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].

• Pain

  The exertion and pain have caused me to use more air than normal, and my tank is nearing the reserve. Over increasingly painful minutes, I surface and hand up my gear. [turtlebaydiveresort.com]

  Kisiel's lawsuit against Mark's Pets and Fish described her sting this way: "I immediately felt intense pain in my right hand. The pain was indescribable. [articles.latimes.com]

  So, for the next three hours, I was in serious, burning, aching, explosive pain. [news-press.com]

  Once the pain becomes more manageable, Peterson applies a bit of Neosporin to the wound. He also takes Benadryl as a precaution against an allergic reaction, and he recommends Ibuprofen for basic pain reduction. [wideopenspaces.com]

  For most people the throbbing, intense pain is going to last for a few hours and will remain less painful for 12 hours or longer. One thing is for sure, everyone reacts differently and has a different experience. [lionfish.co]

• Fishing

  "They're a very popular aquarium fish. But I can't imagine someone not being aware of the fact they're venomous. You look at one of those fish displaying those spines. [articles.latimes.com]

  Lionfish, ( Pterois ), also spelled lion fish or lion-fish, also called turkey fish or fire-fish, any of several species of showy Indo-Pacific fishes of the scorpion fish family, Scorpaenidae (order Scorpaeniformes). [britannica.com]

  Lion fish are here to stay. With the ability to produce up to 30,000 eggs every 4 days, extripating the spiny invader is simply impossible. One of major issues is that there are very few natural predators taking the fish. [idivecayman.com]

  Unlike spiders or snakes, we rarely hear about which fish are the most poisonous (or venomous). This week we are dedicating our blog post to these hazardous fish. (Cooney) First though let’s clarify some terminology. [thefisheriesblog.com]

  Their aggression toward divers has been well documented, and I have already experienced fish swimming aggressively towards me, displaying their spines. The red lionfish is a venomous coral reef fish. [turtlebaydiveresort.com]

• Weakness

  Gameplay Darius II Hyper Sting is a very easy boss, it's only attack being shooting a laser with some bullets from his mouth, which is also his weak spot. [darius.wikia.com]

  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]

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

  Tetrodotoxin is neurotoxic and inhibits neural transmission leading to weakness, paralysis, and even death at relatively low concentrations (~2mg). [thefisheriesblog.com]

  There are many other complications that can arise from any marine creature envenomation such as shortness of breath, weakness, fainting, and cardiac arrest due to shock from the extreme pain. [lionfish.info]

• 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]

• 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]

• Chest Pain

  Severe allergic reactions to Pterois venom include chest pain, severe breathing difficulties, a drop in blood pressure, swelling of the tongue, sweating, runny nose, or slurred speech. Such reactions can be fatal if not treated. [en.wikipedia.org]

• Blister

  At the time of admission, lionfish stings may present as erythema, blistering, or dermal necrosis, depending on the duration of symptoms before the examination. [symptoma.com]

  The injury left his leg covered in severe blisters. Dr. Tom Robert's leg is now covered in severe blisters. He was diving Saturday and when he was coming up, he accidentally kicked his leg right into the spears of a lionfish. [weartv.com]

  Around 6pm, after several hours of keeping his hand in the water, he realised his finger had begun to blister. [caymancompass.com]

  If a person is stung, that person will experience intense throbbing, sharp pain, tingling sensations, sweatiness and blistering. [hawaiiscubaadventures.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]

• Headache

  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]

  You may feel feverish with headaches and dizziness. It is also common to suffer breathing difficulties from lionfish stings. If you get stung by a lionfish you should exit the water immediately and seek medical attention. [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, cramping, nausea, paralysis, seizures and chills. [faculty.washington.edu]

  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]

• Irritability

  The pain will last for a few hours and the irritation will likely last longer, but you will not die. [thoughtco.com]

  After an hour or two in the presence of the trees, she experience severe irritation from inhaling the spines that fell in an invisible shower from the trees above. Dr. [dengarden.com]

• Burning Sensation

  Rubbing alcohol/ isopropyl alcohol or vinegar may help to alleviate the painful burning sensation caused by a bearded fireworm sting. Both alcohol and vinegar are standard in a diving first aid kit. [thoughtco.com]

  However, their venom is fast-acting and can cause extreme pain and burning sensations Contact with humans occurs mostly during sea diving (accidental contact), while hunting for these fishes, or while cleaning tanks. [dovemed.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.