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Abstract

The "Irukandji" syndrome has been associated with stings by Carukia barnesi (Class Cubozoa; Order Carybdeidae)^9,10 (Box 1C), although other jellyfish may cause a similar syndrome.¹¹ C. barnesi has rarely been found in the Northern Territory (P Alderslade, Curator of Coelenterates, Museum and Art Gallery of the Northern Territory, Darwin, NT, personal communication), and the Irukandji syndrome is less common than in far north Queensland.^10,11 Other jellyfish species appear to cause some stings in the Darwin region.^1,4 These include the "Darwin carybdeid",¹ a four-tentacled jellyfish larger than C. barnesi, which appears to cause less severe skin damage than C. fleckeri.

We conducted a prospective study of all jellyfish-sting presentations to Royal Darwin Hospital over 12 months in 1999 and 2000. Our aim was to determine the immediate and delayed effects of all marine stings, and to correlate these with microscopic identification of jellyfish nematocysts using the sticky-tape sampling technique.⁶

Patients were assessed and treated in the Emergency Department according to the Royal Darwin Hospital protocol¹² (Box 2). Clinical and demographic details were entered prospectively, along with details of hospital management, on a standardised form. Details included investigations (eg, electrocardiography [ECG]), type and effect of analgesia (topical [ice], oral [eg, aspirin or codeine], or parenteral [morphine or pethidine]) and whether C. fleckeri antivenom was administered.

The clinical diagnosis was classified as typical or not typical of C. fleckeri sting according to known features (immediate and persistent local pain, linear sting marks and absence of generalised pain, which is seen in Irukandji syndrome).^1,3,11

Sticky-tape sampling

Follow-up

Of the 40 stings, 28 (70%) were clinically typical of C. fleckeri, and 12 (30%) were not typical. Four of the latter were consistent with Irukandji syndrome (minimal local erythema, and delayed systemic symptoms, especially pain), and five with Darwin carybdeid sting (less severe skin pain and markings, with some "overlap" Irukandji features, such as abdominal pain). A typical C. fleckeri sting is shown in Box 4A.

Sticky-tape sampling

Management

Follow-up

Although most C. fleckeri stings are minor and not life-threatening, the potential exists for severe systemic envenomation and even death. It is a concern that, despite considerable public education, eight of our cases were in children. The last 10 deaths from C. fleckeri envenomation in the Northern Territory were all of children, most recently a three-year-old girl from a remote Aboriginal community in February 1996.⁴ In January 2000, a five-year-old boy died soon after a jellyfish sting near Yarrabah, in north Queensland, presumed to be from C. fleckeri.¹⁴

In the past, considerable attention has focused on the use of antivenom in C. fleckeri envenomation.^3,8,15-17 Indications have been cardiac arrest and arrhythmias, analgesia or cosmesis, although evidence supporting the efficacy of antivenom remains limited.⁷ None of our patients received antivenom, as none had cardiac toxicity, and severe local pain was controlled with appropriate analgesia. Nevertheless, it is crucial that antivenom is available for early use in life-threatening situations with arrhythmias or cardiorespiratory arrest.

None of our patients had pressure-immobilisation bandages applied. These bandages are not recommended in the Northern Territory, as they potentially increase nematocyst discharge and are unlikely on theoretical grounds to prevent venom absorption.^7,12,18

Delayed skin eruptions have been reported after jellyfish stings, although C. fleckeri has not been specifically implicated.^19-21 These eruptions typically occurred at the site of the original sting after five days or more, and were pruritic and painless.¹ Their histological features were generally consistent with delayed (type IV) hypersensitivity reactions.²⁰ They are likely to be a response to retained foreign material, such as nematocyst thread or other cellular substances injected into the dermis, but specific antigens have not been identified.

In our study, over half the patients followed up after stings positive for C. fleckeri nematocysts had delayed skin eruptions clinically resembling papular urticaria, similar to those reported after other jellyfish stings.^19-21 This confirms that delayed cutaneous hypersensitivity reactions are common after C. fleckeri stings. Corticosteroid cream, with or without systemic antihistamines, may help relieve symptoms of delayed reactions.^1,7

Correlation of sticky-tape sampling with clinical presentation suggests that there were no false-positive identifications of C. fleckeri nematocysts. The false-negative rate is unknown. However, as the test was negative for nematocysts in only three cases that appeared clinically typical of C. fleckeri envenomation, correlation with clinical findings appears good.

While all the non-C. fleckeri nematocysts detected were carybdeid in appearance, degenerate C. fleckeri nematocysts may sometimes appear similar. Further description and classification is needed of the Darwin carybdeid and other local jellyfish yet to be identified. Clinical features of most of the carybdeid nematocyst-positive stings differed from those of both C. fleckeri stings and the Irukandji syndrome. The Darwin carybdeid appears to cause local pain from tentacle marks, but this pain is less severe than in C. fleckeri stings. The Darwin carybdeid also causes some "overlap" systemic symptoms, similar to those of a mild Irukandji syndrome. Two earlier stings with these features were confirmed to be caused by the Darwin carybdeid through capture and examination of the jellyfish, as well as microscopic identification of nematocysts¹ (Currie BJ, unpublished data).

Finally, although life-threatening envenomation is uncommon, we should continue to pursue public education and prevention policies vigorously. Deaths from severe C. fleckeri envenomation will inevitably occur while people, especially children without protective clothing, enter tropical waters in Australia.

We would like to acknowledge support from the Cooperative Research Centre for Aboriginal and Tropical Health; from the National Health and Medical Research Council Centre of Clinical Excellence grant to the Northern Territory Clinical School, Royal Darwin Hospital; and the staff of the Emergency Department, Royal Darwin Hospital, particularly Carole Mansfield and Marg St Leone. We would also like to acknowledge Phil Alderslade (Northern Territory Museum, Darwin) for assistance and for the photograph of the Darwin carybdeid.

There was no specific funding for this study and no conflict of interest.

1. Williamson JA, Fenner PJ, Burnett JW, Rifikin JF. Venomous and poisonous marine animals. 1st ed. Sydney: University of New South Wales Press, 1996.
2. Williamson JA, Callanan VI, Hartwick RF. Serious envenomation by the northern Australian box-jellyfish (Chironex fleckeri). Med J Aust 1980; 1: 13-15.
3. Williamson JA, Le Ray LE, Wohlfahrt M, Fenner PJ. Acute management of serious envenomation by box-jellyfish (Chironex fleckeri). Med J Aust 1984; 141: 851-853.
4. Currie BJ. Clinical toxicology: a tropical Australian perspective. Ther Drug Monit 2000; 22: 73-78.
5. Currie BJ, Khanh DM, Alderslade P, et al. Jellyfish envenomation in the Northern Terrritory of Australia. Toxicon 1992; 30: 501.
6. Currie BJ, Wood YK. Identification of Chironex fleckeri envenomation by nematocyst recovery from skin. Med J Aust 1995; 162: 478-480.
7. Currie B. Clinical implications of research on the box-jellyfish Chironex fleckeri. Toxicon 1994; 32: 1305-1313.
8. Lumley J, Williamson JA, Fenner PJ, et al. Fatal envenomation by Chironex fleckeri, the north Australian box jellyfish: the continuing search for lethal mechanisms. Med J Aust 1988; 148: 527-534.
9. Barnes JH. Cause and effect in Irukandji stingings. Med J Aust 1964; 1: 897-904.
10. Little M, Mulcahy RF. A year's experience of Irukandji envenomation in far north Queensland. Med J Aust 1998; 169: 638-641.
11. Fenner PJ, Williamson JA, Callanan VI, Audley I. Further understanding of, and a new treatment for, "Irukandji" (Carukia barnesi) stings. Med J Aust 1986; 145: 569-574.
12. Currie B. Box-jellyfish in the Northern Territory. N T Dis Control Bull 1998; 5: 12-14.
13. Guenin DG, Auerbach PS. Trauma and envenomations from marine fauna. In: Tintinalli JE, Ruiz E, Krome RL, editors. Emergency medicine — a comprehensive study guide. 4th ed. New York: McGraw-Hill, 1996: 868-873.
14. Lill J. Fatal sting. Box jellyfish kills boy, 5. The Cairns Post 2000 Jan 25: 1.
15. King GK. Acute analgesia and cosmetic benefits of box-jellyfish antivenom. Med J Aust 1991; 154: 365-366.
16. Beadnell CE, Rider TA, Williamson JA, Fenner PJ. Management of a major box jellyfish (Chironex fleckeri) sting. Lessons from the first minutes and hours. Med J Aust 1992; 156: 655-658.
17. Holmes JL. Marine stingers in far north Queensland. Australas J Dermatol 1996; 37 Suppl 1: S23-S26.
18. Pereira PL, Carrette T, Cullen P, et al. Pressure immobilisation bandages in first-aid treatment of jellyfish envenomation: current recommendations reconsidered. Med J Aust 2000; 173: 650-652.
19. Reed KM, Bronstein BR, Baden HP. Delayed and persistent cutaneous reactions to coelenterates. J Am Acad Dermatol 1984; 10: 462-465.
20. Pierard GE, Letot B, Pierard F. Histologic study of delayed reactions to coelenterates. J Am Acad Dermatol 1990; 22: 599-601.
21. Burnett JW, Cobbs CS, Kelman SN, Calton GJ. Studies on the serologic response to jellyfish envenomation. J Am Acad Dermatol 1983; 9: 229-231.

Authors' details

Menzies School of Health Research, Darwin, NT.
Paula M Lawrie, BSc, Technical Officer.
Bart J Currie, FRACP, FAFPHM, DTMH, Head of Tropical Medicine and International Health Unit; and Professor in Medicine, NT Clinical School, Darwin, NT.

Reprints will not be available from the authors.
Correspondence: Professor B J Currie, Tropical Medicine and International Health Unit, Menzies School of Health Research, PO Box 41096, Casuarina, NT 0811. bartATmenzies.edu.au

©MJA 2001
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