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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 mancaused, 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 35N to 35S

Ciguatoxin concentration from G.Toxicus


consumption

Gambierdiscus
Fish
Humans
Toxicus

Small carnivorous

Larger

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
Barracuda

Parrot Fish
Hogfish

Grouper
Kingfish

Coral trout
Flowery cod

Jacks
Snapper

Red emperor
Wrasses

Surgeonfish

Spanish Mackerel

All carriers of ciguatoxins in their viscera

Snapper

Barracuda

Moray Eel

Flowery Cod

Grouper

Spanish Mackerel

Ciguatoxin: Info & Mechanism


Heat stable and are not

destroyed by cooking, freezing,


or acid
Tasteless & Odorless
Some of the most potent
biological toxins known
Poses a health risk at
concentrations as low as 0.08
to 0.1 g/kg
Start to exert their effects with
a level of detection at ~0.1
parts per billion.

Potent heat stable, nonprotein, lipophilic sodium


channel activator toxin
The poison binds to voltagedependent sodium channels in
muscle and nerve cells, so that
they remain open.
Rest remains unknown
however, other studies suggest
the following:
Can lead to sensitization
to ciguatoxins in CFP
patients
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.
Abdominal pain, nausea,
vomiting, and diarrhea.
Dehydration from GI
symptoms
Dental pain, pruritus,
arhralgias, myalgia,
ataxia, vertigo, and
respiratory paralysis may
also be observed.

paresthesis, painful
paresthesias of the
extremities, and
paradoxical temperature
reversal (reversal of hot
and cold sensation).
Coma, bradycardia, and
hypotension can be seen
in extremely severe cases.

Diagnosis
Although Ciguatera Fish

Poisoning is the most


commonly reported
seafood illness in the
world, doctors do not have
a human biomarker to
confirm Ciguarta fish
posioning.
All diagnosis are
based on clincal signs
and observation of the
patient. (Friedman, M.A.
et al 2008)

A proper diagnosis is made

by looking at the time line


of the symptoms and type
of fish consumed.
Must rule out other
illnesses (mostly shellfish
poisonings or multiple
sclerosis) which exhibit
similar symptoms.

Diagnosis
Current research is

looking into detecting the


presence of ciguatoxin in
human blood or serum
which could be a future
diagnostic tool.
This research is looking
into using ELISA
bioassays for use of
detection.

The most accurate

diagnosis is made after


the timeline of symptoms
has been checked and
verified with symptoms
seen with ciguatera fish
poisoning. If a sample is
present, testing the
viscera of the fish for the
ciguatoxin will give the
most accurate diagnosis.

Treatment
Due to the absence of a

concrete method of
diagnosing an actual
case of CFP, it is hard to
research new drug
treatments. The lack of
accurate diagnosis
paired with the sporadic
cases makes clinical
research for therapeutic
drugs very difficult.

Currently, Mannitol is

the main drug used for


Ciguatoxin cases as it is
the most widely studied.
However, it is the only
drug therapy that has
shown promise in
clinical studies.

Treatment
The main course of

Charcoal can help with GI

decontamination. It only
treatment is to treat the
works if it is administered
symptoms.
within 3-4 hours of the
Treatment varies on the
initial ingestion.
symptoms as the
Antiemetics may control
poisoning presents
nausea and vomiting.
different signs in
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, serotoninnorepinephrine reuptake inhibitors, antihistamines,
analgesics, antipyretics, and anti-inflammatories

Medications

ANTIHISTAMI

NES
Mainly used to relieve

pruritus (itching)

Diphenhydramine

(Benadryl)
It is the main treatment

for pruritus as it blocks


histamine release.

Hydroxyzine (Atarax)
Antagonizes H1

receptors in periphery.
May suppress
histamine activity in
subcortical region of
CNS. It is another
pruritus treatment.

Cyproheptadine
used to treat pruritus.

Unknown mechanism

Medications
SEROTONIN/NOREPI

NEPHRINE
REUPTAKE
INHIBITORS
The inhibitors block the

active reuptake of
norepinephirne and
serotonin.
Have central and
peripheral anticholingeric
and sedative effects.

Amitriptyline is

commonly used to
relieve pruritus and
dysesthesias.
It is most effective for

chronic neurologic
symptoms.
Blocks Na+ channels
that were activated by
the ciguatoxinn

Medications
ANALGESICS
Used for pain relief
Acetaminophen and

Paracetamol are most


commonly used.

Indomethacin (Indocin)
used to relieve myalgias
and arthralgias.

DIURETICS,

OSMOTICS
These medications treat

neurological signs. They


have been proven to
relieve neurological
symptoms within 2 days
(Mitchell, G. et al. 2005).

Mannitol is the main

osmotic diuretic used for


treatment of neurological
symptoms.

Mannitol
Previously, Mannitol was

only used for acute


neurological symptoms.
Recent studies have
shown that Mannitol has
beneficial effects on mild
to moderate cases as well.
(Mitchell, G. 2005)
Mannitol is primarily used
to lessen the severity of
acute cases and to prevent
the onset of chronic
neurologic symptoms.

Mannitol is administered

through IV and should be


administered within 2-3
days after ingestion of
toxic fish.
Precautions must be taken
when administering
Mannitol as it can cause
further dehydration in
patients suffering from
severe vomiting and
diarrhea.

Mannitol
The exact mechanism is

unknown, but it is
thought to be mediated
by the osmotic
reduction of neuronal
edema caused by the
increase of sodium and
ultimate depolarization
of the nerve cell.

Mannitol may inhibit

the reaction of the


ciguatoxin at the
sodium and potassium
channels thus
deactivating the voltage
gated sodium channels
in the cell membranes.

Prognosis
In almost all cases, the

patient will make a full


recovery.
Ciguatera poisoning has
extremely low mortality
rates ~ 0.1%
Most deaths are attributed
to severe cases and are
caused by severe
dehydration,
cardiovascular shock, or
respiratory paralysis.

The patient will feel weak

and lethargic for a period


of a week up to a month
after infection.
In some cases, chronic
neurologic symptoms may
remain for months and in
some cases, years. These
cases have not been
studied at length. Future
studies will focus on this
topic.

Prognosis
Increased sensitivity to

the toxin has been noted


in some cases.
Patients who had a past
bout of CFP experienced a
reoccurrence of ciguatera
poisoning after eating a
ciguateraic fish when
other people who ate it
showed no symptoms.

Ingestion of fish, shellfish,

alcohol, nuts, Opiates, and


Barbiturates have been
reported to intensify the
symptoms among patients
who are recovering from
CFP.
These same products can
also cause a reoccurrence
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

variety of other ways, is it true


to say that G. toxicus can be
used for other things such as
pesticides, cosmetics or
everyday housecleaning
agents?
What is the exact mechanism
that the toxin undergoes in the
fish to cause it to accumulate in
the tissues?
What other health effects does
it have on humans?

Will we ever find a proper

method for testing for and


preventing spread of
ciguatoxins?
Does ciguatoxin have any
biomedical uses?
How can fish avoid eating the
toxic algae?
Do fish feel the same symptoms
as 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
disrupted ocean beds and
reefs, concluding that
oceanic ecosystem
destruction causes harm to
animals and humans via
dispersal of toxin.
When herbivore fish ingest
G. toxicus they accumulate
in organs and tissues as well
as in the next predator fish
that consumes them.
Humans are ailed with
Ciguatera Fish Poisoning
upon ingestion of infected
fish.

Symptoms of illness varies


across individuals.
Mannitol is best treatment
available.
Prevention is key
Know where your fish are
coming from and reduce
oceanic ecosystem
destruction.
Further study must be done to
understand bioaccumulation
of toxin as well as its
mechanism in 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

References

Arnold, T. Toxicity, Ciguatera: Treatment & Medication. eMedicine 2007.


http://emedicine.medscape.com/article/813869-treatment
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CDC/Emerging Infectious Diseases website: http://www.cdc.gov/ncidod/eid/vol11no12/05-0393-G.htm
Empey, C.C. et al. Detection of ciguatoxin in fish tissue using sandwich ELISA and neuroblastoma cell bioassay.
Journal of Clinical Laboratory Analysis 11 July 2008. Vol 22, Issue 4. Pp: 246-25
Friedman, M.A., Fleming, L.E., Fernandez, M., Bienfang, P., Schrank, K., Dickey, R., Bottein, M-Y., Backer, L.,
Ayyar, R., Weisman, R., Watkins, S., Granade, R. and Reich, A. Ciguatera fish poisoning: Treatment, prevention
and management. Marine Drugs, 2008; 6: 456-479.
Inoue, M., et al. Use of monoclonal antibodies as an effective strategy for treatment of ciguatera poisoning. Toxicon
DOI 10.1016. Available Online 2/28/09.
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ciguatera toxin presenting in Avonmouth. Journal of Public Health, 2006; 28: 343-346.
Li, K-M. Ciguatera Fish Poison: A cholinesterase inhibitor. Science, 1965; 147: 1580-1581.
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Pac Health Dialog. 2005 Mar Vol. 12, Issue 1. Pp: 155-157.
Morrison, K.E., Prieto, P.A. and Dominguez, A.C. An ecosystem approach to ciguatera fish poisoning in Cuba:
Preliminary results. IEEE Xplore 2005.
Pearn, J. Neurology of ciguatera. J. Neurol. Neurosurg. Psychiatry, 2001; 70: 4-8.
Perez-Arenello, J-L. et al. Ciguatera Fish Poisoning, Canary Islands. CDC/Emerging Infectious Diseases, 2005; vol.
11, no. 12.
Sobel, J. and Painter, J. Illnesses Caused by Marine Toxins. Food Safety, CID 2005: Vol41 (1 November)
http://www.itg.be/itg/DistanceLearning/LectureNotesVandenEndenE/46_Marine_biotoxinsp2.htm
U.S. Food and Drug Administration website. Ciguatera page. http://www.cfsan.fda.gov/~mow/chap36.html

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