Transcript Jelly Fish Anaphylaxisx

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The Anaphylaxis Blues
Jellyfish strikes back
Dr Daniel Khamoudes
Toxicology Service
Prince Of Wales Hospital
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Outline
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Case
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History
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Facts
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Case
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38M
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Otherwise well
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Hx of anaphylaxis to bee stings
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Blue Bottle Sting at Maroubra 1730
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First aid with water to remove
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Presented POW ED 1800 with pain
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Primary sting L lateral ankle
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Pain locally and L groin 8/10
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Case
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In ambulance bay, hot water submersion
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1830 sudden onset tongue angioedema
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Moved to resus
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Nil respiratory or haemodynamic compromise
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Adrenaline 0.5mg IM at 1855
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Rapid resolution within 5 minutes
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Hydrocortisone 200mg IV
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Ranitidine 50mg IV
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Fexofenadine 180mg po
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Fentanyl 150mcg, in 50mcg aliquots
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Case
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Return of angioedema 2000
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Nil respiratory or haemodynamic compromise
Second dose Adrenaline 0.5mg IM 2010
Resolution of symptoms over 10 minutes
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Further boluses of Fentanyl as groin pain an issue
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Creatine kinase and UEC NAD
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HDU admission for observation re angioedema
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Nil further episodes
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Pain settled overnight
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History
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Discovered 19031
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Richet and Portier
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Dogs vs Jellyfish toxin
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Second exposure lower dose lethal
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1913 Nobel Prize
Origin
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Greek –ana (against) –phylaxis (protection)
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Originally aphylaxis (publicist)
1. Wikipedia
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Mechanism
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Nematoblasts->Nematocysts
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Spring loaded syring
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Discharge within 700ns of contact
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18m/s 5.4x106g
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Pressure 7.7GPa
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Local and systemic injury
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Mechanism
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Mechanism
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Toxin2
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Local and systemic
Tubule
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Collagens, glycoproteins and polysaccharides
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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.
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Mechanism
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Physalia Utriculus
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Physalia physalis vs Physalia utriculus
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Float and Tail
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Nematocysts remain active
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Local effects
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Immediate pain and erythema
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Progressive pain to draining lymph nodes
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Long term scarring unlikely but occurs
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Local Effects
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Systemic Effects
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Venom
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Pore forming in plasma membrane, Ca influx/swelling/lysis2,3
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Neuro/cardio toxicity2,4
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Potential deaths with Physalia physalis 5,6
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Immune Response – immediate and delayed
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Hypersensitivity reaction
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Previous exposure
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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
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Treatment
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Supportive
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Analgesia
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Consider regional
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Hot water submersion3
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Anaphylaxis APP
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ALS
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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) 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.
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Summary
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Local and systemic symptoms
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Treatment supportive +/- specific
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?Steroid topical
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?Sun exposure
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References
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Wikipaedia
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2. J Tibballs, A Yanagihara, H Turner, K Winkel. Immunological and Toxinological Responses to Jellyfish Stings.
Inflammation & Allergy - Drug Targets, 2011, 10, 438-446.
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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.
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4. Burnett, J.W. Treatment of Atlantic cnidarian envenomations. Toxicon, 2009, 54(8), 1201-1205.5.
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5. Tibballs, J. Australian venomous jellyfish, envenomation syndromes, toxins and therapy. Toxicon, 2006,
48(7), 830-859.
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6. L Cegolon, W Heymann, G Mastrangelo. Jellyfish Stings and Their Management: A Review. Marine Drugs,
Feb 2013. 11(2):523-550
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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.
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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.