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Epidemiologic Notes and Reports Ciguatera Fish Poisoning -- Vermont

On October 29, 1985, the Epidemiology Division, Vermont Department of Health, learned of two persons with symptoms consistent with ciguatera fish poisoning. Both had eaten barracuda at a local restaurant on October 19. One ill person, a 48-year-old woman, had vomiting, diarrhea, myalgia, and chills 4 hours after the meal, followed the next morning by pruritus, flushing, burning of the tongue, and reversal of hot and cold temperature sensation of objects held in her hands. The second ill person, a 30-year-old male bartender at the restaurant, sought medical attention for severe myalgia and gingival and dental dysesthesia several hours after eating barracuda. In both patients, most symptoms subsided; however, some pruritus and temperature reversal persisted 6 weeks later. A third patron reported pruritus to the restaurant after the meal but was lost to follow-up. No additional cases were identified by contacting the two local emergency rooms and requesting case reports in the Vermont Disease Control Bulletin.

The restaurant had served 24 portions of barracuda received fresh by air from a fish distributor in Florida. Two other restaurants in Burlington had received barracuda from the same shipment. One served 44 portions, and the second froze all portions received. The fish distributor reported that the fish was purchased from boats fishing in Florida's coastal waters but could not identify the exact location. The distributor ships to locations throughout the contiguous United States. No information was available about the distribution of other fish from the same catch.

All portions of a single barracuda frozen by one restaurant and tested for ciguatoxin by enzyme immunoassay at the Department of Pathology, University of Hawaii, were positive for ciguatoxin. Reported by RL Vogt, MD, State Epidemiologist, Vermont Dept of Health; AP Liang, MD, State Epidemiologist, Hawaii Dept of Health; Div of Field Svcs, Epidemiology Program Office, Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note:Human ciguatera poisoning can occur after consumption of a wide variety of coral reef fish, such as barracuda, grouper, red snapper, amberjack, surgeonfish, and sea bass (1,2). Ciguatoxin and related toxins are derived from dinoflagellates, which herbivorous fish consume while foraging through the macro-algae (3). Humans ingest the toxin by consuming either herbivorous fish or carnivorous fish that have eaten the contaminated herbivores. Larger, more predacious reef fish are generally more likely to be toxic (4,5). Since the toxin is heat-stable, cooking does not make the fish safe to eat.

As the domestic and imported fish industry expands its market, the diagnosis of this "tropical" disease must be considered even in areas to which coral-reef fish are not native. Ciguatera fish poisoning can be diagnosed by the characteristic combination of gastrointestinal and neurologic symptoms in a person who ate a suspect fish (6). The diagnosis can be supported by detection of ciguatoxin in the implicated fish.

Hawaii now uses a "stick test" immunoassay to detect ciguatoxin in fish (7). The test is sensitive, specific, inexpensive, and easy to use in the field. In Hawaii, if an outbreak-related fish tests positive for ciguatoxin, the reef area of catch is posted to discourage further fishing in that area. In Miami, Florida, because barracuda have been frequently associated with ciguatera poisoning, a city ordinance bans the sale of barracuda (8).


  1. Morris JG Jr, Lewin P, Smith CW, Blake PA, Schneider R. Ciguatera fish poisoning: epidemiology of the disease on St. Thomas, U.S. Virgin Islands. Am J Trop Med Hyg 1982;31:574-8.

  2. Halstead BW. Class osteichthyes: poisonous ciguatoxic fishes. In: Halstead BW. Poisonous and venomous marine animals of the world. Princeton: Darwin Press, Inc., 1978:325-402.

  3. Bagnis R, Chanteau S, Chungue E, Hurtel JM, Yasumoto T, Inoue A. Origins of ciguatera fish poisoning: a new dinoflagellate, Gambierdiscus toxicus Adachi and Fukuyo, definitively involved as a causal agent. Toxicon 1980;18:199-208.

  4. CDC. Ciguatera fish poisoning--Bahamas, Miami. MMWR 1982;31:391-2.

  5. Craig CP. It's always the big ones that should get away . JAMA 1980;244:272-3.

  6. Hughes JM, Merson MH. Fish and shellfish poisoning. N Engl J Med 1976;295:1117-20.

  7. Hokama Y. A rapid, simplified enzyme immunoassay stick test for the detection of ciguatoxin and related polyethers from fish tissues. Toxicon 1985;23:939-46.

  8. Lawrence DN, Enriquez MB, Lumish RM, Maceo A. Ciguatera fish poisoning in Miami. JAMA 1980;244:254-8.

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