a) The most common syndrome is immediate pain followed by an erythematous urticarial eruption. Acute local effects may include pain, skin eruption, exaggerated local angioedema, and papular urticaria that becomes noticeable in 4 to 24 hours postexposure. Pruritus may also develop. Mild systemic effects such as weakness, vertigo, nausea, headache, pain and spasms in large muscle groups, arthralgia, lacrimation, and perspiration have been reported.

a) In very severe stings there may be difficulty breathing and pain on respiration, changes in the pulse rate, and severe muscle spasms. Hemolysis with secondary renal failure is very rare, but has been reported.
b) True anaphylactic reactions following jellyfish stings are becoming more common.
c) An "Irukandji syndrome" may occur following jellyfish envenomations which may consist of pain, which may be severe, typically starts in the lower back and may spread to the limbs, abdomen and chest. It may be accompanied by nausea, vomiting, diaphoresis, headache, and sometimes piloerection. Tachycardia, severe hypertension, hyperventilation, headache, restlessness, anxiety, a feeling of impending doom, and palpitations are reported. Hypotension is reported to commonly follow hypertensive crisis. In severe cases, pulmonary edema may develop. This is covered in detail in a separate management (See IRUKANDJI SYNDROME).

a) A 61-year-old man was stung in the face by Physalia utriculus (blue bottle) while swimming. He developed immediate pain, facial swelling and bilateral blurred vision and was treated at the beach with a hot shower followed by cold compresses to the face. On arrival to the Emergency Department he had facial lesions consistent with blue bottle tentacles and bilateral blurred vision and tearing, which improved rapidly in the right eye and gradually improved in the left eye over a day. On slit lam exam he had pseudo-dendritiform lesions and crystalline deposits on the left cornea and conjunctival injection. The crystalline deposits were debrided on the 3rd day and by day 5 he was asymptomatic (Chui et al, 2011).

a) Hypotension occurs with American coelenterate species (Bengston et al, 1991).

a) Hypertension and tachycardia were reported, as part of an Irukandji-like syndrome, in 2 military combat diver students, who were stung by a jellyfish while in the water off of Key West, Florida. Vital signs of both patients returned to normal 3 hours post-envenomation (Grady & Burnett, 2003). Although the specific jellyfish responsible was not identified, it is suggested that a member of the Carybdeid species may have been the causative organism.

a) Tachycardia was reported in a small number of patients with jellyfish stings in Brazil. Patients with systemic effects had larger stings, with long, linear, crossed marks of more than 20 cm on the skin (Haddad et al, 2010).
b) Tachycardia and hypertension were reported, as part of an Irukandji-like syndrome, in 2 military combat diver students, who were stung by a jellyfish while in the waters off of Key West, Florida. Both patients vital signs returned to normal 3 hours post-envenomation (Grady & Burnett, 2003). Although the specific jellyfish responsible was not identified, it is suggested that a member of the Carybdeid species may have been the causative organism.

a) CIRCULATION may be severely impaired by edema caused by jellyfish stings of the extremities. The impairment may cause absent pulses, regional cyanosis, and the threat of distal gangrene (Williamson et al, 1988).

a) Several cases of Mondor's disease (superficial thrombophlebitis of the breast) have been reported after jellyfish stings. This condition may appear as a cord-like, sometimes branched, palpable, swelling. An overlying cutaneous groove is often seen (Ingram et al, 1992).

a) CASE REPORT: A 20-year-old woman presented to the ED with Irukandji-like syndrome, consisting of limb cramping, backache, headache, agitation, hypertension, vomiting, dyspnea, pleuritic chest pain, and welts on her calves, with signs and symptoms occurring less than 2 hours after swimming in the southern waters of Australia. With supportive care, the patient's signs and symptoms completely resolved within 24 hours with no sequelae. It was suggested that the patient's signs and symptoms were a result of a jellyfish envenomation, possibly a non-Carukia jellyfish because of the development of a milder set of signs and symptoms, although the patient did not recall sighting a jellyfish while swimming (Cheng et al, 1999).
b) Two military combat diver students were stung by a jellyfish while in the water off of Key West, Florida, and 30 minutes later developed an Irukandji-like syndrome, consisting of muscular rigidity, headache, back pain, abdominal cramping, nausea, vomiting, lacrimation, salivation, cough, dyspnea, anxiety, and agitation. Symptoms increased in intensity over the next 2 hours post-envenomation and then gradually decreased over the following 4 hours with supportive care (Grady & Burnett, 2003). Although the specific jellyfish responsible was not identified, it is suggested that a member of the Carybdeid species may have been the causative organism.
c) In a series of 280 jellyfish stings reported to Texas poison control centers from 2000 to 2004, 2 patients reported dyspnea (Forrester, 2006).
d) Dyspnea was reported in a small number of patients with jellyfish stings in Brazil. Patients with systemic effects had larger stings, with long, linear, crossed marks of more than 20 cm on the skin (Haddad et al, 2010).

a) In a series of 280 jellyfish stings reported to Texas poison control centers from 2000 to 2004, neurologic effects were reported in 5 patients (2%). This included: confusion (1), dizziness (1), drowsiness (1), headache (2), muscle weakness (1), numbness (1), and tremor (1) (Forrester, 2006).

a) CASE REPORT: A healthy, 67-year-old, 205 pound swimmer was stung by 7 meters of tentacles of Physalia physalis (Portuguese man-of-war). The woman lapsed into an irreversible 5-day coma within 5 minutes of the sting. The death was thought to be due to cardiopulmonary effects of the venom, not allergy (Stein et al, 1989).

a) Paresis of finger, hand, and forearms has developed after swelling due to jellyfish stings of the arms and upper body (Williamson et al, 1988) (Hach-Wunderle, 1987) (Kaufman, 1992).

a) CASE REPORT: Mononeuritis, consisting of pain, muscular weakness, and paresthesias of the extremities, was reported following jellyfish stings. Spontaneous recovery occurred over a period of several months (Burnett et al, 1994).

a) CASE REPORT: A 20-year-old woman presented to the ED with Irukandji-like syndrome, consisting of limb cramping, backache, headache, agitation, hypertension, vomiting, dyspnea, pleuritic chest pain, and welts on her calves, with signs and symptoms occurring less than 2 hours after swimming in the southern waters of Australia. With supportive care, the patient's signs and symptoms completely resolved within 24 hours with no sequelae. It was suggested that the patient's signs and symptoms were a result of a jellyfish envenomation, possibly a non-Carukia jellyfish because of the development of a milder set of signs and symptoms, although the patient did not recall sighting a jellyfish while swimming (Cheng et al, 1999).
b) Two military combat diver students were stung by a jellyfish while in the water off of Key West, Florida, and 30 minutes later developed an Irukandji-like syndrome, consisting of muscular rigidity, headache, back pain, abdominal cramping, nausea, vomiting, lacrimation, salivation, cough, dyspnea, anxiety, and agitation. Symptoms increased in intensity over the next 2 hours post-envenomation and then gradually decreased over the following 4 hours with supportive care (Grady & Burnett, 2003). Although the specific jellyfish responsible was not identified, it is suggested that a member of the Carybdeid species may have been the causative organism.

a) Two military combat diver students were stung by a jellyfish while in the waters off of Key West, Florida, and 30 minutes later developed an Irukandji-like syndrome, consisting of muscular rigidity, headache, back pain, abdominal cramping, nausea, vomiting, lacrimation, salivation, cough, dyspnea, anxiety and agitation. Symptoms increased in intensity over the next 2 hours post-envenomation and then gradually decreased over the following 4 hours with supportive care (Grady & Burnett, 2003). Although the specific jellyfish responsible was not identified, it is suggested that a member of the Carybdeid species may have been the causative organism.
b) In a series of 280 jellyfish stings reported to Texas poison control centers from 2000 to 2004, GI effects were reported in 11 patients (4%). This included: nausea (4), vomiting (4), abdominal pain (3), diarrhea (1), oral irritation (1), and throat irritation (1) (Forrester, 2006).
c) Vomiting was reported in a small number of patients with jellyfish stings in Brazil. Patients with systemic effects had larger stings, with long, linear, crossed marks of more than 20 cm on the skin (Haddad et al, 2010).

a) Cramping was noted after jellyfish ingestion and envenomation (Little & Mulcahy, 1998; Burnett & Calton, 1987).
b) Two military combat diver students were stung by a jellyfish while in the water off of Key West, Florida, and 30 minutes later developed an Irukandji-like syndrome, consisting of muscular rigidity, headache, back pain, abdominal cramping, nausea, vomiting, lacrimation, salivation, cough, dyspnea, anxiety, and agitation. Symptoms increased in intensity over the next 2 hours post-envenomation and then gradually decreased over the following 4 hours with supportive care (Grady & Burnett, 2003). Although the specific jellyfish responsible was not identified, it is suggested that a member of the Carybdeid species may have been the causative organism.

a) CASE REPORT: A 31-year-old man was stung by a jellyfish and, within 30 minutes, developed urticarial lesions on the left forearm at the site of the envenomation, generalized malaise, weakness, lethargy, joint pains, and abdominal bloating. Abdominal distension with absent bowel sounds and vomiting were noted on presentation to the ED 24 hours after the envenomation and a clinical diagnosis of paralytic ileus was made. With supportive care, the patient recovered 4 days later (Ponampalam, 2002).

a) A 4.5 year-old girl was stung by a Portuguese man-of-war. She rapidly developed painful red vesicular lesions in the pattern of tentacles over about 10% of her body surface area. She was initially treated with dexamethasone, epinephrine and diphenhydramine and was discharged. She continued to have severe pain, progressive swelling of the involved extremities and no urine output for 10 hours. On reevaluation she had 40 mL of burgundy colored urine on catheterization that dipped positive for blood but had no red cells on microscopy. Her serum was grossly red, hematocrit was 28.9%, total and conjugated bilirubin were 5.1 and 3.7 mg/100 ml, respectively. Serum creatinine was 1.8 mg/dL, BUN 50 mg/dL and potassium was 6.9 mEq/L. She received red blood cell transfusion, oliguria persisted so she was transferred. About 24 hours after the sting she was icteric with persistent oliguria, edema and sting lesions were present on the left arm and both legs and pulses were reduced in the left arm. Lactic dehydrogenase (LDH) was 7,371 unit/L, SGOT 455 units/L, creatine phosphokinase (CPK) 554 units/L, total bilirubin was 7.4 mg/dL, creatinine concentration was 3.0 and BUN 82 mg/dL. Measurements of serum-free hemoglobin, obtained 48 and 96 hours after the sting, were 12.3/dL and 11.0 mg/dL, respectively. Hematocrit values did not change after the initial transfusion. She remained oliguric despite intravenous fluids and furosemide. She required 5 sessions of hemodialysis. Oliguria resolved 10 days after the sting and urine volumes returned to normal over the following 10 days (Guess et al, 1982; Spielman et al, 1982).

a) A 4.5 year-old girl was stung by a Portuguese man-of-war. She rapidly developed painful red vesicular lesions in the pattern of tentacles over about 10% of her body surface area. She was initially treated with dexamethasone, epinephrine and diphenhydramine and was discharged. She continued to have severe pain, progressive swelling of the involved extremities and no urine output for 10 hours. On reevaluation she had 40 mL of burgundy colored urine on catheterization that dipped positive for blood but had no red cells on microscopy. Her serum was grossly red, hematocrit was 28.9%, total and conjugated bilirubin were 5.1 and 3.7 mg/100 mL, respectively. Serum creatinine was 1.8 mg/dL, BUN 50 mg/dL and potassium was 6.9 mEq/L. She received red blood cell transfusion, oliguria persisted so she was transferred. About 24 hours after the sting she was icteric with persistent oliguria, edema and sting lesions were present on the left arm and both legs and pulses were reduced in the left arm. Lactic dehydrogenase (LDH) was 7,371 units/L, SGOT 455 units/L, creatine phosphokinase (CPK) 554 units/L, total bilirubin was 7.4 mg/dL, creatinine concentration was 3.0 and BUN 82 mg/dL. Measurements of serum-free hemoglobin, obtained 48 and 96 hours after the sting, were 12.3 mg/dL and 11.0 mg/dL, respectively. Hematocrit values did not change after the initial transfusion. She remained oliguric despite intravenous fluids and furosemide. She required 5 sessions of hemodialysis. Oliguria resolved 10 days after the sting and urine volumes returned to normal over the following 10 days (Guess et al, 1982; Spielman et al, 1982).

a) Acute local effects may include pain, skin eruption, exaggerated local angioedema, and papular urticaria (Fisher, 1999; Burnett, 1991).
b) In a series of 280 jellyfish stings reported to Texas poison control centers from 2000 to 2004, dermal irritation or pain was reported in 244 (80%), erythema in 95 (34%), puncture wounds in 67 (24%), welts in 48 (17%), and edema in 40 (14). Other less common effects were rash (13), pruritus (12), cellulitis (2), and ecchymosis (1) (Forrester, 2006).

a) LESIONS: The cutaneous lesions produced by the nematocyst vary considerably, depending chiefly on the organism involved (Letot et al, 1990).
b) The lesions may appear as small papular eruptions in one or several discontinuous lines, particularly when tentacles are involved, or they may appear as a cluster of small wheals, or papules, often surrounded by a reddened, raised area (as in sea anemone stings).
c) The papules may increase in size and proceed to vesication within the first 24 hours (Russell & Tomchik, 1993). Pustules may develop and desquamation is not unusual in more severe cases.
d) Contact with an organism may produce a sharp, shooting pain, or initial pain may be absent. The presenting findings may often show as pruritus and lymphadenopathy.
e) Some stings may result in skin necrosis (Othman et al, 1991).
f) ERYTHEMA NODOSUM with articular manifestations was noted after stings by an unidentified jellyfish (Auerbach & Hays, 1987).
g) There may be both an immediately "toxic" cutaneous reaction, then some days later an allergic reaction (Fisher, 1987).
h) A case of generalized skin eruption was seen after ingestion of jellyfish (Marr, 1967).

a) Piloerection has been seen following stings by many venomous animals, including the coelenterates.

a) Hyperpigmentation is an usual reaction sometimes seen after jellyfish envenomations by Pelagia noctiluca. It may result from post inflammatory melanin deposition or tattooing of the mauve jellyfish pigment into the skin (Kokelj & Burnett, 1990).

a) Initial dermal contact with a non-chirodropid coelenterate may result in localized pain that may radiate to other areas of the body. The severity of pain may range from mild stinging to a severe burning sensation (Fisher, 1999; Kaufman, 1992).
b) In a series of 280 jellyfish stings reported to Texas poison control centers from 2000 to 2004, dermal irritation or pain was reported in 244 (80%) (Forrester, 2006).

a) SEABATHER'S ERUPTION: An usually self-limiting illness that has been associated with the larvae of the jellyfish Linuche unguiculator. These larvae are known as "sea lice" (Tomchik et al, 1993).
b) The condition is an intensely pruritic, vesicular, maculopapular eruption seen around the swimwear of bathers. Onset: Within 24 hours. Duration: 3 to 5 days (Sams, 1949; Strauss, 1956; Moschella, 1951).
c) Systemic symptoms include fever, nausea, vomiting, diarrhea, headache, chills, weakness, malaise, muscle spasms, and arthralgias. It is unknown if these symptoms are an immune response or reaction caused by ingestion of infested water (Russell & Tomchik, 1993).
d) Treatment is symptomatic with use of antihistamines, antipruritics, and corticosteroids. This condition has been reported around various Florida beaches (Tomchik et al, 1993).

a) A 35-year-old woman with diabetes was stung by what was believed to be a Portuguese man-of-war on the dorsum of the foot. The wound was initially incised and a drain was placed. The foot remained red and swollen and she was admitted again for IV antibiotics. About a month after the initial injury her foot became cool and dusky. She was admitted with non-viable skin that was debrided; antibiotics were started. Cultures grew coagulase negative staphylococci and tissue microscopy showed epidermal necrosis. She was readmitted 6 weeks later for further debridement and split thickness skin grafting and recovered (Giordano et al, 2005).

a) An adult developed erythematous, intensely pruritic papular lesions that progressed to urticarial lesions after contact with the hydrozoa Nemalecium lighti while snorkeling. The lesions improved with oral and topical antihistamines (Haddad et al, 2010).

a) Muscle pain and cramps have been reported 5 to 10 minutes after stings by several species (Mulcahy & Little, 1997; Kaufman, 1992).
b) CASE REPORT: A 20-year-old woman presented to the ED with Irukandji-like syndrome, consisting of limb cramping, backache, headache, agitation, hypertension, vomiting, dyspnea, pleuritic chest pain, and welts on her calves, with signs and symptoms occurring less than 2 hours after swimming in the southern waters of Australia. With supportive care, the patient's signs and symptoms completely resolved within 24 hours with no sequelae. It was suggested that the patient's signs and symptoms were a result of a jellyfish envenomation, possibly a non-Carukia jellyfish because of the development of a milder set of signs and symptoms, although the patient did not recall sighting a jellyfish while swimming (Cheng et al, 1999).
c) Three military combat diver students experienced severe back pain and muscle cramping, as part of an Irukandji-like syndrome, within 25 minutes after being stung by a jellyfish while in the water off of Key West Florida. The symptoms increased in intensity over the next 2 hours following envenomation and then gradually decreased over the following 4 hours (Grady & Burnett, 2003). Although the specific jellyfish responsible was not identified, it is suggested that a member of the Carybdeid species may have been the causative organism.

a) Muscle necrosis, compartment syndrome and arterial spasm have been reported after severe stings (Williamson et al, 1988).

a) CASE REPORT: A 74-year-old man was stung by a Portuguese man-of-war while swimming. Redness and edema over the site of the sting lasted 3 days. About a week after the sting he developed swelling of the dorsum of both hands, and wrist pain. Erythrocyte sedimentation rate was elevated but other laboratory studies were normal. He was treated with wrist splints and NSAIDs but symptoms finally resolved after low dose corticosteroid treatment (Weinberg, 1988).

a) Anaphylaxis occurs rarely due to jellyfish stings (Burnett, 1991; Laing & Harrison, 1991). However, true anaphylactic reactions following jellyfish stings are becoming more common.

a) Jellyfish stings will normally elevate serum levels of IgG and IgM. Elevated levels may persist for up to 4 years after a sting (Burnett, 1991; Auerbach & Hays, 1987).