Ciguatera fish poisoning: Treatment, prevention and management

Marine Drugs

Volumn 6, Issue 3, 2008, Pages 456-479

  Friedman, Melissa A ^a,b   Fleming, Lora E ^b   Fernandez, Mercedes ^c   Bienfang, Paul ^d   Schrank, Kathleen ^e   Dickey, Robert ^f   Bottein, Marie Yasmine ^g   Backer, Lorraine ^h   Ayyar, Ram ⁱ   Weisman, Richard ^j   Watkins, Sharon ^k   Granade, Ray ^f   Reich, Andrew ^k  

^a MOUNT SINAI MEDICAL CENTER   (United States)

^b UNIVERSITY OF MIAMI   (United States)

^c Carlos Albizu University   (United States)

^d UNIVERSITY OF HAWAII   (United States)

^e UNIVERSITY OF MIAMI   (United States)

^f CENTER FOR DRUG EVALUATION AND RESEARCH   (United States)

^g CENTER FOR COASTAL ENVIRONMENTAL HEALTH AND BIOMOLECULAR RESEARCH   (United States)

^h NATIONAL CENTER FOR ENVIRONMENTAL HEALTH   (United States)

ⁱ UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE   (United States)

^j Florida Poison Information Center   (United States)

^k FLORIDA DEPARTMENT OF HEALTH   (United States)

more..

Author keywords

Ciguatera fish poisoning; Ciguatoxin; Harmful algal bloom (HAB); Human health; Marine toxins; Treatment

Indexed keywords

AMITRIPTYLINE; ARGUSIA ARGENTEA EXTRACT; ATROPINE; CIGUATOXIN; FLUOXETINE; GABAPENTIN; MANNITOL; NIFEDIPINE; PARACETAMOL; PLANT EXTRACT; SODIUM ION; UNCLASSIFIED DRUG; VOLTAGE GATED SODIUM CHANNEL;

ABDOMINAL PAIN; ARTHRALGIA; BIOLOGICAL MONITORING; CARDIOTOXICITY; CHILL; CHRONICITY; CIGUATERA; CIRCUMORAL PARESTHESIA; CLINICAL FEATURE; DEPRESSION; DIARRHEA; DISEASE COURSE; DISTAL PARESTHESIA; DYSESTHESIA; DYSURIA; EDUCATION PROGRAM; EMERGENCY TREATMENT; FLUID THERAPY; FOOD AND DRUG ADMINISTRATION; FOOD INTAKE; GASTROINTESTINAL SYMPTOM; HALLUCINATION; HEADACHE; HUMAN; INFORMATION DISSEMINATION; MEDICAL INFORMATION; MYALGIA; NAUSEA; NERVE CELL MEMBRANE STEADY POTENTIAL; NEUROTOXICITY; PATIENT INFORMATION; POISON CENTER; PRURITUS; REVIEW; SHELLFISH POISONING; SWEATING; SYMPTOM; TOOTH PAIN; VERTIGO; VOMITING; WEAKNESS;

ALGAE; CIGUATERA;

EID: 53349172723     PISSN: None     EISSN: 16603397     Source Type: Journal    
DOI: 10.3390/md6030456     Document Type: Review

References (106)

1. Pearn, J. Neurology of ciguatera. J. Neurol., Neurosurg. & Psych. 2001, 70, 4-8.
2. Crump, J. A.; McLay, C. L.; Chambers, S. T. Ciguatera fish poisoning. Postgrad. Med. J. 1999, 75, 678-679.
3. Swift, A. E.; Swift, T. R. Ciguatera. J. Toxicol. - Clin. Toxicol. 1993, 31, 1-29.
4. Gillespie, N. C.; Lewis, R. J.; Pearn, J. H.; Bourke, A. T.; Holmes, M. J.; Bourke, J. B.; Shields, W. J. Ciguatera in Australia. Occurrence, clinical features, pathophysiology and management. Med. J. Austr. 1986, 145, 584-590.
5. Lehane, L.; Lewis, R. J. Ciguatera: recent advances but the risk remains. Int. J. Food Microbiol. 2000, 61, 91-125.
6. Fleming, L. E.; Blythe, D. G.; Baden, D. G. ciguatera fish poisoning. Shoreman's Travel Medicine Monthly 1997, 1, 1-5.
7. Baden, D.; Fleming, L. E.; Bean, J. Marine toxins; deWolff, F.A., Ed.; Elsevier Press: Amsterdam, 1995; Vol. 21.
8. Lewis, R. J. The changing face of ciguatera. Toxicon 2001, 39, 97-106.
9. Lawrence, D. N.; Enriquez, M. B.; Lumish, R. M.; Maceo, A. Ciguatera fish poisoning in Miami. J. Am. Med. Assoc. 1980, 244, 254-258.
10. McKee, D.; Fleming, L. E.; Tamer, R.; Weisman, R.; Blythe, D. G. Physician diagnosis and reporting of ciguatera fish poisoning in an endemic area. Harmful Algal Blooms 2001, 451-453.
11. Begier, E.; Weisman, R.; Hammond, R.; Fleming, L. E.; Blythe, D. G.; Backer, L. Outbreak bias in illness reporting and case confirmation in ciguatera fish poisoning Surveillance in South Florida. Pub. Health Rep. 2006, 121, 658-665.
12. Nicholson, G. M.; Lewis, R. J. Ciguatoxins: cyclic polyether modulators of voltage-gated ion channel function. Mar. Drugs 2006, 4, 88-118.
13. Arias, H. R. Marine toxins targeting ion channels. Mar. Drugs 2006, 4, 37-69.
14. Cameron, J.; Flowers, A. E.; Capra, M. F. Electrophysiological studies on ciguatera poisoning in man (Part II). J. Neurol. Sci. 1991, 101, 93-97.
15. Bagnis, R. Clinical aspects of ciguatera (fish poisoning) in French Polynesia. Hawaii Med. J. 1968, 28, 25-28.
16. Bagnis, R.; Kuberski, T.; Laugier, S. Clinical observations on 3,009 cases of ciguatera (fish poisoning) in the South Pacific. Am. J. Trop. Med. Hyg. 1979, 28, 1067-1073.
17. Withers, N. W. Ciguatera fish poisoning. Ann. Rev. Med. 1982, 33, 97-111.
18. Yasumoto, T.; Raj, U.; Bagnis, R. In Symposium on Seafood Toxins from Tropical Regions, Tohoku University Japan, 1984; p. 74.
19. Steidinger, K.; Baden, D. G. Toxic marine dinoflagellates; Academic Press: Orlando, 1985.
20. Calvert, G. M.; Hryhorczuk, D. O.; Leikin, J. B. Treatment of ciguatera fish poisoning with amitriptyline and nifedipine. J. Toxicol. - Clin. Toxicol. 1987, 25, 423-428.
21. Naar, J. P.; Flewelling, L. J.; Lenzi, A.; Abbott, J. P.; Granholm, A.; Jacocks, H. M.; Gannon, D.; Henry, M.; Pierce, R.; Baden, D. G.; Wolny, J.; Landsberg, J. H. Brevetoxins, like ciguatoxins, are potent ichthyotoxic neurotoxins that accumulate in fish. Toxicon 2007, 50, 707-723.
22. Flewelling, I.; Naar, J.; Abbott, J.; Baden, D. G.; Barros, N. B.; Bottein Dechraoui, M.-Y.; Hammond, D.; Haubold, E.; Heil, C.; Henry, M.; Jacocks, H.; Leighfield, T.; Pierce, R.; Pitchford, T.; Rommel, S.; Rowles, T.; Scott, P.; Steidinger, K. A.; Truby, E.; Van Dolah, F.; Landsberg, J. Red tide and marine mammal mortalities. Nature 2005, 435, 755-756.
23. Friedman, M. A.; Arena, P.; Levin, B.; Fleming, L.; Fernandez, M.; Weisman, R.; Bernstein, J.; Schrank, K.; Blythe, D.; Backer, L.; Reich, A. Neuropsychological study of ciguatera fish poisoning: A longitudinal case-control study. Arch. Clin. Neuropsychol. 2007, 22, 545-553.
24. Arena, P.; Levin, B.; Fleming, L. E.; Friedman, M. A.; Blythe, D. G. A pilot study of the cognitive and psychological correlates of chronic ciguatera poisoning. Harmful Algae 2004, 3, 51-60.
25. Quod, J. P.; Turquet, J. Ciguatera in Reunion Island (SW Indian Ocean): epidemiology and clinical patterns. Toxicon 1996, 34, 779-785.
26. Bagnis, R.; Legrand, A. M. In Progress in venom and toxin research; Gopalakrishnakone, P., Tan, C. K., Eds.; National University of Singapore, Singapore, 1987; pp. 372-384.
27. Lewis, R. Ciguatera management. SPC Live Reef Fish Information Bulletin 2000, 7, 11-13.
28. Bagnis, R. In Algal toxins in seafood and drinking water; Falconer, I., Ed.; Academic Press: London, 1993: pp. 105-115.
29. Chateau-Degat, M. L.; Huin-Blondey, M. O.; Chinain, M.; Darius, T.; Legrand, A. M.; Nguyen, N. L.; Laudon, F.; Chansin, R.; Dewailly, E. Prevalence of chronic symptoms of ciguatera disease in French Polynesian adults. Am. J. Trop. Med. Hyg. 2007, 77, 842-846.
30. Kodama, A. M.; Hokama, Y. Variations in symptomatology of ciguatera poisoning. Toxicon 1989, 27, 593-595.
31. Chan, T. Y.; Kwok, T. C. Chronicity of neurological features in ciguatera fish poisoning. Hum. Exp. Toxicol. 2001, 20, 426-428.
32. Blythe, D. G.; de Sylva, D. P.; Fleming, L. E.; Ayyar, R. A.; Baden, D. G.; Shrank, K. Clinical experience with i.v. Mannitol in the treatment of ciguatera. Bull. Soc. Pathol. Exotique 1992, 85, 425-426.
33. Benoit, E.; Laurent, D.; Mattei, C.; Legrand, A. M.; Molgo, J. Reversal of Pacific ciguatoxin-1B effects on myelinated axons by agents used in ciguatera treatment. Cybium 2000, 24, 33-40.
34. Chan, T. Y.; Wang, A. Y. Life-threatening bradycardia and hypotension in a patient with ciguatera fish poisoning. Trans. Roy. Soc. Trop. Med. Hyg. 1993, 87, 71.
35. Ruff, R. L.; Lewis, J. Clinical aspects of ciguatera: an overview. Memoirs of the Queensland Museum 1994, 609-619.
36. Glaziou, P.; Martin, P. M. Study of factors that influence the clinical response to ciguatera fish poisoning. Bull. Soc. Pathol. Exotique 1992, 85, 419-420.
37. Ting, J. Y.; Brown, A. F. Ciguatera poisoning: a global issue with common management problems. Europ. J. Emerg. Med. 2001, 8, 295-300.
38. Bagnis, R. A.; Bronstein, J. A.; Jouffe, G.; Forestier, R.; Meunier, J. L.; Lejan, J.; Brulefer, D.; Parc, F.; Tetaria, C. [Neurologic complications of ciguatera]. Bull. Soc. Pathol. Exotique 1977, 70, 89-93.
39. Bottein Dechraoui, M.-Y.; Wang, Z.; Turquet, J.; Chinain, M.; Darius, T.; Cruchet, P.; Radwan, F. F. Y.; Dickey, R. W.; Ramsdell, J. S. Biomonitoring of ciguatoxin exposure in mice using blood collection cards. Toxicon 2005, 46, 243-251.
40. Bottein Dechraoui, M. Y.; Wang, Z.; Ramsdell, J. S. Optimization of ciguatoxin extraction method from blood for Pacific ciguatoxin (P-CTX-1). Toxicon 2007, 49, 100-105.
41. Ryan, J. C.; Bottein Dechraoui, M. Y.; Morey, J. S.; Rezvani, A.; Levin, E. D.; Gordon, C. J.; Ramsdell, J. S.; Van Dolah, F. M. Transcriptional profiling of whole blood and serum protein analysis of mice exposed to the neurotoxin Pacific Ciguatoxin-1. NeuroToxicol. 2007, 28, 1099-1109.
42. Stinn, J. F.; de Sylva, D. P.; Fleming, L. E.; Hack, E. In GIS in public health, 3rd National Conference, San Diego, CA, 2000.
43. Dickey, R.; Jester, E.; Granade, R.; Mowdy, D.; Moncreiff, C.; Rebarchik, D.; Robl, M.; Musser, S.; Poli, M. Monitoring brevetoxins during a Gymnodinium breve red tide: comparison of sodium channel specific cytotoxicity assay and mouse bioassay for determination of neurotoxic shellfish toxins in shellfish extracts. Nat. Toxins 1999, 7, 157-165.
44. Manger, R. L.; Leja, L. S.; Lee, S. Y.; Hungerford, J. M.; Hokama, Y.; Dickey, R. W.; Granade, H. R.; Lewis, R.; Yasumoto, T.; Wekell, M. M. Detection of sodium channel toxins: directed cytotoxicity assays of purified ciguatoxins, brevetoxins, saxitoxins, and seafood extracts. J. AOAC Int. 1995, 78, 521-527.
45. nd Ed.; Botana, L.M., Ed.; Taylor and Francis (CRC Press), 2008; pp. 479-500.
46. Dechraoui, M. Y.; Naar, J.; Pauillac, S.; Legrand, A. M. Ciguatoxins and brevetoxins, neurotoxic polyether compounds active on sodium channels. Toxicon 1999, 37, 125-143.
47. Bottein Dechraoui, M. Y.; Tiedeken, J.; Persad, R.; Wang, Z.; Granade, H. R.; Dickey, R.; Ramsdell, J. S. Use of two detection methods for discriminating ciguatoxins from brevetoxins: application to Great Barracuda from Florida. Toxicon 2005, 46, 261-270.
48. Pottier, I.; Hamilton, B.; Jones, A.; Lewis, R.; Vernoux, J. P. Identification of slow and fast-acting toxins in highly ciguatoxic barracuda (Sphyraene barracuda) by HPLC/MS and radiolabelled ligand binding. Toxicon 2003, 42, 663-672.
49. Hamilton, B.; Hurbungs, M.; Jones, A.; Lewis, R. J. Multiple ciguatoxins present in Indian Ocean reef fish. Toxicon 2002, 40, 1347-1353.
50. Lombet, A.; Bidard, J. N.; Lazdunski, M. Ciguatoxin and brevetoxins share a common receptor site on the neuronal voltage-dependent Na+ channel. FEBS Lett. 1987, 219, 355-359.
51. Darius, H. T.; Ponton, D.; Revel, T.; Cruchet, P.; Ung, A.; Tchou Fouc, M.; Chinain, M. Ciguatera risk assessment in two toxic sites of French Polynesia using the receptor-binding assay. Toxicon 2007, 50, 612-626.
52. Lewis, R. J.; Jones, A.; Vernoux, J. P. HPLC/tandem electrospray mass spectrometry for the determination of Sub-ppb levels of Pacific and Caribbean ciguatoxins in crude extracts of fish. Anal. Chem. 1999, 71, 247-250.
53. Hamilton, B.; Hurbungs, M.; Vernoux, J. P.; Jones, A.; Lewis, R. J. Isolation and characterisation of Indian Ocean ciguatoxin. Toxicon 2002, 40, 685-693.
54. Lewis, J. In Manual on harmful marine microalgae; Hallegraeff, G.M., Anderson, D.M., Cembella, A.D., Eds.; UNESCO: Paris, 2004; IOC Manuals and Guides No. 33., pp. 1-22.
55. Hokama, Y.; Nishimura, K.; Takenaka, W.; Ebesu, J. S. Simplified solid-phase membrane immunobead assay (MIA) with monoclonal anti-ciguatoxin antibody (MAb-CTX) for detection of ciguatoxin and related polyether toxins. J. Nat. Tox. 1998, 7, 1-21.
56. Wong, C. K.; Hung, P.; Lee, K. L.; Kam, K. M. Study of an outbreak of ciguatera fish poisoning in Hong Kong. Toxicon 2005, 46, 563-571.
57. Dickey, R.; Granade, H. R.; McClure, F. Evaluation of a solid-phase immunobead assay for detection of ciguatera-related biotoxins in Caribbean finfish. Memoirs of the Queensland Museum 1994, 34, 481-488.
58. Hirama, M.; Oishi, T.; Uehara, H.; Inoue, M.; Maruyama, M.; Guri, H.; Satake, M. Total synthesis of ciguatoxin CTX3C. Science 2001, 294, 1904-1907.
59. Murata, M.; Legrand, A. M.; Ishibashi, Y.; Fukui, M.; Yasumoto, T. Structures and configurations of ciguatoxin from the moray eel Gymnothorax javanicus and its likely precursor from the dinoflagellate Gambierdiscus toxicus. J. Am. Chem. Soc. 1990, 112, 4380-4386.
60. Murata, M.; Legrand, A. M.; Ishibashi, Y.; Yasumoto, T. Structures of ciguatoxin and its congener. J. Am. Chem. Soc. 1989, 111, 8929-8931.
61. Crouch, R. C.; Martin, G. E.; Musser, S. M.; Grenade, H. R.; Dickey, R. W. Improvements in the Sensitivity of Inverse-Detected Heteronuclear Correlation Spectra Using Micro Inverse Probes and Micro Cells: HMQC and HMBC Spectra of Caribbean Ciguatoxin - Preliminary Structural Inferences. Tetrahedron Lett. 1995, 36, 6827-6830.
62. Vernoux, J. P.; Lewis, R. J. Isolation and characterisation of Caribbean ciguatoxins from the horse-eye jack (Caranx latus). Toxicon 1997, 35, 889-900.
63. Lewis, R. J.; Sellin, M.; Poli, M. A.; Norton, R. S.; MacLeod, J. K.; Sheil, M. M. Purification and characterization of ciguatoxins from moray eel (Lycodontis javanicus, Muraenidae). Toxicon 1991, 29, 1115-1127.
64. Schnorf, H.; Taurarii, M.; Cundy, T. Ciguatera fish poisoning: a double-blind randomized trial of mannitol therapy. Neurology 2002, 58, 873-880.
65. Bagnis, R.; Spiegel, A.; Boutin, J. P.; Burucoa, C.; Nguyen, L.; Cartel, J. L.; Capdevielle, P.; Imbert, P.; Prigent, D.; Gras, C. [Evaluation of the efficacy of mannitol in the treatment of ciguatera in French Polynesia]. Med. Tropicale 1992, 52, 67-73.
66. Blythe, D. G.; Hack, E.; Washington, G.; Fleming, L. E. In Foodborne Disease Handbook; Hui, Y.H., Kitts, D., Stanfield, P.S., Eds.; Marcel Dekker: New York, NY, 2001; p. 311-320.
67. Palafox, N. A.; Jain, L. G.; Pinano, A. Z.; Gulick, T. M.; Williams, R. K.; Schatz, I. J. Successful treatment of ciguatera fish poisoning with intravenous mannitol. J. Am. Med. Assoc. 1988, 259, 2740-2742.
68. Blythe, D. G.; Fleming, L. E.; Ayyar, R. A.; de Sylva, D. P.; Baden, D. G.; Shrank, K. Mannitol Therapy for acute and chronic ciguatera fish poisoning. Memoirs of the Queensland Museum 1994, 34.
69. Birinyi-Strachan, L. C.; Davies, M. J.; Lewis, R. J.; Nicholson, G. M. Neuroprotectant effects of iso-osmolar d-mannitol to prevent Pacific ciguatoxin-1 induced alterations in neuronal excitability: A comparison with other osmotic agents and free radical scavengers. Neuropharmacol. 2005, 49, 669-686.
70. Lewis, R.; King, G. Ciguatera (fish poisoning); Williamson, J.A., Fenner, P.J., Burnett J.W., Rifkin, J.F., Eds.; University of New South Wales Press: Sydney, 1996.
71. Pearn, J. H.; Lewis, R. J.; Ruff, T.; Tait, M.; Quinn, J.; Murtha, W.; King, G.; Mallett, A.; Gillespie, N. C. Ciguatera and mannitol: experience with a new treatment regimen. Medical Journal of Australia 1989, 151, 77-80.
72. Watters, M. R. Marine neurotoxins as a starting point to drugs; Botana, L.M., Ed.; Taylor and Francis (CRC Press), 2007.
73. Berlin, R. M.; King, S. L.; Blythe, D. G. Symptomatic improvement of chronic fatigue with fluoxetine in ciguatera fish poisoning. Med. J. Austr. 1992, 157, 567.
74. Lange, W. R.; Snyder, F. R.; Fudala, P. J. Travel and ciguatera fish poisoning. Arch. Int. Med. 1992, 152, 2049-2053.
75. Davis, R. T.; Villar, L. A. Symptomatic improvement with amitriptyline in ciguatera fish poisoning. New Engl. J. Med. 1986, 315, 65.
76. Perez, C. M.; Vasquez, P. A.; Perret, C. F. Treatment of ciguatera poisoning with gabapentin. New Engl. J. Med. 2001, 344, 692-693.
77. Bourdy, G.; Cabalion, P.; Amade, P.; Laurent, D. Traditional remedies used in the western Pacific for the treatment of ciguatera poisoning. J. Ethnopharmacol. 1992, 36, 163-74.
78. Blythe, D. G.; de Sylva, D. P. Mother's milk turns toxic following fish feast. J. Am. Med. Assoc. 1990, 264, 2074.
79. Lange, W. R.; Lipkin, K. M.; Yang, G. C. Can ciguatera be a sexually transmitted disease? J. Toxicol - Clin. Toxicol. 1989, 27, 193-197.
80. Lange, W. R. Ciguatera toxicity. Am. Fam. Phys. 1987, 35, 177-182.
81. Lewis, R.; Jones, A.; Vernoux, J. In 5th Indo-Pacific Fish conference Noumea, New Caledonia, 1999, p 739-744.
82. Ebesu, J. Isolation and Characterization of Novel Ciguateric Compounds from Acanthurus Triostegus (Manini), Ph.D. Thesis, University of Hawaii, 1998.
83. Vernoux, J.-P.; Lejeune, J. Ciguatera in the French West Indies. Memoires of the Queensland Museum 1993, 34, 631-638.
84. Tosteson, T.; Ballantine, D. L.; Winter, A. Sea surface temperature, benthic dinoflagellate toxicity and toxin transmission in the ciguatera food web; Reguera, B; Blanco, J; Fernandez, ML; Wyatt, T ed. Xunta de Galicia and IOC, 1998.
85. Villareal, T. A.; Hanson, S.; Qualia, S.; Jester, E. L. E.; Granade, H. R.; Dickey, R. W. Petroleum production platforms as sites for the expansion of ciguatera in the northwestern Gulf of Mexico. Harmful Algae 2007, 6, 253-259.
86. Davin, W. T.; Kohler, C. C. Ciguatera toxins adversely affect piscivorous fishes. Trans. Am. Fish. Soc. 1988, 117, 374-384.
87. Davin, W. T.; Kohler, C. C. Effects of ciguatera toxins on the bluehead. Trans. Am. Fish. Soc. 1986, 115, 908-912.
88. Fleming, L. E.; Baden, D. G.; Bean, J. A.; Weisman, R.; Blythe, D. G. In Harmful Algae; B. Reguera, J. B., M.L. Fernandez, and T. Wyatt, Ed.; Xunta de Galicia and Intergovernmental Oceanographic Commission of UNESCO: Santiago de Compostela (Spain), 1998, p 245-248.
89. Kirkpatrick, B.; Fleming, L. E.; Stephan, W.; Backer, L.; Reich, A.; Dalpra, D.; Weisman, R.; Van De Bogart, G. In International Conference on Harmful Algal bloom, Cape Town, South Africa, Nov 2004.
90. Fleming, L. E.; Jerez, E.; Stephan, W.; Cassedy, A.; Bean, J. A.; Reich, A.; Kirkpatrick, B.; Backer, L.; Nierenberg, K.; Watkins, S.; Weisman, R. In Florida poison information center; University of Miami; Florida Department of Health; CDC; Childrens Hospital Cincinnati; Mote Marine Laboratory: Miami, FL, 2007.
91. Fleming, L. E.; Broad, K.; Clement, A.; Dewailly, E.; Elmir, S.; Knap, A.; Pomponi, S. A.; Smith, S.; Solo Gabriele, H.; Walsh, P. Oceans and human health: Emerging public health risks in the marine environment. Mar. Poll. Bull. 2006, 53, 545-560.
92. Dewailly, E.; Pereg, D.; Knap, A.; Rouja, P.; Galvin, J.; Owen, R. In Oceans and Human Health: Risks and Remedies from the Sea; Walsh, P. J., Smith, S. L., Fleming, L. E., Solo Gabriele, H., Gerwick, W. H, Eds.; Elsevier Science Publishers: New York, NY, in press.
93. Fleming, L. E.; Jerez, E.; Stephan, W.; Cassedy, A.; Bean, J.; Reich, A.; Kirkpatrick, B.; Backer, L.; Nierenberg, K.; Watkins, S.; Hollenbeck, J.; Weisman, R. Evaluation of Harmful Algal Bloom Outreach Activities. Mar. Drugs 2007, 5, 208-219.
94. Tsumuraya, T.; Fujii, I.; Inoue, M.; Tatami, A.; Miyazaki, K.; Hirama, M. Production of monoclonal antibodies for sandwich immunoassay detection of ciguatoxin 51-hydroxyCTX3C. Toxicon 2006, 48, 287-294.
95. Abraham, W. M.; Bourdelais, A. J.; Ahmed, A.; Serebriakov, I.; Baden, D. G. Effects of inhaled brevetoxins in allergic airways: toxin-allergen interactions and pharmacologic intervention. Environ. Health Perspect. 2005, 113, 632-637.
96. Anderson, B. S.; Sims, J. K.; Wiebenga, N. H.; Sugi, M. The epidemiology of ciguatera fish poisoning in Hawaii, 1975-1981. Hawaii Med. J. 1983, 42, 326-334.
97. Morris, J. G., Jr.; Lewin, P.; Hargrett, N. T.; Smith, C. W.; Blake, P. A.; Schneider, R. Clinical features of ciguatera fish poisoning: a study of the disease in the US Virgin Islands. Arch. Int. Med. 1982, 142, 1090-1092.
98. Czernichow, P.; Droy, J. M.; Ezelin, F.; Leroy, J. [Epidemiology of Ciguatera in the lies Saintes (Guadeloupe)]. Rev. Epidemiol. Sante Pub. 1984, 32, 315-321.
99. Lewis, N. D. Disease and development: ciguatera fish poisoning. Soc. Sci. Med. 1986, 23, 983-993.
100. Luber, G.; Azziz-Baumgartner, E.; Latka, R.; Monteihl, C.; Conklin, L.; Backer, L. Surveillance for ciguatera fish poisoning in Culebra, Puerto Rico (in press).
101. McMillan, J.; Granade, H. F.; Hoffman, P. Ciguatera fish poisoning in the United States Virgin Islands: preliminary studies. J. Coll. Virgin Is. 1980, 6, 84-107.
102. Holt, R. J.; Miro, G.; Del Valle, A. An analysis of poison control center reports of ciguatera toxicity in Puerto Rico for one year. J. Toxicol. - Clin. Toxicol. 1984, 22, 177-185.
103. Frennette, C.; Maclean, J. D.; Gyorkos, T. W. A large common-source outbreak of ciguatera fish poisoning. J. Infect. Dis. 1988, 158, 1128-1131.
104. Engleberg, N. C.; Morris, J. G, Jr.; Lewis, J.; McMillan, J. P.; Pollard, R. A.; Blake, P. A. Ciguatera fish poisoning: a major common-source outbreak in the U.S. Virgin Islands. Ann. Int. Med. 1983, 98, 336-337.
105. Escalona de Morta, G.; De la Noceda, G. G. In Proc. 5th Intl Coral Reef Congress Tahiti (French Polynesia), 1985; Vol. 4, pp. 415-416.
106. Chateau-Degat, M. L.; Beuter, A.; Vauterin, G.; Nguyen, N. L.; Chinain, M.; Darius, T.; Legrand, A. M.; Chansin, R.; Dewailly, E. Neurologic signs of ciguatera disease: evidence of their persistence. Am. J. Trop. Med. Hyg. 2007, 77, 1170-1175.