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BITES AND STINGS Severity of Irukandji syndrome and nematocyst identification from skin scrapings Truc T Huynh, Jamie Seymour, Peter Pereira, Richard Mulcahy, Paul Cullen, Teresa Carrette and Mark Little JELLYFISH STINGS in northern Aus- ABSTRACT tralia cause significant morbidity and mortality.The Medical Since Journal early ofdescriptions Australia ISSN: of Objectives: (1) To identify the causative jellyfish species by examining skin scrapings Irukandji0025-729X syndrome, 6 January1,2 2003relatively 178 1 38-41little in patients presenting to Cairns Base Hospital with marine stings, and (2) to describe further©The knowledge Medical Journal has of beenAustralia gained 2002 clinical outcomes of those with Irukandji syndrome and those in whom nematocysts www.mja.com.au about it. Although Carukia barnesi has were identified from skin scrapings. Bites and Stings 3 been shown to cause the syndrome, Design and setting: (1) A retrospective case series of 128 patients, identified from other species of jellyfish are also sus- 3-7 Cairns Base Hospital emergency department records with discharge diagnoses of pected to be responsible. marine stings between 1 July 2001 and 30 June 2002. (2) A prospective study of skin We hypothesise, firstly, that many dif- scrapings from 50 patients presenting with marine stings from the same period. ferent cubozoans may produce Iru- kandji syndrome in Cairns, and Main outcome measures: Number of patients with Irukandji syndrome, their opioid secondly, that these different species of requirements and cardiac findings (where available); identification of causative species jellyfish may be responsible for different from nematocysts isolated from skin scrapings. severities of this syndrome. Results: 116 patients retrospectively identified with marine stings had Irukandji syndrome. Of 50 patients who had skin scrapings, 39 had nematocysts consistent with Carukia barnesi. Symptoms experienced ranged from local pain alone to severe Irukandji syndrome with elevated troponin I levels, changes on electrocardiogram, METHODS cardiac dysfunction on echocardiography, and high opioid dose requirements. One Retrospective case series patient had an unidentified cnidome on his skin scraping. He developed severe Irukandji syndrome and subsequently died from its complications. All patients with a discharge diagnosis Conclusion: This is the first published report of Carukia barnesi being successfully of “marine stings” (ICD-10 code identified from skin scrapings. Most patients with identifiable cnidomes experiencing T63.6)8 after presenting to Cairns Base Hospital, Queensland, between 1 July Irukandji syndrome were stung by Carukia barnesi, which we show causes a wide 2001 and 30 June 2002 were retrospec- range of illness, including cardiac dysfunction. Our finding of a cnidome not consistent tively identified from the emergency with Carukia barnesi in the setting of Irukandji syndrome makes it possible that other department computer database, and species of jellyfish may also cause this syndrome. epidemiological and clinical data were MJA 2003; 178: 38–41 extracted and entered on a standardised form. Details collected included geo- fentanyl according to clinician prefer- ing to emergency department protocols, graphic location of sting, physiological ence, we arbitrarily converted their opi- and additionally had skin scrapings of parameters, analgesia required, bio- oid dose to “morphine equivalents” their sting site performed. Exceptions chemical abnormalities, electrocardio- (where 1 mg morphine = 10 mg were distressed children, patients with graphic and echocardiographic findings. pethidine = 10 g fentanyl) to give a stings to the face, women with stings to We assessed the clinical severity of rough comparison of analgesic require- the breast region, and patients in whom each patient’s condition at presentation ments between patients. an obvious sting site could not be iden- according to peak systolic blood pres- tified; these patients did not have skin sure, total opioid dose administered, scrapings performed. Prospective case series peak troponin I level, and length of The sampling procedure was hospital stay. As individual patients Patients presenting with marine stings explained to patients and verbal consent received either morphine, pethidine or during this period were treated accord- was obtained. The sting site was scraped firmly with a sterile scalpel Emergency Department, Cairns Base Hospital, Cairns, QLD. blade, which was then placed in a sterile Truc T Huynh, MB BS, Emergency Registrar; Peter Pereira, FACEM, Director of Emergency; specimen container containing 10% Richard Mulcahy, FACEM, Emergency Consultant; Paul Cullen, FACEM, Emergency Consultant. buffered formalin. The scalpel was School of Tropical Biology, James Cook University, Smithfield, QLD. shaken vigorously in the specimen con- Jamie Seymour, PhD, Senior Lecturer; Teresa Carrette, BSc, Marine scientist. Emergency Department, Sir Charles Gairdner Hospital, Perth, WA. tainer to cause adherent scrapings to fall Mark Little, FACEM, Emergency Consultant. off. The specimen was then centrifuged Reprints will not be available from the authors. Correspondence: Dr Peter Pereira, Emergency at 5000 revolutions per minute for 10 Department, Cairns Base Hospital, PO Box 902, Cairns, QLD 4870. [email protected] minutes, stained with eosin and distrib- 38 MJA Vol 178 6 January 2003 BITES AND STINGS General clinical findings Forty-two patients (36%) were dis- 1: Map showing the coastline, charged home directly from the emer- islands and reef where patients Peak systolic blood pressure in the 94 were stung gency department within eight hours of adults with Irukandji syndrome ranged presentation. Fifty-four patients (47%) from 100 mmHg to 230 mmHg, with a 16 N were discharged from the emergency Cape Tribulation 147 mean of 145 mmHg. Nineteen of the 22 department observation ward the next Opal Reef G children had their blood pressures day, eight were transferred to the coro- r e recorded. Seven had a systolic blood a nary care unit (CCU), and 11 were t pressure 140 mmHg or above; the high- transferred to the general medical or est of these was 165/95 mmHg in a 12- paediatric ward for ongoing analgesia. year-old child. B Additionally, one patient was trans- a Port Douglas r Total analgesic requirements for r ferred to the intensive care unit in ie adults during their hospital stay ranged r Townsville General Hospital for neuro- from 0 to 255 mg of morphine equiva- surgical care for an intracerebral haem- lents (mean, 31 mg). Of the 10 children orrhage. Palm Cove who had their weight recorded, analge- Green island R sic dose ranged from 0 to 1.4 mg per kg e Skin scrapings e morphine equivalents (mean, 0.29 mg f Cairns per kg). Skin scrapings were taken from 50 Fitzroy Island patients. Of these, four patients had 17 Cardiac findings local symptoms only, and the remainder had symptoms consistent with Irukandji Queensland Normanby Troponin levels (cTnI) were measured syndrome. Forty patients (80%) had Island in 103 patients whose pain did not settle positive scrapings, while, in the remain- with a single dose of parenteral opioid der, either no nematocysts were found uted onto a Kova slide for microscopic analgesia. Twenty five (22%) had ele- or the nematocysts were too damaged to examination. vated cTnI levels, ranging from 1.0 to be confidently identified (positive pre- Specimens were prepared and exam- 34.0 g/L (reference range, < 0.7 g/ dictive value of 80%). Thirty-nine ined by one of the authors (J S), who L). None of these patients had clinical patients had a nematocyst cnidome was blinded to the source. Identification or chest x-ray findings of pulmonary identifiable as Carukia barnesi; two of of jellyfish species was based on a cnid- oedema. Eleven patients had non-spe- these experienced only a mild sting at ome database (a cnidome is a collection cific electrocardiogram (ECG) abnor- the site, and 37 had Irukandji syn- of nematocysts used to distinguish malities, most involving T-wave drome. Of these 39 patients, 13 had a between species of jellyfish) being for- inversion and ST-segment depression. raised cTnI level; five of these had mulated by the examiner and due for Echocardiograms were performed in 18 abnormal echocardiograms and seven publication in 2003. of the 25 patients with elevated cTnI had abnormal ECGs. Thirty-one The results of the species identifica- levels, and abnormalities were found in patients with Carukia barnesi identified tion was then matched to the clinical six. Echocardiographic abnormalities on skin scrapings (79%) were stung at data. ranged from mild impairment of systolic local mainland beaches. The rest were function to moderate dysfunction with stung at Fitzroy Island (4), Green Island segmental hypokinesis. One patient had (1), and Normanby Island (1) (see Box global myocardial dysfunction. Two 1). RESULTS patients had serial echocardiographic The patient with the most severe studies showing normalisation of their symptoms who had Carukia barnesi From 1 July 2001 to 30 June 2002, 128 systolic function over time (one within identified from skin scrapings was a 44- patients at the Cairns Base Hospital three months and the other over six year-old man with a peak blood pres- emergency department had a discharge months). sure of 160/100 mmHg and peak cTnI diagnosis of marine stings. Of these, Among the 91 remaining patients level of 30.8 g/L, who required a total 116 had symptoms consistent with Iru- only one