The lionfish (Pterois volitans) belongs to the group of venomous Scorpaenidae and their natural habitat is restricted to the tropical regions of the world, primarily the Caribbean Sea and Central America [1]. However, studies have confirmed their presence throughout the Atlantic Ocean, resulting in the increased risk for lionfish stings in South America and the United States, in addition to the Caribbean countries [2]. Lionfish sting is considered to be a rare occurrence in clinical practice and activities that increase the risk include fishing, diving, or swimming in the mentioned areas [1] [2]. Some reports have documented stings from lionfish kept in aquariums as well [3]. The pathogenesis of a lionfish sting stems from the neurotoxic venom that is released by the fish during direct contact [4]. Patients almost always present with symptoms involving a single extremity (upper much more commonly than lower) [2] [5], and most common signs are erythema and extensive edema accompanied by pain that is described as quite severe, whereas paresthesias, abdominal cramping, local heat, cyanosis, and blistering of the skin are frequent findings as well [1] [2] [4] [5]. Cardiovascular symptoms, such as hypotension and tachycardia, are seen in a subset of patients, while hyperthermia, development of a localized infection, and transient weakness are less common findings [2] [4] [5] Although the clinical course typically ends with a good recovery without significant sequelae, limb paralysis, anaphylaxis, and heart failure have been reported [2] [4] [5].

• Severe Pain

  Following envenoming the affected individual presents with Immediate severe pain at the sting site Local swelling, bruising and puncture marks. [lifeinthefastlane.com]

  The venom is composed of acetylcholine and a neurotoxin which causes severe pain, swelling and rash in humans. Tim Codling, avid diver and lionfish culler was recently stung while removing a lion fish from the cobalt blue waters of Grand Cayman. [idivecayman.com]

  Signs and symptoms Severe pain Redness, bruising, swelling Treatment Prevention is the best treatment. Stay aware of your surroundings and remember lionfish can sting after they are dead. [tdisdi.com]

  Not only do treatment facilities have access to some really nifty pain medications that you WILL want, there can be other complications that aren’t immediately apparent, too: Severe pain can cause shock which may involves shortness of breath, weakness [lionfish.co]

  The primary symptom of stonefish envenomation is burning, severe pain, which soon begins to spread up the limb. In addition, serious swelling begins shortly after the sting. [dengarden.com]

• Localized Pain

  Judging from this and other reports in the United States, the vast majority of lionfish stings appear to result in uncomplicated wounds with severe local pain that is responsive to immersion therapy. [emedicine.medscape.com]

  In a series of 101 documented cases of captive lionfish envenomations in the US, the following effects were reported (Gallagher, 2001): 92% of patients experienced local pain 60% of patients experienced edema 13% of patients experienced systematic symptoms [reefkeeping.com]

  For example, in a series of 101 documented cases of captive lionfish envenomations here in the United States, the following effects were reported by Gallagher (2001): 92 percent of patients experienced local pain, 60 percent of patients experienced swelling [tfhmagazine.com]

  The pain can can last for days, or even weeks, and increase in intensity as time goes on. Victims of Irukandji Syndrome experience a reaction to the venom that is much worse than localized pain originating at the site of the sting. [dengarden.com]

• Collapse

  A sting from these fish can cause extreme pain, swelling, and in very severe cases, cardiovascular collapse. [thefisheriesblog.com]

  Cardiovascular signs such as hypotension, bradycardia, collapse, pulmonary oedema and cyanosis are rarely reported. Differential diagnosis Other fish stings Stingray injury. [lifeinthefastlane.com]

• Localized Edema

  Lionfish sting is notable for its severe clinical presentation in the form of erythema, paresthesias, profound localized edema, and abdominal cramping. Systemic symptoms are rare. [symptoma.com]

• Fatigue

  […] blister Swelling of the wound Sweating Headaches Abnormal heart rate, reduced blood pressure Allergic shock or reaction, in some cases Shortness of breath; breathing difficulties Muscle cramps, abdominal cramps Nausea, vomiting, and diarrhea Severe fatigue [dovemed.com]

• Sighing

  Okay, so, (sighs). First, most important thing. Hot water, gotta get hot water on my hand as soon as possible. Gotta heat it up. I'll sit down here. Wow. You all right? That is some radiating pain. [read-videos.com]

• Nausea

  Colliding with a lionfish's toxic sting is likely to cause nausea and vomiting. You may feel feverish with headaches and dizziness. It is also common to suffer breathing difficulties from lionfish stings. [private-scuba.com]

  In worst case scenarios the symptoms may include headache, nausea, abdominal pain, delirium, seizures, paralysis of limbs, changes in blood pressure, breathing difficulties, heart failure and tremors, pulmonary edema, and loss of consciousness. [hawaiiscubaadventures.com]

  On rare occasions, when the venom spreads to other parts of the body, people may experience headaches, chills, cramps, nausea, and even paralysis and seizures. [oceanservice.noaa.gov]

  Redness, bruising, swelling, numbness, tingling, and tissue shedding at the wound site Severe reactions include: Nausea Vomiting Abdominal cramps Tremors Abnormal heart rhythms Weakness Shortness of breath Seizures Decreased blood pressure Fainting Paralysis [webmd.com]

  On rare occasions when the venom spreads to other parts of the body, people may experience headaches, cramping, nausea, paralysis, seizures and chills. [faculty.washington.edu]

• Vomiting

  Colliding with a lionfish's toxic sting is likely to cause nausea and vomiting. You may feel feverish with headaches and dizziness. It is also common to suffer breathing difficulties from lionfish stings. [private-scuba.com]

  If the injured person appears intoxicated or is weak, vomiting, short of breath or unconscious, seek immediate advanced medical care. [blog.daneurope.org]

  Although not fatal to humans, the dorsal, anal, and pelvic spines of lionfish can deliver a painful sting, as well as cause headache, vomiting, and respiratory distress. [oceanservice.noaa.gov]

  Redness, bruising, swelling, numbness, tingling, and tissue shedding at the wound site Severe reactions include: Nausea Vomiting Abdominal cramps Tremors Abnormal heart rhythms Weakness Shortness of breath Seizures Decreased blood pressure Fainting Paralysis [webmd.com]

  In humans, lionfish venom can cause systemic effects such as vomiting, fever and sweating. In some cases, it has been lethal. The effect of the venom weakens the force of muscular contractions), and increases the heart rate. [turtlebaydiveresort.com]

• Abdominal Cramps

  Lionfish sting is notable for its severe clinical presentation in the form of erythema, paresthesias, profound localized edema, and abdominal cramping. Systemic symptoms are rare. [symptoma.com]

  Redness, bruising, swelling, numbness, tingling, and tissue shedding at the wound site Severe reactions include: Nausea Vomiting Abdominal cramps Tremors Abnormal heart rhythms Weakness Shortness of breath Seizures Decreased blood pressure Fainting Paralysis [webmd.com]

  Severe reactions include nausea, vomiting, abdominal cramps, tremors, abnormal heart rhythms, weakness, headache, diarrhea, slow heart rate (bradycardia), shortness of breath, seizures, decreased blood pressure, fainting, and paralysis. [emedicinehealth.com]

• Abdominal Pain

  In worst case scenarios the symptoms may include headache, nausea, abdominal pain, delirium, seizures, paralysis of limbs, changes in blood pressure, breathing difficulties, heart failure and tremors, pulmonary edema, and loss of consciousness. [hawaiiscubaadventures.com]

  Worst case scenarios, though not normally fatal to humans, include headache, nausea, abdominal pain, delirium, seizures, paralysis of limbs, changes in blood pressure, breathing difficulties, heart failure and tremours, pulmonary edema, and loss of consciousness [dive-the-world.com]

• Hypotension

  Cardiovascular symptoms, such as hypotension and tachycardia, are seen in a subset of patients, while hyperthermia, development of a localized infection, and transient weakness are less common findings Although the clinical course typically ends with [symptoma.com]

  Cardiovascular signs such as hypotension, bradycardia, collapse, pulmonary oedema and cyanosis are rarely reported. Differential diagnosis Other fish stings Stingray injury. [lifeinthefastlane.com]

  One patient required intravenous antibiotics, one hypotensive patient responded well to intravenous fluids, and 13% of patients had variable, less severe, systemic symptoms. [emedicine.medscape.com]

  Some victims have experienced systematic responses such as nausea, dizziness, muscle weakness, shortness of breath, hypotension, and headache brought on by the venom, or as a reaction to the level of pain, or both, but that's about it. [reefkeeping.com]

  One of the substances in a stonefish sting is called stonustoxin, which can cause severe hypotension (low blood pressure), a serious condition that can be life-threatening. [dengarden.com]

• Cyanosis

  […] present with symptoms involving a single extremity (upper much more commonly than lower), and most common signs are erythema and extensive edema accompanied by pain that is described as quite severe, whereas paresthesias, abdominal cramping, local heat, cyanosis [symptoma.com]

  Cardiovascular signs such as hypotension, bradycardia, collapse, pulmonary oedema and cyanosis are rarely reported. Differential diagnosis Other fish stings Stingray injury. [lifeinthefastlane.com]

• Muscle Weakness

  A sting from one of these fish can cause excruciating pain, rapid swelling, tissue death, muscle weakness, temporary paralysis, and in very rare cases death. A venomous reef stonefish camouflaged as a rock in the Indian Ocean. Source 3. [thefisheriesblog.com]

  Some victims have experienced systematic responses such as nausea, dizziness, muscle weakness, shortness of breath, hypotension, and headache brought on by the venom, or as a reaction to the level of pain, or both, but that's about it. [reefkeeping.com]

  A handful of victims have experienced systemic symptoms like nausea, dizziness, muscle weakness, shortness of breath, and headache brought on by the venom and/or as a reaction to the level of pain, but that’s about it. [tfhmagazine.com]

• Myalgia

  […] infusion Give oxygen, IV fluids and administer IM adrenaline 0.01 mg/kg(max 0.5 mg) to lateral thigh Serum sickness This relatively benign and self limiting complication may occur 5–10 days after antivenom Manifestations include fever, rash, arthralgia and myalgia [lifeinthefastlane.com]

• Excitement

  And I was nervous for this one, I will not lie, and like I told you guys on the boat this morning, that was the first time aside from the manatee episode that i've ever snorkeled before, so I was just excited to be able to catch one of these fish, get [read-videos.com]

  Fortunately, while stories of lionfish stings having horrible effects (including death) abound, and are even heard in Hollywood movies, the truth is far less exciting. [reefkeeping.com]

  Fortunately, while there are stories of lionfish stings actually leading to someone’s death, the truth is far less exciting. [tfhmagazine.com]

Because of the fact that lionfish stings are rather easily treated by immersing the affected extremity in hot water (due to the heat-labile properties of the neurotoxin) [4] [5], early recognition of this clinical entity can lead to prompt and effective therapy. For this reason, the physician's role in obtaining a detailed patient history is vital. Previous activities and confirmation of a lionfish sting by the patient is perhaps the most important piece of information needed to make the diagnosis. A full physical examination should follow, during which a complete inspection, as well as palpation of the affected extremity, must be carried out. At the time of admission, lionfish stings may present as erythema, blistering, or dermal necrosis [1] [6], depending on the duration of symptoms before the examination. Moreover, typical symptoms can be completely absent in the case of an "empty sting", ie. no venom was released from the lionfish [3]. Although isolated reports document several abnormalities during biochemical workup in a small number of patients (hypophosphatemia, elevated liver enzymes, thrombocytopenia) [5], the diagnosis primarily rests on clinical criteria supported by findings revealed during history.

Administration of analgesia ( never use aspirin in conjunction with hot water treatments ). Watch for signs of systemic symptoms and be ready to perform CPR if necessary or treatment for anaphylactic shock. [hawaiiscubaadventures.com]

Signs and symptoms Severe pain Redness, bruising, swelling Treatment Prevention is the best treatment. Stay aware of your surroundings and remember lionfish can sting after they are dead. [tdisdi.com]

The typical treatment is to apply a hot pad soaked in water, but the delay means the venom has spread throughout my leg, from my toes to my hip. The doctor settles me in and does what he can, which includes hydration and the heat treatment. [turtlebaydiveresort.com]

Mary’s Medical Center for treatment. Fire Rescue officials said the hospital has a hyperbaric chamber that can be used for treatment. [wptv.com]

Prognosis The severity of Scorpaenidae envenomations is progressively worse from Pterois to Scorpaena to Synanceia species. [emedicine.medscape.com]

(Etiology) Lionfish Stings release a poisonous chemical into the human skin through their spine, which can affect the human body Depending on the amount of poison injected, the severity of the signs and symptoms is dictated What are the Signs and Symptoms [dovemed.com]

Epidemiology United States The true number of Scorpaenidae envenomations is unknown. [emedicine.medscape.com]

Pathophysiology Common to the family Scorpaenidae are 12-13 dorsal spines, two pelvic spines, and three anal spines. Each spine is associated with a pair of venom glands. A loose integumentary sheath covers each spine. [emedicine.medscape.com]

Prevention is key, the best solution is to wear puncture resistant gloves and take great care in handling the lionfish. Not all of the lionfish spines carry the venom. [lionfishhunting.com]

Remaining spine fragments should be removed from the skin by a Doctor to prevent infection. The medical professional may also administer a painkiller because lionfish stings are painful and you can expect several days of discomfort. [private-scuba.com]

Signs and symptoms Severe pain Redness, bruising, swelling Treatment Prevention is the best treatment. Stay aware of your surroundings and remember lionfish can sting after they are dead. [tdisdi.com]

Weight-bearing surfaces may require removal of spines to prevent chronic pain. Always irrigate copiously after adequate anesthesia. [emedicine.medscape.com]

1. Hobday D, Chadha P, Din AH, Geh J. Denaturing the Lionfish. Eplasty. 2016;16:ic20.
2. Resiere D, Cerland L, De Haro L, et al. Envenomation by the invasive Pterois volitans species (lionfish) in the French West Indies—a two year prospective study in Martinique. Clin Toxicol (Phila) 2016;9:1–6.
3. Haddad V, Stolf HO, Risk JY, Franca FOS, Cardoso JLC. Report of 15 injuries caused by lionfish (Pterois volitans) in aquarists in Brazil: a critical assessment of the severity of envenomations. J Venom Anim Toxins Incl Trop Dis. 2015;21:8.
4. Satora L. Lionfish envenomations in Poland. Przegl Lek. 2009;66(6):285-286.
5. Diaz JH. Marine Scorpaenidae Envenomation in Travelers: Epidemiology, Management, and Prevention. J Travel Med. 2015;22(4):251-258.
6. Patel MR, Wells S. Lionfish envenomation of the hand. J Hand Surg Am. 1993;18:523 – 525.