31 y M presents with n/v/d and altered sensation to hands and feet several hours after going out for a seafood dinner.  Pt states that he ate red snapper at the request of a work colleague and prior to tonight was in his USOH.  Later, during the hospital stay the patient notes that the rail of the stretcher feels hot, but when you go to check said rail it feels cool to you.  What’s the diagnosis?

Ciguatera Poisoning.  This is  caused by Ciguatoxin, a toxin causing sodium channel activation and the stimulation of cholinergic receptors, which is carried by marine plankton (dinoflagellates) covering certain reef fish (barracuda, red snapper, grouper).  Typical symptoms are nausea, vomiting, diarrhea, headaches, cold allodynia – this is the classic finding of ‘hot-cold reversal’ – headache, parasthesias of the mouth and extremities, pruritis, myalgias, weakness; rarely seizures and respiratory arrest.  In some patients parasthesias, neuropsychiatric symptoms and pruritis can last for years.  Onset of symptoms is usually 1-6 hours after ingestion.

The management is mainly supportive.  Several therapies have been proposed (i.e. mannitol) but not validated.