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Ciguatera fish poisoning
Classification and external resources

Chemical structure of the ciguatoxin-CTX1B
ICD-10 T61.0
ICD-9 988.0
DiseasesDB 31122
MedlinePlus 002851
eMedicine emerg/100 ped/403

Ciguatera is a foodborne illness caused by eating certain reef fishes whose flesh is contaminated with toxins originally produced by dinoflagellates such as Gambierdiscus toxicus which lives in tropical and sub-tropical waters. These dinoflagellates adhere to coral, algae and seaweed where they are eaten by herbivorous fish who in turn are eaten by larger carnivorous fish. In this way the toxins move up the foodchain and bioaccumulate. Gambierdiscus toxicus is the primary dinoflagellate responsible for the production of a number of similar but distinct toxins that cause ciguatera. These toxins include ciguatoxin, maitotoxin, scaritoxin and palytoxin. Predator species near the top of the food chain in tropical and sub-tropical waters, such as barracudas, snapper, moray eels, parrotfishes, groupers, triggerfishes and amberjacks, are most likely to cause ciguatera poisoning, although many other species have been found to cause occasional outbreaks of toxicity. Ciguatoxin is very heat-resistant, so ciguatoxin-laden fish cannot be detoxified by conventional cooking.[1][2]

Researchers suggest that Ciguatera outbreaks caused by cooling climatic conditions propelled the migratory voyages of Polynesians between 1000 and 1400.[3]

Contents

Symptoms

Hallmark symptoms of ciguatera include gastrointestinal and neurological effects.[4][5] Gastrointestinal symptoms include nausea, vomiting, and diarrhea usually followed by neurological symptoms such as headaches, muscle aches, paresthesia, numbness, ataxia, and hallucinations.[1][5] Severe cases of ciguatera can also result in cold allodynia, which is a burning sensation on contact with cold (commonly incorrectly referred to as reversal of hot/cold temperature sensation).[4] Doctors are often at a loss to explain these symptoms and ciguatera poisoning is frequently misdiagnosed as Multiple Sclerosis.[6]

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 that produces ciguatera poisoning may be sexually transmitted.[7] As diarrhea and facial rashes have been reported in breastfed infants of mothers with ciguatera poisoning, it is likely that ciguatera toxins are also transferred into the breast milk.[8]

The symptoms can last from weeks to years, and in extreme cases as long as 20 years, often leading to long term disability.[9] Most people do recover slowly over time.[10] Often patients recover but redevelop symptoms in the future. Such relapses can be triggered by consumption of nuts, alcohol, fish or fish-containing products, chicken or eggs, or by exposure to fumes such as those of bleach and other chemicals. Exercise is also a possible trigger.[1] The symptoms of ciguatera may vary with ethnicity with Filipino or Chinese people possibly being more susceptible.[1]

Detection methods

Modern scientific detection

Currently, multiple laboratory methods are available to detect ciguatoxins, including liquid chromatography-mass spectrometry (LCMS), receptor binding assays (RBA), and neuroblastoma assays (N2A). Although testing is possible, in most cases liquid chromatography-mass spectrometry is insufficient to detect clinically relevant concentrations of ciguatoxin in crude extracts of fish.

Folk science detection

In Northern Australia, where ciguatera is a common problem, two different folk science methods are widely believed to be available for determining that fish harbors significant levels of ciguatoxin. The first method is that if a piece of fish is contaminated with the toxin, flies will not land on it. The second is that the toxin can be detected by feeding a piece of fish to a cat, as cats are allegedly highly sensitive to ciguatoxin and will display symptoms. There is a third, less common method for ciguatera testing that involves putting a silver coin under the scales of the suspect fish. If the coin turns black, reportedly, the fish is contaminated; but if it does not turn black then it should be safe. It is not known whether any of these tests produce results that are actually accurate.

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 blocker type drugs such as 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 the cramping of the arterial walls caused by maitotoxin[5][11][12][13] Ciguatoxin lowers the threshold for opening voltage-gated sodium channels in synapses of the nervous system. The effect of opening a sodium channel will cause depolarization, which could sequentially cause paralysis, heart contraction, and changing the senses of hearing and cold. Nifedipine is a calcium channel blocker.[5] Some medications such as the use of Amitriptyline may reduce some symptoms of ciguatera, such as fatigue and paresthesia,[14] although benefit does not occur in every case.[15] Also used are steroids and vitamin supplements, but these merely support the body's recovery rather than directly reducing the toxic effects.

Previously mannitol was used for poisoning after one study reported the reversal of symptoms following its use.[5][16] Followup studies in animals[17] and case reports in humans[18] also found benefit from mannitol. However, a randomized, controlled, double-blind clinical trial of mannitol for ciguatera poisoning did not find any difference between mannitol and normal saline,[19] and based on this result mannitol is no longer recommended.[4]

There are a number of antiquated Caribbean naturopathic and ritualistic treatments, most of which originated in Cuba and nearby islands. The most common old-time remedy involves bed rest subsequent to a Guanabana juice enema. Other folk treatments range from directly porting and bleeding the gastrointestinal tract to "cleansing" the diseased with a dove during a Santeria ritual. The efficacy of these treatments has never been studied or substantiated; nevertheless they are purportedly still used to this day.

Epidemiology

Due to the localized nature of the ciguatoxin-producing microorganisms, ciguatera illness is common in only subtropical and tropical waters, particularly the Pacific and Caribbean, and usually is associated with fish caught in tropical reef waters.[4] Ciguatoxin is found in over 400 species of reef fish, and therefore avoidance of consumption of all reef fish (any fish living in warm tropical waters) is the only sure way to avoid exposure to the toxin.[2] Imported fish served in restaurants have been found to contain the toxin and to produce illness which often goes unexplained by physicians unfamiliar with a tropical toxin and its characteristic symptoms.[20][2] In addition, ciguatoxin has been found in farm-raised salmon.[21]

In 2007, ten people in St. Louis, Missouri were sickened with the disease after eating imported fish.[22]

In February 2008, the U.S. Food and Drug Administration (FDA) reported that several outbreaks of the disease had been traced to fish harvested near 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 consuming any of several species of fish caught as far as 50 miles (80 km) from the sanctuary.[23]

History

Originally, ciguatoxin was linked to poison passed to tropical fish through consumption. However, the exact source of the toxin was unknown, and many sources were identified as the culprit. Some of these included the manchineel fruit, Cocculus berries, palolo worms, compounds containing copper, pumice, and Corallina opuntia.

It is a generally held theory that ciguatera, as a poisonous substance, was named and identified in Dawids house, circa the early 1800s. Local folklore has identified that the etymology stems from a story of an Englishman who caught a barracuda on the Isla de Pinos. After consuming the barracuda, the Englishman became terribly ill. When queried about the origins of his illness, the Englishman claimed to have caught and eaten "a fish, from the seawater". This gave rise to the name of the ailment as ciguatera, a transliteration into Spanish of the English word seawater.[citation needed]. A more commonly encountered explanation is that ciguatera comes from the word 'Cigua', a Cuban name for a gastropod that caused similar symptoms. Captain Cook during his voyages in the Endeavor (1700s) when off New Caledonia describes eating a fish 'with a large ugly head' and goes on to describe symptoms consistent with ciguatera poisoning.

See also

Footnotes

  1. ^ a b c d Swift A, Swift T (1993). "Ciguatera". J. Toxicol. Clin. Toxicol. 31 (1): 1–29. PMID 8433404. 
  2. ^ a b c Schep LJ, Slaughter RJ, Temple WA, Beasley DM (2010). "Ciguatera poisoning: an increasing occurrence in New Zealand". N. Z. Med. J. 123 (1308): 100–2. PMID 20173810. 
  3. ^ Honolulu Advertiser
  4. ^ a b c d Isbister G, Kiernan M (2005). "Neurotoxic marine poisoning". Lancet. Neurol. 4 (4): 219–28. doi:10.1016/S1474-4422(05)70041-7. PMID 15778101. 
  5. ^ a b c d e Clark RF, Williams SR, Nordt SP, Manoguerra AS (1999). "A review of selected seafood poisonings". Undersea Hyperb Med 26 (3): 175–84. PMID 10485519. http://archive.rubicon-foundation.org/2314. Retrieved 2008-08-12. 
  6. ^ Ting J, Brown A (2001). "Ciguatera poisoning: a global issue with common management problems". Eur. J. Emerg. Med. 8 (4): 295–300. PMID 11785597. 
  7. ^ Lange W, Lipkin K, Yang G (1989). "Can ciguatera be a sexually transmitted disease?". J. Toxicol. Clin. Toxicol. 27 (3): 193–7. PMID 2810444. 
  8. ^ Blythe D, de Sylva D (1990). "Mother's milk turns toxic following fish feast". JAMA 264 (16): 2074. doi:10.1001/jama.264.16.2074b. PMID 2214071. 
  9. ^ Gillespie N, Lewis R, Pearn J, Bourke A, Holmes M, Bourke J, Shields W (1986). "Ciguatera in Australia. Occurrence, clinical features, pathophysiology and management". Med. J. Aust. 145 (11-12): 584–90. PMID 2432386. 
  10. ^ Pearn J (2001). "Neurology of ciguatera". J. Neurol. Neurosurg. Psychiatr. 70 (1): 4–8. doi:10.1136/jnnp.70.1.4. PMID 11118239. 
  11. ^ Attaway D, Zaborsky O (1993). Marine Biotechnology. pp. 8. 
  12. ^ Fleming L. "Ciguatera Fish Poisoning". 
  13. ^ Schlossberg D. Infections of leisure. 
  14. ^ Davis R, Villar L (1986). "Symptomatic improvement with amitriptyline in ciguatera fish poisoning". N. Engl. J. Med. 315 (1): 65. PMID 3713788. 
  15. ^ Hampton M, Hampton A (1989). "Ciguatera fish poisoning". J. Am. Acad. Dermatol. 20 (3): 510–1. doi:10.1016/S0190-9622(89)80094-5. PMID 2918120. 
  16. ^ Palafox N, Jain L, Pinano A, Gulick T, Williams R, Schatz I (1988). "Successful treatment of ciguatera fish poisoning with intravenous mannitol". JAMA 259 (18): 2740–2. doi:10.1001/jama.259.18.2740. PMID 3128666. 
  17. ^ Mattei C, Molgó J, Marquais M, Vernoux J, Benoit E (1999). "Hyperosmolar D-mannitol reverses the increased membrane excitability and the nodal swelling caused by Caribbean ciguatoxin-1 in single frog myelinated axons". Brain Res. 847 (1): 50–8. doi:10.1016/S0006-8993(99)02032-6. PMID 10564735. 
  18. ^ Williamson J (1990). "Ciguatera and mannitol: a successful treatment". Med. J. Aust. 153 (5): 306–7. PMID 2118229. 
  19. ^ Schnorf H, Taurarii M, Cundy T (2002). "Ciguatera fish poisoning: a double-blind randomized trial of mannitol therapy". Neurology 58 (6): 873–80. PMID 11914401. 
  20. ^ Geller R, Olson K, Senécal P (1991). "Ciguatera fish poisoning in San Francisco, California, caused by imported barracuda". West. J. Med. 155 (6): 639–42. PMID 1812639. 
  21. ^ DiNubile M, Hokama Y (1995). "The ciguatera poisoning syndrome from farm-raised salmon". Ann. Intern. Med. 122 (2): 113–4. PMID 7992985. 
  22. ^ Bizarre fish poisoning sparks alarm
  23. ^ U.S. Food and Drug Administration (2008-02-05). "FDA Advises Seafood Processors About Ciguatera Fish Poisoning in the Northern Gulf of Mexico Near the Flower Garden Banks National Marine Sanctuary". Press release. http://www.fda.gov/bbs/topics/NEWS/2008/NEW01790.html. Retrieved 2008-02-07. 

References








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