Lionfish and Stonefish Envenomation Clinical Presentation

Updated: Oct 25, 2021
  • Author: Scott A Gallagher, MD, FACEP; Chief Editor: Joe Alcock, MD, MS  more...
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Immediately excruciating and incapacitating localized pain follows a sting from members of the Synanceia (stonefish) genus.

This pain may spread to involve the entire limb and regional lymph nodes, peaking at around 60-90 minutes and lasting up to 12 hours if untreated.

Mild subsequent pain may persist for days to weeks.

Less severe, although extremely painful, symptoms are seen following envenomation with members of the Scorpaena (scorpionfish) and Pterois (lionfish) genera.


Physical Examination

The severity of envenomation depends upon multiple factors including the offending species, the number of stings, and the age and underlying health of the victim. Scorpaenidae stings are progressively more severe from Pterois (lionfish) to Scorpaena (scorpionfish) to Synanceia (stonefish).

Puncture wound

See the image below.

A 45-year-old diver was taking photographs in Aust A 45-year-old diver was taking photographs in Australia at a depth of 60 feet. He suddenly noticed an excruciating pain in his left foot after resting his foot on a large stonefish. Photo courtesy John Williamson, MD and Surf Lifesaving Queensland.

Classic envenomation reveals one or more puncture wounds, each discolored by a surrounding ring of bluish cyanotic tissue.

Subsequent edema, erythema, and warmth may involve the entire limb, although it rarely results in tissue necrosis in the absence of secondary infection (in marked contrast to stingray envenomation injuries).

Vesicle formation, particularly of the hands, may be followed by rapid tissue sloughing, cellulitis, and surrounding hypesthesia.

Systemic effects may be present (eg, nausea, muscle weakness, dyspnea, hypotension).