Ciguatera:
Background:
Ciguatera is a type of food poisoning caused by consuming fish that have accumulated a heat-stable toxin produced by dinoflagellates. The toxins, known as ciguatoxins, primarily concentrate in large predatory reef fish in tropical and subtropical waters.
Clinical Manifestations:
Symptoms include gastrointestinal issues 3-30 hours after consumption (nausea, vomiting, diarrhea), neurological effects (numbness, tingling, temperature reversal***), and cardiovascular manifestations (bradycardia, hypotension). Neuro symptoms may last for weeks or even months (up to 2% of people have this for years).
***the one time I had a patient I thought may have ciguatera, my dumb a** was at the bedside with a bag of ice on their leg, asking this person if they thought it was hot or cold. They looked at me blankly and told me it was cold….
Clinical Management:
There is no specific antidote for ciguatera. Treatment focuses on supportive care, including intravenous fluids for dehydration and medications to alleviate symptoms such as pain and nausea. Amitriptyline and gabapentin are often used for neuro symptoms.
There is note of mannitol use for neuro symptoms if used in the first two days, but showed no benefit over saline in a RCT.
Clinical Disposition:
Most patients are discharged.
Scombroid Poisoning:
Background:
Scombroid poisoning results from the ingestion of improperly handled or spoiled fish, particularly histidine-rich fish like tuna, mackerel, and mahi-mahi. Bacterial decarboxylation of histidine leads to the formation of histamine. Most common in Hawaii and Florida.
Clinical Manifestations:
Symptoms mimic allergic reactions and include flushing, headache, palpitations, and gastrointestinal distress.
Clinical Management:
Treatment involves antihistamines to alleviate symptoms. In severe cases, epinephrine may be required. Albuterol can be used in cases of respiratory distress.
Clinical Disposition:
Typically patients are discharged.
Tetrodotoxin Poisoning:
Background:
Tetrodotoxin is a potent heat stable neurotoxin found in certain pufferfish species. Ingestion of improperly prepared pufferfish can lead to severe poisoning. The tetrodotoxin binds to and blocks fast-gated sodium channels.
Clinical Manifestations:
Symptoms include rapid onset (30 min) of nausea, vomiting, paralysis, and respiratory failure. Death can occur within hours.
Clinical Management:
There is no specific antidote. Treatment involves supportive care, including respiratory support.
Clinical Disposition:
Admit (floor vs ICU depending on respiratory status)
Friedman MA et al. Ciguatera Fish Poisoning: Treatment, Prevention, and Management. Marine Drugs 2008; 6:456-479
Stratta P, Badino G. Scombroid poisoning. CMAJ. 2012 Apr 3;184(6):674. doi: 10.1503/cmaj.111031. Epub 2012 Jan 9. PMID: 22231690; PMCID: PMC3314039.
Kotipoyina HR, Kong EL, Warrington SJ. Tetrodotoxin Toxicity. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507714/