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Ciguatera
From WikEM
Contents
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 and envenomations
- Toxins
- Scombroid
- Ciguatera
- Neurotoxic shellfish poisoning
- Paralytic shellfish poisoning
- Tetrodotoxin (e.g. pufferfish)
- Stingers
- Venomous fish (catfish, zebrafish, scorpion fish, stonefish)
- Lionfish
- Sea urchins
- Cone shells
- Nematocysts
- Jellyfish (Cnidaria)
- Portuguese man-of-war
- Coral reef
- Fire Corals
- Sea anemones
- Sea wasps
- Bites
Evaluation
- Clinical diagnosis
Management
- Symptomatic therapies are the mainstay of treatment
- Antiemetics and IVF
- Atropine for bradycardia
- 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
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.
