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CHIRODROPID COELENTERATES

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) The chirodropid coelenterates are from the cubozoan class of jellyfish and are considered the most lethal order of all of the coelenterates, responsible for over 70 human fatalities in the past century. They have up to 60 tentacles attached to a transparent bell, making them virtually invisible in the water.

Specific Substances

    A) CHIRONEX FLECKERI
    1) C. fleckeri
    2) Box jellyfish
    3) Cubomedusan
    4) Cubo
    5) Fire medusa
    6) Indringa
    7) Sea stinger
    8) Sea wasp
    CHIROPSALMUS QUADRIGATUS
    1) C. quadrigatus
    2) Sea wasp
    3) Habu-kurage (Japanese)
    CHIROPSALMUS QUADRUMANUS
    1) C. quadrumanus

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: These are members of the cubozoan class of jelly fish. Their bodies are clear and difficult to see in water. The tentacles contain nematocysts that fire and inject venom when touched.
    B) TOXICOLOGY: The venoms are complex mixtures that have hemolytic, dermatonecrotic, and neurotoxic effects.
    C) EPIDEMIOLOGY: Chironex fleckeri is predominantly found in northern Australian waters, from Gladstone in Queensland to Broome in western Australia. Chiropsalmus quadrigatus are generally located in the Indian Ocean, along the northern Australian coastline, in the Philippines, and in Japan. Chiropsalmus quadrumanus are found in the Gulf of Mexico and in Brazilian coastal waters. Stings can cause severe toxicity and can be rapidly fatal. The severity of envenomation is related to the size of the jellyfish and length of the tentacles.
    D) WITH POISONING/EXPOSURE
    1) MILD EFFECTS: The most common syndrome is immediate pain followed by an erythematous urticarial eruption. Acute local effects may include severe pain, skin eruption with a frosted, cross-hatching appearance, and dermal necrosis that may occur within 24 hours postexposure.
    2) SEVERE SYSTEMIC EFFECTS: Acute respiratory distress, severe parasympathetic dysfunction (abdominal distention, urinary retention, dry eyes), cyanosis, hemolysis, dysrhythmias, and cardiac arrest may occur following Chirodropid envenomations. Death can occur within minutes of exposure and is typically due to cardiac and/or respiratory failure. In adults, envenomations involving at least 6 meters in tentacle length have resulted in loss of consciousness within minutes. In children, envenomations involving 2 to 4 meters in tentacle length have resulted in death.

Laboratory Monitoring

    A) Monitor vital signs, mental status and pulse oximetry following chirodropid coelenterate envenomations.
    B) Monitor serum electrolytes, renal function, and CBC for evidence of hemolysis.
    C) Institute continuous cardiac monitoring and obtain an ECG after severe envenomation.

Treatment Overview

    0.4.7) BITES/STINGS
    A) SUPPORT
    1) MILD ENVENOMATION: Once nematocysts are deactivated with vinegar and removed, apply ice and use oral acetaminophen or NSAIDs for pain relief.
    2) SEVERE ENVENOMATION: Assisted ventilation is likely to be required. Obtain intravenous access. Treat hypotension with fluids, add vasopressors if necessary. Patients with severe envenomation should receive antivenom.
    B) DECONTAMINATION
    1) Bathe the affected part liberally with sea water. Do not use fresh or hot water as it may cause firing of nematocysts. Apply vinegar (4% to 6% acetic acid) for 30 minutes. Vinegar may irritate the stings, but should still be applied to inhibit nematocyst firing. The remaining tentacles, parts of the animal and nematocysts must be removed manually, ideally using a stick, another implement or a well gloved hand to avoid envenomation of the rescuer.
    C) AIRWAY MANAGEMENT
    1) Patients with severe envenomation are likely to require early endotracheal intubation and mechanical ventilation.
    D) HYPERSENSITIVITY REACTION
    1) MILD/MODERATE: Antihistamines with or without inhaled beta agonists, corticosteroids or epinephrine. SEVERE: Oxygen, aggressive airway management, antihistamines, epinephrine, corticosteroids, ECG monitoring, and IV fluids.
    E) ANTIVENOM
    1) For life-threatening stings or if significant dysrhythmias are present, administer 20,000 units (1 ampule) of Chironex fleckeri antivenin IV diluted 1:10 with an isotonic crystalloid solution and give over 5 to 10 minutes. If unresponsive, up to 60,000 units (3 ampules) may be given IV consecutively.
    F) PATIENT DISPOSITION
    1) HOME CRITERIA: A patient with mild pain and a sting that only involves a small area of skin who do not have systemic effects can be monitored at home once nematocysts have been deactivated and removed.
    2) OBSERVATION CRITERIA: Patients with more severe pain, large surface area of stings, or any systemic effects should be evaluated at a health care facility.
    3) ADMISSION CRITERIA: Patients with severe persistent pain or systemic effects should be admitted.
    4) CONSULT CRITERIA: Consult a toxinologist, medical toxicologist or poison center for any patient with severe envenomation or in whom the diagnosis is unclear.
    G) PITFALLS
    1) Application of fresh water can cause firing of nematocysts and worsening envenomation. Removed tentacles with a stick, another implement or a well gloved hand to avoid envenomation of the rescuer.
    H) TOXICOKINETICS
    1) Onset of severe pain is very rapid, generally within minutes. Patients with severe envenomation generally develop decreased consciousness and collapse within several minutes to an hour of the sting. In more moderate envenomations pain may persist for several hours to a few days.
    I) DIFFERENTIAL DIAGNOSIS
    1) Irukandji syndrome, sea snake bite, anaphylaxis, or a sting from another jellyfish.

Range Of Toxicity

    A) In adults, chirodropid envenomations, involving greater than 6 meters of total tentacle length, may result in loss of consciousness within minutes. Envenomations, involving a minimum of 50 feet (approximately 15 meters) of total tentacle length, are estimated to be fatal.
    B) In children, chirodropid envenomations, involving a total tentacle length of approximately 1 to 4 meters, have been fatal.

Clinical Effects

Summary Of Exposure

    A) BACKGROUND: These are members of the cubozoan class of jelly fish. Their bodies are clear and difficult to see in water. The tentacles contain nematocysts that fire and inject venom when touched.
    B) TOXICOLOGY: The venoms are complex mixtures that have hemolytic, dermatonecrotic, and neurotoxic effects.
    C) EPIDEMIOLOGY: Chironex fleckeri is predominantly found in northern Australian waters, from Gladstone in Queensland to Broome in western Australia. Chiropsalmus quadrigatus are generally located in the Indian Ocean, along the northern Australian coastline, in the Philippines, and in Japan. Chiropsalmus quadrumanus are found in the Gulf of Mexico and in Brazilian coastal waters. Stings can cause severe toxicity and can be rapidly fatal. The severity of envenomation is related to the size of the jellyfish and length of the tentacles.
    D) WITH POISONING/EXPOSURE
    1) MILD EFFECTS: The most common syndrome is immediate pain followed by an erythematous urticarial eruption. Acute local effects may include severe pain, skin eruption with a frosted, cross-hatching appearance, and dermal necrosis that may occur within 24 hours postexposure.
    2) SEVERE SYSTEMIC EFFECTS: Acute respiratory distress, severe parasympathetic dysfunction (abdominal distention, urinary retention, dry eyes), cyanosis, hemolysis, dysrhythmias, and cardiac arrest may occur following Chirodropid envenomations. Death can occur within minutes of exposure and is typically due to cardiac and/or respiratory failure. In adults, envenomations involving at least 6 meters in tentacle length have resulted in loss of consciousness within minutes. In children, envenomations involving 2 to 4 meters in tentacle length have resulted in death.

Heent

    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) DRY EYES: A 52-year-old man initially developed profuse lacrimation that progressed to no lacrimation following envenomation by a jellyfish. A Schirmer's test, performed to determine the amount of lacrimation, showed that lacrimation was 0 mL at the end of 5 minutes (normal: 10 to 12 mL in 5 minutes). One month post-envenomation, a second Schirmer's test showed lacrimation of 5 mL at 5 minutes (Chand & Selliah, 1984). The jellyfish, described by the patient as whitish in color with a bell width of approximately 0.3 meters and the tentacle length of 1 meter, was identified by a marine biologist as a Chironex fleckeri jellyfish.

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) CONDUCTION DISORDER OF THE HEART
    1) WITH POISONING/EXPOSURE
    a) Dysrhythmias may occur following severe Chironex fleckeri envenomations (Currie & Jacups, 2005; Currie, 2003; Currie, 2000).
    B) TACHYCARDIA
    1) WITH POISONING/EXPOSURE
    a) Sinus tachycardia (initial pulse rate of 160 bpm) was reported in a 14-year-old girl following C. fleckeri envenomation (Beadnell et al, 1992).
    C) HYPOTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 14-year-old girl presented with severe pain, dyspnea, tachycardia (141 bpm), and hypotension (85/65 mmHg) less than one hour following a jellyfish sting. Numerous tentacle marks, with a cross-hatched ladder pattern typical of a chirodropid sting, were observed on both legs. Twenty minutes after presentation, following administration of IV fluids, the patient's pulse rate decreased to 130 bpm, but her blood pressure increased to 155/110 mmHg. The patient was given 2 courses of Chironex antivenom (3 ampules IM prior to hospital presentation and one ampule IV 1.5 hours after presentation). Within 30 minutes of the second dose of antivenom, the patient's pulse rate and blood pressure decreased to 111 bpm and 100/65 mmHg, respectively (Beadnell et al, 1992). Over the next 2 days, the patient's dyspnea and pain resolved and she was discharged without sequelae.
    D) CARDIAC ARREST
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 5-year-old boy presented in cardiac arrest approximately 20 minutes after being stung by a jellyfish. Within 4 to 5 minutes of envenomation, the area was doused with 650 mL of vinegar (4% to 6% acetic acid). The child was immediately transported to a hospital where he presented as comatose, apneic, and pulseless, with peripheral and central cyanosis, and urticarial wheals on his legs, hands and lower abdomen. The child did not respond to resuscitative measures and he was pronounced dead approximately 40 minutes post envenomation. Postmortem skin scrapings, from the child, helped to identify Chironex fleckeri as the causative organism (Lumley et al, 1988).
    b) CASE REPORT: Cardiorespiratory arrest occurred in a 3-year-old girl several minutes following jellyfish envenomation. Despite administration of Chironex fleckeri antivenom (3 vials) intramuscularly (no IV access available) and aggressive resuscitation attempts, including CPR, administration of cardioactive drugs (ie, epinephrine, atropine intramuscularly) and electrical cardioversion, the patient was pronounced dead 110 minutes post envenomation. The tentacle contact length, visible on the child, was 1.2 meters. A sticky tape sample indicated that the multiple nematocysts were consistent with C. fleckeri (Currie & Jacups, 2005).
    c) CASE REPORT: A 45-year-old woman was stung while swimming. She develop immediate severe pain and then collapsed. She was taken ashore and CPR was started but she could not be resuscitated. She had lesions on her legs consistent with chirodropid sting (Lippmann et al, 2011).
    3.5.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) CARDIOVASCULAR EFFECTS
    a) RATS - Intravenous administration of Chiropsalmus quadrigatus venom, 0.2 to 5 mcg protein/kg, to anesthetized rats resulted in hypertension, approximately 15 to 30 seconds post-exposure. Following the hypertension, at venom doses greater than 2 mcg/kg, hypotension occurred with decreased pulse pressure. Bradycardia and transient increases in femoral blood flow occurred approximately 1 minute after intravenous administration of venom at doses of 0.2 to 5 mcg/kg. Death due to cardiac arrest was reported in 5 of 8 rats and 6 of 6 rats who received 5 mcg/kg and 10 mcg/kg of venom, respectively (Noguchi et al, 2005).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) BRONCHOSPASM
    1) WITH POISONING/EXPOSURE
    a) Wheezing has been noted after stings of Chironex fleckeri (Laing & Harrison, 1991).
    b) CASE REPORT: A 52-year-old man developed difficulty in breathing, coughing, wheezing, and profuse lacrimation a few minutes after being stung by a jellyfish. Symptoms subsided within 30 minutes post-envenomation. The jellyfish, described as whitish in color with a bell width of approximately 0.3 meters and a tentacle length of 1 meter, was identified by a marine biologist as a Chironex fleckeri jellyfish (Chand & Selliah, 1984).
    B) CYANOSIS
    1) WITH POISONING/EXPOSURE
    a) Peripheral and central cyanosis have been reported in several individuals following chirodropid envenomations (Bengston et al, 1991; Lumley et al, 1988; Williamson et al, 1984; Williamson et al, 1980).
    C) ACUTE LUNG INJURY
    1) WITH POISONING/EXPOSURE
    a) Pulmonary edema was observed 1 hour after Chironex envenomation (Beadnell et al, 1992).
    b) CASE REPORT: Central cyanosis, tachypnea, and oliguria were reported in a 5-year-old girl following a C. fleckeri envenomation. A chest x-ray revealed interstitial pulmonary edema. The child recovered with supportive care (Williamson et al, 1984).
    c) CASE REPORT: A 4-year-old child was stung by a jellyfish while swimming in the Gulf of Mexico and experienced immediate pain. Initially, the jellyfish tentacles were removed from the child's left arm and meat tenderizer was applied to the affected area. On route to the hospital, the child became somnolent and listless approximately 20 minutes post-exposure. On presentation to the ED, approximately 40 minutes post-envenomation, he was cyanotic and limp with fixed and dilated pupils. There were no spontaneous movements or respiratory activity and an ECG showed no cardiac activity. A chest roentgenogram showed massive pulmonary edema. Resuscitative measures were unsuccessful and the child was pronounced dead approximately 1.5 hours following envenomation. Post-mortem skin scrapings revealed coelenterate nematocytes that resembled nematocytes from Chiropsalmus quadrumanus (Bengston et al, 1991).
    D) APNEA
    1) WITH POISONING/EXPOSURE
    a) Respiratory arrest without circulatory arrest may occur following multi-tentacled box jellyfish envenomations (Williamson et al, 1995).
    b) Neuromuscular paralysis leading to respiratory arrest may occur following Chironex fleckeri stings (Holmes, 1996).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) PARALYSIS
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Ulnar nerve palsy was noted a day or two after stings by Chironex fleckeri. The palsy lasted 4 months (Laing & Harrison, 1991).
    b) Neuromuscular paralysis leading to respiratory arrest may occur following Chironex fleckeri stings (Holmes, 1996).
    B) LOSS OF CONSCIOUSNESS
    1) WITH POISONING/EXPOSURE
    a) With severe stings, excruciating pain at the site of the sting is often followed within minutes by decreased consciousness or collapse. Apnea and cardiac arrest may develop shortly after the patient collapses (Thaikruea et al, 2012).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) NAUSEA AND VOMITING
    1) WITH POISONING/EXPOSURE
    a) Nausea and vomiting, along with severe pain, respiratory distress and malaise, were reported in several individuals who were stung by Chiropsalmus quadrumanus while in the waters of the southeastern coast of Brazil (Haddad et al, 2002).
    B) SWOLLEN ABDOMEN
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 52-year-old man was stung on his thighs by a jellyfish and, approximately 2 hours later, developed abdominal distention and urinary retention. On examination, the patient's abdomen showed gaseous distention and the presence of peristaltic sounds. An abdominal x-ray revealed distention of the intestinal loops. The patient recovered within a week following supportive care (Chand & Selliah, 1984). The jellyfish, described by the patient as whitish in color with a bell width of approximately 0.3 meters and the tentacle length of 1 meter, was identified by a marine biologist as a Chironex fleckeri jellyfish.

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) ACUTE RETENTION OF URINE
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 52-year-old man was stung on his thighs by a jellyfish and, approximately 2 hours later, developed abdominal distention and urinary retention. On examination, the patient's urinary bladder was distended 4 centimeters above the symphysis pubis. With supportive care, bladder function returned to normal 2 days later (Chand & Selliah, 1984). The jellyfish, described by the patient as whitish in color with a bell width of approximately 0.3 meters and the tentacle length of 1 meter, was identified by a marine biologist as a Chironex fleckeri jellyfish.

Hematologic

    3.13.2) CLINICAL EFFECTS
    A) HEMOLYSIS
    1) WITH POISONING/EXPOSURE
    a) Hemolytic activity has been identified in the venom of Chironex fleckeri and Chiropsalmus quadrigatus, but it is not a significant part of the clinical envenomation syndrome in humans (Nagai et al, 2002; Comis et al, 1989).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) HYPERSENSITIVITY REACTION
    1) WITH POISONING/EXPOSURE
    a) Delayed hypersensitivity reactions occurred in 11 of 19 patients following Chironex fleckeri stings. The reactions consisted of a pruritic erythematous maculopapular rash that appeared at the initial tentacle contact points and occurred 7 to 14 days after envenomation (O'Reilly et al, 2001). The reactions spontaneously resolved in 7 patients, and 4 patients recovered following treatment with oral antihistamines and topical corticosteroids.

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) JELLYFISH STING
    1) WITH POISONING/EXPOSURE
    a) A cross-hatched, frosted pattern with multiple red, purple, or brown wheals is typical of chirodropid coelenterate stings (Nagai et al, 2002; Holmes, 1996; Williamson & Burnett, 1995; Beadnell et al, 1992; Williamson et al, 1980). Blistering will occur within 8 hours post-envenomation, and within 24 hours, the skin may become blackened and permanent scarring may result (Fenner et al, 1996; Fenner, 1991; Williamson et al, 1984).
    B) DISCOLORATION OF SKIN
    1) WITH POISONING/EXPOSURE
    a) Dark or blackened skin may occur following Chironex fleckeri envenomations (Laing & Harrison, 1991; Fenner, 1991; Williamson et al, 1984; Williamson et al, 1980).
    C) PAIN
    1) WITH POISONING/EXPOSURE
    a) Severe, intractable pain has been reported following chirodropid stings (Haddad et al, 2002; Beadnell et al, 1992; Williamson et al, 1984).
    D) SCAR
    1) WITH POISONING/EXPOSURE
    a) Keloid formation, hyper- or hypopigmentation, fat atrophy, scarring, contractures or dermal necrosis can develop at the site of the sting (Thaikruea et al, 2012).

Musculoskeletal

    3.15.2) CLINICAL EFFECTS
    A) MUSCLE PAIN
    1) WITH POISONING/EXPOSURE
    a) Myalgias of the right thigh and groin were reported in a 26-year-old woman who received multiple stings primarily to her right leg below the knee from a Chironex fleckeri jellyfish. The patient complained of intense pain immediately following envenomation. The skin at the envenomation site began to darken and white papular wheals appeared. The patient's inguinal lymph nodes were also enlarged on her right side. The pain, myalgias, and enlarged lymph nodes resolved approximately 3 hours following administration of Chironex fleckeri antivenom (3.5 hours post-envenomation) (Williamson et al, 1984).
    b) CASE REPORT: A 44-year-old woman developed severe leg pain immediately after being stung on the legs. Severe leg pain gradually resolved over several days, edema of the legs and cellulitis above the area of the sting developed the following day. The areas of the sting developed blisters that healed slowly over 3 months and she had persistent neuropathic pain (Lippmann et al, 2011).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor vital signs, mental status and pulse oximetry following chirodropid coelenterate envenomations.
    B) Monitor serum electrolytes, renal function, and CBC for evidence of hemolysis.
    C) Institute continuous cardiac monitoring and obtain an ECG after severe envenomation.

Radiographic Studies

    A) CHEST RADIOGRAPH
    1) Obtain a chest x-ray in symptomatic patients.

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 severe persistent pain or systemic effects should be admitted.
    6.3.6.2) HOME CRITERIA/BITE-STING
    A) A patient with mild pain and a sting that only involves a small area of skin who do not have systemic effects can be monitored at home once nematocysts have been deactivated and removed.
    6.3.6.3) CONSULT CRITERIA/BITE-STING
    A) Consult a toxinologist, medical toxicologist or poison center for any patient with severe envenomation or in whom the diagnosis is unclear.
    6.3.6.5) OBSERVATION CRITERIA/BITE-STING
    A) Patients with more severe pain, large surface area of stings, or any systemic effects should be evaluated at a health care facility.

Monitoring

    A) Monitor vital signs, mental status and pulse oximetry following chirodropid coelenterate envenomations.
    B) Monitor serum electrolytes, renal function, and CBC for evidence of hemolysis.
    C) Institute continuous cardiac monitoring and obtain an ECG after severe envenomation.

Range Of Toxicity

Summary

    A) In adults, chirodropid envenomations, involving greater than 6 meters of total tentacle length, may result in loss of consciousness within minutes. Envenomations, involving a minimum of 50 feet (approximately 15 meters) of total tentacle length, are estimated to be fatal.
    B) In children, chirodropid envenomations, involving a total tentacle length of approximately 1 to 4 meters, have been fatal.

Minimum Lethal Exposure

    A) In adults, chirodropid envenomations, involving a minimum of 50 feet (approximately 15 meters) of total tentacle length, are estimated to be fatal (Burnett & Calton, 1987).
    B) Fatalities have occurred in children following chirodropid envenomations involving a total tentacle length of approximately 1 to 4 meters (Currie & Jacups, 2005; Mebs, 2002).

Maximum Tolerated Exposure

    A) Loss of consciousness may occur within minutes following chirodropid envenomations involving more than 6 meters of total tentacle length (Mebs, 2002).
    B) In an adult, a life-threatening chirodropid sting is estimated to involve a total tentacle length of 8 to 10 meters, or envenomate an area of at least 50% of one limb (Fenner, 1991).

Pharmacology Toxicology

Toxicologic Mechanism

    A) These venoms are mixtures of both toxic and antigenic polypeptides, and enzymes.
    B) The venom is released from a venom-coated tubule on the tentacle called a nematocyst, which injects a thread into the skin at 2 to 5 pounds of pressure per square inch. This is sufficient to penetrate the upper dermis, where the venom is released (Fenner & Williamson, 1996).
    C) Chirodropids are multi-tentacled and possibly having millions of dischargeable nematocysts, which may lead to rapid envenomation and possible death within minutes (Fenner & Williamson, 1996).
    D) Children may be more vulnerable to death following jellyfish envenomations because they have relatively smaller body mass resulting in a higher concentration of venom in their tissues and organs, they may remain in the water and attempt to pull at the adherent tentacles which may cause further envenomation, and they have less body hair which allows for closer tentacle contact (Fenner & Williamson, 1996).

References

General Bibliography

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