Ciguatera outbreak in New York City

February 1, 2013, 12:44 am

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Ciguatera Fish Poisoning — New York City, 2010-2011. MMWR 2013 Feb 1;62:61-65.

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In the year-long period between August 2010 and July 2011, New York City reported several outbreaks of ciguatera poisoning.  A total of 28 patients were stricken, more than had been reported in NYC during the previous 10 years. This paper documents the city’s Department of Health investigation into these cases.

Patients gave a history of having ingested barracuda (13 cases) or grouper (15 cases). Manifestations of ciguatera poisoning affected three systems: gastrointestinal (abdominal pain, nausea, vomiting, diarrhea); neurological (perioral and peripheral paresthesias, cold-hot temperature reversal, and itching); and cardiovascular (symptomatic bradycardia and hypotension). Some patients experienced weakness and difficulty walking.

This paper gives us the opportunity to review ciguatera poisoning. Let’s do it in the form of a quiz. (Click on the following questions to reveal the answer.)

Ciguatera is caused by ingestion of large predatory coral reef fish, especially barracuda, grouper, snapper, amberjack, and surgeonfish. These predators feed on smaller fish, which acquire ciguatoxin precursors from dining on specific microalgae. As bigger fish eat the smaller ones, toxin is concentrated up the food chain and transformed into a variety of different ciguatoxins (CTX-1, CTX-2, CTX-3). These toxins are odorless, colorless, and heat-stable.

CTX maintains sodium channels in the open position, facilitating the firing of neurons.

As seen in the New York City cases, ciguatoxin affects the gastrointestinal, neurological, and cardiovascular systems. Onset is generally 6-48 hours after ingestion, with abdominal distress, nausea, vomiting, and diarrhea. Headache, pruritus, paresthesias, myalgias, and a distinctive reversal of the sensations of hot and cold have been described. Unusual but striking manifestations have included dysuria and painful ejaculation. Bradycardia and hypotension, as well as tachycardia and hypertension, have been reported.

Indeed it can. In 1989 Lange it al reported 2 cases dyspareunia in sexual partners of males who had developed ciguatera poisoning. Both males described painful ejaculation. The women had not consumed suspect fish.

There is no laboratory test that can prove a patient has ciguatera poisoning. Diagnosis is made on the history of consuming specific fish, clinical manifestations, and clusters of cases. However, samples of suspected fish — if available — can be tested for ciguatoxin.

Treatment is generally symptomatic, since there is no specific antidote. Although mannitol had been recommended for years, a recent trial did not demonstrate that it provided any clinical benefit.

 

 

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