Ciguatera Fish Poisoning

Stephanie Perez
Mallery Quetawki
Sara Jones
Introduction
 Gambierdiscus toxicus
 Importance of study
 Macroalgae in coral reefs
 Ciguatoxins
 Reef Fish
 Mechanism
 Ciguatera Fish Poisoning (CFP)
 Epidemiology
 Symptoms, treatment & prognosis
 Prevention
Introduction cont…
 Fun Facts
 Discussion
 Summary
 Extra info
Importance of Study
 G. Toxicus leads to Ciguatera Fish Poisoning in
humans.
 Sea food diners and consumers need to be educated
on risks for exposure to Ciguatoxins
 Disruption of environment, both natural and man-
caused, can lead to adverse effects on animals and
humans.
 Gambierdiscus toxicus
Photosynthetic benthic dynoflagellates that grow
predominately in association with microalgae in
coral reefs in tropical and subtropical climates
 Gambierdiscus toxicus
Found in the Pacific Ocean, Red Sea, Indian Ocean,
and Caribbean Seas from 35°N to 35°S
 Gambierdiscus toxicus
Ciguatoxin concentration from G.Toxicus consumption

Gambierdiscus Small carnivorous Larger Fish Humans

Toxicus fish

Bio accumulated ciguatoxins in the viscera of fish

becomes progressively concentrated upwards along
the food chain
Cycle of Toxin
• Destruction of coral reef ecosystem, due to human activities or
natural events, cause recolonization of microalgae on damaged
surfaces.

• This sparks an outbreak of ciguatera in the damaged regions. The

freshly grown algae is then consumed by smaller fish where the
toxin accumulates in the liver, eggs and skin.

• It is suggested that there maybe chemical alterations of the toxin as it

is metabolized inside these fish as well as the next carnivorous fish
that eats them.

• This process thus causes accumulation and an increase in lethality as

it goes up the food chain.
Tropical/Subtropical Fish
• Moray eel • Parrot Fish
• Barracuda • Hogfish
• Grouper • Coral trout
• Kingfish • Flowery cod
• Jacks • Red emperor
• Snapper • Wrasses
• Surgeonfish • Spanish Mackerel

All carriers of ciguatoxins in their viscera

Snapper Flowery Cod

Barracuda Grouper

Moray Eel Spanish Mackerel

Ciguatoxin: Info & Mechanism
• Heat stable and are not • Potent heat stable, non-
destroyed by cooking, freezing, protein, lipophilic sodium
or acid channel activator toxin
• Tasteless & Odorless • The poison binds to voltage-
dependent sodium channels in
• Some of the most potent muscle and nerve cells, so that
biological toxins known they remain open.
• Poses a health risk at • Rest remains unknown
concentrations as low as 0.08 however, other studies suggest
to 0.1 μg/kg the following:
• Start to exert their effects with • Can lead to sensitization
a level of detection at ~0.1 to ciguatoxins in CFP
patients
parts per billion.
• the poison inhibits the
action of cholinesterase
Ciguatoxin Type-2 Backbone
Ciguatoxin Type-1 Backbone
Ciguatera Fish Poisoning (CFP)
 Epidemiology
 occurs in 10-50,00 people per year
 incidence rates may be as high as 50 to 500 per
10,000 population per year in the South Pacific region
 Mortality is low (0.1 to 4%)
 Seasonal differences in occurrence of toxin in ecosystems
 Under-reporting occurs in part because individuals with
CFP often do not seek medical attention
 Ciguatera poisoning currently poses the largest single
constraint on fisheries development in the eastern
Caribbean
 Clinical Signs of Ciguatera
Poisoning
• Symptoms begin 6-12 hours
after ingestion of fish
• Occur in 3 major organ
systems: GI, Neurologic, and
Cardiovascular
• First reported symptoms are
usually GI symptoms which last
for a few days after ingestion.
• Within the first 3 hours,
Neurological symptoms can be
present and are commonly
moderate to severe.
• Cardiovascular symptoms are
reported last and are generally
severe.
Clinical Signs
• Numbness and Tingling in • Lingual and circumoral
the mouth. paresthesis, painful
• Abdominal pain, nausea, paresthesias of the
vomiting, and diarrhea. extremities, and
• Dehydration from GI
paradoxical temperature
symptoms reversal (reversal of hot
and cold sensation).
• Dental pain, pruritus,
• Coma, bradycardia, and
arhralgias, myalgia,
ataxia, vertigo, and hypotension can be seen
respiratory paralysis may in extremely severe cases.
also be observed.
Diagnosis
• Although Ciguatera Fish • A proper diagnosis is made
Poisoning is the most by looking at the time line
commonly reported of the symptoms and type
seafood illness in the of fish consumed.
world, doctors do not have • Must rule out other
a human biomarker to illnesses (mostly shellfish
confirm Ciguarta fish poisonings or multiple
posioning. sclerosis) which exhibit
• All diagnosis are similar symptoms.
based on clincal signs
and observation of the
patient. (Friedman, M.A.
et al 2008)
Diagnosis
• Current research is • The most accurate
looking into detecting the diagnosis is made after
presence of ciguatoxin in the timeline of symptoms
human blood or serum has been checked and
which could be a future verified with symptoms
diagnostic tool. seen with ciguatera fish
• This research is looking poisoning. If a sample is
into using ELISA present, testing the
bioassays for use of viscera of the fish for the
detection. ciguatoxin will give the
most accurate diagnosis.
Treatment
• Due to the absence of a • Currently, Mannitol is
concrete method of the main drug used for
diagnosing an actual Ciguatoxin cases as it is
case of CFP, it is hard to the most widely studied.
research new drug However, it is the only
treatments. The lack of drug therapy that has
accurate diagnosis shown promise in
paired with the sporadic clinical studies.
cases makes clinical
research for therapeutic
drugs very difficult.
Treatment
• The main course of • Charcoal can help with GI
treatment is to treat the decontamination. It only
symptoms. works if it is administered
• Treatment varies on the within 3-4 hours of the
symptoms as the initial ingestion.
poisoning presents • Antiemetics may control
different signs in nausea and vomiting.
different patients. • Cold showers and
antihistamines can help
with pain from pruritus.
Medications
 There are six different kinds of medicines that are
most affective in treating CFP.
 They are: neurologic agents, serotonin-
norepinephrine reuptake inhibitors, antihistamines,
analgesics, antipyretics, and anti-inflammatories
Medications
 ANTIHISTAMINES  Hydroxyzine (Atarax)
 Mainly used to relieve  Antagonizes H1
pruritus (itching) receptors in periphery.
May suppress
 Diphenhydramine histamine activity in
(Benadryl) subcortical region of
 It is the main treatment CNS. It is another
for pruritus as it blocks pruritus treatment.
histamine release.  Cyproheptadine
 used to treat pruritus.
Unknown mechanism
Medications
• SEROTONIN/NOREPINE • Amitriptyline is
PHRINE REUPTAKE commonly used to
INHIBITORS relieve pruritus and
• The inhibitors block the dysesthesias.
active reuptake of • It is most effective for
norepinephirne and chronic neurologic
serotonin. symptoms.
• Have central and • Blocks Na+ channels
peripheral that were activated by
anticholingeric and the ciguatoxinn
sedative effects.
Medications
• ANALGESICS • DIURETICS, OSMOTICS
• Used for pain relief • These medications treat
• Acetaminophen and neurological signs. They
Paracetamol are most have been proven to
commonly used. relieve neurological
symptoms within 2 days
• Indomethacin (Indocin)
(Mitchell, G. et al. 2005).
• used to relieve myalgias
and arthralgias.
• Mannitol is the main
osmotic diuretic used for
treatment of neurological
symptoms.
Mannitol
• Previously, Mannitol was • Mannitol is administered
only used for acute through IV and should be
neurological symptoms. administered within 2-3
• Recent studies have days after ingestion of
shown that Mannitol has toxic fish.
beneficial effects on mild • Precautions must be taken
to moderate cases as well. when administering
(Mitchell, G. 2005) Mannitol as it can cause
• Mannitol is primarily used further dehydration in
to lessen the severity of patients suffering from
acute cases and to prevent severe vomiting and
the onset of chronic diarrhea.
neurologic symptoms.
Mannitol
• The exact mechanism is • Mannitol may inhibit
unknown, but it is the reaction of the
thought to be mediated ciguatoxin at the
by the osmotic sodium and potassium
reduction of neuronal channels thus
edema caused by the deactivating the voltage
increase of sodium and gated sodium channels
ultimate depolarization in the cell membranes.
of the nerve cell.
Prognosis
• In almost all cases, the • The patient will feel weak
patient will make a full and lethargic for a period
recovery. of a week up to a month
• Ciguatera poisoning has after infection.
extremely low mortality • In some cases, chronic
rates ~ 0.1% neurologic symptoms may
• Most deaths are attributed remain for months and in
to severe cases and are some cases, years. These
caused by severe cases have not been
dehydration, studied at length. Future
cardiovascular shock, or studies will focus on this
respiratory paralysis. topic.
Prognosis
• Increased sensitivity to • Ingestion of fish, shellfish,
the toxin has been noted alcohol, nuts, Opiates, and
in some cases. Barbiturates have been
• Patients who had a past
reported to intensify the
bout of CFP experienced a symptoms among patients
reoccurrence of ciguatera who are recovering from
poisoning after eating a CFP.
ciguateraic fish when • These same products can
other people who ate it also cause a reoccurrence
showed no symptoms. of neurological symptoms
years later.
• The exact reason for this
is unknown
 Prevention
• Home products are
available and are able to
test if ciguatoxin is present
in fish that are cooked.
However, there is
insufficient data available to
show if these products are
effective or not.
• If you think you may have
ciguatera poisoning, report
your symptoms and what
fish you ate to your doctor,
local emergency room, or
health department. If
possible, save meal
remnants.
Prevention
• Knowledge is your best prevention.
• The next best preventative
measure is to stop or reduce
destruction of coral reefs which
lead to G. Toxicus accumulation.
• Educate yourself about seafood
fish posioning. Know what types of
fish are vectors for the ciguatoxin
and be sure you know where it
came from if you are planning on
consuming reef fish.
• Florida has an aquatic toxins
program to teach their residents
about the dangers of seafood
poisoning.
http://www.myfloridaeh.com/med
icine/aquatic/index.html
Fun Facts: Folk Science
 If no flies on fish= +CFP  Feed fish to cat and the
cat vomits= +CFP
Discussion
 There is a need for protection of aquatic habitats so
that G. toxicus does not disperse.
 There is further research needed to find how
ciguatoxins effect animal and human physiology.
 Greater knowledge about this will lead to better
diagnostic techniques, drug therapies, and treatment
plans.
 Further studies should focus on how and why toxin is
produced during disturbance of coral reef.
Discussion
 Questions remain:
 If other toxins can be used in a  Will we ever find a proper
variety of other ways, is it true method for testing for and
to say that G. toxicus can be preventing spread of
used for other things such as ciguatoxins?
pesticides, cosmetics or  Does ciguatoxin have any
everyday housecleaning biomedical uses?
agents?  How can fish avoid eating the
 What is the exact mechanism toxic algae?
that the toxin undergoes in the  Do fish feel the same symptoms
fish to cause it to accumulate in as humans?
the tissues?
 What other health effects does
it have on humans?
Discussion
 Is this toxin produced as a defense
mechanism for G. toxicus although a
majority of the fish do not seem to exhibit
side effects from exposure?
 Could fish use this toxin, if not harmed by it, for use against predation?

 At what costs are the toxin made?

 Even disruption from natural disasters causes
accumulation of toxin in damaged areas of reef.
 Better dispersal method since natural disturbances are common?
Summary
• G. toxicus emerges from • Symptoms of illness varies
disrupted ocean beds and across individuals.
reefs, concluding that
oceanic ecosystem • Mannitol is best treatment
destruction causes harm to available.
animals and humans via • Prevention is key
dispersal of toxin. • Know where your fish are
• When herbivore fish ingest coming from and reduce
G. toxicus they accumulate oceanic ecosystem
in organs and tissues as well destruction.
as in the next predator fish
that consumes them. • Further study must be done
• Humans are ailed with to understand
Ciguatera Fish Poisoning bioaccumulation of toxin as
upon ingestion of infected well as its mechanism in
fish. humans.
Videos
 Watch interviews on CFP encounters/symptoms.
(8mins)
YouTube - Ciguatera Interviews

 Other video on CFP testing if interested (10mins):

http://www.youtube.com/watch?v=rbdEBUiXKV0
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