The consumption of certain parts of the fish, such as the head, guts, liver, or roe, poses a higher risk for ciguatera poisoning because these parts can contain higher concentrations of the toxin.² Cooking, drying, salting, and freezing do not destroy ciguatoxins.¹ The California Department of Public Health recommends that patients recovering from ciguatera should avoid eating reef fish, fish sauces, shellfish, nuts/nut oils, and alcoholic beverages for up to six months, because these foods may provoke a recurrence. Future exposure can result in more severe symptoms.⁴

Treatment of ciguatera poisoning is supportive and symptomatic. Mannitol has been used; the literature is mixed related to potential benefit. Hospitalization may be necessary for persistent symptoms.

Take-home points include the following:

• Ciguatera poisoning can cause gastrointestinal, cardiac, and neurologic symptoms.
• An altered reaction to cold can be considered confirmatory.
• Periods of heavy rain increase the risk of ciguatera poisoning.
• Reef fish are most often implicated.
• The head, liver, and roe are riskier parts of the fish to eat than the flesh.
• Prior exposure increases the risk of symptoms from repeat exposure.
• Treatment is symptomatic.
• Hospitalization may be necessary for persistent symptoms.
• Patients should be warned about potential future recurrent symptoms.

In conclusion, avoid eating reef fish after periods of heavy rain, especially the head or roe.

Dr. Baker, a Hawaii-based emergency physician with a long-standing interest in toxicology, finds himself both fascinated and concerned by the dangers posed by natural toxins like ciguatera and manmade ones like methamphetamine.

References

1. WHO Department of Food Safety and Zoonoses. Ciguatera poisoning. World Health Organization. Published November 2020. Accessed July 15, 2024.
2. National Center for Emerging and Zoonotic Infectious Diseases. Food poisoning from seafood. Centers for Disease Control and Prevention. Updated March 30, 2022. Accessed July 15, 2024.
3. Friedman MA, Fleming LE, Fernandez M, et al. Ciguatera fish Poisoning: treatment, prevention and management. Mar Drugs. 2008;6(3):456-479.
4. State of California Health and Human Services Agency. Ciguatera fish poisoning fact sheet. California Department of Public Health Division of Communicable Disease. Published December 2017. Accessed July 15, 2024.