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ECHINODERM POISONING

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Starfish and sea urchins belong to the animal phylum Echinodermata. These marine animals are characterized by a calcareous skeleton and plates which form a thick body wall and are covered with spines, spicules, or pedicellariae, all of which may be venomous.

Specific Substances

    A) STARFISH
    1) Acanthaster planci (Crown of thorns starfish)
    2) Aphelasteria japonica
    3) Asterias amurensis
    4) Fish poisoning, starfish
    5) Pycnopodia helianthoides
    6) Asterina pectinifera
    7) Astropecten scoparus
    8) Solaster papposus
    9) Crossaster papposus
    10) Marthasterias glacialis
    11) Astropecten polyacanthus
    12) Astropecten latespinosus
    13) Asteroidea
    14) Asteroid
    15) Sea Stars
    16) Starfish poisoning
    SEA URCHIN
    1) Diadema setosum (black sea urchin)
    2) Paracentrotus lividus
    3) Toxopneustes pileolus
    4) Strongylocentrotus purpuratus
    5) Diadema antillarum (brown sea urchin)

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) TOPIC DESCRIPTION: Echinoderms are marine animals; the phylum includes starfish, sea urchins, sand dollars, and sea cucumbers. They are native to the ocean and are sometimes kept as pets in tropical aquariums. Some species (eg, sea cucumbers) are consumed as a food product.
    B) TOXICOLOGY: ACANTHASTER PLANCI: A venomous starfish; the venom includes histamine-like compounds (saponins) that can cause increased vascular permeability and, at high doses, have produced skin necrosis in rat models. Other components (ie, plancinin) demonstrated anticoagulant effects when given IV, but not orally or subcutaneously. The lethal factor is a basic glycoprotein isolated from the venom that can cause flaccidness, numbness, occasional seizures, hepatotoxicity, and gallbladder swelling. Venom B fraction can cause uterine contraction and enhanced vascular permeability through prostaglandin-mediated effects. OTHER ECHINODERM SPECIES: Little is known about the toxicologic mechanism of action. Extracts from multiple species have also shown cardioinhibitor effects on oyster hearts, but the relationship to human toxicity is unknown. Different asterosaponins of other species have been found to have a wide range of toxicities including hemolytic properties (asterotoxin), steroidal glycoside effects, cytotoxicity to lymphocytes and erythrocytes, neuromuscular blocking activity, anti-inflammatory, analgesic, hypotensive activity, and immobilization of sperm. Tetrodotoxin has been found in some Japanese starfish (Astropecten polyacanthus and Astropecten latespinosus). Refer to TETRODOTOXIN management for further information.
    C) EPIDEMIOLOGY: STARFISH: Found throughout the world's oceans anywhere from low tide line to depths of several thousand feet. Acanthaster planci is located on coral reefs in Australia, Eastern Pacific (Galapagos Islands to the Gulf of California), Hawaii, Indo-Pacific region, and Japan. SEA URCHINS: Commonly inhabit all oceans both in shallow and deep waters. The black sea urchin (Diadema setosum) is found in the Indo-Pacific area from Polynesia to east Africa, Bonin islands, China, and Japan. Paracentrotus lividus inhabits the Atlantic coast of Europe from Ireland to west Africa, the Azors, the Canary Islands, Madeira, and the Mediterranean.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Burning pain occurs immediately following envenomation. It usually resolves within an hour with starfish envenomation, but can last up to a month with sea urchin envenomation. Other effects that may develop following envenomation include dyspnea, vertigo, weakness, paresthesia, prolonged numbness (up to 24 to 48 hours) at the envenomation site, lassitude, muscle spasm, nausea and vomiting, allergic dermatitis, liver enzyme elevation, bleeding and secondary infections from puncture sites, edema and erythema around spine punctures, and foreign body reactions. There have been case reports of delayed hypersensitivity reactions after sea urchin envenomation, and synovitis, arthritis, fasciitis, and bursitis have been reported following injury from sea urchin spines.
    2) SEVERE TOXICITY: Lip/mouth edema, hypotension, respiratory distress, eosinophilic pneumonia, paralysis, and anaphylaxis are infrequently associated with echinoderm envenomation.
    0.2.20) REPRODUCTIVE
    A) At the time of this review, no data were available to assess the teratogenic potential of this agent.
    0.2.21) CARCINOGENICITY
    A) At the time of this review, no data were available to assess the carcinogenic potential of this agent.

Laboratory Monitoring

    A) No serum or blood abnormalities have been noted following stings from Acanthaster planci in humans. If bleeding from the wound(s) persists, monitor the PT, PTT, INR as necessary.
    B) Monitor liver enzymes as indicated. Elevated liver enzymes have been reported following echinoderm envenomation.
    C) Monitor serum electrolytes in patients with significant vomiting.
    D) Soft-tissue radiographs may or may not identify retained spines.

Treatment Overview

    0.4.4) EYE EXPOSURE
    A) Remove contact lenses and irrigate exposed eye with copious amounts of room temperature water or 0.9% saline for a minimum of 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist beyond 15 minutes of irrigation, the patient should be seen in a healthcare facility. Fluorescein staining and slit lamp examination should be done to assess for corneal laceration or ulceration.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) Remove contaminated clothing and jewelry and place in plastic bags. Wash exposed areas thoroughly with soap and water for 10 to 15 minutes. Avoid vigorous scrubbing. Remove all foreign material as it can serve as a nidus for infection. Steroid creams or antihistamines can be used by individuals with sensitivity to starfish slime or sea urchin spines.
    0.4.7) BITES/STINGS
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Treatment is symptomatic and supportive. Treat nausea/vomiting with antiemetics and correct any significant fluid and/or electrolyte abnormalities as needed. Assess for retained spines. Provide adequate pain control and wound care to prevent secondary infection. Immerse the sting in water heated to 113 degrees F (45 degrees C), making sure to not further injure the patient, and administer narcotic or non-narcotic analgesics as necessary; assess need for tetanus prophylaxis.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Treatment is symptomatic and supportive. In patients with acute allergic reaction, oxygen therapy, bronchodilators, diphenhydramine, corticosteroids, vasopressors and epinephrine may be required. Intubate and ventilate patients with respiratory arrest or significant paralysis. Treat hypotension with isotonic fluid boluses and vasopressors agents when refractory.
    C) DECONTAMINATION
    1) PREHOSPITAL: Effects generally develop after dermal contact. Gastrointestinal decontamination is not likely to be necessary. Rinse mouth and dilute with 4 to 8 ounces of milk or water if irritation develops after ingestion. If starfish is contaminated with tetrodotoxin and is ingested, emesis should not be induced. Refer to TETRODOTOXIN management for further information.
    2) HOSPITAL: Effects generally develop after dermal contact. Gastrointestinal decontamination is not likely to be necessary. Rinse mouth and dilute with 4 to 8 ounces of milk or water if irritation develops after ingestion. If starfish is contaminated with tetrodotoxin and is ingested, consider activated charcoal if the overdose is recent, the patient is not vomiting, and is able to maintain airway. Refer to TETRODOTOXIN management for further information.
    D) AIRWAY MANAGEMENT
    1) Provide supplemental oxygen if warranted. Consider intubation if there is airway compromise or paralysis of respiratory muscles.
    E) ANTIDOTE
    1) none
    F) ENHANCED ELIMINATION
    1) It is unlikely that a patient would require enhanced elimination after exposure to echinoderms.
    G) PATIENT DISPOSITION
    1) HOME CRITERIA: A patient with an inadvertent exposure, that remains asymptomatic can be managed at home.
    2) OBSERVATION CRITERIA: Multiple puncture wounds, excessive bleeding, persistent pain, or vomiting may require evaluation in a health care facility. Evaluation for retained spines may be necessary. Soft tissue radiographs may or may not demonstrate radiopaque foreign material. Limited wound exploration may be necessary to locate and remove large pieces of retained spines.
    3) ADMISSION CRITERIA: Patients who remain symptomatic despite treatment should be admitted.
    4) CONSULT CRITERIA: Consult a regional poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.
    H) PITFALLS
    1) Inadequate exploration of the wound, failure to provide tetanus prophylaxis.
    I) DIFFERENTIAL DIAGNOSIS
    1) Sea snake envenomation, jelly fish envenomation, spiny fish (eg, stonefish, lionfish) envenomation, stingray injury or dinoflagellate poisoning.

Range Of Toxicity

    A) TOXICITY: Stings from Acanthaster planci may cause significant pain and discomfort. At least 10 puncture wounds in the hand of one patient from Acanthaster planci caused pain, bleeding, dermatitis, nausea, weakness, vertigo, and paresthesia of the fingertip. The patient recovered with supportive care.

Clinical Effects

Summary Of Exposure

    A) TOPIC DESCRIPTION: Echinoderms are marine animals; the phylum includes starfish, sea urchins, sand dollars, and sea cucumbers. They are native to the ocean and are sometimes kept as pets in tropical aquariums. Some species (eg, sea cucumbers) are consumed as a food product.
    B) TOXICOLOGY: ACANTHASTER PLANCI: A venomous starfish; the venom includes histamine-like compounds (saponins) that can cause increased vascular permeability and, at high doses, have produced skin necrosis in rat models. Other components (ie, plancinin) demonstrated anticoagulant effects when given IV, but not orally or subcutaneously. The lethal factor is a basic glycoprotein isolated from the venom that can cause flaccidness, numbness, occasional seizures, hepatotoxicity, and gallbladder swelling. Venom B fraction can cause uterine contraction and enhanced vascular permeability through prostaglandin-mediated effects. OTHER ECHINODERM SPECIES: Little is known about the toxicologic mechanism of action. Extracts from multiple species have also shown cardioinhibitor effects on oyster hearts, but the relationship to human toxicity is unknown. Different asterosaponins of other species have been found to have a wide range of toxicities including hemolytic properties (asterotoxin), steroidal glycoside effects, cytotoxicity to lymphocytes and erythrocytes, neuromuscular blocking activity, anti-inflammatory, analgesic, hypotensive activity, and immobilization of sperm. Tetrodotoxin has been found in some Japanese starfish (Astropecten polyacanthus and Astropecten latespinosus). Refer to TETRODOTOXIN management for further information.
    C) EPIDEMIOLOGY: STARFISH: Found throughout the world's oceans anywhere from low tide line to depths of several thousand feet. Acanthaster planci is located on coral reefs in Australia, Eastern Pacific (Galapagos Islands to the Gulf of California), Hawaii, Indo-Pacific region, and Japan. SEA URCHINS: Commonly inhabit all oceans both in shallow and deep waters. The black sea urchin (Diadema setosum) is found in the Indo-Pacific area from Polynesia to east Africa, Bonin islands, China, and Japan. Paracentrotus lividus inhabits the Atlantic coast of Europe from Ireland to west Africa, the Azors, the Canary Islands, Madeira, and the Mediterranean.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Burning pain occurs immediately following envenomation. It usually resolves within an hour with starfish envenomation, but can last up to a month with sea urchin envenomation. Other effects that may develop following envenomation include dyspnea, vertigo, weakness, paresthesia, prolonged numbness (up to 24 to 48 hours) at the envenomation site, lassitude, muscle spasm, nausea and vomiting, allergic dermatitis, liver enzyme elevation, bleeding and secondary infections from puncture sites, edema and erythema around spine punctures, and foreign body reactions. There have been case reports of delayed hypersensitivity reactions after sea urchin envenomation, and synovitis, arthritis, fasciitis, and bursitis have been reported following injury from sea urchin spines.
    2) SEVERE TOXICITY: Lip/mouth edema, hypotension, respiratory distress, eosinophilic pneumonia, paralysis, and anaphylaxis are infrequently associated with echinoderm envenomation.

Heent

    3.4.2) HEAD
    A) WITH POISONING/EXPOSURE
    1) LIP EDEMA: The slime found on Marthasterias glacialis may cause swelling on contact with the mouth and lips (Halstead, 1978).

Cardiovascular

    3.5.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) HYPOTENSIVE EPISODE
    a) Hypotension was reported in rat and dog studies following intravenous administration of the crude venom extracted from the spines of Acanthaster planci (Shiroma et al, 1994; Yara et al, 1992).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) DYSPNEA
    1) WITH POISONING/EXPOSURE
    a) Respiratory distress has been reported following multiple puncture wounds of Acanthaster planci (Auerbach, 1991) and is an uncommon systemic effect following an injury from a sea urchin (Baden, 1987).
    B) ALLERGIC PNEUMONIA
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 21-year-old man presented to the emergency department with a fever, headache, dyspnea and cough after stepping on a black sea urchin 3 days prior to presentation. Physical examination showed diffuse rhonchi, respiratory distress, and areas of black tattooing on the plantar surface of his foot indicative of recent contact with a sea urchin. Bronchoscopy confirmed eosinophilia pneumonia. The patient developed increased respiratory distress requiring intubation. Following administration of broad-spectrum antibiotics and corticosteroids, the patient gradually improved over the next 10 days and was discharged on hospital day 13 (Kucewicz et al, 2001).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) DIZZINESS
    1) WITH POISONING/EXPOSURE
    a) Vertigo and weakness were reported in an adult who was stung on the hand (Klaassen et al, 1986).
    B) PARESTHESIA
    1) WITH POISONING/EXPOSURE
    a) Paresthesias and tingling of the finger tips was noted in an adult who had at least 10 puncture wounds on the hand (Klaassen et al, 1986). Prolonged numbness at the sting site may occur (Personal Communication, 1987).
    b) Paresthesias are an uncommon systemic effect following a sea urchin envenomation (Baden, 1987).
    C) PARALYSIS
    1) WITH POISONING/EXPOSURE
    a) Muscular paralysis is a possible effect after multiple stings from Acanthaster planci (Auerbach & Gheer, 1989; Halstead, 1980) Fish & Cobb, 1954).
    b) Paralysis of the facial muscles, tongue and eyelids have been reported following sea urchin envenomation and may persist up to 4 to 6 hours (Mebs, 1995; Auerbach, 1988).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) NAUSEA AND VOMITING
    1) WITH POISONING/EXPOSURE
    a) Nausea and vomiting may be seen after the sting of Acanthaster planci (Lin et al, 2008; Halstead, 1980). Vomiting may occur approximately 1 hour after injury and occur every 3 to 4 hours for 2 to 4 days (Edmonds, 1978; Sutherland, 1983; Barnes & Endean, 1964; Lin et al, 2008).
    b) Nausea is an uncommon systemic effect following a sea urchin envenomation (Baden, 1987).

Hepatic

    3.9.2) CLINICAL EFFECTS
    A) LIVER FUNCTION TESTS ABNORMAL
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Elevated liver enzyme levels were reported in a 47-year-old woman who stepped on a sea urchin with both feet. It is believed that the sea urchin may have been Diadema setosum, the long-spined or black sea urchin (Wu et al, 2003).
    b) CASE REPORT: A 19-year-old girl inadvertently stepped on an A. planci starfish resulting in several spines puncturing her right foot and toes. She experienced immediate pain, and 24 hours following envenomation she developed abdominal pain with nausea and vomiting. Two days after the incident, the patient presented to a US hospital, and initial examination revealed erythema and edema of the right foot. Laboratory results showed elevated liver transaminases (AST 231 Units/L and ALT 449 Units/L). Surgical debridement was performed and deemed successful except for a few thin spines too small for removal; the patient continued follow-up with her primary physician. Liver function tests did not normalize until day 25 following envenomation (16 days post-debridement). The authors speculate the ongoing systemic toxicity and delay in normalization of the patient's liver enzymes to be due to venom of the remaining embedded spines (Lin et al, 2008).

Hematologic

    3.13.2) CLINICAL EFFECTS
    A) HEMORRHAGE
    1) WITH POISONING/EXPOSURE
    a) Puncture wounds from Acanthaster planci bleed freely (Auerbach, 1991; Odom & Fischerman, 1972). The venom contains anticoagulants including the peptide plancinin (Karasudani et al, 1996).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) PAIN
    1) WITH POISONING/EXPOSURE
    a) Stings from Acanthaster planci cause immediate and intense pain. The pain may be a burning sensation or a dull ache. Most pain resolves within hours of the puncture , but the site may remain tender. Erythema and edema may extend for several centimeters from the site of the wound. Numbness, secondary to edema, resolves over 24 to 48 hours (Odom & Fischerman, 1972; Halstead, 1980).
    b) CASE REPORT: A 47-year-old woman experienced faintness and intense pain after stepping on a sea urchin with both feet. She subsequently developed fever, chills, nausea, and persistent serous discharge and tenderness from the affected site. Physical examination showed multiple puncture wounds over both soles, edema and erythema of the right sole and right lower leg, and lymphadenopathy of the right inguinal area. Laboratory analysis revealed elevated liver enzyme levels. The patient gradually recovered following administration of antibiotics and wound debridement (Wu et al, 2003). It is believed that the sea urchin may have been Diadema setosum, the long-spined or black sea urchin.
    c) Burning pain may immediately occur upon dermal contact with sea urchin spines (Burnett & Burnett, 1999). The pain may persist for several hours to months(Burnett et al, 1986).
    d) An observational study, involving 314 patients who received injuries from black sea urchins over a 2-year-period (2009 to 2010), revealed that the primary symptom, occurring in all patients, was pain but it was only perceived with pressure on the exposed area (ie, penetration of spines). Spontaneous intense pain was negligible, occurring in less than 1% of cases. Examination, performed up to 6 hours after exposure, revealed no inflammation at the site of envenomation; however, 72 hours post-exposure showed slight inflammation with erythema. Inflammation appeared to be more prevalent with associated edema in approximately 5% of patients (Haddad, 2012).
    B) DERMATITIS
    1) WITH POISONING/EXPOSURE
    a) Sensitive individuals may develop dermatitis from the slime that covers the starfish (Halstead, 1980). Pruritic rashes have been seen due to the slime of other species including Marthasterias glacialis (Halstead, 1978; Buckley & Porges, 1956).
    b) A pruritic papulourticarial rash may develop after contact with water containing a large number of starfish because toxic substances exuded from the starfish diffuses into the water (Fisher, 1978). Local edema and pruritus may persist for weeks in individuals previously sensitized to Acanthaster planci (Auerbach & Gheer, 1989).
    c) Scratch testing of human skin using the spines or application of the slime using a sterile needle did not produce dermal reactions (Odom & Fischerman, 1972).
    d) CASE REPORT: A 33-year-old woman was stung on her right leg by a sea urchin and, approximately 2 weeks later, developed a pruritic eruption consisting of multiple grouped vesicles, at the site of penetration. The lesion resolved after administration of oral and topical corticosteroids. It is believed that the patient may have become sensitized at the time of injury and subsequently reacted to residual antigens in the skin resulting in a delayed hypersensitivity reaction (Burke et al, 1986).
    e) CASE REPORT: A 28-year-old woman presented with erythema and pruritus of her knees and right ankle approximately 2 months after having been stung by a member of the Diadema species of sea urchin. Immediately after contact with the sea urchin, the patient experienced painful redness and tenderness at the wounded site (her knees and right ankle). Approximately 10 days later, the areas became erythematous and pruritic, which continued until presentation. A radiograph of the affected areas was negative for any embedded radiopaque foreign materials. The patient recovered following topical application of corticosteroids to the affected areas. Patch testing, using Diadema spines, was positive.
    1) It is believed that the patient experienced a delayed hypersensitivity reaction following contact with the sea urchin spines. It is suspected that the patient was sensitized at the time of injury and subsequently developed a reaction to the residual antigens in her skin (Asada et al, 1990).
    C) GRANULOMA
    1) WITH POISONING/EXPOSURE
    a) Granulomatous lesions may develop if spines are retained (Burnett et al, 1986; Auerbach & Gheer, 1989).
    b) Granulomas of the nail apparatus occurred in two patients (the toenail in one patient and the fingernail of the other patient) following injuries from sea urchin spines. Surgical removal of the embedded spines resulted in permanent nail deformities in both patients (Haneke et al, 1996).
    D) DISCOLORATION OF SKIN
    1) WITH POISONING/EXPOSURE
    a) Small areas of black discoloration and edema occurred at the point of contact, in a 12-year-old boy, following dermal contact with urchin spines (Burnett & Burnett, 1999). The black color results from the pigment present in the black-colored species of sea urchins (Baden, 1987).

Musculoskeletal

    3.15.2) CLINICAL EFFECTS
    A) SYNOVITIS
    1) WITH POISONING/EXPOSURE
    a) Synovitis, arthritis, fasciitis, and bursitis have been reported following injuries from sea urchin spines. It is speculated that the proteinaceous covering of the sea urchin spines may be immunologically reactive and contributing to the development of the synovitis and arthritis(Liram et al, 2000; Guyot-Drouot et al, 2000; McHugh & Tweed, 1984).
    b) CASE REPORT: A 55-year-old woman developed stiffness and swelling of her ring finger and middle fingers of her right hand after receiving several sea urchin stings during a diving trip in Kenya. According to hand radiographs and an ultrasound, there were no bony abnormalities or foreign bodies. An MRI demonstrated tenosynovitis of the right flexor tendons of the ring and middle fingers. The patient recovered with supportive therapy (Woo & Lee, 2012).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) LYMPHADENOPATHY
    1) WITH POISONING/EXPOSURE
    a) Lymphadenopathy may occur following multiple puncture wounds of the Acanthaster planci (Auerbach & Gheer, 1989) and was reported in a 47-year-old woman who stepped on a sea urchin believed to be Diadema setosum, the long-spined or black sea urchin (Wu et al, 2003).
    B) HYPERSENSITIVITY REACTION
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 28-year-old woman presented with erythema and pruritus of her knees and right ankle approximately 2 months after having been stung by a member of the Diadema species of sea urchin. Immediately after contact with the sea urchin, the patient experienced painful redness and tenderness at the wounded site (her knees and right ankle). Approximately 10 days later, the areas became erythematous and pruritic, which continued until presentation. A radiograph of the affected areas was negative for any embedded radiopaque foreign materials. The patient recovered following topical application of corticosteroids to the affected areas. Patch testing, using Diadema spines, was positive.
    1) It is believed that the patient experienced a delayed hypersensitivity reaction following contact with the sea urchin spines. It is suspected that the patient was sensitized at the time of injury and subsequently developed a reaction to the residual antigens in her skin (Asada et al, 1990).
    b) CASE REPORT: A 33-year-old woman was stung on her right leg by a sea urchin and, approximately 2 weeks later, developed a pruritic eruption consisting of multiple grouped vesicles, at the site of penetration. The lesion resolved after administration of oral and topical corticosteroids. It is believed that the patient may have become sensitized at the time of injury and subsequently reacted to residual antigens in the skin resulting in a delayed hypersensitivity reaction (Burke et al, 1986).
    C) ANAPHYLAXIS
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: An adult woman, in her 40s, developed anaphylaxis and died 13 hours after being stung on her right middle finger by a crown-of-thorns starfish (Acanthaster planci). Medical history of the patient revealed that she had previously been stung 5 times by a crown-of-thorns starfish with the most recent envenomation, prior to the fatal incident, causing facial swelling and redness. Autopsy of the patient showed severe swelling and discoloration at the site of envenomation, as well as swelling of the right arm. There was also severe edema of the laryngopharynx, causing narrowing of the airway, and severe edema and congestion of the lungs with accumulation of a large amount of pleural effusion and ascites fluid. Microscopic examination of the liver indicated diffuse hepatocellular necrosis. Microscopic examination of the lungs revealed alveolar hemorrhage, and eosinophilic infiltration and aggregation in the intravascular lumen and around the bronchus. Laboratory data at admission and at autopsy revealed severe hemolysis, elevated liver transaminase concentrations, and elevated histamine concentrations (1030 ng/mL; normal, 0.15 to 1.23 ng/mL) (Ihama et al, 2014).

Reproductive

    3.20.1) SUMMARY
    A) At the time of this review, no data were available to assess the teratogenic potential of this agent.

Carcinogenicity

    3.21.2) SUMMARY/HUMAN
    A) At the time of this review, no data were available to assess the carcinogenic potential of this agent.

Genotoxicity

    A) At the time of this review, no data were available to assess the mutagenic or genotoxic potential of this agent.

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) No serum or blood abnormalities have been noted following stings from Acanthaster planci in humans. If bleeding from the wound(s) persists, monitor the PT, PTT, INR as necessary.
    B) Monitor liver enzymes as indicated. Elevated liver enzymes have been reported following echinoderm envenomation.
    C) Monitor serum electrolytes in patients with significant vomiting.
    D) Soft-tissue radiographs may or may not identify retained spines.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) No abnormalities have been noted. Hepatotoxicity has been reported in experimental animals, and two cases of elevated liver enzyme concentrations have been reported following a human envenomation. Monitoring of hepatic function may be indicated following multiple puncture wounds from echinoderms, including Acanthaster planci and sea urchins (Lin et al, 2008; Wu et al, 2003).
    2) Monitor serum electrolytes in patients with significant vomiting.
    B) COAGULATION STUDIES
    1) If bleeding from the wound persists, monitor the PT, INR, PTT as necessary.

Radiographic Studies

    A) RADIOGRAPHIC STUDIES
    1) Soft tissue radiographs may help identify retained spines in wounds due to contact with starfish or sea urchins (Auerbach, 1991; Newmeyer, 1988).

Methods

    A) OTHER
    1) Although methods are available for determination of both starfish saponins and tetrodotoxin, these are not generally available in hospital practice.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.6) DISPOSITION/BITE-STING EXPOSURE
    6.3.6.1) ADMISSION CRITERIA/BITE-STING
    A) Patients who remain symptomatic despite treatment should be admitted.
    6.3.6.2) HOME CRITERIA/BITE-STING
    A) A patient with an inadvertent exposure, that remains asymptomatic can be managed at home.
    6.3.6.3) CONSULT CRITERIA/BITE-STING
    A) Consult a regional poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.
    6.3.6.5) OBSERVATION CRITERIA/BITE-STING
    A) Most stings or puncture wounds from Acanthaster planci or sea urchins produce self-limiting symptoms. Multiple puncture wounds, excessive bleeding, persistent pain, or vomiting may require evaluation in a health care facility. Evaluation for retained spines may be necessary. X-rays may demonstrate radiopaque foreign material, but may not. Limited wound exploration may be necessary to locate and remove large pieces of retained spines (Mebs, 1995; Auerbach, 1991).

Monitoring

    A) No serum or blood abnormalities have been noted following stings from Acanthaster planci in humans. If bleeding from the wound(s) persists, monitor the PT, PTT, INR as necessary.
    B) Monitor liver enzymes as indicated. Elevated liver enzymes have been reported following echinoderm envenomation.
    C) Monitor serum electrolytes in patients with significant vomiting.
    D) Soft-tissue radiographs may or may not identify retained spines.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) ORAL
    1) Effects generally develop after dermal contact. Gastrointestinal decontamination is not likely to be necessary. Rinse the mouth and dilute with 4 to 8 ounces of milk or water if irritation develops after ingestion. If starfish is contaminated with tetrodotoxin and is ingested, emesis should not be induced. Refer to TETRODOTOXIN management for further information.
    B) DERMAL
    1) Remove contaminated clothing and jewelry and place in plastic bags. Wash exposed areas thoroughly with soap and water for 15 minutes. Avoid vigorous scrubbing. Remove all foreign material as it can serve as a nidus for infection.
    C) EYE
    1) Remove contact lenses and irrigate exposed eye with copious amounts of room temperature water or 0.9% saline for a minimum of 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist beyond 15 minutes of irrigation, the patient should be seen in a healthcare facility.
    6.5.2) PREVENTION OF ABSORPTION
    A) SUMMARY
    1) Effects generally develop after dermal contact. Gastrointestinal decontamination is not likely to be necessary. Rinse the mouth and dilute with 4 to 8 ounces of milk or water if irritation develops after ingestion. If starfish is contaminated with tetrodotoxin and is ingested, consider activated charcoal if the overdose is recent, the patient is not vomiting, and is able to maintain airway. Refer to TETRODOTOXIN management for further information.
    B) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.3) TREATMENT
    A) SUPPORT
    1) Treatment should include recommendations listed in the BITES/STINGS EXPOSURE section when appropriate.

Eye Exposure

    6.8.1) DECONTAMINATION
    A) Symptoms from eye exposure have not been reported. Standard decontamination should be done after contact with starfish slime.
    B) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).
    C) Fluorescein staining and slit lamp examination should be performed to evaluate possible retained foreign material. The presence of any retained foreign material should prompt an ophthalmologic evaluation.

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) DERMAL DECONTAMINATION
    1) DECONTAMINATION: Remove contaminated clothing and wash exposed area thoroughly with soap and water for 10 to 15 minutes. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
    6.9.2) TREATMENT
    A) SUPPORT
    1) Steroid creams or antihistamines can be used by individuals with sensitivity to starfish slime or sea urchin spines.
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Enhanced Elimination

    A) LACK OF INFORMATION
    1) It is unlikely that a patient would require enhanced elimination after exposure to echinoderms.

Abstracts

Case Reports

    A) ADULT
    1) Russell, in Klaassen et al (1986), describes a sting from Acanthaster planci.
    2) A student fell on the starfish producing at least 10 puncture wounds in his left hand, which bled profusely. Within 20 minutes the individual had intense pain over the palm, pain up the volar aspect of the forearm, nausea, weakness, vertigo and fingertip tingling. The patient was treated with a mixture of cold water and vinegar applied topically. The pain and nausea subsided within 15 minutes. The patient vomited 5 minutes later, after receiving an injection of 100 mg of meperidine. The cause of the vomiting was uncertain.
    3) The patient was hospitalized and treated with cold vinegar/water and occasional aluminum acetate soaks for the next 48 hours. Several broken spines had to be removed surgically.
    4) Burning and itching developed 4 days after the sting. The left palm was scaly and erythematous. The individual was treated with systemic steroids. The dermatitis cleared within 6 days (Klaassen et al, 1986).

Range Of Toxicity

Summary

    A) TOXICITY: Stings from Acanthaster planci may cause significant pain and discomfort. At least 10 puncture wounds in the hand of one patient from Acanthaster planci caused pain, bleeding, dermatitis, nausea, weakness, vertigo, and paresthesia of the fingertip. The patient recovered with supportive care.

Minimum Lethal Exposure

    A) CASE REPORT: An adult woman, in her 40s, developed anaphylaxis and died 13 hours after being stung on her right middle finger by a crown-of-thorns starfish (Acanthaster planci). Medical history of the patient revealed that she had previously been stung 5 times by a crown-of-thorns starfish with the most recent envenomation, prior to the fatal incident, causing facial swelling and redness. Autopsy of the patient showed severe swelling and discoloration at the site of envenomation, as well as swelling of the right arm. There was also severe edema of the laryngopharynx, causing narrowing of the airway, and severe edema and congestion of the lungs with accumulation of a large amount of pleural effusion and ascites fluid. Microscopic examination of the liver indicated diffuse hepatocellular necrosis. Microscopic examination of the lungs revealed alveolar hemorrhage, and eosinophilic infiltration and aggregation in the intravascular lumen and around the bronchus. Laboratory data at admission and at autopsy revealed severe hemolysis, elevated liver transaminase concentrations, and elevated histamine concentrations (1030 ng/mL; normal, 0.15 to 1.23 ng/mL) (Ihama et al, 2014).

Maximum Tolerated Exposure

    A) SUMMARY
    1) Stings from Acanthaster planci may be painful, and can cause significant symptoms. At least 10 puncture wounds in the hand of one patient from Acanthaster planci caused pain, bleeding, dermatitis, nausea, weakness, vertigo, and paresthesia of the fingertip. The patient recovered with supportive care (Klaassen et al, 1986).
    2) TETRODOTOXIN: Some starfish have been shown to contain tetrodotoxin. Astropecten polyacanthus has been specifically named (Mosher & Fuhrman, 1984).

Pharmacology Toxicology

Toxicologic Mechanism

    A) Acanthester planci -
    1) Crude extracts of the venom from A. planci given intravenously produced systemic and pulmonary hypotension in dogs which returned to baseline within 60 minutes of administration (Shiroma et al, 1994). Thrombocytopenia and leukopenia also developed (Shiroma et al, 1994; Yara et al, 1992). Writhing responses, hemolysis and dose related increases in capillary permeability have also been reported. Intradermal injection of high doses produced central necrosis in rat skin. The inflammatory effects may be partially medicated by histamine (Everitt & Jurevics, 1973; Heiskanen et al, 1973).
    2) The venom of Acanthaster planci contains saponins, histamine-like compounds and hemolytic and anticoagulants.
    3) Plancinin is an anticoagulant factor has been isolated. It demonstrates greater anticoagulant activity when compared to heparin. In mice, prolongation of bleeding time was dose related and only occurred when plancinin was given IV, not PO or subcutaneously (Karasudani et al, 1996).
    4) Lethal factor is a basic glycoprotein that has been isolated. When administered via intraperitoneal injection to mice caused flaccidness, numbness and occasional seizures. Hepatotoxicity, including increases in liver function tests, swelling of the gall bladder and discoloration of the liver was noted in mice given lethal factor (Shironu, 1990; (Shiomi et al, 1988).
    5) The venom B fraction caused contraction so the rat uterus and enhanced vascular permeability when administered to rabbits. These effects were mediated, in part, by prostaglandins (Karasudani et al, 1996).
    B) OTHER SPECIES
    1) Little is known of the toxicologic mechanism of action. Cats who have eaten species have developed ataxia and seizures prior to death (Parker, 1881). Extracts prepared from the alimentary tissues of Aphelasteria japonica, Asterias amurensis and Astropecten scoparius (Japanese starfish) have been shown to have a cardioinhibitor effect on oyster hearts. The relationship to human toxicity is unknown.
    2) A 1960 study by Hashimoto and Yasumoto found that the asterotoxin found in Asterina pectinifera to be a saponin with strong hemolytic properties. Zollo et al (1986) also demonstrated a steroidal glycoside saponin in Pentaceraster alveolatus. Owellen et al (1973) also found a saponin in Asterias vulgaris which had cytotoxic effects on both lymphocytes and erythrocytes. Hashimoto & Yasumoto developed an isolation technique to aid in identifying the saponin and found 2 distinct fractions, one of which resembled halothurin (found in sea cucumbers) (Hashimoto & Yasumoto, 1960; Zollo et al, 1986; Owellen et al, 1973).
    3) Tetrodotoxin has been proven to exist in some Japanese starfishes (Astropecten polyacanthus and Astropecten latespinosus) (Noguchi et al, 1982; Maruyama et al, 1984).
    4) Biologic activities of asterosaponins include a hemolytic activity toward erythrocytes, cytotoxicity; neuromuscular blocking activity, anti-inflammatory, analgesic and hypotensive activity, and immobilization of sperm (Fusetani et al, 1984).
    5) A lethal factor is a basic glycoprotein with an approximate molecular weight of 20,000 (Shiomi et al, 1988). Experimentally it produces hemolytic activity and edema secondary to capillary permeability-increasing activities.

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