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VENOMOUS SCORPAENIDAE STINGS

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Approximately 225 species of marine fishes are known to be venomous. This management covers envenomations by Scorpaenidae family (subfamilies: Scorpaenidae [scorpionfish]; Synanceiidae [stonefish]; Pteroinae [lionfish, turkeyfish]). Refer to other managements "STINGRAY INJURIES" and "FISH STINGS" for information on stingrays, weeverfishes, toadfishes, stargazers, catfishes, sharks, ratfishes, and surgeonfishes.

Specific Substances

    A) LIONFISH
    1) Butterfly cod
    2) Clearfin lionfish
    3) Dendrochirus
    4) Dendrochirus barberi (Hawaiian lionfish)
    5) Feather-fins
    6) Firefish
    7) Radiata lionfish
    8) Radial firefish
    9) Pterois miles
    10) Pterois radiata
    11) Pterois volitans (red lionfish)
    12) Tailbar lionfish
    13) Turkeyfish
    SCORPIONFISH
    1) Atlantic black scorpionfish
    2) Black scorpionfish
    3) Californian Scorpion fish
    4) Helicolenus (genera of Scorpaenidae)
    5) Pontinus (genera of Scorpaenidae)
    6) Scorpaena (genera of Scorpaenidae)
    7) Scorpaena plumieri (the black or spotted scorpionfish)
    8) Scorpaena brasiliensis (the red scorpionfish or barbfish)
    9) Scorpaena grandicornis
    10) Scorpaena guttata
    11) Scorpaena isthmensis
    12) Scorpaena dispar
    13) Scorpaenidae
    14) Sculpin
    15) Sea scorpion
    16) Spotted scorpionfish
    STONEFISH
    1) Devil fish
    2) Estuarine stonefish
    3) Indian stonefish
    4) Stout
    5) Synanceja
    6) Synanceja alula
    7) Synanceja horrida (Indian stonefish)
    8) Synanceja nana
    9) Synanceja trachynis (Estuarine stonefish)
    10) Synanceja verrucosa (Reef stonefish)
    11) Reef stonefish
    12) Warty-ghoul

Overview

Life Support

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

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) BACKGROUND: Approximately 225 species of marine fishes are known to be venomous. This management covers envenomations by Scorpaenidae family (scorpionfish, stonefish, lionfish, turkeyfish). Injuries from stingrays, weeverfishes and other fish are covered in separate managements.
    B) TOXICOLOGY: The scorpaenids are the most venomous fishes in the world. Most of the severe envenomations in humans are from stonefishes (Synanceja), lionfishes (Pterois), and scorpionfishes (Scorpaena). In animal studies, venom from stonefish had myotoxic, cytolytic, neurotoxic, vascular-leakage and myocardial effects. In animal studies, venom from scorpionfish had hemorrhagic, hemolytic and proteolytic effects.
    C) EPIDEMIOLOGY: A large number of venomous fishes are encountered worldwide. Fatalities and severe envenomations from poisonous fish are very rare.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Patients with mild to moderate toxicity usually report pain. Pain following stonefish sting peaks in 60 to 90 minutes and persists for 6 to 12 hours. Swelling, tenderness, discoloration, and elevated skin temperature immediately around the wound are common. Erythema, edema and sweating have been reported following envenomation by scorpion fish. Wounds may develop infections secondary to the injury. Weakness and paresthesias frequently occur. Nausea is a common complaint. Agitation, malaise, and intense pain with irradiation of pain have been reported following envenomations by scorpion fish. Cardiovascular signs and symptoms may occur but they tend to be transient in nature.
    2) SEVERE TOXICITY: Vomiting, diarrhea, and abdominal cramps usually occur only following severe envenomations. Sweating, axillary, or inguinal pain are commonly reported following severe envenomations. Severe envenomations from scorpion fish or stonefish can lead to hypotension, respiratory arrest, dysrhythmias to include ventricular fibrillation, cardiovascular failure and death. Respiratory distress is not a common complaint but it may occur following a severe stonefish envenomation. Seizures have been reported after severe lionfish envenomations.
    0.2.3) VITAL SIGNS
    A) WITH POISONING/EXPOSURE
    1) SCORPION FISH: Fever has been reported following envenomations by S. plumieri and S. brasiliensis.
    0.2.13) HEMATOLOGIC
    A) WITH POISONING/EXPOSURE
    1) Hemolysis has been reported after stonefish stings.
    0.2.19) IMMUNOLOGIC
    A) WITH POISONING/EXPOSURE
    1) Adenopathy has been reported following envenomation by scorpion fish.

Laboratory Monitoring

    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) For severe envenomations, monitor vital signs.
    C) Following a severe envenomation, obtain a baseline ECG and institute continuous cardiac monitoring.
    D) Monitor serum electrolytes in patients with significant vomiting and/or diarrhea.
    E) Soft-tissue ultrasound or radiographs of the sting site should be performed to evaluate for a retained spine, integumentary sheath or other foreign bodies. Regardless of the findings, direct exploration of the wound should be performed.

Treatment Overview

    0.4.7) BITES/STINGS
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Submerge the injured part in hot water at as high a temperature as the patient can tolerate without injury (less than 113 degrees F or 45 degrees C), for 30 to 90 minutes or more. Control pain with NSAIDs or oral or parenteral opioids. Digital nerve block or local anesthesia (lidocaine or bupivacaine, no more than 2 mg/kg body weight) should be considered for pain relief in patients who have persistent pain despite an adequate trial of hot water immersion (at least 2 hours). Do NOT use a digital nerve block or local anesthesia administration and immersion in hot water simultaneously as it may lead to significant burns. TETANUS: Administer antitetanus as indicated. WOUND CARE: Explore the wound, irrigate extensively and remove any debris. ANTIBIOTICS: Wounds may become infected. Antibiotic choice should be guided by culture results. Do not apply an arterial tourniquet or use the compression/immobilization bandaging of the wounds to a venomous fish sting.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) HYPOTENSIVE EPISODE: Administer IV 0.9% saline, add vasopressors, if hypotension persists. SEIZURE: Attempt initial control with a benzodiazepine (diazepam or lorazepam). If seizures persist or recur administer phenobarbital or propofol. ANTIBIOTICS: Some physicians administer antibiotics routinely. If antibiotic prophylaxis is used VIBRIO species should be covered. Trimethoprim-sulfamethoxazole is appropriate for oral administration, while third generation cephalosporins are best for IV administration.
    C) WOUND CARE
    1) The injured part should then be submerged in hot water at as high a temperature as the patient can tolerate without injury (less than 113 degrees F or 45 degrees C) for 30 to 90 minutes or more. Explore the wound, irrigate extensively and remove any debris. An ultrasound or radiograph may help identify foreign bodies.
    D) AIRWAY MANAGEMENT
    1) Airway management is unlikely to be necessary except in rare cases of stonefish envenomation. Endotracheal intubation may be necessary for paralysis/loss of airway reflexes or recurrent seizures after severe lionfish envenomation.
    E) ANTIDOTE
    1) STONEFISH ANTIVENOM: The Commonwealth Serum Laboratory Stonefish Antivenom (Australia) is available for stonefish envenomations. Indications include: early hypotension, severe pain and other manifestations. DOSE: The usual dose is dependent on the number of visible puncture sites: 1 to 2 punctures: 1 vial (2,000 units) IM; 3 to 4 punctures: 2 vials (4,000 units) IM; 5 or more punctures: 3 vials (6,000 units) IM. Call a local Poison Center at 1-800-222-1222 to locate the nearest source of antivenom.
    F) PATIENT DISPOSITION
    1) HOME CRITERIA: All patients should be sent to a medical facility for evaluation/treatment of the wound and treatment of any systemic symptoms.
    2) OBSERVATION CRITERIA: Patients with only local effects can be discharged once pain control is adequate and wound care is complete. Patients with stings that can cause systemic toxicity should be observed for 6 hours and may then be discharged if no systemic toxicity has developed.
    3) ADMISSION CRITERIA: Any patients with cardiovascular toxicity or neurologic symptoms more severe than pain and mild paresthesias should be admitted.
    4) CONSULT CRITERIA: A medical toxicologist or poison center should be consulted on all severe envenomations or when antivenom administration is being considered.
    G) PITFALLS
    1) Pitfalls include inadequate exploration of the wound, failure to provide tetanus prophylaxis, and failure to cover Vibrio species when prescribing antibiotics for wound infections.
    H) PHARMACOKINETICS
    1) Absorption occurs rapidly following envenomation. The rate of metabolism and clearance is unknown.
    I) DIFFERENTIAL DIAGNOSIS
    1) Sea snake envenomation, jelly fish envenomation, weaverfish or other fish sting, or dinoflagellate poisoning may be mistaken for a scorpion or lion fish sting.

Range Of Toxicity

    A) TOXIC DOSE: Severe toxicity with systemic effects may be observed after a stonefish, lionfish, or scorpionfish sting. Fatalities have occurred but are very rare. Stonefish are considered the most venomous of fish.

Clinical Effects

Summary Of Exposure

    A) BACKGROUND: Approximately 225 species of marine fishes are known to be venomous. This management covers envenomations by Scorpaenidae family (scorpionfish, stonefish, lionfish, turkeyfish). Injuries from stingrays, weeverfishes and other fish are covered in separate managements.
    B) TOXICOLOGY: The scorpaenids are the most venomous fishes in the world. Most of the severe envenomations in humans are from stonefishes (Synanceja), lionfishes (Pterois), and scorpionfishes (Scorpaena). In animal studies, venom from stonefish had myotoxic, cytolytic, neurotoxic, vascular-leakage and myocardial effects. In animal studies, venom from scorpionfish had hemorrhagic, hemolytic and proteolytic effects.
    C) EPIDEMIOLOGY: A large number of venomous fishes are encountered worldwide. Fatalities and severe envenomations from poisonous fish are very rare.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Patients with mild to moderate toxicity usually report pain. Pain following stonefish sting peaks in 60 to 90 minutes and persists for 6 to 12 hours. Swelling, tenderness, discoloration, and elevated skin temperature immediately around the wound are common. Erythema, edema and sweating have been reported following envenomation by scorpion fish. Wounds may develop infections secondary to the injury. Weakness and paresthesias frequently occur. Nausea is a common complaint. Agitation, malaise, and intense pain with irradiation of pain have been reported following envenomations by scorpion fish. Cardiovascular signs and symptoms may occur but they tend to be transient in nature.
    2) SEVERE TOXICITY: Vomiting, diarrhea, and abdominal cramps usually occur only following severe envenomations. Sweating, axillary, or inguinal pain are commonly reported following severe envenomations. Severe envenomations from scorpion fish or stonefish can lead to hypotension, respiratory arrest, dysrhythmias to include ventricular fibrillation, cardiovascular failure and death. Respiratory distress is not a common complaint but it may occur following a severe stonefish envenomation. Seizures have been reported after severe lionfish envenomations.

Vital Signs

    3.3.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) SCORPION FISH: Fever has been reported following envenomations by S. plumieri and S. brasiliensis.
    3.3.3) TEMPERATURE
    A) WITH POISONING/EXPOSURE
    1) SCORPION FISH: In one study (n=23), fever was reported in 11 (69.6%) patients following envenomations by S. plumieri and 9 (39.1%) patients following envenomations by S. brasiliensis along the Brazilian coast (Haddad et al, 2003).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) HEART FAILURE
    1) WITH POISONING/EXPOSURE
    a) Cardiovascular symptoms and signs may occur but they tend to be transient in nature.
    b) STONEFISH: Cardiovascular failure has occurred following stonefish stings. Animal experiments have shown hypotension, ECG changes such as ventricular fibrillation, and respiratory arrest (Saunders, 1960).
    c) SCORPION FISH: In animal studies, cardiovascular disorders and death have been reported following Californian scorpion fish (Scorpaena guttata) (Gomes et al, 2010).
    B) TACHYCARDIA
    1) WITH POISONING/EXPOSURE
    a) SCORPION FISH: In one study (n=23), tachycardia/dysrhythmias were reported in 6 (26%) patients following envenomations by S. plumieri and 4 (17.4%) patients following envenomations by S. brasiliensis (Haddad et al, 2003).
    C) HYPOTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) Diaphoresis, nausea, hypotension, and syncope from the severe pain can occur (Williamson, 1995).
    b) LIONFISH: In one study, hypotension was reported in 1 (2%) of 45 patients following envenomations by lionfish (Kizer et al, 1985).
    c) ANIMAL STUDY
    1) STONEFISH: In animal studies, the intravenous injection of either Synanceia verrucosa or Synanceia horrida venom to rabbits resulted in hypotension, respiratory arrest, atrioventricular block and ventricular fibrillation (Williamson, 1995; Kizer et al, 1985).
    D) PERICARDITIS
    1) WITH POISONING/EXPOSURE
    a) SCORPION FISH: After being stung on the right third finger by a California scorpion fish (Scorpaena guttata), a 36-year-old man developed severe pain and slight swelling of his finger. He had mild tingling, swelling, and tenderness over the right hand. Although his symptoms resolved over the next 12 hours, he developed pain in the left shoulder, the left anterior chest and substernal area the next day. The pain was constant, severe, sharp and pleuritic. He had no previous history of chest pain, or cardiac or respiratory disease. An initial ECG showed normal sinus rhythm, normal PR interval and QRS duration, a small Q wave, and 1 mm ST elevation in the inferior leads, with an inverted T wave in lead III. A chest x-ray revealed an infiltrate in the left base, partially obscuring the left heart border, and left hemidiaphragm. Laboratory results revealed a WBC of 17,300 and CPK of 359 Units/L (normal 25 to 200; 100% skeletal muscle). The next day, a second ECG revealed a shift of the Q axis to the right, and an increase in the ST segment elevation of 2 to 3 mm in the inferior and lateral leads, consistent with pericarditis. At this time, a diagnosis of viral-type pericarditis was made. A chest x-ray on day 3 revealed a decrease in the infiltrate on the left side. At this time, CPK was 1257 Units/L, with 92% skeletal and 8% cardiac (normal less than 5%). Following supportive care, he recovered gradually and was discharged after 5 days of hospitalization (Abdun-Nur et al, 1981).
    E) CHEST PAIN
    1) WITH POISONING/EXPOSURE
    a) LIONFISH: In one study, chest pain was reported in 1 (2%) of 45 patients following envenomation by lionfish (Kizer et al, 1985).
    F) SYNCOPE
    1) WITH POISONING/EXPOSURE
    a) LIONFISH: In one study, syncope was reported in 1 (2%) of 45 patients following envenomation by lionfish (Kizer et al, 1985).
    b) SCORPION FISH: In one study, syncope was reported in 1 of 6 patients following envenomation by lionfish (Kizer et al, 1985).
    3.5.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) STONEFISH: In animal studies, the intravenous injection of either Synanceia verrucosa or Synanceia horrida venom to rabbits resulted in hypotension, respiratory arrest, atrioventricular block and ventricular fibrillation (Williamson, 1995).
    2) SCORPION FISH (SCORPAENA PLUMIERI): In animal studies, doses of scorpion fish venom (14 to 216 mcg protein/kg) given to rats resulted in a transient increase in the mean arterial pressure. Hypotension and death occurred after higher doses (338 mcg protein/kg). The administration of venom doses 108 mcg/kg or higher produced a temporary increase in heart rate followed by bradycardia. Dose-dependent positive ventricular chronotropic, inotropic, lusitropic and coronary vasoconstriction responses were observed following the administration of crude venom (5 to 80 mcg protein) in isolated rat hearts. The administration of prazosin and propranolol, adrenergic blockers, significantly attenuated all the responses to crude venom. It is concluded that the venom could be acting, at least partially, directly on the adrenoreceptors (presence of some adrenergic agonist in the venom) and/or indirectly (via the release of endogenous stores of norepinephrine from the sympathetic varicosities in the heart) (Gomes et al, 2010).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) DYSPNEA
    1) WITH POISONING/EXPOSURE
    a) LIONFISH: In one study, difficulty breathing was reported in 2 (4%) of 45 patients following envenomations by lionfish (Kizer et al, 1985).
    B) ACUTE LUNG INJURY
    1) WITH POISONING/EXPOSURE
    a) STONEFISH: Respiratory distress and pulmonary edema are not common complaints, but may occur following severe envenomations, particularly stonefish stings (Burnett, 1998; Lehmann & Hardy, 1993).
    b) Two patients developed severe pain, central cyanosis, pulmonary edema, coma, and died within the hour of stonefish envenomation in the foot (Williamson, 1995).
    3.6.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) STONEFISH: In animal studies, the intravenous injection of either Synanceia verrucosa or Synanceia horrida venom to rabbits resulted in hypotension, respiratory arrest, atrioventricular block and ventricular fibrillation (Williamson, 1995).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) PAIN
    1) WITH POISONING/EXPOSURE
    a) SUMMARY: Pain is the most common complaint in all fish stings, pain at time can be severe. Inguinal or axillary lymph nodes may be painful (Haddad et al, 2015; Haddad et al, 2003; Al-Ghananim et al, 2013; Ngo et al, 2009; Rosson & Tolle, 1989).
    1) LIONFISH
    a) CASE REPORT: Severe pain, radiating up the arm, occurred in a 35-year-old man following a lionfish sting under the patient's thumbnail. Most of the pain subsided within a few hours, however, there was still some pain at the sting site 5 days later (Bangh, 1997).
    b) CASE REPORT: A 41-year-old man developed severe pain and nausea following a lionfish sting on his right index finger. The pain continued despite administration of oral analgesics and immersion in hot water and only subsided following a digital nerve block with 3 mL of 0.25% Bupivacaine (Garyfallou & Madden, 1996).
    c) CASE REPORT: A 53-year-old man experienced severe pain in the second and third fingers of the right hand after a lionfish envenomation. Physical examination of the affected fingers showed ecchymosis and vesicles. The patient's severe pain was unresponsive to hot water immersion therapy; but quickly resolved following administration of analgesics (Vetrano et al, 2002).
    d) CASE SERIES: In one study (n=23), pain was reported in 15 (65.2%) patients following envenomation by lionfish. Swelling and vesicle formation developed in 7 (30.4%) and 2 (8.7%) patients, respectively (Trestrail & al-Mahasneh, 1989).
    e) CASE SERIES: In one study, all of the patients (n=45) developed localized wound pain after envenomation by lionfish. Pain in most or all of the affected extremity, swelling, and erythema or ecchymosis were reported in 10 (22%), 23 (51%), 5 (11%) patients, respectively (Kizer et al, 1985).
    f) CASE SERIES: In a series of 15 envenomations of aquarists in Brazil over a period of 18 years (1997-2014), intense pain, sometimes described as excruciating occurred in 14 victims. Most patients classified their pain as intense and it usually presented with behavioral changes, cold sweating and restlessness. Nausea and vomiting were the only systemic effects observed and were associated with pain symptoms (Haddad et al, 2015).
    2) SCORPION FISH
    a) In one study (n=23), intense pain was reported in 14 (60.9%) patients following envenomations by S. plumieri and 8 (34.8%) patients following envenomations by S. brasiliensis. Radiation of the pain up the affected limb occurred in 4 (17.4%) patients following envenomations by S. plumieri and 2 (8.7%) patients following envenomations by S. brasiliensis along the Brazilian coast (Haddad et al, 2003).
    b) In one study, localized wound pain was reported in all patient (n=6) following envenomations by California scorpion fish. Four patients developed swelling at site of envenomation. Erythema or ecchymosis developed in 3 (50%) of patients (Kizer et al, 1985).
    3) STONEFISH
    a) Intense pain is usually immediate and involves the whole of the affected limb (Al-Ghananim et al, 2013; Williamson, 1995; Prentice et al, 2008; Ngo et al, 2009; Ling et al, 2009). Pain peaks in 60 to 90 minutes and persists for 6 to 12 hours (Auerbach, 1991). Diaphoresis, nausea, hypotension, and syncope from the severe pain can occur (Williamson, 1995).
    b) INCIDENCE: In a series of patients with stonefish envenomation, all (n=30) cases developed pain at the injury site (Ling et al, 2009).
    c) Two patients developed severe pain, central cyanosis, pulmonary edema, coma, and died within the hour of stonefish envenomation in the foot (Williamson, 1995).
    B) ANXIETY
    1) WITH POISONING/EXPOSURE
    a) LIONFISH: Anxiety has been reported following envenomation of lionfish (Trestrail & al-Mahasneh, 1989).
    b) LIONFISH: In one study, anxiety or fear was reported in 8 (18%) of 45 patients following envenomations by lionfish (Kizer et al, 1985).
    c) SCORPION FISH: In one study, anxiety or fear was reported in 2 (33%) of 6 patients following envenomations by lionfish (Kizer et al, 1985).
    C) DIZZINESS
    1) WITH POISONING/EXPOSURE
    a) LIONFISH: Dizziness and disorientation have been reported following envenomation of lionfish (Trestrail & al-Mahasneh, 1989).
    b) LIONFISH: In one study, dizziness was reported in 2 (4%) of 45 patients following envenomations by lionfish (Kizer et al, 1985).
    D) HEADACHE
    1) WITH POISONING/EXPOSURE
    a) LIONFISH: Headache has been reported following envenomation of lionfish (Trestrail & al-Mahasneh, 1989).
    E) MUSCLE WEAKNESS
    1) WITH POISONING/EXPOSURE
    a) STONEFISH: Weakness may be present, more so in stonefish/lionfish stings (Wasserman & Johnston, 1979; Bangh, 1997). True paralysis is very rare.
    b) LIONFISH: In one study, generalized weakness was reported in 1 (2%) of 45 patients following envenomation by lionfish (Kizer et al, 1985).
    c) SCORPION FISH: In one study, generalized weakness was reported in 1 (17%) of 6 patients following envenomation by lionfish (Kizer et al, 1985).
    F) PARESTHESIA
    1) WITH POISONING/EXPOSURE
    a) Paresthesia/numbness around the wound is not uncommon (Ling et al, 2009; Trestrail & al-Mahasneh, 1989).
    G) SEIZURE
    1) WITH POISONING/EXPOSURE
    a) LIONFISH: Seizures have been reported after severe lionfish envenomations (Trestrail & al-Mahasneh, 1989; Nair et al, 1985).
    H) MALAISE
    1) WITH POISONING/EXPOSURE
    a) SCORPION FISH: In one study (n=23), malaise was reported in 14 (60.9%) patients following envenomations by S. plumieri and 8 (34.8%) patients following envenomations by S. brasiliensis along the Brazilian coast (Haddad et al, 2003).
    I) PSYCHOMOTOR AGITATION
    1) WITH POISONING/EXPOSURE
    a) SCORPION FISH: In one study (n=23), agitation was reported in 14 (60.9%) patients following envenomations by S. plumieri and 8 (34.8%) patients following envenomations by S. brasiliensis along the Brazilian coast (Haddad et al, 2003).
    3.7.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) STONEFISH: In animal studies, the subcutaneous injection of 4 mg Synanceia venom to guinea pig resulted in muscular weakness, coma, and death within 3 hours (Williamson, 1995).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) NAUSEA
    1) WITH POISONING/EXPOSURE
    a) SUMMARY: Nausea is a common complaint in severe envenomations (Haddad et al, 2003; Trestrail & al-Mahasneh, 1989; Garyfallou & Madden, 1996; Auerbach, 1991; Auerbach et al, 1987).
    b) SCORPION FISH: In one study (n=23), nausea was reported in 10 (43.5%) patients following envenomations by S. plumieri and 9 (39.1%) patients following envenomations by S. brasiliensis along the Brazilian coast (Haddad et al, 2003).
    c) LIONFISH: In one study, nausea or vomiting was reported in 6 (13%) of 45 patients following envenomations by lionfish (Kizer et al, 1985).
    d) SCORPION FISH: In one study, nausea or vomiting was reported in 2 (33%) of 6 patients following envenomations by lionfish (Kizer et al, 1985).
    B) VOMITING
    1) WITH POISONING/EXPOSURE
    a) SUMMARY: Vomiting, diarrhea, and abdominal cramps may occur only following severe envenomations (Haddad et al, 2003; Auerbach, 1991; Wasserman & Johnston, 1979).
    b) LIONFISH: A 35-year-old man was stung under his thumbnail by a pet lionfish and experienced joint pain, nausea, abdominal cramps, and severe vomiting more than 24 hours later. The vomiting gradually subsided following administration of prochlorperazine (Bangh, 1997).
    c) LIONFISH: In one study, nausea or vomiting was reported in 6 (13%) of 45 patients following envenomations by lionfish (Kizer et al, 1985).
    d) SCORPION FISH: In one study (n=23), vomiting was reported in 10 (43.5%) patients following envenomations by S. plumieri and 9 (39.1%) patients following envenomations by S. brasiliensis along the Brazilian coast (Haddad et al, 2003).
    e) SCORPION FISH: In one study, nausea or vomiting was reported in 2 (33%) of 6 patients following envenomations by lionfish (Kizer et al, 1985).
    C) DIARRHEA
    1) WITH POISONING/EXPOSURE
    a) SCORPION FISH: In one study (n=23), diarrhea was reported in 3 (13.1%) patients following envenomations by S. plumieri and 1 (4.3%) patient following envenomations by S. brasiliensis along the Brazilian coast (Haddad et al, 2003).
    D) ABDOMINAL PAIN
    1) WITH POISONING/EXPOSURE
    a) LIONFISH: In one study, abdominal pain was reported in 1 (2%) of 45 patients following envenomation by lionfish (Kizer et al, 1985).

Hematologic

    3.13.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Hemolysis has been reported after stonefish stings.
    3.13.2) CLINICAL EFFECTS
    A) HEMOLYSIS
    1) WITH POISONING/EXPOSURE
    a) The venom of the stonefish (Synanceja horrida) exhibits hemolytic properties, but this has not been observed in human envenomations (Khoo et al, 1992).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) SKIN FINDING
    1) WITH POISONING/EXPOSURE
    a) SCORPION FISH
    1) In one study (n=23), erythema was reported in 14 (60.9%) patients following envenomations by S. plumieri and 8 (34.8%) patients following envenomations by S. brasiliensis. Edema occurred in 14 (60.9%) patients following envenomations by S. plumieri and 8 (34.8%) patients following envenomations by S. brasiliensis (Haddad et al, 2003).
    b) STONEFISH/LIONFISH
    1) The venom exhibits edema-inducing properties and may cause mottling or skin discoloration (Al-Ghananim et al, 2013; Ling et al, 2009; Burnett, 1998; Khoo et al, 1992). Local paleness and cyanosis were present following envenomation by lionfish (Haddad et al, 2015).
    2) Cellulitis is seen after stonefish envenomation (Auerbach, 1991).
    3) Wounds may take months to heal (Auerbach, 1991).
    4) Bacterial infection may develop following a lionfish envenomation (Haddad et al, 2015).
    5) Severe vesication may occur after stings by lionfish (Auerbach et al, 1987).
    6) INCIDENCE: In a series of patients (n=30) with stonefish envenomation, 21 (70%) developed erythema, 20 (67%) had edema and sting mark(s) were observed in 17 (57%) patients. Pain was reported by all patients (Ling et al, 2009).
    7) ADULT
    a) CASE REPORT: A 33-year-old chef developed severe pain after being punctured in his finger by a spine of a stonefish while preparing the fish. The finger was throbbing with continuous pain and numbness extending into the palm of the hand. No systemic effects were observed. A spine was not detected but first aid measures included immersion in hot water. Severe symptoms resolved within 30 minutes. At follow-up, the patient reported that pain and tenderness lasted for approximately 18 hours (Yamamoto et al, 2010).
    b) CASE REPORT: A 50-year-old chef developed immediate pain and swelling of his finger after stonefish envenomation. Despite initial immersion of the site in hot water and IV antibiotic therapy, he had progressive localized swelling and tenderness of his finger 16 hours after exposure. Blisters were present on the finger and he had a complaint of paraesthesia. Stonefish antivenom (1 vial) was administered IV. An emergent fasciotomy was also performed to relieve edema and improve circulation to the fingers. The patient was discharged one week later with relief of pain and numbness. At 3 months, he had full range of motion (Ling et al, 2009).
    c) CASE REPORT: A 53-year-old man experienced severe pain in the second and third fingers of the right hand after a lionfish envenomation. Physical examination of the affected fingers showed ecchymosis and vesicles. The patient's severe pain was unresponsive to hot water immersion therapy, but quickly resolved following administration of analgesics (Vetrano et al, 2002).
    d) CASE REPORT: A 32-year-old man experienced severe pain in his medial left dorsal wrist after a lionfish envenomation while emptying his aquarium. Physical examination of the affected area 3 days later showed several superficial parallel lacerations and edema with tiny vesicles between the linear marks. One week later, several erythematous edematous areas between the lacerations were noted. Vesicles or bullae were formed on these lesions and then ruptured and crusted. He also experienced pain on his mid upper arm. Approximately a month after the injury, the lesions had marked clearing in the center. Four months after the injury, the wound became inflamed with several spicules noted on the skin surface, which required surgical removal and debridement. A skin graft was later performed to close the 5 cm ulcer that developed (Burnett, 2001).
    e) CASE REPORT: A 52-year-old woman developed severe pain with 15 minutes after being stung by a single spine of a stonefish (Synanceja horrida). Her limb was immersed in hot water for 15 minutes, but she did not experience any relief. At this time, she had numbness around the injury, swelling of her knee, and painful upper leg. Her pain slowly decreased after 14 hours, however, local hypesthesia persisted for a few days. No systemic signs were observed (Brenneke & Hatz, 2006).
    f) CASE REPORT: A 62-year-old woman developed pain, swelling, and violaceous discoloration of the left leg after stonefish envenomation in the Red Sea off Taba, Egypt. Despite supportive therapy, including hot water immersion, IM steroids, antibiotics, and tetanus shot, her symptoms did not resolve. A biopsy specimen of the lesion revealed telangiectasis and a mild perivascular mononuclear infiltrate. Examination of the toe 3 months after envenomation revealed a neuroma at the medial aspect of the mid phalanx of the toe. Her pain resolved after an amputation of the toe (Rishpon et al, 2008).
    8) PEDIATRIC
    a) CASE REPORT: A 12-year-old girl was swimming in the Red Sea of Aqaba and was envenomated by a stonefish (identified by a local guide) after stepping on the fish and developed immediate intense pain. She was transported immediately to the hospital and initial treatment included irrigation and immersion of the foot in warm water. Swelling of the foot was observed within 2 hours despite elevation. Therapy included stonefish antivenom (2000 Units/1 vial), antibiotic therapy and meperidine for severe pain. Significant pain continued the following day. By day 5, she had improved significantly and was transferred back to her home. The patient had a recurrence of poor wound healing about 6 weeks after envenomation, but improved with supportive care and did not require surgical intervention (Al-Ghananim et al, 2013).
    B) NECROTIZING FASCIITIS
    1) WITH POISONING/EXPOSURE
    a) STONEFISH
    1) CASE REPORT: A 57-year-old healthy woman presented to her private physician after dropping a stonefish on her foot. Her leg was swollen and painful. The pain subsided after treatment with hot water immersion, a 7-day course of ofloxacin was prescribed, and the patient was sent home. Subsequently she developed a temperature of 38.5 degrees C and progression of swelling. An urgent fasciotomy was performed with signs of necrotizing fasciitis. An aspirate culture was found positive for Vibrio vulnificus. Histological examination confirmed the diagnosis of necrotizing fasciitis. The patient received a 7-day course of IV amoxicillin/clavulanate and ciprofloxacin. She was able to return to work after 8 weeks (Tang et al, 2006).
    2) CASE REPORT: A 27-year-old healthy man developed necrotizing fasciitis after a stonefish envenomation to his right ring finger. He presented 4 hours after the sting occurred with pain and swelling of the right hand extending up to the mid-forearm. Treatment with hot water immersion for 90 minutes decreased pain and swelling, however, symptoms returned within 2 hours. Amoxicillin/clavulanate and ciprofloxacin were started. The patient was unable to close his hand due to severe pain. Pus was discovered by exploration and fasciotomy. Histology confirmed the diagnosis of necrotizing fascitis. The patient required 6 weeks of physical therapy before returning to work (Tang et al, 2006).
    C) EXCESSIVE SWEATING
    1) WITH POISONING/EXPOSURE
    a) SUMMARY: Diaphoresis, nausea, hypotension, and syncope from the severe pain can occur(Haddad et al, 2003; Williamson, 1995).
    b) LIONFISH: In one study, diaphoresis was reported in 1 (2%) of 45 patients following envenomation by lionfish (Kizer et al, 1985).
    c) SCORPION FISH: In one study (n=23), sweating was reported in 12 (52.2%) patients following envenomations by S. plumieri and 5 (21.7%) patients following envenomations by S. brasiliensis along the Brazilian coast (Haddad et al, 2003).
    d) SCORPION FISH: In one study, diaphoresis was reported in 1 (17%) of 6 patients following envenomation by lionfish (Kizer et al, 1985).
    D) NECROSIS
    1) WITH POISONING/EXPOSURE
    a) STONEFISH
    1) CASE REPORT: A 61-year-old man was envenomated on his right foot by a stonefish and was admitted 10 days later with a plantar cutaneous lesion. Findings included skin necrosis, edema and lymphangitis. The patient was started on antibiotic therapy (clindamycin, clarithromycin and imipenem) and underwent extensive surgical debridement which was closed by using a vacuum-assisted closure dressing. Histologic examination revealed a necrotic suppurating process and signs of vasculitis. The patient gradually improved but persistent edema and lymphangitis delayed the closure of the wound (by a full-thickness skin graft) for a month. At follow-up 3 years later, the patient had no functional disability with weight bearing or walking. (Nistor et al, 2010).
    2) CASE REPORT: A 47-year-old man stepped on a stonefish in the shallow waters of Cook Islands. Initial treatment consisted of analgesia, fluids, and hot water immersion. Eight days later, the patient presented with ischemia of the left great toe and necrosis over the plantar aspect of the first metatarsal head. Surgery revealed thrombosis of vessels to the forefoot tissue and great toe. Amputation of the great toe and first metatarsal head was necessary (Dall et al, 2006).
    E) FLUSHING
    1) WITH POISONING/EXPOSURE
    a) LIONFISH: In one study, facial flushing was reported in 1 (2%) of 45 patients following envenomation by lionfish (Kizer et al, 1985).

Musculoskeletal

    3.15.2) CLINICAL EFFECTS
    A) INCREASED MUSCLE TONE
    1) WITH POISONING/EXPOSURE
    a) Muscle contractions are common and usually due to pain. Muscle fasciculations are sometimes seen.
    B) JOINT PAIN
    1) WITH POISONING/EXPOSURE
    a) LIONFISH: Joint pain has been reported following envenomation of lionfish (Trestrail & al-Mahasneh, 1989).

Immunologic

    3.19.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Adenopathy has been reported following envenomation by scorpion fish.
    3.19.2) CLINICAL EFFECTS
    A) FINDING OF LYMPH NODE
    1) WITH POISONING/EXPOSURE
    a) SCORPION FISH: In one study (n=23), adenopathy was reported in 2 (8.7%) patients following envenomations by S. plumieri along the Brazilian coast (Haddad et al, 2003).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) For severe envenomations, monitor vital signs.
    C) Following a severe envenomation, obtain a baseline ECG and institute continuous cardiac monitoring.
    D) Monitor serum electrolytes in patients with significant vomiting and/or diarrhea.
    E) Soft-tissue ultrasound or radiographs of the sting site should be performed to evaluate for a retained spine, integumentary sheath or other foreign bodies. Regardless of the findings, direct exploration of the wound should be performed.

Radiographic Studies

    A) CHEST RADIOGRAPHY
    1) Following a severe envenomation with pulmonary symptoms, a chest radiograph may be indicated.
    B) FISH SPINES
    1) Soft-tissue radiographs of the sting site may reveal a retained integumentary sheath or other foreign body. Regardless of the x-ray findings direct exploration of the wound should be performed.
    2) Ultrasound may be preferred as it can detect radiolucent foreign bodies.

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) Any patients with cardiovascular toxicity or neurologic symptoms more severe than pain and mild paresthesias should be admitted.
    6.3.6.2) HOME CRITERIA/BITE-STING
    A) All patients should be sent to a medical facility for evaluation/treatment of the wound and treatment of any systemic symptoms.
    6.3.6.3) CONSULT CRITERIA/BITE-STING
    A) A medical toxicologist or poison center should be consulted on all severe envenomations or when antivenom administration is being considered.
    6.3.6.5) OBSERVATION CRITERIA/BITE-STING
    A) Patients with only local effects can be discharged once pain control is adequate and wound care is complete. Patients with stings that can cause systemic toxicity should be observed for 6 hours and may then be discharged if no systemic toxicity has developed.

Monitoring

    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) For severe envenomations, monitor vital signs.
    C) Following a severe envenomation, obtain a baseline ECG and institute continuous cardiac monitoring.
    D) Monitor serum electrolytes in patients with significant vomiting and/or diarrhea.
    E) Soft-tissue ultrasound or radiographs of the sting site should be performed to evaluate for a retained spine, integumentary sheath or other foreign bodies. Regardless of the findings, direct exploration of the wound should be performed.

Abstracts

Case Reports

    A) STONEFISH
    1) CASE REPORT: An adult stepped on a stonefish and became dyspneic over 15 minutes. By 35 minutes he developed blood-tingled sputum, respiratory rate of 60 and heart rate of 140 bpm. There were 6 puncture wounds; edema and erythema to the ankle. A chest film showed diffuse, fluffy, bilateral infiltrates. The patient was intubated, ventilated, and given 6000 units of antivenin. The wound was debrided and the foot soaked in water for 45 minutes. Ventilation was normal by the next morning; the lungs were clear (Lehmann & Hardy, 1993).

Range Of Toxicity

Summary

    A) TOXIC DOSE: Severe toxicity with systemic effects may be observed after a stonefish, lionfish, or scorpionfish sting. Fatalities have occurred but are very rare. Stonefish are considered the most venomous of fish.

Minimum Lethal Exposure

    A) SUMMARY
    1) Severe toxicity is likely to occur following a stonefish, lionfish, or scorpionfish sting.
    B) STONEFISH
    1) STONEFISH: Stonefish are considered the most venomous of fish (Yamamoto et al, 2010). Two patients developed severe pain, central cyanosis, pulmonary edema, coma, and died within an hour of stonefish envenomation in the foot (Williamson, 1995).
    C) ANIMAL STUDIES
    1) STONEFISH: In mice, intravenous injections were fatal within 30 minutes. LD50 (intraperitoneal) in mice was 1.3 to 2 mg/kg (Williamson, 1995).
    a) Synanceja verrucosa venom: LD50 (intravenous) in mouse: 200 mcg/kg IV (Saunders, 1959).
    b) Synanceja trachynis venom: LD50 (intraperitoneal) in mouse: 0.02 to 0.03 mg/mouse (Wiener, 1959).
    c) Synanceja trachynis venom: LD50 (subcutaneous) in mouse: 0.04 to 0.06 mg/mouse (Wiener, 1959).
    2) SCORPION FISH: Scorpaena plumieri venom: LD50 (intravenous) in mouse: 0.28 mg/kg IV; hemorrhagic, hemolytic, and proteolytic activities (Gomes et al, 2011; Gomes et al, 2010).

Maximum Tolerated Exposure

    A) CASE REPORT
    1) STONEFISH: A 33-year-old chef developed severe pain after being punctured in his finger by a spine of a stonefish while preparing the fish. The finger was throbbing with continuous pain and numbness extending into the palm of the hand. No systemic effects were observed. A spine was not detected but first aid measures included immersion in hot water. Severe symptoms resolved within 30 minutes. At follow-up, the patient reported that pain and tenderness lasted for approximately 18 hours (Yamamoto et al, 2010).
    2) CASE REPORT: A 12-year-old girl was swimming in the Red Sea of Aqaba and was envenomated by a stonefish (identified by a local guide) after stepping on the fish and developed immediate intense pain. She was transported immediately to the hospital and initial treatment included irrigation and immersion of the foot in warm water. Swelling of the foot was observed within 2 hours despite elevation. Therapy included stonefish antivenom (2000 Units/1 vial), antibiotic therapy and meperidine for severe pain. Significant pain continued the following day. By day 5, she had improved significantly and was transferred back to her home. The patient had a recurrence of poor wound healing about 6 weeks after envenomation, but improved with supportive care and did not require surgical intervention (Al-Ghananim et al, 2013).
    B) CASE SERIES
    1) SCORPION FISH: Twenty-three cases of stings by scorpion fishes of the genus Scorpaena occurred among fishermen along the Brazilian coast. In most cases, stings occurred on the hands and presented as puncture wounds. Fourteen envenomations were caused by black scorpionfish (S. plumieri), 8 were due to red scorpionfish (S. brasilienisis) and one fish was not identified. Systemic events occurred in 20 patients and included nausea, vomiting, profuse sweating, diarrhea, tachycardia, fever (not estimated), arrhythmia (that was not evaluated), agitation and malaise. Local events included intense pain, erythema, and edema. Treatment consisted of hot water immersion in 6 patients with good relief of pain and other home remedies were ineffective. Patients that were admitted to the hospital received systemic analgesics and pain was relieved in most patients within 24 hours with only one patient complaining of pain after 24 hours (Haddad et al, 2003)
    2) LIONFISH: In a series of 15 envenomations of aquarists in Brazil over a period of 18 years (1997-2014), intense pain, sometimes described as excruciating occurred in 14 victims. Most patients classified their pain as intense and it usually presented with behavioral changes, cold sweating and restlessness. Nausea and vomiting were the only systemic effects observed and were associated with pain symptoms (Haddad et al, 2015).
    C) ANIMAL STUDIES
    1) In animal studies, the subcutaneous injection of 4 mg Synanceia venom to guinea pig resulted in muscular weakness, coma, and death within 3 hours (Williamson, 1995).
    2) In animal studies, doses of scorpion fish (Scorpaena plumieri) venom (14 to 216 mcg protein/kg) given to rats resulted in a transient increase in the mean arterial pressure. Hypotension and death occurred after higher doses (338 mcg protein/kg). The administration of venom doses 108 mcg/kg or higher produced a temporary increase in heart rate followed by bradycardia. Dose-dependent positive ventricular chronotropic, inotropic, lusitropic and coronary vasoconstriction responses were observed following the administration of crude venom (5 to 80 mcg protein) in isolated rat hearts. The administration of prazosin and propranolol, adrenergic blockers, significantly attenuated all the responses to crude venom. It is concluded that the venom could be acting, at least partially, directly on the adrenoreceptors (presence of some adrenergic agonist in the venom) and/or indirectly (via the release of endogenous stores of norepinephrine from the sympathetic varicosities in the heart) (Gomes et al, 2010).

Pharmacology Toxicology

Toxicologic Mechanism

    A) The venoms of fishes vary considerably in their chemistry and pharmacology. The venom components of marine fishes have not been purified or characterized (Gomes et al, 2010).
    B) The main toxic substance in Scorpaenidae venom is believed to be a nondialyzable, heat-labile protein. Although the venom is similar for all the Scorpaenidae species, they have different potency (Kizer et al, 1985). After the animal's death, the venom will still have full potency for at least 24 to 48 hours (Trestrail & al-Mahasneh, 1989; Brenneke & Hatz, 2006).
    C) SCORPION FISH
    1) Scorpaena plumieri venom possesses hemorrhagic, hemolytic, and proteolytic activities (Gomes et al, 2011; Gomes et al, 2010).
    2) In animal studies, doses of scorpion fish (Scorpaena plumieri) venom (14 to 216 mcg protein/kg) given to rats resulted in a transient increase in the mean arterial pressure. Hypotension and death occurred after higher doses (338 mcg protein/kg). The administration of venom doses 108 mcg/kg or higher produced a temporary increase in heart rate followed by bradycardia. Dose-dependent positive ventricular chronotropic, inotropic, lusitropic and coronary vasoconstriction responses were observed following the administration of crude venom (5 to 80 mcg protein) in isolated rat hearts. The administration of prazosin and propranolol, adrenergic blockers, significantly attenuated all the responses to crude venom. It is concluded that the venom could be acting, at least partially, directly on the adrenoreceptors (presence of some adrenergic agonist in the venom) and/or indirectly (via the release of endogenous stores of norepinephrine from the sympathetic varicosities in the heart) (Gomes et al, 2010).
    D) STONEFISH
    1) Stonefish venom appears to have a variety of biological activities, such as cytolitic, neurotoxic, cardiotoxic, neuromuscular, edematogenic and hemolytic. The toxin has a high molecular mass (approximately 150 kDa). Lethal toxins have been purified from S. horrida (stonustoxin) (Gomes et al, 2010).
    2) Some early experiments showed that Synanceja venom contains a non-specific myotoxin that acts on skeletal, involuntary, and cardiac muscle (Austin et al, 1961).
    3) In one animal study, it was suggested that the cardiovascular effects of stonefish venom are mediated mainly by action at muscarinic receptors and adrenoreceptors. It is added that the action on adrenoreceptors is mainly direct, rather than by the release of endogenous catecholamines. However, it is not clear if the action at muscarinic receptors is caused by the presence of acetylcholine or a related substance in the venom or by the release of endogenous acetylcholine by the venom (Church & Hodgson, 2000).

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