LIHU'E, Kauai — A Kauai man's case of ciguatera poisoning that hospitalized him for more than two months highlights the danger of eating reef fish in Hawaii.

Tom Pickett, 53, speared a knifejaw fish while free diving off Kauai's north shore on Aug. 2 and he and his wife, Katie, dined on it two days later.

The Picketts both became ill within hours of eating the "delicious" fish and "we both knew what it was," Katie Pickett told The Advertiser.

What they couldn't know then was that Tom Pickett would be hospitalized until mid-October, at times unable to walk, talk or feed himself because of the neurotoxin's effects.

Pickett has been home in Kílauea a little more than three weeks, but is still measuring progress by small increments, such as gaining back a couple of the 50 pounds he lost, or reclaiming daily routines such as shaving and flossing.

Pickett can eat now, but is still getting supplemental nutrition. He's expected to need physical and occupational therapy for some time.

"Our big goal for him is a shower," said Katie Pickett, who has mostly recovered from a milder case of the disease and has been by her husband of 25 years throughout the ordeal.

For the active bodysurfer, free diver and co-owner of Kílauea Bakery and Pau Hana Pizza, the slowdown has been extreme, Katie Pickett said.

Tom Pickett still struggles with corralling his thoughts and the physical act of speaking, and chose not to comment for this article.

"I was never concerned he was going to die," Katie Pickett said in a phone interview. But it's now clear that her husband will be one of the cases for whom recovering from ciguatera is a months-long, or even years-long process.

SIGNS OF DANGER

Ciguatera is a naturally occurring marine toxin produced by microorganisms that live on algae. The toxin accumulates in fish that eat the algae but doesn't affect them.

People who eat fish containing the neurotoxin usually experience symptoms that can include weakness and muscle pain, diarrhea, vomiting, chills, itching, sweating, dizziness, numbness, tingling and headache. A unique symptom is the sense of "temperature reversal," when hot things feel cold and cold things feel hot.

"I feel it's safe to say that his situation is severe by normal standards, but certainly not without precedent in the population of ciguatera sufferers," Paul Bienfang, ciguatera project leader at the Pacific Research Center for Marine Biomedicine, said of Pickett's case.

Bienfang, with the help of spearfishing clubs on Oahu and Maui, has been collecting data on "hot spots" for ciguatera-containing fish in the Islands for about two years. His maps are posted at www.fish4science.

But that doesn't mean other locations are ciguatera free.

The state Department of Health compiles the number of ciguatera fish poisoning cases reported each year by doctors. Through September, 14 illnesses had been reported this year. The highest number of cases in the past decade was in 2002, when 69 cases were reported to the Health Department statewide.

The numbers are believed to be much lower than actual instances of illness because many people don't see a doctor for a mild case and doctors aren't required to report the cases they see, said Becky Kanenaka, the Health Department's foodborne disease surveillance and response coordinator.

By comparison, the most reported foodborne illness for Hawaii was campylobacteriosis (usually transmitted by chickens) with 657 cases in 2008, Kanenaka said.

Ciguatera fish poisoning is also under-reported worldwide, according to information on Bienfang's Web site.

Anyone who insists on eating reef fish can improve their chances of avoiding ciguatera, Bienfang said, by:

• Avoiding "the usual suspects," which include roi, barracuda, jacks, wrasses, wild kähala, menpachi, ulua and papio, eel, kole, weke, manini, palani and hapuupuu.

• Never eating the head, viscera, gonads, liver or eggs of reef fish, which can contain higher concentrations of toxin.

All aquaculture and deep sea fish are fine, Bienfang said. "There has never been a ciguatera incidence with aquacultured moi or kähala."

However, "the idea that there is safety in avoiding the bigger fish, but the smaller ones are OK is simply not true," Bienfang warned.

"Within species, we see no size-dependency of frequency or degree of toxicity."

Some fishermen say there is seasonal variation in the instance of ciguatera around the Hawaiian Islands, but "I'm not a fisherman," Kanenaka said.

"It's whether or not fish consume the toxin" that makes them transmitters of the disease, Kanenaka said. "In a school of fish, not all the fish may have it."

Fishermen are concerned enough about ciguatera that Hawaii Fishing News magazine publishes DOH statistics about ciguatera poisonings, with the type of fish caught and location.

"Not a lot of people get it, but when you get something like that, it becomes a real big deal" for the person who is sick, said Chuck Johnston, Hawaii Fishing News editor and publisher.

"It's always out there. It's like winning the lottery, but in a bad way," Johnston said.

Many anglers use the one commercially available test kit, Cigua-Check, which was developed at the University of Hawaii and is marketed by Oceanit.

Tom Pickett regularly used Cigua-Check and didn't eat fish that tested positive, Katie Pickett said.

In retrospect, the Picketts believe the test kit he used on the knifejaw they ate was compromised because it had been exposed to high temperatures during a camping trip. They don't blame the test, which comes with a disclaimer that it must be used as directed, Katie Pickett said.

Bienfang, who does testing for the DOH, confirmed ciguatera by testing leftovers of the Picketts' fish.

During Tom Pickett's stays at the Rehabilitation Hospital of the Pacific and Kuakini Hospital, doctors made exhaustive tests on him, looking for something other than ciguatera poisoning that might be causing his symptoms, but found nothing, Katie Pickett said.

They concluded that Tom Pickett had a milder case of ciguatera in the past, which makes a person more susceptible to future illness, she said.

There's no real treatment for ciguatera poisoning.

"The disease causes a lot of fatigue," Katie Pickett said. "It's a fine line to balance trying to keep him active and build up more muscle and at the same time not tire him."

Friends and family from Hawaii, the Mainland and around the globe — including the Picketts' two daughters away at college — have used a Web log to send get-well wishes to Tom.

"We have been trying a few new meds this week with no ill side effects, and are getting ready to add a big mix of nutrients and supplements, which the docs feel he needs to regain all the natural health he had," Katie Pickett wrote recently on the Web log.

"It's all basically an experiment, but I feel better about being more proactive," Katie wrote. "We all know that his nerve damage will take time to heal ... there are no magic potions, but he definitely took a lot of damage to his system and our aim is to support the healing."

Friends of the Picketts are bringing them meals, cleaning their house and otherwise helping out.

Tom Pickett's "voice can be weak, hard to understand," Katie Pickett said.

"His thinking is affected in weird ways," she said. "Some things he can remember, but he's also had a lot of hallucinations and delusions.

"He often thinks he can get up and go to work and do the things that he's always done."

Friends and family must guard to see that Pickett doesn't hurt himself with a fall, as happened in the hospital.

Katie Pickett said she's grateful to have medical insurance, but it doesn't pay more than the bare minimum for home care needs.

While being home has raised Tom Pickett's spirits, "there's the realization that you can't do all the things you'd normally do when you're at home. ... It can be overwhelming," she said. "We're trying to see what works for us right now."