What are marine toxins? Marine toxins are naturally occurring chemicals that can contaminate certain seafood.

The seafood contaminated with these chemicals frequently looks, smells, and tastes normal. When humans eat such seafood, disease can result. What sort of diseases do marine toxins cause? The most common diseases caused by marine toxins in United States in order of incidence are scombrotoxic fish poisoning, ciguatera poisoning, paralytic shellfish poisoning, neurotoxic shellfish poisoning and amnesic shellfish poisoning. Scombrotoxic fish poisoning also known as scombroid or histamine fish poisoning, is caused by bacterial spoilage of certain finfish such as tuna, mackerel, bonito, and, rarely, other fish. As bacteria break down fish proteins, byproducts such as histamine and other substances that block histamine breakdown build up in fish. Eating spoiled fish that have high levels of these histamines can cause in human disease. Symptoms begin within 2 minutes to 2 hours after eating the fish. The most common symptoms are rash, diarrhea, flushing, sweating, headache, and vomiting. Burning or swelling of the mouth, abdominal pain, or a metallic taste may also occur. The majority of patients have mild symptoms that resolve within a few hours. Treatment is generally unnecessary, but antihistamines or epinephrine may be needed in certain instances. Symptoms may be more severe in patients taking certain medications that slow the breakdown of histamine by their liver, such as isoniazide and doxycycline. Ciguatera poisoning or ciguatera is caused by eating contaminated tropical reef fish. Ciguatoxins that cause ciguatera poisoning are actually produced by microscopic sea plants called dinoflagellates. These toxins become progressively concentrated as they move up the food chain from small fish to large fish that eat them, and reach particularly high concentrations in large predatory tropical reef fish. Barracuda are commonly associated with ciguatoxin poisoning, but eating grouper, sea bass, snapper, mullet, and a number of other fish that live in oceans between latitude 35 N and 35 S has caused the disease. These fish are typically caught by sport fishermen on reefs in Hawaii, Guam and other South Pacific islands, the Virgin Islands, and Puerto Rico. Ciguatoxin usually causes symptoms within a few minutes to 30 hours after eating contaminated fish, and occasionally it may take up to 6 hours. Common nonspecific symptoms include nausea, vomiting, diarrhea, cramps, excessive sweating, headache, and muscle aches. The sensation of burning or "pins-and-needles," weakness, itching, and dizziness can occur. Patients may experience reversal of temperature sensation in their mouth (hot surfaces feeling cold and cold, hot), unusual taste sensations, nightmares, or hallucinations. Ciguatera poisoning is rarely fatal. Symptoms usually clear in 1 to 4 weeks. Paralytic shellfish poisoning is caused by a different dinoflagellate with a different toxin, than that causing ciguatera poisoning. These dinoflagellates have a red-brown color, and can grow to such numbers that they cause red streaks to appear in the ocean called "red tides." This toxin is known to concentrate within certain shellfish that typically live in the colder coastal waters of the Pacific states and New England, though the syndrome has been reported in Central America. Shellfish that have caused this disease include mussels, cockles, clams, scallops, oysters, crabs,

and lobsters. Symptoms begin anywhere from 15 minutes to 10 hours after eating the contaminated shellfish, although usually within 2 hours. Symptoms are generally mild, and begin with numbness or tingling of the face, arms, and legs. This is followed by headache, dizziness, nausea, and muscular incoordination. Patients sometimes describe a floating sensation. In cases of severe poisoning, muscle paralysis and respiratory failure occur, and in these cases death may occur in 2 to 25 hours. Neurotoxic shellfish poisoning is caused by a third type of dinoflagellate with another toxin that occasionally accumulates in oysters, clams, and mussels from the Gulf of Mexico and the Atlantic coast of the southern states. Symptoms begin 1 to 3 hours after eating the contaminated shellfish and include numbness, tingling in the mouth, arms and legs, incoordination, and gastrointestinal upset. As in ciguatera poisoning, some patients report temperature reversal. Death is rare. Recovery normally occurs in 2 to 3 days. Amnesic shellfish poisoning is a rare syndrome caused by a toxin made by a microscopic, redbrown, salt-water plant, or diatom called Nitzchia pungens. The toxin produced by these diatoms is concentrated in shellfish such as mussels and causes disease when the contaminated shellfish are eaten. Patients first experience gastrointestinal distress within 24 hours after eating the contaminated shellfish. Other reported symptoms have included dizziness, headache, disorientation, and permanent short-term memory loss. In severe poisoning, seizures, focal weakness or paralysis, and death may occur. How can these diseases be diagnosed? Diagnosis of marine toxin poisoning is generally based on symptoms and a history of recently eating a particular kind of seafood. Laboratory testing for the specific toxin in patient samples is generally not necessary because this requires special techniques and equipment available in only specialized laboratories. If suspect, leftover fish or shellfish are available, they can be tested for the presence of the toxin more easily. Identification of the specific toxin is not usually necessary for treating patients because there is no specific treatment. How can these diseases be treated? Other than supportive care there are few specific treatments for ciguatera poisoning, paralytic shellfish poisoning, neurotoxic shellfish poisoning, or amnesic shellfish poisoning. Antihistamines and epinephrine, however, may sometimes be useful in treating the symptoms of scombrotoxic fish poisoning. Intravenous mannitol has been suggested for the treatment of severe ciguatera poisoning. Are there long-term consequences to these diseases? Ciguatera poisoning has resulted in some neurologic problems persisting for weeks, and in rare cases, even years. Symptoms have sometimes returned after eating contaminated fish a second time. Amnesic shellfish poisoning has resulted in long-term problems with short-term memory. Long-term consequences have not been associated with paralytic shellfish poisoning, neurotoxic shellfish poisoning, and scombrotoxic fish poisoning.

How common are these diseases? Every year, approximately 30 cases of poisoning by marine toxins are reported in the United States. Because healthcare providers are not required to report these illnesses and because many milder cases are not diagnosed or reported, the actual number of poisonings may be much greater. Toxic seafood poisonings are more common in the summer than winter because dinoflagelates grow well in warmer seasons. It is estimated from cases with available data that one person dies every 4 years from toxic seafood poisonings. What can I do to prevent poisoning by marine toxins? General guidelines for safe seafood consumption: 1. Although any person eating fish or shellfish containing toxin or disease-causing bacteria may become ill, persons with weakened immune systems or liver problems should not eat raw seafood because of their higher risk of Vibrio infection (see Vibrio FAQhttp://www.cdc.gov/ncidod/DFBMD/diseaseinfo/vibriovulnificus_g.htm). 2. Keep seafood on ice or refrigerated at less than 38 Fahrenheit to prevent spoilage. Specific advise for avoiding marine toxin poisoning: 1. Keep fresh tuna, mackerel, grouper, and mahi mahi refrigerated to prevent development of histamine. Don't believe that cooking spoiled or toxic seafood will keep you safe. These toxins are not destroyed by cooking. 2. Do not eat barracuda, especially, those from the Caribbean. 3. Check with local health officials before collecting shellfish, and look for Health Department advisories about algal blooms, dinoflagellate growth or "redtide" conditions that may be posted at fishing supply stores. 4. Do not eat finfish or shellfish sold as bait. Bait products do not need to meet the same food safety regulations as seafood for human consumption. 5. What is the government doing about these diseases? 6. Some health departments test shellfish harvested within their jurisdiction to monitor the level of dinoflagellate toxins and asses the risk for contamination. Based on the results of such testing, recreational and commercial seafood harvesting may be prohibited locally during periods of risk. State and federal regulatory agencies monitor reported cases of marine toxin poisoning, and health departments investigate possible outbreaks and devise control measures. The Centers for Disease Control and Prevention (CDC) provides support to investigators as needed. 7. What else can be done to prevent these diseases? 8. It is important to notify public health departments about even one person with marine toxin poisoning. Public health departments can then investigate to determine if a restaurant, oyster bed, or fishing area has a problem. This prevents other illnesses. In any food poisoning occurrence, consumers should note foods eaten and freeze any uneaten portions in case they need to be tested. A commercial test has been developed in Hawaii to allow persons to test sport caught fish for ciguatoxins. 9. How can I learn more about this and other public health problems?

10. You can discuss any medical concerns you may have with your doctor or other healthcare provider. Your local city, county, or state health department can provide more information about this and other public health problems that are occurring in your area. General information about the public health of the nation is published every week in the Morbidity and Mortality Weekly Report, by CDC in Atlanta, GA (http://www.cdc.gov/mmwr/). Epidemiologists in your local and state health departments are tracking a number of important public health problems, investigating special problems that arise, and helping to prevent them from occurring in the first place, and from spreading if they do occur.

Food Poisoning from Marine Toxins

Vernon E. Ansdell Seafood poisoning from marine toxins is an underrecognized hazard for travelers, particularly in the tropics and subtropics. Furthermore, the risk is increasing because of factors such as climate change, coral reef damage, and spread of toxic algal blooms.

CIGUATERA FISH POISONING

Ciguatera fish poisoning occurs after eating reef fish contaminated with toxins such as ciguatoxin or maitotoxin. These potent toxins originate from small marine organisms (dinoflagellates) that grow on and around coral reefs. Dinoflagellates are ingested by herbivorous fish. The toxins are then concentrated as they pass up the food chain to large carnivorous fish (usually >6 lb) and finally to humans. Toxins in fish are concentrated in the liver, intestinal tract, roe, and head. Gambierdiscus toxicus, which produces ciguatoxin, tends to proliferate on dead coral reefs. The risk of ciguatera is likely to increase as more coral reefs die because of climate change, construction, and nutrient runoff. Risk for Travelers More than 50,000 cases of ciguatera poisoning occur globally every year. The incidence in travelers to highly endemic areas has been estimated as high as 3 per 100. Ciguatera is widespread in tropical and subtropical waters, usually between the latitudes of 35N and 35S; it is particularly common in the Pacific and Indian Oceans and the Caribbean Sea. Fish that are most likely to cause ciguatera poisoning are carnivorous reef fish, including barracuda, grouper, moray eel, amberjack, sea bass, or sturgeon. Omnivorous and herbivorous fish such as parrot fish, surgeonfish, and red snapper can also be a risk. Clinical Presentation

Typical ciguatera poisoning results in a gastrointestinal illness, followed by neurologic symptoms and, rarely, cardiovascular collapse. The first symptoms usually appear 13 hours after eating contaminated fish and include nausea, vomiting, diarrhea, and abdominal pain. Neurologic symptoms appear 372 hours after the meal and include paresthesias, pain in the teeth or the sensation that the teeth are loose, itching, metallic taste, blurred vision, or even transient blindness. Cold allodynia (dysesthesia when touching cold water or objects) is characteristic and almost pathognomonic of ciguatera poisoning. Neurologic symptoms usually last a few days to several weeks. Chronic neuropsychiatric symptoms resembling chronic fatigue syndrome may be disabling, last several months, and include malaise, depression, headaches, myalgias, and fatigue. Cardiac manifestations include bradycardia, other arrhythmias, and hypotension. The overall death rate from ciguatera poisoning is approximately 0.1% but varies according to the toxin dose and availability of medical care to deal with complications. The diagnosis of ciguatera poisoning is based on the clinical signs and symptoms and a history of eating fish that are known to carry ciguatera toxin. Commercial kits are available to test for ciguatera in fish. They are sensitive but expensive. There is no test for ciguatera in humans. Preventive Measures for Travelers Travelers can take the following precautions to prevent ciguatera fish poisoning:

Avoid or limit consumption of the reef fish listed above, particularly when the fish weighs 6 lb or more. Never eat high-risk fish such as barracuda or moray eel. Avoid the parts of the fish that concentrate ciguatera toxin: liver, intestines, roe, and head.

Remember that ciguatera toxins do not affect the texture, taste, or smell of fish, and they are not destroyed by gastric acid, cooking, smoking, freezing, canning, salting, or pickling. Commercial kits (if available) can be used to check if the fish is safe to eat. Treatment There is no specific antidote for ciguatoxin or maitotoxin. Treatment is generally symptomatic and supportive. Intravenous mannitol has been reported to reduce the severity and duration of neurologic symptoms, particularly if given within 48 hours of the appearance of symptoms.

SCOMBROID
Scombroid, one of the most common fish poisonings, occurs worldwide in both temperate and tropical waters. The illness occurs after eating improperly refrigerated or preserved fish containing high levels of histamine, and often resembles a moderate to severe allergic reaction.

Fish that cause scombroid have naturally high levels of histidine in the flesh and include tuna, mackerel, mahimahi (dolphin fish), sardine, anchovy, herring, bluefish, amberjack, and marlin. Histidine is converted to histamine by bacterial overgrowth in fish that has been improperly stored (>20C) after capture. Histamine and other scombrotoxins are resistant to cooking, smoking, canning, or freezing. Clinical Presentation Symptoms of scombroid poisoning resemble an acute allergic reaction and usually appear 1060 minutes after eating contaminated fish. They include flushing of the face and upper body (resembling sunburn), severe headache, palpitations, itching, blurred vision, abdominal cramps, and diarrhea. Untreated, symptoms usually resolve within 12 hours. Rarely, there may be respiratory compromise, malignant arrhythmias, and hypotension requiring hospitalization. Diagnosis is usually clinical. A clustering of cases helps exclude the possibility of fish allergy. Preventive Measures for Travelers Fish contaminated with histamine may have a peppery, sharp, salty, or bubbly taste but may also look, smell, and taste normal. The key to prevention is to make sure that the fish is promptly chilled (below 38F) after capture. Cooking, smoking, canning, or freezing will not destroy histamine in contaminated fish. Treatment Scombroid poisoning usually responds well to antihistamines (H1-receptor blockers, although H2-receptor blockers may also be of benefit).

SHELLFISH POISONING
Several forms of shellfish poisoning may occur after ingesting filter-feeding bivalve mollusks (such as mussels, oysters, clams, scallops, and cockles) that contain potent toxins. The toxins originate in small marine organisms (dinoflagellates or diatoms) that are ingested and concentrated by shellfish. Risk for Travelers Contaminated shellfish may be found in temperate and tropical waters, typically during or after dinoflagellate blooms or red tides. Clinical Presentation Poisoning results in gastrointestinal and neurologic illness of varying severity. Symptoms typically appear 3060 minutes after ingesting toxic shellfish but can be delayed for several hours. Diagnosis is usually made clinically in patients who recently ate shellfish.
Paralytic Shellfish Poisoning

This is the most common and most severe form of shellfish poisoning. Symptoms usually appear 3060 minutes after eating toxic shellfish and include numbness and tingling of the face, lips, tongue, arms, and legs. There may be headache, nausea, vomiting, and diarrhea. Severe cases are associated with ingestion of large doses of toxin and clinical features such as ataxia, dysphagia, mental status changes, flaccid paralysis, and respiratory failure. The case-fatality ratio averages 6%. The death rate may be particularly high in children.
Neurotoxic Shellfish Poisoning

Neurotoxic shellfish poisoning usually presents as gastroenteritis accompanied by minor neurologic symptoms, resembling mild ciguatera poisoning or mild paralytic shellfish poisoning. Inhalation of aerosolized toxin in the sea spray associated with a red tide may cause an acute respiratory illness, rhinorrhea, and bronchoconstriction.
Diarrheic Shellfish Poisoning

This produces chills, nausea, vomiting, abdominal cramps, and diarrhea. No deaths have been reported.
Amnesic Shellfish Poisoning

This is a rare form of shellfish poisoning that produces a gastroenteritis that may be accompanied by headache, confusion, and permanent short-term memory loss. In severe cases, seizures, paralysis, and death may occur. Preventive Measures for Travelers Shellfish poisoning can be prevented by avoiding potentially contaminated bivalve mollusks. This is particularly important in areas during or shortly after red tides. Travelers to developing countries should avoid eating all shellfish because they carry a high risk of viral and bacterial infections. Marine shellfish toxins cannot be destroyed by cooking or freezing. Treatment Treatment is symptomatic and supportive. Severe cases of paralytic shellfish poisoning may require mechanical ventilation. Marine toxins are naturally occurring chemicals that can contaminate certain seafood. The seafood contaminated with these chemicals frequently looks, smells, and tastes normal, but can make people sick if they eat it.

There are three main types of marine toxins:[1]

Those caused by eating fish, including: o Scombrotoxic fish poisoning

Ciguatera poisoning Tetrodotoxin poisoning (fugu or pufferfish poisoning) Those caused by eating shellfish, including: o Paralytic shellfish poisoning (PSP) o Red tide/neurotoxic shellfish poisoning (NSP) o Diarrheic shellfish poisoning (DSP) o Amnesic shellfish poisoning (ASP) Those caused by contaminated water, including: o Aerosolized Florida red tide/brevetoxins o Blue-green algae (Cyanobacteria) o Pfiesteria and the Pfiesteria-like organisms (PLOs)

o o

In United States, the most common diseases caused by marine toxins, in order of incidence, are scombroid poisoning, ciguatera poisoning, paralytic shellfish poisoning, neurotoxic shellfish poisoning and amnesic shellfish poisoning.

Fish
Scombrotoxic fish poisoning

Also known as scombroid or histamine fish poisoning, is caused by bacterial spoilage of certain finfish such as tuna, mackerel, bonito, and, rarely, other fish. As bacteria break down fish proteins, byproducts such as histamine and other substances that block histamine breakdown build up in fish. Eating spoiled fish that have high levels of these histamines can cause human disease. Symptoms begin within 2 minutes to 2 hours after eating the fish. The most common symptoms are rash, diarrhea, flushing, sweating, headache, and vomiting. Burning or swelling of the mouth, abdominal pain, or a metallic taste may also occur. The majority of patients have mild symptoms that resolve within a few hours. Treatment is generally unnecessary, but antihistamines or epinephrine may be needed in certain instances. Symptoms may be more severe in patients taking certain medications that slow the breakdown of histamine by the liver, such as isoniazid and doxycycline.

Ciguatera poisoning

Ciguatera is caused by eating contaminated tropical reef fish. Ciguatoxins that cause ciguatera poisoning are actually produced by microscopic sea plants called dinoflagellates. Dinoflagellates are single-celled marine organisms that are extremely diverse. About 90% of them are marine plankton with two small protein strands called flagella that makes it possible for them to move through the water. They are a source of food for many other marine organisms. The toxins become progressively concentrated as they move up the food chain from small fish to large fish that eat them, and reach particularly high concentrations in large predatory tropical reef fish. Barracuda are commonly associated with ciguatoxin poisoning, but eating grouper, sea bass, snapper, mullet, and a number of other fish that live in tropical oceans has caused the disease. These fish are typically caught by sport fishermen on reefs in Hawaii, Guam and other

South Pacific islands, the Virgin Islands, and Puerto Rico. Ciguatoxin and the closelyrelated maitotoxin are both produced by dinoflagellates and cause symptoms by interfering with ion channels on cell membranes. Ciguatoxin opens sodium channels and maitotoxin opens calcium channels, disrupting the signaling between nerves and muscles. Ciguatoxin usually causes symptoms within a few minutes to 30 hours after eating contaminated fish, and occasionally it may take up to 6 hours. Common nonspecific symptoms include nausea, vomiting, diarrhea, cramps, excessive sweating, headache, and muscle aches. The sensation of burning or "pins-and-needles," weakness, itching, and dizziness can occur. Patients may experience reversal of temperature sensation in their mouth (hot surfaces feeling cold and cold, hot), unusual taste sensations, nightmares, or hallucinations. Ciguatera poisoning is rarely fatal. Symptoms usually clear in 1 to 4 weeks. Treatment is generally supportive; mannitol (an osmotic diuretic) may be used to increase urine output.[2]

Tetrodotoxin poisoning

Tetrodotoxin causes this type of poisoning; it is found the liver, gonads, intestines, and skin of pufferfish (fugu), as well as in less-commonly eaten animals like California newt, parrotfish, frogs of the genus Atelopus, the blue-ringed octopus, starfish, angelfish, and xanthid crabs.[3] The disease is potentially deadly. Most cases are from fish in the Pacific, and the disease is particularly notorious in Japan, where pufferfish is a delicacy and must be prepared in such a way as to avoid serving toxin to diners. Symptoms include numbness of the lips and tongue, tingling in the body, and a sensation of lightness. Nausea and vomiting, diarrhea, and belly pain may occur. Paralysis sets in after that, as well as difficulty breathing. Eventually heart rhythm abnormalities, seizures, and death follow. Death may occur in as quickly as 20 minutes.[3] Treatment is supportive, and may include giving the person charcoal, pumping the stomach, giving IV fluids, and placing them on a ventilator in severe cases. There is no antidote.[4]

Shellfish
Paralytic shellfish poisoning

Paralytic shellfish poisoning is caused by a different dinoflagellate with a different toxin than the one responsible for ciguatera poisoning. These dinoflagellates have a red-brown color, and can grow to such numbers that they cause red streaks to appear in the ocean called "red tides." This toxin is known to concentrate within certain shellfish that typically live in the colder coastal waters of the Pacific states and New England. The syndrome has been reported in Central America as well. Shellfish that have caused this disease include mussels, cockles, clams, scallops, oysters, crabs, and lobsters. Saxitoxin is the poisonous molecule in these organisms that causes paralysis by blocking sodium channels necessary for muscles to contract. Symptoms begin anywhere from 15 minutes to 10 hours after eating the contaminated shellfish, although usually within 2 hours. Symptoms are generally mild, and begin with

numbness or tingling of the face, arms, and legs. This is followed by headache, dizziness, nausea, and muscular incoordination. Patients sometimes describe a floating sensation. In cases of severe poisoning, muscle paralysis and respiratory failure occur, and in these cases death may occur in 2 to 25 hours. Treatment: There is no specific antidote; victims require supportive care that may include mechanical ventilation.

Red tide/neurotoxic shellfish poisoning

Neurotoxic shellfish poisoning is caused by a third type of dinoflagellate with another toxin that occasionally accumulates in oysters, clams, and mussels from the Gulf of Mexico and the Atlantic coast of the southern United States. Brevetoxin is the poisonous molecule in this case, and acts by opening sodium channels (as opposed to saxitoxin, which blocks them). Symptoms begin 1 to 3 hours after eating the contaminated shellfish and include numbness, tingling in the mouth, arms and legs, incoordination, and gastrointestinal upset. As in ciguatera poisoning, some patients report temperature reversal. Death is rare. Recovery normally occurs in 2 to 3 days. Treatment: Supportive care is given to help the patient feel more comfortable while recovering.

Diarrheic shellfish poisoning

Diarrheic shellfish poisoning is caused by the accumuluation of a toxin called okadaic acid. This acid is produced by dinoflagellates, which are the food of bivalve shellfish. The acid builds up in the shellfish and causes toxic symptoms in people who eat them. Commonly affected shellfish include mussels, oysters, and scallops. Symptoms include nausea, vomiting, diarrhea, and abdominal pain accompanied by chills, headache, and fever. The symptoms are generally mild and subside on their own in 2 or days.[5]

Amnesic shellfish poisoning

Amnesic shellfish poisoning is a rare syndrome caused by a toxin made by a microscopic, red-brown, salt-water plant, or diatom called Nitzchia pungens. The toxin produced by these diatoms is concentrated in shellfish such as mussels and causes disease when the contaminated shellfish are eaten. The active molecule involved in amnesic shellfish poisoning is domoic acid, and works by stimulating glutamate receptors in the central nervous system. Patients first experience gastrointestinal distress within 24 hours after eating the contaminated shellfish. Other reported symptoms have included dizziness, headache, disorientation, and permanent short-term memory loss. In severe poisoning, seizures, focal weakness or paralysis, and death may occur.

Contaminated water

A red tide off the coast of California. Source: Wikimedia Commons

The dinoflagellate Karenia brevis annually blooms, or undergoes especially abundant growth, in waters off the coast of Florida. These blooms are called red tides. When it does so, it releases brevetoxins into the air. This leads to fish and marine mammal deaths as well as irritation of the respiratory tract in humans.[6][7] These are the same brevetoxins that lead to neurotoxic shellfish poisoning in contaminated shellfish, but in this case the toxins are in the air.

Blue-green algae (Cyanobacteria)

Blue-green algae are actually a type of bacteria called cyanobacteria. Some kinds, such as Anabaena, Aphanizomenon, and Microcystis species native to North America, produce toxins sporadically, while others such as the Indian native Cylindrospermopsis produce it all the time. These algae, also known as pond scum, have been known to kill livestock that drink the water in which the algae are growing.[8] Blue-green algae can produce both neurotoxins, which affect the nervous system, and hepatotoxins, which affect the liver. These toxins can quickly kill livestock who drink contaminated water. Symptoms in humans include fever, sore throat, dizziness, stomach cramps, diarrhea or vomiting, which may last for several days. Swimming may lead to irritated eyes or skin.[9] Deaths have occasionally been reported.[10]

Pfiesteria and the Pfiesteria-like organisms

Pfiesteria are dinoflagellate organisms found in estuaries, which are areas where rivers empty into oceans. These organisms were discovered in the 1990s in association with large-scale fish die-offs in the Chesapeake Bay of the United States. Symptoms of exposure include eye and respiratory irritation, headache, and gastrointestinal complaints; skin irritation; and difficulties with learning and memory.[11]

Diagnosis
Diagnosis of marine toxin poisoning is generally based on symptoms and a history of recently eating a particular kind of seafood. Laboratory testing for the specific toxin in patient samples is generally not necessary because this requires special techniques and equipment available in only specialized laboratories. If leftover fish or shellfish are available, they can be tested for the presence of the toxin more easily. Identification of the specific toxin is not usually necessary for treating patients because there is no specific treatment.

Treatment
Other than supportive care there are few specific treatments for ciguatera poisoning, paralytic shellfish poisoning, neurotoxic shellfish poisoning, or amnesic shellfish poisoning. Antihistamines and epinephrine, however, may sometimes be useful in treating the symptoms of

scombrotoxic fish poisoning. Intravenous mannitol has been suggested for the treatment of severe ciguatera poisoning.

Long-term consequences
Ciguatera poisoning has resulted in some neurologic problems that can last for weeks, and in rare cases, even years. Symptoms have sometimes returned after eating contaminated fish a second time. Shellfish poisoning has resulted in long-term problems with short-term memory in some people. Long-term consequences have not been associated with paralytic shellfish poisoning, neurotoxic shellfish poisoning, and scombrotoxic fish poisoning.

Chances of Developing Marine Toxin Poisoning

In the United States, approximately 30 cases of poisoning by marine toxins are reported each year. Because health care providers are not required to report these illnesses and because many milder cases are not diagnosed or reported, the actual number of poisonings is much greater. Toxic seafood poisonings are more common in the summer than winter because dinoflagellates grow well in warmer seasons. It is estimated from cases with available data that one person dies every 4 years from toxic seafood poisonings.

Prevention
It is important to notify public health departments about even one person with marine toxin poisoning. Investigators can then try to determine if a specific restaurant, oyster bed, or fishing area has a problem. This prevents other illnesses. In any food poisoning occurrence, consumers should note foods eaten and freeze any uneaten portions in case they need to be tested. In Hawaii, a commercial test has been developed to allow persons to test sport-caught fish for ciguatoxins.

Guidelines for safe seafood consumption

Although anyone eating fish or shellfish containing toxin or disease-causing bacteria may become ill, persons with weakened immune systems or liver problems should not eat raw seafood because of their higher risk of infection. Seafood should be kept on ice or refrigerated at less than 38 Fahrenheit to prevent spoilage.

Avoiding marine toxin poisoning

1. Fresh tuna, mackerel, grouper, and mahi mahi should be refrigerated to prevent development of histamine. Cooking spoiled or toxic seafood will not make it safe to eat. These toxins are not destroyed by cooking. 2. Barracuda should not be eaten, especially not those from the Caribbean.

3. Local health officials should be consulted before shellfish are collected. Health Department advisories about algal blooms, dinoflagellate growth or "redtide" conditions may be posted at fishing supply stores. 4. Finfish or shellfish sold as bait should not be eaten. Bait products do not need to meet the same food safety regulations as seafood for human consumption.

Natural Marine Toxins: PSP and Domoic Acid

Paralytic shellfish poisoning (PSP) toxins and domoic acid are naturally occurring marine toxins. Singlecelled marine plants (phytoplankton) produce these toxins. Marine animals that filter their food from seawater may accumulate these toxins. The toxins do not appear to directly harm the animals, but people or some predatory animals eating toxic seafoods may become poisoned. PSP toxins and domoic acid are powerful nerve poisons. PSP toxins and domoic acid have no taste or odor. There is no visible difference between toxic and safe seafoods. Cleaning seafoods in many cases will not remove the toxins. Cooking does not destroy the toxins.

Paralytic Shellfish Poisoning Toxins

Certain one-celled organisms called dinoflagellates produce PSP toxins. Bivalve shellfish (2 shells) filter these organisms from the water. PSP toxins accumulate in the dark digestive organs or viscera of most shellfish. In Washington clams, PSP toxins also accumulate in the siphons (necks). Mussels, oysters, clams, and scallops have caused PSP outbreaks in California, but abalone, crab, shrimp and fish have never been implicated as a source of PSP. PSP symptoms begin within a few minutes to a few hours after eating toxic shellfish. Symptoms begin with tingling and numbness of the lips, tongue and fingertips. Later symptoms are lack of balance, lack of muscle coordination, slurred speech and problems in swallowing. Complete paralysis and death can occur in severe cases.

Domoic Acid
Domoic acid was only recently discovered (1991) in California. Certain one-celled plants called diatoms produce domoic acid. Bivalve shellfish and some finfish filter these diatoms from the water. In most cases, domoic acid accumulates in the viscera of these animals. In razor clams, domoic acid also accumulates in the meat. Unsafe levels of domoic acid have been found in mussels, oysters, razor clams and the viscera (but not in the muscle tissue) of sardines, anchovies, crab and lobster. Many other species have yet to be investigated. Domoic acid poisoning symptoms begin within 30 minutes to 24 hours after eating toxic seafood. In mild cases, symptoms may include vomiting, diarrhea, stomach cramps, headache, dizziness and confusion. Difficulty breathing, seizures, coma and death can occur in severe cases. Survivors of severe cases have suffered permanent loss of short-term memory, a condition known as amnesic shellfish poisoning (ASP).

California's Mussel Quarantine

The California Department of Health Services (CDHS) places a quarantine on sport harvesting of mussels for food from May 1 through October 31. This is the period when mussels are most likely to accumulate PSP toxins. The annual mussel quarantine also provides protection from domoic acid poisoning. If monitoring activities confirm unsafe levels of toxins, the quarantine may be expanded to include all bivalve shellfish in the affected area. Local health officers enforce the quarantine. They post signs advising people of the quarantine. These signs also warn people that clams and scallops at times may contain toxins. During the quarantine period, sport harvesters should remove the viscera from clams and scallops and remove the siphons from Washington clams, and eat only the remaining white meat. Missing or destroyed signs do not change the quarantine period.

Marine Toxin Monitoring Program

CDHS monitors marine toxins in sport and commercial seafoods year-round. This program allows CDHS to follow changes in toxin levels and to alert the public and local health agencies if necessary. When CDHS finds unsafe toxin levels in seafoods, the CDHS does not allow the affected species to be commercially harvested or sold. CDHS also issues public warnings for sport harvesters of these species. Unsafe toxin levels sometimes occur outside the annual quarantine period. CDHS declares special local quarantines whenever unsafe levels of toxins appear. Almost all (over 99%) of PSP cases in California have occurred during the annual quarantine months. Domoic acid poisoning has never been reported in humans in California.

Commercially Harvested Shellfish

The annual mussel quarantine does not apply to companies licensed by the State as certified shellfish harvesters. CDHS tests and certifies the shellfish from these companies to be safe. Oysters are the principal bivalve shellfish harvested commercially in California. Other shellfish are available in California retail food stores and restaurants throughout the year. These products come from both local and out-of-state sources. State and federal agencies regulate all commercially harvested shellfish in the United States. These regulations make certain that only safe and wholesome shellfish are available to the consumer. Mussels may be harvested and sold for fish bait at any time. Labels on containers of mussels for fish bait state:

"MUSSELS FOR BAIT ONLY UNFIT FOR HUMAN FOOD"

Annual Mussel Quarantine in California: May 1 - October 31

Shellfish Information Line

CDHS provides a recorded current update on marine toxin activity in California. The messages also report any special quarantines or public warnings. The telephone number is:

510/412-4643 (callers in 510 area code, or out of state) 800/553-4133 (Calif. callers outside the 510 area code)

CDHS updates the message as needed. Callers may leave a message at this number to request more detailed information. Annual reports on the shellfish monitoring program are available from: http://www.dhs.ca.gov/ps/ddwem/environmental/shellfish/default.htm .

Myths About Red Tides

During late spring, summer, or fall, localized patches or streamers of color appear in the ocean or bays along the California coast. These reddish areas or "red tides" appear suddenly and last from a few days to a few months before disappearing. The color of the water comes from the millions of tiny organisms in the water. Water color varies from brown to red depending on how many and what kinds of organisms are present. Many people believe that red tides cause shellfish to be toxic. Most red tides are harmless. Toxin-producing organisms do not generally cause red tides. Although the presence of a red tide is a warning that shellfish may be toxic, the absence of a red tide does not mean they are safe to eat. Shellfish can consume enough toxic organisms to become toxic even when there is no visible red tide.

Safety Tips For Sport Harvesters

During a quarantine:

Do not gather mussels or other quarantined shellfish for food. Toxic mussels are very dangerous because people eat the entire mussel including the viscera. In toxic razor clams, the toxin is present in the meat. In toxic Washington clams, the toxin is present in the siphons. Remove and discard the viscera of all clams and scallops, and the siphons of Washington clams. When domoic acid may be present, remove the viscera of anchovies and crabs immediately after capture. In fish and crabs, domoic acid is confined to the internal organs.

During nonquarantine periods:

Scallop viscera can remain toxic year-round. Do not eat scallop viscera at any time. Following an outbreak of PSP, the siphons of Washington clams may retain toxins for a year or more. If this occurs, CDHS sets and publicizes special local quarantines on Washington clams. Razor clams apparently retain domoic acid in their meat; this phenomenon is currently under study.

Be familiar with the California Department of Fish and Game sport fishing regulations. These regulations are available on the internet and in stores selling sporting goods. Gather shellfish only in areas free from sewage contamination. If in doubt, contact the local county environmental health agency to find out if the shellfish are safe to eat.

Bivalve shellfish include: clams, mussels, oysters and scallops

Marine Toxins

Topic Overview Related Information Credits

Topic Overview
What are marine toxins? Marine toxins are chemicals and bacteria that can contaminate certain types of seafood. Eating the seafood may result in food poisoning. The seafood may look, smell, and taste normal. There are five common types of marine toxins, and they all cause different symptoms. Food poisoning through marine toxins is rare. Every year, about 30 cases are reported to health authorities. But because milder cases are often not reported, the incidence may be greater. Marine toxin poisoning occurs most often in the summer. How is marine toxin poisoning diagnosed and treated? Your doctor will do a medical history and a physical exam and ask you questions about your symptoms and any fish you have recently eaten. Laboratory testing is typically not needed. There are no specific treatments for marine toxin poisoning. Treatment generally consists of managing complications and being supportive until the illness passes. Dehydration caused by diarrhea and vomiting is the most common complication. To prevent dehydration, take frequent sips of a rehydration drink (such as Pedialyte). Try to drink a cup of water or rehydration drink for each large, loose stool you have. Soda and fruit juices have too much sugar and not enough of the important electrolytes that are lost during diarrhea, and they should not be used to rehydrate.

Try to stay with your normal diet as much as possible. Eating your usual diet will help you to get enough nutrition. Doctors believe that eating a normal diet will also help you feel better faster. But try to avoid foods that are high in fat and sugar. Also avoid spicy foods, alcohol, and coffee for 2 days after all symptoms have disappeared. How can I prevent marine toxin poisoning? Always keep seafood refrigerated or on ice. If you have a weak immune system, you should consider not eating raw seafood. To help avoid marine toxins:

Do not eat barracuda, especially if it is from the Caribbean Sea. Refrigerate fresh tuna, mackerel, grouper and mahimahi. Remember that cooking does not destroy the toxins in spoiled or toxic seafood. Check with health officials about local advisories on algae blooms, dinoflagellate growth, or red tide. Do not eat fish or shellfish sold as bait. These products do not have to meet the same standards as seafood for eating.

What are the types of marine toxin poisoning? Scombrotoxic fish poisoning:

Is caused by bacteria. The bacteria may produce a chemical (histamine) that results in the food poisoning. Is usually found in finfish such as tuna, mackerel, and bonito. Causes symptoms within 2 minutes to 2 hours of eating the fish. The most common symptoms are rash, diarrhea, flushing, sweating, headache, and vomiting. Burning or swelling of the mouth, stomach pain, and a metallic taste may also occur. Most people have mild symptoms that are gone within a few hours. In severe cases, antihistamines or epinephrine may be needed. Cooking does not destroy the chemical, so buy your fish from a good source.

Ciguatera poisoning:

Is caused by ciguatoxins, which are produced by tiny sea plants called dinoflagellates. Is usually found in tropical reef fish (such as barracuda) that kill other fish. But it may be found in grouper, sea bass, snapper, mullet, and other fish living in tropical waters. Common locations for these fish are the reefs surrounding Hawaii, the Virgin Islands, Puerto Rico, and Guam and other South Pacific Islands. Causes symptoms within a few minutes to 30 hours. Symptoms include nausea, vomiting, diarrhea, cramps, excessive sweating, headache, and muscle aches. A feeling of burning and "pins and needles" as well as weakness, itching, and dizziness can occur. You may also experience unusual taste sensations, nightmares, and hallucinations. Symptoms usually are over in 1 to 4 weeks.

Cooking does not destroy the toxins, so buy your fish from a good source.

Paralytic shellfish poisoning:

Is caused by a dinoflagellate, although not the same one that causes ciguatera poisoning. These dinoflagellates have a red-brown color and in large numbers can cause a red streak called "red tide" in the ocean. Is usually found in shellfish in colder coastal waters, such as the Pacific Northwest and New England. Shellfish that have caused the condition include mussels, cockles, clams, scallops, oysters, crabs, and lobsters. Usually causes symptoms within 2 hours of eating the shellfish, although symptoms may occur within 15 minutes or after as long as 10 hours. Symptoms usually begin with numbness or tingling in the face, arms, and legs, followed by headache, dizziness, nausea, and loss of coordination. Symptoms are usually mild, although severe symptoms have occurred. Cooking may not destroy the toxins, so buy your fish from a good source.

Neurotoxic shellfish poisoning:

Is caused by a type of dinoflagellate. Is usually found in oysters, clams, and mussels from the Gulf of Mexico and the Atlantic Coast of the southern United States. Cause symptoms in 1 to 3 hours. They include numbness, loss of coordination, an upset stomach, and tingling in the mouth, arms, and legs. They usually last 2 to 3 days.

Amnesic shellfish poisoning:

Is caused by toxins produced by a salt-water plant. Is found in shellfish such as mussels. Causes symptoms within 24 hours. Symptoms include an upset stomach, dizziness, headache, disorientation, and short-term memory loss. Seizures may occur in severe cases.

Marine toxins show promise as cancer drugs

Sept. 26, 2005
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Vibrantly colored creatures from the depths of the South Pacific Ocean harbor toxins that potentially can act as powerful anti-cancer drugs, according to research findings from UWMadison biochemists and their Italian colleagues.

The research team has defined the structure of the toxins and provided a basic understanding that can be used to synthesize pharmaceuticals, according to a study published this week in the Proceedings of the National Academy of Sciences (PNAS). "We've determined how this class of toxins interacts with actin," an important protein responsible for cellular structure and movement, says Ivan Rayment, a professor of biochemistry in the College of Agricultural and Life Sciences who worked with John Allingham, a postdoctoral fellow, on the study. "We're adding to fundamental understanding which will be taken up by others to simplify chemical synthesis of what could potentially be powerful cancer treatments." The toxins, which are produced naturally by organisms that exist symbiotically on deep-sea sponges, work by disrupting the activity of actin, an abundant protein that gives structure to eukaryotic cells. "Actin forms long chains, or filaments, that are essential for cellular locomotion, division and growth," explains Allingham. "Because cancer cell masses grow faster than other cells in the body, actin provides an excellent target for drugs that could inhibit such rapid growth."

Simple marine organisms provide a promising source of natural anti-tumor compounds. Recent structural and functional studies reveal that many toxic marine macrolides utilize a common

strategy for interacting with actin in the cytoskeleton of cancer cells. This provides constraints for the design of new pharmacological agents. (Art: H. Adam Steinberg; Nudibranch photo: Gary Cobb, Deep sea sponge, Reidispongia coerule. Adds Allingham: "These marine toxins can knock out the lynchpins in these long chains or cap their ends and kill cancer cells. Moreover, initial work shows that even a low dose of these toxins can bring a significant response." Prior to the study published in PNAS, it was known that the marine toxins affect several forms of cancer - but not how they worked, says Rayment. The recent findings will enable the toxins to be synthesized in a lab instead of harvested from the depths of the ocean floor, meaning that the drugs can be engineered to be as effective as possible. "In order to chemically synthesize a better drug, it is a good idea to know how the natural compound works," he says. "Scientists who study natural products take their cues from what nature has already done. We're adding deep biochemical meaning to this area." He adds that synthetic chemists hope that actin-based drugs might one day rival the success of Taxol, a powerful drug derived from a natural product that keeps breast-cancer cells from dividing. "Actin-based drugs have not yet been used as successful drugs as have those that target microtubules, like Taxol, in part because we haven't understood how to target actin," Rayment explains. Rayment and Allingham collaborated with Angela Zampella and Maria Valeria D'Auria at the Universita degli Studi di Napoli in Naples, Italy. The work was supported in part by a Canadian Institutes of Health Research Fellowship, a grant from the National Institutes of Health and the state of Wisconsin.