Tropical fish poisonings in Germany 2012–2017 - What is ciguatera?

Abstract

Purpose: Ciguatera fish poisoning (CFP) is the most common fish intoxication worldwide caused by ciguatoxin(CTX)-containing tropical reef fish. CFP is dominated by long-lasting neurologic symptoms, whereas gastro-intestinal symptoms may be present in the acute phase, only. In continental Europe, CFP may occur when CTX-contaminated fish is consumed during or after trips to endemic areas, or when it is exported to non-endemic countries. At the subtropical European Canary Islands and Madeira, CFP has been reported since the early 2000s. CTX-producing microalgae have been recently found in the Mediterranean Sea. In Germany, a CFP outbreak occurred in each of the years 2012 to 2017 caused by snappers imported from India, Vietnam and Indonesia. As outbreak investigations showed, German physicians are not aware of CFP, and patients were unsatisfied with medical care. Clinical and epidemiological characteristics of this series of CFP outbreaks are demonstrated here. Channels to report CFP cases and outbreaks to Public Health authorities without an established notification system will be shown. Methods & Materials: Reports by physicians according to §16e of the German Chemicals Act were analyzed in order to retrieve CFPs based on the case definition of the EuroCigua-project. The degree of severity was evaluated on the bases of the Poison Severity Score (PSS). CFP cases were clustered according to the place where the fish was purchased. Results: Between 2012 and 2017, six outbreaks with 65 CFP cases were registered in Germany. All patients suffered from neurologic disorders. Three patients showed severe symptoms like bradycardia <40 min-1 or morphine resistant abdominal cramps. Nearly 20% of the patients were hospitalized. All outbreak cases were caused by snappers from India, Indonesia and Vietnam. Lutjanus bohar was the fish species present in all German CFP outbreaks. Conclusion: Ciguatera caused by imported tropical fish is an emerging disease in Germany. Physicians should acquaint knowledge of CFP symptoms and therapeutic options, and are requested to report CFP to the German Federal Institute for Risk Assessment (BfR). CFP patients should be reminded to provide fish leftovers to local Public Health authorities for laboratory investigations. DRG code T 61.0 should be used when the CFP case definition of the EuroCigua project is applicable.