Ciguatera

Ciguatera is food poisoning caused by ingesting tropical and subtropical carnivorous fish that in turn have ingested herbivorous fish contaminated with toxins (ciguatoxins, maitotoxins) produced by dinoflagellate organisms (Gambierdiscus toxicus) that live in detritus and algae of coral and rocky reefs, forming part of phytoplankton (Traylor 2019, Armstrong 2016, Valiente 2011, CDC 2009, FAO 2004).
Among the fish species most affected by these toxins are needlefish, barracuda, caranx latus (Galician, horse mackerel), serranus decimalis, grouper, sailfish, dorado, wahoo, seabream, moray eels, greater amberjack, sturgeon (Maya 2007, FAO 2004).
It is the most common food poisoning from eating fish in the world, being endemic in tropical and subtropical areas: the Caribbean, Indian Ocean, South Pacific and Atlantic (Traylor 2019, Armstrong 2016, Valiente 2011).

Ciguatoxins are lipid compounds of very high molecular weight, between 1,023 and 1,157 daltons (Soliño 2018). They are heat and freeze stable (Thompson 2017, FAO 2004) and do not affect fish that contain them which appear healthy. Ciguatoxins result from the biotransformation in fish of their precursors, gambiertoxins (Lehane 2000). They accumulate more in the brain, viscera, gonads and skin of fish.

Poisoning manifests itself within a few hours of having consumed contaminated fish in the form of gastrointestinal symptoms (vomiting, diarrhea, abdominal pain), neurological symptoms (paresthesia in the mouth, face, hands and feet with tingling, pain, asthenia and thermal cold-heat confusion ), cutaneous symptoms (severe itching and skin rash) and, less frequently, cardiovascular symptoms (hypotension, bradycardia). Symptoms typically last one to three weeks but can persist for months, leading to chronic fatigue and are worsened by alcohol consumption (Thompson 2017, Armstrong 2016, Valiente 2011, CDC 2009, Maya 2007).

Treatment is symptomatic. In the acute phase, it consists of oral or intravenous rehydration and intravenous infusion of mannitol and calcium gluconate. Subsequently, antihistamines, calcium salts and amitriptyline are used for paresthesias (Traylor 2019, Valiente 2011, Maya 2007, FAO 2004).

The high molecular weight of ciguatoxins makes its excretion in clinically significant amounts in breastmilk unlikely.
Children also appear to be less sensitive to ciguatoxin than adults (Maya 2007).

Only 5 cases have been reported, some poorly documented and all prior to 1990, of infants of mothers with ciguatera who continued to breastfeed and their babies presented mild diarrhea, colic, and/or moderate spontaneously resolving rashes (Blythe 1990, Anon 1989 and Bagnis 1987 in Swift 1991).

There is a more recently published case of a mother with ciguatera whose 8-month-old breastfed baby did not present any symptoms and no ciguatoxins were found in breastmilk (CDC 2009).
We have been informed of a case of a mother with ciguatera living in Cuba and treated with calcium carbonate who continued to breastfeed throughout the disease and whose 5-month-old infant did not present symptoms.
Increased tenderness has been described in the nipples of breastfeeding mothers with ciguatera (Lehane 2000).

Given the high frequency of this type of food poisoning, the scarcity of reported cases and complications during breastfeeding is noteworthy.

If the mother is not affected in a very acute way, breastfeeding can possibly continue, while monitoring possible symptoms in the infant (diarrhea, rash...) and temporarily suspending it only if these raise concern.