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Transcript
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The Anaphylaxis Blues
Jellyfish strikes back
Dr Daniel Khamoudes
Toxicology 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
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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) 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.
+
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.