Image of the Day 35: Jellyfish Sting

16 years old boy presented to casualty after alleged stung by jelly fish at his left leg while swimming in Lahad Datu Coast. However, the exact species that stung him was unknown but he describes it as red colored jellyfish. There were no sign and symptoms of anaphylaxis.

On examination, vital sign were stable. On inspection of the left lower limb, there were deep red tentacle lashes marks surrounded by area of erythematous and swollen leg. On palpation, it was warm and tender. Both DPA/PTA pulses were palpable.

He was treated with IV Tramadol 50 mg, IV Maxolon 10 mg and covered for allergic reaction with IV Hydrocortisone 200 mg and IV Piriton 10 mg and discharged after un eventful six hours of observation.

Deep red tentacle lashes marks surrounded by area of erythematous and swollen leg

Discussion

Jellyfish are non vertebrae, free swimming aquatic organism, mostly marine with gelatinous body structure, long trailing tentacles and classed under the phylum Cnidaria. They are defined by the specialized cells called cnidocytes used for capturing prey. They have being roaming in marine world for more than 500 millions year, making them the oldest multi organ animal. Even so, their organ system is very simple and less developed.

Cnidaria was further classified into sessile Anthozoa, and swimming Scyphozoa (true jellyfish), Cuboza (box jellies), Hydrozoa and Staurozoa (stalked jellyfish).

Most of the jellyfish are harmless, but some of them may cause local and systemic envenomation. Local response typically involving local pain or itchiness while systematically, it will trigger anaphylactic reaction or triggering cardiac arrest due to very potent venom.

Among the species, box jellyfish are known for its venomous sting. Irukandji syndrome after sting by Irukandji jellyfish like Carukia barnesi (Australia cost) and Malo kingi (Port Douglas, Queensland) may cause severe intense pain, sudden surge of blood pressure and cardiac arrest within 20 minutes of envenomation, possibly due to sudden release of catecholamine.  Apart from that, other species that can cause Irukandji syndrome includes Carukia shinju, Carybdea xaymacana, Malo maxima, Alatina mordens, Gerongia rifkinae, and Morbakka fenneri

Fenner & Haddock (2002) reported a case of 58 year old male tourist who died of Irukandji syndrome in which he initially develop muscle cramps, sweating, anxiety, hypertension and later develop intracerebral hemorrhage after 30 hours.

Chironex fleckeri is another lethal type of box jellyfish which causing rapid cardio respiratory depression.

Venomous jellyfish usually found in Australian Coast, South Africa, New Zealand, Japan, California and Mediterranean. However, they are more and more reported case of box jellyfish stung in Thailand, Indonesia and Philippines.

In Malaysia, most of the jellyfish are not highly dangerous but they are some under reported case of box jellyfish sting in west coast Malaysia. The theory behind why these venomous jellyfish starts to invade Malaysia Coast is believed due to transportation through ballast tank ship.

Deposition of nematocyst tubules that is covered by mineralized chitinous spines in the skin will release the venom. This venom contains potent proteinaceous porins (cellular membrane pore-forming toxins), neurotoxic peptides, bioactive lipids and small molecule that will activate local reaction, toxinological responses and immunological responses. Among the reaction includes;

1. Direct stimulation of the pain receptors at skin by venom porin, secretagogues bioactive small molecules,

2. Modulation of neuronal sodium channels leading to surging release of catecholamine, causing the sympathetic storm and acute heart failure.

3. CrTX-A and CrTX-B toxins of Carybdea rastoni may cause less severe reaction as they are large protein.

4. Formation of pore to cell membrane causing leakage of potassium and causing cardiac arrhythmia due to hyperkalaemia.

5. Activation of mast cell that will

      a) Release histamine, leukotrienes, prostaglandins and Nerve Growth Factor (NGF) causing pruritus and pain.

     b) Release cytokines, chemokines, leukotrianes, prostaglandin and vasoactants causing vasodilation and leukocyte recruitment.

     c) Inflammation

6. Activation of necrosis receptors by dendritic cells due to effect of tubular structural antigens

7. Sustained activation of innate immunological pro inflammatory cells, dendritic cells, macrophage and mast cells by chitinous spines and tubule collagen.

The aim of management in dealing with jellyfish sting are alleviating the local effect of venom, preventing further nematocyst discharge and controlling systemic reaction including anaphylaxis, shock and catecholamine surge. However lack of evidence based management in managing this condition due to no establish randomized control trials.

Old practice like urinating on the affected part of body is not of evidence based practice and cannot be proved its effectiveness. 

Hot water and ice packs are affective for pain management but in some cases, patient may require topical or intravenous pain killers.

Using vinegar may help in preventing the further discharge of unfired nematocyst but the exact mechanism of action is unknown and it’s not working on all species of jellyfish. Applying Alcohol methylated spirit, fresh water and pressure bandage should be avoided as they may trigger the release of nematocyst.

Intravenously-administered phentolamine, an alpha-adrenergic receptor blocking drug has been shown to be beneficial in controlling hypertension and reducing excessive sweating and tremors in Irukandji syndrome. Diazepam may help in alleviating anxiety.

The role of anti histamine and steroids remain debatable especially in managing Irukandji syndrome. However, based on the pathogenesis of the toxin, it can be applied as part of management.

Supportive treatment for cardio and respiratory depression with balance of hydration, nutrition, pain management, blunting the catecholamine effect and anaphylaxis control should be institutes in severe envenomation.

Reference:

1. Bailey PM, Little M, Jelinek GA, Wilce JA, "Jellyfish envenoming syndromes: unknown toxic mechanisms and unproven therapies.", Med J Aust. 2003 Jan 6;178(1):34-7.

2. Cegolon L, Heymann WC, Lange JH, Mastrangelo G, "Jellyfish stings and their management: a review", Mar Drugs. 2013 Feb 22;11(2):523-50. doi: 10.3390/md11020523.

3. Fenner PJ, Hadok JC, "Fatal envenomation by jellyfish causing Irukandji syndrome.", Med J Aust. 2002 Oct 7;177(7):362-3.

4. Tibballs J, "Australian venomous jellyfish, envenomation syndromes, toxins and therapy", Toxicon. 2006 Dec 1;48(7):830-59. Epub 2006 Jul 15.

5. Tibballs J, Li R, Tibballs HA, Gershwin LA, Winkel KD, "Australian carybdeid jellyfish causing "Irukandji syndrome", Toxicon. 2012 May;59(6):617-25. doi: 10.1016/j.toxicon.2012.01.006. Epub 2012 Feb 14.

6. Tibballs J, Yanagihara AA, Turner HC, Winkel K, "Immunological and toxinological responses to jellyfish stings", Inflamm Allergy Drug Targets. 2011 Oct;10(5):438-46.