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Tetrodotoxin and Ciguatera share common manifestations and pose special risks to people of the Mediterranean regions. Aim of the Study To report progressively increasing reports of ciguatera and tetrodotoxin fish poisoning and document the pattern of their invasion to the Mediterranean Sea. Subjects and Results All fish intoxicated cases from red or Mediterranean sea since 2006 were clinically described. Poisoning after fish consumption accounted for 294 patients, 19 of which had fatal outcome. Paresthesia, vertigo, sensory deficits early appearing and gastrointestinal signs were shared by both conditions. Tetrodotoxin was differentiated by the progression of the picture with muscle weakness, collapse, altered sensorium, respiratory muscle paralysis and failure. Discussion Higher risks are associated with larger fish or with consumption of liver or gonads. Diagnosis relies on the described clinical picture following the consumption of toxic fish. Documentation and rapid reporting of newly affected locations and manifestations of either condition may reduce the hazards of toxicity to other Mediterranean countries. [ABSTRACT FROM AUTHOR]