Clinic: Physalia sp.

Examine for venom effects

Autopharmacological and allergic effects

• Nausea, vomiting, abdominal pain, diarrhoea,
• urtitcaria, angio-oedema,
• bronchospasm,
• arterial hypotension, shock (cause: systemic allergic reactions).

Local Effects

• Acute (within minutes) painful linear, urticarial or papular skin lesions (see 'morphological characteristics').

• Later: necrosis, ulceration.

(Haematological Effects)

• Pale sclera, etc. (haemolytic anaemia)

(Muscular effect)

• Generalised muscle cramps and spasms of the abdominal musculature,

• Rhabdomyolysis (see "Other effects rarely observed" below)

Neurological effects / Cardiac effects

• Bradycardia, tachycardia, arrhythmias
• Arterial hypotension
• Myocardial failure, cardiocenic shock
• Respiratory failure

Species-specific envenoming pattern

The assessment of the envenoming pattern is based on the data from publication in which the identification of the snakes is clearly specified and in accordance with accepted criteria. 

Other effects rarely observed

Haematological effects
Haemolysis concomitant with acute renal failure (Guess et al. 1982, Spielman et al. 1982).

Muscular effects
Generalised muscle cramps and spasms of the abdominal musculature (Marr 1967).
Rhabdomyolysis (2 case reports in which Physalia sp. was "suspected": Buscetta et al. 2023; Maldonado et al. 2017) 

Physalia sp.

Differences between species

^APhysalia utriculus causes local and, very rarely, minor systemic effects.

^BPhysalia physalis causes local and systemic effects which can be severe, including death in rare instances. 

¹Autopharmacological and allergic effects

Anaphylactic reactions, in particular anaphylactic shock, may be difficult to distinguish in differential diagnostic terms from systemic toxic effects (Tibballs et al. (2011). Tibballs (2006) comments: “A case of rapid collapse (unconsciousness, pulselessness and unreactive dilated pupils) after a sting by P. utriculus has been considered circumstantially an allergic phenomenon (Golan 1968)”. “In another case, features of immediate hypersensitivity (urticaria, oedma and bronchospasm) responded quickly to treatment with epinephrine, volume expansion and steroids but one week later a pruritic vesicular eruption occurred on skin initially stung” (Edwards and Edwards 2000). “In a series of 66 patients who had exhibited cutaneous, extracutaneous or anaphylactoid reactions to stings by either Physalia physalis or Chrysaora quinquecirrha (Sea nettle), the majority had developed IgG antibodies, some had developed IgE antibodies to the toxins of the two jellyfish and some patients developed cross-reacting antibodies to toxins of both jellyfish (Russo et al. 1983).
As in other cnidarian skin contact, delayed immunological reactions are observed (Auerbach et al. 1987; Guevara et al. 2017).

²Local effects

Radial, ulnar and brachial pulse of the stung extremity not palpable 3 h after the accident (Adiga 1984, Williamson et al. 1988); impaired circulation in the stung upper extremities with consequent muscle necroses (Williamson et al. 1988).

³Neurological effects

Signs of respiratory insufficiency/respiratory failure, respiratory arrest within minutes of the sting (Kizer and Piel 1982; Stein et al. 1989).
Stein et al. (1989): “In our patient, death may have resuited from primary respiratory failure because a normal ECG was seen when the patient was apneic. Indeed, no evidence of myocardial cell death was seen five days later at post- mortem examination.”
Respiratory failure due to hyperventilation etc must be distinguished: “… there was actual hyperventilation with significant hypocarbia combined with intra-pulmonary shunting, despite the clear subjective sensations of being unable to breathe adequately. Actual respiratory depression did not seem to feature in our case.” (Burnett et al. 1994)

⁴Cardiac effects

Burnett and Gable (1989) argue in the patient they reported: “The patient probably died a cardiac death since he was massively envenomated and rapidly became unresponsive after uttering several calls for help. Additional support for this hypothesis comes from the fact that his past history and autopsy failed to uncover evidence of cardiovascular disease.”

Other signs & symptoms

Nausea, vomiting.

Morbidity

Delayed immunological reactions: Recurrent skin symptoms (Burnett et al. 1987, Mansson et al. 1985, Ohtaki et al. 1986 ; Tibballs et al. 2011). Erythema nodosum with joint pain 4 weeks after the sting (Auerbach and Hays 1987).
Scarring and keloid formation after healing of the skin lesions. Sequelae of acute vascular insufficiency in the area supplied by the stung extremity (necroses, paralysis, impairment/loss of function) (Williamson et al. 1988).
Serious envenomations have been reported from both sides of the Atlantic. In 2011, about 10% of Physalia physalis victims in Aquitaine (France) presented life-threatening systemic conditions (especially respiratory distress), which required hospitalization (Labadie et al. 2012).

Case fatality rate

Fatal envenomations from Physalia physalis have been reported from the US (Southern Atlantic coast) (Stein et al. 1989, Burnett and Gable 1989).
Cause(s) of death debated; respiratory vs cardiac (see footnotes 3 and 4 above). 

Species-specific publications: see ‘References’ at the end of the file. 

Clinical management

See also Clinical Management: cnidarians

for advice on diagnosis (clinical, laboratory) and treatment (supportive).

First Aid Measures for Jellyfish stings

The Cochrane review of 2023 came to the following conclusion (McGee et al. 2023):

“For people with symptoms and signs of jellyfish stings, and their first responders or treating clinicians, treatment will depend on the species of jellyfish, as the stings from different species produce symptoms of varying severity. However, we cannot be certain which is the best treatment for any species of jellyfish. Although our evidence was very uncertain, the data from the included studies evaluating heat application after non-box jellyfish stings in Australia and Hawaii are consistent with the ARC 2010 guideline, which suggests starting treatment with heat after stings in non-tropical Australia. We have found no evidence to refute heat application for non-box jellyfish stings in non-tropical Australia. For box jellyfish envenomation, the evidence is more limited, but both the ARC 2010 and ILSF 2000 guidelines recommend the application of vinegar to inactivate the nematocyst. Our review did not find sufficient evidence to support these recommendations, but the recommendations are consistent with evidence from in vitro studies (Yanagihara 2017)”. 

The review of Cunha et al. (2022) came by and large to the same conclusions: The first aid and treatment recommendation are based on individual cases and cases series and expert opinion.
Pek et al. 2025 conclude in their systematic review “There were very few studies and a significant risk of bias and heterogeneity, leading to very low-quality evidence on first aid treatment for jellyfish stings.”
Yanagihara et al. (2025) publishedadditional experimental observations.

The current uncertainty of recommendations is also reflected in the accompanying document ‘Research on Jellyfish Stings’ of the 2025 version of the ANZCOR Guidelines ‘Guideline 9.4.5 - First Aid Management of Marine Envenomation’

The ANZCOR Guidelines emphasize:
“The most important part of first aid for a potentially fatal jellyfish sting is to watch for cardiac arrest, treat with CPR (Refer to ANZCOR Guideline 8) if this occurs, and expedite transfer to definitive care including antivenom.”

Due to the high regional diversity of jellyfish, the unpredictable dynamics caused by global warming and the uncertainty of the evidence base for the various recommendations, we refer to regional/national guidelines. We recommend to follow-up developments of the evidence carefully.

Local treatment

Pain control
Wound management
Tetanus prophylaxis
Standard wound care (WHO 2010) 
Eye injury
Most stings affecting the eyes described to date were painful injuries with conjunctival congestion, chemosis, corneal oedema and mild iridocyclitis that resolved on their own or with local treatment within 48 h. However, there have also been reports of iritis, chronic unilateral glaucoma, mydriasis, accommodation disturbances, peripheral anterior synechia, iris depigmentation and blurred vision (Glasser et al. 1992, 1993, Mitchell 1962, Rapoza et al. 1986, Wong and Matoba 1985).

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

• Comprehensive ABCDE approach

• ICRC Basic Emergency Care: approach to the acutely ill and injured (SAMPLE  and ABCDE approach: first module)

Obey physalia sp. - specific features

see 'Species-specific envenoming pattern above'. 

Key issues

Supportive treatment is lifesaving

Cardiocascular failure 

• Cardiovascular management

ABCDE-approch is lifesaving as supportive. 

IMPORTANT
Cnidarian venoms are (thermo-)labile. It is assumed that they lose their activity within 15–20 min after absorption into the tissue or the blood circulation. The patient's condition may deteriorate again after a temporary improvement of the circulatory condition due to renewed mobilisation of venom from the periphery (Williamson et al. 1984b).

Respiratory failure

• Airway management

• Breathing: Oxygen ⇨ assisted ventilation ⇨ mechanical ventilation

ABCDE-approch is lifesaving as supportive treatment.

Very rare

• Haemolysis; Laboratory results: Anaemia with haemolytic pattern.
• rhabdomyolysis (?),
• acute regional vascular insufficiency distal to the sting (?)

Specific treatment (antivenoms)

No antivenom available. 

References

Reviews

• D'Ambra I, Lauritano C. A Review of Toxins from Cnidaria. Mar Drugs. 2020 Oct 6;18(10):507. PMID: 33036158; PMCID: PMC7600780. https://doi.org/10.3390/md18100507 
• Cegolon L, Heymann WC, Lange JH, Mastrangelo G. Jellyfish stings and their management: a review. Mar Drugs. 2013 Feb 22;11(2):523-50. PMID: 23434796; PMCID: PMC3640396. https://doi.org/10.3390/md11020523
• Cunha SA, Dinis-Oliveira RJ. Raising Awareness on the Clinical and Forensic Aspects of Jellyfish Stings: A Worldwide Increasing Threat. Int J Environ Res Public Health. 2022 Jul 10;19(14):8430. PMID: 35886286; PMCID: PMC9324653. https://doi.org/10.3390/ijerph19148430
• McGee RG, Webster AC, Lewis SR, Welsford M. Interventions for the symptoms and signs resulting from jellyfish stings. Cochrane Database Syst Rev. 2023 Jun 5;6(6):CD009688. PMID: 37272501; PMCID: PMC10240560. https://doi.org/10.1002/14651858.CD009688.pub3
• Pek JH, Lim SH, Ong GY, Djarv T, Douma M, Welsford M, Charlton NP. First Aid Treatment of Jellyfish Stings: A Systematic Review. Cureus. 2025 May 17;17(5):e84289. PMID: 40525026; PMCID: PMC12169498. https://doi.org/10.7759/cureus.84289

• Premmaneesakul H, Sithisarankul P. Toxic jellyfish in Thailand. Int Marit Health. 2019;70(1):22-26. PMID: 30931514. https://doi.org/10.5603/imh.2019.0004
• Tibballs J. Australian venomous jellyfish, envenomation syndromes, toxins and therapy. Toxicon. 2006 Dec 1;48(7):830-59. Epub 2006 Jul 15. PMID: 16928389. https://doi.org/10.1016/j.toxicon.2006.07.020
• Tibballs J, Yanagihara AA, Turner HC, Winkel K. Immunological and toxinological responses to jellyfish stings. Inflamm Allergy Drug Targets. 2011 Oct;10(5):438-46. PMID: 21824077; PMCID: PMC3773479. https://doi.org/10.2174/187152811797200650
• Ward NT, Darracq MA, Tomaszewski C, Clark RF. Evidence-based treatment of jellyfish stings in North America and Hawaii. Ann Emerg Med. 2012 Oct;60(4):399-414. Epub 2012 Jun 6. PMID: 22677532. https://doi.org/10.1016/j.annemergmed.2012.04.010

Original publications

• Adiga KM. Brachial artery spasm as a result of a sting. Med J Aust. 1984 Feb 4;140(3):181-2. PMID: 6141522. https://doi.org/10.5694/j.1326-5377.1984.tb103977.x
• Auerbach PS, Hays JT. Erythema nodosum following a jellyfish sting. J Emerg Med. 1987 Nov-Dec;5(6):487-91. PMID: 2892880. https://doi.org/10.1016/0736-4679(87)90211-3
• Buscetta G, Rizzo C, La Barbera L, Camarda F, Federico A, Garbo BM, Florena AM, Guggino G. Severe case of rhabdomyolysis following jellyfish envenomation in the Mediterranean Sea. RMD Open. 2023 Nov;9(4):e003569. PMID: 37945287; PMCID: PMC10649889. https://doi.org/10.1136/rmdopen-2023-003569
• Burnett JW, Gable WD. A fatal jellyfish envenomation by the Portuguese man-o'war. Toxicon. 1989;27(7):823-4. PMID: 2571201. https://doi.org/10.1016/0041-0101(89)90050-0
• Burnett JW, Hepper KP, Aurelian L, Calton GJ, Gardepe SF. Recurrent eruptions following unusual solitary coelenterate envenomations. J Am Acad Dermatol. 1987 Jul;17(1):86-92. PMID: 2886519. https://doi.org/10.1016/s0190-9622(87)70177-7
• Burnett JW, Fenner PJ, Kokelj F, Williamson JA. Serious Physalia (Portuguese man o’war) stings: implications for scuba divers. Journal of Wilderness Medicine. 1994;5(1):71-76. https://doi.org/10.1580/0953-9859-5.1.71
• Edwards EK Jr, Edwards EK Sr. Immediate, anaphylactic and delayed reactions to jellyfish. Contact Dermatitis. 2000 Oct;43(4):244-5. PMID: 11011943.
• Gollan, J. A. (1968) The dangerous Portuguese man-of-war. Med. J. Aust. 1: 973
• Guess HA, Saviteer PL, Morris CR. Hemolysis and acute renal failure following a Portuguese man-of-war sting. Pediatrics. 1982 Dec;70(6):979-81.PMID: 6128712.
• Guevara BE, Dayrit JF, Haddad V Jr. Delayed allergic dermatitis presenting as a keloid-like reaction caused by sting from an Indo-Pacific Portuguese man-o'-war (Physalia utriculus). Clin Exp Dermatol. 2017 Mar;42(2):182-184. Epub 2017 Jan 2. PMID: 28044352. https://doi.org/10.1111/ced.13003
• Kizer KW, Piel M. Arterial blood gas changes with bluebottle envenomation--a case report. Hawaii Med J. 1982 Jul;41(7):193-4.PMID: 6127332.
• Labadie M, Aldabe B, Ong N, Joncquiert-Latarjet A, Groult V, Poulard A, Coudreuse M, Cordier L, Rolland P, Chanseau P, de Haro L. Portuguese man-of-war (Physalia physalis) envenomation on the Aquitaine Coast of France: an emerging health risk. Clin Toxicol (Phila). 2012 Aug;50(7):567-70. Epub 2012 Jul 11. PMID: 22780958. https://doi.org/10.3109/15563650.2012.707657
• Maldonado E, Maillaud C, Barguil Y, Labadie M. Rhabdomyolysis during envenomation by Physalia sp envenomation in New Caldonia. Med Sante Trop. 2017 Feb 1;27(1):105-108. English. PMID: 28406403. https://doi.org/10.1684/mst.2017.0655
• Månsson T, Randle HW, Mandojana RM, Calton GJ, Burnett JW. Recurrent cutaneous jellyfish eruptions without envenomation. Acta Derm Venereol. 1985;65(1):72-5.PMID: 2578711.
• Marr JJ. Portuguese Man of War envenomization. A personal experience. JAMA. 1967 Jan 30;199(5):337-8.PMID: 4380939.
• Ohtaki N, Satoh A, Azuma H, Nakajima T. Delayed flare-up reactions caused by jellyfish. Dermatologica. 1986;172(2):98-103. PMID: 2868932. https://doi.org/10.1159/000249306
• Russo AJ, Calton GJ, Burnett JW. The relationship of the possible allergic response to jellyfish envenomation and serum antibody titers. Toxicon. 1983;21(4):475-80. PMID: 6137884. https://doi.org/10.1016/0041-0101(83)90125-3
• Spielman FJ, Bowe EA, Watson CB, Klein EF Jr. Acute renal failure as a result of Physalia physalis sting. South Med J. 1982 Nov;75(11):1425-6. PMID: 6128793. https://doi.org/10.1097/00007611-198211000-00033
• Stein MR, Marraccini JV, Rothschild NE, Burnett JW. Fatal Portuguese man-o'-war (Physalia physalis) envenomation. Ann Emerg Med. 1989 Mar;18(3):312-5. PMID: 2564268. https://doi.org/10.1016/s0196-0644(89)80421-4
• Williamson JA, Burnett JW, Fenner PJ, Hach-Wunderle V, Hoe LY, Adiga KM. Acute regional vascular insufficiency after jellyfish envenomation. Med J Aust. 1988 Dec 5-19;149(11-12):698-701. PMID: 2904646. https://doi.org/10.5694/j.1326-5377.1988.tb120829.x

Images of tentacle prints

• Cunha SA, Dinis-Oliveira RJ. Raising Awareness on the Clinical and Forensic Aspects of Jellyfish Stings: A Worldwide Increasing Threat. Int J Environ Res Public Health. 2022 Jul 10;19(14):8430. PMID: 35886286; PMCID: PMC9324653. https://doi.org/10.3390/ijerph19148430

Internet links providing general clinical guidance

• WHO (2010) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139
• WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured (2018)  https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured
• WHO ABCDE Approach  https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2

Internet links providing specific information

ANZCOR Guidelines ‘Guideline 9.4.5 - First Aid Management of Marine Envenomation’

Species-specific evidence

Physalia sp.

Case reports

Australia

P. utriculus

• Gollan (1968)
  

  1 sting. Identification: attributed to Physalia sp.; criteria not indicated.

Europe

Mediterranean Sea (Italy)

• Buscetta et al. (2023) 
  1 sting; P. physalis suspected

France (Atlantic)

• Maldonado et al. (2017) 
  1 sting; ""unanimal, constitue d’un flotteur de couleur bleue visible" la surface de l’eau, avec de longs filaments, dont l’aspect e´taittre`s evocateur d’une physalie."
• Labadie et al. (2012)
  Summer of 2008: 40 victims were recorded on the same day on one beach in the Southern French Atlantic coast. In 2009, no cases reported.2010: 154 cases in 2010. 2011: 885cases.
  Severe manifestations with 15-20% of patients suffering of general symptoms; in some considered as potentially life-threatening. In 2011: 8% of patients muscle pain, cramps with fasciculations, confusion and drowsiness, fainting, respiratory distress. No deaths over the 4-year study period.

Indian Ocean

• Adiga (1984)
  1 sting. Identification: attributed to Physalia sp.; recognition from photos; immunological (ELISA): high P. physalis antibody titre (Williamson et al. 1988). 
• Williamson et al. (1988)
  1 sting. Identification: attributed to Physalia sp.; immunological (ELISA): P. physalis antibody titre; differential diagnosis: Cassiopea xamachana.

Indonesia

• Maharani and Widiastuti et al. (2021)

Malaysia

• Paraja et al. (2015)

Panama Canal Zone

• Marr (1967)
  1 sting. Identification: attributed to Physalia sp.; criteria not indicated.

USA (Florida)

• Stein et al. (1989)
  1 sting. Identification: P. physalis; jellyfish was brought onto land. Nematocysts. ELISA positive.

• Burnett et al (1994) 
  1 sting. Identification: P. physalis;observed and ELISA.
• Matusow (1980)
  1 sting. Identification: attributed to Physalia sp.; observed by patient.

USA (Hawaii)

• Kizer and Piel (1982)
  1 sting. Identification: attributed to Physalia sp.; criteria not indicated.

USA (North Carolina)

• Burnatt and Gable (1989) 
  1 sting. Identification: P. physalis; tentacles.
• Guess et al. (1982)
  1 sting. Identification: attributed to Physalia sp.; based on the description of the observed tentacles; case identical to that described by Spielman et al. 1982.
• Spielman et al. (1982)
  1 sting. Identification: attributed to Physalia sp.; criteria not indicated; case identical to that described by Guess et al. 1982.

References

• Adiga KM. Brachial artery spasm as a result of a sting. Med J Aust. 1984 Feb 4;140(3):181-2. PMID: 6141522. https://doi.org/10.5694/j.1326-5377.1984.tb103977.x
• Burnett JW, Gable WD. A fatal jellyfish envenomation by the Portuguese man-o'war. Toxicon. 1989;27(7):823-4. PMID: 2571201. https://doi.org/10.1016/0041-0101(89)90050-0
• Burnett JW, Fenner PJ, Kokelj F, Williamson JA. Serious Physalia (Portuguese man o’war) stings: implications for scuba divers. Journal of Wilderness Medicine. 1994;5(1):71-76.doi:10.1580/0953-9859-5.1.71
• Buscetta G, Rizzo C, La Barbera L, Camarda F, Federico A, Garbo BM, Florena AM, Guggino G. Severe case of rhabdomyolysis following jellyfish envenomation in the Mediterranean Sea. RMD Open. 2023 Nov;9(4):e003569. PMID: 37945287; PMCID: PMC10649889. https://doi.org/10.1136/rmdopen-2023-003569
• Gollan, J. A. (1968) The dangerous Portuguese man-of-war. Med. J. Aust. 1: 973
• Guess HA, Saviteer PL, Morris CR. Hemolysis and acute renal failure following a Portuguese man-of-war sting. Pediatrics. 1982 Dec;70(6):979-81.PMID: 6128712.
• Kizer KW, Piel M. Arterial blood gas changes with bluebottle envenomation--a case report. Hawaii Med J. 1982 Jul;41(7):193-4.PMID: 6127332.
• Labadie M, Aldabe B, Ong N, Joncquiert-Latarjet A, Groult V, Poulard A, Coudreuse M, Cordier L, Rolland P, Chanseau P, de Haro L. Portuguese man-of-war (Physalia physalis) envenomation on the Aquitaine Coast of France: an emerging health risk. Clin Toxicol (Phila). 2012 Aug;50(7):567-70. Epub 2012 Jul 11. PMID: 22780958. https://doi.org/10.3109/15563650.2012.707657
• Maharani T, Widiastuti W. First envenomation report of the Cnidarian Physalia physalis in Indonesia. Int Marit Health. 2021;72(2):110-114. PMID: 34212350. https://doi.org/10.5603/imh.2021.0019
• Maldonado E, Maillaud C, Barguil Y, Labadie M. Rhabdomyolysis during envenomation by Physalia sp envenomation in New Caldonia. Med Sante Trop. 2017 Feb 1;27(1):105-108. English. PMID: 28406403. https://doi.org/10.1684/mst.2017.0655
• Marr JJ. Portuguese Man of War envenomization. A personal experience. JAMA. 1967 Jan 30;199(5):337-8. PMID: 4380939.
• Matusow (1980) Oral inflammatory response to a sting from a Portuguese man-of-war. J. Amer. dent. Ass. 100: 73-75
• Paraja J, Sulaiman KN, Mohamad Hanifah MH. Portuguese Man-o'-war (Physalia physalis) Envenomation in a Child: First Confirmed Case in Malaysia. Wilderness Environ Med. 2025 Nov 18:10806032251393141. Epub ahead of print. PMID: 41252475. https://doi.org/10.1177/10806032251393141
• Spielman FJ, Bowe EA, Watson CB, Klein EF Jr. Acute renal failure as a result of Physalia physalis sting. South Med J. 1982 Nov;75(11):1425-6. PMID: 6128793. https://doi.org/10.1097/00007611-198211000-00033
• Stein MR, Marraccini JV, Rothschild NE, Burnett JW. Fatal Portuguese man-o'-war (Physalia physalis) envenomation. Ann Emerg Med. 1989 Mar;18(3):312-5. PMID: 2564268. https://doi.org/10.1016/s0196-0644(89)80421-4
• Williamson JA, Burnett JW, Fenner PJ, Hach-Wunderle V, Hoe LY, Adiga KM.Acute regional vascular insufficiency after jellyfish envenomation. Med J Aust. 1988 Dec 5-19;149(11-12):698-701. PMID: 2904646. https://doi.org/10.5694/j.1326-5377.1988.tb120829.x