Ciguatera fish poisoning
- Erin N Marcus, MD, MPH, FACP
Erin N Marcus, MD, MPH, FACP
- Associate Professor of Clinical Medicine
- University of Miami Miller School of Medicine
- Section Editors
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics
- Harvard Medical School
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Daniel F Danzl, MD
Daniel F Danzl, MD
- Section Editor — Environmental Emergencies
- Professor of Emergency Medicine
- University of Louisville School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This topic describes the clinical manifestations, diagnosis, and management of ciguatera poisoning. Poisoning caused by ingestion of other seafood (eg, scombroid fish, shellfish, or pufferfish) is discussed in detail separately. (See "Overview of shellfish and pufferfish poisoning" and "Scombroid (histamine) poisoning".)
Ciguatera fish poisoning is a foodborne illness that is caused by ingestion of reef fish (eg, barracuda, amberjack, moray eel, and certain types of grouper, snapper, or parrotfish) that are contaminated with toxins that arise from Gambierdiscus toxicus, a single-celled organism that grows on coral reefs. Ciguatera fish poisoning accounts for approximately 20 percent of the fish-related foodborne disease outbreaks in the United States , and is a common fish food poisoning in tropical coastal regions . Approximately 20,000 to 50,000 people develop this poisoning annually worldwide , although this may be an underestimate because of missed diagnoses and underreporting . In the United States, an estimated 16,000 cases occur annually, resulting in more than 300 hospitalizations but fewer than five deaths .
Estimates of lifetime prevalence of ciguatera fish poisoning range from 7 percent in Puerto Rico  to 70 percent in the Polynesian Islands . Most cases originate in the tropics and subtropics, between 35 degrees north latitude and 35 degrees south latitude. However, cases of ciguatera toxicity may also occur in more temperate regions because of increasing tourism, fish exportation, and unusual fish migration. Multiple cases of ciguatera fish poisoning have also been reported after ingestion of imported fish purchased at markets in New York City  and in northern Germany , as well as fish imported to Paris from Guadeloupe . In addition, two cases of ciguatera fish poisoning have been reported following consumption of fish (barracuda) caught off the coast of South Carolina, well north of the typical location for such poisoning .
Some experts postulate that increasing seawater temperature due to climate change may increase the frequency of ciguatera fish poisoning, because the organisms that produce the toxin thrive in warmer waters and could potentially migrate to nontraditional areas .However, a 2013 analysis reported that the incidence of ciguatera poisoning has not increased in the US Virgin Islands over the past 30 years despite an overall increase in seawater temperatures at that site .
More than 400 different fish species have been associated with ciguatera fish toxicity. Reef-dwelling tropical fish such as barracuda, moray eel, amberjack, and certain types of grouper, mackerel, parrotfish, and red snapper are the most common sources. Rare cases exist of ciguatera fish poisoning occurring after the ingestion of temperate fish, including farm-raised salmon . In general, however, toxicity from nontropical fish is extremely rare.
- Outbreak alert. Closing the gaps in our federal food-safety net. Centers for Science in the Public Interest (CSPI), Washington, DC, 2008. http://cspinet.org/new/pdf/outbreak_alert_2008_report_final.pdf (Accessed on July 09, 2013).
- Glaziou P, Legrand AM. The epidemiology of ciguatera fish poisoning. Toxicon 1994; 32:863.
- Whittle K, Gallacher S. Marine toxins. Br Med Bull 2000; 56:236.
- Dickey RW, Plakas SM. Ciguatera: a public health perspective. Toxicon 2010; 56:123.
- Pennotti R, Scallan E, Backer L, et al. Ciguatera and scombroid fish poisoning in the United States. Foodborne Pathog Dis 2013; 10:1059.
- Holt RJ, Miro G, Del Valle A. An analysis of poison control center reports of ciguatera toxicity in Puerto Rico for one year. J Toxicol Clin Toxicol 1984; 22:177.
- Lewis ND. Disease and development: ciguatera fish poisoning. Soc Sci Med 1986; 23:983.
- Centers for Disease Control and Prevention (CDC). Ciguatera fish poisoning - New York City, 2010-2011. MMWR Morb Mortal Wkly Rep 2013; 62:61.
- Mattei C, Vetter I, Eisenblätter A, et al. Ciguatera fish poisoning: a first epidemic in Germany highlights an increasing risk for European countries. Toxicon 2014; 91:76.
- Epelboin L, Pérignon A, Hossen V, et al. Two clusters of ciguatera fish poisoning in Paris, France, related to tropical fish imported from the French Caribbean by travelers. J Travel Med 2014; 21:397.
- Centers for Disease Control and Prevention (CDC). Ciguatera fish poisoning--Texas, 1998, and South Carolina, 2004. MMWR Morb Mortal Wkly Rep 2006; 55:935.
- Tester PA, Feldman RL, Nau AW, et al. Ciguatera fish poisoning and sea surface temperatures in the Caribbean Sea and the West Indies. Toxicon 2010; 56:698.
- Radke EG, Grattan LM, Cook RL, et al. Ciguatera incidence in the US Virgin Islands has not increased over a 30-year time period despite rising seawater temperatures. Am J Trop Med Hyg 2013; 88:908.
- DiNubile MJ, Hokama Y. The ciguatera poisoning syndrome from farm-raised salmon. Ann Intern Med 1995; 122:113.
- Baden DG, Fleming LE, Bean JA. Marine Toxins. In: Handbook of Clinical Neurology, deWolff, FA (Eds), Elsevier Science B V, New York 1995. p.149.
- Mines D, Stahmer S, Shepherd SM. Poisonings: food, fish, shellfish. Emerg Med Clin North Am 1997; 15:157.
- Sobel J, Painter J. Illnesses caused by marine toxins. Clin Infect Dis 2005; 41:1290.
- Lipp EK, Rose JB. The role of seafood in foodborne diseases in the United States of America. Rev Sci Tech 1997; 16:620.
- Lehane L. Ciguatera update. Med J Aust 2000; 172:176.
- Zhang X, Cao B, Wang J, et al. Neurotoxicity and reactive astrogliosis in the anterior cingulate cortex in acute ciguatera poisoning. Neuromolecular Med 2013; 15:310.
- Clark RF, Williams SR, Nordt SP, Manoguerra AS. A review of selected seafood poisonings. Undersea Hyperb Med 1999; 26:175.
- Friedman MA, Fleming LE, Fernandez M, et al. Ciguatera fish poisoning: treatment, prevention and management. Mar Drugs 2008; 6:456.
- Pearn J. Neurology of ciguatera. J Neurol Neurosurg Psychiatry 2001; 70:4.
- Bagnis R, Kuberski T, Laugier S. Clinical observations on 3,009 cases of ciguatera (fish poisoning) in the South Pacific. Am J Trop Med Hyg 1979; 28:1067.
- Oh SY, Kim DH, Seo MW, Shin BS. Reversible cerebellar dysfunction associated with ciguatera fish poisoning. J Emerg Med 2012; 43:674.
- Gatti C, Oelher E, Legrand AM. Severe seafood poisoning in French Polynesia: a retrospective analysis of 129 medical files. Toxicon 2008; 51:746.
- Quod JP, Turquet J. Ciguatera in Réunion Island (SW Indian Ocean): epidemiology and clinical patterns. Toxicon 1996; 34:779.
- Withers NW. Ciguatera fish poisoning. Annu Rev Med 1982; 33:97.
- Lawrence DN, Enriquez MB, Lumish RM, Maceo A. Ciguatera fish poisoning in Miami. JAMA 1980; 244:254.
- Begier EM, Backer LC, Weisman RS, et al. Outbreak bias in illness reporting and case confirmation in ciguatera fish poisoning surveillance in south Florida. Public Health Rep 2006; 121:658.
- Friedman MA, Arena P, Levin B, et al. Neuropsychological study of ciguatera fish poisoning: a longitudinal case-control study. Arch Clin Neuropsychol 2007; 22:545.
- Bilic E, Hajnsek S, Kello N, et al. Neurotoxin-induced fibromyalgia or fibromyalgia after ciguatera (tilapia fish) poisoning? Neurol Croat 2014; 63:1.
- Centers for Disease Control and Prevention (CDC). Cluster of ciguatera fish poisoning--North Carolina, 2007. MMWR Morb Mortal Wkly Rep 2009; 58:283.
- Pearn JH. Chronic fatigue syndrome: chronic ciguatera poisoning as a differential diagnosis. Med J Aust 1997; 166:309.
- Chan TY. Lengthy persistence of ciguatoxin in the body. Trans R Soc Trop Med Hyg 1998; 92:662.
- Gillespie NC, Lewis RJ, Pearn JH, et al. Ciguatera in Australia. Occurrence, clinical features, pathophysiology and management. Med J Aust 1986; 145:584.
- Lewis RJ. The changing face of ciguatera. Toxicon 2001; 39:97.
- Lange WR, Snyder FR, Fudala PJ. Travel and ciguatera fish poisoning. Arch Intern Med 1992; 152:2049.
- Granade, HR. Ciguatoxin. Bad bug book-Foodborne pathogenic microorganisms and natural toxins handbook, 2nd edition, Food and Drug Administration, 2012, p. 176 . http://www.fda.gov/downloads/Food/FoodSafety/FoodborneIllness/FoodborneIllnessFoodbornePathogensNaturalToxins/BadBugBook/UCM297627.pdf (Accessed on February 03, 2013).
- Isbister GK, Kiernan MC. Neurotoxic marine poisoning. Lancet Neurol 2005; 4:219.
- Senthilkumaran S, Meenakshisundaram R, Michaels AD, et al. Cardiovascular Complications in Ciguatera Fish Poisoning: A Wake-up Call. Heart Views 2011; 12:166.
- Hung YM, Hung SY, Chou KJ, et al. Short report: persistent bradycardia caused by ciguatoxin poisoning after barracuda fish eggs ingestion in southern Taiwan. Am J Trop Med Hyg 2005; 73:1026.
- Lawrence DT, Dobmeier SG, Bechtel LK, Holstege CP. Food poisoning. Emerg Med Clin North Am 2007; 25:357.
- Benoit E, Juzans P, Legrand AM, Molgo J. Nodal swelling produced by ciguatoxin-induced selective activation of sodium channels in myelinated nerve fibers. Neuroscience 1996; 71:1121.
- Palafox NA, Jain LG, Pinano AZ, et al. Successful treatment of ciguatera fish poisoning with intravenous mannitol. JAMA 1988; 259:2740.
- Schwarz ES, Mullins ME, Brooks CB. Ciguatera poisoning successfully treated with delayed mannitol. Ann Emerg Med 2008; 52:476.
- Eastaugh JA. Delayed use of intravenous mannitol in ciguatera (fish poisoning). Ann Emerg Med 1996; 28:105.
- Schnorf H, Taurarii M, Cundy T. Ciguatera fish poisoning: a double-blind randomized trial of mannitol therapy. Neurology 2002; 58:873.
- Perez CM, Vasquez PA, Perret CF. Treatment of ciguatera poisoning with gabapentin. N Engl J Med 2001; 344:692.
- Davis RT, Villar LA. Symptomatic improvement with amitriptyline in ciguatera fish poisoning. N Engl J Med 1986; 315:65.
- Calvert GM, Hryhorczuk DO, Leikin JB. Treatment of ciguatera fish poisoning with amitriptyline and nifedipine. J Toxicol Clin Toxicol 1987; 25:423.
- Brett J, Murnion B. Pregabalin to treat ciguatera fish poisoning. Clin Toxicol (Phila) 2015; 53:588.
- Public Health England National Health Service: Advice for prescribers on the risk of the misuse of pregabalin and gabapentin. 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/385791/PHE-NHS_England_pregabalin_and_gabapentin_advice_Dec_2014.pdf (Accessed on July 17, 2015).
- Berlin RM, King SL, Blythe DG. Symptomatic improvement of chronic fatigue with fluoxetine in ciguatera fish poisoning. Med J Aust 1992; 157:567.
- Blythe DG, Hack E, Washington G. The medical management of seafood poisonings. In: Foodborne Disease Handbook: Seafood and Environmental Toxins, Hui YH, Gorham JR, Murrell KD, et al (Eds), Marcel Dekker Inc., New York 2001.
- Lehane L, Lewis RJ. Ciguatera: recent advances but the risk remains. Int J Food Microbiol 2000; 61:91.
- Venomous and Poisonous Marine Animals: A Medical and Biological Handbook, Williamson JA, Fenner PJ, Burnett JW, Rifkin JF. (Eds), University of South Wales Press, Sydney 1996.
- Pupić-Bakrač M, Brnčić N, Lakošeljac D, et al. Ciguatera food poisoning in Croatian seamen. In: 8th International Symposium on Maritime Health, Institute of PUblic HEalth Rijeka May, 2005.
- Darius HT, Drescher O, Ponton D, et al. Use of folk tests to detect ciguateric fish: a scientific evaluation of their effectiveness in Raivavae Island (Australes, French Polynesia). Food Addit Contam Part A Chem Anal Control Expo Risk Assess 2013; 30:550.
- Crump JA, McLay CL, Chambers ST. Ciguatera fish poisoning. Postgrad Med J 1999; 75:678.
- Ciguatera fish poisoning poster. Florida Department of Health. http://www.myfloridaeh.com/medicine/aquatic/ciguatera.htm (Accessed on February 21, 2013).