Irukandji syndrome: Difference between revisions

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=='''Background'''==
==Background==
*Caused by certain jellyfish from the Cubozoa class (box jellyfish) species
[[File:Avispa marina cropped.png|thumb|Box jellyfish]]
[[File:Nematocyst discharge.png|thumb|Nematocyst stages of discharge]]
*Caused by certain jellyfish from the Cubozoa class ([[box jellyfish]]) species
*Usually develops within 2 hours of envenomation & can last up to 2 days <ref> Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 4 of 5. ACEP Now. https://www.acepnow.com/article/emergen-sea-medicine-overview-of-marine-envenomations/4/.</ref>
*Usually develops within 2 hours of envenomation & can last up to 2 days <ref> Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 4 of 5. ACEP Now. https://www.acepnow.com/article/emergen-sea-medicine-overview-of-marine-envenomations/4/.</ref>
* The sympathomimetic-like manifestations are due to the venom, which is proteinaceous and contains a neural sodium channel activator. **Acts on the same sodium channels that are sensitive to tetrodotoxin, causing the release of catecholamines, particularly norepinephrine and epinephrine, and also direct vasoconstrictor effects.<ref>Kong EL, Nappe TM. Irukandji Syndrome. [Updated 2021 May 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562264/</ref>
* The sympathomimetic-like manifestations are due to the venom, which is proteinaceous and contains a neural sodium channel activator.  
**Acts on the same sodium channels that are sensitive to tetrodotoxin, causing the release of catecholamines, particularly norepinephrine and epinephrine, and also direct vasoconstrictor effects.<ref>Kong EL, Nappe TM. Irukandji Syndrome. [Updated 2021 May 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562264/</ref>


=='''Clinical Features'''==
==Clinical Features==
*Rare but potentially fatal complications can manifest in diverse ways:
*Rare but potentially fatal complication. It often involves intense pain, diffuse muscle cramps, vasconstriction and marked hypertension due to a catacholamine surge.
**Myalgias
**Beware of [[hypertensive emergency]]: Look for signs of end organ damage (ie ACS, CHF, intracranial hemorrhage, renal injury)
**Back pain
**Chest pain
**Abdominal pain
**Nausea and vomiting
**Diaphoresis
**Hypertensive crisis
**Cardiogenic pulmonary edema
**Intracranial hemorrhage
**Death


===[[Envenomations, bites and stings]]===
==Differential Diagnosis==
*[[Marine toxins and envenomations]]
{{Marine envenomation DDX}}
**Toxins ([[ciguatera]], [[neurotoxic shellfish poisoning]], [[paralytic shellfish poisoning]], [[scombroid]], [[tetrodotoxin]]
**Stingers ([[stingray injury]])
**Venomous fish (catfish, zebrafish, scorpion fish, stonefish, [[cone shells]], [[Lionfish envenomation|lionfish]], [[sea urchins]])
**[[Nematocysts]] ([[coral reef]], [[Fire coral contact|fire coral]], [[box jellyfish]], [[Sea wasp sting|sea wasp]], [[portuguese man-of-war]], [[sea anemones]])
**[[Phylum porifera]] (sponges)
**Bites ([[alligator and crocodile attacks|alligator/crocodile]], [[octopus bite|octopus]], [[shark bite|shark]])
*[[Scorpion envenomation]]


==Evaluation==
==Evaluation==    
*Electrocardiogram
*EKG
*Cardiac enzymes
*Troponin & ProBNP
*Chemistry
*CBC
*Blood count
*CMP
*Liver enzymes
*Lipase
*Lipase
*Chest X-ray
*Chest X-ray
*Bedside echocardiogram if acute heart failure is suspected
*CT imaging of the brain in cases of headache or acute encephalopathy<ref>Kong EL, Nappe TM. Irukandji Syndrome. [Updated 2021 May 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562264/</ref>   
*CT imaging of the brain in cases of headache or acute encephalopathy


=='''Management'''==
==Management==
*Manage pain with 4-5% acetic acid/vinegar & Hot water immersion (111-114F)<ref> Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 4 of 5. ACEP Now. https://www.acepnow.com/article/emergen-sea-medicine-overview-of-marine-envenomations/4/.</ref>
*Manage pain with 4-5% acetic acid (household vinegar) & Hot water immersion (111-114F)<ref> Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 4 of 5. ACEP Now. https://www.acepnow.com/article/emergen-sea-medicine-overview-of-marine-envenomations/4/.</ref>
*Fentanyl IV or other opiate for pain.
*IV magnesium sulfate (0.2mmol/kg, max 10mmol in adults) given as a bolus over 5-15 minutes for pain refractory to opioids
*IV magnesium sulfate (0.2mmol/kg, max 10mmol in adults) given as a bolus over 5-15 minutes for pain refractory to opioids
*Hypertension should be treated with short-acting titratable medications (eg., phentolamine, esmolol, nicardipine, nitroprusside) d/t potential for hypotension in the later stages of toxicity
*Hypertension should be treated with short-acting titratable medications (eg., nitroglycerin, phentolamine, esmolol, nicardipine, nitroprusside) due to potential for hypotension in the later stages of toxicity
 
==Disposition==
 
==See Also==
*[[Box jellyfish]]
 
==External Links==


==References==
==References==

Latest revision as of 02:42, 31 July 2021

Background

Box jellyfish
Nematocyst stages of discharge
  • Caused by certain jellyfish from the Cubozoa class (box jellyfish) species
  • Usually develops within 2 hours of envenomation & can last up to 2 days [1]
  • The sympathomimetic-like manifestations are due to the venom, which is proteinaceous and contains a neural sodium channel activator.
    • Acts on the same sodium channels that are sensitive to tetrodotoxin, causing the release of catecholamines, particularly norepinephrine and epinephrine, and also direct vasoconstrictor effects.[2]

Clinical Features

  • Rare but potentially fatal complication. It often involves intense pain, diffuse muscle cramps, vasconstriction and marked hypertension due to a catacholamine surge.
    • Beware of hypertensive emergency: Look for signs of end organ damage (ie ACS, CHF, intracranial hemorrhage, renal injury)

Differential Diagnosis

Marine toxins, envenomations, and bites

Evaluation

  • EKG
  • Troponin & ProBNP
  • CBC
  • CMP
  • Lipase
  • Chest X-ray
  • CT imaging of the brain in cases of headache or acute encephalopathy[3]

Management

  • Manage pain with 4-5% acetic acid (household vinegar) & Hot water immersion (111-114F)[4]
  • Fentanyl IV or other opiate for pain.
  • IV magnesium sulfate (0.2mmol/kg, max 10mmol in adults) given as a bolus over 5-15 minutes for pain refractory to opioids
  • Hypertension should be treated with short-acting titratable medications (eg., nitroglycerin, phentolamine, esmolol, nicardipine, nitroprusside) due to potential for hypotension in the later stages of toxicity

Disposition

See Also

External Links

References

  1. ↑ Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 4 of 5. ACEP Now. https://www.acepnow.com/article/emergen-sea-medicine-overview-of-marine-envenomations/4/.
  2. ↑ Kong EL, Nappe TM. Irukandji Syndrome. [Updated 2021 May 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562264/
  3. ↑ Kong EL, Nappe TM. Irukandji Syndrome. [Updated 2021 May 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562264/
  4. ↑ Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 4 of 5. ACEP Now. https://www.acepnow.com/article/emergen-sea-medicine-overview-of-marine-envenomations/4/.
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