Jellyfish Sting

Jellyfish are found in every ocean and are prevalent in the tropics and northern Europe [1] [2] [3] [4] [5]. Of nearly 9000 species, only around 100 cause harm to humans [1] [2]. Specifically, Physalia physalis [5], Chironex fleckeri [6], and Carukia barnesi are the three most toxic species. Jellyfish sting is a frequent event as it has been reported that 150 million incidents occur annually [7]. There are as many as 800 incidents in some Pacific locations daily [8]. Fortunately, most jellyfish stings result in recovery.

Depending on the type of species and the envenomation dose [9], effects can range from mild symptoms to rapid fatality [10] [11] [12]. Local symptoms and signs include pain, swelling, pruritus, and eventually necrosis at the site of an injection [1] [10] [13]. Purplish-brownish vesicles develop and may last anywhere from minutes to weeks.

Systemic findings, if present, include nausea, emesis, fever, malaise, headache, paresthesias, and muscular spasms [14] [15]. Multiorgan effects reflect the involvement of gastrointestinal, cardiovascular, hematologic, neurologic, urinary, musculoskeletal, immunologic, and/or pulmonary systems [10] [16]. Additionally, ophthalmologic manifestations can include conditions such as ulceration of the cornea, conjunctivitis, and swelling of the eyelids.

While the majority of cases are nontoxic, some lead to sequelae such as infection of the wound, acute kidney failure, hemolysis, rhabdomyolysis, pulmonary edema and respiratory distress, dangerous arrhythmias, and cardiopulmonary arrest [14] [15] [16] [17].

Chronic effects include dermatologic features such as the development of keloids and granulomas and changes in pigmentation.

Vital signs changes may include tachycardia and alteration in blood pressure [14] [15]. Furthermore, the sting site is characterized by tenderness, erythema, and edema [6]. The color change and scarring may be permanent [16].

A detailed history should be elicited from the patients and/or witnesses if possible. The key questions should consist of details about the time of the sting, the onset and evolvement of the clinical features, the location of the incident, and identity of the organism. Very importantly, a physical exam must be performed and the patient should be immediately evaluated for the basic life support as well as for the evidence of local and systemic effects [10]. Additionally, the clinician should eliminate the tentacles as much as possible [1] [18]. Note that patients with anaphylaxis should be managed urgently and resuscitated promptly. Pain and wound care are also important to treat.

Individuals with severe manifestations should be assessed for organ damage with a complete blood count (CBC), complete metabolic panel (CMP) including renal and liver function tests, cardiac enzymes, thyroid function tests, and creatine phosphokinase. Additionally, urinalysis and arterial blood gases (ABG) should be performed.

Chest radiography is indicated for patients with respiratory distress.

Electrocardiogram (ECG) is useful for identifying arrhythmias. Finally, skin samples can be evaluated for the presence of nematocysts.

1. Williamson JA, Fenner PJ, Burnett JW, Rifkin JF. Venomous & Poisonous Marine Animals: A Medical and Biological Handbook. Surf Life Saving Australia and University of New South Wales Press; Sydney, Australia: 1996.
2. Kramp PL. Synopsis of the medusae of the world. J Mar Biol Assoc UK. 1961;40:1–469.
3. Prestwich H. Treatment of jellyfish stings in UK coastal waters: Vinegar or sodium bicarbonate? Emerg Med. J. 2007;24(9):664.
4. Tønseth A. Health damage after jellyfish stings. Tidsskr Nor Laegeforen. 2007;127(13):1777-1778.
5. Labadie M, Aldabe B, Ong N, et al. Portuguese man-of-war (Physalia physalis) envenomation on the Aquitaine Coast of France: An emerging health risk. Clin Toxicol (Phila). 2012;50(7):567–570.
6. Nimorakiotakis B, Winkel KD. Marine Envenomations Part 1—Jellyfsh. Aust Fam Physician. 2002;32(12):969–974.
7. Boulware DR. A randomized controlled field trial for the prevention of jellyfish stings with a topical sting inhibitor. J Travel Med. 2006;13(3):166–171.
8. Thomas C, Scott SA, Galanis DJ, Goto RS. Box jellyfish (Carybdea alata) in Waikiki: Their influx cycle plus the analgesic effect of hot and cold packs on their stings to swimmers at the beach: A randomized, placebo-controlled, clinical trial. Hawaii Med J. 2001;60(4):100–107.
9. Yanagihara AA, Shohet R. Cubozoan venom-induced cardiovascular collapse is caused by hyperkalemia and prevented by zinc gluconate in mice. PLoS ONE. 2012;7(12):e51368.
10. Cegolon L, Heymann W, Lange J, Mastrangelo G. Jellyfish stings and their management: A review. Mar Drugs. 2013;11(2):523–550.
11. Fenner PJ, Williamson JA. Worldwide deaths and severe envenomation from jellyfish stings. Med J Aust. 1996;165(11-12):658–661.
12. De Donno A, Idolo A, Bagordo F, et al. Impact of stinging jellyfish proliferations along south Italian coasts: Human health hazards, treatment and social costs. Int J Environ Res Public Health. 2014;11(3):2488-2503.
13. Mariottini GL, Pane L. Mediterranean jellyfish venoms: A review on scyphomedusae. Mar Drugs. 2010;8(4):1122–1152.
14. Naumann D, Hejmadi RK, Evriviades D. Ocean enemy's lasting sting: chronic cutaneous reaction after Cnidarian attack. J R Nav Med Serv. 2013; 99(3):169-170.
15. Salam AM, Albinali HA, Gehani AA, Al Suwaidi J. Acute myocardial infarction in a professional diver after jellyfish sting. Mayo Clin Proc. 2003; 78(12):1557-1560.
16. Tibballs J. Australian venomous jellyfish, envenomation syndromes, toxins and therapy. Toxicon. 2006;48(7):830–859.
17. Freeman SE, Turner RJ. Cardiovascular effects of toxins isolated from the cnidarian Chironex fleckeri Southcott. Br J Pharmacol. 1971;41(1):154-166.
18. Burnett JW, Fenner PJ, Kokelj F, Williamson JA. Serious Physalia (Portuguese Man O’ War) stings: Implications for scuba divers. J Wilderness Med. 1994;5(1):71–76.