The phylum Cnidaria (formerly Coelenterata) includes more than 9000 species, of which approximately 100 are known to injure humans. They are commonly referred to as jellyfish; however, their phylogenetic designations separate "true jellyfish" and other organisms into distinct classes (Table 120–1; Figure 120–1a). All species possess microscopic cnidae (the Greek knide means nettle), which are highly specialized organelles consisting of an encapsulated hollow barbed thread bathed in venom. Thousands of these stinging organelles, called nematocysts (or cnidoblasts), are distributed along tentacles. A trigger mechanism called a cnidocil regulates nematocyst discharge. Pressure from contact with a victim's skin, or chemical triggers such as osmotic changes, stimulates discharge of the thread and toxin from its casing. Penetration of flesh leads to intradermal venom delivery. Nematocysts of most Cnidaria are incapable of penetrating human skin, rendering them harmless. Cnidaria causing human envenomation, such as the box jellyfish, discharge threads capable of penetrating into the papillary dermis.135
Table 120–1. Characteristics of Common Cnidaria |Favorite Table|Download (.pdf)
Table 120–1. Characteristics of Common Cnidaria
|Latin Name||Common Name||Habitata|
|Chironex fleckerib||Box jellyfish||Tropical Pacific Ocean, Indian Ocean, Gulf of Oman|
|Carukia barnesib||Irukandji jellyfish||North Australian coast|
|Chiropsalmus sppb||Sea wasp or fire medusa||North Australian coast, Philippines, Japan, Indian Ocean, Gulf of Mexico, Caribbean|
|Carybdea alata||Hawaiian box jelly fish||Hawaii|
|Physalia physalisb||Portuguese man-of-war||Eastern US Coast from Florida to North Carolina, Gulf of Mexico, Australian coastal waters (rare reports)|
|Physalia utriculus||Bluebottle||Tropical Pacific Ocean, particularly Australia|
|Millepora alcicornis||Fire coral||Widespread in tropical waters, including Caribbean|
|Chrysaora quinquecirrha||Sea nettle||Chesapeake Bay, widely distributed in temperate and tropical waters|
|Stomolophus meleagris||Cabbage head or cannonball jelly fish||Gulf of Mexico, Caribbean|
|Stomolophus nomuraib||Yellow Sea between China and South Korea|
|Cyanea capillata||Lion's mane or hair jelly fish||Northwest US coast up to Arctic Sea, Norwegian and British coastlines as well as Australia|
|Pelagia noctiluca||Mauve stinger or purple-striped jelly fish||Wide distribution in tropical zones|
|Linuche unguiculata||Thimble jelly fish||Florida, Mexico, and Caribbean|
|Anemonia sulcata||European stinging anemone||Eastern Atlantic, Mediterranean, Adriatic Sea|
|Actinodendron plumosum||Hell's fire anemone||South Pacific|
|Actinia equina||Beadlet anemone||Great Britain, Ireland|
(A) North Atlantic Portuguese Man-O-War Physalia physalis with multiple tentacles dangling in the water. The tentacles filled with venomous nematocysts, and extend several meters in length. (Image contributed by Adam Laverty Reproduced with permission from Knoop et al., The Atlas of Emergency Medicine, 3e (c) 2010, McGraw-Hill Inc., New York, New York.) (B) Linear eruption from contact with an unidentified jellyfish in the South Atlantic Ocean. (Image contributed by David Goldfarb.)
Members of the class Cubozoa are not true jellyfish. Animals in the Cubomedusae order have a cube-shaped bell with four corners, each of which supports between one and 15 tentacles. Species from this order produce the greatest morbidity and mortality of all Cnidaria. The order has two main families of toxicologic importance: Chirodropidae and Carybdeidae.
The Chirodropidae family is well known for the box jellyfish Chironex fleckeri (Greek cheiro means hand, Latin nex means murderer; therefore, "assassin's hand").131 When full grown, its bell measures 25 to 30 cm in diameter, and 15 tentacles are attached at each "corner" of the bell. These tentacles may extend up to 3 m in length. Another member of this family is Chiropsalmus quadrigatus, the sea wasp. Its pale blue color makes detection in water nearly impossible.
The Carybdeidae family is most notable for Carukia barnesi, the Irukandji jellyfish.60 Its small size, with a bell diameter of 2.5 cm, limits detection in open waters.
The Hydrozoa class, like the Cubozoa, are also not true jellyfish; however, they are capable of inflicting considerable pain and even death in humans. The order Siphonophora (Physaliidae family) includes two unusual creatures of toxicologic concern: Physalia physalis, the Portuguese man-of-war, and its smaller counterpart, Physalia utriculus, the bluebottle. They are pelagic (floating) colonial Hydrozoa, meaning they exist as a colony of multiple hydroids in a formed mass. The easily recognizable blue sail that floats above the surface of the water is filled with nitrogen and carbon monoxide. Tentacles of P. physalis may reach lengths in excess of 30 meters and contain more than 750,000 nematocysts in each of its numerous tentacles (up to 40). P. utriculus has only one tentacle, which measures up to 15 m.
The Milleporina order is well known for the sessile Millepora alcicornis (fire coral) that exists as a fixed colony of hydroids. It appears much like true coral and has a white to yellow-green lime carbonate exoskeleton. Small tentacles protrude through minute surface gastropores. The overall structure ranges from 10 cm to 2 m.
True jellyfish belong to the class Scyphozoa and are extremely diverse in size, shape, and color. Common varieties known to envenomate humans are Cyanea capillata (lion's mane or hair jelly), Chrysaora quinquecirrha (sea nettle), and Pelagia noctiluca (mauve stinger). The mauve stinger is easily recognized; it appears pink in daylight and phosphorescent at night. Larvae of certain Linuche unguiculata cause sea bather's eruption (SBE). The larvae are pinhead sized and are seen only when they are grouped in large numbers near the surface of the water.
The Anthozoa class has a diverse membership, including true corals, soft corals, and anemones. Only the anemones are of toxicologic importance. They are common inhabitants of reefs and tide pools and attach themselves to rock or coral. Armed with modified nematocysts known as sporocysts located on their tentacles, they produce stings similar to those of organisms from other Cnidaria classes.
Stings from Cnidaria represent the overwhelming majority of marine envenomations. In Australia, approximately 10,000 stings per year are recorded from Physalia spp alone.55 Most Cnidaria stings occur during the warmer months of the year. Stings occur with greatest frequency on hotter-than-average days with low winds, particularly during times of low precipitation. "Stinger nets" are used in high-risk areas of the Australian coastline; however, one study reported that 63% of stings requiring medical attention occurred within netted waters.85 Each stinger season, the Royal Darwin Hospital in Australia treats approximately 40 patients with stings.41 A prospective evaluation of stings presenting to that hospital during a 12-month period from 1999 to 2000 revealed that 70% resulted from the box jellyfish. The remaining 30% involved other Cubozoa such as C. barnesi.106 Although this finding may indicate a predominance of box jellyfish as the cause of stings, it also suggests that stings from box jellyfish are more severe and require medical attention with greater frequency than stings from other species of Cnidaria.
Cases of SBE, a stinging rash evoked by contact with Cnidaria larvae, occur in clusters. Variation in intensity and frequency occurs from year to year as exemplified by a 25-year hiatus during which no cases were reported in Florida.142 In 1992, more than 10,000 cases of SBE occurred in south Florida, with similar peaks in the 1940s and 1960s. Cases of SBE also are reported in Cuba, Mexico, the Caribbean, and occasionally in Long Island, New York.
Cnidaria common to the United States include the Portuguese man-of-war and sea nettle. Other species are widely distributed throughout the tropical and temperate waters of the globe (see Table 120–1). Locations with documented Cnidaria-related deaths include the United States (Florida, North Carolina, Texas), Australia, the Indo-Pacific region (Malaysia, Langkawi Islands, Philippines, Solomon Islands, Papua New Guinea), and the coast of China. Since 1884 the number of deaths in Australia attributed to C. fleckeri is approximately 70.55,84 An estimated two to three deaths per year occur in Malaysia from an unknown species.55 Approximately 20 to 40 deaths are reported yearly in the Philippines from an unidentified species of the Chirodropidae family.55 Three deaths are well documented from P. physalis in the United States (Florida, North Carolina).22,55,134 One death from Chiropsalmus quadrumanus occurred along the coast of Texas.12 Eight fatalities in the Bohai waters of China (Yellow Sea) have been reported from Stomolophus nomurai.55,158 Although Chirodropidae are found off the western coast of Africa, no fatalities in that region are documented in the medical literature.
Cnidaria venoms contain a variety of components that may induce dermatonecrosis, myonecrosis, hemolysis, or cardiotoxicity, depending on the particular species. In rats, C. fleckeri venom evokes transient hypertension, followed by hypotension and cardiovascular collapse within minutes.109 Cardiac effects in animals include negative inotropy, conduction delay, ventricular tachycardia, and decreased coronary artery blood flow.41 However, experiments using the purest venom extracts without contamination from tentacle material demonstrate cardiovascular collapse without electrocardiographic changes.109 C. fleckeri venom also possesses dermatonecrotic and hemolytic fractions, although hemolysis in humans is not documented.9 Two myotoxins from C. fleckeri cause powerful sustained muscle contractions in isolated muscle fibers.45 Isolated heart models using C. fleckeri venom suggest its mechanism of action is nonspecific enhancement of cation conductance leading to increased Na+ and Ca2+ entry into cells.101 Other in vitro work confirms increased Na+ permeability in cardiac tissue.62
C. barnesi, the Irukandji jelly, likely induces its dramatic vasopressor effects via catecholamine release. In rats the venom produces a pressor response that is blocked by α1-adrenergic antagonism.112 The pressor response is not dose dependent; therefore, catecholamines in the venom would not explain this effect. In vitro experiments suggest a sodium channel modulator effect leading to massive catecholamine release.153 No electrocardiographic abnormalities occurred in envenomated rats.
Venom from Physalia spp blocks neural impulses in isolated frog sciatic nerve81 and produces ventricular ectopy, cardiovascular collapse, hyperkalemia, and hemolysis in dogs.71 Physalia spp venom inhibits Ca2+ entry into the sarcoplasmic reticulum.81 Similar mechanisms are proposed for Chrysaora, Chiropsalmus, and Stomolophus. C. quinquecirrha venom contains a 150-kDa polypeptide that induces atrioventricular block19 and produces myocardial ischemia, hypertension, dysrhythmias, and nerve conduction block,23,24 as well as hepatic and renal necrosis.100 C. quinquecirrha–induced hepatotoxicity is believed to be a direct toxin effect not mediated by pore formation or Ca2+ channel effects.73 Equinatoxin II (EqtII), found in the venom of the anemone Actinia equina, creates pores in cell membranes leading to hemolysis.1 This protein belongs to a group of anemone lysins known as actinoporins that bind to cell membranes and form pores via oligimerization.90
An immune-mediated response to venom may explain some sting-related symptoms. Elevated serum anti–sea nettle immunoglobulin IgM, IgG, and IgE may persist for years in patients with exaggerated reactions to stings compared with controls.20 A direct correlation between titers against Chrysaora and Physalia and severity of a visible skin reaction to envenomation strongly suggests an allergic component.123 Elevated IgG titers were demonstrated in one death from P. physalis.134 Dermatonecrosis from C. fleckeri may involve the release of leukotrienes and other arachidonic acid derivatives as well as direct toxin-mediated cell damage.42 Postenvenomation syndromes may result from an exaggerated, prolonged, aberrant T-cell response.25,26 Erythema nodosum following a sting from P. physalis lends further support to a immunologic component.5 SBE displays a characteristic delay in onset of symptoms and can be effectively treated with steroids, suggesting a primary immune-mediated process for this entity. This is further supported by histopathology revealing the presence of perivascular and interstitial infiltrates with lymphocytes, neutrophils, and eosinophils.154
Most patients with stings are treated beachside and never require hospitalization. The vast majority of patients with stings who seek medical care have severe pain without evidence of systemic poisoning.41 However, severe systemic manifestations may develop following stings from C. fleckeri, C. barnesi, P. physalis, and a few other Cnidaria.
Envenomation by C. fleckeri inflicts the most severe pain and is frequently associated with systemic toxicity. Common symptoms include immediate severe pain, followed by an erythematous whiplike linear rash with a "frosted ladder" appearance. The pain often is excruciating and may require parenteral analgesia. Systemic symptoms include nausea, vomiting, muscle spasms, headache, malaise, fever, and chills. Pain generally abates over several hours, although the rash may persist for days. In a prospective series of C. fleckeri stings, 58% manifested delayed hypersensitivity reactions in the form of an itchy maculopapular rash at 7 to 14 days.106 Most resolved spontaneously; some were treated with antihistamines and topical corticosteroids.
Fatality is documented to occur with only 4 m of tentacle markings.135 Death is rapid, preventing many victims from reaching shore. Cardiac arrest and pulmonary edema may develop in young, healthy patients without prior cardiopulmonary disease.77,89,152 Survival is possible with immediate cardiopulmonary resuscitation (CPR).151 C. quadrumanus, a close relative of the box jellyfish, induces symptoms that parallel C. fleckeri stings, including pulmonary edema and death.12
Previous reports suggesting a 15% to 20% fatality rate118 following C. fleckeri envenomation likely represent a gross overestimation given the low number of documented fatalities in the context of the extraordinary number of yearly stings. A prospective study of stings from Cubozoa over 1 year in Australia revealed no dysrhythmias, pulmonary edema, or death.106 No patient received antivenom, and analgesia was the only pharmacotherapy implemented. Hospital admission was not required for any victim. Although most victims suffer only local severe pain, serious systemic toxicity occurs occasionally, and may include vertigo, ataxia, paralysis, delirium, syncope, respiratory distress, pulmonary edema, hypotension, and dysrhythmia. The last 10 reported deaths from C. fleckeri occurred in children, suggesting vulnerability due to lower body mass and thinner dermis.41
Irukandji syndrome is a severe form of envenomation following Cubozoa stings from C. barnesi.74 However, nematocysts obtained from one fatality could not be identified, suggesting the existence of another causative species. Although the syndrome is considered unique to Australia, an unidentified species produced three cases of Irukandji-like syndrome in the Florida Keys.68
Individuals afflicted with Irukandji syndrome often notice a mild sting while they are in the water; however, skin findings typically are absent. Severe systemic symptoms develop within 30 minutes and mimic a catecholamine surge: tachycardia, palpitations, hyperpnea, headache, pallor, restlessness, apprehension, sweating, and a sense of impending doom. A prominent feature is severe whole-body muscle spasms that come in waves and preferentially affect the back. Spasms are described as unbearable and frequently require parenteral analgesia. Symptoms generally abate over several hours. Admission rates in patients presenting to medical care can exceed 50%.85 Hypertension is universal and may be severe, with systolic blood pressures well over 200 mm Hg. Two fatalities are described involving severe hypertension (systolic 280/150 mm Hg and 230/90 mm Hg) resulting in intracranial hemorrhage.51,74 Hypotension frequently follows, requiring vasopressor support. Pulmonary edema can develop within hours. Echocardiograms consistently reveal global ventricular dysfunction,85,87,92 although focal hypokinesis may occur.74 Restored cardiac function typically returns after several days.86 A retrospective review of 116 cases of Irukandji presenting to Cairns Base Hospital identified elevated troponin I measurements in 22% of patients,74 although a higher frequency is documented (78%).87 Electrocardiographic changes are described as nonspecific.
P. physalis envenomation typically induces severe pain, bullae, and skin necrosis (see Figure 120–1b). Systemic symptoms include weakness, numbness, anxiety, headache, abdominal and back spasms, lacrimation, nasal discharge, diaphoresis, vertigo, hemolysis, cyanosis, renal failure, shock, and rarely death. Some patients experience local numbness and paralysis of the affected extremity that resolves spontaneously.75 As with serious C. fleckeri stings, cardiovascular collapse and death can occur within minutes of envenomation.22 However, fatalities can be delayed several days following envenomation and relate to complications such as myocardial infarction and aspiration pneumonitis.134 An unusual presentation is reported of a 4-year-old child who was stung along the North Carolina coast and developed massive hemolysis requiring transfusions, followed by renal failure necessitating temporary dialysis.69 In contrast to P. physalis, P. utriculus stings typically are mild, although systemic toxicity occasionally develops.57
M. alcicornis (fire coral) is a common cause of stings in southern United States and Caribbean waters. While a member of the same phylogenetic class as P. physalis, it produces far less significant injuries. It is a nuisance to divers who touch the coral and suffer moderate burning pain for hours. Untreated pain generally lessens within 90 minutes, with skin wheals flattening at 24 hours and resolving within 1 week. Hyperpigmentation may persist for up to 8 weeks.15 The feather hydroid is the most numerous of the Hydrozoa and produces only mild stings.94
True jellyfish typically are less harmful to humans than Cubozoa or Hydrozoa. However, systemic toxicity and occasional deaths are reported from certain species such as S. nomurai, C. capillata, C. quinquecirrha, and P. noctiluca. Stomolophus meleagris is a common cause of stings; however, its weak venom produces only minor injury.4
Larvae of Linuche unguiculata are the primary cause of a pruritic papular eruption on the skin of sea bathers in Florida, occurring mostly in areas covered by a bathing suit as a result of larvae trapped under the garments. Cases were first noted in 1949 and dubbed sea bather's eruption (SBE).124 The larvae appear as pin-sized brown to green-brown spheres in the upper 2 inches of the water and are typically unnoticed. In a retrospective review, 50% of people reported a stinging sensation while they were in the water, and 25% reported itching upon exiting the water.154 The remainder of patients developed symptoms within 11 hours. Skin lesions develop within hours of itching and appear as discrete, closely spaced papules, with pustules, vesicles, and urticaria. Most lesions occur in areas covered by the bathing suit where the larvae accumulate; however, folds of skin such as the axilla, breasts, and neck may be affected. Itching often is severe and prevents sleep. New lesions may continue to develop over 72 hours. The average duration of symptoms is just under 2 weeks, and a small percentage of patients experience a recurrence of lesions several days later. Systemic symptoms such as chills, headache, nausea, vomiting, and malaise may occur.
Following stings from sea anemones, victims may develop either immediate or delayed pain. Skin findings range from mild erythema and itching to ulceration. A review of 55 stings from Anemonia sulcata presenting to a hospital in Yugoslavia (Adriatic Sea) revealed that, in addition to the local skin findings, many patients suffered nausea, vomiting, muscle aches, and dizziness.91 Larvae of the anemone Edwardsiella lineata also cause SBE among ocean swimmers in Long Island, New York. The hell's fire anemone Actinodendron plumosum is native to the South Pacific and produces significant local pain. One death occurred in the Virgin Islands following envenomation from an unknown species described as a "white anemone with blue tips." The onset of hepatic and renal failure was rapid and required transplantation, after which the patient died.64 Nonfatal elevation of hepatic enzyme concentrations following anemone sting also is reported.16
Laboratory evaluation may be warranted in patients suffering systemic toxicity following Cnidaria envenomation. Serial measurement of serum cardiac markers should be obtained from victims of Irukandji stings or others with consequential cardiovascular toxicity. Following severe stings from a variety of Cnidaria, urinalysis, hematocrit, and serum creatinine measurements should be considered to detect the presence of hemolysis and subsequent renal injury. Chest radiography is indicated for complaints of dyspnea or abnormalities in oxygenation. Venom assays are not available, and serum antibody titers are not clinically useful.
Initial interventions after Cnidaria envenomation should follow standard management strategies. Secondary measures are directed toward the prevention of further nematocyst discharge, which could intensify pain and enhance toxicity. Many topical therapies have been used for this purpose, including sea water, vinegar, a commercial solution known as Stingose, methylated spirits, ethanol, isopropyl alcohol, dilute ammonium hydroxide, urine, sodium bicarbonate, papain, shaving cream, and sand.
Vinegar is a common first-line treatment for topical application following Cnidaria stings. In vitro trials with C. fleckeri tentacles demonstrate complete irreversible inhibition of nematocyst discharge following a 30-second application.70 Additional study findings include massive nematocyst discharge with application of urine or ethanol, and no effect on discharge with use of sodium bicarbonate. Follow-up in vivo experiments demonstrate that vinegar is effective for other Cubozoa, including Morbakka (large Cubozoan in Australia),50Carybdea rastoni,53 and C. barnesi.54 Although massive nematocyst discharge occurs when vinegar is applied to C. capillata tentacles in vitro, clinical exacerbation following this treatment is not reported in humans.49 Massive discharge also occurs with C. quinquecirrha.28 A smaller degree of discharge (30%) occurs with P. physalis,57 whereas nematocysts of P. utriculus are unaffected by application of vinegar.70
Stingose is a commercially available product designed to counteract venom of insects, bees, stinging plants, and marine stingers. It is an aqueous solution of 20% aluminum sulfate and 1.1% surfactant. Its purported mechanism of action is denaturing of proteins and long-chain polysaccharides via interactions with the Al3+ ion, as well as osmotic removal of venom. A human volunteer trial involving stings from live tentacles of C. fleckeri demonstrated pain relief within 5 seconds of Stingose application.72 Similar results were achieved following treatment of stings from C. quinquecirrha. Further investigation involved beachside evaluation of 17 C. fleckeri and 150 P. utriculus sting victims treated with Stingose immediately following injury. All victims reported rapid relief. However, placebo or alternative therapies were not used in this case series. The efficacy of treatment with vinegar, Stingose, methylated spirits, and salt water was measured in human volunteers following forearm application of P. physalis tentacles.145 Vinegar demonstrated superior pain control compared with Stingose, whereas methylated spirits increased pain. The study assessed pain relief only and did not investigate the effects of the treatments on nematocyst discharge or systemic toxicity.
In many cases the identity of the "jellyfish" causing injury is unknown. In those cases, therapy must be guided by geographic location. In the United States, where P. physalis and C. quinquecirrha are of greatest consequence, sea water should be used to aid in tentacle removal given that vinegar enhances nematocyst discharge in those species. In the Indo-Pacific region, where C. fleckeri and C. barnesi are of greatest concern, vinegar should be used. Following a 30-second application, adherent tentacles must be carefully removed. This can be accomplished with a gloved or towel-covered hand, or with sand and gentle scraping with a credit card or other blunt, straight-edged tool.
In a nonrandomized trial, ice packs provided rapid, effective relief for patients with mild to moderate pain from Cnidaria stings in Australia.46 Patients with severe pain were less likely to benefit from ice packs. Some authors suggest that the use of heat is not only ineffective for venom neutralization, but that it increases pain.17 However, recent controlled trials designed to address this controversy highlight the efficacy of hot water immersion in lieu of cold packs for the treatment of stings from Carybdea alata and Physalia sp.57,88,103,140,157 Hot-water immersion therapy for treatment of C. fleckeri stings has not been rigorously evaluated.
Pressure immobilization bandaging is a technique that applies sufficient pressure to a wound to impede lymphatic drainage and prevent the entrance of venom into systemic circulation. Its application for snake bites is commonplace, while its role following Cnidaria stings has sparked controversy. Given the rapid onset of symptoms, the utility of a technique that impedes lymphatic drainage is unlikely to provide benefit. Although the technique would be used only after tentacle removal, some microscopic nematocysts remain adherent to the skin after visible tentacles are removed. In vitro data investigating the effect of pressure on discharged nematocysts demonstrate not only that discharged nematocysts still contain venom, but that applying pressure forces more venom down the hollow tube.108 This finding is correlated clinically as patients can deteriorate following pressure immobilization bandaging.56 Given the lack of evidence suggesting benefit, coupled with clear in vitro evidence of increased venom delivery with this technique, it should not be implemented for treatment of Cnidaria stings.
Box jellyfish antivenom is sheep-derived whole IgG raised against the "milked" venom of C. fleckeri. It has been available in Australia since 1970. Combining C. fleckeri venom with box jellyfish antivenom prior to injection into pigs prevents all toxicity.145 An isolated chick muscle experiment demonstrates that box jellyfish antivenom prevents the neurotoxicity and myotoxicity from C. fleckeri following pretreatment; however, there is no "rescue effect."110 Given that antivenom in humans is always used as a rescue therapy, this research raises concerns regarding efficacy in the clinical setting. Pretreatment of rats with box jellyfish antivenom prevented cardiovascular collapse in 40%, but did not blunt the initial hypertensive effect.111 In vitro data demonstrate that box jellyfish antivenom neutralizes the dermatonecrotic, hemolytic, and lethal fractions of venom from Chiropsalmus spp; however, the venom of P. physalis and C. quinquecirrha were not neutralized.10 Other in vitro and in vivo data demonstrate incomplete neutralization of Chiropsalmus spp venom.10,110
There are no controlled studies in humans evaluating the efficacy of box jellyfish antivenom in the treatment of C. fleckeri envenomations, nor is there convincing evidence that its administration has saved human lives. Despite the frequency of hospital visits for stings from C. fleckeri in Australia, the use of box jellyfish antivenom is rare.41 Evidence for its efficacy stems from case reports suggesting that pain abates rapidly after administration.14,152 Although box jellyfish antivenom may improve pain control, patients still may require parenteral narcotics for analgesia following antivenom administration.11 Significant morbidity and mortality still occur despite antivenom use.40,89,135 Case reports of box jellyfish antivenom use for C. barnesi stings demonstrate no apparent benefit.48
Many serious stings occur in the Northern Territory of Australia, where stinger nets are not commonly used. Distance from medical care limits the ability to obtain antivenom in a timely fashion.41 Although box jellyfish antivenom can be administered by paramedics via intramuscular (IM) injection,56 poor IM absorption and incomplete venom neutralization with antivenoms, as well as delayed peak serum concentrations, limit the utility of this approach.117 The amount of antivenom required to neutralize twice the lethal dose in humans is estimated at 12 vials.41 The manufacturer recommends treating initially with one ampule intravenously (IV) diluted 1:10 with saline or three undiluted ampules (1.5–4 mL each) IM at three separate sites, if IV access is unavailable. Some authors who have treated multiple patients with antivenom suggest treating coma, dysrhythmia, or respiratory depression with one ampule IV, titrating up to three ampules with continuation of CPR in patients with refractory dysrhythmia until a total of six ampules have been administered.106 For less serious envenomations, clinicians may consider administering one ampule if ice packs and parenteral analgesia prove ineffective.106 Serious adverse events or delayed sequelae following the use of IV antivenom are uncommon, although allergic reactions are a consideration.136
Verapamil was evaluated as a treatment for C. fleckeri stings based on evidence that calcium entry into cells represents an important mechanism of toxicity. One animal model demonstrated synergy with use of verapamil in combination with box jellyfish antivenom,27 whereas another showed verapamil pretreatment as well as rescue prolonged survival.18 This is in contrast to other models demonstrating that verapamil negates the benefits of antivenom111 and increases mortality.141 Verapamil administration to animals with C. quinquecirrha envenomation demonstrated no benefit.100 Interestingly, addition of magnesium to antivenom for treatment of C. fleckeri envenomation in rats prevented cardiovascular collapse in 100%, suggesting that magnesium may have a role in the treatment of stings from this species.111 Given that animal data are inconsistent with regard to verapamil and that hypotension may develop with severe envenomation, use of calcium channel blockers is not recommended for treatment of C. fleckeri stings.
Treatment for Irukandji syndrome should focus on analgesia and blood pressure control. Several modalities for control of severe hypertension have been suggested and include phentolamine, IV magnesium sulfate and nitroglycerin.39,52 Whereas hypotension may occur in late stages of toxicity, clinicians should also consider short-acting titratable agents such as esmolol, nitroprusside or nicardipine.
The phylum Mollusca (Latin mollis meaning soft) includes the classes Cephalopoda (octopus, squid, and cuttlefish) and Gastropoda (cone snails). Cephalopod species of toxicologic concern are limited to the blue-ringed octopus Hapalochlaena maculosa and the greater blue-ringed octopus Hapalochlaena lunulata. The blue-ringed and greater blue-ringed octopi are found in the Indo-Pacific region, primarily in Australian waters (Figure 120–2). Of the 400 species of cone snails that belong to the genus Conus, 18 are implicated in human envenomations.
The Blue Ringed octopus, Hapalochlaena maculosa. (Image contributed by Dr. Roy Caldwell, Professor of Integrative Biology, University of California, Berkeley.)
The blue-ringed octopus normally displays a yellow-brown color, but develops iridescent blue rings when threatened. The species is not aggressive and only bites humans when handled. A 1983 review of reported octopus envenomations uncovered a total of 14 cases, all of which occurred in Australia.146 There were two deaths61,133 and four serious envenomations. Other reviews suggest that up to seven deaths may have occurred prior to 1969, some outside Australia.44
Estimates of reported cone snail envenomations suggest only 15 human deaths have occurred worldwide.47 Conus geographicus (fish hunting cone) is the most common species implicated, although Conus textile may also cause death in humans. Cone snails predominantly inhabit the Indo-Pacific, including all parts of Australia, New Guinea, Solomon Islands, and the Philippines. Two deaths from C. geographicus occurred in Guam.83
The blue ringed octopus salivary gland secretes a toxin originally designated maculotoxin and later identified as tetrodotoxin.128 The beak of the octopus creates small punctures in human skin through which venom is introduced. Tetrodotoxin blocks Na+ conductance in neurons, leading to paralysis. Venom also contains serotonin (5-HT), hyaluronidase, tyramine, histamine, tryptamine, octopine, taurine, acetylcholine, and dopamine.137 Rabbits subjected to bites develop rapid flaccid paralysis without cardiotoxicity and die from asphyxia.137 Other animal models using venom gland extract demonstrate rapid onset of respiratory muscle paralysis and severe hypotension.59 Death occurs despite artificial respiration and results from hypotension.
Cone snails have a hollow proboscis that contains a tooth bathed in venom. Envenomations occur when the shells are handled. The proboscis can extend the length of its shell, thereby envenomating the hand of someone touching the opposite end of the shell. Any Conus species contains approximately 100 peptides or conotoxins in its venom. Targets include voltage- and ligand-gated ion channels as well as G-protein–linked receptors (Table 120–2).105,139 Many of these peptides are used extensively in laboratory research for their ability to selectively target a variety of specific calcium channel subtypes. Venom from Conus imperialis (worm hunter) contains a substantial amount of 5-HT, a component not found in any other Conus venom tested thus far.96 This species also contains a vasopressin-like peptide.102 The neuropeptide >- conotoxin, isolated from Conus magnus, is valued for its antinociceptive properties that arise from blockade of the N-type voltage-sensitive calcium channel in spinal cord afferents.95 The Food and Drug Administration approved ziconotide (Prialt, Elan Pharmaceuticals) in 2004 for intrathecal (IT) infusion in patients with severe chronic pain that require IT therapy, and in whom other treatment modalities such as IT morphine are not tolerated or ineffective. Patients reported modest improvements in pain with long-term treatment.148 Frequent side effects such as dizziness, nausea, confusion, and memory impairment limit the broad application of this novel therapy.
Table 120–2. Conus Peptide Targets |Favorite Table|Download (.pdf)
Table 120–2. Conus Peptide Targets
|Ligand-gated ion channels|
|Voltage-gated ion channels|
|δ-Conotoxin||Delayed channel activation|
|Vasopressin receptor||Conopressin-G||Receptor agonism|
|Neurotensin receptor||Contulakin-G||Receptor agonism|
The blue-ringed octopus creates one or two puncture wounds with its chitinous jaws, inflicting only minor discomfort. A wheal may develop with erythema, tenderness, and pruritus. Tetrodotoxin exerts a curarelike effect characterized by paralysis without depressing mental status. Symptoms include perioral and intraoral paresthesias, diplopia, aphonia, dysphagia, ataxia, weakness, nausea, vomiting, flaccid muscle paralysis, respiratory failure, and death. Detailed case reports describe rapid onset of symptoms.146 Complete paralysis requiring intubation with findings of fixed and dilated pupils is followed within 24 to 48 hours by near-complete recovery of neuromuscular function.146 In one reported death, a young man placed the octopus on his shoulder. He subsequently noted a small puncture wound, developed dry mouth, dyspnea, inability to swallow, and became apneic. Asystole occurred 30 minutes after arrival at the hospital despite artificial ventilation.61 Another similar bite resulted in symptom onset at 10 minutes, followed by death at 90 minutes, despite bystander CPR.137 With less severe envenomations, cerebellar signs may arise without paralysis. Near-total paralysis with intact mentation resolving over 24 hours is described in humans.137
Cone snail envenomation results from careless handling of the animal or rummaging through sand. Cone snails are nocturnal feeders, so they may present more of a hazard to night divers. Localized symptoms range from a slight sting to excruciating pain, tissue ischemia, cyanosis, and numbness. Systemic symptoms include weakness, diaphoresis, diplopia, blurred vision, aphonia, dysphagia, generalized muscle paralysis, respiratory failure, cardiovascular collapse, and coma. Death is rapid and occurs within 2 hours. Based on military medical records of more than 30 cases predating 1970, the mortality rate approaches 25%, with C. geographicus causing the most deaths.83 Other estimates suggest that, without medical care, mortality may reach 70%.156 Given the rarity of severe human envenomation from cone snails, the manner of death, whether purely from respiratory insufficiency or direct cardiovascular toxicity, remains unknown.
Laboratory testing following envenomation from octopi or cone snails should be directed by clinical findings. Coma, respiratory failure, and hypotension merit evaluation of serum metabolic parameters, chest radiography, and electrocardiogram. Although not a widely available assay, tetrodotoxin can be detected in the urine or serum using high-performance liquid chromatography with subsequent fluorescence detection.104
Primary interventions include maintenance of airway, breathing, and circulation. Some authors recommend hot water (45°–50°C, 113°–122°F) following cone snail stings for pain relief.83 Unlike Cnidaria envenomations, where nematocysts full of venom can persist on the skin and lead to continued venom delivery, stings from the octopus and cone snail mirror those of snake bites, where venom delivery is an immediate and finite event. Therefore, pressure immobilization bandaging may blunt toxin distribution by decreasing lymphatic spread.47 Additional measures include local wound care and tetanus prophylaxis. Antivenom is not available for octopus or cone snail venoms.
Echinodermata, Annelida, and Porifera
The Echinodermata phylum includes sea stars,, brittle stars, sea urchins, sand dollars, and sea cucumbers. Annelida are segmented worms that include the Polychaetae family of bristle worms. Sponges are classified in the Porifera phylum. One feature that all three phyla share is the passive envenomation of people who mistakenly handle or step on the animals. Most stings from these creatures are mild.
Echinoderms, annelids, and sponges are ubiquitous ocean inhabitants. The crown-of-thorns Acanthaster planci is found in the warmest waters of Polynesia to the Red Sea and is a particularly venomous species because of its sharp spines that easily puncture human skin. Sea urchins inhabit all oceans of the world. Bristle worms such as Hermodice carunculata typically inhabit tropical waters such as those of Florida and the Caribbean. However, some species thrive in the frigid waters of Antarctica. The fire sponge Tedania ignis is a brilliant yellow-orange sponge identified in large numbers off the coast of Hawaii and in the Florida Keys. Other common American sponges are Neofibularia nolitangere (poison-bun sponge or touch-me-not sponge) and Microciona prolifera (red sponge). Neofibularia mordens (Australian stinging sponge) is a common Southern Australian variety. In the Mediterranean, sponges are often colonized with sea anemones that may inflict severe stings.15
Sea urchins are covered in spines and pedicellariae. The pedicellariae are pincerlike appendages used for feeding, cleaning, and defense. They generally contain more venom than the spines and are more difficult to remove from wounds. Urchins laden with pedicellariae can evoke more severe stings than urchins with less pedicellariae. Venom contained within the spines consists of steroid glycosides, serotonin, hemolysin, protease, and acetylcholinelike substances. Some species harbor neurotoxins. The most venomous are species of Diadema, Echinothrix, and Asthenosoma. Sea stars are less noxious because they generally have short, blunt spiny projections. The crown-of-thorns is the exception with its longer, sharp spines containing toxic saponins with hemolytic and anticoagulant effects as well as histaminelike substances.138 Sea cucumbers excrete holothurin, a sulfated triterpenoid oligoglycoside, from the anus (organs of Cuvier) as a defense. The toxin inhibits neural conduction in fish, leading to paralysis. Some sea cucumbers eat Cnidaria and subsequently secrete their venom.
Bristle worms have many parapodia that have the appearance, but not the function, of legs. Several bristles extend from each parapodium giving the family (Polychaeta) its name (poly means many, chaetae means bristles). The bristles may penetrate human skin, leading to envenomation with an unknown substance.
Sponges have an elastic skeleton with spicules of silicon dioxide or calcium carbonate. They attach to the sea floor or coral beds. Toxins include halitoxin, odadaic acid, and subcritine, the nature of which is uncertain.21 Dried sponges are nontoxic; however, on rewetting they may produce toxicity even after several years.132
Most injuries from sea urchins are caused by inadvertently stepping on the spines or attempting to handle the animal. An intense burning with local tissue reaction occurs, including edema and erythema. Rarely, with multiple punctures, lightheadedness, numbness, paralysis, bronchospasm, and hypotension may reportedly occur, although this is not documented in the peer-reviewed medical literature.3 Reports of death are not well substantiated. The Pacific urchin Tripneustes has a neurotoxin with a predilection for cranial nerves.15 Mild elevations of hepatic enzymes are reported in one patient with foot cellulitis from an urchin sting.155 Small cuts on the skin from handling starfish may allow venom to penetrate, leading to contact dermatitis. The crown-of-thorns may cause severe pain, nausea, vomiting, and muscular paralysis.94 Cutaneous, scleral, or corneal exposure to sea cucumbers triggers contact dermatitis, intense corneal inflammation, and even blindness. Bristle worms are shrouded with bristles that can produce a reddened urticarial rash. Symptoms typically are mild and resolve over several hours to days.
Contact with the fire sponge, poison-bun sponge, or red-moss sponge causes erythema, papules, vesicles, and bullae that generally subside within 3 to 7 days. Victims may develop fever, chills, and muscle cramps. Skin desquamation occurs at 10 days to 2 months,4 with chronic skin changes lasting several months.21 Erythema multiforme and anaphylaxis are uncommon complications associated with Neofibularia spp exposure.15 Contact with sponges that are colonized with Cnidaria can lead to dermatitis with skin necrosis, referred to as sponge diver's disease.
The primary objective following envenomation from sea urchins and crown-of-thorns starfish is analgesia. Submersion of the affected extremity in hot water (105°F–115°F, 40.6°C–46.1°C) and administration of oral analgesics often is sufficient.47,94 Puncture wounds require radiographic evaluation to locate potential foreign bodies. Spines frequently crumble with attempted extraction. Intraarticular spines necessitate surgical removal. Decisions regarding spines in other locations should be influenced by ease of removal, presence of infection, and persistent pain. Tetanus immune status must be addressed. Decisions regarding antibiotic prophylaxis should be based on degree of injury and patient factors such as diabetes or other immunocompromise. Although most infections likely are secondary to human skin flora, marine flora such as Mycobacterium marinum and Vibrio parahaemolyticus are potential wound contaminants. Treatment of sponge exposures usually requires only removal of spicules using adhesive tape or the edge of a credit card. Antihistamines and topical steroids often provide no relief from stinging sponges.21