An Unusual Presentation of Severe Ciguatera Poisoning: Case Report

BACKGROUND Ciguatera poisoning is presently estimated to afflict approximately 16 000 people in the United States each year. Ciguatera toxicity is due to the ingestion of warm-water reef fish that are known to consume dinoflagellates that contain ciguatoxins (CTXs). Historically, the diagnosis of ciguatera poisoning is confirmed in the emergency department when this ingestion is followed by manifestations of neurologic and gastrointestinal organ symptoms. Some individuals also manifest cardiac symptoms. These symptoms can vary within each organ system in type and duration. CASE REPORT In this report, 2 patients (husband and wife) are presented that consumed the same barracuda, resulting in severe ciguatera poisoning diagnosed in the emergency department. One had the complete triad of symptoms of gastrointestinal (GI), neurologic, and cardiac involvement. The other patient lacked neurological symptoms but did experience severe gastrointestinal and cardiac symptoms. It was assumed by the inpatient team, the consulted infectious disease specialist, and, initially, the in-house toxicologist that the lack of neurologic symptoms excluded the diagnosis of ciguatera. CONCLUSIONS If these patients had presented separately, only the former would have been considered to have ciguatera poisoning. These 2 cases demonstrate the misunderstanding among healthcare practitioners of the literature on the diagnostic criteria. Therefore, this article aims to analyze ciguatera diagnosis in the emergency department, which will ultimately guide prognostics and management, particularly for severe cardiac symptoms.