+

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.