Ciguatera: Current Concepts
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Ciguatera: Current concepts DAVID Z. LEVINE, DO Ciguatera poisoning develops unraveling the diagnosis may prove difficult. after ingestion of certain coral reef-asso Although the syndrome has been known for at ciated fish. With travel to and from the least hundreds of years, its mechanisms are tropics and importation of tropical food only beginning to be elucidated. Effective treat fish increasing, ciguatera has begun to ments have just begun to emerge. appear in temperate countries with more Ciguatera is a major public health prob frequency. The causative agents are cer lem in the tropics, with probably more than tain varieties of the protozoan dinofla 30,000 poisonings yearly in Puerto Rico and gellate Gambierdiscus toxicus, but bacte the US Virgin Islands alone. The endemic area ria associated with these protozoa may is bounded by latitudes 37° north and south. have a role in toxin elaboration. A specif Ciguatera in temperate countries is a concern ic "ciguatoxin" seems to cause the symptoms, because people returning from business trips, but toxicosis may also be a result of a fam vacations, or living in the tropics may have ily of toxins. Toxicosis develops from 10 been poisoned through food they had eaten. minutes to 30 hours after ingestion of poi The development of worldwide marketing of soned fish, and the syndrome can include fish from a variety of ecosystems creates a dan gastrointestinal and neurologic symptoms, ger of ciguatera intoxication in climates far as well as chills, sweating, pruritus, brady removed from sandy beaches and waving·palms. cardia, tachycardia, and long-lasting weak Outbreaks have been reported in Vermont, ness and fatigue. More severe features are Rhode Island, New York State, Montreal, and rare. In this review, the pathophysiologic British Columbia. In Canada alone, ciguatera features and symptoms of ciguatera are costs more than $3 million a year in medical and reviewed and compared with those of other indirect costs.1 seafood-related syndromes. Although no definitive therapy is known, the most Means of toxicosis promising treatment for ciguatera is intra Ingestion of anyone of more than 400 species venous administration of mannitol. Physi of tropical or subtropical reef fish can cause cians should warn patients who are trav ciguatera. Larger reef-associated carnivorous eling to endemic areas about this toxicosis. fish such as barracuda, some groupers, jacks, (Key words: Ciguatera, ciguatoxin, fish, and snappers are most likely to cause toxicosis, mannitol, seafood, shellfish, temperature but many other fish are implicated as well reversal) (Table 1). Ciguatoxin (CTX) itself has been identified Worldwide, ciguatera is the most common tox as a lipid polyether with several hydroxyl groups icity borne by fish. Its group of symptoms is and a molecular weight of 1112, one of the most bizarre, and unless the physician is familiar potent nonproteinaceous poisons known. Con with the strange manifestations of ciguatera, troversy exists as to whether toxicosis results from one toxin or from many. Through research in the past 5 years, the picture regarding the Dr Levine is board certified in family practice and is in solo practice in Port Orchard, Wash. causative agent has actually become less clear. Correspondence to David Z. Levine, DO, 3280 SE Lund (Yet another example of just how right Heisen Ave, Suite 9, Port Orchard, WA 98366. berg really was! The closer we get to a subject, Review article • Levine JAOA • Vol 95 • No 3 • March 1995 • 193 Table 1 Some Fish Implicated in Cases '-"" ' ....,: :~ .,~, . of Ciguatera Poisoning Herrings Goatfish ,'.. .. Tarpon Mullet . ~ " ~ : '{,:/ ( :';: Anchovy Triggerfish , .;!;"~';' ...,.:. .P;'~ ~ . True eels Snappers " Flying fish Porgies " Squirrelfish Jacks Sea perch Parrotfish Dolphins Surgeonfish Sailfish Grunts Figure. Author's drawing of GambierdisCllS toxiCllS, a benthic Bass Tunas dinoflagellate involved in ciguatera poisoning. (Source: "Ciguat· era in the North Eastern Caribbean," Datos Marinos, No. 7A, Grouper Swordfish Department of Marine Sciences, UPR·RUM, Mayaguez, PR [undated)) the less we seem able to understand it.) It may rhea, and abdominal pain in common with other be that toxicosis results from a family of tox food poisonings. Onset is 10 minutes to 30 hours ins rather than from one specific ciguatoxin.2 after ingestion of a toxic meal, and this gas Ciguatoxin(s) are evolved by certain vari trointestinal aspect of the intoxication usually eties of the protozoan dinoflagellate Gam resolves in 24 to 48 hours. Arthralgia and myal bierdiscus toxic us (Figure ). Recently, it has been gia are common. The neurologic symptoms are suggested that they may also be elaborated by the most bizarre and are also most specific to another strain of dinoflagellate, Ostreopsis len ciguatera as an entity. The patient may have ticularis, which is found associated with G tox dizziness, oral and circumoral paresthesia, icus. To complicate matters even further, recent headache, paresthesia of the extremities, and research indicates that certain bacteria are taste disturbance. Chills and profuse sweat found symbiotically associated with dinofla ing are relatively common. Whole-body pruri gellates and seem to have a role in the elabo tus or pruritus limited to the palms and soles ration of toxins by the symbiont dinoflagellates. can be extremely distressing. Bradycardia and Bacteria found associated with dinoflagellates hypotension or tachycardia and mild hyper include strains of Pseudomonas (most common), tension may occur. Nocardia, Vibrio, Aeromonas, Flavobacterium, The "signature" of ciguatera is hot/cold and Moraxella. 3,4 reversal. The patient perceives cold sensations Dinoflagellates are responsible for several as hot (for example, interpreting a cool breeze other known toxins, as well as the infamous as burning hot) and vice versa (Table 2). In "red tides." It has been suggested that G toxi very rare cases, delirium, coma, cardiac and cus flourishes where reef ecology has been dis respiratory failure, and death may occur, but turbed by construction, pollution, military activ no deaths from ciguatera have occurred in ity, or natural causes.5 The organism attaches North America. Persistent weakness and fatigue itself to macro algae and is eaten by herbivo are the symptoms most responsible for loss of rous reef fish. These herbivores are eaten by working days.6 Discomfort may lead to severe carnivores, and these carnivores are preyed insomnia. upon by larger carnivores, passing on-and con centrating-the toxin. When humans are at the Differential diagnosis top of this food chain, they become vulnerable Most other forms of seafood poisoning should to ingestion of ciguatoxin and other benthic be reasonably easy to distinguish from ciguat (sea-bottom)-associated) marine toxins. era (Table 3 ). Scombroid poisoning usually results from ingestion of tuna or mackerel that Clinical characteristics has been inadequately refrigerated. The disor The symptoms of ciguatera are unique (Table 2), der is histamine mediated and resembles other although ciguatera has nausea, vomiting, diar- histamine reactions. Patients may experience 194· JAOA· Vol 95 • No 3 · March 1995 Review article • Levine Table 2 Signs and Symptoms of Ciguatera General Gastrointestinal Neurologic Weakness Nausea Oral and circumoral (especially Vomiting paresthesias lower extremity) Diarrhea Acral paresthesias Malaise Abdominal pain Dizziness Fatigue Temperature reversal Myalgia Pruritus Arthralgia Ataxia Chills flushing, coryza, severe headache, dizziness, the fish is toxic, the coating turns a deep blue burning of the mouth and throat, abdominal purple.10 The assay has been used very suc cramps, nausea, vomiting, diarrhea, and pruritus. 7 cessfully by commercial fisherman in Hawaii, Paralytic shellfish poisoning and neurotoxic according to Dr Hokama (personal telephone shellfish poisoning result from ingestion of communication, 1992).11 It has been argued, dinoflagellate-contaminated shellfish. Neuro however, that the test is inadequately specific toxic shellfish poisoning is typically a mild syn and has been tested only in Hawaii, where drome involving the usual gastrointestinal ciguatera is reportedly not a major problem, symptoms, as well as varying paresthesias and and that therefore the appearance of success may cerebellar symptoms. It is limited to a few days' be caused by the Hawthorn effect. (T.R. Toste duration.8 (Temperature reversal has also been son, PhD, conversation, December 1992). The noted with this syndrome, which somewhat patent for the stick test was sold by the Uni complicates the diagnosis of ciguatera.) Paralytic versity of Hawaii to a California corporation shellfish poisoning, as the name would suggest, (Ciguatect, Hawaii Chemtect International, carries more potential morbidity and mortali Pasadena, Calif). Apparently it has been devel ty, and is usually encountered in the summer. oped for commercial marketing, but release An initial neurologic symptom, circumoral pares has been delayed indefinitely pending litiga thesia, may be followed by cerebellar symp tion between the company and the University toms, cranial nerve involvement, and motor of Hawaii (Robert Goldsmith, MA, Hawaii paralysis including respiratory failure. Treatment Chemtect International, personal telephone is supportive, and patients usually recover with communication, February 1995). It is hoped in a week.9 that the stick test, if proved practical, will soon