Ciguatera Toxicity Treatment & Management

Updated: May 14, 2022
  • Author: Thomas C Arnold, MD, FAAEM, FACMT; Chief Editor: Michael A Miller, MD  more...
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Approach Considerations

Treatment is largely supportive and symptom driven. If performed within 3-4 hours of toxin ingestion, gastric decontamination with activated charcoal may help. Avoid administering ipecac syrup because of its potential to worsen fluid losses. Antiemetics may control nausea and vomiting.

Cool showers and antihistamines help relieve pruritus. If these measures do not provide relief, amitriptyline administration has proved effective and may also diminish severity of residual symptoms (eg, chronic pain syndromes). [25]

Mannitol infusion can help alleviate neurologic symptoms. [26] Start intravenous (IV) administration as soon as the diagnosis is confirmed. Patients given mannitol need adequate IV hydration; mannitol's diuretic effect requires strict observation of fluid intake and output. However, at least one prospective, controlled study found no difference between mannitol and normal saline in the treatment of ciguatera poisoning. [27]

Manage hypotension with volume replacement; pressor agents are rarely needed. Bradyarrhythmias respond well to atropine.

Gabapentin was found to be helpful in the resolution of symptoms in 2 patients diagnosed with ciguatera poisoning. [28] Intake of large amounts of vitamin B-12 has been reported to attenuate some of the symptoms.

Orogastric lavage is not recommended. It is not of proven benefit for ciguatera poisoning, and risks of this procedure are likely to outweigh benefits. Opiates and barbiturates may exacerbate symptoms and are not recommended.

One group in Japan has reported developing a strategy to use monoclonal antibodies to treat ciguatera toxicity. [29] Possibly an effective treatment will be available in the near future.


Long-Term Monitoring

During the recovery period, victims of ciguatera poisoning should avoid ingesting any of the following, which can cause an exacerbation of symptoms:

  • Any fish products
  • Shellfish products
  • Alcoholic beverages
  • Nuts
  • Nut oils


Travelers to ciguatera-endemic areas should take the following precautions:

  • Avoid consuming large (eg, more than 6 lb) predatory reef fish (especially barracuda or moray eel)
  • Avoid eating the head, viscera, or roe of any reef fish
  • Avoid eating fish caught in areas known to be ciguatoxic

Instruct lactating mothers with ciguatoxin poisoning to avoid breastfeeding. The mother also may experience excessive nipple pain, and the infant may develop diarrhea. Advise patients that ciguatoxin can be transmitted through sexual intercourse.

No screening tests for the detection of ciguatera toxin in fish before they are distributed or consumed are available. Home products are available to detect ciguatoxin in fish at the time of preparation, but the reliability of these products in the hands of the consumer has not been validated.