ciguatera fish poisoning in peel region

DIAGNOSIS, TREATMENT, PREVENTION AND MANAGEMENT

BY: PARESH GANDHI

Ciguatera Fish Poisoning in Peel Region

Presenter

Presentation Notes

Ciguatera poisoning is caused by consumption of reef fish contaminated with ciguatoxin, which originates with certain dinoflagellates (ie, algae) associated with coral reef systems and accumulates up the food chain from small herbivorous fish to larger carnivorous fish, such as barracuda (see the image below) and grouper. Contaminated fish have no specific odor, color, or taste, making identification of potential contamination extremely difficult. Barracuda. See 5 Cases of Food Poisoning: Can You Identify the Pathogen?, a Critical Images slideshow, to help identify various pathogens and symptoms related to foodborne disease. Signs and symptoms Ciguatera poisoning is a clinical diagnosis based upon a constellation of symptoms temporally related to ingestion of suspect fish products. Onset of symptoms may be within 15 minutes or as late as 24 hours (rarely) after ingestion of the toxin. Generally, symptoms are noted within 6-12 hours after ingestion of tropical reef fish. Symptoms increase in frequency and severity over the subsequent 4-6 hours. Reported symptoms are numerous but commonly affect 3 major organ systems: GI, neurologic, and cardiovascular. GI symptoms, which often appear first, may include the following: •Abdominal pain •Nausea •Vomiting •Diarrhea •Painful defecation Neurologic symptoms may include the following: •Lingual and circumoral paresthesias •Painful paresthesias of the extremities •Paradoxical temperature reversal (eg, cold objects feel hot and hot objects feel cold; classic symptom) •Dental pain (teeth feel loose) •Pruritus •Arthralgias •Myalgias •Weakness •Ataxia, vertigo •Respiratory paralysis •Coma In children, irritability may be the only presenting neurologic symptom. Cardiovascular findings may reflect the following: •Bradycardia •Hypotension •Pulmonary edema Other general symptoms include the following: •Dysuria •Chills •Sweating •Painful ejaculation •Metallic taste •Polymyositis See Clinical Presentation for more detail. Diagnosis All routine laboratory tests are nonspecific for ciguatera poisoning, but the results may reflect volume depletion from fluid losses. Mild creatine phosphokinase (CPK) and lactate dehydrogenase (LDH) elevations, if present, reflect muscle tissue breakdown. See Workup for more detail. Management Treatment is largely supportive and symptom driven. Medications used to treat ciguatera poisoning include the following: •Activated charcoal •Antihistamines •Amitriptyline •Mannitol •Analgesics •Nonsteroidal anti-inflammatory drugs (NSAIDs) •Gabapentin See Treatment and Medication for more detail.

Ciguatera Fish Poisoning

1.

Background

2.

Diagnosis

3.

Case study

4.

Treatment

5.

Prevention & Management

Background

Ciguatera Fish Poisoning (CFP) is caused from the consumption of certain large tropical predatory reef fish that have bio-accumulated Ciguatoxin (CTX) [1]

The main source of Ciguatoxin is the dinoflagellate Gambierdiscus toxicus, associated with seaweeds, sediments and dead coral. It is distributed around the tropics within the latitudes 32oN and 32oS and grows in shallow waters [2]

Flower Garden Banks National Marine Sanctuary. source: NOAA, Nov 13, 2008,web, August 30, 2014

Presenter

Presentation Notes

http://research.myfwc.com/engine/download_redirection_process.asp?file=gambierdiscus_toxicus_2607.pdf&objid=24290&dltype=article

Ciguatoxin

Fish are not affected by CTX [3]

Fish do not appear spoiled or taste different [2]

Toxin is heat stable, colourless and odourless [3]

Highest concentration in viscera of fish

[2]

Affects the Na/K channels in humans

[2]

Sexually Transmitted and can pass to child through breast milk

[2]Gambierdiscus toxicus Source: Florida Fish and Wildlife Conservation Commission (FWC)

Presenter

Presentation Notes

http://research.myfwc.com/engine/download_redirection_process.asp?file=gambierdiscus_toxicus_2607.pdf&objid=24290&dltype=article The toxin does pass through the placenta however no adverse long term effects have been observed on fetus

Types of Ciguatoxin

0.1 mg/kg

0.01 mg/kg

Source: Structures are by Fred

Fry, Jr., Ph.D. Bad Bug Book

2nd

edition

Presenter

Presentation Notes

Pacific Ciguatoxin is the Most potent of all the Ciguatoxins. It shows health effects at 0.1 μg/kg. Caribbean Ciguatoxin is not as potent at 0.1 mg/kg

Ciguatoxin Associated Fish

SnapperGrouper

BarracudaAmberjack

SurgeonfishSource: www.fda.gov/

Presenter

Presentation Notes

Kingfish could also be included in this list. It is estimated that up to 400 species of fish are associated with Ciguatoxin.

Distribution of Great Barracuda

Reviewed Native Distribution Map for Sphyraena barracuda (modelled 2100 map based on IPCC A2 emissions scenario) (Great barracuda). www.aquamaps.org, version of Aug. 2013. Web. Accessed 8 Sep. 2014.

Presenter

Presentation Notes

http://www.aquamaps.org/receive.php Reviewed Native Distribution Map for Sphyraena barracuda �(modelled 2100 map based on IPCC A2 emissions scenario) (Great barracuda). www.aquamaps.org, version of Aug. 2013. Web. �

Background: Exposure Pathway

Presenter

Presentation Notes

Most likely route of transmission is through predatory fish however herbivorous fish can also be implicated although the symptoms are usually not as severe.

Background: Occurrence of CFP

Globally 500,000 cases estimated annually

[2]

In Canada 22 cases reported over 14 year period

[2]

In U.S. 508 cases reported over 9 year period

[2]

In China 397 cases reported over a 4 year period [2]

Presenter

Presentation Notes

Only 10% of the cases are reported. Misdiagnosis is common especially in non-tropical areas.

Diagnosis of Ciguatera Fish Poisoning

No reliable tests available for diagnosis in humans [5]

Current standard method of diagnosis is matching the symptoms with fish consumption [5]

Gold Standard [5]

Confirmation of CTX in the consumed fish through laboratory testing

Numerous individuals consuming the same fish showing signs and symptoms of CFP

Incubation Period consistent with symptoms

Presenter

Presentation Notes

Peel Health was able to meet all of these criteria in obtaining a positive CFP result

Toxin Symptoms Incubation Time

Neurotoxic Shellfish Poisoning (NSP) (brevetoxins)

Reversal of hot and cold sensation, tingling; numbness of lips, tongue &

throat; muscle aches, dizziness, diarrhea, vomiting.

2�5 min to 3�4 h

Histamine (scombroid) Headache, dizziness, nausea,

vomiting, peppery taste, burning of throat, facial swelling and flushing,

stomach pain, itching of skin.

Less than 1 h

Paralytic Shellfish Poisoning (PSP) (saxitoxins)

Tingling, burning, numbness, drowsiness, incoherent speech,

respiratory paralysis. 0.5 to 2 h

Ciguatera ToxinTingling and numbness,

gastroenteritis, dizziness, dry mouth, muscular aches, dilated pupils,

blurred vision, paralysis, reversal of hot and cold sensation.

1�6 h

Note. Adapted from Clinical Manifestations of Ciguatera, p. 143-144, by N.A. Palafox and L.E. Buenconsejo-Lum

Presenter

Presentation Notes

Differential Diagnosis Talk about how to identify it from other similar FBI

ACUTEACUTE CHRONICCHRONIC

Gastrointestinal : Vomiting, Diarrhea, abdominal pain[5]

Cardiovascular: hypotension, bradycardia, [5]

Neurological: Paresthesia , temperature reversal*, ataxia, severe itching[5]

CFP Symptoms: Acute vs. Chronic

Presenter

Presentation Notes

Acute symptoms usually within 24 hours. Chronic symptoms appear 1 to 2 days later and may last for weeks or even months. Its important to note that different types of Ciguatoxin present these symptoms in varying amounts and the timing may be different. Polynesian Ciguatoxin for example shows Paresthesia and dysthesia in 90% of the time as the initial symptom Temperature related dysthesia is a key symptom of Ciguatera Poisoning. The only other illness that is similar is shell fish poisoning and can quickly be differentiated through client interviews

Ciguatoxin Testing in Fish

In vitro Assay[6]

Liquid Chromatography-

Mass Spectrometry (LC-

MS) [6]

Standard Testing

Source: Mar Drugs. 2010; 8(6): 1838–1907. Jun 14, 2010,web accessed September 5, 2014

Presenter

Presentation Notes

In vitro Assay: includes the examination of the effects of the toxin in mice. Once step one is verified step 2 includes liquid Chromatography Total ion chromatogram for a fish sample extract containing P-CTX-1 (3.83 min, 0.8 mg/kg), P-CTX-2 (5.01 min, 1.1 mg/kg) and P-CTX-3 (5.35 min, 1.4 mg/kg).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901828/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901828/

Investigation Timeline: Outbreak #1

August 7, 2013: complaint comes to Peel Health

Environmental Contact Centre

Etobicoke General contacts Peel Health

5 Patients, 3 in emergency

Suspected Barracuda fish (Sheela in Tamil)

Date of consumption: August 4, 2013

Incubation Period: 3 hours

Symptoms: nausea, vomiting, abdominal cramps, tingling and numbness of fingers and toes. Still had symptoms


3 are in hospital emergency

2 individuals seeing general physician

Blood samples done. Infectious disease specialist is investigating

Blood sampling did not reveal condition

Investigation Timeline

August 7, 2013

The owner was contacted by phone and asked to fax shipping invoices so that trace back could be done.

Visited store and put 10 barracuda on hold.

The store owner indicated that one barracuda came in a box of Kingfish but it was different than other Barracuda they normally order.

Presenter

Presentation Notes

There were some language barriers. The fish is called Sheela in Tamil. I was unsure what types of fish were included in this categorization. Since the fish sold to complainant was one of a kind. There were no other fish in store to determine which fish should be put on hold. The operator kept saying the 10 barracuda also called sheela but these are different type.

Investigation Timeline: Inspection

Great Barracuda vs. King Fish

© State of New South Wales through Department of

T d

d

I

R i

l I f

d

Presenter

Presentation Notes

http://outdoorchannel.com/article.aspx?id=14335&articletype=article http://hideousseacreatures.tumblr.com/post/62725293711/great-barracuda-warning-some-graphic-content-of-human Great Barracuda Max length : 200 cm TL male/unsexed; (Ref. 7251); common length : 140 cm TL male/unsexed; (Ref. 3692); max. published weight: 50.0 kg (Ref. 6949) © State of New South Wales through Department of Trade and Investment, Regional Infrastructure and Services King Fish


August 8 2013

Barracuda taken from complainant’s home

Received shipping invoices via fax from shop owner

Presenter

Presentation Notes

This is the piece of frozen fish steak that was take from complainants home. As u can see its really difficult to id this. Client had purchased bottom half of Fish from tail to mid-portion of fish.


one Kingfish from display and two Barracuda fish from the box of 10 on hold, were taken for further analysis by CFIA

CFIA to decide if they will test sample for Ciguatera toxin.

Uncertain if trace-back could be done

Frozen leftover sample which was taken from the complainant's home was provided to CFIA along with shipping invoices and one food history

CFIA still trying to determine if lab will be able to test the sample taken from the complainant’s home

No other complaints received from the importer or distributor according to CFIA

Surveying PHIs revealed no further fish related illness in Peel

Peel received confirmation that complainants sample will be tested at the end of the day

August 14 2013August 9 2013

Presenter

Presentation Notes

Challenges at this point: Fish needed to be identified. Was it kingfish, was it barracuda or was it something else?? Label on fish was blurred. No trace-back could be done based on the information available and it was unclear what type of fish was consumed

August 28, 2013

Peel Health was waiting to hear back from CFIA regarding toxin analysis in Fish

DNA analysis revealed that fish was Great Barracuda that was sold to complainant

Investigation Timeline: Outbreak # 2

August 29, 2013

2nd

case received by Peel Health through after hours Environmental Contact Centre


Family of five ate the front half of the fish

Date of consumption: August 19, 2013

Incubation time: 4 hours

Cooked fish discarded

No raw fish available for testing

Fish purchased from shop on August 1, 2013

One case fainted due to hypotension, difficulty breathing, burning and tingling of tongue, joint pain in lower extremities, cool breeze creates burning sensation.

Diarrhea, nausea, abdominal pain, vomiting

Presenter

Presentation Notes

This family had bought the other half of the same fish. Symptoms appear to be worse quite possibly since the top half of fish was eaten which may had included head

Investigation Timeline: Barracuda on Hold

Presenter

Presentation Notes

There are 26 species of Barracudas. This is one type of Barracuda that is normally shipped to the store. These were identified as Southern Sennat in the Barracuda Family. The one that was sold was not like this one. The store owner said it was bigger and accidentally packed in a box of kingfish. They decided to sell it. Max length : 36- 61 cm max. published weight: 1.1 kg (Ref. 40637) http://www.fishbase.ca/summary/Sphyraena-picudilla.html

August 30, 2013

The fish shop was visited again with CFIA inspector and 16 Barracuda put on hold as precaution

Cases interviewed

Cases asked to go see family doctor for symptoms

August 31, 2013

Stool kits dropped off for 3 of the 5 clients who wanted to provide stool samples.


Presenter

Presentation Notes

We had some idea at this point that these fish were different than the one implicated in the foodborne illness but we didn’t want to take any further risks. At this point we had some verification that what the shop owner was saying was true. That one fish was shipped in a box of kingfish and sold. As a precaution and to rule out other illnesses stool kits were dropped off


September 4, 2013

It was determined by CFIA that the Great Barracuda is not imported by the importer

The supplier does not ship Great Barracuda either

CFIA was informed of symptoms from 2nd

outbreak and that no food samples were available for testing

September 5, 2013

Names of suppliers were released to Peel Health

The shipment originated in southern United States


September 13, 2013

Family doctor of second set of cases follows up with Peel AMOH Dr. de Villa for assistance after patients’

symptoms

persist

Family doctor of first set of cases works at same clinic with the doctor with second set of cases and they realize the patients have the same conditions

Both sets of cases were referred to tropical disease specialist in Toronto

Investigation Timeline: Result

September 19, 2013

Analysis complete. No quantitative result available. Sample suspect positive of Caribbean Ciguatoxin


October 1st, 2013

Ciguatera toxin testing is not common in Canada

Few labs world wide that have the full capability to do testing including Canada, U.S. and Australia

In order to do testing lab must have the purified version of actual toxin for instrument calibration

The suspect positive Caribbean CTX was based on manual inputs of molecular weights of Caribbean CTX

Presenter

Presentation Notes

Discussion with National Manager at the Food safety lab in Darthmourth. Darthmouth lab had Pacific toxin but no Carribbean toxin for calibration.


October 1, 2013

U.S. FDA lab had Caribbean CTX but were not willing to provide it due to lack of availability and high cost

Alabama lab had agreed to test the sample in their lab

Lab affected by US federal government shutdown Oct 1-Oct 16, 2013

300 gm of Great Barracuda submitted.

Presenter

Presentation Notes

Each test requires 10 grams of the sample and usually takes 5 to 10 days to run the test


January 21, 2014

Peel Health received confirmation from the CFIA National lab that the U.S. FDA lab was able to confirm their result of a positive Caribbean CTX finding

Quantitative analysis not done due to cost and time constraints

Materials used for testing cost $10,000 for 1 mg of substance

Presenter

Presentation Notes

Some of the material purchased by the lab to run the test was We were also informed that the US lab usually does have materials to perform a quantitative analysis but were not interested due to cost and time constraints

Summary of Testing Dates

August 9, 2013: Sample provided to CFIA

August 14, 2013: Sample shipped to Dartmouth, Nova Scotia lab

August 22, 2013: Ciguatera toxin testing began after DNA ID analysis had been done.

September 19, 2013 : Analysis complete. No quantitative result available. Suspect positive of Caribbean Ciguatoxin

Jan 21, 2014: U.S. FDA lab confirms positive test result

Treatment: Supportive

IV fluids and electrolyte re-balance [5]

Mannitol within 72 hours of onset of symptoms has shown to be the most effective [5]

Side effects include further loss of fluids if patient still has vomiting and diarrhea [5]

Mannitol can adversely effect patients still suffering from bradycardia and hypotension [5]

Atropine has been used effectively for bradycardia [5]

Presenter

Presentation Notes

There is no antidote or direct treatment method for CFP. Only supportive therapy exists. Mannitol has been the most studied and most effective option for treatment In some cases it has even shown to prevent the chronic symptoms Mannitol can still be given after 72 hours but will not be as effective Mannitol cannot be given if diarreah and vomiting are still present Activated charcoal has been used to absorb excess toxin from the body.

Prevention of CFP: Education

Education [2]

Recreational Fishermen

Commercial Fishermen

Travellers

Travel Companies

Local Fish shops

Consumers need to know the risk

Avoid head, viscera and roe of reef fish [2]

79% of cases in U.S. are from sport fishing [2]

Cigua-Check TM [4]

Source: http://www.floridahealth.gov/environmental‐health/aquatic‐

toxins/ciguatera‐fish‐poisoning.html.accessed august 29,2014

Presenter

Presentation Notes

Education of not only the travellers going to tropical destinations but of the commercial and recreational fishermen. This poster is aimed at the fishermen in Florida and was developed by the State department of health. http://www.floridahealth.gov/environmental-health/aquatic-toxins/ciguatera-fish-poisoning.html Cigua-check is only comercially available test kit awaiting FDA approval that seems to work. It offers a 92.3 sensitivity and 85.7 specificity at concentration of 80 picograms of ciguatoxin per gram of fish. There may be illness in some people at 50 picograms of toxin.

Management of CFP

In EU fishery products containing bio-toxins cannot be offered for sale [2]

In U.S. FDA has proposed guidance levels of less than 0.1 μg/kg C-CTX-1 equivalents and less than 0.01 μg/kg P-CTX-1 equivalents [2]

Globally, prohibition of the sale of high risk fish taken from areas where CTXs are known to be present [2]

Bans on fish over a certain weight and complete ban on certain fish [2]

Sale of Barracuda banned in Miami [2]

Presenter

Presentation Notes

No action limits in the U.S. Such bans have been used with success in Australia, Fiji, Hawaii and Florida. Weight based bans have been effective in cuba.

Challenges for Public Health

No analytical standard in Canada for interpretation of results

No human bio-markers for diagnostic purposes [5]

No FDA approved commercial test kit which can be used on site to detect toxins [5]

Purified CTX is very expensive and not widely available for instrument calibration and research [5]

Medical staff need to recognize the signs and symptoms for improved diagnosis and treatment

Climate change, increasing travel, increasing importation of fish [5]

Presenter

Presentation Notes

If sea surface temperatures increase the habitat of the algae will change and so will the spread of the illness Europe is already seeing an increase in cases Certain cultures are specifically fond of eating barracuda and seek out importers of the fish.

Ciguatoxin Testing Video

http://youtu.be/yCgrhUQIhcE

Presenter

Presentation Notes

This is Cigua check

References

1.

De Fouw, J.C., Van Egmond, H.P., Speijers, G.J.A. 1999. Ciguatera fish poisoning: a review. RIVM Report

No.388802021 .

2.

H.P. Van Egmond, M.E. Van Apeldoorn and G.J.A. Speijers, et al,

Marine Biotoxins, Food and

Agriculture Organization of the United Nations Rome, 2004.

3.

Food and Drug Administration. Bad Bug Book, Foodborne Pathogenic Microorganisms and Natural

Toxins. Second Edition. [Ciguatoxin, pp. 194‐199 ]. 2012.

4.

Palafox N.A, Buenconsejo‐lum L.E., Ciguatera Fish Poisoning:Review of clinical manifestations, J.

Toxicol‐toxin reviews 20(2) 141‐160, 2001.

5.

Friedmann M.A.,*

Fleming L.E, Fernandez M, et al, Ciguatera Fish Poisoning: Treatment, Prevention

and Management,

Mar Drugs.; 6(3): 456–479, Sep 2008.6.

Caillud A, Iglesia P, Darius HA, Update on Methodologies Available for Ciguatoxin Determination:

Perspectives to Confront the Onset of Ciguatera Fish Poisoning in Europe ,Mar Drugs. 8(6): 1838–

1907.,2010.

7.

Pennotti R, Scallan E., Backer L., et al, Ciguatera and Scromboid Fish Poisoning in the United States,

Foodborne Pathogens and Disease ;10(12) 1059‐1066, 2013.

8.

Williams R.A, Zorn D.J, Hazard analysis and critical control point systems applied to public health risks:

the example of seafood, Rev. sci. tech. off.int.Epiz, 16 (2) 349‐358, 1997.

9.

Todd E.C.D, Seafood‐associated diseases and control in Canada, Rev.Sci.tech.off.int.Epiz., 16 (2) 661‐

672, 1997.

10.

Juranovic LR, Park DL, Foodborne toxins in marine origin:ciguatera, Reviews of Environmental

Contamination and toxicology,117:51‐94, 1991.

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ciguatera fish poisoning in peel region

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