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Managing an Unidentified Jellyfish Sting with Mixed Envenomation Syndrome at a Noncoastal Hospital: Is This a New Form of Jellyfish Envenomation?

Sivanasworn NK, Anantham G, Jamal SM, Hatta MM, Ismail AK

Wilderness Environ Med, 2023 Jun;34(2):225-230.
PMID: 36935280 DOI: 10.1016/j.wem.2023.01.010

Jellyfish stings are the most common cause of marine envenomation in humans. Various species of box jellyfish have been identified around Penang Island, Malaysia, and these include multitentacled and four-tentacled box jellyfish (class Cubozoa). The typical syndrome following envenomation from these jellyfish has been poorly documented, posing a greater challenge when managing an unidentified jellyfish sting from Penang Island. We report a case of a 32-y-old man from Penang Island who was stung by an unidentified jellyfish while walking into the sea. The patient reported that he felt an immediate and severe electric current‒like pain over both thighs, left flank, and left forearm, followed by chest discomfort and breathlessness. Vinegar was applied over the affected areas, and he was rushed to a hospital, where he was treated with analgesia, steroids, and antihistamine. He refused hospitalization and was discharged against medical advice. He then presented to a noncoastal hospital 377 km away in Kuala Lumpur on the following day with severe pain over the affected sites as well as chest discomfort, shortness of breath, and abdominal cramps. The electrocardiograph demonstrated features of Wolff-Parkinson-White. Serial blood test results showed elevated creatine kinase but normal troponin I levels. The patient was managed symptomatically over a period of 4 d and was discharged with cardiology follow-up. Appropriate health-seeking behavior needs to be emphasized. This case report provides an opportunity to document the signs and symptoms of envenomation from possibly an undescribed jellyfish species near the coastal waters of Penang Island.

Matched MeSH terms: Cnidarian Venoms*
Haemolytic, oedema and haemorrhage inducing activities of tentacular extract of the blubber jellyfish (Catostylus mosaicus)

Azila N, Siao FK, Othman I

Comp Biochem Physiol C Comp Pharmacol Toxicol, 1991;99(1-2):153-6.
PMID: 1675964

1. An extract prepared from the tentacle of the jellyfish (CE), Catostylus mosaicus exhibited haemolytic, oedema and haemorrhage-inducing activities. 2. Acetone treatment of the tentacle extract produced an acetone soluble extract (AE) which showed an increase in specific haemolytic and haemorrhagic activities by 25- and 120-fold respectively; the minimum oedema dose was reduced by 30-fold. 3. The AE caused a rapid onset of oedema in the mouse foot pad. The effect was long-lasting, reaching a maximum in about 30 min after injection and sustained up to 4 hr. 4. Fractionation of the AE on Q-Sepharose gave 4 bound fractions which induced oedema and haemorrhage; however only 3 of the fractions exhibited haemolytic activity.

Matched MeSH terms: Cnidarian Venoms/isolation & purification; Cnidarian Venoms/toxicity*
Fulltext Prey Capture Ecology of the Cubozoan Carukia barnesi

Courtney R, Sachlikidis N, Jones R, Seymour J

PLoS One, 2015;10(5):e0124256.
PMID: 25970583 DOI: 10.1371/journal.pone.0124256

Adult Carukia barnesi medusae feed predominantly on larval fish; however, their mode of prey capture seems more complex than previously described. Our findings revealed that during light conditions, this species extends its tentacles and 'twitches' them frequently. This highlights the lure-like nematocyst clusters in the water column, which actively attract larval fish that are consequently stung and consumed. This fishing behavior was not observed during dark conditions, presumably to reduce energy expenditure when they are not luring visually oriented prey. We found that larger medusae have longer tentacles; however, the spacing between the nematocyst clusters is not dependent on size, suggesting that the spacing of the nematocyst clusters is important for prey capture. Additionally, larger specimens twitch their tentacles more frequently than small specimens, which correlate with their recent ontogenetic prey shift from plankton to larval fish. These results indicate that adult medusae of C. barnesi are not opportunistically grazing in the water column, but instead utilize sophisticated prey capture techniques to specifically target larval fish.

Matched MeSH terms: Cnidarian Venoms/metabolism; Cnidarian Venoms/toxicity*
Fulltext Fatal and severe box jellyfish stings, including Irukandji stings, in Malaysia, 2000-2010

Lippmann JM, Fenner PJ, Winkel K, Gershwin LA

J Travel Med, 2011 Jul-Aug;18(4):275-81.
PMID: 21722240 DOI: 10.1111/j.1708-8305.2011.00531.x

Jellyfish are a common cause of injury throughout the world, with fatalities and severe systemic events not uncommon after tropical stings. The internet is a recent innovation to gain information on real-time health issues of travel destinations, including Southeast Asia.

Matched MeSH terms: Cnidarian Venoms/poisoning*
Intravenous ascorbic acid as a treatment for severe jellyfish stings

Kumar S, Miranda-Massari JR, Gonzalez MJ, Riordan HD

P R Health Sci J, 2004 Jun;23(2):125-6.
PMID: 15377062

We report a case of jellyfish envenomation in a 39 year old male. He was stung extensively on both lower limbs by an unidentified jellyfish. This occurred in shallow waters of a beach in the vicinity of Labuan Island, Malaysia. The patient received ambulatory treatment with parenteral and oral ascorbate with remarkable recovery.

Matched MeSH terms: Cnidarian Venoms/adverse effects*
Haemolytic and phospholipase A activities of the tentacle extract of Catostylus mosaicus

Azila N, Othman I

Biochem. Int., 1990;20(2):291-9.
PMID: 1969267

An extract prepared from the tentacle of Catostylus mosaicus was shown to lyse erythrocytes from rat, rabbit and human to a different extent; those from the rat being most susceptible followed by those from rabbit and human. The haemolytic activity was dependent on the concentration of crude extract protein exhibiting a sigmoidal curve. Only 60% of the haemolytic activity was retained after treament with heat and proteolytic enzyme. The extract was devoid of hydrolytic enzymes normally present in venoms except for phospholipase A activity, which resulted in the hydrolysis of membrane phospholipids with concomittant appearance of their lyso-derivatives.

Matched MeSH terms: Cnidarian Venoms/toxicity*
Expansion of Hydra actinoporin-like toxin (HALT) gene family: Expression divergence and functional convergence evolved through gene duplication

Yap WY, Tan KJSX, Hwang JS

Toxicon, 2019 Dec;170:10-20.
PMID: 31513812 DOI: 10.1016/j.toxicon.2019.09.007

Hydra actinoporin-like toxin 1 (HALT-1) was previously shown to cause cytolysis and haemolysis in a number of human cells and has similar functional properties to the actinoporins equinatoxin and sticholysin. In addition to HALT-1, five other HALTs (HALTs 2, 3, 4, 6 and 7) were also isolated from Hydra magnipapillata and expressed as recombinant proteins in this study. We demonstrated that recombinant HALTs have cytolytic activity on HeLa cells but each exhibited a different range of toxicity. All six recombinant HALTs bound to sulfatide, while rHALT-1 and rHALT-3 bound to two additional sphingolipids, lysophosphatidic acid and sphingosine-1-phosphate as indicated by the protein-lipid overlay assay. When either tryptophan133 or tyrosine129 of HALT-1 was mutated, the mutant protein lost binding to sulfatide, lysophosphatidic acid and sphingosine-1-phosphate. As further verification of HALTs' binding to sulfatide, we performed ELISA for each HALT. To determine the cell-type specific gene expression of seven HALTs in Hydra, we searched for individual HALT expression in the single-cell RNA-seq data set of Single Cell Portal. The results showed that HALT-1, 4 and 7 were expressed in differentiating stenoteles. HALT-1 and HALT-6 were expressed in the female germline during oogenesis. HALT-2 was strongly expressed in the gland and mucous cells in the endoderm. Information on HALT-3 and HALT-5 could not be found in the single-cell data set. Our findings show that subfunctionalisation of gene expression following duplication enabled HALTs to become specialized in various cell types of the interstitial cell lineage.

Matched MeSH terms: Cnidarian Venoms
Corneal Toxicity Associated With Aquarium Coral Palytoxin

Farooq AV, Gibbons AG, Council MD, Harocopos GJ, Holland S, Judelson J, et al.

Am J Ophthalmol, 2017 Feb;174:119-125.
PMID: 27793603 DOI: 10.1016/j.ajo.2016.10.007

PURPOSE: To report a series of patients who developed corneal toxicity after exposure to aquarium coral palytoxin.
DESIGN: Multicenter retrospective case series.
METHODS: Retrospective review.
RESULTS: Seven patients presented with corneal findings ranging from superficial punctate epitheliopathy to bilateral corneal melt with subsequent perforation. Among those with mild corneal findings, resolution was achieved with topical steroids and lubrication, whereas some patients who developed progressive corneal melt required therapeutic penetrating keratoplasty. The history in all patients revealed exposure to aquarium zoanthid corals shortly before disease onset. A review of the literature revealed that there are few prior reports of coral-associated corneal toxicity and that some species of coral secrete a substance known as palytoxin, a potent vasoconstrictor that inhibits the membranous sodium-potassium ATPase pump across cell types and can cause rapid death if inhaled or ingested.
CONCLUSIONS: This is the largest case series to date demonstrating patients with aquarium coral palytoxin-associated corneal toxicity, and is the first to provide details of related histopathologic findings. Similar to other forms of toxic keratoconjunctivitis, a detailed history and careful clinical assessment are required, as well as timely removal of the offending agent from the patients' ocular milieu and environment. Mild ocular surface and corneal disease may be treated effectively with aggressive topical steroid therapy and lubrication. Given the potential severity of ocular as well as systemic adverse effects, there should be increased awareness of this entity among eye care professionals, aquarium enthusiasts, and the general public.

Matched MeSH terms: Cnidarian Venoms