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Picture As Pdf Download BITES AND STINGS Irukandji syndrome in northern Western Australia: an emerging health problem Conrad J Macrokanis, Nicole L Hall and Jacki K Mein rukandji syndrome is a collection of ABSTRACT hypercatecholaminergic symptoms aris- ing from jellyfish envenomation.1 This Objectives: (1) To assess the number and severity of episodes of Irukandji syndrome in I Broome, Western Australia. (2) To correlate demographic, seasonal, geographic and variable syndrome includes severe general- ised pain, distress, hypertension, cardiomy- climatic features of Irukandji stings. (3) To assess treatment of Irukandji syndrome at opathy and cardiogenic pulmonary oedema. Broome Health Service. (4) To assess the public health impact. Irukandji syndrome was first described in Design and setting: (1) A retrospective analysis of jellyfish data forms and charts Cairns by Flecker in 1952 and named after of 111 patients, identified from Broome Health Service Emergency Department with a 2,3 discharge diagnosis of marine sting between 1 January 2001 and 1 July 2003. the localThe AboriginalMedical Journal tribe. of Barnes Australia first ISSN:cor- (2) Correlation between climate and Irukandji envenomation data. related0025-729X Irukandji 6/20syndrome December with 2004 the 181small 11/ box (cubozoan) jellyfish Carukia barnesi.2 Main outcome measures: Number of patients with Irukandji syndrome; their 12 699-702 The ©Thesyndrome Medical is Journalwell documented of Australia 2004in demographic and environmental features; the clinical syndrome; treatment requirements. Queenslandwww.mja.com.au north of the Tropic of Capricorn Results: 111 patients were prospectively identified with marine stings; 88 were 4,5 and inBites the and Northern stings Territory, with two identified with Irukandji syndrome. Non-Irukandji syndrome data were excluded for deaths recently reported from north Queens- analysis. The “jellyfish season” extends from January to May, although stings occur all 6 land. Although a recent published series of year round. Only 38% of patients had vinegar applied to the sting site before hospital cardiac toxicity and pulmonary oedema from presentation. Signs and symptoms were variable between individuals, with 20% having Irukandji syndrome included one case from no signs of sting at all and welts found in 16%. Fifty per cent of patients were 7 Broome, little is known about the incidence hypertensive at presentation. Distress was found in the majority of patients, with 90% and severity in Western Australia. C. barnesi requiring opioid analgesia (morphine equivalent: mean, 20 mg; median, 13 mg) and 17% has never been identified in Western Aus- requiring admission. There was one evacuation to Perth with cardiotoxic marine tralia. envenomation resulting in pulmonary oedema, which necessitated 4 days in intensive The risk of envenomation has a large care. Stings were significantly more common when the ambient median temperature potential impact on public health, com- was greater than 28.3°C, after midday, on an incoming high tide and on windy days. merce, leisure and tourism in tropical Aus- 8 Conclusion: The rate of envenomation in northern WA is likely to be the highest tralian communities. Our aims were to currently documented in Australia. There is syndromic variability when compared with characterise the incidence, demographics, the north Queensland experience. This implies different causative jellyfish species that and management of Irukandji syndrome in are not yet identified. Stings in Broome can be severe and life threatening; there are Broome, WA, over the past three seasons, significant commercial and public health implications as a result. Management at and to correlate the incident data with sea- Broome Hospital is contemporary and effective. sonal and climatic changes. MJA 2004; 181: 699–702 METHODS tients and emergency department patients Patient symptoms and signs in the emer- Broome has a population of about 16 000 identified by jellyfish forms were exam- gency department were examined, and the from October to March, which rises to about ined retrospectively for the period 1 Janu- maximum values recorded. Pain scores 40 000 in the April to September tourist ary 2001 to 1 July 2003. Irukandji were assessed using verbal pain scales. All 9 season. This is increasing annually. Broome syndrome was diagnosed if the criteria in opiates were calculated as morphine District Hospital is the sole provider of Box 1 were met. equivalents: 1 mg morphine = 10 mg emergency care. The jellyfish data forms collected patient pethidine = 10 µg fentanyl. All jellyfish stings were recorded pro- demographic details, details of jellyfish The Broome Bureau of Meteorology pro- spectively using jellyfish data forms. To stings (including site and timing), first aid identify patients with Irukandji syndrome, management, jellyfish awareness, patient vided wind speed, moon phase, tides, air the medical records of all hospital inpa- symptoms and signs, and treatment. temperature, and cloud cover information for the study period. The National Tidal FOR EDITORIAL COMMENT, SEE PAGE 685 Facility provided data on Broome Port Department of Medicine, Broome Health Service, Broome, WA. water temperatures. Time of sting was then Conrad J Macrokanis, MB BS, FRACGP, BSc(Hons), District Medical Officer. correlated with meteorological data. A Department of Medicine, University of Western Australia, Perth, WA. control day (when no sting occurred) was Nicole L Hall, Medical Student. allotted for each case as close as possible Department of Public Health, Kimberley Population Health Unit, Broome, WA. Jacki K Mein, MB BS, FACCHP, MAE, Kimberley Public Health Medical Officer. from two days before to a week after the Reprints will not be available from the authors. Correspondence: Dr C J Macrokanis, day of the sting. Each climatic variable for Department of Medicine, Broome Health Service, PO Box 62, Broome, WA 6725. both case and control days was compared Conrad.Macrokanis@health.wa.gov.au using χ2 with Intercooled STATA 7.10 MJA • Volume 181 Number 11/12 • 6/20 December 2004 699 BITES AND STINGS Treatment and outcomes 1 Case definition for Irukandji 2 Comparison of features of syndrome Of the 58% of Irukandji syndrome victims Irukandji syndrome in Broome who had vinegar applied to the sting site, • and north Queensland Contact with seawater within 60 minutes two-thirds received it before hospital arrival. • Minor skin pain at envenomation site Opiate analgesia was required by nearly North • 5–60 minutes’ delay to symptom onset 90% of all adults. The average adult mor- Broome, Queensland, • At least three of the following: severe low phine-equivalent given was 20 mg (median, 2001–2003 199611 back pain; muscle cramps in all four limbs, 13 mg; range, 5–90 mg). Three patients Number of 88 62 the abdomen and chest; sweating; received intravenous magnesium sulfate as a patients anxiety; restlessness; nausea; vomiting; bolus or infusion (10–80 mmol) before headache Age range 1–63 18–56 receiving opiates. In all three patients, the (years) initial response to magnesium was dramatic, with reduction in pain scores from 10 to less Male 57% 47% This process was considered an audit of than 5 within minutes. In all three patients, Peak season January December existing data and did not require ethics although magnesium infusions were estab- for sting to May to January approval. lished at different times, the infusion alone Clinical features was ineffective in establishing effective anal- Pain score 10/10 45% Not available RESULTS gesia, and breakthrough pain occurred between 15 and 35 minutes. Fifteen people Abdominal 57% 40% During the study period, 137 jellyfish data were admitted to hospital (median stay, 1 cramps forms were collected. Twenty-six forms did day). Two patients developed pulmonary Back pain 58% 39% not have a corresponding hospital medical oedema, one requiring air evacuation and a Leg cramps 49% 34% record, were duplicated, or were not jelly- 4-day stay in a Perth tertiary hospital inten- fish stings (eg, diving-related injuries). sive care unit.7 The other recovered in Chest tightness 31% 26% These were excluded. Twenty-three were Broome. Hypertension 49% 50% non-Irukandji marine stings. There were no Chironex Nausea and 33% 39% recognised box jellyfish stings. Climate Irukandji syndrome was diagnosed in 88 vomiting patients (see Box 2 for comparison with Climate correlations with Irukandji syn- Distress 84% 24% drome included both water and air temper- north Queensland data). Sixty per cent were Flushing 28% Not available locals. Twenty-five per cent of patients iden- ature greater than the yearly median of ° Diaphoresis 22% Not available tified as Indigenous. Most (57%) were aware 28.3 C (OR, 5.5; 95% CI, 2.6–11.7) and of jellyfish risk from swimming, but only wind speed greater than the median of Treatment and outcomes 15 km/h (OR, 3.3; 95% CI, 1.6–6.7). There 14% stated that they had seen warning signs Vinegar used 58% 81% at the beach. Thirty-five per cent of tourists were fewer stings in the morning and on P Opiates used 90% 61% were jellyfish aware. low or incoming tides ( <0.001). There was no significant correlation with phase of (mean dose)* (20 mg) (not available) the moon or cloud cover. 17% 28% Seasonality and geography Admission rate The median time of sting was nearly 15:00, Pulmonary 2 patients 2 patients with a median 30-minute delay to emer- DISCUSSION oedema gency department presentation. Ninety per This is the first reported series of Irukandji Climatic variables cent of stings occurred from January to May syndrome in WA and the second-largest Time Afternoon Not available (Box 3). collection of hospital records nation- Water > 28.3°C Higher Reported stings increased at both Cable 5,11,12 ally. Cairns averages 40 Irukandji temperature (median) than Beach and Roebuck Bay/Beach in 2003. In stings per season, with about a million Higher than average December–March, 90% of stings occurred people swimming each year (Dr J Seymour, average in the east-facing Roebuck Bay, and in Senior Lecturer, School of Tropical Biology, No Less than March–June 95% of stings occurred at west- Rain James Cook University, Cairns, personal correlation average in facing Cable Beach (Box 4).
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