Ciguatera fish poisoning: A first epidemic in Germany highlights an increasing risk for European countries

• Ciguatoxins, polyether sodium channel activators, are biotoxins accumulating in fish flesh via the marine food chain.
• Cold allodynia and pruritus are pathognomonic symptoms of Ciguatera and correspond to the clinical picture of a distal sensory axonopathy.
• Global warming and coral reef destruction cause a rise of ciguatera incidence through thriving of poisonous microalgae.
• In addition global trade and tourism pose previously non-endemic areas in temperate climates at risk.

Toxin-producing microalgae are thriving worldwide due to coral reef destruction and global warming with major consequences on ecosystems, international trade and human health. Microalgae belonging to the family of flagellate protists, in particular dinoflagellates, secrete a variety of high-molecular-weight polyether toxins that accumulate through the marine food chain to cause disease in humans by acting as sodium channel activator toxins; ciguatera is the most frequent seafood-borne illness worldwide with 50,000 to 500,000 global incidences per annum and is usually limited to endemic areas located between 35° northern and 35° southern latitude. The rising global incidence frequency renders it a major human health problem, because no curative treatment is available yet and reliable detection assays are lacking. During the last decade ciguatera has increasingly become endemic in previously unaffected areas for two reasons: first global warming has contributed to the emergence of dinoflagellate species in subtropical and even temperate regions that previously had been constrained to tropical areas and second: in Europe globalization of fishing industry and tourism has led to a progressive increase in the number of ciguatera cases and a lack of awareness among medical personnel contributes to under-reporting. We review, through a recent ciguatera outbreak in Germany, the risk for ciguatera poisoning in Europe and highlight characteristic symptoms, current knowledge about disease pathomechanisms and treatment options.