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Letter
Ciguatera Fish Poisoning,
Canary Islands
Jose-Luis Pérez-Arellano,*†
Octavio P. Luzardo,* Ana Pérez Brito,‡ Michele Hernández Cabrera,*† Manuel
Zumbado,* Cristina Carranza,*† Alfonso Angel-Moreno,*† Robert W. Dickey,§
and Luis D. Boada*
*University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria,
Spain; †Hospital Universitario Insular de Gran Canaria (Canary Health
Service), Las Palmas de Gran Canaria, Spain; ‡Hospital de Fuerteventura,
Puerto del Rosario, Spain; and §Gulf Coast Seafood Laboratory (Food and
Drug Administration), Dauphin Island, Alabama, USA
Suggested
citation for this article
To the Editor: Ciguatera outbreaks usually occur in the area between
35° north and 35° south latitude, mainly in the Caribbean, Indo-Pacific
islands, and the Indian Ocean (1–5) (Figure).
Occasionally, ciguatera poisoning has been reported outside disease endemic
areas, such as the Bahamas, Canada, or Chile, but no case had been described
in the West African region until now. European and Spanish cases have
been rarely described and are mainly associated with seafood imported
from disease-endemic regions (6).
Ciguatera fish poisoning is a clinical syndrome caused by eating contaminated
fish (1). The causative toxins of its clinical manifestations
are ciguatoxins (7). These toxins are transmitted by
dinoflagellates of the species Gambierdiscus toxicus, which lives
adhered to damaged coral reefs in tropical seas (2).
Herbivorous fish species accumulate toxins in their musculature, liver,
and viscera after ingesting dinoflagellates. Larger marine carnivores
eat contaminated fish and concentrate ciguatoxins (1,2).
More than 425 species of fish are associated with ciguatera poisoning
in humans. The most commonly implicated fish are barracuda, red snapper,
grouper, amberjack, sea bass, surgeonfish, and moray (eel) (2,3).
In January 2004, 2 fishermen captured a 26-kg amberjack (local name: Medregal
Negro; scientific name: Seriola Rivoliana) while scuba diving along
the coast of the Canary Islands, Spain. The fishermen filleted the fish
and stored fillets in a household freezer. Within a few days, one of the
fishermen and 4 family members consumed some fish, and neurologic and
gastrointestinal symptoms developed within 30 minutes to 28 hours. The
5 family members sought treatment at the emergency room of Hospital de
Fuerteventura and the Outpatient Clinic of Infectious Diseases and Tropical
Medicine Service of Hospital Insular de Las Palmas.
The 5 family members exhibited a combination of gastrointestinal (diarrhea
[4 persons], nausea/vomiting [3 persons], metallic taste [1 person]),
cardiologic (heart rhythm disturbances [2 persons]), systemic (fatigue
[5 persons], itching [3 persons], dizziness (1 person]), and neurologic
manifestations (myalgia [3 persons], peripheral paresthesia [3 persons],
perioral numbness [2 persons], and reversal of hot and cold sensations
[3 persons], which is pathognomonic of ciguatera poisoning). These clinical
observations and laboratory data were collected from a prospective questionnaire
filled in by physicians at the patients' first visits. No hematologic
or biochemical abnormalities were detected in any patient. Based upon
the symptomatic profiles, relationships of the patients, and their common
dietary histories, ciguatera intoxication was diagnosed in all. None of
the patients required hospitalization. The neurologic and gastrointestinal
symptoms resolved over several weeks, but intermittent recurrence of some
symptoms, at lower intensities, was noted for several months.
A portion of the implicated fish was recovered from freezer storage at
the fisherman's home. A solid-phase membrane immunobead assay with a monoclonal
antibody directed against Pacific ciguatoxins and related polyether toxins
was used to detect ciguatoxins or other antigenically related substances
in fish tissues. Results were positive.
A 150-g sample of the fish was delivered to the US Food and Drug Organization's
Gulf Coast Seafood Laboratory, Dauphin Island, Alabama, USA, for sodium
channel–specific in vitro assay (8) and liquid chromatography–mass
spectrometry (LC/MS/MS) analysis. Assay results were positive and the
ciguatoxin content of the fish sample was estimated to be 1.0 ppb (ng/g).
Caribbean ciguatoxin (CCTX-1: MH+ m/z 1141.6) was confirmed by LC/MS/MS
by using multiple reaction monitoring (9). The amount
of ciguatoxin in the fish tissue estimated by in vitro assay was low,
and close to the limit the LC/MS/MS method can detect. At least 2 additional
toxins were detected in the fish sample by in vitro assay of liquid chromatography
fractions. We cannot rule out the possibility that these toxins represent
new ciguatoxinlike structures unique to the eastern Atlantic. Further
studies are necessary to elucidate all toxins implicated in this outbreak.
Classic symptoms of ciguatera developed in our patients after eating
a fish they captured in the Canary Islands, which are not in the ciguatera-endemic
zone (Figure). The preliminary results of this outbreak
investigation suggest the presence of ciguatoxins or ciguatoxinlike structures
in fish from temperate waters of the eastern Atlantic. Ciguatera poisoning
is a matter of public health concern and residents of coastal West Africa
and the regional island archipelagos could be a new community at risk
for this seafood intoxication syndrome. We emphasize that ciguatera poisoning
is a debilitating disease, and therapeutic intervention strategies are
very limited (10).
Acknowledgments
We thank Ana Gago,
for her collaboration in analytical procedures and Isaías. Naranjo for
his editorial assistance in preparing the manuscript.
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Suggested citation
for this article:
Peréz-Arellano J-L,
Luzardo OP, Brito AP, Hernández Cabrera M, Zumbado M, Carranza C, et al.
Ciguatera fish poisoning, Canary Islands [letter]. Emerg Infect Dis [serial
on the Internet]. 2005 Dec [date cited]. Available from http://www.cdc.gov/ncidod/EID/vol11no12/05-0393.htm
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