The present study used liquid chromatography-tandem mass spectrometry (LC-MS/MS) to investigate retrospectively ciguatoxin (CTX)-positive samples as determined by mouse bioassay (MBA) in the past 10 years in Hong Kong. The results showed that Pacific CTXs (P-CTX-1, -2 and -3) were the most commonly observed toxins found in the samples, indicating Pacific Ocean areas as the most important origin of ciguatera fish poisoning. Clinical diagnosis from ciguatera patients also revealed the predominance of neurological illnesses in most cases, supporting intoxication of Pacific origin. This study demonstrated the ability of laboratory analysis to identify and quantify Pacific CTXs in suspected fish samples, so as to support the clinical diagnosis of ciguatera. Comparative analysis (Student's t-test and Spearman's rank correlation analysis) on the two CTX detection methods showed approximate linearity for overall P-CTXs (P-CTX-1, -2 and -3)/P-CTX-1 alone as derived by LC-MS/MS and total toxicity levels (P-CTX-1 equivalent) as determined by MBA. The LC-MS/MS method coupled with the rapid extraction method could allow the detection of trace amount of CTXs at levels below the clinically relevant limit, 0.1 ppb P-CTX-1 in fish flesh. For practical application, the adoption of a two-tiered approach for testing, chemical analysis by LC-MS/MS for toxic fish screening, coupled with biological assay by MBA for final toxicity confirmation, was proposed for first-line screening of CTX in potentially contaminated fish samples in the market, with an aim to minimizing the use of laboratory mice and at the same time providing reasonably effective means for routine analysis. Copyright © 2014 Elsevier Ltd. All rights reserved.