Why do my hands feel so cold?

Ciguatera, the illness caused by eating foods contaminated by ciguatoxin, can ruin your day, week, or month. The problem starts with Gambierdiscus toxicus, a dinoflagellate that is eaten by small fish. They produce ciguatoxins, which biaccumulate up the food chain until they are present in toxic levels in larger reef fish.

The article gives an in depth review of ciguatera. It likely affects somewhere between 10,000 and 50,000 people per year. It is reportable to the health department in many states. Unfortunately, no tests can detect it in humans, so it remains a diagnosis based on history and physical. The symptoms are quite variable in patients, so much so that the author uses 1.5 pages of a table to demonstrate this. The hot/cold reversal that is pathognomic of this disease at ABEM General is not always present in patients with CFP. It can also be present in Neurotoxic Shellfish Poisoning, so buyer beware.

Treatments have sadly been wanting. Few well designed trials have demonstrated a benefit of certain treatments, but there are some that show promise. IV Mannitol is the most studied, and is recommended as a treatment if given in the first 48-72 hours after symptom onset. All other treatments are purely symptomatic based on symptoms, such as atropine for bradycardia, TCAs for paresthesias and headaches, and antiemetics. They note that opiates should be avoided due to possible effects with maitotoxin, which can be present in fish with ciguatoxin. No herbal remedies are recommended due to lack of evidence.

Interestingly, the authors report that alcohol, nuts, caffeine, fish, pork, chicken, and physical activity have all caused recurrence of symptoms, but again, the effect is variable. They also list a large list of fish that commonly cause ciguatera, and the usual commentary on not eating viscera or roe of the same.

The authors do point out that only 17% of the physicians in one study gave mannitol to a classic CFP patient, and less than half knew it was a reportable condition(in the state they practiced). They end with an exhaustive, 11 point list of recommendations for “best practice” that is far too long to post here.

Friedman MA et al. Ciguatera fish poisoning: treatment, prevention and management. Mar Drugs. 2008;6(3):456-79. [PMC2579736]

EBM Gone Wild sea 700 400

EBM Gone Wild

Wilderness Medicine

Emergency physician with interests in wilderness and prehospital medicine. Medical Director of the Texas State Aquarium, Padre Island National Seashore, Robstown EMS, and Code 3 ER | EBM gone Wild | @EBMGoneWild |

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.