Skip to main content
PMC home page
Journal of Neurology, Neurosurgery, and Psychiatry logoLink to Journal of Neurology, Neurosurgery, and Psychiatry
. 2001 Jan;70(1):4–8. doi: 10.1136/jnnp.70.1.4

Neurology of ciguatera

J Pearn 1
PMCID: PMC1763481  PMID: 11118239

Abstract

Ciguatera is a widespread ichthyosarcotoxaemia with dramatic and clinically important neurological features. This severe form of fish poisoning may present with either acute or chronic intoxication syndromes and constitutes a global health problem. Ciguatera poisoning is little known in temperate countries as a potentially global problem associated with human ingestion of large carnivorous fish that harbour the bioaccumulated ciguatoxins of the photosynthetic dinoflagellate Gambierdiscus toxicus. This neurotoxin is stored in the viscera of fish that have eaten the dinoflagellate and concentrated it upwards throughout the food chain towards progressively larger species, including humans. Ciguatoxin accumulates in all fish tissues, especially the liver and viscera, of "at risk" species. Both Pacific (P-CTX-1) and Caribbean (C-CTX-1) ciguatoxins are heat stable polyether toxins and pose a health risk at concentrations above 0.1 ppb. The presenting signs of ciguatera are primarily neurotoxic in more than 80% of cases. Such include the pathognomonic features of postingestion paraesthesiae, dysaesthesiae, and heightened nociperception. Other sensory abnormalities include the subjective features of metallic taste, pruritis, arthralgia, myalgia, and dental pain. Cerebellar dysfunction, sometimes diphasic, and weakness due to both neuropathy and polymyositis may be encountered. Autonomic dysfunction leads to hypotension, bradycardia, and hypersalivation in severe cases. Ciguatoxins are potent, lipophilic sodium channel activator toxins which bind to the voltage sensitive (site 5) sodium channel on the cell membranes of all excitable tissues. Treatment depends on early diagnosis and the early administration of intravenous mannitol. The early identification of the neurological features in sentinel patients has the potential to reduce the number of secondary cases in cluster outbreaks.



Full Text

The Full Text of this article is available as a PDF (108.1 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Allsop J. L., Martini L., Lebris H., Pollard J., Walsh J., Hodgkinson S. Les manifestations neurologiques de la ciguatera. Trois cas avec étude neurophysiologique et examen d'une biopsie nerveuse. Rev Neurol (Paris) 1986;142(6-7):590–597. [PubMed] [Google Scholar]
  2. Bagnis R., Berglund F., Elias P. S., van Esch G. J., Halstead B. W., Kojima K. Problems of toxicants in marine food products. 1. Marine biotoxins. Bull World Health Organ. 1970;42(1):69–88. [PMC free article] [PubMed] [Google Scholar]
  3. Benoit E., Juzans P., Legrand A. M., Molgo J. Nodal swelling produced by ciguatoxin-induced selective activation of sodium channels in myelinated nerve fibers. Neuroscience. 1996 Apr;71(4):1121–1131. doi: 10.1016/0306-4522(95)00506-4. [DOI] [PubMed] [Google Scholar]
  4. Cameron J., Flowers A. E., Capra M. F. Effects of ciguatoxin on nerve excitability in rats (Part I). J Neurol Sci. 1991 Jan;101(1):87–92. doi: 10.1016/0022-510x(91)90021-x. [DOI] [PubMed] [Google Scholar]
  5. Cameron J., Flowers A. E., Capra M. F. Electrophysiological studies on ciguatera poisoning in man (Part II). J Neurol Sci. 1991 Jan;101(1):93–97. doi: 10.1016/0022-510x(91)90022-y. [DOI] [PubMed] [Google Scholar]
  6. Cameron J., Flowers A. E., Capra M. F. Modification of the peripheral nerve disturbance in ciguatera poisoning in rats with lidocaine. Muscle Nerve. 1993 Jul;16(7):782–786. doi: 10.1002/mus.880160714. [DOI] [PubMed] [Google Scholar]
  7. Chungue E., Bagnis R., Fusetani N., Hashimoto Y. Isolation of two toxins from a parrotfish Scarus gibbus. Toxicon. 1977;15(1):89–93. doi: 10.1016/0041-0101(77)90075-7. [DOI] [PubMed] [Google Scholar]
  8. Chungue E., Bagnis R., Fusetani N., Yasumoto T. Le complexe toxinique des poissons perroquets. Biochimie. 1977;59(8-9):739–741. doi: 10.1016/s0300-9084(77)80255-1. [DOI] [PubMed] [Google Scholar]
  9. DeFusco D. J., O'Dowd P., Hokama Y., Ott B. R. Coma due to ciguatera poisoning in Rhode Island. Am J Med. 1993 Aug;95(2):240–243. doi: 10.1016/0002-9343(93)90268-t. [DOI] [PubMed] [Google Scholar]
  10. Fukuda K., Straus S. E., Hickie I., Sharpe M. C., Dobbins J. G., Komaroff A. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med. 1994 Dec 15;121(12):953–959. doi: 10.7326/0003-4819-121-12-199412150-00009. [DOI] [PubMed] [Google Scholar]
  11. Gillespie N. C., Lewis R. J., Pearn J. H., Bourke A. T., Holmes M. J., Bourke J. B., Shields W. J. Ciguatera in Australia. Occurrence, clinical features, pathophysiology and management. Med J Aust. 1986 Dec 1;145(11-12):584–590. [PubMed] [Google Scholar]
  12. Habermehl G. G., Krebs H. C., Rasoanaivo P., Ramialiharisoa A. Severe ciguatera poisoning in Madagascar: a case report. Toxicon. 1994 Dec;32(12):1539–1542. doi: 10.1016/0041-0101(94)90312-3. [DOI] [PubMed] [Google Scholar]
  13. Karalis T., Gupta L., Chu M., Campbell B. A., Capra M. F., Maywood P. A. Three clusters of ciguatera poisoning: clinical manifestations and public health implications. Med J Aust. 2000 Feb 21;172(4):160–162. doi: 10.5694/j.1326-5377.2000.tb125539.x. [DOI] [PubMed] [Google Scholar]
  14. Katz A. R., Terrell-Perica S., Sasaki D. M. Ciguatera on Kauai: investigation of factors associated with severity of illness. Am J Trop Med Hyg. 1993 Oct;49(4):448–454. doi: 10.4269/ajtmh.1993.49.448. [DOI] [PubMed] [Google Scholar]
  15. Lee C. Fish poisoning with particular reference to ciguatera. J Trop Med Hyg. 1980 Jun;83(3):93–97. [PubMed] [Google Scholar]
  16. Lehane L. Ciguatera update. Med J Aust. 2000 Feb 21;172(4):176–179. doi: 10.5694/j.1326-5377.2000.tb125546.x. [DOI] [PubMed] [Google Scholar]
  17. Leung K. P., Chan T. Y., Sze F. K. Ciguatera poisoning in Hong Kong: a report of two cases. Southeast Asian J Trop Med Public Health. 1992 Sep;23(3):543–544. [PubMed] [Google Scholar]
  18. Lewis R. J. Ciguatoxins are potent ichthyotoxins. Toxicon. 1992 Feb;30(2):207–211. doi: 10.1016/0041-0101(92)90474-j. [DOI] [PubMed] [Google Scholar]
  19. Lewis R. J., Holmes M. J. Origin and transfer of toxins involved in ciguatera. Comp Biochem Physiol C. 1993 Nov;106(3):615–628. doi: 10.1016/0742-8413(93)90217-9. [DOI] [PubMed] [Google Scholar]
  20. Lewis R. J., Hoy A. W. Comparative action of three major ciguatoxins on guinea-pig atria and ilea. Toxicon. 1993 Apr;31(4):437–446. doi: 10.1016/0041-0101(93)90179-m. [DOI] [PubMed] [Google Scholar]
  21. Lewis R. J., Jones A., Vernoux J. P. HPLC/tandem electrospray mass spectrometry for the determination of Sub-ppb levels of Pacific and Caribbean ciguatoxins in crude extracts of fish. Anal Chem. 1999 Jan 1;71(1):247–250. doi: 10.1021/ac980598h. [DOI] [PubMed] [Google Scholar]
  22. Morris J. G., Jr, Lewin P., Hargrett N. T., Smith C. W., Blake P. A., Schneider R. Clinical features of ciguatera fish poisoning: a study of the disease in the US Virgin Islands. Arch Intern Med. 1982 Jun;142(6):1090–1092. [PubMed] [Google Scholar]
  23. Moulignier A., Binet D., Frottier J. Ciguatera fish poisoning: also in Europe. J Neurol Neurosurg Psychiatry. 1995 Aug;59(2):192–192. doi: 10.1136/jnnp.59.2.192. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Pearn J. H. Chronic fatigue syndrome: chronic ciguatera poisoning as a differential diagnosis. Med J Aust. 1997 Mar 17;166(6):309–310. doi: 10.5694/j.1326-5377.1997.tb122320.x. [DOI] [PubMed] [Google Scholar]
  25. Pearn J. H., Lewis R. J., Ruff T., Tait M., Quinn J., Murtha W., King G., Mallett A., Gillespie N. C. Ciguatera and mannitol: experience with a new treatment regimen. Med J Aust. 1989 Jul 17;151(2):77–80. doi: 10.5694/j.1326-5377.1989.tb101165.x. [DOI] [PubMed] [Google Scholar]
  26. Pearn J. Around the rim: the role of surgeons in discovery and research in the Pacific rim. Part I. Surgeons in the Pacific: expeditioners and expedition leaders. Aust N Z J Surg. 1994 Jan;64(1):38–44. doi: 10.1111/j.1445-2197.1994.tb02131.x. [DOI] [PubMed] [Google Scholar]
  27. Scheuer P. J., Takahashi W., Tsutsumi J., Yoshida T. Ciguatoxin: isolation and chemical nature. Science. 1967 Mar 10;155(3767):1267–1268. doi: 10.1126/science.155.3767.1267. [DOI] [PubMed] [Google Scholar]
  28. Stommel E. W., Jenkyn L. R., Parsonnet J. Another case of polymyositis after ciguatera toxin exposure. Arch Neurol. 1993 Jun;50(6):571–571. doi: 10.1001/archneur.1993.00540060013009. [DOI] [PubMed] [Google Scholar]
  29. Stommel E. W., Parsonnet J., Jenkyn L. R. Polymyositis after ciguatera toxin exposure. Arch Neurol. 1991 Aug;48(8):874–877. doi: 10.1001/archneur.1991.00530200116031. [DOI] [PubMed] [Google Scholar]
  30. Strachan L. C., Lewis R. J., Nicholson G. M. Differential actions of pacific ciguatoxin-1 on sodium channel subtypes in mammalian sensory neurons. J Pharmacol Exp Ther. 1999 Jan;288(1):379–388. [PubMed] [Google Scholar]
  31. Ting J. Y., Brown A. F., Pearn J. H. Ciguatera poisoning: an example of a public health challenge. Aust N Z J Public Health. 1998 Feb;22(1):140–142. doi: 10.1111/j.1467-842x.1998.tb01158.x. [DOI] [PubMed] [Google Scholar]

Articles from Journal of Neurology, Neurosurgery, and Psychiatry are provided here courtesy of BMJ Publishing Group

RESOURCES