Humphead wrasse (Cheilinus undulatus) is an apex predator from coral reefs of the Indo-Pacific region. A food surveillance project using a validated mouse bioassay revealed the presence of ciguatoxins in significantly greater amounts in its flesh than in groupers and other coral reef fishes commonly available in Hong Kong wholesale market. Humphead wrasse has long been known to cause ciguatera, but there was a lack of clinical reports. A 45-year-old woman developed ciguatera after eating humphead wrasse. She required ICU care and infusions of intravenous fluids and dopamine for management of severe hypotension. All 5 published case series are also reviewed to characterise the types, severity and chronicity of ciguatera symptoms after its consumption. In addition to the gastrointestinal, neurological and other features that were typical of ciguatera, some subjects developed sinus bradycardia, hypotension, shock, neuropsychiatric features (e.g. mental exhaustion, depression, insomnia and memory loss), other central nervous system symptoms (e.g. coma, convulsions and ataxia) and myocardial ischaemia. Other subjects still experienced residual symptoms 6 months later; these were mainly neurological or neuropsychiatric complaints and skin pruritus. To prevent ciguatera, the public should avoid eating humphead wrasse and other large coral reef fishes. They should realise that consumption of the high-risk fish may result in more severe and chronic illness, including life-threatening complications and neuropsychiatric features.