Correspondence
Treatment of Ciguatera Poisoning with Gabapentin
N Engl J Med 2001; 344:692-693March 1, 2001
- Article
To the Editor:
Ciguatera poisoning from fish is caused by a neurotoxin (ciguatoxin) present in the dinoflagellate Gambierdiscus toxicus. The toxin is transferred through herbivorous reef fish to carnivorous tropical reef fish, which are consumed by humans. The toxin is lipid-soluble and is not inactivated by cooking, cold, or gastric juice. More than 200 species of fish have been implicated in causing ciguatera poisoning, the most common being grouper, red snapper, and barracuda. The primary endemic areas include the Caribbean and South Pacific islands, where the incidence is between 50 and 500 cases per 10,000 population.1,2
The symptoms of ciguatera poisoning, which develop 1 to 30 hours after the ingestion of poisoned fish, are nausea, vomiting, abdominal cramps, and watery diarrhea, followed by such neurologic symptoms as numbness and paresthesia of lips, tongue, and throat; pruritus, myalgia, or sharp, shooting pains in the legs; dysesthesia involving a reversal of the sensations of cold and heat; and in severe cases, hypotension, bradycardia, and respiratory paralysis. These symptoms can last for months and recur intermittently. There is no effective treatment.1,2
We evaluated two patients who had ciguatera poisoning after the ingestion of dusky grouper in the Dominican Republic; both were treated successfully with gabapentin. Patient 1 was a 30-year-old woman who had an episode of diarrhea during a vacation in Punta Cana. Several hours later, dysesthesia developed, along with intense pruritus of the legs, hands, and breasts, which increased with exposure to cold. The physical examination and results of laboratory studies were normal. Patient 2, a 37-year-old woman, had a similar history, except that she had generalized pruritus and sharp, shooting pains in her legs. In both patients, the symptoms were disabling and persisted for weeks.
One month after the onset of symptoms, the patients were treated with gabapentin (400 mg orally three times daily), with rapid improvement. Twenty days later, we stopped the drug; the symptoms returned in a few hours in both patients. Gabapentin therapy was resumed, and the patients had immediate relief of symptoms. The drug was then administered for three weeks. Subsequently, Patient 1 had only minor dysesthesia, and Patient 2 had some leg pain but chose not to resume treatment.
Gabapentin is an antiepileptic drug structurally related to γ-aminobutyric acid that has been used successfully to treat neuropathic pain.3,4 We believe this drug is an effective treatment for ciguatera poisoning.
4 ReferencesCarlos M. Perez, M.D.
Patricia A. Vasquez, M.D., D.T.M.&H.
Cecilia F. Perret, M.D., M.Trop.Ped.
Hospital Clinico Universidad Catolica de Chile, Santiago, Chile1
Sodeman W. Poisonous plants and fish. In: Strickland GT, ed. Hunter's tropical medicine and emerging infectious diseases. 8th ed. Philadelphia: W.B. Saunders, 2000:879-89.
2
Rakita RM . Ciguatera poisoning. J Travel Med 1995;2:252-254
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Morris GL . Gabapentin. Epilepsia 1999;40:Suppl 5:S63-S70
CrossRef | Web of Science | Medline4
Laird MA ,Gidal BE . Use of gabapentin in the treatment of neuropathic pain. Ann Pharmacother 2000;34:802-807
CrossRef | Web of Science | Medline
- Citing Articles (14)
Citing Articles
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Shilpa Kumar-Roiné, H. Taiana Darius, Mariko Matsui, Nicolas Fabre, Mohamed Haddad, Mireille Chinain, Serge Pauillac, Dominique Laurent. (2011) A Review of Traditional Remedies of Ciguatera Fish Poisoning in the Pacific. Phytotherapy Researchn/a-n/a
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Juan M. Herrero-Martínez, Ana Pérez-Ayala, José A. Pérez-Molina, Rogelio López-Vélez. (2011) Un caso de ciguatera en viajera a la República Dominicana. Enfermedades Infecciosas y Microbiología Clínica 29:1, 71-72
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Carlos A. Luciano, Nivia Hernandez-Ramos. 2011. Treatment and Management of Infectious, Granulomatous, and Toxic Neuromuscular Disorders. , 237-260.
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Robert W. Dickey, Steven M. Plakas. (2010) Ciguatera: A public health perspective. Toxicon 56:2, 123-136
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Gregory P. Wedin, Daniel E. Keyler, Elisabeth F. Bilden. 2009. Poisons of Animal Origin. .
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David T. Lawrence, Stephen G. Dobmeier, Laura K. Bechtel, Christopher P. Holstege. (2007) Food Poisoning. Emergency Medicine Clinics of North America 25:2, 357-373
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Jose-Luis Pérez-Arellano, Octavio P. Luzardo, Ana Pérez Brito, Michele Hernández Cabrera, Manuel Zumbado, Cristina Carranza, Alfonso Angel-Moreno, Robert W. Dickey, Luis D. Boada. (2005) Ciguatera Fish Poisoning, Canary Islands. Emerging Infectious Diseases 11:12, 1981-1982
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Raphaële Boydron-Le Garrec, Evelyne Benoit, Martin-Pierre Sauviat, Richard J. Lewis, Jordi Molgó, Dominique Laurent. (2005) Ability of some plant extracts, traditionally used to treat ciguatera fish poisoning, to prevent the in vitro neurotoxicity produced by sodium channel activators. Toxicon 46:6, 625-634
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Geoffrey K Isbister, Matthew C Kiernan. (2005) Neurotoxic marine poisoning. The Lancet Neurology 4:4, 219-228
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Y. Keynan, I. Pottesman. (2004) Neurological symptoms in a traveller returning from Central America. Journal of Internal Medicine 256:2, 174-175
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Elijah W. Stommel, Michael R. Watters. (2004) Marine neurotoxins: Ingestible toxins. Current Treatment Options in Neurology 6:2, 105-114
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P Arena, B Levin, L.E Fleming, M.A Friedman, D Blythe. (2004) A pilot study of the cognitive and psychological correlates of chronic ciguatera poisoning. Harmful Algae 3:1, 51-60
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Heather M. Barbier, James H. Diaz. (2003) Prevention and Treatment of Toxic Seafoodborne Diseases in Travelers. Journal of Travel Medicine 10:1, 29-37
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William A. Burke, Patricia A. Tester. (2002) Skin problems related to noninfectious coastal microorganisms. Dermatologic Therapy 15:1, 10-17
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