Cnidaria Envenomation Clinical Presentation

  • Author: G Patrick Daubert, MD; Chief Editor: Scott H Plantz, MD, FAAEM   more...
 
Updated: Apr 29, 2010
 

History

  • Envenomations usually result in 3 main types of mechanisms: immediate allergic, immediate toxic, and delayed allergic response.
  • Obtain the following information regarding the envenomation:
    • Time of envenomation
    • Nature of incident - Geographic location, quality of symptoms, progression of symptoms
    • Description of animal
  • Toxicity depends on the following:
    • Age of patient
    • Underlying health of patient (especially those with hepatic disease)
    • Potency of venom
    • Number of nematocysts triggered
    • Amount of skin involved
  • Look for envenomation lesions in patients with unexplained near drowning or collapse in water.
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Physical

  • Chironex fleckeri is the most toxic jellyfish in the world. However, most encounters appear to result in mild envenoming. Stings from small C fleckeri are incapable of penetrating adult skin but may cause papular-urticarial eruptions in infants and small children. Stings from larger animals can be severe.
    • Patients initially develop severe pain despite removal of the tentacle. Tentacle marks are purple to brown and may resemble that made by a whip. Areas rapidly develop erythema, edema, and vesicles and may go on to full-thickness necrosis over the next 1-2 weeks. Death is probable if the total length of the wheals is greater than 6-7 meters.
    • Initial systemic reactions include headache, malaise, fever, nausea, vomiting, muscle spasm, pallor, respiratory distress, hemolysis, and acute renal failure.
    • Death may be rapid (minutes) and is often the result of combined cardiovascular and respiratory arrest. In northern Australia, 67 deaths have been reported as a result of C fleckeri envenomings. Deaths can also occur by drowning secondary to incapacitation following painful envenomations.
  • Irukandji syndrome is most likely due to encounters with Carukia barnesi, although other jellyfish may also be responsible. It derives its names from the Aboriginal tribe that formerly inhabited the areas in and around Cairns.
    • The initial sting from C barnesi is often mild to moderately painful but well tolerated. Approximately 30 minutes after envenomation (range, 5 min to 2 h) patients develop severe low back pain, cramping abdominal pain, nausea, vomiting, profuse sweating, headache, restlessness, agitation, tachycardia, and hypertension.
    • Severe toxicity may involve pulmonary edema and cardiac failure. Although the systemic reaction can be significant, the envenomation site frequently is not visible.
  • In regards to most jellyfish encounters, the most common presentation is a painful papular-urticarial eruption at the site of contact. Lesions can last for minutes to hours, and the rash may progress to urticaria. Further progression can lead to vesicular, hemorrhage, or necrotizing lesions. "Sea lice" or seabather's eruption affects covered areas of the body and is a result of trapped larvae of certain thimble jellyfish. The severely pruritic urticarial lesions can last up to 2 weeks.
    • Uncommon local reactions include angioedema, recurrent reactions, contact dermatitis, and papular urticaria.
    • Systemic reactions can develop along with local cutaneous findings including weakness, headache, nausea, vomiting, muscle spasm, fever, pallor, syncope, respiratory distress, and paresthesias.
    • Ocular contact has resulted in conjunctivitis, chemosis, corneal ulcerations, and lid edema.
    • Immediate and delayed hypersensitivity reactions may occur, but anaphylaxis is rare.
    • Chronic reactions include keloids, granulomas, hyperpigmentations, fatty atrophy, contractions, and vascular spasms.
    • Ingestion of jellyfish has resulted in abdominal pain, cramping, and generalized urticaria.
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Causes

Contact with a Cnidaria is the cause of envenomation, although some patients have developed mild symptoms after ingestion of jellyfish.

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Contributor Information and Disclosures
Author

G Patrick Daubert, MD  Assistant Professor, Assistant Medical Director, Sacramento Division, California Poison Control System; Director of Clinical and Medical Toxicology Education, Department of Emergency Medicine, University of California, Davis Medical Center

G Patrick Daubert, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Dana A Stearns, MD  Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital

Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

A Antoine Kazzi, MD  Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon

A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Scott H Plantz, MD, FAAEM  Associate Clinical Professor of Emergency Medicine, Rosalind Franklin University of Medicine and Science, Chicago Medical School; Medical Director, WeCare Med, Inc

Scott H Plantz, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

References

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Cnidaria and jellyfish envenomations. Close-up photograph of sea anemone demonstrating tentacles surrounding the central mouth structure. Contact with tentacles results in discharge of nematocysts. Photo courtesy of Scott A. Gallagher, MD.
Cnidaria and jellyfish envenomations. Close-up photograph of a sea anemone demonstrating one of several tentacle types observed among different species. Photo courtesy of Scott A. Gallagher, MD.
 
 
 
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