A New Zealand woman who has spent more than two years battling rare and extreme complications from eating toxic fish has made a desperate plea for help.
Amanda Austrin returned to her Whakatane home last December after spending more than eight months debilitated on a bed in Tauranga Hospital.
The 42-year-old has a severe case of ciguatera poisoning - a rare illness with no cure or antidote - after accidentally eating the toxic gut of a reef fish while holidaying in Fiji in July 2011.
The odourless and tasteless toxin, found in predator fish in tropical and sub-tropical waters, can cause vomiting, diarrhoea, cramps, weakness, reversal of the normal sense of hot and cold, high blood pressure, paralysis - and in rare cases coma and death.
Most sufferers get over their illness within weeks or even a few days, but Mrs Austrin is among the very rare cases in which symptoms have lasted more than a year.
She still vomits daily and suffers from hot and cold reversals - meaning cold metal objects seem white hot and she must wear winter clothing in the warmer summer temperatures.
Walking to the mailbox leaves her spent. She eats via a machine that feeds her for several hours every day and has an extensive list of foods she cannot eat.
She says the toxin has attacked her pancreas and has made her a diabetic. Her condition worsens if she's near household chemicals, car fumes or is dehydrated.
She has developed neurological problems resulting in memory loss, movement and co-ordination problems and numbness and tingling.
"I'm just holding my own, really," she said.
"I still have that feeding tube in my stomach so I have to have nightly feeds and during the day I still can't take in much food at all, but I am staying out of hospital."
Mrs Austrin says a neurological assessment this year did little and referrals from her GP to specialists did not help as none knew anything about the toxin.
To make matters worse, the specialist who had taken an interest in her case died in March.
After the Herald ran her story a year ago, offers of help came from medical professionals and others who had suffered ciguatera poisoning.
But Mrs Austrin says while she was grateful, none could cure her.
"I emailed two or three people and there was one couple from Fiji itself.
"They got in touch with some person in one of the resorts who knew of all these treatments but it was really weird stuff like swimming out to the reef and drinking coconut milk ...
"I can't swim out there, I'm too weak for that and at the time I was too ill to even fly over there."
Mrs Austrin spends much of her time scouring the internet searching for someone who can treat her, but has been unable to find anyone who can help.
"I would put a plea out if there is any doctor here in New Zealand who is willing to take me on because my GP has referred me to three or four specialists and they have all declined because they don't have any experience in dealing with the toxin."
Robin Slaughter of the National Poisons Centre in Dunedin said there were five reported fish poisoning cases, three of which involved ciguatera poisoning where people had returned from holidaying in Fiji.
He said some people can have prolonged symptoms, but Mrs Austrin's case was "weird" and highly unusual.
Mr Slaughter said it was unlikely there had been any local breakthroughs in terms of treating the illness.
A 2010 article in the New Zealand Medical Journal noted an increasing number of travellers returning home with the symptoms, which many local doctors may not be familiar with.
The New Zealand Doctor magazine said that in major endemic areas, including Australia, the Caribbean and the South Pacific islands, the incidence of ciguatera poisoning is about 50,000 cases a year.
Mrs Austrin married her husband in January and rode a horse to the ceremony. "I only managed to spend two hours of the wedding out of bed," she said.
What is ciguatera poisoning?
It is a poisoning caused by the consumption of fish from tropical and sub-tropical reefs. These fish contain heat-stable marine biotoxins called ciguatoxins. They are produced by microscopic, single-celled algae that are believed to live on dead coral, thriving in seas rich in algae, fungi, yeast and bacteria. The toxins and their metabolites transfer up the food chain as the algae are consumed by herbivorous fish, which are eaten by larger carnivorous fish, which in turn are consumed by people.