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


===Differential Diagnosis===
==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]])


==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 (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>
*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/.