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WEEVER FISH

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Weever fishes are small venomous fishes. Stings from weever fishes are very painful. They are a potentially serious problem for fishermen who work in sandy or muddy bays. Overall, there are hundreds of people stung by weever fishes each year. Most of these are not serious, and are not seen in a healthcare setting.

Specific Substances

    1) Echiichthys vipera
    2) Greater weeverfish
    3) Lesser weeverfish (Echiichthys vipera)
    4) Trachinidae
    5) Trachinus araneus (Araneus weeverfish)
    6) Trachinus draco (Greater weeverfish)
    7) Trachinus radiatus (Vive a tete rayonnee)
    8) Trachinus vipera (Lesser weeverfish)
    9) Vive a tete rayonnee
    10) Weever

Overview

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) DESCRIPTION/BACKGROUND: Weever fishes are small venomous fishes. Stings from weever fishes are very painful. They are a potentially serious problem for fishermen who work in sandy or muddy bays. Even in dead fish, the toxin remains potent for hours. Weever fish are often found buried in the sand and the slightest disturbance results in the dorsal spine becoming erect and may cause a single or multiple puncture wounds to bathers. Wearing protective shoes may be helpful but weever fish spines can penetrate tennis shoes or diving booties.
    B) TOXICOLOGY: In most cases weever fish stings cause intense local pain and carry the potential for infection as these are puncture wounds that may contain retained fragments of the sting apparatus and waterborne bacteria. The venom may contain several peptides, a protein of high molecular weight (dracotoxin), a kinin or kinin-like substance, serotonin, epinephrine, norepinephrine, histamine, 5-hydroxytryptamine, and several enzymes.
    C) EPIDEMIOLOGY: A large number of venomous fishes are encountered worldwide. The actual incidence of weever fish stings is unknown because likely many exposures go unreported. Severe envenomations from poisonous weever fish are rare. Deaths have been reported following weever stings; however, the exact cause of death could not be established. Secondary infection may occur. Septicemic death has been reported.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Wounds by weever fish are puncture-type and may be multiple. The initial symptom is an intense burning pain that lasts for up to 24 hours. Local erythema, swelling, tingling and numbness around the wound are common. Edema starts at the puncture site, but progresses to the entire extremity within 30 to 60 minutes. The affected limb is commonly edematous for up to 10 days. but cases have been reported where the swelling lasted for more than a year. Wounds may develop infections secondary to the injury.
    2) SEVERE TOXICITY: Weever fish stings cause particularly severe pain. Patients with severe pain may also experience nausea, vomiting and abdominal pain following severe envenomations. Severe reactions may rarely produce tachycardia or bradycardia, hypotension, syncope, aphonia, and respiratory distress. Secondary infection may occur, producing lymphangitis, lymphadenitis, pyogenesis, necrosis, or gangrene. Septicemic death has been reported.
    0.2.20) REPRODUCTIVE
    A) At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.

Laboratory Monitoring

    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) Monitor vital signs following severe envenomations.
    C) Monitor serum electrolytes in patients with significant vomiting.
    D) Soft-tissue radiographs or ultrasound of the sting site may reveal a retained spine or other foreign bodies. Regardless of the x-ray 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 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. ANTIBIOTICS: Wounds may become infected. Antibiotic choice should be guided by culture results.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) 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. HYPOTENSIVE EPISODE: Administer IV 0.9% saline, add vasopressors, if hypotension persists.
    C) PAIN
    1) Submerge the injured part in hot water (less than 113 degrees F or 45 degrees C) at as high a temperature as the patient can tolerate without injury to the skin for 30 to 90 minutes or more. Control pain with NSAIDs or oral or parenteral opioids. Digital nerve block or local anesthesia 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.
    D) WOUND CARE
    1) Attempt to remove the spines if they can be seen in the wound. The following method has been used to remove sea urchin spines and should be considered for fish spines: radiographic localization of the spine is recommended to determine joint disruption or bony penetration to determine the number of spines and degree of serration. Inject a 1.5 mL bolus of subcutaneous lidocaine into each lateral surface of the involved phalanx to produce tumescent local anesthesia. Use the point of a scalpel blade to nick the apex of the edematous wound or site of maximal discoloration or pain to extrude the spine. Culture any liquid discharge as indicated. Irrigate the wound thoroughly.
    E) AIRWAY MANAGEMENT
    1) Airway management is unlikely to be necessary except in rare cases of severe allergic reactions or severe respiratory distress.
    F) ANTIDOTE
    1) None. Several sources have reported the availability of a horse antiserum for intravenous use against weever fish sting in Yugoslavia (institute of Immunology, Rockerfellerova 2, Zagreb); however, there are no published articles regarding its use.
    G) PATIENT DISPOSITION
    1) HOME CRITERIA: Most patients with mild pain and/or trivial wounds can be managed at home with local wound care.
    2) OBSERVATION CRITERIA: Patients with significant pain or wounds that require debridement should be referred to a healthcare facility for evaluation and treatment.
    3) ADMISSION CRITERIA: Patients with wounds that become secondarily infected or skin necrosis should be admitted.
    4) CONSULT CRITERIA: A medical toxicologist or poison center should be consulted on all severe envenomations. Consult a surgeon if skin necrosis develops.
    H) 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.
    I) PHARMACOKINETICS
    1) Absorption occurs rapidly following envenomation.
    J) DIFFERENTIAL DIAGNOSIS
    1) Sea snake envenomation, jelly fish envenomation, or dinoflagellate poisoning may be mistaken for a fish sting envenomation.

Life Support

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

Range Of Toxicity

    A) TOXICITY: One sting will produce symptoms. Not all stings are equally severe. Many of the stings do not require medical attention. Deaths have been reported following weever stings; however, the exact cause of death could not be established. Secondary infection may occur. Septicemic death has been reported.

Clinical Effects

Summary Of Exposure

    A) DESCRIPTION/BACKGROUND: Weever fishes are small venomous fishes. Stings from weever fishes are very painful. They are a potentially serious problem for fishermen who work in sandy or muddy bays. Even in dead fish, the toxin remains potent for hours. Weever fish are often found buried in the sand and the slightest disturbance results in the dorsal spine becoming erect and may cause a single or multiple puncture wounds to bathers. Wearing protective shoes may be helpful but weever fish spines can penetrate tennis shoes or diving booties.
    B) TOXICOLOGY: In most cases weever fish stings cause intense local pain and carry the potential for infection as these are puncture wounds that may contain retained fragments of the sting apparatus and waterborne bacteria. The venom may contain several peptides, a protein of high molecular weight (dracotoxin), a kinin or kinin-like substance, serotonin, epinephrine, norepinephrine, histamine, 5-hydroxytryptamine, and several enzymes.
    C) EPIDEMIOLOGY: A large number of venomous fishes are encountered worldwide. The actual incidence of weever fish stings is unknown because likely many exposures go unreported. Severe envenomations from poisonous weever fish are rare. Deaths have been reported following weever stings; however, the exact cause of death could not be established. Secondary infection may occur. Septicemic death has been reported.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Wounds by weever fish are puncture-type and may be multiple. The initial symptom is an intense burning pain that lasts for up to 24 hours. Local erythema, swelling, tingling and numbness around the wound are common. Edema starts at the puncture site, but progresses to the entire extremity within 30 to 60 minutes. The affected limb is commonly edematous for up to 10 days. but cases have been reported where the swelling lasted for more than a year. Wounds may develop infections secondary to the injury.
    2) SEVERE TOXICITY: Weever fish stings cause particularly severe pain. Patients with severe pain may also experience nausea, vomiting and abdominal pain following severe envenomations. Severe reactions may rarely produce tachycardia or bradycardia, hypotension, syncope, aphonia, and respiratory distress. Secondary infection may occur, producing lymphangitis, lymphadenitis, pyogenesis, necrosis, or gangrene. Septicemic death has been reported.

Heent

    3.4.6) THROAT
    A) WITH POISONING/EXPOSURE
    1) APHONIA: Aphonia has occurred (Halstead, 1978).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) TACHYCARDIA
    1) WITH POISONING/EXPOSURE
    a) Tachycardia may occur as a reaction to weever fish stings (Halstead, 1978).
    B) BRADYCARDIA
    1) WITH POISONING/EXPOSURE
    a) Bradycardia has been reported after an envenomation (Halstead, 1980).
    C) HYPOTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) Hypotension has been reported as a result of envenomation (Cain, 1983) .
    D) RAYNAUD'S PHENOMENON
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 47-year-old man developed intense pain after being stung on the fourth finger of the right hand by a weever fish. He immersed his finger in ice water several times for a few minutes to relieve the pain. His finger became erythematous and edematous for a few days, but his symptoms gradually resolved over the next 2 weeks. He presented 6 weeks later with paroxysmal blanching, numbness, and coldness. His symptoms worsened following exposure to cold. An infrared thermogram revealed marked hypothermia of the fourth finger of the right hand. He received nifedipine (10 mg orally 3 times daily) after a diagnosis of Raynaud's phenomenon was made. It is suggested that the combination of the vasoconstrictor effect of the venom and ice water immersion caused the cutaneous neurovascular damage (Carducci et al, 1996).
    3.5.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) HYPOTENSION
    a) Intravenous injection into animals produces profound hypotension (Evans, 1907a; Evans, 1907b; Russell & Emery, 1960). Experimental evidence would indicate the hypotension was cardiogenic in nature (Skeie, 1962c).
    2) DYSRHYTHMIAS
    a) RHYTHM CHANGES: Experimental studies indicated that the venom may cause both rhythm changes and direct cardiac tissue damage, but that actual damage to the heart was minor (Russell & Emery, 1960).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) DYSPNEA
    1) WITH POISONING/EXPOSURE
    a) Respiratory distress can occur, with a feeling of choking (Skeie, 1966).
    B) CYANOSIS
    1) WITH POISONING/EXPOSURE
    a) Cyanosis has been reported after an envenomation (Halstead, 1980).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) PAIN
    1) WITH POISONING/EXPOSURE
    a) ONSET: A sting causes immediate burning, stabbing pain that reaches a peak in under 30 minutes. Victims may scream in agony, and move about uncontrollably. DURATION: If untreated, the pain can last 2 to 24 hours (Emerson, 2012; Halpern et al, 2002; Williamson, 1995; Halstead, 1978). Feelings of irritation and discomfort may persist especially with weight bearing following a sting on the foot (Davies & Evans, 1996).
    b) CASE REPORT: A 47-year-old man developed intense pain after being stung on the fourth finger of the right hand by a weever fish. He immersed his finger in ice water several times for a few minutes to relieve the pain. His finger became erythematous and edematous for a few days, but his symptoms gradually resolved over the next 2 weeks. He presented 6 weeks later with paroxysmal blanching, numbness, and coldness. His symptoms worsened following exposure to cold. An infrared thermogram revealed marked hypothermia of the fourth finger of the right hand. He received nifedipine (10 mg orally 3 times daily) after a diagnosis of Raynaud's phenomenon was made (Carducci et al, 1996).
    c) CASE REPORT: A 38-year-old woman was admitted with a 2 month history of foot pain after stepping on a weever fish while bathing. Initially, severe pain occurred and lasted for several hours. However, she continued to have pain in her foot with increasing difficulty upon weight bearing. She also reported 3 episodes of infection and was treated with antibiotics. Upon examination, an indurated area (approximately 2 cm) was found on the plantar aspect of her foot with a central area of discoloration that was consistent with a foreign body. Following surgical exploration, a foreign body was not found but a small amount of pus was present. Cultures were obtained. Mixed bacterial growth was present but the count was low and a histology exam showed an inflammatory fibrosis with a foreign body giant cell reaction surrounding foreign material. The incision was closed and the wound healed well with no further symptoms (Mulcahy et al, 1996).
    B) PARESTHESIA
    1) WITH POISONING/EXPOSURE
    a) Tingling and numbness around the puncture site may follow the initial pain (Halstead, 1978).
    C) SYNCOPE
    1) WITH POISONING/EXPOSURE
    a) Syncope has been reported after an envenomation (Halstead, 1957; Halstead & Modglin, 1958).
    D) SECONDARY PERIPHERAL NEUROPATHY
    1) WITH POISONING/EXPOSURE
    a) Peripheral neuritis and ankylosis was noted for at least 3 years in one patient who was stung on the finger. There was actual finger atrophy (Bottard, 1885).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) GASTROINTESTINAL TRACT FINDING
    1) WITH POISONING/EXPOSURE
    a) Abdominal pain, nausea and vomiting may occur after a sting (Cain, 1983; Halstead, 1957).

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) URINARY SYSTEM FINDING
    1) WITH POISONING/EXPOSURE
    a) URGENCY: After being stung, there may be a need to urinate (Halstead, 1978).

Hematologic

    3.13.2) CLINICAL EFFECTS
    A) HEMOLYSIS
    1) WITH POISONING/EXPOSURE
    a) The venom contains a hemolyzing agent (Evans, 1907a; Evans, 1907b); the agent's effects can be seen experimentally (Skeie, 1966). Hemolysis has not bee reported in clinical cases.
    B) HEMORRHAGE
    1) WITH POISONING/EXPOSURE
    a) Although weever fish puncture wounds do not in general bleed heavily, the sting of T. vipera may bleed freely (Maretic, 1982).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) SKIN FINDING
    1) WITH POISONING/EXPOSURE
    a) Local erythema and swelling around the wound are common. Edema starts at the puncture site, but progresses to the entire extremity within 30 to 60 minutes. The affected limb is commonly edematous for up to 10 days (Davies & Evans, 1996; Williamson, 1995; Halstead, 1978; Auerbach, 1988), but cases have been reported where the swelling lasted for more than a year (Maretic, 1982).
    b) Significant local tissue damage and gangrene have also been reported (Williamson, 1995).
    3.14.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) INJECTION SITE NECROSIS
    a) Animals treated with intramuscular or subcutaneous injections of the venom developed necrosis at the injection site (Skeie, 1962c).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) ACUTE ALLERGIC REACTION
    1) WITH POISONING/EXPOSURE
    a) Severe acute allergic reaction may occur (Williamson, 1995).

Reproductive

    3.20.1) SUMMARY
    A) At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.
    3.20.2) TERATOGENICITY
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the teratogenic potential of this agent.
    3.20.3) EFFECTS IN PREGNANCY
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.

Carcinogenicity

    3.21.3) HUMAN STUDIES
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the carcinogenic potential of this agent.

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) Monitor vital signs following severe envenomations.
    C) Monitor serum electrolytes in patients with significant vomiting.
    D) Soft-tissue radiographs or ultrasound of the sting site may reveal a retained spine or other foreign bodies. Regardless of the x-ray findings, direct exploration of the wound should be performed.

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 with wounds that become secondarily infected or skin necrosis should be admitted.
    6.3.6.2) HOME CRITERIA/BITE-STING
    A) Most patients with mild pain and/or trivial wounds can be managed at home with local wound care.
    6.3.6.3) CONSULT CRITERIA/BITE-STING
    A) A medical toxicologist or poison center should be consulted on all severe envenomations. Consult a surgeon if skin necrosis develops.
    6.3.6.5) OBSERVATION CRITERIA/BITE-STING
    A) Patients with significant pain or wounds that require debridement should be referred to a healthcare facility for evaluation and treatment.

Monitoring

    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) Monitor vital signs following severe envenomations.
    C) Monitor serum electrolytes in patients with significant vomiting.
    D) Soft-tissue radiographs or ultrasound of the sting site may reveal a retained spine or other foreign bodies. Regardless of the x-ray findings, direct exploration of the wound should be performed.

Range Of Toxicity

Summary

    A) TOXICITY: One sting will produce symptoms. Not all stings are equally severe. Many of the stings do not require medical attention. Deaths have been reported following weever stings; however, the exact cause of death could not be established. Secondary infection may occur. Septicemic death has been reported.

Minimum Lethal Exposure

    A) Deaths have been reported following weever stings (Halstead, 1957; Halstead & Modglin, 1958; Evans, 1943; Russell & Emery, 1960; Skeie, 1962b; Skeie, 1962e); however, the exact cause of death could not be established.

Maximum Tolerated Exposure

    A) As few as one sting will cause symptoms. Not all stings produce equal severity. Many of the stings do not require medical attention.
    B) CASE SERIES
    1) In a case series of fisherman (n=79) from the Israeli Mediterranean Coast, the most common injury reported by fisherman were due to stingrays (n=24; 30.4%) followed by weever fish (n=17; 21.5%), rabbit fish (n=10; 12.7%) and stripped sea catfish (n=8; 10.1%) and the remaining cases were due other fish. Most injuries were due to envenomation (80%) compared to secondary infections (11.5%) or other injuries. Most cases were of moderate (53%) or minor severity (29%) and 9% reported no effect. The remaining 9% of cases were considered severe (ie, loss of a finger, permanent severe scar). Secondary infections and an injury by a stingray (Dasyatis pastinaca) produced the greatest pain and toxicity resulting in 3 cases of hospitalization for over 10 days. No deaths occurred (Gweta et al, 2008).

Toxicity Information

    7.7.1) TOXICITY VALUES

Pharmacology Toxicology

Toxicologic Mechanism

    A) VENOM
    1) The venom of weever fish is a protein mixture that is antigenic and labile with storage and handling. It can cause peripheral vascular disorders (Williamson, 1995). The venom may contain several peptides, a protein of high molecular weight (dracotoxin), a kinin or kinin-like substance, serotonin, epinephrine, norepinephrine, histamine, 5-hydroxytryptamine, and several enzymes. Dracotoxin has toxic membrane depolarizing and hemolytic activities (Halpern et al, 2002; Carducci et al, 1996; Russell, 1983).
    2) The venom is known to contain a hemolytic agent (Briot, 1902).
    3) TRACHINUS VIPER (Lesser Weever) Venom: Thought to contain 5-hydroxy-typtamine and a small molecular histamine releaser (Carlisle, 1962).
    4) TRACHINUS DRACO (Greater Weever) Venom: Thought to contain histamine, cholinesterase, adrenaline, and noradrenaline (Haavaldsen & Fonnum, 1963).

References

General Bibliography

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