Ciguatera Toxicity Clinical Presentation

Updated: May 14, 2022
  • Author: Thomas C Arnold, MD, FAAEM, FACMT; Chief Editor: Michael A Miller, MD  more...
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Currently, ciguatera poisoning is a clinical diagnosis based upon a constellation of symptoms temporally related to ingestion of suspect fish products. Multiple individuals consuming the same fish and experiencing signs and symptoms consistent with ciguatera fish poisoning (CFP), strongly supports the diagnosis. [3]

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: gastrointestinal (GI), neurologic, and cardiovascular.

GI symptoms often appear first and can last 1-2 days. GI symptoms may include the following:

  • Abdominal pain
  • Nausea
  • Vomiting
  • Diarrhea
  • Painful defecation

Neurologic symptoms usually are multiple, varied, and, at times, bizarre. In children, however, irritability may be the only presenting neurologic symptom. Neurologic symptoms may begin within a few hours to 3 days after the meal and can be persistent, lasting weeks to several months. They may be worsened by alcohol consumption, exercise, sexual intercourse, or changes in dietary behavior.

Neurologic 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)
  • Dental pain (teeth feel loose)
  • Pruritus
  • Arthralgias
  • Myalgias
  • Weakness
  • Ataxia, vertigo
  • Respiratory paralysis
  • Coma

Paradoxical temperature reversal is a classic reported finding. However, one study suggests that this perception is likely the result of the exaggerated and intense nerve depolarization and that gross temperature perception remains intact. [21]

Cardiovascular symptoms often resolve within 2-5 days and may reflect the following:

  • Bradycardia
  • Hypotension
  • Pulmonary edema

Other general symptoms include the following:

  • Dysuria
  • Chills
  • Sweating
  • Painful ejaculation
  • Metallic taste
  • Polymyositis

Physical Examination

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