Case reports

Australia
Gollan 1968: 1 sting. Identification: attributed to Physalia sp.; criteria not indicated.

India (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.

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.
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)
Burnett 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.

Signs & symptoms

Autopharmacological effects

Anaphylactic reactions, in particular anaphylactic shock, may be difficult to distinguish in differential diagnostic terms from systemic toxic effects.

Local effects

Linear urticarial or papular skin marks; diameter 1–2 mm; can be very long (Fig. 4.11); painful (Guess et al. 1982, Spielman et al. 1982, Stein et al. 1989).

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).

Haemolytic effects

Scleral icterus (Guess et al. 1982).

Neurological effects

Signs of respiratory insufficiency/respiratory failure, respiratory arrest within minutes of the sting (Kizer and Piel 1982, Stein et al. 1989).

Aetiology: central neurological effect of the venom?

Muscular effects

Generalised muscle cramps and spasms of the abdominal musculature (Marr 1967).

Cardiac effects

Cardiac dysrhythmias, cardiac insufficiency, cardiac failure, irreversible coma within 5 min after the sting (Aetiology: impaired calcium transport?). It is argued that this was a case of primary respiratory failure, because a normal ECG was recorded at the time of the respiratory arrest, and 5 days later at autopsy no myocardial cell damage was found (Burnett and Gable 1989).

Renal effects

Acute renal failure with concomitant haemolysis (Guess et al. 1982, Spielman et al. 1982).

Other signs & symptoms

Nausea, vomiting.

Morbidity

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).

Recurrent skin symptoms (Burnett et al. 1987, Mansson et al. 1985, Ohtaki et al. 1986). Erythema nodosum with joint pain 4 weeks after the sting (Auerbach and Hays 1987).

Case fatality rate

1/1 (Stein et al. 1989),
1/1 (Burnett and Gable 1989).

Laboratory and physical investigations

1. Haemoglobin, haematocrit, haptoglobin, LDH, bilirubin (total) (haemolysis)
Haemolysis and acute renal failure in a 4-year-old girl (Spielman et al. 1982).

2. ELISA

Within a few days after the sting, specific IgG antibodies are formed that persist for many months. The species of jelly fish that caused the sting can be identified retrospectively using antibody detection with an ELISA test. However, there are problems with specificity. Thus, for example, Physalia and Chrysaora antibodies cross-react, and this leads to false-positive results in both directions (Burnett et al. 1983, 1988a).

First aid

Loten et al. 2006: Open-label, randomized comparison trial of hot water (45°C) versus ice packs for pain relief. Primary analysis by intention to treat, secondary analysis of nematocysts-confirmed stings. Setting: Surf lifesaving first aid facilities at two beaches in eastern Australia. 96 cases presenting after swimming with an apparent sting by a bluebottle. Cases who had a sting to the eye or required ambulance attendance were excluded (n=?), in addition to very minor stings, age < 8 years, cases who did not want to consent or to wait 20 minuntes, investigators busy (cases excluded in total: 273). Primary outcome measure: clinically significant reduction in pain measured by the visual analogue scale. Outcome: Hot water was more effective at 20 minutes in both analyses, by intention to treat and in nematocyst-confirmed stings (95% versus 29%; p=0.002). A time-dependent effect  of hot water immersion was demonstrated and, in addition, pain did not recur. This lead the authors to conclude that immersion in water at 45°C for 20 minutes is an effective treatment for bluebotte stings and that the mechanism of reducing pain may be inactivation of venom.

Cold packs or ice in dry plastic bag is recommended if heat reatment fails. Fresh water should not come in direct contact with the sting, it may cause discharge of undischarged nematocysts. Care needs to be taken that no ice burns are caused (Exton et al. 1989, Fenner et al. 1993, Australian Resuscitation Council website: Guideline 9.4.5 Envenomation - Jellyfish Stings).

Experience in Australia shows that vinegar, which is very effective in cases of Chironex envenoming, may actually stimulate nematocyst discharge in Physalia (Exton 1988, Fenner et al. 1993), while a good inhibitory effect of vinegar has been reported in the USA (Burnett et al. 1983b).

Treatment (symptomatic)

1. Pain
Hot water (45°C) immersion for the teatment of Physalia sp. stings in Australia has been shown to be effective for pain relief  (Loten et al 2006; see above). Cooling with ice is recommended (Exton et al. 1989), in Australia in particuar if immersion in hot water fails (For Australia see Australian Resuscitation Council website: Guideline 9.4.5 Envenomation - Jellyfish Stings).

Pethidine 1–2 mg/kg BW, repeat as needed.

2. Cardiac dysfunction (cardiac dysrhythmias, hypotonia, cardiac failure)

Verapamil has been recommended on the basis of theoretical considerations and results of animal experiments (Physalia venom impairs calcium transport, which may be counteracted with the calcium antagonist verapamil) (Burnett et al. 1985, Stein et al. 1989). The debate on the use of verapamil in other jellyfish envenomings (Chironex fleckeri) has, however, tilted against its use (Bailey et al 2003, Isbister et al 2004).

Treatment (specific)

Antivenom
No antivenom available.