Ciguatera Toxicity in Emergency Medicine Clinical Presentation

  • Author: Thomas C Arnold, MD, FAAEM, FACMT; Chief Editor: Asim Tarabar, MD   more...
 
Updated: May 21, 2010
 

History

Currently, ciguatera poisoning is a clinical diagnosis based upon a constellation of symptoms temporally related to ingestion of suspect fish products. Onset of symptoms may be within 15 minutes or as late as 24 hours (rarely) after ingestion of the toxin. Generally, symptoms are noted within 6-12 hours after ingestion of tropical reef fish. Symptoms increase in frequency and severity over the subsequent 4-6 hours. Reported symptoms are numerous but commonly affect 3 major organ systems: GI, neurologic, and cardiovascular.

  • GI symptoms often are the first to appear, may last 1-2 days, and include the following:
    • Abdominal pain
    • Nausea
    • Vomiting
    • Diarrhea
  • Neurologic symptoms usually are multiple, varied, and, at times, bizarre. Symptoms may begin within a few hours to 3 days after the meal and can be persistent, lasting weeks to several months. Symptoms may include the following:
    • Lingual and circumoral paresthesias
    • Painful paresthesias of the extremities
    • Paradoxical temperature reversal (eg, cold objects feel hot and hot objects feel cold) (This is a classic reported finding; however, at least one study suggests that this perception is likely the result of the exaggerated and intense nerve depolarization and that gross temperature perception remains intact).
    • Dental pain (teeth feel loose)
    • Pruritus
    • Arthralgias
    • Myalgias
    • Weakness
    • Ataxia, vertigo
    • Respiratory paralysis
    • Coma
  • Cardiovascular symptoms are less common but can be severe. They usually resolve within 2-5 days. Patients may experience weakness and dizziness from bradycardia and hypotension.
  • Other features include dyspnea, sweating, salivation, chills, neck stiffness, and pruritus.
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Physical

  • Dehydration from GI losses is a common finding.
  • Neurologic findings are extremely variable, from mild to life threatening.
  • Cardiovascular findings include bradycardia and hypotension. Signs of shock may be observed. Hypotension results from the following:
    • Fluid loss
    • Bradycardia
    • Peripheral vasodilation
    • Myocardial depression
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Causes

Ingestion of sufficient quantities of fish with accumulated ciguatoxin produces this syndrome.

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Contributor Information and Disclosures
Author

Thomas C Arnold, MD, FAAEM, FACMT  Professor and Chairman, Department of Emergency Medicine, Section of Clinical Toxicology, Louisiana State University School of Medicine in Shreveport; Medical Director, Louisiana Poison Control Center

Thomas C Arnold, MD, FAAEM, FACMT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Louisiana State Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Dana A Stearns, MD  Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital

Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Michael J Burns, MD  Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

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