029780 |accessdate=31 October 2015 |work=CBC New Brunswick |agency=CBC |publisher=CBC |date=13 April 2015}}</ref> After the incident, Marine Catering Services issued a reminder to seafarers that the UK Food Act makes it illegal for crews to fish for food from their vessels.<ref>{{cite news |title=Seafarers told no fishing! |work=The Sea|issue=236 |publisher=Mission to Seafarers Limited |date=Jul–Aug 2015}}</ref>
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| *In September 2016, a British holidaymaker died while on honeymoon in Mexico after consuming fish contaminated with the algae that causes ciguatera poisoning.<ref name=Telegraph-2016-10-13>{{cite news|url=https://www.telegraph.co.uk/news/2016/10/13/newlywed-bride-dies-10-days-after-wedding-from-heart-attack-beli/ |title=Newlywed bride dies 10 days after wedding from heart attack believed to have been caused by 'contaminated fish' |publisher=Telegraph Media Group |newspaper=The Daily Telegraph |date=13 October 2016 |accessdate=14 October 2016}}</ref> During October 2016, more than 100 people suffered from ciguatera poisoning after eating fish heads supplied by an export firm in Mangalore, India.<ref>{{cite news|url=http://timesofindia.indiatimes.com/city/mangaluru/Love-your-fish-Then-know-about-seafood-poisoning-too/articleshow/54666846.cms |title=Love your fish? Then know about seafood poisoning too |newspaper=Times of India |publisher= |date=4 October 2016 |accessdate=14 October 2016}}</ref>
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| ==History==
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| Ciguatera was first described by one of the surgeon's mates, [[William Anderson (naturalist)|William Anderson]], on the crew of {{HMS|Resolution|1771|6}} in 1774.<ref>{{cite news |title=Fish Tale|url=https://www.nytimes.com/2010/04/11/magazine/11FOB-diagnosis-t.html?ref=magazine |quote=The illness was first described in 1774 by a surgeon's mate on the crew of Captain Cook's South Pacific exploration aboard HMS Resolution. The crewman, John Anderson, documented the symptoms described by several shipmates who had eaten a large fish caught in the tropical waters. |work=[[The New York Times]] |date=April 5, 2010 |accessdate=2010-04-10 | first1=Lisa | last1=Sanders}} (''The New York Times'' incorrectly gives William Anderson's first name as John.)</ref>
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| Researchers suggest that ciguatera outbreaks caused by warm climatic conditions in part propelled the [[History of the Polynesian people|migratory voyages of Polynesians]] between 1000 and 1400AD.<ref>{{cite journal |doi=10.1111/j.1365-2699.2009.02139.x |title=Did ciguatera prompt the late Holocene Polynesian voyages of discovery? |year=2009 |last1=Rongo |first1=Teina |last2=Bush |first2=Mark |last3=Van Woesik |first3=Robert |journal=Journal of Biogeography |volume=36 |issue=8 |pages=1423–32}}</ref><ref>{{cite news |title=Did fish poisoning drive Polynesian colonization of the Pacific? |url=http://news.mongabay.com/2009/0707-morgan_ciguatera.html |accessdate=1 June 2018 |work=news.mongabay.com |date=7 July 2009}}</ref>
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| ===Folk tales===
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| {{refimprove section|date=October 2014}}
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| In Northern Australia, where ciguatera is a common problem, two different [[folk science]] methods are widely believed to detect whether fish harbor significant ciguatoxin. The first method is that flies are supposed not to land on contaminated fish. The second is that cats will either refuse to eat or vomit/display symptoms after eating contaminated fish. A third, less common testing method involves putting a silver coin under the scales of the suspect fish. If the coin turns black, according to the theory, it is contaminated.
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| On [[Grand Cayman]] and other islands the locals will test barracuda by placing a piece of the fish on the ground and allowing ants to crawl on it. If the ants do not avoid the flesh and will eat it, then the fish is deemed safe. {{citation needed|date=January 2014}}
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| In Dominican Republic, another common belief is that during months whose names do not include the letter "R" (May through August), it is not recommended to eat certain kinds of fish, because they are more likely to be infected by the ciguatera toxin.
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| The validity of many of these tests has been scientifically rejected.<ref>{{cite journal|last1=Park|first1=D. L.|title=Evaluation of methods for assessing ciguatera toxins in fish.|journal=Reviews of Environmental Contamination and Toxicology|date=1994|volume=136|pages=1–20|pmid=8029489}}</ref>
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| === Folk remedies ===
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| Leaves of ''[[Heliotropium foertherianum]]'' (Boraginaceae) – also known as ''octopus bush'' – are used in many Pacific islands as a traditional medicine to treat ciguatera fish poisoning. Senescent octopus bush leaves contain [[rosmarinic acid]] and derivatives, which are known for their [[Antiviral drug|antiviral]], [[antibacterial]], [[antioxidant]], and [[anti-inflammatory]] properties.<ref>{{cite journal |doi=10.1016/j.jep.2012.05.045 |title=Protective effect of Heliotropium foertherianum (Boraginaceae) folk remedy and its active compound, rosmarinic acid, against a Pacific ciguatoxin |year=2012 |last1=Rossi |first1=Fanny |last2=Jullian |first2=Valérie |last3=Pawlowiez |first3=Ralph |last4=Kumar-Roiné |first4=Shilpa |last5=Haddad |first5=Mohamed |last6=Darius |first6=H. Taiana |last7=Gaertner-Mazouni |first7=Nabila |last8=Chinain |first8=Mireille |last9=Laurent |first9=Dominique |journal=Journal of Ethnopharmacology |volume=143 |pages=33–40 |pmid=22706150 |issue=1 }}</ref> Rosmarinic acid may remove the [[ciguatoxin]]s from their sites of action, as well as being an anti-inflammatory.
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| An account of ciguatera poisoning from a linguistics researcher living on Malakula island, [[Vanuatu]], indicates the local treatment: "We had to go with what local people told us: avoid salt and any seafood. Eat sugary foods. And they gave us a tea made from the roots of ferns growing on tree trunks. I don't know if any of that helped, but after a few weeks, the symptoms faded away".<ref>{{cite journal |last=Dimock |first=Laura |title=Rescue mission for fading tongue |url=http://www.educationreview.co.nz/teach-international/june-2010/rescue-mission-for-fading-tongue/ |journal=New Zealand Education Review |date=June 2010 |access-date=2014-01-04 |archive-url=https://web.archive.org/web/20140104205240/http://www.educationreview.co.nz/teach-international/june-2010/rescue-mission-for-fading-tongue/ |archive-date=2014-01-04 |url-status=dead }}</ref>
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| Various Caribbean folk and ritualistic treatments originated in [[Cuba]] and nearby islands. The most common old-time remedy involves bed rest subsequent to a [[guanabana]] juice [[enema]].{{Citation needed|date=June 2010}} In [[Puerto Rico]], natives drink a [[tea]] made from [[mangrove]] buttons, purportedly high in [[B vitamins]], to flush the toxic symptoms from the system.{{Citation needed|date=June 2010}} There has never been a funded study of these treatments. Other folk treatments range from directly porting and bleeding the gastrointestinal tract to "cleansing" the diseased with a dove during a [[Santería]] ritual.{{Citation needed|date=June 2010}}
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| == See also ==
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| *[[Algal bloom]]
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| *[[Gambierdiscus toxicus]]
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| *[[Red tide]]
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| *[[Yessotoxin]]
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| ==Footnotes==
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| {{reflist}}
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| ==References==
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| *[https://www.cdc.gov/nceh/ciguatera/default.htm Ciguatera fish poisoning [[Centers for Disease Control and Prevention|CDC]] ]
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| *{{cite journal|pmc=5367029|year = 2017|last1 = Friedman|first1 = M. A.|title = An Updated Review of Ciguatera Fish Poisoning: Clinical, Epidemiological, Environmental, and Public Health Management|journal = Marine Drugs|volume = 15|issue = 3|page = 72|last2 = Fernandez|first2 = M.|last3 = Backer|first3 = L. C.|last4 = Dickey|first4 = R. W.|last5 = Bernstein|first5 = J.|last6 = Schrank|first6 = K.|last7 = Kibler|first7 = S.|last8 = Stephan|first8 = W.|last9 = Gribble|first9 = M. O.|last10 = Bienfang|first10 = P.|last11 = Bowen|first11 = R. E.|last12 = Degrasse|first12 = S.|last13 = Flores Quintana|first13 = H. A.|last14 = Loeffler|first14 = C. R.|last15 = Weisman|first15 = R.|last16 = Blythe|first16 = D.|last17 = Berdalet|first17 = E.|last18 = Ayyar|first18 = R.|last19 = Clarkson-Townsend|first19 = D.|last20 = Swajian|first20 = K.|last21 = Benner|first21 = R.|last22 = Brewer|first22 = T.|last23 = Fleming|first23 = L. E.|pmid = 28335428|doi = 10.3390/md15030072}}
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| {{plankton}}
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| {{Poisoning and toxicity}} | | {{Poisoning and toxicity}} |
| | | [[Category:Foodborne illnesses]] |
| [[Category:Toxic effect of noxious substances eaten as food]] | | [[Category:Marine toxins]] |
| [[Category:Fish and humans]] | | [[Category:Tropical diseases]] |
| [[Category:RTT]] | | [[Category:Reef fish]] |
| | [[Category:Rare diseases]] |
| {{stub}} | | {{stub}} |
| | <gallery> |
| | File:Ciguatoxin.svg|Ciguatera fish poisoning |
| | </gallery> |
