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[[image:ciguatoxin.svg|thumb|300px|none|Chemical structure of the ciguatoxin CTX1B]]
[[image:ciguatoxin.svg|thumb|300px|none|Chemical structure of the ciguatoxin CTX1B]]
'''Ciguatera''' is a [[foodborne illness]] poisoning in humans caused by eating marine species whose flesh is contaminated with a toxin known as ''ciguatoxin'', which is present in many micro-organisms (particularly, the micro-algae ''[[Gambierdiscus toxicus]]'') living in tropical waters. Like many naturally and artificially occurring toxins, ciguatoxin accumulates in lower-level organisms, resulting in higher concentration of the toxin at higher levels of the [[food chain]], an example of [[biomagnification]][http://unesdoc.unesco.org/images/0011/001113/111307eo.pdf]. [[Predator]] species near the top of the food chain in tropical waters, such as [[barracuda]], [[moray eel]], [[parrotfish]], [[grouper]] and [[amberjack]], are most likely to cause ciguatera poisoning, although many other species have been found to cause occasional outbreaks of ciguatera. Ciguatoxin is very heat-resistant, so ciguatoxin-laden fish cannot be detoxified by cooking.
'''Ciguatera''' is a [[foodborne illness]] poisoning in humans caused by eating marine species whose flesh is contaminated with a toxin known as ''ciguatoxin'', which is present in many micro-organisms (particularly, the micro-algae ''[[Gambierdiscus toxicus]]'') living in tropical waters. Like many naturally and artificially occurring toxins, ciguatoxin accumulates in lower-level organisms, resulting in higher concentration of the toxin at higher levels of the [[food chain]], an example of [[biomagnification]].<ref>{{cite web | author=King M, King S | title =The Oceans and Coastal Areas and their Resources | publisher = UNESCO-UNEP: International Environmental Education Programme | date = 1995 | url =http://unesdoc.unesco.org/images/0011/001113/111307eo.pdf | format = [[PDF]] | accessdate = 2007-04-27}}</ref> [[Predator]] species near the top of the food chain in tropical waters, such as [[barracuda]], [[moray eel]], [[parrotfish]], [[grouper]] and [[amberjack]], are most likely to cause ciguatera poisoning, although many other species have been found to cause occasional outbreaks of ciguatera. Ciguatoxin is very heat-resistant, so ciguatoxin-laden fish cannot be detoxified by cooking.<ref name="Swift-1993">{{cite journal |author=Swift A, Swift T |title=Ciguatera |journal=J. Toxicol. Clin. Toxicol. |volume=31 |issue=1 |pages=1-29 |year=1993 |pmid=8433404}}</ref>


⚫
==History==
Due to the localized nature of the ciguatoxin-producing micro-organisms, ciguatera illness is only common in [[tropics|tropical waters]], particularly the [[Caribbean]], and usually is associated with fish caught in tropical reef waters.
⚫
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, ''corallina opuntia''. As an extreme explanation, some scientists linked the passing on of toxicity to moonlight or stars.{{Fact|date=February 2007}}


⚫
In Northern [[Australia]], where ciguatera is a common problem, there are two commonly believed ways of determining that fish carry significant levels of ciguatoxin. The first belief is that if a piece of fish is contaminated with the toxin, flies will not land on it. The second belief 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. It is not known whether there is any veracity to either belief.
The symptoms of ciguatera are gastrointestinal distress (nausea, vomiting) followed by neurological symptoms such as headaches, muscle aches, numbness, [[ataxia]], and hallucinations. Severe cases of ciguatera can also result in hot-cold reversal, in which hot and cold sensations seem reversed.


⚫
==Etymological Roots==
Ciguatera toxin poisoning is frequently misdiagnosed as [[Multiple Sclerosis]]. The relapse/remit characteristic of the disease can be tied to the consumption of nuts, alcohol, fish or fish-containing products, or exposure to fumes such as those of bleach and other chemicals. Exercise is also a possible trigger.
⚫
It is a generally held theory that ciguatera, as a poisonous substance, was named and identified in Cuba, circa early 1800's. Local folklore has identified the etymology stems from a story of an Englishman who caught a barracuda on the Isla de Pinos. After consuming the barracuda, said 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.” It is the poor interpretation of the word seawater that allegedly gives the ailment the name ciguatera, or “from the seawater” in Spanish.{{Fact|date=April 2007}}


==Distribution==
Hallmark symptoms of ciguatera include memory loss, muscle weakness, numbness, and extreme fatigue. Doctors are often at a loss to explain these symptoms, but for the victim of this neuro-toxin poisoning, avoidance of certain foods, alcohol, and any extreme physical exertion are extremely important, and can, in fact, prevent a relapse of symptoms. A complete listing of foods to avoid are listed in the [[Annals of Emergency Medicine]].
Due to the localized nature of the ciguatoxin-producing micro-organisms, ciguatera illness is only common in [[tropics|tropical waters]], particularly the [[Pacific]] and [[Caribbean]], and usually is associated with fish caught in tropical reef waters. 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. Imported fish served in restaurants have been found to contain the toxin and result in illness which often goes unexplained by physicians unfamiliar with a tropical toxin and its characteristic symptoms.<ref>{{cite journal |author=Geller R, Olson K, Senécal P |title=Ciguatera fish poisoning in San Francisco, California, caused by imported barracuda |journal=West. J. Med. |volume=155 |issue=6 |pages=639-42 |year=1991 |pmid=1812639}}</ref> In addition, ciguatoxin has been found in farmed raised salmon.<ref> {{cite journal |author=DiNubile M, Hokama Y |title=The ciguatera poisoning syndrome from farm-raised salmon |journal=Ann. Intern. Med. |volume=122 |issue=2 |pages=113-4 |year=1995 |pmid=7992985}}</ref>


==Symptoms==
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. Imported fish served in restaurants have been found to contain the toxin and result in illness which often goes unexplained by physicians unfamiliar with a tropical toxin and its characteristic symptoms. In addition, ciguatoxin has been found in farmed raised salmon. The symptoms can last from weeks to years, and in extreme cases lasting as many as 20 years, again in a relapse/remit pattern based on exposures to triggering foods and activities.


Hallmark symptoms of ciguatera include [[gastrointestinal]] and [[neurological]] effects.<ref name="Isbister-2005">{{cite journal |author=Isbister G, Kiernan M |title=Neurotoxic marine poisoning |journal=Lancet neurology |volume=4 |issue=4 |pages=219-28 |year=2005 |pmid=15778101}}</ref> Gastrointestinal symptoms include [[nausea]], [[vomiting]], and [[diarrhea]] usually followed by neurological symptoms such as [[headache]]s, muscle aches, [[paresthesia]], numbness, [[ataxia]], and [[hallucination]]s.<ref name="Swift-1993"/> 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).<ref name="Isbister-2005"/> Doctors are often at a loss to explain these symptoms and ciguatera poisoning is frequently misdiagnosed as [[Multiple Sclerosis]].
⚫
==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, ''corallina opuntia''. As an extreme explanation, some scientists linked the passing on of toxicity to moonlight or stars.{{Fact|date=February 2007}}


The symptoms can last from weeks to years, and in extreme cases lasting as many as 20 years; often leading to long term disability.<ref>{{cite journal |author=Gillespie N, Lewis R, Pearn J, Bourke A, Holmes M, Bourke J, Shields W |title=Ciguatera in Australia. Occurrence, clinical features, pathophysiology and management |journal=Med. J. Aust. |volume=145 |issue=11-12 |pages=584-90 |year=1986 |pmid=2432386}}</ref> Most people do recover slowly over time.<ref> {{cite journal |author=Pearn J |title=Neurology of ciguatera |journal=J. Neurol. Neurosurg. Psychiatr. |volume=70 |issue=1 |pages=4-8 |year=2001 |pmid=11118239}}</ref> Often patients recover but redevelop symptoms in the future. This relapse/remit characteristic of the disease can be tied to the consumption of nuts, alcohol, eating fish or fish-containing products, eating chicken or eggs, and exposure to fumes such as those of [[bleach]] and other chemicals. Exercise is also a possible trigger.<ref name="Swift-1993"/>
⚫
In Northern Australia, where ciguatera is a common problem, there are two commonly believed ways of determining that fish carry significant levels of ciguatoxin. The first belief is that if a piece of fish is contaminated with the toxin, flies will not land on it. The second belief 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. It is not known whether there is any veracity to either belief.

⚫
==Etymological Roots==
⚫
It is a generally held theory that ciguatera, as a poisonous substance, was named and identified in Cuba, circa early 1800's. Local folklore has identified the etymology stems from a story of an Englishman who caught a barracuda on the Isla de Pinos. After consuming the barracuda, said 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.” It is the poor interpretation of the word seawater that allegedly gives the ailment the name ciguatera, or “from the seawater” in Spanish.


==Treatment==
==Treatment==
The most effective treatment for ciguatera poisoning is prompt [[intravenous]] [[mannitol]], at a dosage of 1 gram per kilogram of body mass. An initial study resulted in a majority of patients relieved of all symptoms. Later research suggests that mannitol is most effective when administered within 72 hours of exposure. If not there is a greater chance that the disease will have a greater effect.


There is no effective treatment or antidote for ciguatera poisoning. Previously [[mannitol]] was used for poisoning after 1 study reported the reversal of symptoms following its use.<ref>{{cite journal |author=Palafox N, Jain L, Pinano A, Gulick T, Williams R, Schatz I |title=Successful treatment of ciguatera fish poisoning with intravenous mannitol |journal=JAMA |volume=259 |issue=18 |pages=2740-2 |year=1988 |pmid=3128666}}</ref> Follow up studies in animals<ref>{{cite journal |author=Mattei C, Molgó J, Marquais M, Vernoux J, Benoit E |title=Hyperosmolar D-mannitol reverses the increased membrane excitability and the nodal swelling caused by Caribbean ciguatoxin-1 in single frog myelinated axons |journal=Brain Res. |volume=847 |issue=1 |pages=50-8 |year=1999 |pmid=10564735}}</ref> and case reports in humans<ref>{{cite journal |author=Williamson J |title=Ciguatera and mannitol: a successful treatment |journal=Med. J. Aust. |volume=153 |issue=5 |pages=306-7 |year=1990 |pmid=2118229}}</ref> also found benefit from mannitol. However, a randomised, controlled, double-blinded, clinical trial of mannitol for ciguatera poisoning did not find any difference between mannitol and normal saline,<ref>{{cite journal |author=Schnorf H, Taurarii M, Cundy T |title=Ciguatera fish poisoning: a double-blind randomized trial of mannitol therapy |journal=Neurology |volume=58 |issue=6 |pages=873-80 |year=2002 |pmid=11914401}}</ref> based on this result mannitol is no longer recommended.<ref name="Isbister-2005"/>
[[Amitriptyline]] and similar medications may reduce some symptoms of Ciguatera, such as fatigue and paresthesias. Also used are steroids and vitamin supplements, but these merely support the body's recovery rather than directly reduce the toxic effects.


The mainstay of treatment is supportive care. Some medications such as the use of [[Amitriptyline]] may reduce some symptoms of ciguatera, such as fatigue and paresthesias.<ref>{{cite journal |author=Davis R, Villar L |title=Symptomatic improvement with amitriptyline in ciguatera fish poisoning |journal=N. Engl. J. Med. |volume=315 |issue=1 |pages=65 |year=1986 |pmid=3713788}}</ref> Although benefit does not occur in every case.<ref>{{cite journal |author=Hampton M, Hampton A |title=Ciguatera fish poisoning |journal=J. Am. Acad. Dermatol. |volume=20 |issue=3 |pages=510-1 |year=1989 |pmid=2918120}}</ref> Also used are steroids and vitamin supplements, but these merely support the body's recovery rather than directly reduce the toxic effects.
It should be noted that there are a number of antiquated Caribbean [[homeopathic]] treatments, as well as ritualistic ones, most of which originated from Cuba and nearby islands. The most common old-time remedy involves bed-rest subsequent to a Guanavana juice enema. Some more avant-garde old-time treatments ranged from directly porting and bleeding the gastrointestinal tract, to ‘cleansing’ the diseased with a dove during a Santeria ritual.


The efficacy of these treatments have never been studied or substantiated; nevertheless they are purportedly still used to this day.
There are a number of antiquated Caribbean [[homeopathic]] treatments, as well as ritualistic ones, most of which originated from Cuba and nearby islands. The most common old-time remedy involves bed-rest subsequent to a Guanavana juice enema. Some more avant-garde old-time treatments ranged from directly porting and bleeding the gastrointestinal tract, to ‘cleansing’ the diseased with a dove during a Santeria ritual. The efficacy of these treatments have never been studied or substantiated; nevertheless they are purportedly still used to this day.


== See also ==
== See also ==
*[[algal bloom]] (see "toxic chemicals" in paragraph 2)
*[[Algal bloom]] (see "toxic chemicals" in paragraph 2)
*[[dinoflagellate]] (see "neurotoxins" and "red tide" under [[dinoflagellate#Ecology and fossils|Ecology and fossils]] and see "phosphate" under [[dinoflagellate#Cautions|Cautions]])
*[[Dinoflagellate]] (see "neurotoxins" and "red tide" under [[Dinoflagellate#Ecology and fossils|Ecology and fossils]] and see "phosphate" under [[dinoflagellate#Cautions|Cautions]])
*[[paralytic shellfish poisoning]] (PSP)
*[[Paralytic shellfish poisoning]] (PSP)
*[[red tide]]
*[[Red tide]]

==Footnotes==
<div class="references-small">
<references />
</div>


==References==
==References==

Revision as of 13:38, 26 April 2007

Ciguatera fish poisoning
SpecialtyToxicology Edit this on Wikidata
Chemical structure of the ciguatoxin CTX1B

Ciguatera is a foodborne illness poisoning in humans caused by eating marine species whose flesh is contaminated with a toxin known as ciguatoxin, which is present in many micro-organisms (particularly, the micro-algae Gambierdiscus toxicus) living in tropical waters. Like many naturally and artificially occurring toxins, ciguatoxin accumulates in lower-level organisms, resulting in higher concentration of the toxin at higher levels of the food chain, an example of biomagnification.[1] Predator species near the top of the food chain in tropical waters, such as barracuda, moray eel, parrotfish, grouper and amberjack, are most likely to cause ciguatera poisoning, although many other species have been found to cause occasional outbreaks of ciguatera. Ciguatoxin is very heat-resistant, so ciguatoxin-laden fish cannot be detoxified by cooking.[2]

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, corallina opuntia. As an extreme explanation, some scientists linked the passing on of toxicity to moonlight or stars.[citation needed]

In Northern Australia, where ciguatera is a common problem, there are two commonly believed ways of determining that fish carry significant levels of ciguatoxin. The first belief is that if a piece of fish is contaminated with the toxin, flies will not land on it. The second belief 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. It is not known whether there is any veracity to either belief.

Etymological Roots

It is a generally held theory that ciguatera, as a poisonous substance, was named and identified in Cuba, circa early 1800's. Local folklore has identified the etymology stems from a story of an Englishman who caught a barracuda on the Isla de Pinos. After consuming the barracuda, said 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.” It is the poor interpretation of the word seawater that allegedly gives the ailment the name ciguatera, or “from the seawater” in Spanish.[citation needed]

Distribution

Due to the localized nature of the ciguatoxin-producing micro-organisms, ciguatera illness is only common in tropical waters, particularly the Pacific and Caribbean, and usually is associated with fish caught in tropical reef waters. 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. Imported fish served in restaurants have been found to contain the toxin and result in illness which often goes unexplained by physicians unfamiliar with a tropical toxin and its characteristic symptoms.[3] In addition, ciguatoxin has been found in farmed raised salmon.[4]

Symptoms

Hallmark symptoms of ciguatera include gastrointestinal and neurological effects.[5] Gastrointestinal symptoms include nausea, vomiting, and diarrhea usually followed by neurological symptoms such as headaches, muscle aches, paresthesia, numbness, ataxia, and hallucinations.[2] 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).[5] Doctors are often at a loss to explain these symptoms and ciguatera poisoning is frequently misdiagnosed as Multiple Sclerosis.

The symptoms can last from weeks to years, and in extreme cases lasting as many as 20 years; often leading to long term disability.[6] Most people do recover slowly over time.[7] Often patients recover but redevelop symptoms in the future. This relapse/remit characteristic of the disease can be tied to the consumption of nuts, alcohol, eating fish or fish-containing products, eating chicken or eggs, and exposure to fumes such as those of bleach and other chemicals. Exercise is also a possible trigger.[2]

Treatment

There is no effective treatment or antidote for ciguatera poisoning. Previously mannitol was used for poisoning after 1 study reported the reversal of symptoms following its use.[8] Follow up studies in animals[9] and case reports in humans[10] also found benefit from mannitol. However, a randomised, controlled, double-blinded, clinical trial of mannitol for ciguatera poisoning did not find any difference between mannitol and normal saline,[11] based on this result mannitol is no longer recommended.[5]

The mainstay of treatment is supportive care. Some medications such as the use of Amitriptyline may reduce some symptoms of ciguatera, such as fatigue and paresthesias.[12] Although benefit does not occur in every case.[13] Also used are steroids and vitamin supplements, but these merely support the body's recovery rather than directly reduce the toxic effects.

There are a number of antiquated Caribbean homeopathic treatments, as well as ritualistic ones, most of which originated from Cuba and nearby islands. The most common old-time remedy involves bed-rest subsequent to a Guanavana juice enema. Some more avant-garde old-time treatments ranged from directly porting and bleeding the gastrointestinal tract, to ‘cleansing’ the diseased with a dove during a Santeria ritual. The efficacy of these treatments have never been studied or substantiated; nevertheless they are purportedly still used to this day.

See also

Footnotes

  1. ^ King M, King S (1995). "The Oceans and Coastal Areas and their Resources" (PDF). UNESCO-UNEP: International Environmental Education Programme. Retrieved 2007-04-27.
  2. ^ a b c Swift A, Swift T (1993). "Ciguatera". J. Toxicol. Clin. Toxicol. 31 (1): 1–29. PMID 8433404.
  3. ^ 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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  4. ^ DiNubile M, Hokama Y (1995). "The ciguatera poisoning syndrome from farm-raised salmon". Ann. Intern. Med. 122 (2): 113–4. PMID 7992985.
  5. ^ a b c Isbister G, Kiernan M (2005). "Neurotoxic marine poisoning". Lancet neurology. 4 (4): 219–28. PMID 15778101.
  6. ^ 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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  7. ^ Pearn J (2001). "Neurology of ciguatera". J. Neurol. Neurosurg. Psychiatr. 70 (1): 4–8. PMID 11118239.
  8. ^ 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. PMID 3128666.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ^ 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. PMID 10564735.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  10. ^ Williamson J (1990). "Ciguatera and mannitol: a successful treatment". Med. J. Aust. 153 (5): 306–7. PMID 2118229.
  11. ^ 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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ^ Davis R, Villar L (1986). "Symptomatic improvement with amitriptyline in ciguatera fish poisoning". N. Engl. J. Med. 315 (1): 65. PMID 3713788.
  13. ^ Hampton M, Hampton A (1989). "Ciguatera fish poisoning". J. Am. Acad. Dermatol. 20 (3): 510–1. PMID 2918120.

References

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