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Jellyfish stings

Jellyfish stings
Literature review current through: Jan 2024.
This topic last updated: Nov 17, 2023.

INTRODUCTION — This topic will discuss the clinical manifestations, diagnosis, and treatment of jellyfish stings. Recognition and treatment of marine envenomations by other animals are discussed separately. (See "Marine envenomations from corals, sea urchins, fish, or stingrays".)

MARINE BIOLOGY — Jellyfish are members of the phylum Cnidaria. They are invertebrates that float in salt and brackish water and have a central bell and lengthy tentacles that disconnect easily (picture 1 and picture 2). Jellyfish consume fish, crustaceans, and mollusks by injecting venomous capsules called nematocysts into their prey. The nematocysts are clustered along the jellyfish's tentacles and discharge rapidly on contact. Although Physalia species (Portuguese man-of-war or bluebottle jellyfish), which are also members of the phylum Cnidaria, are not true jellyfish, they are discussed here as well.

VENOM DELIVERY AND PROPERTIES — Jellyfish do not actively seek out humans. However, they can be difficult to see, and most injuries occur when humans blunder into their tentacles. After skin contact, jellyfish nematocysts release a hollow barbed tube that injects a mixture of proteinaceous toxins into the victims' skin. These rapidly fire with an approximate force of 2 to 5 pounds per square inch [1,2].

The venom enters the dermis and systemic circulation. Depending upon the stinging species, it can cause both skin and systemic symptoms. Victims may also experience an immune reaction to the implanted barb of the nematocyst [3].

Jellyfish venom is a complex mixture of enzymes. These include cytolytic pore-forming toxins, neurotoxins with activity at fast sodium and inwardly-rectifying potassium channels, and nonprotein bioactive components [2,4]. The functions and contributions of these toxins to clinical envenomation are evolving but still poorly understood.

DANGEROUS SPECIES — Jellyfish envenomation commonly causes local effects that consist of cutaneous pain, swelling, and redness. When tentacles contact a large surface area of skin (eg, entire trunk or extremity), stings by certain jellyfish species can cause serious and life-threatening systemic effects [5] (see 'Clinical manifestations' below):

Chironex fleckeriC. fleckeri is a box jellyfish found in tropical Australia and Indo-Pacific regions [6,7]. Multiple tentacles arise from the four corners of this large jellyfish and may stretch up to 2 meters. These tentacles are lined with nematocysts containing venom. Stings can produce sudden cardiac arrest, cardiogenic shock, and dermonecrotic effects in humans, as well as hemolytic effects in in vitro models [8,9].

Carukia barnesiC. barnesi is another box jellyfish found in the northern territories of Australia. It is one of the species that causes Irukandji syndrome. This syndrome is characterized by minimal to moderate local pain followed by delayed onset of generalized back and abdominal pain up to one hour later. This is often accompanied by nausea, vomiting, diaphoresis, tachycardia, and severe hypertension akin to sympathomimetic toxicity and most likely due to release of endogenous catecholamines. Cardiomyopathy with pulmonary edema and cardiogenic shock is reported in severe cases [10,11]. C. barnesi has a tiny bell (often 2 cm in diameter) and long tentacles. Other jellyfish in the Indo-Pacific region that can cause Irukandji syndrome include the Carybdea, Malo, Alatina, Gerongia, and Morbakka species [12].

In addition, there have been case reports of an Irukandji-like syndrome occurring in locations outside the habitat of Carukia barnesi, including off the coasts of Hawaii and southern Florida [13].

Physalia physalisP. physalis is a Hydrozoa (not a true jellyfish) found worldwide. It is also known as the Portuguese man-of-war, Pacific man-of-war, or bluebottle, and it has a blue or purplish, boat-like pneumatophore (bell equivalent) that is up to 25 cm in length with multiple trailing tentacles up to 30 m long [5]. Physalia form a colony, meaning that the bell and the tentacles arise from different organisms. They also differ in size: large in the Atlantic ("Portuguese man-of-war") and smaller in the Pacific ("bluebottle jellyfish"). P. physalis stings usually result in local effects that consist of moderate to severe pain and skin lesions with erythema or necrosis. However, systemic symptoms rarely develop. These include vomiting, abdominal pain, muscle spasms, headache, syncope, confusion, shortness of breath, and chest pain [5]. Death from primary respiratory arrest has been described [14].

EPIDEMIOLOGY — Jellyfish are found in warm and cold coastal waters throughout the world. With approximately 100 of 10,000 species dangerous to humans, jellyfish sting an estimated 150 million people annually [5,15]. As an example, approximately 500,000 cases of envenoming occur annually in the Chesapeake Bay (eastern United States). Estimates suggest 60,000 to 200,000 stings occur along the Florida coast annually [16]. A similar number of cases is estimated on the east coast of Australia.

The long-term effects of climate change and overfishing on jellyfish populations and associated jellyfish stings are uncertain. Jellyfish numbers appear to be increasing in some ecosystems but decreasing in others [17].

CLINICAL MANIFESTATIONS — The clinical presentation of a patient with jellyfish sting varies according to the type of jellyfish, the individual characteristics of the patient, duration of exposure, area of skin exposed, and the type of treatment administered at the time of exposure. Clinicians should familiarize themselves with common jellyfish species in their region.

Most jellyfish envenomations cause local symptoms confined to pain and swelling at the sting site [5]. However, jellyfish stings by certain species can rarely cause severe pain, systemic symptoms, and even death. (See 'Dangerous species' above.)

Local envenomation — With local envenomation, patients often do not see the jellyfish or tentacle but experience immediate pain at the time of the sting. Linear, red, urticarial lesions usually develop a few minutes later. Sometimes these lesions do not appear for several hours [18,19]. The lesions often burn intensely and may itch and throb. The pain may radiate up the limb to the torso.

Skin findings include "tentacle prints" and, less commonly, vesiculation and ecchymosis (figure 1 and picture 3 and picture 4 and picture 5) [19].

Lesions usually resolve within 10 days, although they may occasionally persist for weeks [20].

Skin necrosis can occur with more severe stings, including those caused by C. fleckeri and P. physalis. The initial erythematous lesions are usually localized to the area of the sting. In some cases, papular urticarial eruptions (picture 6) can recur 7 to 14 days later and may be intensely pruritic [7]. Finger or toe ischemia can rarely develop; it presents with pain, paresthesias, and erythema that progresses over 1 to 10 days into edema, cyanosis, and signs of necrosis [21,22]. In case reports, symptoms improved after administration of intravenous prostaglandin analogues or intra-arterial urokinase. Fasciotomy for compartment syndrome and debridement for tissue necrosis is often required if there is no improvement after medical therapy.

Systemic envenomation

Irukandji syndrome — Irukandji syndrome typically begins with a mild to moderately painful local stinging sensation that is followed within minutes to an hour by waves of severe generalized back, chest, and abdominal pain, vomiting, sweating, agitation, severe hypertension, and tachycardia [10,11,23].

Patients may develop myocardial injury and pulmonary edema several hours after the stings [24]. Fatal intracranial hemorrhage secondary to severe hypertension has also been reported [25].

Cardiorespiratory arrest — Box jellyfish (eg, C. fleckeri) stings have resulted in more than 70 confirmed deaths in Australia and the Indo-Pacific region [26]. While most box jellyfish stings occurring in Australia are of little consequence [26,27], C. fleckeri (the Australian box jellyfish) can cause rapid onset of cardiac arrest or severe shock if tentacles contact a large area of skin (picture 7) [28].

Although rare, death has also been reported following stings by P. physalis (the Portuguese man-of-war) due to respiratory arrest. In addition, drowning has resulted from limb paralysis by Chiropsalmus quadrumanus (sudden cardiac arrest in a child) [14,19,29].

Anaphylaxis — Anaphylaxis rarely occurs after jellyfish stings and causes oral mucosal swelling, wheezing, generalized urticaria, and distributive shock [30,31]. (See "Anaphylaxis: Emergency treatment".)

Ocular sting — Jellyfish stings to the eyes initially cause burning pain, photophobia, epithelial keratitis, corneal stromal edema, endothelial cell swelling, and anterior chamber inflammation. These usually resolve within 48 hours [32]. However, severe iritis and increased intraocular pressure after corneal stings have been described, which rarely develop into glaucoma.

DIAGNOSIS — In most cases, the diagnosis of a jellyfish sting is made clinically or is simply recognized by the patient who has been stung in waters known to harbor jellyfish. Clues to the type of jellyfish include the geographic area where the sting occurred, the prevalent species of jellyfish washed up on the shore, the distance from the shore, and the pattern of the tentacle print on the skin (figure 1). In particular, C. fleckeri tentacles produce a characteristic "frosted ladder" appearance to the sting site (picture 7). For many patients, the specific type of stinging jellyfish is unclear, and management is based upon the prevalent species in the region.

A definitive diagnosis is sometimes needed when the clinical picture is unclear or for forensic or research purposes. When such a diagnosis is required, nematocysts can be examined under a microscope and compared with known nematocysts from various jellyfish. Nematocysts can generally be easily identified for common jellyfish.

For uncommon jellyfish or in areas where stings are uncommon, the microscopic examination should be performed by an expert who has access to examples of cnidomes of medically significant jellyfish.

Nematocysts can be obtained from skin scrapings or by applying sticky tape to the sting site [7,10]. Skin scraping is the preferred method for retrieving nematocysts but is slightly painful; it is the only method that can be used to collect nematocysts from bell stings (eg, C. barnesi). The skin is scraped over the sting site to collect remaining nematocysts, which are then put in 1 to 4 percent formalin.

Application of sticky tape to the sting site is appropriate for tentacles stings and is less painful. Adhesive tape is placed over the site and then pulled off to remove nematocysts. The tape is then applied to a microscope slide. This method is useful for both Chironex and Physalia stings [7,33].

DIFFERENTIAL DIAGNOSIS — When jellyfish stings are suspected, marine envenomation by a variety of animals (eg, corals, sea urchins, fish, and stingrays) and skin rashes associated with marine animals are the primary diagnostic considerations. Marine envenoming is suggested by the presence of lacerations or puncture wounds (picture 8 and picture 9 and picture 10) and the lack of adherent tentacles or jellyfish prints (figure 1).

Swimmer's itch (cercarial dermatitis) (picture 11), seabather's eruption (picture 12), and stinging sponge dermatitis are identified by the predominance of pruritus rather than pain and a characteristic eruption. Differentiating features of these diagnoses are discussed in greater detail separately. (See "Marine envenomations from corals, sea urchins, fish, or stingrays", section on 'Differential diagnosis'.)

MANAGEMENT

Immediately after exposure (first aid at the scene) — First aid at the shore is guided by the prevalent jellyfish species in the region. Individuals at the scene are generally unlikely to accurately identify the jellyfish.

Australia and the Indo-Pacific — In tropical Australia and other parts of the Indo-Pacific, where potentially dangerous jellyfish species such as C. fleckeri, C. barnesi, or Alatina alata (Hawaiian box jellyfish) are commonly found, our treatment recommendations are largely consistent with those of the Australian Resuscitation Council (algorithm 1) [34]:

Severe stings – The rescuer should remove the victim from the water and assess the airway, breathing, and circulation, and provide basic life support measures as needed.

For patients stung in tropical Australia or the Indo-Pacific region (including Hawaii) who have moderate or severe pain, systemic symptoms (eg, nausea, vomiting, pain beyond the local sting site, headache, or altered mental status), or cardiorespiratory arrest, we suggest topical application (dousing or spraying) of vinegar for 30 seconds, whenever available, followed by manual removal of visible tentacles. Manual removal should be performed by plucking the tentacles using the tips of the fingers and does not pose a danger to the rescuer, although a minor sting may occur. After removing the tentacles, the rescuer should rinse his or her hands with seawater.

If vinegar is not available, the rescuer should remove visible tentacles by hand and then rinse the sting site with seawater. Fresh water promotes nematocyst activation and should not be used for rinsing the sting site. Because pressure during manual tentacle removal can promote nematocyst discharge and seawater rinsing may distribute intact nematocysts to previously unaffected areas, it is important to apply vinegar first, if at all possible [35].

Scraping of the sting site is ineffective or potentially harmful and should be avoided. Similarly, shaving cream and baking soda mixed with seawater may promote nematocyst discharge by A. alata and likely should be avoided for stings by other jellyfish species as well [35].

Once topical treatment and tentacle removal have occurred, pain control may be provided by application of a chemical cold pack or ice in a dry plastic bag [36]. Patients with severe jellyfish stings warrant timely ambulance transfer to definitive medical care.

Based upon in vitro studies, vinegar (5 percent acetic acid) inhibits the discharge of nematocysts from Australian box jellyfish [35,37]. Vinegar has not been tested on species that cause Irukandji syndrome but is still suggested for these stings as well [38]. A commercial product that contains vinegar, urea, magnesium sulfate, and calcium gluconate has been associated with decreased nematocyst discharge and easier removal of adherent tentacles in an in vitro model of C. fleckeri envenomation [35]. However, further evidence from human studies that show improved clinical outcomes are needed before its use can be recommended over vinegar alone.

Although immobilization of the affected body part and application of a pressure bandage after tentacle removal was once proposed for severe box jellyfish stings [39,40], this therapy appears to be dangerous and should not be performed [34,41].

Minor stings or stings occurring in nontropical regions of Australia – If there is any doubt as to the severity of the sting or if a dangerous jellyfish sting is suspected for other reasons, then the rescuer should provide first aid as described above for severe stings.

For patients with minor stings (ie, limited local pain and no systemic findings) that are not likely to be caused by a box jellyfish based upon the geographic region where they occurred, types of jellyfish seen at that beach, or sting appearance, first aid includes the following:

Get the patient out of the water and have him or her rest while being observed.

Prevent the patient from rubbing the sting area.

Manually remove any visibly adherent tentacles by plucking them off with the tips of the fingers.

Rinse the sting site with seawater.

For patients with significant pain, we recommend treatment with hot water immersion or application of hot packs rather than cold therapy or irrigation with vinegar. When using hot water immersion, the water temperature should be 40 to 45°C (104 to 113°F) and should be applied by immersion of a limb or by hot shower for approximately 20 minutes. If a thermometer is not available, use the hottest water temperature that can be tolerated by rescuer or the alert patient on an unaffected limb; adults should test the water temperature for young children. If hot water or hot packs are not available, cold chemical packs or ice in a dry plastic bag may be applied.

Patients with stings of the eye, persistent and intolerable pain, or the development of systemic symptoms should contact emergency medical services for transfer to definitive medical care.

Heat may alter the protein structure and degrade the function of jellyfish toxins [42]. Based upon a meta-analysis of seven trials (435 participants), hot water more effectively relieved pain from stings by Physalia species (Portuguese man-of-war or bluebottle jellyfish) [43]. Several small trials have also found that heat provides better analgesia compared with cold therapy after A. alata (Hawaiian box jellyfish) stings [44,45].

Although vinegar prevents further discharge of nematocysts from at least some species of jellyfish, it does not treat established envenomation effects. Furthermore, based upon small trials, the symptomatic pain relief that it provides appears to be inferior to the analgesia associated with hot water immersion after stings by A. alata or Physalia species [46].

Other world regions — For jellyfish stings that occur outside of tropical Australia and the Indo-Pacific region (including Hawaii), we suggest that the victim undergo manual removal of visible jellyfish tentacles, rinsing of the sting site with seawater, and treatment of pain with hot water immersion or application of a hot pack rather than irrigation with vinegar or cold therapy. When using hot water immersion, the water temperature should be 40 to 45°C (104 to 113°F) and should be applied by immersion of a limb or by hot shower for approximately 20 minutes. If a thermometer is not available, use the hottest water temperature that can be tolerated by rescuer or the alert patient on an unaffected limb; adults should test the water temperature for young children. If hot water is not available, then the rescuer should apply a cold pack or ice in a dry plastic bag to the sting.

Because mechanical pressure can cause nematocysts to discharge, rubbing of the sting site should be prevented [35]. Similarly, irrigation with fresh water promotes nematocyst firing and should be avoided.

These stings are not usually life-threatening. However, the patient should still be observed because cardiorespiratory arrest has rarely occurred after stings by Physalia species (Portuguese man-of-war or bluebottle jellyfish), and C. quadrumanus and anaphylaxis following jellyfish stings has been described [14,19,29-31]. Otherwise, intolerable pain is the main indication for emergency medical treatment.

Although evidence is lacking regarding the use of hot water immersion to treat pain after jellyfish stings for many species, it is more effective than cold therapy for treating pain after stings by Physalia species (Portuguese man-of-war or bluebottle jellyfish) and A. alata (the Hawaiian box jellyfish) [44,45,47].

Some experts advise irrigation of the sting site with vinegar to inactivate nematocysts followed by tentacle removal that involves spraying the site with shaving cream and then using a thin plastic object (such as a credit card) to scrape them off. With this approach, the shaving cream is postulated to act as a physical barrier that traps the removed nematocysts so that they do not touch the skin again. Success with this treatment regimen is anecdotal and confined to jellyfish stings likely caused by P. physalis (the Portuguese man-of-war) or Cnidaria aurelia (east coast jellyfish, United States) [48].

Although some investigators have found that vinegar inhibits discharge from some Physalia species [3,39,49], others have found that it provokes nematocyst discharge with exacerbation of pain [38,50,51]. In a systematic review of 19 studies on treatment of jellyfish stings that primarily evaluated evidence from North American and Hawaiian species, vinegar exacerbated pain after stings from most jellyfish species but appeared to be beneficial after Physalia species stings, although the effect on Physalia stings was inferior to treatment with hot water immersion [46]. Furthermore, in vitro models of jellyfish envenomation suggest that application of shaving cream and scraping of nematocysts may be ineffective and potentially increase nematocyst firing [35]. (See 'Pain control' below and 'Australia and the Indo-Pacific' above.)

Older observational studies from Australia suggested that cold packs provide effective analgesia for Physalia (Portuguese man-of-war and bluebottle jellyfish) and, on this limited evidence, some experts propose cold packs as an appropriate first aid measure [50,52]. In our experience, cold therapy does not appear to be harmful as long as prolonged ice application is avoided, and is a reasonable therapy if hot water immersion or chemical heat pack application is not readily available.

There are several topical remedies proposed for immediate treatment of stings, but evidence regarding their effectiveness varies, and in some instances (eg, baking soda), benefit is limited to specific jellyfish species:

Papain meat tenderizer – Meat tenderizer (which contains papain, a proteolytic enzyme that theoretically cleaves nematocyst toxins) has been advocated for the treatment of jellyfish stings [53]. However, evidence is insufficient to support its routine use and suggests that hot water immersion is more effective [44].

Baking soda – Based upon in vitro testing, baking soda inhibits nematocyst discharge from the sea nettle (Chrysaora quinquecirrha) [39]. However, pain relief in victims of sea nettle stings is anecdotal. Baking soda has been associated with reduced pain of stings from other jellyfish species such as Chrysaora hysoscella, Cyanea capillata, and P. physalis; but has been associated with worsening of symptoms in some Physalia stings [54].

Other remedies – Methylated spirits, ethanol, human urine, ammonia, and meat tenderizer (bromelain) trigger nematocyst discharge after exposure to Australian box jellyfish, sea nettle, or Portuguese man-of-war tentacles [37,51]. In addition, ammonia and ethanol worsen pain symptoms [51]. All of these treatments should be avoided.

Emergency department management — Emergency department care should focus on treatment of life-threatening envenomation (primarily occurring in Australia and the Indo-Pacific region), assurance that appropriate first aid is performed, and pain control.

Cardiotoxicity (cardiac arrest or cardiogenic shock) — Patients in cardiac arrest should receive resuscitation according to the principles of Advanced Cardiac Life Support or Pediatric Advanced Life Support. (See "Advanced cardiac life support (ACLS) in adults", section on 'Pulseless patient in sudden cardiac arrest' and "Pediatric advanced life support (PALS)", section on 'Pulseless arrest algorithm'.)

If not already performed, the patient should also receive first aid measures to prevent further nematocyst discharge, including irrigation of the sting site with vinegar, removal of tentacles, and application of either cold packs or ice in a dry plastic bag for pain. (See 'Australia and the Indo-Pacific' above.)

Patients presenting with acute decompensated heart failure and cardiogenic shock warrant treatment based upon presenting features and the presence of underlying cardiac disease as described separately (table 1). (See "Treatment of acute decompensated heart failure: Specific therapies".)

For patients with cardiac arrest or other signs of cardiotoxicity after stings by C. fleckeri (the Australian box jellyfish) who present within one hour of the sting, we suggest administration of specific sheep serum antivenom [28].

Antivenom must be administered quickly (ideally within one hour of sting) to be effective. The physician should administer one vial (20,000 units) intravenously over 5 to 10 minutes as the initial dose; dosing may be repeated up to a maximum of three vials for patients who remain in cardiogenic shock or cardiac arrest. The same dose is used for adults and children. For any benefit, early administration is required because most deaths occur within 5 to 20 minutes of the sting [41].

This recommendation is based upon expert opinion and anecdotal experience [34]. Human evidence to support the efficacy of antivenom for the treatment of cardiotoxicity after box jellyfish stings is lacking [4]. Furthermore, given the infrequent occurrence of severe box jellyfish stings, it is unlikely that any clinical trial of antivenom treatment for severe cardiotoxicity will be performed. Animal studies indicate some biologic activity for the antivenom but raise significant concerns regarding its efficacy [8]. In vitro, the antivenom binds all major toxins (on Western blot) [55]. In a rat model, mixtures of venom-antivenom do not cause cardiovascular collapse, while this occurs rapidly with venom alone. However, when the antivenom was administered to the rats, rather than preincubated with venom, it was ineffective in preventing cardiovascular collapse even when administered intravenously prior to giving the venom. This animal study shows that although the antivenom is biologically active, it may not act quickly enough to prevent the rapid cardiotoxicity after box jellyfish stings in humans.

Irukandji syndrome (generalized pain and severe hypertension) — Severe pain should be managed by systemic opioid medications (eg, fentanyl or morphine). If not already performed, the patient should receive first aid measures to prevent further nematocyst discharge, including vinegar irrigation of the sting site, removal of tentacles, and either application of chemical hot packs to the site or immersion in hot water. (See 'Australia and the Indo-Pacific' above.)

Severe hypertension in patients with Irukandji syndrome is secondary to catecholamine release. Similar to treatment for amphetamine overdose, we suggest that the patient first receive benzodiazepines. If elevated blood pressure persists, then the patient should receive short-acting medications appropriate for sympathetic overactivity, such as nitroglycerin, sodium nitroprusside, or phentolamine [5].

Patients with severe hypertension are also at risk for acute coronary syndrome, heart failure, cardiogenic pulmonary edema, and intracranial hemorrhage (particularly if on anticoagulant therapy). They warrant evaluation and monitoring for these complications, and supportive treatment should signs develop. (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department" and "Noncardiogenic pulmonary edema", section on 'Treatment' and "Spontaneous intracerebral hemorrhage: Acute treatment and prognosis", section on 'Triage'.)

Although intravenous magnesium sulfate has been proposed for the treatment of Irukandji syndrome, we do not support its use because evidence is lacking to support improved clinical outcomes [56-59]. A case report and a small case series have suggested that treatment of Irukandji syndrome with magnesium sulfate is associated with significantly reduced pain and blood pressure [56,57]. However, in a small trial of 39 patients with Irukandji syndrome, magnesium did not significantly decrease morphine dose, blood pressure, serum creatine kinase levels, serum troponin levels, and length of stay when compared with placebo [58]. Furthermore, the large amounts of magnesium sometimes administered can lead to adverse effects, including neurotoxicity (ie, altered mental status and muscle weakness).

Anaphylaxis — Anaphylaxis warrants rapid administration of intramuscular or intravenous epinephrine and further management as described separately (table 2 and table 3). (See "Anaphylaxis: Emergency treatment".)

Pain control — The clinician should ensure that appropriate first aid measures for pain control have been performed according to the geographic region in which the sting has occurred. (See 'Immediately after exposure (first aid at the scene)' above.)

Most jellyfish stings cause mild to moderate local pain that responds to local measures and oral medications such as acetaminophen or ibuprofen. Even though immediate heat application may relieve pain from stings from several species, it may not provide analgesia if there is a significant delay. For example, a small trial of patients treated in the emergency department for suspected C. fleckeri (Australian box jellyfish) stings found that hot water immersion did not provide better analgesia compared with cold therapy [36].

Application of topical lidocaine (4 percent or higher) has been associated with reduced subjective pain in two subjects tested with sea nettle and Portuguese man-of-war tentacles. It also inhibits nematocyst discharge in in vitro models. However, topical lidocaine requires further study before it can be recommended for clinical use [51].

Envenomation by several jellyfish, including Chironex, Physalia, and Carukia species, can cause severe and prolonged pain that may require parenteral opioids (eg, fentanyl or morphine) in addition to the local measures provided above.

Corneal stings — Patients with corneal jellyfish stings should undergo liberal irrigation of the eyes with saline or, during first aid, seawater. They warrant urgent evaluation and management by an ophthalmologist, including assessment for iritis and increased intraocular pressure. Treatment depends upon findings and may include topical steroids, antibiotics, antihistamines, or cycloplegics [60,61].

Delayed hypersensitivity — Delayed hypersensitivity reactions are common after Australian box jellyfish (C. fleckeri) stings. In case reports, patients who did not improve spontaneously benefited from oral antihistamines and topical corticosteroids [7]. (See 'Clinical manifestations' above.)

PREVENTION

General measures — The underwater tentacles of jellyfish can be long and difficult to see and pose a hazard to all ocean swimmers. It is important to avoid touching tentacles along the shore because they often contain nematocysts that can discharge and sting [5]. In regions where box jellyfish stings occur, not entering the water during jellyfish season is the most effective means of prevention.

"Stinger nets" and "stinger suits" exist that can provide a mechanical barrier to some jellyfish. However, stinger net enclosures do not appear to protect against the small jellyfish that cause Irukandji syndrome [27]. In a study of several types of protective garments including wetsuits, many commercial garments were found to be protective against Carukia barnesi (a common Australian Irukandji jellyfish) [62]. Since Irukandji tentacles are approximately 0.25 mm, protective clothing with a mesh size <0.25 mm is recommended to prevent Irukandji syndrome.

There are some reports that other clothing that creates a barrier, such as "rash guards" worn by surfers [63], may protect against tentacle stings. While it seems reasonable that these would offer at least some protection, there are no well-performed trials demonstrating effectiveness.

Topical sting inhibitor — Jellyfish sting inhibitors (eg, Safe Sea lotions) are marketed for protection against jellyfish stings. The contents mimic the mucous coating that clown fish use to inhibit stings by sea anemones [15]. Two small trials (one with known exposure of Chrysaora fuscescens [a type of sea nettle] and C. quadrumanus [a type of box jellyfish], and one performed in the Caribbean) have shown decreased frequency of stings when an inhibitor is used [15,63]. In one trial, the inhibitor significantly decreased the frequency of stings as evidenced both by subjective pain and objective erythema [63].

SEABATHER'S ERUPTION — Seabather's eruption is an itchy dermatitis that has been described in Florida, the Caribbean, Bermuda, and Long Island, New York [64]. It occurs on parts of skin that are covered by a swimsuit and is believed to be caused by jellyfish and sea anemone larvae that become trapped and pressed between the garment and the person's skin (picture 12). The skin reaction may recur when the outfit is worn again, due to persistence of nematocysts in the fabric. Malaise, fever, and gastrointestinal symptoms can also occur in a minority of patients with this condition.

Treatment of seabather's eruption is symptomatic and typically consists of oral antihistamines (eg, diphenhydramine, hydroxyzine, or loratadine), topical antipruritic agents (eg, calamine lotion), and low (genital) or medium potency (trunk or limbs) topical corticosteroid preparations (table 4) [20,65,66]. Oral corticosteroids (eg, prednisone, prednisolone) may be necessary in severe cases. The skin lesions typically resolve spontaneously in one to two weeks.

Removing swimwear and showering soon after ocean bathing may prevent the stings.

ADDITIONAL RESOURCES

Regional poison control centers — Regional poison control centers in the United States are available at all times for consultation on patients with known or suspected poisoning, and who may be critically ill, require admission, or have clinical pictures that are unclear (1-800-222-1222). In addition, some hospitals have medical toxicologists available for bedside consultation. Whenever available, these are invaluable resources to help in the diagnosis and management of ingestions or overdoses. Contact information for poison centers around the world is provided separately. (See "Society guideline links: Regional poison control centers".)

Society guideline links — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Envenomation by snakes, arthropods (spiders and scorpions), and marine animals".)

SUMMARY AND RECOMMENDATIONS

Biology – Jellyfish are invertebrates that float in salt and brackish water. They can be difficult to see, and most injuries occur when humans blunder into their tentacles while wading or swimming at beaches. They have a central bell and lengthy tentacles that disconnect easily (picture 1 and picture 2) and contain venomous capsules called nematocysts. (See 'Marine biology' above and 'Venom delivery and properties' above.)

Clinical manifestations of jellyfish stings – Patients usually present with linear, red, urticarial and/or painful skin lesions, but manifestations vary depending on the type of jellyfish. (See 'Clinical manifestations' above.)

Stings by several jellyfish found in tropical Australia and the Indo-Pacific region can cause life-threatening systemic effects (see 'Dangerous species' above):

Carukia barnesi, and several other species can cause Irukandji syndrome, which is characterized by an initially mild to moderately painful local sting that is followed within minutes to an hour by the onset of waves of severe generalized back, chest, and abdominal pain, vomiting, sweating, agitation, severe hypertension, and tachycardia. (See 'Irukandji syndrome' above.)

Chironex fleckeri (the Australian box jellyfish) can cause rapid onset of cardiac arrest or cardiogenic shock if its tentacles contact a large area of skin (picture 7).

Diagnosis – In most cases, the diagnosis of a jellyfish sting is made clinically or is simply recognized by the patient who has been stung in waters known to harbor jellyfish. Clues to the type of jellyfish include the geographic area where the sting occurred, the prevalent species of jellyfish washed up on the shore, the distance from the shore, and the pattern of the tentacle print on the skin (figure 1). In particular, C. fleckeri tentacles produce a characteristic "frosted ladder" appearance to the sting site (picture 7). (See 'Diagnosis' above.)

First aid at the shore – For many patients, the specific type of stinging jellyfish is not certain, and management is empiric based upon the prevalent species in the region (see 'Immediately after exposure (first aid at the scene)' above):

Australia and the Indo-Pacific region (including Hawaii) – Our approach is provided in the algorithm (algorithm 1) (see 'Australia and the Indo-Pacific' above):

-In a patient with moderate or severe pain, systemic symptoms (eg, nausea, vomiting, pain beyond the local sting site, headache, or altered mental status), or cardiorespiratory arrest, we suggest topical application (dousing or spraying) of vinegar for 30 seconds onto the sting site followed by manual removal of visible tentacles (Grade 2C).

-In a patient with stings by C. fleckeri (Australian box jellyfish) or displaying Irukandji syndrome, after tentacle removal, we suggest cold therapy rather than hot water immersion for control of pain (Grade 2C). (See 'Pain control' above.)

-In a patient with significant pain but no systemic symptoms suggestive of Irukandji syndrome or of C. fleckeri envenomation, after tentacle removal, we recommend treatment by hot water immersion or application of hot packs rather than cold therapy or irrigation with vinegar (Grade 1B). If hot water immersion is performed, the water temperature should be 43 to 45°C (110 to 113°F) and should be applied by immersion of a limb or by hot shower for approximately 20 minutes. If a thermometer is not available, use the hottest water temperature that is tolerated by the rescuer or the patient on an unaffected limb; adults should test the water temperature for young children.

Outside of Australia and the Indo-Pacific region (including Hawaii) – In a patient with a jellyfish sting outside of these regions, we suggest manual removal of visible jellyfish tentacles, rinsing of the sting site with seawater, and treatment of pain with hot water immersion or application of a hot pack rather than irrigation with vinegar or cold therapy (Grade 2B). (See 'Other world regions' above.)

Emergency department management – Care should focus on treatment of any life-threatening envenomation (primarily occurring in Australia and the Indo-Pacific region), ensuring that appropriate first aid is performed, and pain control. Most jellyfish stings cause mild to moderate local pain that responds to local measures and oral medications such as acetaminophen or ibuprofen. (See 'Emergency department management' above.)

Cardiac arrest or severe shock – Provide resuscitation and supportive care according to the principles of Advanced Cardiac Life Support or Pediatric Advanced Life Support. (See "Advanced cardiac life support (ACLS) in adults" and "Pediatric advanced life support (PALS)".)

In a patient with cardiac arrest or other signs of cardiotoxicity after stings by C. fleckeri (Australia and Indo-Pacific region) who present within one hour of the sting, we suggest administration of specific sheep serum antivenom (Grade 2C). Administer one vial (20,000 units) intravenously over 5 to 10 minutes as the initial dose; dosing may be repeated up to a maximum of three vials for patients who remain in cardiogenic shock or cardiac arrest. The same dose is used for adults and children. (See 'Cardiotoxicity (cardiac arrest or cardiogenic shock)' above.)

Irukandji syndrome – We administer a parenteral opioid (eg, fentanyl or morphine) for pain. In a patient with severe hypertension, we suggest administering a benzodiazepine (Grade 2C). If elevated blood pressure persists, then we administer a short-acting antihypertensive medications appropriate for sympathetic overactivity, such as nitroglycerin, sodium nitroprusside, or phentolamine. These patients also require evaluation and monitoring for potential complications such as acute coronary syndrome, heart failure, cardiogenic pulmonary edema, and intracranial hemorrhage. (See 'Irukandji syndrome (generalized pain and severe hypertension)' above.)

Prevention – In tropical Australia and the Indo-Pacific region where box jellyfish stings occur, not entering the water during jellyfish season is the most effective means of prevention. When swimming in waters with box jellyfish, we suggest wearing clothing or suits that provide a mechanical barrier to stings (Grade 2C). In areas with jellyfish known to cause Irukandji syndrome (eg, northern Australia), protective clothing with a mesh size <0.25 mm should be worn. For swimmers at high risk of exposure to jellyfish, we suggest the application of a jellyfish sting inhibitor (eg, Safe Sea lotions) (Grade 2B). (See 'Prevention' above.)

Seabather's eruption – An itchy dermatitis that occurs in areas covered by a swimsuit and is believed to be caused by jellyfish and sea anemone larvae that become trapped and pressed between the garment and the person's skin (picture 12). The skin reaction may recur when the outfit is worn again, due to persistence of nematocysts in the fabric. Malaise, fever, and gastrointestinal symptoms can also occur in a minority of patients. Treatment is symptomatic and typically consists of oral antihistamines (eg, diphenhydramine, hydroxyzine, or loratadine), topical antipruritic agents (eg, calamine lotion), and low (genital) or medium potency (trunk or limbs) topical corticosteroid preparations (table 4). (See 'Seabather's eruption' above.)

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Topic 2752 Version 25.0

References

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