Correspondence

Ciguatera Poisoning

N Engl J Med 2004; 351:2020November 4, 2004

Article

To the Editor:

In the Clinical Problem-Solving article by Christian and Detsky (July 1 issue),1 ciguatera poisoning is considered as the cause of the patient's symptoms but is then ruled out — on the wrong basis. On learning that the implicated fish had been caught the day before its consumption and transported on ice and that no ciguatoxin-containing algae were in bloom at the time, the clinician concluded that “this new information rules out ciguatera poisoning.” This statement implies that one or more of these factors removes ciguatera as a possible cause, but that is inaccurate. Ciguatera poisoning can result from the consumption of freshly caught, well-refrigerated fish, and the toxin is not rendered harmless by either cooking or freezing.2 Moreover, large specimens of piscivorous fish can accumulate the toxin over time and do not require a current bloom of Gambierdiscus toxicus — the producer of the ciguatoxin — to be toxic.3 In fact, many cases of ciguatera are not associated with a noticeable algal bloom. Ciguatera is generally underdiagnosed,4,5 and clarification of when it might occur is important for persons who may consume potentially dangerous fish.

Uzi M. Selcer, M.D.
Eureka Internal Medicine, Eureka, CA 95501

5 References

1. 1

   Christian MD, Detsky AS. A twist of fate? N Engl J Med 2004;351:69-73
   Full Text | Web of Science | Medline

2. 2

   Ciguatera fish poisoning -- Texas, 1997. MMWR Morb Mortal Wkly Rep 1998;47:692-694
   Medline

3. 3

   Pottier I, Vernoux JP, Lewis RJ. Ciguatera fish poisoning in the Caribbean islands and Western Atlantic. Rev Environ Contam Toxicol 2001;168:99-141
   Web of Science | Medline

4. 4

   Ting JY, Brown AF. Ciguatera poisoning: a global issue with common management problems. Eur J Emerg Med 2001;8:295-300
   CrossRef | Medline

5. 5

   Lehane L, Lewis RJ. Ciguatera: recent advances but the risk remains. Int J Food Microbiol 2000;61:91-125
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Selcer is indeed correct. Because the toxin is deposited in the tissues of the fish over time, ciguatera poisoning can still develop in a person who eats the fish, even when the algae are not in bloom. This additional piece of information would not have made a difference in determining whether the patient had this disorder. What we should have said is that the constellation of symptoms and signs (including their duration) made such a diagnosis unlikely.

Michael D. Christian, M.D.
Allan S. Detsky, M.D., Ph.D.
Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada