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Dangers in the Ocean: the Traveler and Marine Envenomation. I. Jellyfish

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Dangers in the Ocean: the Traveler and Marine Envenomation. I. Jellyfish 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 heart failure. 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 animal groups: (1)jelly- ularly cause human deaths each year (Table 1; Fig. 3). fish, and (2) “other” marine animals. 3. “Other jellyfish” (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 Australia, 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 Chironex fleckeri,the North Australian box jellyfish. 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 hypertension, 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.
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