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REVIEW ARTICLE

Dangers in the Ocean: The Traveler and Marine Envenomation. I. Tellvfish PeterJ. Fenner

Envenomation by marine creatures is more common mation may have occurred, but has been classified as than is often realized, and regularly accounts for both death a myocardial infarction, followed by . Downloaded from https://academic.oup.com/jtm/article/5/3/135/1821068 by guest on 30 September 2021 and severe morbidity in humans. Chirodropids, having more than one tentacle in Worldwide marine envenomation morbidity and each corner of the bell (Fig. 1,2).Chirodropids reg- mortality result from two main groups: (1)jelly- ularly cause human deaths each year (Table 1; Fig. 3). fish, and (2) “other” marine . 3. “Other ” (Class Hydrozoa). These are not Venomous jellyfish are discussed in part I of this arti- actually jellyfish, although they resemble them, and are cle, with relevant information on their distribution and best dealt with as such. This group includes the appearance, and on symptoms of envenomation; first aid siphonophore Physalia sp., commonly known as the and medical treatment are also suggested. “Portuguese man-0’-war’’ (Fig. 4,5), and Gonionemtrs,

Jellyfish

Three main classes of jellyfish pose a threat to humans:’

Scyphozoans (Class Scyphozoa)-the “true” jelly- fish. Members of this group, which are common worldwide, have tentacles arising at regular intervals all around the bell (and often in other areas inside the bell), i.e., they are “radially” arranged. Cubozoans (Class Cubozoa)-the “box” jellyfish. These are the most dangerous jellyfish and have caused hundreds, possibly thousands, of human deaths in tropical and subtropical waters worldwide. They have a box, or cube, shape with tentacles arising only from the corners. There are two subgroups, or Families: Carybdeids (e.g., Irukandji), having just one tentacle (except in rare cases) arising from each lower corner of the bell. They have not caused a documented human fatality to date, although there is a pckibility that death from heart failure after Irukandji enveno-

Peter J. Fenner, MD (Lond), FACTM, FRCGP: General Practitioner, Mackay, North’Queensland, Honorary National Medical Officer, Surf Life Saving , Adviser to WHO, Figure 1 Anatomy of a Chirodropid (box) jellyfish. Note the AMA on marine envenomation. ”box-shaped” bell with four corners, and multiple (up to 15) ten- Reprint requests: Dr. Peter Fenner, PO Box 3080, North tacles arising from the corners only. Also visible in the top of Mackay, Queensland 4740, Australia. the bell are the gonads. The sense organs can be seen on the JTravel Med 1998; 5:135-141. bottom of the bell, midway between the tentacles.

135 136 Journal of Travel Medicine, Volume 5, Number 3

Table 1 Human Fatalities from Jellyfish Envenomation Approx. No. Jeflyfirh Geographical Locations Deaths Chirodropids Australia 66 Borneo 6+ Brunei Labuan (Malaysia) Sabah Sarawak Kalimatan (Indonesia) Downloaded from https://academic.oup.com/jtm/article/5/3/135/1821068 by guest on 30 September 2021 Japan (Okinawa Island) 2 Malaysia 2 (Penang & Langkawi Is.) Papua New Guinea 1+ Philippines 100’s Solomon (Bougainvillea) Is. 1 United States (Texas) 1 Physalia physalis United States 3 (Portuguese man-0’-war)

Stornolophus nornurai China (east coast) 8 (sand. jellyfish)

Figure 2 ,the North Australian . To date, it has been responsible for 66 human deaths in Aus- tralia. (Photo, courtesy of Surf Life Saving Queensland.)

a small hydrozoan, which causes sting problems in the Jellyfish Causing Human Fatalities Sea of Japan. i) Chirodropids (multi-tentacled box jellyfish) are the jellyfish causing most of the human fatalities. Fatal Jellyfish Envenomation stings regularly occur worldwide in tropical and sub- tropical waters (see Table 1). The tentacles of all jellyfish, and the bells of a few, ii) Portuguese man-0’-war (Pkysaliu ghysulis) is a siphono- have donsof small stinging cells, containing organelles phore colony that looks like a jellyfish, and is com- called nematocysts. These microscopic structures have a monly regarded as one by the general public. It has small “trigger” on the outside of the organelle.When this caused three human fatalities in the SE corner of the trigger touches live tissue (e.g., its potential victim), it is United States (see Table l).334 stimulated by both tactile and chemical mechanisms. A iii) A large scyphozoan jellyfish, Stomolophus novnuvai coiled tube, present on the inside, then everts in milli- (sandjellyfish), has now caused eight recorded deaths seconds, puncturing the integument of the victim and in one area of the South China Sea around Qindao, penetrating just to the dermis. The tube is bathed in China (see Table venom, so as it everts itself, venom is present on the out- side of the tube. These everting thread tubes have been Jellyfish Causing Severe Envenomation shown to directly penetrate small dermal capillaries,2 with Systemic Effects thus giving an intravascular injection of venom. The thread tubes also have a hollow lumen through which Several species ofjellyfish cause severe morbidity, not further venom is deposited in dermal tissues, where it is necessarily resulting in death: absorbed, probably by the lymphatic system, thus result- i) Irukandji (Curukia barriesi) is a carybdeid which causes ing in increased envenomation. severe systemic symptoms, called the Irukandji syn- Jellyfish can be subdivided into three main groups, drome.6 Symptoms of severe , pulmonary based on the symptoms they cause: those causing human edema and heart failure may be life-threatening.’ fatalities, those causing severe envenomation with systemic ii) Gonionemus is a tiny hydrozoan that occurs almost effects, and those causing nuisance stings. worldwide, but has been reported to cause severe Fen ner, Je I lyf i s h 137

systemic symptoms, similar to the Irukandji syn- drome, only in one small area in the Sea of Japan.7 iii) The multi-tentacled F‘kysalia physalis (Portuguese man-0’-war) causes severe skin pain, and again, sys- temic symptoms similar to the Irukandji.’ iv) Large carybdeids (box jellyfish) occur in most trop- ical or temperate seas, worldwide. In about 10% of cases they may cause a mild Irukandji-like syndrome.’

Description of Jellyfish Downloaded from https://academic.oup.com/jtm/article/5/3/135/1821068 by guest on 30 September 2021 Chirodropids (multi-tentacled box jellyfish) Distribution. Chirodropids are found on tropical coasts in Figure3 Welts caused bytypical severe sting from Chironex the following oceans: the east and west coasts of the fleckeri, which was almost fatal. (Photo, courtesy of Surf Life Atlantic Ocean, the east coast and mid-ocean of the Saving Queensland.) Indian Ocean, and the Indo West Pacific.’

Season. Chirodropids occur in tropical waters in the Adherent tentacles,like sticky threads, usually adhere summer months of either the Northern or Southern to the victim: tentacle marks look like the victim has been Hemispheres. Their season is longest closer to the equa- whipped, or branded with irons.’ If the victim lives, tor; e.g., in Darwin, Australia, which is the area in Aus- blistering and skin necrosis occur over the next few tralia closest to the equator, fatalities have occurred in all hours (Fig. 3);scarring often occurs, and lasts for life. Vic- months except July, but stings have been reported in every tims may rapidly stop breathing, sometimes within a month of the year. Areas furthest from the equator have few minutes of the initial envenomation, with death a correspondingly shorter jellyfish season-perhaps just occurring rapidly unless prompt first aid and medical aid a month or two in the height of summer in their distri- is available (Table 2,3). bution extremities (approximately the Tropic of Capri- Human Fatality. Documented human fatalities from chi- corn and the Tropic of Cancer).’ rodropid jellyfish (see Table 1) include 66 deaths in trop- Appearance. Chirodropids usually have a transparent bell, ical Australia, where fairly accurate records have been kept which may be up to 25-30 cm in diameter in the mature since 1884;’ one death in Texas, USA;9 and two deaths adult (see Fig. 1, 2). They have four corners (hence in Okinawa,’ the latest on 13 August 1997 (Cheryl “box”jellyfkh), with up to 15 tentacles in each corner Lewis, personal communication, August 1997). (up to 60 tentacles in total). These tentacles may extend Elsewhere in the world, accurate figures are not up to 3 m, resulting theoretically in a total tentacle kept, and most reports of fatalities are heard “through the length of up to 180 m. As the shortest tentacle length grapevine.” Approximately 10 other deaths have been causing fatality in a child has been just 1.2 m, it earns its reported from around the Indo West Pacific, excluding reputation as “the most deadly animal in the world!”’ the Philippines, but this information is probably only the Envenomation. Envenomation usually occurs in shallow tip of the iceberg, with many more probably occurring, water. Severe stings occur more often in women and but remaining unreported where the information is young children, who are smaller and relatively hairless. freely available. Hair can prevent more intimate tentacle contact, and con- Based on personal experience, the author, after a sequently prevents envenomation. visit to the Philippines in 1984, calculated that between Chirodropids swim into shallow water when the 20-50 human deaths occur each year from chirodropid wind is light and hot, and the water is calm. Unsuspect- stings.’ These figures have since been corroborated by ing victims frequently walk, or run, into tentacles trail- Dr. Paul Cornelius, The Natural History Museum, ing behind the jellyfish bell. The bell is difficult to see London (personal communication, 1994) and by Prof. in the water, and the tentacles are almost invisible. Thomas Heegar.’” Pain is instant and savage; the victim will often scream with pain. Children often stand in the water,pick- lrukandji (Carukiabarnesi) ing at the tentacles and getting stung on the hands and Distribution. The distribution of Irukandji in Australia, arms, increasing the envenomation, while adults fre- in tropical waters from Gladstone, north Queensland quently run out of the water and rub the tentacles. Most on the east coast, northwards and westwards over Aus- stings occur on the lower legs and body. tralia as far south as Exmouth, Western Australia.’ 138 Journal of Travel Medicine, Volume 5, Number 3 Downloaded from https://academic.oup.com/jtm/article/5/3/135/1821068 by guest on 30 September 2021

Figure 4 Portuguese man-0’-war (Physalia physalis). Note Figure 5 Characteristic sting from Physalia physalis. Note the the large gas-filled float on the surface of the water, and the ”beading“ effect on the skin caused by multiple tentacles. multiple tentacles trailing beneath. (Photo from Halstead 1965, courtesy of United States Office of the Assistant Secretary of Defense, Washington, DC.) first aider!); restlessness, moving continuously; severe frontal or global , which may be incapacitating; Cleland and Southcott reported jellyfish similar in nausea-often with severe, intractable ; increased appearance in West Irian and Papua New Guinea (PNG), respiratory rate-often of a ‘sighing nature’; tremor; pal- during World War 11, which caused similar envenoma- lor, or peripheral cyanosis; oliguria due to reduced renal tion symptoms.” Despite having an extensive database perfusion and fluid loss from the sweating and/or vom- ofworldwide stings, the author has no further reports of iting; -often irregular with ventricular extra- similar stings since then, although information on any envenomation from Papua New Guinea is particularly Table 2 First Aid Treatment of Chirodropid Envenomation scarce and sketchy.8 1. Ketrieve the victim from the water and restrain, if Season. Its season is the summer months, similar to the necessary. chirodropid season in Australia.’ 2. If bystanders are available, immediately send them for Appearance. Irukandji is a tiny transparent bell (< 2 cni ambulance/nie&cal help. diameter), with four small tentacles, one in each corner. 3. Check the victim’s Airway, Breathing and Circulation It is a type of box jellyfish called a carybdeid. (ABC). Treat with Expired Air Resuscitation (EAR),or Cardiopulmonary Resuscitation (CPR),if necessary. Envenomation. Envenomation starts with a skin sting, 4. If others are available, or if resuscitation is not needed, which may be so mild as to be hardly felt, or may be some- pour vinegar over the stung area for a minimum of what uncomfortable. However, some 5-40 minutes later 30 seconds to inactivate remaining stinging cells on (usually 30 minutes) the severe systeniic symproms start: any adherent tentacles left on the skin. these are called the ‘Irukandji syndrome.’6 5. AFTER vinegar application, apply conipression bandages directly over major stings. Major stings are those The first symptom is usually a severe ‘boring’ pain a) covering an area more than half of one limb in the sacral area. Other symptoms quickly develop and b) causing impairment of consciousness include muscle pains or ‘cramps,’ moving rapidly into all c) causing impairment of breathing four limbs and the abdomind and chest wall muscles. The d) causing inipairnient of circulation. pain is described as severe, unbearable and coming on in If vinegar is unavailable, the rescuer should pull tentacles off using their fingers (only a faint, harmless prickling will ‘waves’(sindar to labor pains), although never fadmg com- be felt) before applying the compression bandages. pletely. or ‘tightness’ occurs fiom spasm of the 6. Cold packs may be used (15 minutes and repeated when intercostal muscles and probable cardiac muscle pain. necessary) to help ease the skin pain in conscious victims. Many of the associated with the 7. In severe envenomation, use oxygen if available. Inhaled Irukandji syndrome resemble those of an adrenal analgesia (i.e., entonox or methoxyflurane) can be administered for unremitting pain in conscious, breathing, medullary tumor (phaeochromocytoma), with exces- cooperative patients. Its use should be discontinued if the sive release of catecholamines into the bloodstream. patient’s condition worsens. Symptoms include the following: sweating-localized or 8. In Australia, if available, use CSL Chirowex antivenom for generalized, often prohse and drenchng;localized or gen- all major cases. Three ampules each containing 20,000 erahzed piloerection; and ‘wretchedness’-the vic- units may be given intramuscularly, above the bandages, tim feels ‘absolutely dreadful’ and often has ‘a feeling of by a trained health professional on the beach. Medical personnel may give one ampule intravenously. impending doom’ (a feeling often shared by the treating Fenner, Jellyfish 139

Table 3 Medical Treatment of Chirodropid Stings Table 5 Primary Hospital Treatment of Irukandji, and Irukandji-like Syndrome* 1. If nececsary, continue resuscitation with endotracheal incubation and 100%1oxygen (if appropriate), Analgesia: IV infusion with boluses 5-10 mg monitoring the oxygen hemoglobin saturation (adult); 50 mg IV 3 hrly prn and electrocardiography. Catecholamine-like effects: phentolamine 5-1 0 mg 2. Insert an intravenous line; monitor urine and cardiac boluses (adult) +/- infusion output. Chest pain: IV GTN (50 nig in 500 ml 5% dextrose) 3. In major chirodropid stings, administer a minimum of commencing at 3 mL/hour 1 ampule of diluted antivenom (20,000 units) 1V If the Pulse occimetry: administer oxygen to keep hemoglobin clinical response is inadequate, three (or more) ampules oxygen saturation > 93%) may be given IV, according to clinical response. Check BP regularly (automatic machine - dynamap, if

4. Inotropes such as or dopamine should be possible) Downloaded from https://academic.oup.com/jtm/article/5/3/135/1821068 by guest on 30 September 2021 considered for persisting hypotension; however, calcium Monitor ECG should not be given. Chest X-ray if respiratory rate increases, or 0’ sats 5. Intermittent positive pressure ventilation with 100% reduced oxygen will also assist in control of . Blood for cardiac enzymes: CK, CK:MB, catecholamines Note: Cardiopulmonary resuscitation with oxygen (if possible) (preferably 100%) should be continued and not Admit to high dependency ward abandoned until more antivenom (at least 6 ampules total Echocardiogram within first 24 hours dose, if available) and inotropes have been administered. If heart failure: refer to Physician for high flow oxygen, 6. Intravenously administered analgesia may be necessary CPAF’, increase GTN, frusaniide, CVP line, inotropes (1 mg/kg of pethidine up to 50 mg adult dose initially). For pain not relieved by cold packs and narcotic analgesia, *No first aid treatment is available for lrukandji syndrome, although one in chirodropid stings, consider administration of 1 ampule method is being tested at present. of antivenom IV as in #3. 7. Intravenous antivenom (administered as in #3) may confer cosmetic benefits in stings involving cosmetically Appearance. The Portuguese man-0’-war has a clearly vis- sensitive areas (e.g., face or neck) especially in females. ible blue float up to 25 cm in length (see Fig. 4). It sits on the surface of the water with long blue tentacles systoles; hypertension, with levels as high as 280/150 nim hanging in the water. These are highly retractable and Hg in previously normotensive victims. Recommended may extend up to 30 m in length! The smaller version hospital treatment is described in Table 5. of the same species in the Pacific is often referred to as Later complications may be acute pulmonary edema, the Pacific man-0’-war, and the smaller cousin, the sin- usually some 15-1 8 hours post-envenomation (occa- gle-tentacled species (Physalia crtriculus), which is the sionally less), and secondary toxic global cardiac dilata- most common species in Australia, is usually known as tion with left ventricular dysfunction, proven by the bluebottle.’ echocardiography. ’ Envenomation. The smaller bluebottle causes uncom- fortable skin pain. However, both the Pacific and Por- Portuguese Man-0’-War (Physalia physalis) tuguese man-0’-war cause very painful skin stings (see Distribution. Distribution of the multi-tentacled Portuguese Fig. 5), although not as severe as that of Chivonex box jel- man-o’-war is worldwide in temperate and tropical zones. lyfish (see Fig. 3). Physalia pliysnlis causes painful breath- Stings appear to be more severe in warmer waters.’ ing, even leading to hypoxia,” as well as nausea, muscle cramps and anxiety-similar to the initial effects of the Irukandji, therefore referred to as an “Irukandji-like” Table 4 First Aid Treatment of Non-chirodropid (see Table 5 for hospital treatment). Envenomation There have now been three deaths recorded from 1. If fresh, adherent tentacles are present on the skin, they the Portuguese man-0’-war in south eastern United should be flushed off with seawater. If this is unavailable, States (see Table l).3,4 tentacles can be picked off the skin with the fingers (only a harmless prickling of the fingers will be felt). Physalia sp. was also thought to be responsible for a 2. Ice in a polyethylene bag, wrapped in a cloth, or cold severe envenomation resulting in brachial artery spasm packs are applied to the stung area and left in place for after a second sting, 2 weeks after the initial sting, at Man- 5-15 minutes. This will relieve most skin pain. galore in the Indian Ocean in the summer of 1983.14The 3. The ice or cold packs can be reapplied if the skin pain is cause was attributed to hypersensitivity. Serious enven- unrelieved, or returns. 4. Unresolved pain or any further systemic symptoms are omation from an Indian Ocean (Goa) jellyfish was immediately referred to medical care. reported, in which a Physalia sp. was suspected, on the 5. Inhaled analgesia (such as entonox or penthrane) may be basis of serologic titers, of producing localized necrosis, available from the local ambulance for more severe pain, vasospasm and gangrene, although the identity of the jelly- but further medical aid should be sought. fish was not confirmed.” 140 Journal of Travel Medicine, Volume 5, Number 3

It has since been reported that a little-known jelly- elers should be aware that this jellyfish has stinging cells fish cakd Sunderia present in the Indian Ocean can also on the bell which may also cause stingsJ8 cause severe symptoms, and may have been responsible Envenomation. The organisms cause skin pain, &om “burn- for these unusual stings.‘ ing” to a very painful sting, although not as severe as that of chirodropid jellyfish. In approximately 10% of cases, it may cause a similar syndrome to the Irukandji, but not Gonionemus sp. as severe, known as an Irukandji-like syndrome.’ Distribution. Distribution of Gonionemus sp. is worldwide; however, Gonionemus has been reported as causing severe Jellyfish Causing Nuisance Stings envenomation effects only in the Sea of Japan around Nuisance stings from jellyfish occur all around the

Vladivostock (previously USSR), and the northwest world. Fortunately, it is unnecessary to identie these Downloaded from https://academic.oup.com/jtm/article/5/3/135/1821068 by guest on 30 September 2021 shores of Honshu Island,Japan.’ stings as the symptoms are skin pain only in the stung Season. Serious stings from Gonionemus tend to occur in region, and the only treatment necessary is the use of cold the hot summer month of August in the Northern packs to relieve the pain. Should there be systemic symp- Hemisphere in the Sea ofJapan. toms, which rarely occur, they can be treated on an ‘ad Appearance. Gonionernus is a small jellyfish in the class hoc’ basis (see Tables 2-5).* Hydrozoa, measuring 5-15 mm in diameter, with many tentacles attached to the entire edge of the bell. A sym- Avoiding Jellyfish Stings metrical, right-angled cross is visible in the transparent bell.’ Awareness Travelers should be aware of several factors which Envenomation. Three forms of intoxication have been may make jellyfish stings a potential danger: described: painful, respiratory and mixed.”j In the painful form (approximately 37%), the symp- time of the year (summer) toms are severe muscle,joint, chest and loin pains, which geographical location (tropical and subtropical waters) persist for 2-3 days. There is general muscle fasciculation. weather (hot, stdl weather with light northerly winds). In the respiratory form (44%),patients develop aller- If these conditions exist, travelers should at all times gic rhinitis, lacrimation, hoarseness, cough and dyspnea. be using patrolled beaches (surf lifesaver on duty).’ These symptoms persist from several hours to 2 days. In the mixed form (19%), in addition to severe joint and Prevention muscular pains, cough, bronchospasm, throat irritation, Travelers need to do the following:’ rhinitis and lacrimation, some patients have a tachycar- obey warning signs (advising of dangerous jellyfish) dia (up to 100 beats per minute), and mild hypertension wear protective clothing (pantyhose, lycra “stinger (up to 150/100 mm Hg). suits”) Severe stings documented by physicians are accom- swim on patrolled beaches panied by psychic dysfunction.16Neuropsychatric symp- swim in stinger-resistant nets, if available (there are now toms, depression and hallucinations are also possible.’ 17 in north Queensland). In Japan, the stings mainly occur underneath bathing costumes. A similar syndrome has been reported in Treatment of Jellyfish Stings northern Japan after the victim ate raw seaweed. As Gonionemus lives in this seaweed, it is presumed the syn- Treatment of stings includes first aid treatment drome results from its ingestion.” (Tables 2 and 3),medical treatment (Table 4), and hos- pjtal treatment (Table 5). large Carybdeids (Tamoya and sp.) Conclusion Distribution. Distribution of large carybdeids (box jelly- fish) appears to be all temperate, subtropical and tropi- Envenomation by venomous jellyfish can be a fatal cal oceans, although they are much more common in the event. Morbidity is even more common and the victim latter. may suffer severe systemic reactions. With the increas- Season. They may be present any time of the year, but ing numbers of travelers worldwide, especially to the more are more common at the beginning and end of summer.’ remote areas, travel medicine experts and general prac- Appearance. The large carybdeids are large box-shaped titioners must warn their patients of these dangers, in ad&- jellyfish with just a single large tentacle in each corner. tion to providing the more common forms of advice. The bell may be from 4-18 cm in height, with the four Although marine envenomation may be caused by tentacles up to a meter long in the larger specimens.Trav- a number of jellyfish species, in addition to immediate Fenner, Jellyfish 141 resuscitation, three main treatments cover first aid man- Pigulevsky SV,MichalevPV. Poisoning by the medusa Gonio- agement of the stings of all jellyfish species: nernus vertcns in the Sea ofJapan. Toxicon 1969; 7 145-149. Fenner PJ. The global problem of cnidarian stinging. MD 1) Cold packs to stop skin pain ofjellyfish stings Thesis. London University, 1997:1-202. 2) Vinegar, to prevent further stinging from chirodropid Bengston K, Nichols MM, Schnadig V, Ellis MD. Sudden death (box jellyfish) stings in a child following jellyfish envenomation by CIziropsalmus 3) Compression/immobilization to reduce the spread of quadrumanus. JAMA 1991;266:1404-1406. venom from bites depositing large amounts of venom 10. Heegar T. Harmful jellyfish (Scyphozoa, Cubozoa and Hydro- in one spot. zoa, ) of the Philippines. Article presented at 1996 Conference on Marine Biology: Marine Biology Dept., San Although medical treatment is more extensive and Carlos University, Cebu City 6000. Philippines. variable, prompt first aid by those first on the scene will 11. Cleland JB, Southcott RV. Injuries to man from marine Downloaded from https://academic.oup.com/jtm/article/5/3/135/1821068 by guest on 30 September 2021 usually be life saving. in the Australian region. National Health and Medical Research Council, Special Report Series No’ 12. Canberra, 1965: 143. References 12. Kizer KW. Case report: decompression sickness or Por- tuguese man’o’war envenomation. Wilderness Med 1984; 1. Williamson JA, Fenner PJ, Burnett JW, RifiinJ. Venomous 1:7-8. and poisonous marine animals: a medical and biological 13. Burnett JW, Fenner PJ, Kokelj F, Williamson JA. Serious handbook. Sydney: New South Wales University Press, Physalia (Portuguese Man o’war) stings: implications for 1996. scuba divers. J Wilderness Med 1994;5:71-76. 2. Rikin JF, Endean R. Arrangement of accessory cells and 14. Adiga KM. Brachial spasm as a result of a sting. Med J Aust nematocysts bearing mastigophores in the tentacles of the 1984; 14O:18O-181. cubozoan Chiuonex.peckeri. J Morphol 1988; 195:103-115. 15. Williamson JA, Burnett JW, Fenner PJ, et al. Acute regional 3. Stein MR, Marraccini JV, Rothschild NE, Burnett JW. Fatal vascular insufficiency after jellyfish envenomation. Med J Portuguese man-0’-war (Physalta physalis) envenomation. Aust 1988; 149:698-701. Ann Emerg Med 1989; 18:312-315. 16. Migas EA, Popova GA. Instructions on rendering medical asis- 4. Burnettm, Gable WD. A fatal jellyfish envenomation by the tance to persons stung by a venomous krestovik-medusa Portuguese man-0’-war. Toxicon 1989; 27:823-824. from the Sea ofJapan. Vladivostok 1988: 1-10 [in Russian]. 5. Mingliang Z,Qin Shede. The marine stinger in South China 17. Otsuru M, Sekikawa H, Hiroii Y, et al. Observations on the Sea. Chinese J Marine Drugs 1991;4:36. sting occurring among swimmers in the rocky seashore. 6. Flecker H. ‘Irukandji’sting to north Queensland bathers with- Aquatic Sci Fish Abst 1974: 4Q10805M. out production of wheals but with severe general symp- 18. Fenner PJ, Fitzpatrick PE Hartwick RJ, Slunner R. ‘Morbakka’, toms. Med J Aust 1952; 1 :89-91. another cubomedusan. Med J Aust 1985; 143:550-555.