Ciguatera fish poisoning (CFP) is a foodborne illness caused by fish containing ciguatoxin (CTX). The toxin is produced by the microalgae Gambierdiscus spp. which are then eaten by reef fish; humans contract the illness when eating either fish that have eaten the algae, or carnivorous fish that have eaten those fish. CTX is an odorless, tasteless, and colorless neurotoxin that blocks voltage-sensitive Na(+) channels and accumulates in many tissues of the fish, especially the viscera. The illness is typically mild to moderate in severity with gastrointestinal (diarrhea, cramping, nausea, vomiting) and neurological (paraesthesias, cold allodynia, fatigue, pruritis) manifestations. Rarely, the disease can be more severe with significant neuropathic or cardiac effects such as bradycardia and hypotension. Endemic to Hawai'i and islands throughout the Caribbean and Pacific, CFP incidence rates range from several to thousands of cases per 100,000 per year. Since fishing is important for local food supply, exportation, and recreation throughout the Pacific, CFP is medically and economically significant in these areas. We present a case of CFP from Hawai'i to illustrate the disease, demonstrating that the diagnosis is primarily clinical, with confirmatory tests from fish samples available in some cases. Treatment is supportive and symptomatic with no disease specific remedy. The prognosis for most cases is good with a short duration of self-limited symptoms, but for some cases neurological sequelae can become chronic. With no effective treatment, education on which species of reef fish and which body parts to avoid eating is essential in the prevention of CFP.