What is the most likely cause of these symptoms?

Ciguatera-the answer is b, ciguatera.ciguatoxin is a common public health problem. it is produced by the dinoflagellate gambierdiscus toxicus, which attach to marine algae and are eaten and passed up the food chain. this toxin is responsible for more than half of all fish-related poisonings in the united states. once ingested, the toxin causes gastrointestinal (gi) and neurologic symptoms. the gi symptoms begin 2 to 24 hours after ingestion and include nausea, vomiting, crampy abdominal pain, profuse watery diarrhea, and diaphoresis. the neurologic complaints follow and include dysesthesia, paresthesia, and occasionally cns complaints such as ataxia, vertigo, weakness, confusion, and coma. sensory reversal dysesthesia (distortion of temperature perception) is highly suggestive of ciguatera poisoning. another classic finding of this disorder is the return or worsening of symptoms with consumption of alcohol, so all patients should be cautioned against use of alcohol until all symptoms have abated. this condition usually lasts 1 to 2 weeks but can persist for 8 weeks or more. treatment is supportive. patients with hypotension or bradycardia from the anticholinesterase activity of the toxin might need atropine and dopamine. pruritus can be managed with an h1 antagonist. amitriptyline (25 mg bid) can also help with pruritus and the dysesthesias. bacillus cereus is an aerobic, spore-forming, gram-positive rod that is ubiquitous in the soil and in raw, dried, or processed food, including uncooked rice. when the rice is prepared, the spores can survive boiling and germinate, and the person who eats it develops profound abdominal cramps and emesis 2 to 3 hours later. the duration of this illness is approximately 10 hours. this diagnosis should be suspected in patients with upper gi illness that developed less than 6 hours after eating fried rice. management is supportive and includes avoidance of ill-prepared or stored foods. clostridium perfringens is probably the most common cause of acute food poisoning in the united states. it is caused by ingestion of poultry or meat contaminated with enterotoxin produced by sporulation of c. perfringens type a heat-resistant spores. symptoms usually begin within 6 to 12 hours after ingestion and include frequent, watery diarrhea and moderately severe cramping. fever, nausea , and vomiting are rare. this illness is self-limiting and rarely lasts more than 24 hours. some patients will require intravenous hydration. scombroid poisoning occurs after ingestion of heat-stable toxins from bacterial actionon the dark meat of fish. these toxins have histidine decarboxylase activity, which produces histamine and histamine-like substances and histamine intoxication symptoms (facial flushing, diarrhea, severe headache, dry mouth, nausea, vomiting, urticaria). some patients report that the fish had a metallic, bitter, or peppery taste. patients with scombroid poisoning should be treated with diphenhydramine 50 mg iv and cimetidine 300 mg iv and discharged on oral antihistamines. vibrio parahaemolyticus is a gram-negative marine bacteria species present in the warm coastal waters of the united states. vibrio infection is caused by eating raw or undercooked shellfish. the predominant symptom is diarrhea, but patients might also have abdominal cramps, fever, nausea, and headache. the symptoms usually begin within 8 to 12 hours of ingestion but can be delayed up to 48 hours. this illness is self-limited and usually resolves in 24 to 48 hours. most patients do not require any specific treatment other than occasional intravenous fluids.(marx [rosens], 1470-1474)