Ciguatera fish poisoning in Brazilian traveler to Caribbean

brazjinfectdis2019;23(3):200–202

w w w . e l s e v ie r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Case

report

Ciguatera

fish

poisoning

in

Brazilian

traveler

to

Caribbean

Cidney

K.

Neves

Junior,

Luciano

Z.

Goldani

InfectiousDiseasesSection,HospitaldeClínicasdePortoAlegre,UniversidadeFederaldoRioGrandedoSul,PortoAlegre,RS,Brazil

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Articlehistory:

Received1June2019

Accepted29June2019

Availableonline10July2019

Keywords: Ciguatera Caribbean Braziliantraveller Fishpoisoning

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Ciguaterapoisoningisthemostcommonformofnon-bacterialfood-poisoningfromfish

worldwide.The incidenceamongBraziliansreturningfromhigh-riskregionsisunclear

becauseitisnota mandatoryreportabledisease.Wedescribeapreviouslyhealthy

53-year-oldBrazilianwomandevelopedCiguaterafishpoisoningwhiletravelingtoHavana,

Cuba.Physiciansandhealthcareprofessionalsshouldadvisetravelerstoavoideating

cigua-toxicfishspeciesandpotentiallytoxicfishspeciesintheCaribbeanislands.Despitethe

prognosisformostcasesisgoodwithashortdurationofself-limited symptoms,early

recognitionoftheidentifyingclinicalfeaturesofciguateracanresultinimprovedpatient

care.

©2019PublishedbyElsevierEspa ˜na,S.L.U.onbehalfofSociedadeBrasileirade

Infectologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Ciguaterafishpoisoningisafood-borneillnesscausedbythe

consumptionofreeffishcontainingciguatoxins.1,2Although

mostciguateracasesareseeninendemictropicalareas,there

isanincreasingpotentialforcasestobeencounteredin

tem-perateregions.Inthisreport,wedescribeahealthy53-year-old

Brazilianpatientthatacquiredciguaterapoisoningfollowing

traveltoHavana,Cuba,foroneweekonbusiness.Shestayed

inahotelandatefoodspreparedinrestaurants.Threenights

beforeherdeparturetoBrazil,sheateaportionofafish

iden-tifiedby thehostas redsnapper. Approximately 10h after

hermeal,shewenttotheemergencyroomcomplainingof

severeheadacheaccompaniedbypaininthebackandjoints,

particularlyherknees,abdominaldiscomfortassociatedwith

nauseaandvomiting.Shealsodescribedparesthesiaofmouth

andextremities,extremitypruritusandcoldallodynia. The

∗ _{Correspondingauthor.}

E-mailaddress:lgoldani@ufrgs.br(L.Z.Goldani).

diagnosis ofciguatera poisoningwasmadeon thebasisof

theepidemiologicaldataandtheassociationof

gastrointesti-nalandneurologicalsymptoms.Managementwassupportive

including oralhydratation,antiemetics andantihistamines,

andnon-steroidalanti-inflammatorydrugs.

After returning to Brazil, hersymptoms persisted, with

notedweaknessdepressedmooddespiteavoidingheavy

exer-cise,alcoholandcaffeineconsumption.Bythreemonthsafter

onset,thesymptomshadresolvedentirely, andthepatient

returnedtohernormallifewithoutdietrestrictions.

Ciguatera isa food-borne illness that occurs in

inhabi-tants,andvisitorsofislandssurroundedbycoralreefs.Surface

microalgaeattachedtobiodetritusandmacroalgaeoncoral

reefsareassociatedwiththecausativetoxins.3_{Certainstrains}

ofGambierdicustoxicusandOstreopsislenticularisproduce

toxins that are modified in the stomachoffish.

Ciguatox-insarepredominatelyconcentratedintheCaribbean.Ithas

beenestimatedthatlessthan20%ofciguateraillnessesare

reported, with the extent of underreporting likely to vary

https://doi.org/10.1016/j.bjid.2019.06.004

1413-8670/©2019PublishedbyElsevierEspa ˜na,S.L.U.onbehalfofSociedadeBrasileiradeInfectologia.Thisisanopenaccessarticle

brazj infect dis.2019;23(3):200–202

201

Table1–CasereportsofciguaterapoisoningacquiredintheCaribbean.

References Location Age/sex Clinicalmanifestations Outcome

1 Bahamas 15/M Nausea,vomiting,diarrhea,tonicclonicseizures,

alteredmentalstatus,encephalopathy,dysmetria

Alive

2 Cuba 39/M Paradoxicaldysesthesia,paresthesia,arthralgia Alive

Dominican Republic

68/M Nausea,vomiting,diarrhea,generalizedpruritus,

paresthesia

Alive Dominican

Republic

68/F Nausea,vomiting,diarrhea,generalizedpruritus,

paradoxicaldysesthesia

Alive

3 Cuba 4/M Gastrointestinalmanifestations,arthralgia Alive

4 Dominican

Republic

44/F Nausea,vomiting,diarrhea,pruritus,myalgia,

arthralgia,hypotension,bradycardia

Alive

5 Caribbean 29/M Vomiting,diarrhea,myalgia,paresthesia,abdominal

cramps

Alive

Caribbean 23/F Vomiting,diarrhea,myalgia,chill,abdominal

cramps,allodynia,mydriasis,photosensitivity,

dysphagia

Alive

6 Caribbean 45/M Nausea,abdominalcramps,diarrhea,pruritusofthe

feet,paradoxicaldysesthesia,paresthesia,fatigue

Alive

7 Aruba 35/M Nausea,vomiting,abdominalcramps,

diarrhea,sweating,myalgia,generalizedpruritus

Alive

8 Mexico 32/F Righthemiparesthesia,insomnia,pruritus,

paresthesiamyalgia,fatigue,sleepiness.

Alive

9 Tortola 45/F Abdominalcramps,headaches,fatigue,

paresthesias,paradoxicaldysaesthesia

Alive

Bahamas 44/M Nausea,vomiting,chills,fatigue,headaches,

paresthesias,paradoxicaldysesthesia

Alive Dominican

Republic

53/M Pruritusofextremities,photosensitivity,toothache,

paradoxicaldysesthesia,paresthesias,fatigue

Alive

10 Caribbean 60/F Fatigue,myalgia,diarrhea,pruritus,paradoxical

dysesthesia

Alive

Caribbean 63/F Nausea,diarrhea,headache,myalgia,fatigue,oral

paresthesias,pruritus

Alive

betweencountries.TouristarrivalstoCaribbeandestinations

reached29.9milliontouristvisitsin2018.Table1describesthe

casereportsofpatientswithciguaterapoisoningacquiredin

theCaribbean.4–13_{TheincidenceamongBraziliansreturning}

fromhigh-riskregionsisunclearbecauseitisnota

manda-toryreportableillness. Therehasbeen apreviousreportof

ciguaterapoisoninginBrazilianstravelers.8_Althoughthe

mor-talityratesfromciguaterapoisoningarelow,themorbidityis

high.Gastrointestinalmanifestationsstart6–12hafter

con-sumptionofcontaminatedfish.Neurologicalandsometimes

psychiatricsymptoms appear24–72h later,with weakness

ofthelimbs,perioralparesthesia,andsensationofhot/cold

temperature reversal (paradoxical dysesthesiaor cold

allo-dynia).Myalgia, arthralgia,headache,ataxia, and dizziness

canalsobeobserved.Othermanifestationsincludeasthenia,

pruritus,cutaneousrash,eyeanddental pain,and dysuria.

Inseverecases,cardiovasculardisorders(hypotension,

brady-cardia)canoccur.Thereiscurrentlynostandardlaboratory

testtoconfirmciguaterapoisoning,however,thereareassays

thatcanqualitativelymeasureciguatoxininthefish fluid.1

Management includes avoidance of potential exacerbating

triggers.2_{Reportofheavyexercises,consumptionofcaffeine,}

peanuts,seafood,andalcoholhaveallbeenassociatedwith

worsening ofsymptoms. Although thereare noconsistent

studies,intravenousmannitoltherapyhadbeenproposedas

thetreatmentofchoice.Theeffectofmannitolisthoughtto

bemediatedbythereductionofneuronaledemathroughthe

modulationofsodiumionconcentrationsacrosscell

mem-branes.Gabapentinandamitriptylinewereusedtotreatpain,

andparesthesiasandfluoxetineforneuropsychiatric

condi-tions suchasanxietyand chronicfatigue.Topreventmass

ciguaterafishpoisoning,physiciansand healthcare

profes-sionalsshouldadvisetravellerstoavoideatingciguatoxicfish

species and potentially toxic fish species inthe Caribbean

islandsincludinglargereeffishandoceanpredatorssuchas

barracuda,grouper,andsnapper.3

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