Cutaneous Manifestations Following Exposures to Marine Life

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, as shown below). Others, such as injuries followed by the exposure to venoms, can be very mild and self-limited but may also lead to fatal consequences.

Jellyfish stings. Courtesy of the Department of Dermatology, UTMB at Galveston, Texas.

Mechanical injuries without infection

Wounds are caused by punctures (eg, sea urchin spine, stingray barbs), 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.[9]

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,[10] 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.

The Irukandji syndrome is caused by a small amount of venom leading to severe muscle cramps, back pain, and systemic signs and symptoms, including psychological phenomena. The Irukandji jellyfish is very small (< 10 mm), but its tentacles can be 1 meter long. Whereas only a few fatal cases have been identified, the frequency and severity of jellyfish stings are significantly underestimated.[11] The length of the Irukandji season increased, but (possibly because of better beach management) the number of cases seems to decrease.[12] Underreporting of cases and very likely inconsistencies of classification can lead to difficulties in establishing effective and standard treatment.[13]

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.[14]

Mixed or hard-to-classify manifestations

These include granulomatous processes that may actually be caused by a microorganism (eg, Mycobacterium marinum genome identified in some granulomas).

Toxins of dinoflagellates and algae can cause contact dermatitis and conjunctivitis. Ingestion of fish containing ciguatoxin may cause severe neurological manifestations (known as ciguatera), but dermatitis and pruritus are also described. Ingestion of pufferfish meat containing a potent neurotoxin (tetrodotoxin) is frequently fatal.[15]

Inhalation of coral vapor was described in a case series, resulting in respiratory and other systemic manifestations.[16]

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 (see image below), cone shell, starfish, and sea snakes (after bites).

Envenomation caused by Portuguese-man-of-war. Courtesy of the Department of Dermatology, UTMB at Galveston, Texas.

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 corals[17] and in a case of an angler using a marine worm as fishing bait.[18]

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.

Predisposition to marine animal envenomation or injury is not limited by age, sex, or race.

Limited local reactions usually resolve without serious sequelae. Otherwise, prognosis depends on the extent of local and systemic reactions, such as cardiovascular collapse, or functional impairment of the limbs or other structures.

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.

Children and elderly patients may be extremely susceptible to exposure to venoms. Immunocompromised patients are more vulnerable to systemic infections and life-threatening sequelae.

Prevention is important. Instruct patients to protect against re-exposure. Avoid touching marine animals, including beached organisms or animal parts (eg, broken jellyfish tentacles). Use protective equipment such as specially designed gloves when cleaning fish, shellfish, or invertebrates. Wear a wet suit while surfing, snorkeling, or diving. Avoid areas with known high risk of exposure such as shallow coral reefs where sea urchins can dwell.

Other methods of avoiding marine life are specific to given geographic areas (eg, walking with a shuffle in shallow water where stingrays may be encountered) and to a particular commercial or recreational activity (eg, fish cleaning).

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.

Most of the cutaneous sequelae of aqueous exposure resolve without severe long-term problems. Pigmentary changes and scarring may occur. Functional limitation and disfigurement may be observed, and these can be treated (see Surgical Care). Delayed-type reactions may require treatment.

Patients are usually seen in the dermatologist's office several hours or days after the initial injury. By the time of this encounter, the patient might already have undergone emergency treatment, including the use of specific measures such as the use of antivenins.

Evaluate the nature of the initial lesion and ask patients to describe any first aid measures that have been applied.

If a foreign body is found or suspected, evaluate for deeper penetration. When in doubt, perform appropriate radiographic examinations. See Surgical Care for surgical evaluation. Remove the foreign body and close the wound if not infected. Consider using broad-spectrum oral antibiotics.

In case of erythema, vesiculation, or blistering, instruct the patient regarding appropriate care. Prevent secondary infection by meticulous wound care and by protecting denuded areas. Topical corticosteroids are beneficial in combating the local reactions. Systemic steroids may be indicated in severe cases.

Pain can be managed with analgetics selected according to severity of pain, pain tolerance of the patient, and other considerations (eg, age, presence of other medical problems).

Scars or keloids causing disfigurement or functional limitations may be treated surgically.

A case report described treatment of stonefish envenomation caused by cutting a stonefish during food preparation. The patient's hand was immersed in hot water and the signs and symptoms of the hand resolved within 18 hours.[19]   Similarly, in a case when a tourist stepped on a stonefish and parenteral and local anesthesia were ineffective, soaking the foot in hot water relieved the pain.[20]

Surgical care depends on the nature of the injury and the available level of medical care. In emergency situations, initiate first aid measures. Remember to exercise caution when removing animals or animal parts because these may still contain toxins or foreign bodies that can be harmful to both the patient and the physician.

First steps during acute care include controlling bleeding, cleaning the wound, removing visible foreign bodies (including sand), and covering with a (preferably sterile) dressing. Absorption of a toxin can be delayed by applying pressure over the wound and by placing elastic bandages approximately 15 cm (6 in) both distally and proximally of the wound. Check circulation periodically; arterial pulses should be detectable. In addition, immobilizing the patient or at least the affected area (eg, splinting the extremity, placing a sling) could help in delaying the absorption of the venom.

Stings can be neutralized by irrigation with vinegar, baking soda (paste prepared with water), salt water, or papain powder or solution (meat tenderizer). Remove tentacles only after adequate neutralization. Remove sea urchin spines if possible. Submerse the affected area in hot water (up to 45°C or 113°F), scrub with water and soap, and irrigate copiously with fresh water. Remove deeply lodged spines after careful evaluation. Hot water immersion has also been suggested for nonpenetrating marine envenomation.[21] Depending on the depth of the puncture wound, longer incubation times may be needed for the heat to penetrate the deeper portions of the skin to be effective in deactivation of the venom.[22]

Although vinegar completely inhibited cnidae firing under experimental conditions, newly developed proprietary formulations containing copper gluconate, magnesium sulfate, and urea seemed to be more effective to inhibit both tentacle firing and subsequent venom-induced hemolysis.[22]

Nematocysts can discharge their contents on exposure to fresh water; therefore, irrigation of the exposed areas with fresh water is contraindicated. For the same reason, be sure that melting ice, applied for local pain control, cannot irrigate the wound site before neutralization.

Assessing the need for further surgical care depends on the following:

• Foreign bodies remaining in the wound and how deeply they may be lodged: Ideally, all foreign bodies should be removed because they can cause further toxin release, infection, granuloma formation, and functional limitations.

• The presence of infection: In this case, obtain specimens for culturing. Initiate broad-spectrum antibiotic treatment and modify according to clinical response and culture results.

• Cyanosis or necrosis: Determine the cause and initiate appropriate management.

• Necessary debridement: Apply basic wound care measures as necessary.

• Scarring: Any scarring that would be functionally limiting or cosmetically unacceptable. Consider treatment with intralesional steroid injections or surgical reconstruction.

• Need for prosthetic replacement of a limb or its part: Subspecialty consultation may be appropriate.

Consult specialists as required by the type of injury or complication (eg, orthopedic surgeon in case of joint or bone involvement, plastic surgeon in cases of extensive scars, infectious diseases specialist for complicated primary or secondary infections).

Class Summary

Corticosteroids are used to alleviate local inflammation and accompanying pruritus or pain. Several topical steroids are available. Select the product according to the severity and location of the lesions. Triamcinolone is discussed only as a prototype.

Systemic steroids are used for the treatment of severe hypersensitivity reactions. They have anti-inflammatory effects and modify the immunologic responses. Exercise caution because of their metabolic effects. Prednisone is discussed as a prototype.

Triamcinolone topical (Aristocort)

Triamcinolone topical treats inflammatory dermatoses responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.

Prednisone (Deltasone)

Prednisone has anti-inflammatory properties. It must be metabolized to the active metabolite prednisolone for effect, and thus, its conversion may be impaired in liver disease.

Class Summary

Antibiotics are used for the prevention of infection (eg, patient experienced a penetrating injury, foreign body was inoculated into the wound) or for the treatment of a clinically apparent infection.

Initially, a broad-spectrum antibiotic should be selected. Penicillin G was once the drug of choice; however, it has fallen out of favor because of inactivity against penicillinase-producing bacteria, including many strains of staphylococci. Ideally, antibiotics should be selected after establishing the sensitivity of the microorganism.

For mycobacterial infections, the antibiotic treatment may be lengthy.

Ceftriaxone (Rocephin)

Ceftriaxone is a third-generation cephalosporin with broad-spectrum gram-negative activity, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. It arrests bacterial growth by binding to one or more penicillin-binding proteins.

Rifampin (Rifadin, Rimactane)

Rifampin is used primarily for the treatment of tuberculosis. It inhibits DNA-dependent bacterial but not mammalian RNA polymerase. It may be effective against aquatic M marinum. Additional medications can include co-trimoxazole, alone or combined with minocycline, clarithromycin, doxycycline, and ethambutol. Minocycline, doxycycline, or tetracycline as single agents have been used successfully to treat localized M marinum infections.

Trimethoprim and sulfamethoxazole (Bactrim DS, Septra DS, Cotrim)

Trimethoprim and sulfamethoxazole inhibits bacterial growth by inhibiting the synthesis of dihydrofolic acid. The antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa. It has been found to be effective in some nontuberculotic mycobacterial infections.

Minocycline (Dynacin, Minocin)

Minocycline treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma. It has been found to be effective in some nontuberculotic mycobacterial infections.