Persistent Bradycardia Caused by Ciguatoxin Poisoning After Barracuda Fish Eggs Ingestion in Southern Taiwan

Abstract

We report an outbreak of ciguatoxin poisoning after barracuda fish ingestion in southern Taiwan. Three members of a family developed nausea, vomiting, watery diarrhea, and myalgias about 1 hour after eating three to ten eggs of a barracuda fish. Numbness of the lips and extremities followed the gastrointestinal symptoms about 2 hours after ingestion. Other manifestations included hyperthermia, hypotension, bradycardia, and hyperreflexia. Bradycardia persisted for several days, and one patient required a continuous infusion of intravenous atropine totaling 40 mg over 2 days. Further follow-up of the patients disclosed improvement of neurologic sequelae and bradycardia, but sensory abnormalities resolved several months later. In conclusion, ciguatoxin poisoning causes mainly gastrointestinal and neurologic effects of variable severity. In two patients with ciguatoxin poisoning after barracuda fish egg ingestion, persistent bradycardia required prolonged atropine infusion.

Ciguatera fish poisoning: A first epidemic in Germany highlights an increasing risk for European countries

“…In most cases, the family physician was visited, but one couple called an ambulance and was hospitalized because of strong vegetative symptoms including hypotension and repetitive fainting. In fact, in some ciguatera cases early cardiovascular symptoms can dominate the disease with potentially life-threatening bradycardia and hypotension, and may require the use of atropine, hydration and inotropic drugs (Chan and Wang, 1993;Chan, 2013;Hung et al, 2005;Senthilkumaran et al, 2011). For these two patients, the diagnosis was gastroenteritis caused by enterotoxins due to the history of fish consumption.…”

Gambierol, a toxin produced by the dinoflagellate Gambierdiscus toxicus, is a potent blocker of voltage-gated potassium channels

“…Severe cases of ciguatera can involve bradycardia, hypotension, paralysis, respiratory difficulties and are often associated with liver toxicity manifested by elevated serum ammonia levels (Sims, 1987). The duration of the illness is usually 1 or 2 days, but residual weakness and sensory changes can persist for weeks, even years in severe cases (Hung et al, 2005).…”

Emerging tropical diseases in Australia. Part 2. Ciguatera fish poisoning

“…The characteristic and pathognomonic signs and symptoms of CFP are now well documented in many case reports and case series, and the unusual neurological features of the disease probably help to stimulate and maintain a steady flow of case reporting and case investigation across a variety of generalist and specialist biomedical journals. Such reports can be found in the literature on tropical medicine (Hung et al, 2005;Wasay et al, 2008), clinical neurology (Achaibar et al, 2007), epidemiological surveillance (Ng and Gregory, 2000;Villareal et al, 2006), general medicine (Fenner et al, 1997;Slobbe et al, 2008), clinical toxicology (Lange et al, 1989;de Haro et al, 2003), emergency medicine (Asaeda, 2001), toxinology (Lechuga-Devéze and Sierra-Beltrán, 1995;Hamilton et al, 2009), military medicine (Arnett and Lim, 2007), gastroenterology (Sanner et al, 1997), communicable diseases (Frenette et al, 1988) and public health (Ting et al, 1998;Kipping et al, 2006). While there is a significant body of case reports in the literature, this does not suggest either that CFP is a homogeneous disease or that all facets of the illness are yet completely characterised and understood.…”

“…Severe intoxications may require ventilatory and haemodynamic support in the acute stage (Crump et al, 1999;de Haro et al, 2003;Friedman et al, 2008). Intravenous atropine can be used to treat any bradycardia (Geller et al, 1991;Hung et al, 2005). Tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRI), benzodiazepines, anticonvulsants, antihistamines, analgesics, oral and topical steroids and topical antipruritics have all been used to treat various CFP-related symptoms, such as fatigue, arthralgia, pruritus, paraesthesias and dysaesthesias, with variable responses (Lee and Pang, 1945;Delord et al, 1984;Geller et al, 1991;Lange et al, 1992;Eastaugh, 1996;Crump et al, 1999;Friedman et al, 2008;Schwarz et al, 2008).…”