Neuro
Ciguatera Poisoning
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Ciguatera Poisoning
, Ciguatera Toxin, Ciguatoxin
See Also
Biological Neurotoxin
Biological Toxin
Foodborne Illness
Epidemiology
Most common reported fish ingestion related
Poisoning
in U.S.
Reaction occurs in up to 90% of Ciguatoxin ingestions
Most common outbreaks
Florida
Hawaii
West Indies
Puerto Rico
U.S. Virgin Islands
Pathophysiology
Dinoflagellates (unicellular protozoa)
Gambierdiscus toxicus bioaccumulates in carnivorous reef fish
Reef fish ingestion results in reaction (>500 individual species have been associated)
Amberjack
Grouper
Snapper
Sturgeon
King Mackerel
Barracuda
Moray eel
Toxin
Ciguatoxin is a tasteless, odorless, lipid soluble toxin
Ciguatoxin is heat stable and acid-stable
Ciguatoxin may be transferred via
Breast
milk and placenta as well as via semen
Mechanism
Ciguatoxin binds to open
Sodium
channels on
Neuron
s (depolarized
Neuron
s)
Results in
Sodium
influx into
Neuron
s, resulting in
Neuron
al edema
Symptoms
Anticholinergic Reaction
Onset of symptoms at 2 to 6 hours after ingestion (up to 24 hours)
Gastrointestinal (duration 24-48 hours)
Nausea
or
Vomiting
Voluminous, watery
Diarrhea
Abdominal Pain
and cramping
Neurologic (duration days to weeks)
Cold-hot
Sensation
reversal (Cold
Allodynia
)
Hot feels cold and cold feels hot
Occurs in 80% of cases
Pathognomonic for Ciguatera Toxin
Numbness or
Paresthesia
s of hands, feet and face (
Tongue
, lips, throat, perioral region)
Vertigo
or
Ataxia
Weakness
Myalgias
Headache
Seizure
s
Vision
Changes
Cardiopulmonary changes (duration days to weeks)
Bradycardia
Orthostatic Hypotension
Miscellaneous
Diaphoresis
Sensation
of loose or painful teeth
Post-coital symptoms in women (
Dysuria
,
Dyspareunia
,
Pelvic Pain
)
Labs
See
Unknown Ingestion
Serum
Electrolyte
s
Evaluate for
Electrolyte
losses (related to
Diarrhea
)
Ciguatoxin Testing (
ELISA
or HPLC)
Confirms diagnosis, but typically delayed results
Ciguatera Poisoning is a clinical diagnosis
Diagnostics
Electrocardiogram
(EKG)
Imaging
As indicated based on presentation and differential diagnosis
Course
Anticholinergic Symptoms
within 2-6 hours after ingestion
Reactions delayed up to 24 hours in some cases
Symptom duration: 7 to 14 days
More severe cases with prior Ciguatoxin reactions
Paresthesia
s may persist for months
Management
See
Unknown Ingestion
Consider
Activated Charcoal
(1 mg/kg)
Consider if ingestion within prior 1-2 hours and patient alert
Supportive care
Antiemetic
s (e.g.
Zofran
IV)
Electrolyte
replacement and intravenous hydration as needed
May require
Vasopressor
s for
Hypotension
May require
Unstable Bradycardia
management
Avoid
Alcohol
Mannitol
does not appear effective in shortening course
Has been used at 1 g/kg over 30-240 min
Schnorf (2002) Neurology 58:873-80 [PubMed]
Admission Criteria
Unclear diagnosis (See
Unknown Ingestion
)
Significant neurologic or cardiac symptoms
Significant
Dehydration
or
Electrolyte
abnormalities
Complication
Stocking-Glove distribution neuropathic pain
Peripheral Neuropathy
symptoms may persist for weeks after onset
Medications to consider
Amitriptyline
25 mg orally once to twice daily
Gabapentin
300-400 mg orally three times daily (start with bedtime dosing)
Pregabalin
150 mg orally twice daily
Prevention
Avoid ingestion of large warm-water reef fish
Limit intakes to small quantities
Avoid ingesting internal organs of fish
No food preparation method deactivate Ciguatoxin
References
Koch and Tomaszewski (2021) Crit Dec Emerg Med 35(8): 28
Perkins (2004) Am Fam Physician 69(4):885-90 [PubMed]
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