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Worldwide deaths and severe envenomation from jellyfish stings

Peter J Fenner and John A Williamson

From our database of fatal and serious human envenomations, we report several cases, look at the distribution of these events, and discuss treatment.

MJA 1996; 165: 658

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Introduction - Distribution of jellyfish and reported envenomations - Sting seasons - Reflections on treatment - Applying vinegar - Removing adherent tentacles - The role of steroid therapy - Chironex fleckeri antivenom - Conclusions - Acknowledgments - References - Authors' details

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Introduction

 We have collected worldwide information about jellyfish and their stings since 1990, through personal communication with members of the International Consortium of Jellyfish Stings (ICJS), 1 investigating reports of serious jellyfish stings heard on the "grapevine", and travelling in areas of chirodropid (multitentacled "box" jellyfish) distribution. Annual reports of our data have been published from 1991 to 1993. 2

Our database now records over 1100 individual cases of stings (some severe and fatal), as well as some 1000 monthly reports of jellyfish numbers and stings, from surf life saving clubs in Queensland over the past six years. Our data are only the "tip of the iceberg" and probably an inadequate indication of the extent of the problem worldwide. However, we continue to seek information, now also by internet and e-mail.

Our data include information on envenomation by Physalia , the Portu guese man-o'-war or bluebottle. Although not a true jellyfish (actually a siphonophore, or hydroid colony), it stings like one, is popularly regarded as one, and we treat it as one in this article.

A brief description of the mechanism of a jellyfish sting is provided in Box 1. While many suspected deaths from envenomation, and the jellyfish species involved, remain inadequately authenticated, documented deaths from jellyfish stings usually involve species of chirodropid, 5,6 described and shown in Box 2.

In this article we examine the distribution of serious and fatal jellyfish envenomations (illustrated in the Map), the animals involved and aspects of treatment, and we describe some previously unreported cases (Table).

Distribution of jellyfish and reported envenomations

Australia In Australia, particularly on the east coast, up to 10 000 stings occur each summer from the bluebottle (Physalia spp.) alone, with others also from the "hair jellyfish" (Cyanea) and "blubber" (Catostylus). More bluebottle stings occur in South Australia and Western Australia, as well as stings from a single-tentacled box jellyfish, the "jimble" (Carybdea rastoni) (personal data) .

The chirodropid Chironex fleckeri 3,4,8 is known to be the most lethal jellyfish in the world, 3 and has caused at least 63 recorded deaths in tropical Australian waters off Queensland and the Northern Territory since 1884. 3

Indo-Pacific region

 The presence of chirodropids has now been confirmed in the tropical Indo-Pa cific ocean from the Maldive Islands 9-12 in the west, eastwards to the Philippines, north to Amani Island, Japan (see below), and south to tropical Australia; this includes Brunei, Sarawak, Sabah (L Marsh, Curator of Marine Invertebrates, West Australian Museum, 1993, personal communication), Papua New Guinea, the Malaysian archipelago, Gulf of Thailand, 8 Java and southern India. 12

Deaths have previously been reported from Penang (Malaysia), the Philippines, Bougainville Island, the Solomon Islands, "North Borneo" (now Sarawak, Brunei, Sabah), and Papua New Guinea (d'Entrecasteaux Islands). 8

Medical officers at the Labuan District Hospital (in Malaysia) have been quoted as saying that there are two to three deaths there each year from jellyfish stings and another one or two victims who survive, but require intensive care and commonly remain unconscious for 12-24 hours. 13

Chirodropid jellyfish are well known in the Philippines, and an estimated annual death rate from jellyfish stings there of 20-40 does not seem excessive (P J F, 1987, personal experience). More recently, Dr Paul Cornelius, of the British Museum of Natural History, has made a similar estimate of fatalities (unpublished observations, April 1994). As a death certificate is not necessary for burial in the Philippines, these estimates cannot be verified.


World map showing human fatalities from chirodropid and other jellyfish stings, and presently confirmed and probable chirodropid distribution.

The Americas

 Chirodropids have been described in waters along the eastern coast of the Americas between the Tropics, including the waters around many Caribbean islands. 11,14 Serious stings from these chirodropids have also been reported from beaches in Puerto Rico during the summer months (B Cutress, Associate Investigator, Marine Biology Department, Puerto Rico University, 1992, personal communication).

In 1990, a 4-year-old boy at Galveston Island, in the Gulf of Mexico, was stung and died within 20 minutes, despite cardiopulmonary resuscitation. 6 Stinging cells were identified as being from a chirodropid previously described in that region. 14

Three fatal envenomations from Physalia physalis have been reported from Florida and North Carolina, in the United States. 15,16 Serious envenomations have also been reported from both sides of the Atlantic. 17-19

China

 Apart from Physalia species and chirodropids, the only other jellyfish presently known to cause deaths in humans are large specimens (up to 1 m diameter) of Stomolophus nomurai (Mingliang, Research Assistant, Qingdao Hospital, 1991, personal communication), a jellyfish found in the Yellow Sea between China and South Korea. Reports of eight deaths have now been published, five in detail. 20,21 Victims die with acute pulmonary oedema some 2-24 hours after the initial envenomation.

Africa

 A chirodropid occurs in the tropical oceans of west Africa, 22,23 but we know of no published reports of deaths or serious stings. Although chirodropids have not been reported to occur on the eastern tropical coastline of Africa, they must be expected in these waters.

South India and Sri Lanka

 Serious jellyfish envenomations occur in the Indian region, with peripheral ischaemia reported in at least two victims. 24,25 Although the jellyfish is frequently unidentified, chirodropids, Sanderia and Physalia species occur in this region.

Two fatalities were reported recently on the eastern side of the Indian Ocean, on Langkawi Island, a tourist resort in Kedah, a northern state of Malaysia. From the rapid demise of the victims, and appearance of sting marks, they probably died of chirodropid envenomation (Dr Iekhsan Othman, Malaysia, personal communication). 12

Sting seasons

 In the Southern Hemisphere, chirodropid stings occur mainly in the summer months (December-May), 3 but over a longer season in areas closer to the Equator. In the Northern Territory stings have occurred in every month, with deaths in all months except July. 3,4,8 Chirodropids may occur only in December and January at the southern extreme of their recorded range (just north of Bundaberg, Queensland). 3

In the northern area of Borneo (Northern Hemisphere), stings usually occur in the dry hot season, from March to July, when seas are calm.

Reflections on treatment

Applying vinegar Two to 10 per cent acetic acid in water was recommended as a first-aid treatment for Chironex fleckeri nematocyst inhibition by Hartwick et al. in 1980. 26 Household vinegar has been a traditional treatment for box jellyfish stings in the Philippines since the turn of the century, although other "traditional" treatments were also used. Fishermen in Kukup also describe stings from cubozoan jellyfish in Malaysia as being treated with vinegar (P J F, personal observation, 1987). We do not know how long this remedy has been used.

In two cases recorded on our database ( Table, Cases 3 and 7), victims seemed to stop breathing after vinegar was poured on the envenomed area. Whether this was a cause-related effect is not known; further research is needed.

Removing adherent tentacles

 In another of our cases ( Table, Case 5), removal of the adherent tentacle material was accompanied by impairment of consciousness. Our advice has been for the rescuers to remove the tentacles physically with fingers, if vinegar is unavailable, before applying any compression bandages. 3 While this single report scarcely invalidates such advice, further case studies and research are awaited.

The issue of removing adherent tentacle material in any jellyfish (especially serious chirodropid) stinging is complex. Fully extended tentacle material presents most of the nematocysts to the victim's skin, 27 and most will have discharged by the time adherent tentacles on the skin are being dealt with by the first-aiders. However, even partial contraction of tentacle material protects some nematocysts from discharge upon contact, 27 and the response of chirodropid tentacles to sudden entanglement with a human victim seems likely to involve at least some immediate tentacular contraction. Consequently, it seems probable that some nematocysts in adherent tentacle material will remain undischarged, and inappropriate stimulation could result in additional venom being injected into an already seriously envenomed person.

If tentacles have not been inactivated with vinegar, 26 it would seem prudent to carefully, but promptly, "pick them off" the patient's skin with minimal handling, and no rubbing, before applying either compression bandages (in the case of serious chirodropid stings) or analgesic cold packs (for use in chirodropid or other cnidarian stings). Applying compression bandages directly over untreated adherent tentacle material cannot be recommended. However, once tentacles have been doused with vinegar for a minimum of 30 seconds, no time should be lost in removing them before applying bandages. 3

One of our cases (Table, Case 3) describes papilloedema after a chirodropid sting. This is the first such observation published, although Heazlewood (personal communication, 1992) reports a case of cerebral oedema in a 4-year-old in Cairns in 1980, after an "irukandji" (the carybdeid Carukia barnesi ) sting.

The role of steroid therapy

 Steroid creams may be useful for mild itching in the immediate healing period after a cubozoan sting, 27 although Burnett 3 now doubts their efficacy. Systemic steroids should be used for severe cases of delayed hypersensitivity, given as prednisone (0.5-1 mg/kg body weight, daily), until the symptoms are fully controlled -- usually just a few days. After such a short course, it is unnecessary to taper the dose.

Chironex fleckeri antivenom

 The exact mechanism of action of Chironex fleckeri venom and antivenom remains incompletely understood, despite several studies. 28,29 The efficacy of Chironex fleckeri antivenom in stings from the Australian chirodropid named Chiropsalmus quadrigatus is also unclear -- as is the exact identification of this species. 3 An early study showed in-vitro neutralisation of the dermatonecrotic, haemolytic and lethal factors of the venom of this Australian species when Chironex antivenom was used. However, although passive immunisation of mice with the antivenom reduced dermato necrosis, it did not protect against the lethal effects of Chiropsalmus quadrigatus venom. 30 Another study, using rabbit antisera prepared against Chironex fleckeri venom, showed no in-vitro cross- protection against the venom of Chiropsalmus quadrigatus . 31 However, the Commonwealth Serum Laboratories (CSL) currently recommends the use of Chironex antivenom for severe envenomation from the Australian " Chiro psalmus quadrigatus ".

The possible benefits of Chironex antivenom for severe envenomations by chirodropids worldwide need investigation. Chironex antivenom has been shown to be of little benefit in the "irukandji" syndrome (it neither relieves the pain of envenomation nor reduces any other systemic problem), 32 and is currently not recommended for envenomation from any other (non-chirodropid) jellyfish species.

Conclusions

 Lethal, or potentially lethal, chirodropid jellyfish occur worldwide, around every major land mass in the tropical and some subtropical oceans, and deaths and serious morbidity are more common than previously believed. Physicians practising in these areas, or those advising people who travel to such areas, must be aware of the problem, and advise their patients on awareness, prevention and treatment (summarised in Box 3) of potentially lethal jellyfish envenomation. The toxicology of the venoms needs further study.

Acknowledgments

 We would like to thank Associate Professor Nor Azila and Dr Iekhsan Othman (Malaysia), Loisette Marsh (Australia), Major (Dr) R Hooper (Sabah), Dr T K Chan, Bertha Cutress (Puerto Rico), Drs Y Tomihara, Y Araki and M Kohama (Japan) for assistance with compilation of data. The photograph at the beginning of this section was provided by Surf Life Saving Queensland Inc.

References
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Authors' details

Corner of Palmer and Grendon Streets, North Mackay, QLD.
Peter J Fenner, FACTM, FRCGP, General Practitioner and Marine Stinger Officer, Surf Life Saving Queensland Inc.
Hyperbaric Medicine Unit, Department of Anaesthesia and Intensive Care, Royal Adelaide Hospital, Adelaide, SA.
John A Williamson, FANZCA, FACTM, Director and Associate Professor.
No reprints will be available. Correspondence: Dr P J Fenner, PO Box3080, North Mackay, QLD 4740.

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