What is the treatment approach for suspected Pompano toxicity due to ciguatera fish poisoning?

From the Guidelines

The treatment for suspected Pompano toxicity due to ciguatera fish poisoning primarily involves supportive care and symptom management, as there is no specific antidote. The approach to managing such cases emphasizes the importance of timely and effective supportive care, including airway management, hemodynamic support, and correction of critical vital sign and metabolic derangements, as highlighted in the 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning 1.

Key Components of Treatment

• Initial treatment may include intravenous mannitol to reduce neurological symptoms by decreasing nerve cell swelling.
• Symptomatic treatment involves the use of antihistamines for itching, NSAIDs for pain, and antiemetics for nausea and vomiting.
• Patients should avoid certain triggers that can exacerbate symptoms, such as alcohol, nuts, and additional fish consumption, for several months.
• Maintaining adequate hydration is crucial throughout the recovery period.

Given the lack of a specific antidote for ciguatera fish poisoning, the focus remains on managing symptoms and providing supportive care to mitigate the effects of the toxin on the body, as outlined in recent guidelines 1. The treatment strategy aims to address the disruption caused by ciguatoxin to nerve cell function, which is responsible for the neurological, gastrointestinal, and cardiovascular symptoms associated with ciguatera poisoning.

From the Research

Treatment Approach for Suspected Pompano Toxicity due to Ciguatera Fish Poisoning

• The treatment approach for suspected Pompano toxicity due to ciguatera fish poisoning involves the use of intravenous mannitol, which has been shown to be effective in reducing symptoms and improving patient outcomes 2, 3.
• A study published in 1989 found that an intravenous infusion of 1.0 g/kg of mannitol given over 45 minutes can be of significant benefit to acutely intoxicated victims, with some patients experiencing a dramatic reversal of symptoms 2.
• Another study published in 2008 reviewed the literature on treatments for ciguatera fish poisoning and found that while there are reports of symptom amelioration with some interventions, including IV mannitol, the appropriate treatment for CFP remains unclear to many physicians 4.
• A 2017 review of the evidence regarding the use of mannitol or other drugs in treating ciguatera fish poisoning found that it is reasonable to consider using intravenous mannitol in cases of acute ciguatera fish poisoning, and that medications used in other neuropathic syndromes may suppress the paresthesiae of persistent ciguatera cases 5.
• The use of mannitol has been supported by several uncontrolled case series and case reports, although a small randomized controlled trial found no significant difference between mannitol and normal saline 5.
• Other treatments, such as amitriptyline, fluoxetine, duloxetine, gabapentin, pregabalin, or tocainide, have been described in case reports and case series, but the evidence is of low quality and none of these treatments has been shown to be superior to mannitol 5.

Prevention and Management

• Prevention of ciguatera fish poisoning involves avoiding consumption of relatively large predatory reef fish species known to be from ciguatoxic-endemic areas 6.
• Medical and public health practitioners should be educated to inquire about recent fish consumption when evaluating patients with clinically compatible signs and symptoms, and to report suspected CFP cases to public health authorities to facilitate source-food traceback efforts 6.
• Syndromic surveillance systems capable of detecting CFP are essential public health tools to identify outbreaks and enhance investigations 6.