Ciguatera
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2008-07-14T06:58:41Z
Ifraserq
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/* Treatment */
{{Infobox_Disease
| Name = Ciguatera fish poisoning
| Image =
| Caption =
| DiseasesDB = 31122
| ICD10 = {{ICD10|T|61|0|t|51}}
| ICD9 = {{ICD9|988.0}}
| ICDO =
| OMIM =
| MedlinePlus = 002851
| eMedicineSubj = emerg
| eMedicineTopic = 100
| eMedicine_mult = {{eMedicine2|ped|403}}
| MeshID =
}}
'''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 [[microorganisms]] (particularly the micro-[[alga]] ''[[Gambierdiscus toxicus]]'') living in tropical waters. Like many naturally and artificially occurring toxins, ciguatoxin [[bioaccumulate]]s 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]]s, [[moray eel]]s, [[parrotfish]]es, [[grouper]]s, [[triggerfish]]es and [[amberjack]]s, 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]].<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>
[[image:ciguatoxin.svg|thumb|300px|right|Chemical structure of the [[ciguatoxin]]-CTX1B]]
==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, [[Eunicidae|palolo worms]], compounds containing [[copper]], [[pumice]], and ''[[Corallinales|corallina opuntia]]''.
==Etymology==
It is a generally held theory that ciguatera, as a poisonous substance, was named and identified in [[Cuba]], 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''.{{Fact|date=April 2007}}
==Distribution==
Due to the localized nature of the ciguatoxin-producing microorganisms, 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 to produce 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 farm-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>
In February 2008, the [[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 {{convert|50|mi|km}} from the sanctuary.<ref>
{{cite press release
| title = FDA Advises Seafood Processors About Ciguatera Fish Poisoning in the Northern Gulf of Mexico Near the Flower Garden Banks National Marine Sanctuary
| publisher = [[FDA]]
| date = 2008-02-05
| url = http://www.fda.gov/bbs/topics/NEWS/2008/NEW01790.html
| accessdate = 2008-02-07
}}</ref>
==Detection methods==
In Northern [[Australia]], where ciguatera is a common problem, two different 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. It is not known whether there is any veracity to either belief.
==Symptoms==
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 |doi=10.1016/S1474-4422(05)70041-7}}</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]].<ref>{{cite journal |author=Ting J, Brown A |title=Ciguatera poisoning: a global issue with common management problems |journal=European journal of emergency medicine : official journal of the European Society for Emergency Medicine |volume=8 |issue=4 |pages=295–300 |year=2001 |pmid=11785597}}</ref>
[[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.<ref>{{cite journal |author=Lange W, Lipkin K, Yang G |title=Can ciguatera be a sexually transmitted disease? |journal=J. Toxicol. Clin. Toxicol. |volume=27 |issue=3 |pages=193–7 |year=1989 |pmid=2810444}}</ref> 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.<ref>{{cite journal |author=Blythe D, de Sylva D |title=Mother's milk turns toxic following fish feast |journal=JAMA |volume=264 |issue=16 |pages=2074 |year=1990 |pmid=2214071 |doi=10.1001/jama.264.16.2074b}}</ref>
The symptoms can last from weeks to years, and in extreme cases as long 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 |doi=10.1136/jnnp.70.1.4}}</ref> 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.<ref name="Swift-1993"/>
==Treatment==
There is no effective treatment or antidote for ciguatera poisoning. The mainstay of treatment is supportive care. Some medications such as the use of [[Amitriptyline]] may reduce some symptoms of ciguatera, such as [[fatigue (medical)|fatigue]] and [[paresthesia]],<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 reducing the toxic effects.
Previously [[mannitol]] was used for poisoning after one 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 |doi=10.1001/jama.259.18.2740}}</ref> Followup 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 |doi=10.1016/S0006-8993(99)02032-6}}</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 randomized, controlled, double-blind 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> and based on this result mannitol is no longer recommended.<ref name="Isbister-2005"/>
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.
In the Torres Strait, juice from the fruit of Morinda citrifolia (Cheese Fruit tree)is mixed with coconut milk or water and given to patients as an effective cure for Ciguatera.
== See also ==
*[[Algal bloom]]
*[[Dinoflagellate]] (see "neurotoxins" and "red tide" under [[Dinoflagellate#Ecology and fossils|Ecology and fossils]] and see "phosphate" under [[dinoflagellate#Cautions|Cautions]])
*[[Red tide]]
==Footnotes==
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<references />
</div>
==References==
*[http://www.cdc.gov/nceh/ciguatera/default.htm Ciguatera fish poisoning [[Centers for Disease Control and Prevention|CDC]] ]
*Ciguatera fish poisoning—[[Florida]], [[1991]]. [[MMWR]] [[June 4]], [[1993]];42(21):417-8
*Ciguatera fish poisoning—[[Texas]], [[1997]]. [[MMWR]] [[August 28]], [[1998]];47(33):692-4
*Epidemiologic notes and reports ciguatera fish poisoning—[[Bahamas]], [[Miami]]. [[MMWR]] [[July 23]], [[1982]];31(28):391-2
*Epidemiologic notes and reports ciguatera fish poisoning—Vermont. [[MMWR]] [[April 25]], [[1986]];35(16):263-4
*[http://www.whoi.edu/redtide/illness/ciguatera_fish_poisoning.html Ciguatera fish poisoning]
*[http://www.rehablink.com/ciguatera/poison.htm The Ciguatera Homepage]
{{Poisoning and toxicity}}
[[Category:Foodborne illnesses]]
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