Box Jellyfish (Chironex fleckeri)

Box Jellyfish (Chironex fleckeri)

The box jellyfish is found in tropical Australian waters. Most stings are benign and respond to supportive measures. Severe envenoming has been associated with at least 67 deaths in Australia, the last 12 being children. All deaths occur within 5 minutes of the sting, probably secondary to direct cardiac toxicity.

Cable Beach Jellyfish Warning

Cable Beach Jellyfish Warning

 


Toxin

The specific venom components are still being identified. They are thought to affect sodium and calcium channels leading to abnormal membrane ion transport.

 


Clinical presentation and course

  • Stings are associated with immediate severe pain, typically lasting up to 8 hours, and linear welts, which characteristically occur in a crosshatched pattern
  • In 25-30% of cases the jellyfish tentacles are still adherent
  • Systemic envenoming is heralded by collapse or sudden death within a few minutes of the sting
  • Cardiovascular effects include hypertension, hypotension, tachycardia, impaired cardiac contraction and arrhythmias
  • Delayed hypersensitivity reactions occur in at least 50% of patients and manifest as pruritic erythema at the original sting site, 7-14 days after the sting.
snapshot-2008-12-22-15-48-03

Box Jellyfish Sting

Near fatal Box Jellyfish sting

Near fatal Box Jellyfish sting

 


Management
  • Reassure the patient, apply an ice pack and give simple oral analgesia such as paracetamol
  • Apply generous volumes of vinegar (acetic acid) to all visible sting sites to inactivate all undischarged nematocysts (sting cells)
  • Do not apply a pressure immobilisation bandage (PIB) as this may promote systemic envenoming
  • Transport all patients with pain refractory to first‑aid, or systemic symptoms, to a medical facility
jellyfish-first-aid-vinegar

Jellyfish First Aid - Vinegar

  • Rarely, box jellyfish envenoming is a life‑threatening emergency
  • Patients should be managed in an area equipped for cardiorespiratory monitoring and resuscitation
  • Potential early life‑threats that require immediate intervention include cardiac arrest, hypotension or hypertension and cardiac arrhythmia
  • In cardiac arrest, undiluted antivenom, administered as a rapid IV push, may be life‑saving. All immediately available Box Jellyfish antivenom (up to 6 ampoules) should be given. Intravenous magnesium (10 mmol) should be given if there is no response to antivenom
  • Give titrated morphine (0.1 mg/kg IV up to 5 mg every 10 minutes) to patients with pain refractory to first‑aid
  • Give three ampoules (3 × 20,000 units) IV diluted in 100 mL normal saline over 20 minutes to all patients with systemic envenoming as evidenced by collapse, hypotension or significant cardiac arrhythmia. The patient is observed closely for response to treatment and ongoing features of envenoming prompt a further dose of antivenom (up to three ampoules)
  • Give one ampoule (1 × 20,000 units) for pain refractory to IV opioid analgesia

Differential diagnosis

  • Bluebottle stings (Physalia species) are also associated with immediate pain and dermal markings. Pain usually resolves within 1 hour and systemic symptoms are extremely rare
  • Pain associated with Irukandji syndrome is usually delayed, severe and generalised. Significant linear dermal markings or welts are not seen
  • Decompression illness may lead to severe pain and collapse shortly after a diver has surfaced. Local pain and welts are not seen

Handy tips

  • Reassurance is important. Despite its reputation, the vast majority of box jellyfish stings require only first‑aid
  • A steroid or antihistamine cream may provide symptomatic relief if a delayed hypersensitivity rash occurs
  • Immediate pain after a jellyfish sting, occurring in shallow tropical waters between November and April, associated with linear welts with a cross‑hatched pattern, is pathognomonic of Chironex fleckeri sting
  • Pressure immobilisation bandaging for box jellyfish stings has now been abandoned because direct pressure over tentacles leads to increased venom release from nematocysts
  • Ice is currently recommended as appropriate first‑aid. It is possible that heat is more effective

If you’ve read this far, you’re ready for Toxicology Conundrum #010!

References

  • Bastian Bentlage, Paulyn Cartwright, Angel A. Yanagihara, Cheryl Lewis, Gemma S. Richards and Allen G. Collins.Evolution of box jellyfishes (Cnidaria: Cubozoa), a group of highly toxic invertebratesProceedings of the Royal Society, November 18, 2009 DOI:10.1098/rspb.2009.1707
  • Disarming the box-jellyfish: nematocyst inhibition in Chironex fleckeri. MJA [Reference]
  • 10 year old girl survives box jellyfish attack [Guardian 2010][CNN 2010]
  • Survival stories from box jellyfish [The Chronicle 2010]
  • Box Jellyfish [Wikipedia]
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Comments

  1. says

    I am a herpetologist by training, and know a bit about various venoms from snakes; those which attack the heart, muscle, nerve systems, healthy tissue, all by a multitude of means, and to various degrees.
    However, I was taken aback to learn that this ‘fish’s’ method of envenomation point toward the sodium and calcium channels; something we call the “Sodium Pump”, a real and necessary way to transport electrolytes along a membrane (healthy) , allowing for normal function.
    To my knowledge (I am NOT sure, but I’ve never known) any snake to attack via venom components by this route.
    So, (from a scientists’ perspective), it is fascinating. And I say this with the utmost respect to those stricken by such a powerful animal.
    Thank You.

  2. says

    I am a herpetologist by training, and know a bit about various venoms from snakes; those which attack the heart, muscle, nerve systems, healthy tissue, all by a multitude of means, and to various degrees.
    However, I was taken aback to learn that this ‘fish’s’ method of envenomation point toward the sodium and calcium channels; something we call the “Sodium Pump”, a real and necessary way to transport electrolytes along a membrane (healthy) , allowing for normal function.
    To my knowledge (I am NOT sure, but I’ve never known) any snake to attack via venom components by this route.
    So, (from a scientists’ perspective), it is fascinating. And I say this with the utmost respect to those stricken by such a powerful animal.
    Thank You.

  3. says

    I am a herpetologist by training, and know a bit about various venoms from snakes; those which attack the heart, muscle, nerve systems, healthy tissue, all by a multitude of means, and to various degrees.
    However, I was taken aback to learn that this ‘fish’s’ method of envenomation point toward the sodium and calcium channels; something we call the “Sodium Pump”, a real and necessary way to transport electrolytes along a membrane (healthy) , allowing for normal function.
    To my knowledge (I am NOT sure, but I’ve never known) any snake to attack via venom components by this route.
    So, (from a scientists’ perspective), it is fascinating. And I say this with the utmost respect to those stricken by such a powerful animal.
    Thank You.

  4. KiteDoc says

    I disagree with your management plan described above. Having lived and worked in Darwin for 3 years, I have been involved in the management of many Chironex fleckeri envenomations. I have had to treat only 1 near-fatal envenomation in all that time spent in ED and remote. Most people, as you suggest, require simple first aid measures only.

    The management strategies that actually benefit the patient the most are:

    1. Copius vinegar poured over any visible tentacles still attached to the individual just envenomed

    This is imperative, as the vinegar inactivates the nematocysts (the stinging cells) from releasing more venom. DO NOT first apply ice, as suggested in the management paln, as this will actually have the REVERSE effect -- it will cause the nematocysts to fire, thus increasing the venom serum dose, and increasing the likelihood of cardio-toxicity.

    2. Antivenom

    There is actually a lot of debate as to whether the anti-venom works. after discussion with leading Chironex researchers in Darwin, it appears that you either die pretty much instantly (last death in the NT was December 2007, a child from the neighbouring Tiwi Islands), or not at all. If your patient has collapsed, they require BLS +/- ALS. The anti-venom may be a useful adjunct for analgesia (see point 3 below). This is currently being further investigated.

    3. Analgesia

    These stings hurt. A lot. Give adequate analgesia, ie opioids. You can try ice, or a hot (warm) bath -- neither will really work. There is a study currently underway by Assoc. Prof Bart Currie (FRACP), who is the leading physician investigating box jellies and their envenoming. He is based in Darwin, both as an ID physician and as a researcher at Menzies, and also Dr Geoff Ibister, a leading toxinologist based in Newcastle, NSW.

    4. MgSO4.

    Magnesium has been used in envenoming as an analgesic adjunct, not as a cardiac stabiliser. Its use is controversial. In my experience, it doesn’t actually work. This is currently also under investigation by Dr Currie et al.

    5. Steroids (for the rash).

    THe welts often scar. Steroid use (systemic or oral) is NOT indicated in the acute phase of the envenomation. For the majority of patients (such as my husband) who develop the pruritic delayed hypersensitivity reaction, a steroid cream is useful to manage the extreme itch, that keeps the patient (and their spouse) awake at night!

    Finally -- Vinegar + BLS = life saved.

  5. says

    Hi KiteDoc,

    Thanks for your detailed comment. I don’t disagree with your comment in any substantial way. However, except for emphasizing that vinegar should be applied first -- a point that does deserve emphasis -- I am not sure in what way you disagree with the management plan described.

    I am also familiar with Bart’s management protocol in Darwin -- as I have also lived and worked there for a couple of years and have coauthoured a paper on jellyfish envenoming with him -- and it doesn’t differ substantially from the advice given on this site.

    You are right to point out the absence of evidence for the administration of antivenom and magnesium. However, if a patient is in dire straits I doubt the majority of toxicologists and emergency docs in Australia would hesitate to administer these therapies, although it is important not to get distracted from the essentials of good resuscitation. As for magnesium, no one really knows if or how it might work or what the indications should be…

    Cheers,
    Chris

  6. says

    Hi KiteDoc,

    Thanks for your detailed comment. I don’t disagree with your comment in any substantial way. However, except for emphasizing that vinegar should be applied first -- a point that does deserve emphasis -- I am not sure in what way you disagree with the management plan described.

    I am also familiar with Bart’s management protocol in Darwin -- as I have also lived and worked there for a couple of years and have coauthoured a paper on jellyfish envenoming with him -- and it doesn’t differ substantially from the advice given on this site.

    You are right to point out the absence of evidence for the administration of antivenom and magnesium. However, if a patient is in dire straits I doubt the majority of toxicologists and emergency docs in Australia would hesitate to administer these therapies, although it is important not to get distracted from the essentials of good resuscitation. As for magnesium, no one really knows if or how it might work or what the indications should be…

    Cheers,
    Chris

  7. Leanne says

    While I detest the creatures, if they were relegated to extinction, so, too, would be loggerhead turtles, sunfish, certain octopi, and other creatures that depend on this beast as their main food source. Any creature made extinct affects the entire planet ecosystem, some way, some how. It is better for humans to learn how to avoid them, and to better treat the injuries caused when they are encountered.

    • Danika says

      how does anything eat a jellyfish with those crazy stingers and its like eating water they are 90% water!

  8. Sydney says

    Most jellyfish are drifters that feed on living or dead prey: small fish, eggs, zooplankton and other invertebrates that become caught in their tentacles. Prey items are brought (by tentacles, if they have any) into the cavity, called coelenteron, where they are digested. Some jellyfish are parasites.

    Jellyfish have cells called cnidocytes, which contain nematocysts, and located usually on their tentacles, mainly. Whenever a prey comes in contact with cnidocytes, hundreds to thousands of nematocysts’ filaments are ejected into the prey’s direction. These stinging cells are thus able to latch onto the prey, and the tentacles, or the oral arms (developed from the manubrium) bring the prey item into their mouth for digestion. Nutrients then pass along the animal’s radial canals to the various tissues of the body.

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  1. [...] any sort of painful sensation in the water that could conceivably be a sting from a multi-tentacled box jellyfish (Chironex fleckeri) or a jellyfish that can causes Irukandji Syndrome (Carukia barnesi) vinegar [...]

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