Papilloedema and coma in a child: undescribed symptoms of the "Irukandji" syndrome

MJA 1997; 167: 650  

To the Editor: The "Irukandji" syndrome, so named in 1952,1 refers to the severe systemic symptoms that follow envenomation by the jellyfish Carukia barnesi,2,3 named by Dr Jack Barnes in 1964.4 Here, we report papilloedema and coma in a seven-year-old child who developed Irukandji syndrome after a jellyfish sting in the tropical waters of Cairns, in far north Queensland. The child was treated by one of us (R J H) in 1981, but not reported at the time and only recently described to colleagues. The boy was admitted to hospital with the severe systemic symptoms of Irukandji syndrome, including generalised muscle cramps, anxiety and sweating. Ten hours later, he was confused, disoriented, tachycardic and tachypnoeic, and had several episodes of profound sweating, cyanosis and agitation. Bilateral crepitations (more marked on the left) were heard on chest auscultation, and a chest x-ray showed increased interstitial markings consistent with pulmonary oedema. He had 4+ glycosuria, Dextrostix of 130 mg/100 mL (normal range, 80-120 mg/100 mL), and periodic auditory and visual hallucinations. The boy was pale and in obvious respiratory distress, requiring oxygen 6 L/min via facemask to maintain his central colour. Examination of his fundi showed blurring of the disc margins. Initial management consisted of an intravenous dexamethasone infusion and intermittent intravenous frusemide (exact doses not known). His symptoms persisted through the first 24 hours of admission, and by the second evening he was more disoriented and unresponsive to commands. He was given 100 mL of 20% mannitol intravenously and within two hours had a huge diuresis with a wet bed. Three hours later, he was answering questions with a grunt, and shortly after was obeying commands and was easily rousable. Ten hours later, he was talking freely and answering questions, and subsequently made a complete recovery with no neurological sequelae. To our knowledge, this is the first reported case of papilloedema and unconsciousness associated with the Irukandji syndrome. We believe this indicates cerebral oedema, but no cerebral scan was done to confirm this. Recently, a case of cerebral oedema was reported after a chirodropid (multitentacled box jellyfish) sting.5 We suggest that the patient's level of consciousness be carefully monitored in all serious jellyfish envenomations, and that any deterioration of consciousness be appropriately investigated. Peter J Fenner Honorary Medical Officer, Surf Life Saving Association, PO Box 3080, Mackay, QLD 4740 RJ Heazlewood Visiting Medical Officer, Cairns Base Hospital, QLD Flecker H. "Irukandji" sting to north Queensland bathers without production of wheals but with severe general symptoms. Med J Aust 1952; 1: 89-91. Fenner PJ, Williamson JAM, Callanan V, Audley I. Further understanding of, and a new treatment for, "Irukandji" (Carukia barnesi) stings. Med J Aust 1986; 145: 569-574. Fenner PJ, Williamson JA. World wide deaths and severe envenomation from jellyfish stings. Med J Aust 1996; 165: 658-661. Barnes JH. Cause and effect in Irukandji stingings. Med J Aust 1964; 1: 897-904. Fenner PJ, Williamson JA, Burnett JW, et al. The "Irukandji syndrome" and acute pulmonary oedema. Med J Aust 1988; 149: 150-156.