History

A detailed history is essential, when possible, to determine the time of the incident. A typical incident involves walking, swimming, and/or diving in temperate to tropical waters with accidental contact with a cone snail or incorrect handling of a hazardous specimen. If possible, the type of cone should be identified.

Symptoms include the following:

Sharp burning or stinging sensation at time of envenomation
Local numbness and paresthesias
Perioral paresthesias
Generalized paresthesias
Nausea
Blurred vision and diplopia
Malaise
Generalized weakness
Dysphagia
Areflexia
Aphonia
Paralysis
Apnea
Pruritus
Headache

Physical Examination

A patient with a cone snail envenomation may manifest an array of symptoms.

Vital signs should include pulse oximetry.

The envenomed area may become swollen and pale or cyanotic.

A pulmonary examination should assess for respiratory failure and/or respiratory arrest.

A cardiac examination should assess for ectopy and tachycardia.

A detailed neurologic examination should assess for the following:

Level of consciousness
Visual acuity
Motor examination
Deep tendon reflexes (decreased/absent)

Serial vital signs and cardiopulmonary and/or neurologic examination are imperative.

Differential Diagnoses

Lavergne V, Harliwong I, Jones A, et al. Optimizing deep-targeted proteotranscriptomic profiling reveals unexplored Conus toxin diversity and novel cysteine frameworks. Proceedings of the National Academy of Sciences of the United States of America. Available at http://www.pnas.org/content/112/29/E3782.full. July 6, 2015; Accessed: March 6, 2017.
Gorson J, Holford M. Small Packages, Big Returns: Uncovering the Venom Diversity of Small Invertebrate Conoidean Snails. Integr Comp Biol. 2016 Jul 1. [QxMD MEDLINE Link].
Puillandre N, Duda TF, Meyer C, Olivera BM, Bouchet P. One, four or 100 genera? A new classification of the cone snails. J Molluscan Stud. 2015 Feb. 81 (1):1-23. [QxMD MEDLINE Link].
Layer RT, Wagstaff JD, White HS. Conantokins: peptide antagonists of NMDA receptors. Curr Med Chem. 2004 Dec. 11 (23):3073-84. [QxMD MEDLINE Link].
Safavi-Hemami H, Gajewiak J, Karanth S, Robinson SD, Ueberheide B, Douglass AD, et al. Specialized insulin is used for chemical warfare by fish-hunting cone snails. Proc Natl Acad Sci U S A. 2015 Feb 10. 112 (6):1743-8. [QxMD MEDLINE Link].
Menting JG, Gajewiak J, MacRaild CA, Chou DH, Disotuar MM, Smith NA, et al. A minimized human insulin-receptor-binding motif revealed in a Conus geographus venom insulin. Nat Struct Mol Biol. 2016 Oct. 23 (10):916-920. [QxMD MEDLINE Link].
Dutertre S, Jin AH, Vetter I, Hamilton B, Sunagar K, Lavergne V, et al. Evolution of separate predation- and defence-evoked venoms in carnivorous cone snails. Nat Commun. 2014 Mar 24. 5:3521. [QxMD MEDLINE Link].
Kohn AJ. Human injuries and fatalities due to venomous marine snails of the family Conidae. Int J Clin Pharmacol Ther. 2016 Jul. 54 (7):524-38. [QxMD MEDLINE Link].
Halford ZA, Yu PY, Likeman RK, Hawley-Molloy JS, Thomas C, Bingham JP. Cone shell envenomation: epidemiology, pharmacology and medical care. Diving Hyperb Med. 2015 Sep. 45 (3):200-7. [QxMD MEDLINE Link].
Phuong MA, Mahardika GN. Targeted sequencing of venom genes from cone snail genomes improves understanding of conotoxin molecular evolution. Mol Biol Evol. 2018 Mar 5. [QxMD MEDLINE Link].
Hu H, Bandyopadhyay PK, Olivera BM, Yandell M. Elucidation of the molecular envenomation strategy of the cone snail Conus geographus through transcriptome sequencing of its venom duct. BMC Genomics. 2012 Jun 28. 13:284. [QxMD MEDLINE Link].
Yuan DD, Liu L, Shao XX, Peng C, Chi CW, Guo ZY. Isolation and cloning of a conotoxin with a novel cysteine pattern from Conus caracteristicus. Peptides. 2008 Sep. 29(9):1521-5. [QxMD MEDLINE Link].
Phuong MA, Mahardika GN, Alfaro ME. Dietary breadth is positively correlated with venom complexity in cone snails. BMC Genomics. 2016 May 26. 17:401. [QxMD MEDLINE Link].
Duda TF Jr. Differentiation of venoms of predatory marine gastropods: divergence of orthologous toxin genes of closely related Conus species with different dietary specializations. J Mol Evol. 2008 Sep. 67(3):315-21. [QxMD MEDLINE Link].
Han TS, Teichert RW, Olivera BM, Bulaj G. Conus venoms- a rich source of peptide-based therapeutics. Current Pharmaceutical Design. 2008. 14(24):2462-79. [QxMD MEDLINE Link].
Ekberg J, Craik DJ, Adams DJ. Conotoxin modulation of voltage-gated sodium channels. Int J Biochem Cell Biol. 2008. 40(11):2363-8. [QxMD MEDLINE Link].
Kapil S, Cooper JS. Toxicity, Cone Snails. 2018 Jan. [QxMD MEDLINE Link]. [Full Text].
Veraldi S, Violetti SA, Serini SM. Cutaneous abscess after Conus textile sting. J Travel Med. 2011 May-Jun. 18 (3):210-1. [QxMD MEDLINE Link].
Brown CK, Shepherd SM. Marine trauma, envenomations, and intoxications. Emerg Med Clin North Am. 1992 May. 10(2):385-408. [QxMD MEDLINE Link].

Media Gallery

Cone snail ingesting a small fish. Cone snails incapacitate their prey by injecting a cocktail of neurotoxins, which can be dangerous to humans. Courtesy of Wikimedia Commons and David Burdick.

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Author

David Vearrier, MD, MPH Professor of Emergency Medicine, Department of Emergency Medicine, University of Mississippi Medical Center

David Vearrier, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

James Steven Walker, DO, MS Clinical Professor of Surgery, Department of Surgery, University of Oklahoma College of Medicine

James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Samuel M Keim, MD, MS Professor and Chair, Department of Emergency Medicine, University of Arizona College of Medicine

Samuel M Keim, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM Professor of Emergency Medicine, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine; Medical Director, Fast Track, Department of Emergency Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

William H Shoff, MD, DTM&H Former Director, PENN Travel Medicine; Former Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Conidae Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

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