Ciguatera fish poisoning

Foodborne illness

Ciguatera fish poisoning
Synonyms	Ciguatera, ciguatera food poisoning
Pronounce
Field
Symptoms	Diarrhea, vomiting, numbness, itchiness, sensitivity to hot and cold, dizziness, weakness<ref name=Fri2017/><ref name=Yellow2018/>
Complications
Onset	30 min to 2 days<ref name=FAO2004/>
Duration	Few weeks to months<ref name=FAO2004/>
Types
Causes	Ciguatoxin and maitotoxin within certain reef fish<ref name=Yellow2018/>
Risks	Barracuda, grouper, moray eel, amberjack, sea bass, surgeon fish.<ref name=Yellow2018/>
Diagnosis	Based on symptoms and recently eating fish<ref name=Fri2017/>
Differential diagnosis	Paralytic shellfish poisoning, neurotoxic shellfish poisoning, scombroid food poisoning, pufferfish poisoning<ref name=Fri2017/>
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 simply as ciguatera, is a foodborne illness caused by eating reef fish whose flesh is contaminated with certain toxins.<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 slow heart rate and low blood pressure may also occur.<ref name=Yellow2018/>

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 They are originally made by a small marine organism, Gambierdiscus toxicus, that grow on and around coral reefs in tropical and subtropical waters.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 more concentrated as they move up the food chain.<ref name=FAO2004>,

 Marine biotoxins, 
  
 Food and Agriculture Organization, 
  
  
  
 ISBN 978-92-5-105129-0,</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/>

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>

Food Poisoning from Marine Toxins - Chapter 2 - 2018 Yellow Book(link). CDC.

2017.

This article incorporates text from this source, which is in the public domain.</ref> Mannitol may be considered, but the evidence supporting its use is not very strong.<ref name=Fri2017>,

 An Updated Review of Ciguatera Fish Poisoning: Clinical, Epidemiological, Environmental, and Public Health Management., 
 Marine Drugs, 
 
 Vol. 15(Issue: 3),
 
 DOI: 10.3390/md15030072,
 PMID: 28335428,
 PMC: 5367029,</ref> Gabapentin or amitriptyline may be used to treat some of the symptoms.<ref name=Yellow2018/>

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/>

Signs and symptoms

Hallmark symptoms of ciguatera in humans include gastrointestinal, cardiovascular, and neurological effects.<ref name=Isbister-2005>,

 Neurotoxic marine poisoning, 
 The Lancet Neurology, 
 2005,
 Vol. 4(Issue: 4),
 pp. 219–28,
 DOI: 10.1016/S1474-4422(05)70041-7,
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 A review of selected seafood poisonings, 
 Undersea Hyperb Med, 
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 PMID: 10485519,
 
 
 Full text,</ref> Gastrointestinal symptoms include nausea, vomiting, and diarrhea, usually followed by neurological symptoms such as headaches, muscle aches, paresthesia, numbness of extremities, mouth and lips, reversal of hot and cold sensation,<ref>Patel, Ryan, 
 Ionic mechanisms of spinal neuronal cold hypersensitivity in ciguatera, 
 The European Journal of Neuroscience, 
 
 Vol. 42(Issue: 11),
 pp. 3004–3011,
 DOI: 10.1111/ejn.13098,
 PMID: 26454262,
 PMC: 4744673,</ref><ref>Vetter, Irina, 
 Ciguatoxins activate specific cold pain pathways to elicit burning pain from cooling, 
 The EMBO Journal, 
 
 Vol. 31(Issue: 19),
 pp. 3795–3808,
 DOI: 10.1038/emboj.2012.207,
 PMID: 22850668,
 PMC: 3463840,</ref> ataxia, vertigo, and hallucinations.<ref name=Swift-1993>, 
 Ciguatera, 
 J. Toxicol. Clin. Toxicol., 
 1993,
 Vol. 31(Issue: 1),
 pp. 1–29,
 DOI: 10.3109/15563659309000371,
 PMID: 8433404,</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>, 
 Ciguatera poisoning: a global issue with common management problems, 
 Eur. J. Emerg. Med., 
 2001,
 Vol. 8(Issue: 4),
 pp. 295–300,
 DOI: 10.1097/00063110-200112000-00009,
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 Full text,</ref> Cardiovascular symptoms include bradycardia, tachycardia, hypotension, hypertension, orthostatic tachycardia, exercise intolerance, and rhythm disorders.<ref>Hokama, Y., 
 Ciguatera fish poisoning, 
 Journal of Clinical Laboratory Analysis, 
 
 Vol. 2(Issue: 1),
 pp. 44–50,
 DOI: 10.1002/jcla.1860020110,</ref> Death from the condition can occur, but is very rare.<ref name=Telegraph-2016-10-13 />

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>,

 Can ciguatera be a sexually transmitted disease?, 
 J. Toxicol. Clin. Toxicol., 
 1989,
 Vol. 27(Issue: 3),
 pp. 193–7,
 DOI: 10.3109/15563658909038583,
 PMID: 2810444,</ref> Diarrhea and facial rashes have been reported in breastfed infants of poisoned mothers, suggesting that ciguatera toxins migrate into breast milk.<ref>, 
 Mother's milk turns toxic following fish feast, 
 JAMA, 
 1990,
 Vol. 264(Issue: 16),
 
 DOI: 10.1001/jama.264.16.2074b,
 PMID: 2214071,</ref>

The symptoms can last from weeks to years, and in extreme cases as long as 20 years, often leading to long-term disability.<ref>,

 Ciguatera in Australia. Occurrence, clinical features, pathophysiology and management, 
 Med. J. Aust., 
 1986,
 Vol. 145(Issue: 11–12),
 pp. 584–90,
 
 PMID: 2432386,</ref> Most people do recover slowly over time.<ref>Pearn J, 
 Neurology of ciguatera, 
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 2001,
 Vol. 70(Issue: 1),
 pp. 4–8,
 DOI: 10.1136/jnnp.70.1.4,
 PMID: 11118239,
 PMC: 1763481,</ref>

Cause

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 long-chain alcohol palytoxin.<ref name=Identifying>Faust, MA and Gulledge RA. 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, 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, Ciguatera Fish Poisoning: Causative organisms:. Woods Hole Oceanographic Institution.</ref>

Diagnosis

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 />

The reversal of hot and cold sensations is an occasional symptom of CFP that may help differentiate it from intestinal "flu".<ref>,

 Ciguatera: recent advances but the risk remains, 
 International Journal of Food Microbiology, 
 
 Vol. 61(Issue: 2–3),
 pp. 91–125,
 DOI: 10.1016/S0168-1605(00)00382-2,
 PMID: 11078162,</ref>

Treatment

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>,

 Marine Biotechnology, 
  
  
 1993,</ref><ref>

Fleming L. Ciguatera Fish Poisoning(link). {{{website}}}. Woods Hole Oceanographic Institution.

</ref><ref>{{{last}}},

 Schlossberg D, 
  
 Infections of leisure, 
  
  
 1999, 
  
  
 ISBN 978-3-540-94069-2,</ref> Ciguatoxin lowers the threshold for opening voltage-gated sodium channels in synapses 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 and paresthesia,<ref>, 
 Symptomatic improvement with amitriptyline in ciguatera fish poisoning, 
 N. Engl. J. Med., 
 1986,
 Vol. 315(Issue: 1),
 
 DOI: 10.1056/NEJM198607033150115,
 PMID: 3713788,</ref> although benefit does not occur in every case.<ref>, 
 Ciguatera fish poisoning, 
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 1989,
 Vol. 20(Issue: 3),
 pp. 510–1,
 DOI: 10.1016/S0190-9622(89)80094-5,
 PMID: 2918120,</ref>

Mannitol

Mannitol was once used for poisoning after one study reported symptom reversal.<ref name=uhm /><ref>,

 Successful treatment of ciguatera fish poisoning with intravenous mannitol, 
 JAMA, 
 1988,
 Vol. 259(Issue: 18),
 pp. 2740–2,
 DOI: 10.1001/jama.259.18.2740,
 PMID: 3128666,</ref> Follow-up studies in animals<ref>, 
 Hyperosmolar D-mannitol reverses the increased membrane excitability and the nodal swelling caused by Caribbean ciguatoxin-1 in single frog myelinated axons, 
 Brain Res., 
 1999,
 Vol. 847(Issue: 1),
 pp. 50–8,
 DOI: 10.1016/S0006-8993(99)02032-6,
 PMID: 10564735,</ref> and case reports in humans<ref>Williamson J, 
 Ciguatera and mannitol: a successful treatment, 
 Med. J. Aust., 
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 Vol. 153(Issue: 5),
 pp. 306–7,
 
 PMID: 2118229,</ref> also found benefit from mannitol. However, a randomized, double-blind clinical trial found no difference between mannitol and normal saline.<ref>, 
 Ciguatera fish poisoning: a double-blind randomized trial of mannitol therapy, 
 Neurology, 
 2002,
 Vol. 58(Issue: 6),
 pp. 873–80,
 DOI: 10.1212/WNL.58.6.873,
 PMID: 11914401,</ref> Despite this its use may still be considered.<ref name=Fri2017 />

Epidemiology

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"> </ref>

Due to the limited habitats of ciguatoxin-producing microorganisms, ciguatera is common only in subtropical and 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"/>

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>,

 Ciguatera poisoning: an increasing occurrence in New Zealand, 
 N. Z. Med. J., 
 2010,
 Vol. 123(Issue: 1308),
 pp. 100–102,
 
 PMID: 20173810,</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>, 
 Ciguatera fish poisoning in San Francisco, California, caused by imported barracuda, 
 West. J. Med., 
 1991,
 Vol. 155(Issue: 6),
 pp. 639–642,
 
 PMID: 1812639,
 PMC: 1003121,</ref> Ciguatoxin can also occur in farm-raised salmon.<ref>, 
 The ciguatera poisoning syndrome from farm-raised salmon, 
 Annals of Internal Medicine, 
 1995,
 Vol. 122(Issue: 2),
 pp. 113–114,
 DOI: 10.7326/0003-4819-122-2-199501150-00006,
 PMID: 7992985,</ref>  Furthermore, species substitution, labeling a reef fish as a non-reef fish at restaurants and retail, can complicate efforts by consumers to avoid ciguatera.

20th and 21st centuries

• 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>
• In 2007, ten people in St. Louis, Missouri developed the disease after eating imported fish.<ref>

Bizarre fish poisoning sparks alarm(link). {{{website}}}. NBC News. 2019-05-01.

</ref>

• In February 2008, the 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 50 miles (80 km) from the sanctuary.<ref>

</ref>

• 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>,

 Ciguatera fish poisoning - New York City, 2010-2011, 
 MMWR. Morbidity and Mortality Weekly Report, 
 2013,
 Vol. 62(Issue: 4),
 pp. 61–5,
 
 PMID: 23364271,
 PMC: 4604878,
 
 Full text,</ref>

• 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>

,

 Isolated Cases of Ciguatera Poisoning in Lanzarote Full text, 
 Information Lanzarote, 
 Information Lanzarote, 
 April 17, 2012,

</ref>

• 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>

,

 Ciguatera poisoning from Spanish Mackerel caught off Scotts Head Full text, 
 ABC News, 
  
 2014-03-04, 
  
  
 Accessed on: 2017-10-16.

</ref>

• 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>

,

 Balsa 85 ID'd as ship in Saint John whose crew was hit by food poisoning Full text, 
 CBC New Brunswick, 
 CBC, 
 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> ,

 Seafarers told no fishing! , 
 The Sea, 
 Mission to Seafarers Limited, 
 Jul–Aug 2015,

</ref>

• 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>

,

 Newlywed bride dies 10 days after wedding from heart attack believed to have been caused by 'contaminated fish' Full text, 
 , 
 Telegraph Media Group, 
 13 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> ,

 Love your fish? Then know about seafood poisoning too Full text, 
 , 
  
 4 October 2016,

</ref>

History

Ciguatera was first described by one of the surgeon's mates, William Anderson, on the crew of Template:HMS in 1774.<ref> ,

 Fish Tale Full text, 
 The New York Times, 
  
 April 5, 2010,
(The New York Times incorrectly gives William Anderson's first name as John.)</ref>

Researchers suggest that ciguatera outbreaks caused by warm climatic conditions in part propelled the migratory voyages of Polynesians between 1000 and 1400AD.<ref>,

 Did ciguatera prompt the late Holocene Polynesian voyages of discovery?, 
 Journal of Biogeography, 
 2009,
 Vol. 36(Issue: 8),
 pp. 1423–32,
 DOI: 10.1111/j.1365-2699.2009.02139.x,</ref><ref>

,

 Did fish poisoning drive Polynesian colonization of the Pacific? Full text, 
 news.mongabay.com, 
  
 7 July 2009,

</ref>

Folk tales

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.

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. ^{(January 2014)}

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.

The validity of many of these tests has been scientifically rejected.<ref>,

 Evaluation of methods for assessing ciguatera toxins in fish., 
 Reviews of Environmental Contamination and Toxicology, 
 
 Vol. 136,
 pp. 1–20,
 
 PMID: 8029489,</ref>

Folk remedies

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, antibacterial, antioxidant, and anti-inflammatory properties.<ref>,

 Protective effect of Heliotropium foertherianum (Boraginaceae) folk remedy and its active compound, rosmarinic acid, against a Pacific ciguatoxin, 
 Journal of Ethnopharmacology, 
 2012,
 Vol. 143(Issue: 1),
 pp. 33–40,
 DOI: 10.1016/j.jep.2012.05.045,
 PMID: 22706150,</ref> Rosmarinic acid may remove the ciguatoxins from their sites of action, as well as being an anti-inflammatory.

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>Dimock, Laura,

 Rescue mission for fading tongue, 
 New Zealand Education Review, 
 
 
 
 
 
 
 
 Full text,
 Accessed on: 2014-01-04.</ref>

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. ^{(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.

^{(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.

^{(June 2010)}

See also

• Algal bloom
• Gambierdiscus toxicus
• Red tide
• Yessotoxin

References

• Ciguatera fish poisoning CDC
• ,

 An Updated Review of Ciguatera Fish Poisoning: Clinical, Epidemiological, Environmental, and Public Health Management, 
 Marine Drugs, 
 2017,
 Vol. 15(Issue: 3),
 
 DOI: 10.3390/md15030072,
 PMID: 28335428,
 PMC: 5367029,

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