====== Ciguatera ======

Ciguatera is endemic to regions in the Indo-Pacific as well as the Caribbean. However, the transport of fish by air has meant that ciguatera can occur almost anywhere. The ciguatera toxins are accumulated in tropical reef fish and then cause poisoning when ingested. Numerous fish have been implicated, including Spanish mackerel, bass, moray eels and some cod species (see table 1).

**Table 1**: A list of fish species that have been implicated in ciguatera from the Pacific and the Caribbean.[1,2]  * Specific problems in the Caribbean.

|**Fish Family** |**of fish and their common names** |
|Scombrids|Mackerel, including tunas, Spanish mackerel|
|Lutjanids|Red bass, snappers|
|Muraenids|Moray eels|
|Lethrinids|Emperors and scavengers|
|Epinephelids|Cod, including flowery cod and spotted cod|
|Serranids|Sea bass and groupers, includes coral trout from the Great Barrier Reef|
|Carangids*|Jacks and scads,|
|Sphyraenids*|Barracuda|

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===== CLINICAL MANIFESTATIONS =====

There are two forms of ciguatera, a combination of gastrointestinal and neurotoxicity in the Indo-Pacific region and mainly gastrointestinal effects in the Caribbean. The range of clinical effects are listed in the table. Gastrointestinal effects occur early within hours of ingestion and resolve within 24 hours. The neurological effects develop later within 24 hours and may persist for days. The most characteristic finding is cold allodynia which is the uncomfortable sensation when touching cold objects, sometimes referred to as heat reversal.

**Table 2**: Frequency of clinical effects in ciguatera cases from Pacific Regions and the Atlantic [3-12]

|**Clinical Features** |**Frequency Range (percent)** |
|**Gastrointestinal Features** \\ Nausea \\ Vomiting \\ Diarrhea \\ Abdominal Pain|26 – 55 \\ 30 – 38 \\ 50 – 78 \\ 47 – 70|
|**Neurological Effects** \\ Myalgia \\ Paresthesiae (mouth, hands and/or feet) \\ Arthralgia \\ Cold allodynia (burning on contact with cold) \\ Headache \\ Ataxia \\ Dizziness or vertigo|56 – 83 \\ 52 – 91 \\ 62 – 86 \\ 55 – 94 \\ 50 – 74 \\ 38 – 54 \\ 38 – 62|
|**Other Effects:** \\ Loss of energy/asthenia/weakness \\ Pruritus \\ Perspiration \\ Mood Disorders \\ Bradycardia \\ Eye pain \\ Dental pain \\ Dysuria \\ Skin Rash|60 – 90 \\ 42 – 78 \\ 34 – 43 \\ 23 – 50 \\ 9 – 16 \\ 22 – 41 \\ 25 – 43 \\ 10 – 26 \\ 0 – 26|

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===== REFERENCES =====

1. Lewis RJ. The changing face of ciguatera. Toxicon. 2001; 39(1): 97-106.\\
2. Isbister GK, Kiernan MC. Neurotoxic marine poisoning. Lancet Neurol. 2005; 4(4): 219-28.\\
3. Meier J. Venomous and Poisonous Animals - A Biologist's View. In: Meier J, White J, editors. Clinical Toxicology of Animal Venoms and Poisons. Boca Raton: CRC Press; 1995. p. 1-8.\\
4. Bagnis R, Kuberski T, Laugier S. Clinical observations on 3009 cases of ciguatera (fish poisoning) in the South Pacific. American Journal of Tropical Medicine & Hygiene. 1979; 28: 1067-73.\\
5. Bagnis R, Legrand AM. Clinical features on 12,890 cases of ciguatera (fish poisoning) in French Polynesia. In: Gopalakrishnakone P, Tan CK, editors. Progress in venom and toxin research. Singapore: National University of Singapore and International Society of Toxinology, Asia Pacific Section; 1987. p. 372-7.\\
6. Schnorf H, Taurarii M, Cundy T. Ciguatera fish poisoning: a double-blind randomized trial of mannitol therapy. Neurology. 2002; 58(6): 873-80.\\
7. Gillespie NC, Lewis RJ, Pearn JH, Bourke ATC, Holmes MJ, Bourke JB, Shields WJ. Ciguatera in Australia: Occurrence, clinical features, pathophysiology and management. Medical Journal of Australia. 1986; 145: 584-90.\\
8. Narayan Y. Fish poisoning in Fiji. Fiji Medicine. 1980; 8: 567-74.\\
9. Johnson R, Jong EC. Ciguatera: Caribbean and Indo-Pacific Fish Poisoning. Western Journal of Medicine. 1983; 138: 872-4.\\
10. Lawrence DN, Enriquez MB, Lumish RM. Ciguatera fish poisoning in Miami. Journal of the American Medical Association. 1980; 244 254-8.\\
11. Lange WR, Snyder FR, Fudala PJ. Travel and ciguatera fish poisoning. ArchInternMed. 1992; 152(10): 2049-53.\\
12. Karalis T, Gupta L, Chu M, Campbell BA, Capra MF, Maywood PA. Three clusters of ciguatera poisoning: clinical manifestations and public health implications. Medical Journal of Australia. 2000; 172(4): 160-2.

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