eMedicine Specialties > Dermatology > Environmental

Cutaneous Manifestations Following Exposures to Marine Life

Author: Zoltan Trizna, MD, PhD, Private Practice
Contributor Information and Disclosures

Updated: Feb 20, 2009

Introduction

Background

Exposure to aquatic life encompasses a variety of clinical situations. Dermatologists usually encounter patients with erythema, blisters, wheals, edema, scars, pigmentary changes, and paresthesias. Whereas the circumstances under which they occur and the distribution of these injuries can be characteristic, most of these lesions are not specific.

Cutaneous exposure to marine life occurs not only in the water but also when encountering living or dead marine animals on the beach. Commercial and recreational activities (eg, commercial or recreational fishing, beach combing, snorkeling, scuba diving, fish processing) have their specific concerns. Note that exposure to aquatic life can accompany various hobbies (eg, the keeping of saltwater fish tanks) or merchandising activities (eg, sellers of fish tank equipment of tropical fish).^1,2 Exposure to freshwater life can also cause cutaneous injuries, sometimes manifesting with skin lesions similar to those caused by saltwater life.

Treatment of the severe acute sequelae of exposure to hazardous marine animals (eg, cardiorespiratory arrest, anaphylactic shock, bleeding) is in the realm of emergency medicine. This article focuses only on the cutaneous sequelae of exposure to aquatic life. Some first-aid measures are briefly mentioned. For further details, see the eMedicine Emergency Medicine section, for example, the following articles:

• Conidae
• Cnidaria Envenomation
• Lionfish and Stonefish
• Octopus Envenomation
• Stingray Envenomation

Pathophysiology

The injuries can be grouped into several general categories. Overlap can also occur (such as when an abrasion also allows a toxin into injured skin or when microbes are inoculated into a puncture wound). Some of the injuries may be accompanied by bleeding and/or functional impairment of the affected area (eg, after extensive exposure to jellyfish tentacles). Others, such as injuries followed by the exposure to venoms, can be very mild and self-limited but may also lead to fatal consequences.

• Mechanical injuries without infection: Wounds are caused by punctures (eg, sea urchin spine), bites (eg, octopus or fish), cuts (eg, coral), suction (eg, octopus), abrasions, and lacerations (eg, shells). In rare instances, the human body can sustain a fatal injury to a vital organ, as documented by the case of "Crocodile Hunter" Steve Irwin. A strange case of a catfish sting causing fatal myocardial perforation was also documented.³
• Mechanical injuries followed by infection: Wounds become secondarily infected by either debris or microscopic organisms found in the water. Improper wound care (eg, rinsing injuries with seawater possibly loaded with microorganisms) can be a source of wound infections. Inoculation of infectious agents can commonly occur with penetration injuries or lacerations caused by sea urchin spine, stingray, seal bite,⁴ or other bites (eg, octopus, fish). Depending on the depth of the inoculation and on the microorganisms inoculated, severe infections of the underlying tissues and structures can also occur. In addition to possibly evolving into severe systemic infection, such processes may lead to deformities and loss of function.
• Mechanical injuries accompanied by the inoculation of a venom or a substance with sensitizing properties (eg, from sea anemone, sponges, scorpionfish, stonefish, lionfish, or stingray): The most commonly encountered phylum in this regard is the Cnidaria. These are animals that exhibit radial symmetry. Their body walls contain a jellylike substance. This phylum includes fire corals, hydroids, Portuguese man-of-war, jellyfish, sea anemones, and true corals.
  • Almost all of these possess nematocysts, frequently on a tentacle. The nematocysts contain a toxin that is injected into the skin. The sequelae of envenomations depend on the species involved, the nature and quantity of the toxin, and the size of the injured person.
  • Cutaneous reactions can be immediate (eg, wheals, vesicles, bullae, angioedema) or delayed hypersensitivity reactions. Complications include pain, postinflammatory hyperpigmentation, scarring, and contractions.
  • Systemic reactions range from mild to severe (eg, cardiac arrest, anaphylactic shock).
  • Two species of box jellyfish around Queensland (Australia) are known to produce venom with hemolytic, dermatonecrotic, and cardiotoxic components.
• Cutaneous exposure to a dead animal or its parts (including tentacles drifted to beaches): The lesions can be similar to those described in the above categories.
• Invasion of the skin by organisms: Cercarial dermatitis (ie, clam digger's itch, swimmer's itch) is caused by Schistosoma organisms penetrating the unprotected skin.
• Pyodermas and infections of the eyes, ears, or the urogenital tract: These can occur after bathing in contaminated water (eg, in areas where domestic or agricultural sewage mixes with water otherwise used for recreational activities), even in the absence of preceding mechanical injury. Existing wounds can become readily infected.⁵
• Mixed or hard-to-classify manifestations: These include, for example, granulomatous processes that may actually be caused by a microorganism (eg, Mycobacterium marinum genome identified in some granulomas).

Frequency

United States

Geographic area, season, and type of activity affect the prevalence of these injuries. With the increase of worldwide traveling, dermatologists may encounter lesions that would otherwise be unknown in their local area.

Mortality/Morbidity

Mortality or morbidity depends on the nature and severity of the injury. Infection with Vibrio vulnificus in an immunocompromised host can lead to septicemia and death. Morbidity observed in dermatologic practice includes infection, pigmentary changes, scarring, severe deformities, and loss of function.

Race

Persons of any race can be affected.

Sex

Both sexes can be affected.

Age

People of any age can be affected.

Clinical

History

• Patients can usually recall the circumstances of the encounter and the immediate sequelae.
• The encounter is usually noted because of either sudden trauma or an immediate stinging or burning pain. Dermatitis accompanied by local pain or systemic symptoms usually follows.
• Recent travels and recreational activities are relevant.
• Ask about preexisting wounds, which can provide a portal of entry for infections.
• Some professions may ignore the risk of such infections.

Physical

• Examine location and characteristics of the affected areas.
  • Certain contacts result in typical patterns and distribution (such as contact with tentacles resulting in characteristic linear eruptions on unprotected skin, seabather's eruption occurring on areas covered by clothing).
  • Stingray injuries commonly affect the unprotected skin of the legs.
  • Fingers are common areas for bites or injury when touching a life form that releases a toxin or inoculates microbes into the skin.
  • Tips of sea urchin spines can break off and become embedded in the wound.
• Carefully explore wounds.
  • Look for penetrating injuries, especially over joints.
  • Assess the wounded area for the presence of cellulitis, lymphangitis, pyogenic infections, cyanosis, and necrosis.
• Some bacterial infections are typically observed on certain sites.
  • Erysipeloid, caused by Erysipelothrix rhusiopathiae, typically affects the hands of anglers, although a diffuse cutaneous form has been described. Infection with this organism has been associated with septicemia and endocarditis.⁶
• Vibrio vulnificus infection usually manifests on the lower extremities as hemorrhagic bullae progressing to ulceration and necrosis. It may also cause life-threatening sepsis.
• M marinum infections may show sporotrichoid spread on the hand, wrist, and arm.
• Venoms have rarely been described to cause injuries to other organs, such as acute renal failure.⁷
• Delayed-type skin lesions such as erythema nodosum can occasionally be observed.⁸

Causes

• Bites and suction, where the injury is primarily mechanical, are caused by octopus, fish (eg, moray eel, barracuda, triggerfish), sharks, mammals (eg, sea lion, seal), and turtles.
• Cuts, abrasions, lacerations, and punctures can be caused by any part of the animal that is sharp or pointed, including sea urchins, starfish, stingray, coral, barnacles, broken shells, cone shell, spines of fish fins (eg, surgeonfish, needlefish), and leeches. Inanimate objects can also cause these types of injuries.
• Contact with toxic substances, including stings and other mechanical injuries resulting in the transfer of a venom, can occur after contact with fire coral, sea cucumber, bristleworm, sea anemone, sponges, stonefish, lionfish, scorpionfish, zebrafish, turkeyfish, catfish, jellyfish, Portuguese man-of-war, cone shell, starfish, and sea snakes (after bites).
• Mechanical injuries can result in wounds inoculated with microorganisms during the injury or in the course of wound care.
• Preexisting wounds can provide a readily available portal of entry for marine microorganisms (eg, V vulnificus) even in the absence of fresh trauma.
• Irritant dermatitis attributed to algae has been described in anglers working with nets.
• Delayed systemic sensitization has rarely been documented, manifesting as conjunctivitis, rhinitis, and asthma in anglers exposed to dragnets accidentally collecting red soft corals⁹ and in a case of an angler using a marine worm as fishing bait.¹⁰

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