AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

With more than 10,000 species in the sea, jellyfish are responsible for the most common human envenomations. More than 100 species are toxic to humans, and contact with toxic jellyfish causes a wide range of conditions, from cutaneous rashes to cardiovascular and respiratory collapse.

Jellyfish are categorized into 4 classes as follows:

• Hydrozoa (Portuguese man-of-war)
• Scyphozoa (true jellyfish; most common)
• Cubozoa (box jellyfish; most toxic)
• Anthozoa (sea anemones and corals)

Jellyfish have a single gastrovascular cavity opening, which is used for digestion and circulation, and a set of tentacles. The tentacles are covered with batteries of specialized stinging cells termed nematocytes. Each nematocyte contains a stinging apparatus known as the nematocyst. This stinging apparatus basically consists of a poison sac with an attached sharp hollow tube armed with barbs.

Detached tentacles found on the beach pose a hazard to humans because they remain capable of envenomation for several weeks.

Pathophysiology

The stinging process of the nematocyte resembles a jack-in-the-box mechanism. Specifically, mechanical and chemical stimulation of the sensory hairs (ie, cnidocil) surrounding the pressurized nematocyte results in a calcium-mediated bioelectric signal that causes an opening of its lid, allowing the ejection of the nematocyst into the prey to express the venom. This pressurized process has a high internal hydrostatic pressure of 150 atm that causes the ejection to occur within 3 milliseconds, with an acceleration power of 40,000g and a force of penetration of 20-33 kPa. In addition, the nematocyst is capable of penetrating up to a depth of 0.9 mm. This depth deposits the toxin into the microvasculature of the dermal tissue to be absorbed into the systemic circulation and anchors the tentacles to the prey. Finally, the nematocyte must be replaced because it cannot regenerate the ejected nematocyst. This replacement is done via differentiation of the pluripotent cells.

Nematocysts

The nematocysts' size and arrangement on jellyfish tentacles differ from species to species, much like a fingerprint. This architectural arrangement of warts, ridges, spirals, and terminal swelling may be reflected in the skin pattern left via the sting and helps identify the species involved in the envenomation.

Toxin

Microscopically, nematocysts appear structurally similar from one species to another, but the venom differs in composition. For example, because the box jellyfish feeds on fish larger than its own body, it requires potent venom for rapid paralysis. While the amount of toxin expressed by a single nematocyst is minute, several thousand nematocysts discharging at once have a significant effect.

Functionally, the toxin causes sodium and calcium ion transport abnormalities, disrupts cellular membranes, releases inflammatory mediators, and acts as a direct toxin on the myocardium, nervous tissue, hepatic tissue, and kidneys.

Specifically, the toxin may contain catecholamines, vasoactive amines (eg, histamine, serotonin), kinins, collagenases, hyaluronidases, proteases, phospholipases, fibrinolysins, dermatoneurotoxins, cardiotoxins, neurotoxins, nephrotoxins, myotoxins, and antigenic proteins. The protein component of the toxin tends to be heat labile, nondialyzable, and is degradable by proteolytic agents.

Reaction to venom

Immediate acute reactions to the venom tend to be toxic rather than allergic. Since pain occurs immediately after exposure, venom injection into different mammals induces similar clinical results, and victims can be stung repeatedly without differences in symptoms. The more rapidly the venom gets into the bloodstream, the higher the venom concentration in blood and the more rapid the onset of systemic symptoms. Delayed reactions to jellyfish stings are related immunologically, as evidenced by persistent immunoglobulin G (IgG) levels, prolonged T-cell response, and cross-reactivity among various jellyfish venom antigens.

Frequency

United States

Jellyfish stings occur most commonly during the summer along coastal regions. As the coastal population grows and more tourists come to the beaches, the frequency of jellyfish sting is likely to increase. One investigator reported 500,000 annual envenomations in the Chesapeake Bay area and 200,000 annually along the Florida coast.

International

Jellyfish stings occur in tropical oceans, especially between latitudes 30° south to 45° north, because of a high natural concentration of coelenterates. This is especially true of the east coast of Australia during the warm summer months between November and May.

Mortality/Morbidity

Jellyfish stings usually are mild, except those caused by species in the South Pacific, such as the box jellyfish or Portuguese man-of-war. Exact mortality and morbidity is not known because of underreporting and the lack of an international jellyfish sting registry. However, a recent epidemiology study of 118 cases of jellyfish stings from the Texas gulf coast showed 0.8% had no effect, 80.5% had minor effects, and 18.6% had moderate effects.

• Box jellyfish venom has a median lethal dose of 40 mcg/kg, which makes it the most potent marine toxin. The venom may kill a person weighing 70 kg within 3 minutes and is responsible for a mortality rate of 20%. Box jellyfish venom has caused 72 deaths secondary to respiratory paralysis, neuromuscular paralysis drowning, and cardiovascular collapse.
• The sting of the Portuguese man-of-war is more painful than a common jellyfish sting. It has been described as feeling like being struck by a lightning bolt, and some victims dread it more than a shark bite. This sting has been responsible for 2 reported deaths.
• The Arctic jellyfish is the largest, with tentacles reaching 200 ft, allowing the jellyfish to sweep an area slightly larger than a basketball court.

Race

No racial predilection exists. Any differences in individual reactions to jellyfish are a reflection of immune status rather than race.

Sex

• Men are more likely to be stung than women because they are more likely to participate in water activities such as surfing, sailing, saltwater fishing, and scuba diving.
• Lower body weight makes women more susceptible than men to the same amount of jellyfish venom.

Age

• Children are most susceptible to the effects of toxins because of their large surface area–to–volume ratio and lower body weight.
• Older adults are more susceptible than younger adults because of their decreased physiologic reserves and concurrent debilitation.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

For patients presenting with jellyfish stings, it is essential to ascertain (1) the time of envenomation, (2) the nature of the incident, (3) a description of the coelenterate, and (4) local and systemic symptoms.

• Toxicity and variations of symptoms depend on several factors.
• • Patient age and health
  • Patient body weight relative to the toxin amount
  • Patient surface area involved in the sting (any sting >50% of limb area is associated with severe envenomation)
  • Thickness of the skin at contact points (calloused palms and soles are most resistant)
  • Site of envenomation (proximity to head and torso results in quicker venom absorption into central circulation)
  • Species of the jellyfish
  • Maturity of the jellyfish
  • Venom potency
  • Number of nematocysts discharged
• Hot water sensation with skin tingling or stinging may be reported at the body site where the jellyfish originally made contact, secondary to pain and stinging after the release of thousands of nematocysts at the site.
• Jellyfish stings are suggested in patients who experience an unexplained near drowning or collapse in water secondary to incapacitating muscle spasms or loss of consciousness. Interestingly, an Australian jellyfish sting epidemiology study showed 17% stings occurred while entering the water and 83% occurred in water 1 m or less deep.
• Precipitant environmental factors are as follows:
• • Lower than average rainfall in last 7 days
  • Onshore winds greater than 15 km/h
  • Summer temperatures warmer than average

Physical

Variations in reactions to the sting appear to be related to the specific toxicity of the venom. Venom deposited intravascularly causes quicker onset of symptoms and signs. Physical findings of envenomation can be classified as local effects, systemic effects, delayed effects, or specific jellyfish syndromes.

• Mild envenomation
• • Local skin contact reactions
    • Tenderness, burning, and pruritus, which may spread centrally and differ in intensity depending on the species involved
    • Local soft tissue edema and angioedema
    • Erythematous papules and blisters in a whiplike pattern with desquamation within 1-8 weeks
    • Ischemic changes distal from localized arterial vasospasm underlying the sting site
    • Thrombophlebitis of the vessel underlying the sting site
    • Local neurapraxia occurring adjacent to sting site from immunologic reaction to toxin or to toxin-induced alteration of the nerve's ionic permeability
    • Tender regional lymphadenopathy
    • Distant skin site reactions secondary to a hypersensitive response to the antigenic component of the venom
• Ophthalmologic contact reactions
  • Conjunctival hyperemia with chemosis
  • Punctate epithelial keratosa
  • Corneal stromal inflammatory edema
  • Anterior chamber inflammation
  • Iritis
  • Mydriasis secondary to sphincter myotoxicity
  • Ophthalmic sequelae, including corneal ulcer with scarring, lens opacification, and elevated intraocular pressure (32-48 mmHg) secondary to obstruction of trabecular meshwork with inflammatory debris
• Moderate or severe envenomation implies the appearance of systemic symptoms following the initial localized reaction.
• • Cardiovascular
    • Peripheral and coronary vasospasm
    • Dilated cardiomyopathy
    • Hypokinetic cardiac failure (hyperkinetic failure in Irukandji syndrome)
    • Arrhythmia from toxin-induced damage to Purkinje fibers
    • Cardiovascular collapse or arrest, usually indicating a larger amount of envenomation than in respiratory arrest
  • Respiratory
    • Laryngeal edema
    • Bronchospasm
    • Pulmonary edema/acute respiratory distress syndrome
    • Hypoxia and acidosis from intercostal muscle spasm and pain
    • Respiratory failure and arrest
  • Neurologic
    • Autonomic dysfunction from alteration of sodium and calcium ion transport
    • Spastic paralysis
    • Headache, agitation, and neuropsychiatric disturbances
    • Ataxia
    • Cerebral edema
    • Seizures
    • Stupor or coma
  • Gastrointestinal
    • Nausea and vomiting
    • Abdominal muscle rigidity and pain
    • Hypersalivation and dysphagia
    • Hepatic inflammatory necrosis from direct toxin injury to hepatocytes
    • Renal failure from toxin-induced glomerulonephritis or RBC hemolysis
  • Musculoskeletal
    • Incapacitating muscle spasm of limb and torso
    • Reactive arthritis
    • Rhabdomyolysis
  • Hematologic/immunologic
    • Hemolysis
    • Hypersensitive reaction (anaphylaxis is rare) to jellyfish venom
  • Long-term or delayed reactions
    • Keloids
    • Pigmented striae
    • Lichenification from persistent rubbing
    • Granuloma
    • Ulceration and necrosis
    • Gangrene
    • Fat atrophy
    • Scarring and contractures
    • Recurrent reactions without repeated exposure occurring at the original sting site secondary to sequestered, intracutaneous, antigen-induced, immunologic reaction (may be more severe than original reaction)
• Specific jellyfish envenomations
• • Seabather eruption
    • Intensely pruritic eruption develops under swimwear, occurring minutes to 12 hours after exposure to the larvae of the thimble jellyfish (Linuche unguiculata).
    • Itching is worse at night and tends to prevent the patient from sleeping.
    • Erythematous macules and papules last for 2-14 days and resolve spontaneously.
• Irukandji syndrome
  • Delayed, severe, systemic symptoms occur 10-40 minutes (mean of 30 min) after the initial sting by Carukia barnesi. The latent period results from traveling of the venom in the lymphatic system into the central circulatory system.
  • The sting frequently is not visible or may resemble small insect bites.
  • Systemic symptoms mimic an autonomic-excess picture, with abdominal muscle rigidity, vomiting, profuse sweating, and excessive shaking. This is followed by pyrexia, tachyarrhythmias, hypertensive crisis, and hyperkinetic cardiogenic shock with pulmonary edema and elevated troponin I levels and echocardiographic ventricular dysfunction.
• Box jellyfish envenomation
  • Pathognomonic frosted-looking lesions develop in a transverse crosshatched pattern 8-10 mm wide. Secondary blistering occurs.
  • Lesions occur within 6 hours of the sting and superficial ulceration or necrosis follows in another 12-18 hours.
  • Immediate, intense, localized pain occurs with incapacitating muscular spasm resulting in death by drowning.
  • The pain and spasms spread centrally as the venom travels to the central circulatory system, inducing parasympathetic overstimulation and respiratory-cardiac arrest. Most fatalities occur within 20 minutes of the envenomation; according to animal studies, approximately 5-10 mcg/kg of venom is required to induce cardiac arrest.

Causes

• Injury occurs as a result of accidental exposure to jellyfish tentacles. Jellyfish move slowly and are nonaggressive.
• Bathers, waders, and divers are at risk of contacting these creatures in seawater with strong currents or poor visibility.
• The curious are at risk because of careless or unknowledgeable handling of jellyfish.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Anaphylaxis
Decompression sickness if victim has been stung during a dive
Echinoderm envenomations
Poison ivy, poison oak, or poison sumac dermatitis
Stingray envenomation

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Order a CBC count to evaluate toxin-induced hemolysis.
• Order electrolyte levels, BUN/creatine ratio, and glucose levels to determine if an abnormality is present that can worsen the toxin-induced muscular paresis.
• Order liver function tests, which are elevated because of toxin-induced liver inflammation.
• Order creatine phosphokinase levels and urinalysis to evaluate rhabdomyolysis.
• While knowledge of location, time, and resulting skin pattern of the encounter may aid clinical identification of the envenoming jellyfish species, true identification is made only by actual visualization of the jellyfish, by microscopic examination of the nematocysts, or by serologic testing.

Imaging Studies

• Radiographs for traces of foreign material introduced via envenomation, especially for imbedded fire corals
• Angiography for venom-induced arterial vessel thrombosis

Other Tests

• Slitlamp examination is performed to detect nematocysts attached to the cornea.
• ECG is performed because the venom may be toxic to the Purkinje fiber.
• Electromyelogram is performed to delineate the amount of diminished nerve conduction velocity induced via the venom on the nerve.
• Radioallergosorbent test is used to detect specific IgG or immunoglobulin E (IgE) antibody titers against the jellyfish.
• • The more severely envenomated the patient, the higher the titers. Elevated titers may persist for several years.
  • Elevated IgE titers tend to cause subsequent attacks to be more severe because the patient is in a hypersensitive state. Elevated IgG titers tend to render subsequent attacks less severe.
  • A titer greater than 1 in 50 provides serologic identification of a jellyfish species and may exhibit serologic cross-reactivity to other jellyfish species.

Procedures

• Nematocyst identification
• • Sticky tape method: Microscopic examination of transparent tape that has been pressed against the sting site where the nematocysts are located is performed. This method does not distort the nematocysts morphologically, but it cannot serve as a permanent microscopic record.
  • Superficial skin keratin-scraping method: Scraping of the sting site is performed, followed by smearing of the scraped material onto a glass slide. This method yields a permanent record for microscopic identification of the jellyfish.

Histologic Findings

Acute skin reaction to jellyfish stings demonstrates discharged nematocysts in the stratum corneum, epidermis, or dermis, as well as demonstrating intracellular edema of the keratinocytes, extravasation of erythrocytes, and an interstitial infiltrate of neutrophils, eosinophils, and lymphocytes.

Skin biopsy of persistent lesions demonstrates a granulomatous infiltrate. Skin biopsy of recurrent eruptions demonstrates an abundance of helper T cells in the edematous perivascular dermis. The lymphocyte response to jellyfish venom is greater in patients with recurring lesions than in those without recurring lesions.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

The severity of injury directs treatment of envenomation. Treatment usually consists of (1) nematocyst deactivation, (2) pain control, (3) local wound care, (4) symptomatic treatment, (5) support of the vital organs in which function is affected, and (6) use of antivenin for box jellyfish envenomation. Capture of the responsible jellyfish should not be necessary because the nematocysts imbedded in the patient can be preserved and sent for identification. The examiner must be aware that stings can occur through surgical gloves.

• Local skin treatment involves immediate nematocyte inactivation, analgesia, and removal.
  • Rinse the wound with sterile normal saline to prevent nematocyte activation. Although seawater can be used as a last resort, it carries marine pathogens into the wound. Avoid using fresh water and rubbing the skin, since these activities trigger unfired nematocytes.
  • Soak the wound in 5% acetic acid for 15-30 minutes to further inhibit nematocyte discharge. Although acetic acid inhibits nematocytes, it does not provide pain relief. Other possible inhibitors include 70% isopropyl alcohol or the papain found in meat tenderizer to denature the proteinase toxins. Unfortunately, these other inhibitors have little effect on nonproteinaceous toxins.
  • After the inactivation, carefully remove any visible tentacles with forceps, followed by the removal of the nematocytes/nematocysts, as described in Surgical Care.
  • Apply topical anesthetics once the nematocytes/nematocysts are removed. Cold pack compresses at the sting site for 5-10 minutes relieve all but the most severe site pain. Avoid direct application of ice to the area, since the hypotonic water from the melting ice may stimulate unremovable, unfired nematocytes. Also, avoid hot compresses, since they increase systemic uptake of venom.
  • Administer antihistamines and topical and systemic corticosteroids for severe local reactions as well as to decrease the probability of serum sickness symptoms from the antivenin, provided no secondary concurrent infection is present.
  • Administer muscle relaxants (eg, benzodiazepine, methocarbamol) for severe local spasms.
  • Narcotic analgesias are appropriate for severe local pain not responding to topical anesthetics.
  • Administer a tetanus shot as a prophylactic measure.
  • Administer systemic antibiotics if signs of secondary infection exist.
• Systemic treatment
  • Remove patient from danger.
  • Remove patient from water to prevent drowning.
  • Monitor ABCs to provide adequate airway, ventilation, and perfusion.
  • Provide supportive care (eg, central venous monitoring, fluids, inotropic support, pressors for hypokinetic cardiac failure).
  • Immobilize and sedate the patient to prevent rapid absorption of venom resulting from muscle movement.
  • Apply a lymphatic-venous compression bandage proximally to the sting site to reduce venous and lymphatic flow of the venom but not to stop arterial flow. Usually, a range of 40-70 mmHg for the upper extremity and 55-70 mmHg for the lower extremity is used. Remove the bandaging only when the provider is ready to render systemic support and the antivenin has been initiated.
  • Antivenin for box jellyfish envenomation is obtained from the Commonwealth Serum Laboratory of Melbourne, Australia. The dose is 1 ampule IV over 5 minutes or 3 ampules IM with repeat doses administered according to clinical circumstances. Unfortunately, the antivenin is ineffective if the toxin already has entered a cell.
  • Anaphylaxis is rare, but can be treated with airway support, oxygen, intravascular resuscitation, epinephrine, H1 and H2 blockers, steroids, and a beta2-agonist nebulizer.
  • Treat catecholamine-excess hypertension with phentolamine.
  • Intraarterial urokinase has been anecdotally successful in the treatment of arterial vessel thrombosis-induced severe limb ischemia.
• Ophthalmic treatment
  • Nonaqueous topical anesthetic drops followed by copious irrigation with isotonic normal saline are used. Avoid acetic acid irrigation, since it causes more damage than the nematocysts.
  • Administer ophthalmic steroids to decrease the corneal inflammatory response.
  • Beta-blockers and carbonic-anhydrase inhibitors are used for documented increased intraocular pressure resulting from the corneal jellyfish sting.
• Experimental treatments
  • Monoclonal antibody against jellyfish toxin
  • Phototherapy of the sting site with ultraviolet light to suppress immune response resulting in chronic lesions
  • Verapamil adjunct to antivenin for decreasing venom-induced cardiotoxicity
  • Gadolinium for inhibiting nematocyte firing through blockade of the calcium-permeable mechanosensitive ion channels involved in nematocyte activation

Surgical Care

• Once the nematocytes are inactivated, they can be removed by dusting the area with a paste of shaving cream, baking soda, and talc for 1 hour to coalesce the nematocyte, followed by scraping the area with a dull object (eg, spoon). Strong adhesive tape applied to the area and then removed also can be used.
• Clean ulcerating lesions 3 times per day, followed by application of antibiotic ointment (eg, erythromycin) effective against potential marine pathogens.

Consultations

• Poison control centers or national aquariums may provide guidance in treating jellyfish envenomation.
• Antivenom index published by the American Zoo and Aquarium Association lists the location, amount, and types of antivenom stores.
• Marine biologists may be consulted for nematocyst identification.

Activity

Rest and immobilization of the sting site is recommended to prevent rapid absorption of the venom into the circulation.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goal of pharmacotherapy is to reduce morbidity and to prevent complications.

Drug Category: Antivenins

Used to neutralize box jellyfish toxin. Skin testing prior to administration of the antivenin is not recommended because it delays treatment for this lethal venom. Pretreatment of victim with antihistamine and steroid prior to administering antivenom is recommended. Antivenin efficacy is based on the rate of changing severity of systemic symptoms.

Drug Category: Corticosteroids

Administered as pretreatment for antivenin; also act to stabilize lymphocytes, to reduce release of endogenous vasoactive compounds, and to lessen delayed tissue reactions to jellyfish antigens. Topical anti-inflammatory agents may be used to treat acute local reactions to jellyfish stings via decreasing PMN migration, reducing capillary permeability.

Drug Category: Antihistamines

H1 and H2 blockers can be administered as premedication for antivenom.

Drug Category: Immunizations

Tetanus booster in previously immunized individuals is recommended. Patients who have not been immunized previously against tetanus should receive tetanus immune globulin.

Drug Category: Local anesthetics

Decrease pain at sting site.

Drug Category: Benzodiazepines

Used to sedate the patient and decrease envenomation-induced muscle spasms.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Inpatient care is dictated by the severity of the envenomation and consists of stabilizing the patient, neutralizing the venom, providing supportive care, and preventing complications.
• Treat all patients with severe systemic symptoms in an ICU setting because of the potentially serious nature of the envenomation and the risks associated with antivenin administration.

Further Outpatient Care

• Warn patients that recurrent episodes of urticaria may occur without reexposure for up to 4 weeks at the site of envenomation.
• Warn patients who received antivenin of the symptoms of serum sickness, and instruct them to seek prompt medical care if symptoms occur.
• Patients who are asymptomatic or have only minor localized reactions after 4-hour observation, as well as normal vital signs and laboratory results, are unlikely to have suffered a significant envenomation and may be safely discharged with close follow-up monitoring. If the sting site was treated with a pressure bandage, symptoms may be delayed and inpatient observation is warranted.
• Provide medical follow-up observation of the sting site for wound infection and local wound care instructions.

Transfer

• Transfer is appropriate if antivenin administration or ICU treatments are not available at the institution at which the patient initially presents.

Deterrence/Prevention

• Advise patients to wear a physical barrier between tentacles and skin.
• • Wet suits, Lycra suits, and body stockings
  • Gloves and face masks
• Advise patients to swim only on patrolled beaches and within special barriers that keep jellyfish out. More importantly, they should remain out of the water when jellyfish warnings are posted.
• • Advise patients to learn the risk seasons and locations.
  • Advise patient to beware of on-shore winds or strong currents that make avoiding jellyfish difficult.
• Advise patients to avoid touching beached jellyfish tentacles.
• Advise patients to carry vinegar in known jellyfish areas.
• An experimental jellyfish sting inhibitor lotion applied prophylactically in 12 volunteers (who were subsequently exposed to a jellyfish sting) has been shown to reduce the erythema and pain associated with the jellyfish sting. A double-blinded, randomized, placebo-controlled study showed that the topical sting inhibitor results in a relative risk reduction of 82%.

Complications

• Secondary wound infection, especially with marine pathogens, may occur. Although infection is uncommon, if it occurs, it carries significant morbidity because of injury location and infecting agents in the marine environment. Staphylococci and streptococci are common pathogens, but the following marine pathogens also must be considered:
  • Vibrio (vulnificus, parahaemolyticus) species cause necrotizing fasciitis, myositis, gas gangrene, and sepsis with a 20-50% mortality rate. Infection with Vibrio species can be treated with a third-generation cephalosporin, aminoglycoside, or fluoroquinolones.
  • Aeromonas hydrophilia can cause a clostridial-like gangrene and can be treated with antibiotics used for Vibrio species.
  • Mycobacterium marinum causes a chronic suppurative and granulomatous reaction at the sting site. Treatment options for M marinum include minocycline, Bactrim, rifampin, ethambutol, or clarithromycin. Surgical debridement may be necessary. Dissemination is rare except in patients who are immunocompromised; however, lesions may progress to ulceration and lymphangitic spread simulating sporotrichosis.
• Anaphylactic shock may occur.
• Serum sickness may occur 5 days to 3 weeks after antivenin administration.

Prognosis

• Prognosis is excellent with the exception of box jellyfish envenomation. Box jellyfish venom can circulate in the body in as little as 30 seconds; therefore, it may be unlikely that antivenin can be administered quickly enough to benefit the victim.

Patient Education

• Educate all patients on avoiding jellyfish.
• Advise patients to wear a physical barrier between tentacles and skin, including wet and Lycra suits, body stockings, gloves, and masks.
• Advise patients to swim only on patrolled beaches and within special barriers that keep jellyfish out. More importantly, they should remain out of the water when jellyfish warnings are posted. Patients should learn the risk seasons and locations.
• Advise patient to beware of on-shore winds or strong currents that make avoiding jellyfish difficult and to avoid touching the tentacles of beached jellyfish.
• Advise patients to carry vinegar in known jellyfish areas.
• For excellent patient education resources, visit eMedicine's Bites and Stings Center, Infections Center, and Environmental Exposures and Injuries Center. Also, see eMedicine's patient education articles Jellyfish Stings, Tetanus, The Bends - Decompressions Syndromes, and Stingray Injury.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to stabilize vital signs prior to specific interventions directed against the venom
• Failure to treat patients adequately as a result of underestimating the effects of envenomation
• Failure to advise patients with Irukandji syndrome against reentering the water during the latent period of the disease
• Failure to admit patients for systemic symptoms
• Failure to avoid use of fresh water irrigation for local skin treatment and failure to avoid use of acetic acid irrigation for ophthalmic jellyfish injury
• Failure to warn patients of potential complications and failure to arrange follow-up observation
• Failure to administer tetanus prophylaxis

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Boulware DR. A randomized, controlled field trial for the prevention of jellyfish stings with a topical sting inhibitor. J Travel Med. May-Jun 2006;13(3):166-71. [Medline].
• Burnett JW. Clinical manifestations of jellyfish envenomation. Hydrobiologia. 1991;216/217:629-35.
• Burnett JW, Calton GJ. Response of the box-jellyfish (Chironex fleckeri) cardiotoxin to intravenous administration of verapamil. Med J Aust. Aug 20 1983;2(4):192-4. [Medline].
• Burnett JW, Calton GJ, Burnett HW. Jellyfish envenomation syndromes. J Am Acad Dermatol. Jan 1986;14(1):100-6. [Medline].
• Burnett JW, Weinrich D, Williamson JA, et al. Autonomic neurotoxicity of jellyfish and marine animal venoms. Clin Auton Res. Apr 1998;8(2):125-30. [Medline].
• Burnett JW, Bloom DA, Imafuku S, et al. Coelenterate venom research 1991-1995: clinical, chemical and immunological aspects. Toxicon. Nov-Dec 1996;34(11-12):1377-83. [Medline].
• Burnett JW, Calton GJ, Fenner PJ, Williamson JA. Serological diagnosis of jellyfish envenomations. Comp Biochem Physiol C. 1988;91(1):79-83. [Medline].
• Burnett JW. Human injuries following jellyfish stings. Md Med J. Jun 1992;41(6):509-13. [Medline].
• Currie BJ. Marine antivenoms. J Toxicol Clin Toxicol. 2003;41(3):301-8. [Medline].
• Currie BJ, Jacups SP. Prospective study of Chironex fleckeri and other box jellyfish stings in the "Top End" of Australia's Northern Territory. Med J Aust. Dec 5-19 2005;183(11-12):631-6. [Medline].
• Edmonds C. Dangerous Marine Creatures: Field Guide for Medical Treatment. 2nd ed. Flagstaff, Ariz: Best Publishing; 1995.
• Fenner PJ, Williamson JA, Burnett JW, Rifkin J. First aid treatment of jellyfish stings in Australia. Response to a newly differentiated species. Med J Aust. Apr 5 1993;158(7):498-501. [Medline].
• Fenner PJ, Williamson JA. Worldwide deaths and severe envenomation from jellyfish stings. Med J Aust. Dec 2-16 1996;165(11-12):658-61. [Medline].
• Fisher AA. Toxic versus allergic reactions to jellyfish. Cutis. Nov 1984;34(5):450-4. [Medline].
• Forrester MB. Epidemiology of jellyfish stings reported to poison centers in Texas. Hum Exp Toxicol. Apr 2006;25(4):183-6. [Medline].
• Glasser DB, Noell MJ, Burnett JW, et al. Ocular jellyfish stings. Ophthalmology. Sep 1992;99(9):1414-8. [Medline].
• Halstead BW. Coelenterate (cnidarian) stings and wounds. Clin Dermatol. Jul-Sep 1987;5(3):8-13. [Medline].
• Hessinger HA. Nematocyst venoms and toxins. In: Biology of Nematocysts. San Diego, Calif: Academic Press; 1988:. 333-69.
• Holstein T, Tardent P. An ultrahigh-speed analysis of exocytosis: nematocyst discharge. Science. Feb 24 1984;223(4638):830-3. [Medline].
• Huynh TT, Seymour J, Pereira P, et al. Severity of Irukandji syndrome and nematocyst identification from skin scrapings. Med J Aust. Jan 6 2003;178(1):38-41. [Medline].
• Kimball AB, Arambula KZ, Stauffer AR, et al. Efficacy of a jellyfish sting inhibitor in preventing jellyfish stings in normal volunteers. Wilderness Environ Med. 2004;15(2):102-8. [Medline].
• Letot B, Pierard-Franchimont C, Pierard GE. Acute reactions to coelenterates. Dermatologica. 1990;180(4):224-7. [Medline].
• Macrokanis CJ, Hall NL, Mein JK. Irukandji syndrome in northern Western Australia: an emerging health problem. Med J Aust. Dec 6-20 2004;181(11-12):699-702. [Medline].
• Mansson T, Randle HW, Mandojana RM, et al. Recurrent cutaneous jellyfish eruptions without envenomation. Acta Derm Venereol. 1985;65(1):72-5. [Medline].
• Noguchi K, Sakanashi M, Matsuzaki T, et al. Cardiovascular effects and lethality of venom from nematocysts of the box-jellyfish Chiropsalmus quadrigatus (Habu-kurage) in anaesthetized rats. Toxicon. Mar 15 2005;45(4):519-26. [Medline].
• O''Donnell BF, Tan CY. Persistent contact dermatitis from jellyfish sting. Contact Dermatitis. Feb 1993;28(2):112-3. [Medline].
• Ohtaki N, Oka K, Sugimoto A, et al. Cutaneous reactions caused by experimental exposure to jellyfish, Carybdea rastonii. J Dermatol. Feb 1990;17(2):108-14. [Medline].
• Reed KM, Bronstein BR, Baden HP. Delayed and persistent cutaneous reactions to coelenterates. J Am Acad Dermatol. Mar 1984;10(3):462-6. [Medline].
• Salleo A, La Spada G, Barbera R. Gadolinium is a powerful blocker of the activation of nematocytes of Pelagia noctiluca. J Exp Biol. Feb 1994;187:201-6. [Medline].
• Strutton G, Lumley J. Cutaneous light microscopic and ultrastructural changes in a fatal case of jellyfish envenomation. J Cutan Pathol. Aug 1988;15(4):249-55. [Medline].
• Tu A. Handbook of Natural Toxins: Marine Toxins and Venoms. New York, NY: Marcel Dekker; 1988:. 279-326; 493-566.
• Williamson JA, Fenner PJ, Rifkin JF, Burnett J. Venomous and Poisonous Marine Animals: A Medical and Biological Handbook. International Specialized Book Services;1996:120-310.
• Wong DE, Meinking TL, Rosen LB, et al. Seabather''s eruption. Clinical, histologic, and immunologic features. J Am Acad Dermatol. Mar 1994;30(3):399-406. [Medline].

Article Last Updated: Feb 21, 2007