CASE REPORT

A 31 year old man was on a beach in Medan, Sumatra, when he came across a large jelly-like mass floating in the water. He picked it up and handled it for a minute or two before feeling a sharp pain on his left forearm. He immediately dropped the unknown creature and noticed a linear urticarial lesion on the left forearm (fig 1). This corresponded with a jellyfish sting reaction. Within half an hour he developed generalised malaise, weakness, lethargy, and joint pains followed by a sensation of abdominal bloatedness. He was treated at a local hospital but decided to seek further treatment in Singapore. The patient presented at the Department of Emergency Medicine at Singapore General Hospital 24 hours after envenomation. He complained of persistence of his original symptoms and was beginning to develop abdominal distension, vomiting, and had no urge to move his bowels since the incident. Examination revealed a lethargic looking patient with linear urticarial lesions on his left forearm. Vital signs were stable and neurological examination was essentially normal. Pupils were 4 mm, equal and reactive bilaterally. Abdominal distension was noted with absent bowel sounds. No abdominal tenderness was elicited and per rectal examination revealed soft brown stools. A clinical diagnosis of paralytic ileus (adynamic intestinal obstruction) was made. Abdominal radiographs showed distended small and large bowel loops with multiple fluids levels confirming the clinical suspicion. Full blood count, serum electrolytes, amylase, cardiac enzymes, liver function tests, and coagulation profile were all normal except for mildly increased total white with polysmorphonuclear leucocytosis of 81.6%. Electrocardiogram showed normal sinus rhythm with rate of 75 beats/minute. A surgical consultation was made and patient was treated conservatively with intravenous infusion and suction. The patient was admitted and treatment continued for four days before symptoms resolved and patient was able to move his bowels again. He was discharged on the fourth day and returned for review a week later when he was noted to be well and discharged without any further follow up.

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Figure 1

Linear urticarial lesion on the forearm typical of jellyfish sting.

DISCUSSION

Jellyfish belong to the phylum called cnidarians or coelenterates. The unique feature of these organisms is the presence of millions of nematocysts (or stinging cells) on their tentacles, which surround the venom glands. These act as the plunger of the hypodermic syringe discharging the contents of the venom gland when activated either by contact or pressure. The organism has no control over the discharge of the nematocyst and hence, envenomation can occur when people brush against the tentacles even of dead jellyfish.

There are several species of jellyfish that have been known to produce envenomations in humans. These include the Chironex fleckeri (box jellyfish or sea wasp), Carukia barnesi, and Physalia physalis (Portuguese man of war). The Chironex is a large jellyfish, which has 50 to 60 tentacles each five to six feet long. Fatalities have been reported with envenomation with this species. This species tends to be found around the coastal waters of Australia and because of its lethal stings the emergency ambulance services carry the antivenom and have protocols for administering it in the prehospital setting. The Portuguese man of war jellyfish is found in tropical waters and floats on the water surface. It tends to cause severe local urticarial lesions and joint pain on being stung. Carukia barnesi is found off the coastal waters of Northern Australia. Its bell reaches 2 cm diameter when fully grown. It has been noted to cause the Irukanji Syndrome manifesting with sudden cardiac arrest or heart failure.

Human reactions to jellyfish envenomation can be fatal, local, or systemic.¹

Local reactions are usually linear and papular or urticarial skin lesions. These are attributable to kinin-like mediators in the venom. These may progress to erythematous, vesicular, haemorrhagic, necrotising, or ulcerative lesions. Localised hyperhidrosis, lymphadenopathy, fat atrophy, vasospasm with limb necrosis and gangrene have been reported. Persistent rubbing can produce lichenification.

A variety of systemic reactions have been reported involving the cardiac, respiratory, and neurological systems. Neurological manifestations include dysautonomia, peripheral sensory neuropathies, mononeuritis multiplex, central or peripheral motor paralysis, ophthalmological symptoms, neuropsychological derangements, and cardiomyopathies.²

Parasympathetic dysautonomia resulting from jellyfish sting to the thighs of a Chinese fisherman was reported in 1984.³ This patient presented with abdominal distension, retention of urine, constipation, absence of lacrimation, and failure of erection. This was possibly the result of a selective anti-muscarinic effect of the jellyfish venom. In our case, the patient presented with isolated paralytic ileus with no other manifestations of parasympathetic dysfunction. Occasional reports of cases of jellyfish sting presenting with isolated neurological deficits are noted in the past. One such case had prolonged blurring of vision after jellyfish sting, which persisted for a week.⁴ The exact mechanism of these isolated effects is yet to be discovered.

There are a wide variety of manifestations after jellyfish envenomation. The pathological effects are attributable to a combination of toxic and allergic mechanisms. The actual pathogenesis of human injury from jellyfish venom is yet to be elucidated. Allergic effects are managed in a similar way as any other anaphylaxis. Toxic effects are managed with a combination of specific antidotes and supportive care.

The aetiology of paralytic ileus secondary to toxins include effects of drugs such as opioids, anticholinergics and tricyclics; as well as intestinal ischaemia after cocaine or oral contraceptive use; and electrolyte disturbances such as hypokalaemia and hypomagnesaemia produced by toxins. It is now apparent that jellyfish envenomation should be added to the differential diagnosis of patients presenting with paralytic ileus after an unidentified marine bite or sting.

Contributors

Dr Ponampalam was responsible for the management of the patient at the emergency department, reviewing inpatient and follow up patient records, literature review, and writing of the paper.