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The Anaphylaxis BluesJellyfish strikes back
Dr Daniel KhamoudesToxicology Service
Prince Of Wales Hospital
+Outline
Case
History
Facts
+Case
38M
Otherwise well
Hx of anaphylaxis to bee stings
Blue Bottle Sting at Maroubra 1730 First aid with water to remove
Presented POW ED 1800 with pain
Primary sting L lateral ankle
Pain locally and L groin 8/10
+Case
In ambulance bay, hot water submersion
1830 sudden onset tongue angioedema Moved to resus
Nil respiratory or haemodynamic compromise Adrenaline 0.5mg IM at 1855
Rapid resolution within 5 minutes Hydrocortisone 200mg IV Ranitidine 50mg IV Fexofenadine 180mg po Fentanyl 150mcg, in 50mcg aliquots
+Case
Return of angioedema 2000 Nil respiratory or haemodynamic compromise Second dose Adrenaline 0.5mg IM 2010 Resolution of symptoms over 10 minutes
Further boluses of Fentanyl as groin pain an issue
Creatine kinase and UEC NAD
HDU admission for observation re angioedema
Nil further episodes
Pain settled overnight
+History
Discovered 19031
Richet and Portier Dogs vs Jellyfish toxin Second exposure lower dose lethal 1913 Nobel Prize
Origin Greek –ana (against) –phylaxis (protection) Originally aphylaxis (publicist)
1. Wikipedia
+Mechanism
Nematoblasts->Nematocysts
Spring loaded syring
Discharge within 700ns of contact
18m/s 5.4x106g
Pressure 7.7GPa
Local and systemic injury
+Mechanism
+Mechanism
Toxin2
Local and systemic
Tubule Collagens, glycoproteins and polysaccharides Innate and adaptive cellular and humoral responses
2. J Tibballs, A Yanagihara, H Turner, K Winkel. Immunological and Toxinological Responses to Jellyfish Stings. Inflammation & Allergy - Drug Targets, 2011, 10, 438-446.
+Mechanism
+Physalia Utriculus
Physalia physalis vs Physalia utriculus
Float and Tail
Nematocysts remain active
+Local effects
Immediate pain and erythema
Progressive pain to draining lymph nodes
Long term scarring unlikely but occurs
+Local Effects
+Systemic Effects
Venom Pore forming in plasma membrane, Ca influx/swelling/lysis2,3
Neuro/cardio toxicity2,4
Potential deaths with Physalia physalis 5,6
Immune Response – immediate and delayed
Hypersensitivity reaction Previous exposure Cross reactivity
3. Edwards, L.P.; Whitter, E.; Hessinger, D.A. Apparent membrane pore-formation by Portuguese Man-of-war (Physalia physalis). Toxicon, 2002, 40(9), 1299-1305.4. Burnett, J.W. Treatment of Atlantic cnidarian envenomations. Toxicon, 2009, 54(8), 1201-1205.5.5. Tibballs, J. Australian venomous jellyfish, envenomation syndromes, toxins and therapy. Toxicon, 2006, 48(7), 830-859. 6. L Cegolon, W Heymann, G Mastrangelo. Jellyfish Stings and Their Management: A Review. Marine Drugs, Feb 2013. 11(2):523-550
+Treatment
Supportive Analgesia Consider regional
Hot water submersion3
Anaphylaxis APP
ALS
IgG production noted8
7. C Loten, B Stokes, D Worsley, J Seymour, S Jiang, G Isbister. A randomised controlled trial of hot water (45°C) immersionversus ice packs for pain relief in bluebottle stings. MJA April 2006. 184(7):329-333.8. Russo, A.J.; Calton, G.J.; Burnett, J.W. The relationship of the possible allergic response to jellyfish envenomation and serum antibody titers. Toxicon, 1983, 21(4), 475-480.
+Summary
Local and systemic symptoms
Treatment supportive +/- specific
?Steroid topical
?Sun exposure
+References
Wikipaedia
2. J Tibballs, A Yanagihara, H Turner, K Winkel. Immunological and Toxinological Responses to Jellyfish Stings. Inflammation & Allergy - Drug Targets, 2011, 10, 438-446.
3. Edwards, L.P.; Whitter, E.; Hessinger, D.A. Apparent membrane pore-formation by Portuguese Man-of-war (Physalia physalis). Toxicon, 2002, 40(9), 1299-1305.
4. Burnett, J.W. Treatment of Atlantic cnidarian envenomations. Toxicon, 2009, 54(8), 1201-1205.5.
5. Tibballs, J. Australian venomous jellyfish, envenomation syndromes, toxins and therapy. Toxicon, 2006, 48(7), 830-859.
6. L Cegolon, W Heymann, G Mastrangelo. Jellyfish Stings and Their Management: A Review. Marine Drugs, Feb 2013. 11(2):523-550
7. C Loten, B Stokes, D Worsley, J Seymour, S Jiang, G Isbister. A randomised controlled trial of hot water (45°C) immersion versus ice packs for pain relief in bluebottle stings. MJA April 2006. 184(7):329-333.
8. Russo, A.J.; Calton, G.J.; Burnett, J.W. The relationship of the possible allergic response to jellyfish envenomation and serum antibody titers. Toxicon, 1983, 21(4), 475-480.