Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 4 294 Jellyfish sting resulting in severe hand ischaemia successfully treated with intra-arterial urokinase Taiseer Abu-Nema, Khalid Ayyash, The Departments of Surgery, Al-Kabeer Hospital, Kuwait. lbrahim Biochemistry K. Wafaii, Jassim Al-Hassan and Pharmacology, INTRODUCTION SEVERE ischaemia following jellyfish sting is exceedingly rare and has been reported only once before. Two sting resulting in severe hand cases of jellyfish ischaemia successfully treated with local intra-arterial infusion of urokinase are reported. An interesting feature observed in the present cases is the early appear- ance of severe swelling of the extremity but the later appearance of circulatory impairment, indicating arterial spasm complicated by subsequent thrombosis. Kuwait and Olav Thulesius University, Kuwait and Mubarak arches and digital arteries could not be seen (Fig. 2). The picture was suggestive of severe spasm but distal thrombosis could not be ruled out. Since prior treatment with reserpine, pentoxifyline and sympathectomy had no effect the patient was given 50 000 i.u. of urokinase through an indwelling arterial catheter with its tip situated just above the brachial bifurcation. Urokinase was infused over a period of approximately 30min and resulted in colour improvement shortly zyxwvutsrq CASE REPORTS Case 1 While swimming in sea water, a 27-year-old female was stung on her left arm and complained of severe pain which forced her to seek medical advice in a neighbouring hospital. Examination revealed diffuse oedematous swelling, with red and blue patches, of the left arm. Antihistamines, penicillin and prednisone resulted in no improvement and 3 days later she was referred to our unit for further management. Examination revealed severe swelling of the left supra- and infraclavicular areas, and of the left arm. Four areas with multiple linear wheals were found in different locations in the affected arm, but not on the hand (Fig. 1). The left hand disclosed bluish discoloration of the thenar eminence and the lateral three fingers, with absent touch sensation in the latter. Doppler examination revealed a normal brachial flow but the flow was diminished in the ulnar artery and non-existent in the radial artery. The clinical impression was of a jellyfish sting with severe local reaction and distal ischaemia due to arterial spasm. A marine biologist demonstrated nematocysts from the surface of the lesions without using special stains. Initially she was treated with heparin, dextran and methyl prednisolone but cold cyanosis progressed to the rest of her fingers. When intra-arterial reserpine 0.5 mg and intravenous pentoxifyline 100 mg resulted in no improvement, a left cervicodorsal sympathectomy, was performed. This resulted in no improvement and 12 h later a transfemoral arteriogram revealed the radial and ulnar arteries to be extremely narrowed with cut-off at the level of the radiocarpal joint. Palmar Fig. 1. Swollen left upper extremity with ischaemic fingers. Two sting sites are seen on the infradeltoid area (black arrow) and the lateral aspect of the left elbow (empty arrow). 0 1988 Butterworth & Co (Publishers) Ltd 0020-1383/88/040294-03 $0340 Fig. 2. Arteriogram showing the radial and ulnar arteries to be extremely narrowed with cut-off at the level of radiocarpal joint. Palmar arches and digital arteries could not be visualized. 295 Case reports afterwards. A few hours later the radial and ulnar pulses were easily felt. The swelling gradually decreased. Eventually she had partia! thickness skin loss at the site of the sting sites but this did not require skin grafting. Three weeks later she regained motor function in her hand except for opposition of the thumb. She also lost temperature sensation. in the medial two fingers and the palm of the hand. Two months later she had no residual motor dysfunction but there was loss of pinprick, temperature and light touch sensation in the affected fingers. The girth of the left forearm was 2cm less than the right and she was back to her previous occupation as a typist. Six months later she was asymptomatic but diminished superficial sensation in her affected fingers was observed. discharged home. Forty days later the only residual damage was diminished pinprick and temperature sensation over the distal phalanx of the right thumb which was still present when the patient was seen I year later. The sting site was still visible but fading 1 year after the incident. DISCUSSION The phylum coelenterata (Cnidaria) includes some of the most venomous creatures inhabiting the oceans. They are best known to biotoxicologists because of their ability to inflict painful stings by means of their highly developed venomous apparatus (Halstead, 1981). Jellyfish belong to the phylum coelenterata and possess a type of stinging mechanism that is unique. The nematocysts found in the animal’s tentacles conCase 2 tain stinging capsules which possess trigger hairs and In the same month a 26year-old female was stung on her * muscle strands. They are also equipped with barbed right forearm while swimming in shallow sea water 3 days threads. When stimulated the nematocysts contract and before admission. Immediately following the sting she shoot out, with great force, minute hollow barbed noticed red discoloration of the sting site and developed burning pain of the forearm and hand. She was given an threads which sting or entangle the prey. The threads ointment in a private clinic but a few hours later her right with open ends act like microscopic hypodermic thumb became cyanosed and the forearm and hand swollen. needles and inject venom into the victim either to kill Over the next 2 days she continued to complain of painful or narcotize it (Pope, 1953). In human victims, the swelling of the forearm and hand in addition to cyanosis of nematocysts are found on the surface of the skin, the the thumb. The latter was anaesthetic. threads of which penetrate through to the dermis. A Examination in our unit revealed a lesion measuring 7cm stain is not necessary for identification. in the transverse diameter, typical of a jellyfish sting, situated The nerve damage encountered in the two patients on the anteromedial aspect of the right forearm (Fig. 3). can partly be explained by ischaemia, but a direct toxic Nematocysts were demonstrated by microscopic examination effect from jellyfish toxin (JFT) is another possible of the sting site. There was moderate swelling of the forearm and the dorsum of the hand. The thumb was cyanosed and cause. Sea nettle nematocyst venom damages cellular sensation was lost. Intermittent changes in cyanosis were and subcellular tissue preparations including nerve and noticed until a few hours later when it became fixed and the muscle of rats and frogs (Schryock and Bianchi, 1983). thumb was extremely painful (Fig. 4). Doppler ultrasound C. quinquecirrha exerted an effect on the isolated examination revealed a diminished ulnar flow and no radial canine Purkinje fibres which mimicked the action reflow. Based on our experience with Case 1, transfemoral sulting from low calcium concentration on the memangiography with selective brachial injection was performed, brane level (Calton et al.. 1973). Perhaps the one study revealing changes similar to those described in Cuse 1’. With that relates to the two patients described is that carried the catheter tip in the brachial artery tolazoline 5Omg and out by Walker (1977). Toxin from Cy anea capillata was pentoxifyline tflomg were injected intra-arterially with no improvement 3Omin later. Urokinase 50 O(H) units in SOml dermatonecrotic in rats and guinea pigs. It had irresaline was injected over 3Omin and the patient was returned versible spasmogenic action on isolated smooth muscle to the ward. preparations, mammalian heart and frog rectus muscle. A few hours later cold cyanosis was still present but a weak Anaesthetized rats were perfused with crude toxin into radial how was detected. No improvement in colour was seen an artery supplying a vascular bed and the toxin pro24 h later and repeat arteriography was performed revealing duced an initial rise in vascular perfusion pressure essentially the previous changes. Pentoxifyline 100 mg. reserfollowed by raised resting basal pressure in isolated pine 0.5 mg and urokinase 50 000 units were given through blood vessels together with enhanced sensitivity to the arterial catheter for 3Omin and this resulted in improvenoradrenaline. ment shortly afterwards. Six hours later arterial flows were It is possible that JFT contains, like many animal equal in both radial arteries with the radial and ulnar pulses toxins. phospholipase A which catalyses the hydrolysis palpable without difficulty. Subsequently she did well and was zyxwvutsrqpon Fig. 4. Ischaemic &, 3. Jellyfish sting on the right arm of Cuss 2. changes of the right thumb and partial ischaemia of right thenar eminence. Sting site is seen on the forearm (arrow’). 296 Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 4 al. used local urokinase in four patients with an average of fat ester linkages in phospholipids, releasing dose of 64 OOOu/hour infused over an average of 43 h. lysophosphatides and saturated and unsaturated fatty acids which are precursors of prostanoids (such as Rentrop et al. (1981) on the other hand infused intracoronary streptokinase at 1000-2000 u/min for 1% thromboxane A) and leucotrienes. Certain phospholi95 min, resulting in significant clot lysis. We opted to use pases have not only been implicated with inflammatory local urokinase in a systemic dose of 1500-20OOu/min reactions and thrombosis, but also neuromuscular over 30 min because we felt that leaving an indwelling block (Russell, 1983). Recently it has been reported catheter in the brachial artery for an extended period of that JFT from the tentacles of Curybdea rastonii caused time may be associated with serious side-effects. vasoconstriction through activation of calcium channels A remarkable feature of our cases is the delayed and platelet aggregation, by depolarization of platelet onset of severe ischaemia of the affected extremity (3 membranes (Azuma et al., 1986). days). Severe and long-lasting vasospasm may eventualThe sting of the single tentacled zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Physaliu utriculus causes a discontinuous line of small papules each sur- ly result in thrombosis, as seen in cases of ergotamine rounded by a small zone of erythema. There may be poisoning (Berde and Schild, 1978) and a similar mechanism is thought to have caused ischaemia in our well-defined linear welts or scattered areas of punctate whealing and redness (Halstead, 1981). Chironex and cases. Chiropsalmus inflict extremely painful stings resulting in localized areas of whealing, oedema and vesiculation which later result in necrosis involving full thickness of the skin. In the two cases described, positive identification of nematocysts was achieved but the jellyfish was not identified. This is in agreement with Halstead (1981) REFERENCES Azuma H, Sekizaki S., Satoh A. et al. (1986) Platelet who stated that the jellyfish is usually not seen and even aggregation caused by a partially purified jellyfish toxin if observed it is seldom identified by the layman. The from Cary bdea rastonii. Toxicon 24, 489. gross appearance of the sting site suggested either Berde B. and Schild H. 0. (1978) Ergot Alkaloids and Chironex or Chiropsalmus as the offending jellyfish. Related Compounds. Berlin: Springer, 817. The only report we found describing a condition similar Calton G. J.. Brunett J. W.. Garbus J. et al. (1973) The effect of Chrysaora and physalia venoms on mitochondrial structo the one encountered by us was that of an English ture and function. Proc. Sot. Exp. Biol. Med. 143, 471. woman who was swimming in the Arabian Gulf where Dotter C. T., Rosch J., Seaman A. J. (1974) Selective clot our patients were injured. She was aware of seaweedlysis with low dose streptokinase. Diagn. Radiol. 111, 31. like material crossing her right arm. Ten minutes later Drury J. K.. Noonan J. D., Pollock J. G. et al. (1980) there was marked oedema of both the hand and foreJellyfish sting with serious hand complications. Injury, 12, arm. Digital ischaemia followed and the hand became 66. blue and cold. Arteriographic findings were similar to Halstead B. W. (1981) Current status of marine biotoxiour cases. Following intra-arterial naftidrofuryl oxalate cology, an overview. C/in. Toxicol. 18, 1. and upper thoracic sympathectomy, demarcation was Halstead B. W. (1078) Poisonous and Venomous M arine established at the proximal interphalangeal joint and Animals of the W orld. Princeton, New Jersey: The Darwin Press Inc. amputation performed. The sting was assumed to have Katzen B. T. and Breda V. A. (19X1) Low dose streptokinase been caused by either Chironex fleckeri or Chiropsalin the treatment of arterial occlusions. AJR 136, 1171. mus quadrigarus (Drury et al., 1980). Pillari G., Doscher W., Fierstein J. et al. (1983) Low dose Failure to respond to potent vasodilators, including streptokinase in the treatment of celiac and superior cervicodorsal sympathectomy in the first case, and later mesenteric artery occlusion. Arch. Surg. 118, 1340. positive response to intra-arterial urokinase, indicate Pope E. C. (1953) Sea lice or jellyfish. The Australian that severe vasospasm complicated by distal thrombosis M useum M agazine 11 (l), 16. was the underlying pathology in Case I. A similar Rentrop P., Blanke H., Karsch K. R. et al. (1981) Selective sequence was noticed in Cuse 2, although no initial intracoronary thrombolysis in acute myocardial infarction response was noticed with vasodilatation and urokiand unstable angina pectoris. Circulation 63, 307. nase, such that a second arteriogram and further similar Russell F. E. (1983) Snake Venom Poisoning. Great Neck, New York: Scholium Int. Inc. treatment was required. If vasospasm alone was responsible for the ischaemic Shryock J. C. and Bianchi C. P. (1983) Sea nettle (Chrysaora quinquecirrha) nematocyst venom. Mechanism of action process described in our patients it should have reon muscle. Toxicon 21, 81. sponded to potent vasodilatation, while the long time Totty W. G., Gilula L. A., McClennan et al. (1982) Low dose taken from the initial injury to the onset of ischaemia is intravascular hbrinolytic therapy. Diagn. Radiof. 143, 59. against thrombosis as the only cause. Experience with Walker M. J. A. (1977) Pharmacological and biochemical local, low dose fibrinolytic therapy for acute arterial properties of a toxin containing material from the jellyfish, occlusion is not-abundant, although there are favourCyanea capillata. Toxicon 15, 3. able reports (Dotter et al., 1974; Katzen and Breda, 1981; Totty et al., 1982; Pillari et al., 1983). Totty et Paper accepted 14 January 1988. Requesfs for reprinf.s should he addressed IO: Taiseer Ah-Nema 13110, Kuwait. MI). FIC‘A, Faculty of Medicine. Department of Surgery, PO Box 24923, Safat,