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Ciguatera fish poisoning

Erin N Marcus, MD, MPH, FACP
Section Editors
Michele M Burns, MD, MPH
Stephen J Traub, MD
Daniel F Danzl, MD
Deputy Editor
James F Wiley, II, MD, MPH


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 [1], and is a common fish food poisoning in tropical coastal regions [2]. Approximately 20,000 to 50,000 people develop this poisoning annually worldwide [3], although this may be an underestimate because of missed diagnoses and underreporting [4]. In the United States, an estimated 16,000 cases occur annually, resulting in more than 300 hospitalizations but fewer than five deaths [5].

Estimates of lifetime prevalence of ciguatera fish poisoning range from 7 percent in Puerto Rico [6] to 70 percent in the Polynesian Islands [7]. 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 [8] and in northern Germany [9], as well as fish imported to Paris from Guadeloupe [10]. 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 [11].

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 [12]. 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 [13].

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 [14]. In general, however, toxicity from nontropical fish is extremely rare.

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Literature review current through: Nov 2017. | This topic last updated: May 08, 2017.
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