Studies

Australia
Sutherland 1992: 26 cases; not identified; see below, "Specific treatment".

French Polynesia
Bagnis 1968: 51 cases; attributed to Synanceia verrucosa. The accidents occurred over a period of 5 years. Hospitalisation necessary in 25/51 patients.
Lagraulet et al. 1972: 11 cases; not identified.

Papua New Guinea
Phelps 1963 (cited in Sutherland 1983): 21 cases.

Singapore

Lee et al. 2004: 8 cases; direct identification 4/8, picture identification 3/8, strong history 1/8.

Case reports

Australia
Sutherland 1983: 9 cases, some of which were cases from Bagnis 1968 (6/9); not identified.
Wiener 1958: 1 case; not identified.

Kenya
Moser and Stürchler 1979: 1 case; not identified.

Maldives
Scharnagl et al. 1987: 1 case; not identified.

Mozambique
Smith 1957: 1 case; victim died within an hour of the accident; Stonefish not identified.

Seychelles
Smith 1957: 1 case; victim died within a short time after the accident; Stonefish not identified.

Signs & symptoms

Stonefish venom contains venom components that can induce severe pain and cause local tissue necroses.

Local injury: puncture wounds. If the spine breaks off, parts of it may remain in the wound, as may other foreign matter, and, in addition to causing local toxic effects and bacterial infections, can lead to poor wound healing and extensive necroses.

Local effects

Local pain that can radiate as far as the trunk, local paraesthesias, local swelling that can involve the entire extremity, necroses (Bagnis 1968, Lagraulet et al. 1972, Lee et al. 2004, Moser and Stürchler 1979, Scharnagl et al. 1987, Sutherland 1983).
Wound infections: common.

Systemic signs and symptoms

Systemic effects of the venom are not well documented. The following symptoms have been reported in association with Stonefish stings: nausea, vomiting, diarrhoea, increased perspiration, confusion, loss of consciousness, cardiac arrhythmias, paralyses (Bagnis 1968, Lagraulet et al. 1972, Wiener 1958). 0/8 (Lee et al. 2004).

Morbidity

Wound infections, necroses.

Case fatality rate

2/2 (Smith 1957); the exact circumstances of course of envenoming in the fatalities described in the literature are not known. No fatalities have been reported in more recent times.

First aid and treatment

Immersion of the affected extremity in water as hot as can be tolerated, especially if it is not possible to get immediate medical assistance (water temperature approx. 45°C; temperature should be checked by a companion or with a healthy extremity in order to avoid burns; duration of treatment if necessary >30 min). Stonefish venom, which, in addition to the physical injury, is responsible for pain and tissue destruction, is believed to be heat-labile. It is assumed that the hot water treatment may have an inactivating effect on the venom. However, this method is controversial, due to the risk of additional tissue damage. Its efficacy has not yet been documented in a controlled study.

Symptomatic treatment

Pain: injection of a local anaesthetic without the addition of a vasoconstrictor (lignocaine 1%) directly into and around the wound. Nerve block anaesthesia with lignocaine 1% or preferably bupivacaine because it has a longer duration of action (analogous to Fenner et al. 1989b, Dormon 1985).

Injury: wound cleaning and disinfection. Wound exploration in order to remove foreign matter (parts of the spine and spine sheath). Regular wound inspection and dressing changes until the wound has healed fully.

Tetanus prophylaxis. Antibiotic treatment if there is a clinically evident wound infection.

If envenoming takes a severe course, hospitalisation and intensive care monitoring.

Specific treatment

Antivenom:

Stonefish Antivenom (CSL, Parkville, Australia). See MAVIN-Antivenom index

Sutherland 1992: 26 cases in which antivenom was administered and which are well documented. In all cases debilitating pain commenced immediately after the sting. The hot water method (see above) only provided limited pain relief.

Dose: 1 vial i.m. 18/26, 2 vials i.m. 8/26.

Efficacy: efficient and permanent relief of pain in all patients.

Adverse reactions: 15/26 were observed for a sufficient period of time. 2 developed serum sickness.

Antivenom indications

All patients with Stonefish envenoming.

Exceptions: only mild complaints; straightforward accident that occurred several hours previously, and if there has already been improvement of the symptoms (Sutherland 1983).

Recommended dose (Sutherland 1983)
1 or 2 punctures: 1 vial (2,000 units),
3 or 4 punctures: 2 vials (4,000 units),
5 or 6 punctures: 3 vials (6,000 units).