4. Musculoskeletal or rheumatologic: abdominal rigidity, diffuse myalgia and muscle cramps, muscle spasm,
fat atrophy, arthralgias, reactive arthritis (sero-negative symmetric synovitis with pitting edema), and
thoracolumbar pain
5. Gastrointestinal: nausea, vomiting, diarrhea, dysphagia, hypersalivation, and thirst
6. Ocular: conjunctivitis, chemosis, corneal ulcers, corneal epithelial edema, keratitis, iridocyclitis, elevated
intraocular pressure, synechiae, iris depigmentation, chronic unilateral glaucoma, and lacrimation
7. Other: acute renal failure, lymphadenopathy, chills, fever, and nightmares
The extreme example of envenomation occurs with Chironex fleckeri, the dreaded box-jellyfish. Physalia and
anemone stings, although extremely painful, are rarely fatal. Death after Physalia stings has been attributed to
primary respiratory failure or cardiac arrhythmia, which may have reflected an element of anaphylaxis.
Confirmed deaths following coelenterate envenomation have been attributed to Chironex fleckeri,
Chiropsalmus quadrigatus, and Chiropsalmus quadrumanus. Stomolophus nomurai (the sand jellyfish) has
caused at least 8 deaths in the South China Sea.
While there have been other deaths, the animals have not been
definitively identified.
Clinical reports and studies on the serologic response to jellyfish envenomation suggest that allergic
reactions may play a significant pathophysiologic role in humans. When crude or partially purified
nematocyst venom and an antigen are used in an enzyme-linked immunosorbent assay (ELISA), both IgG and
IgE can be detected. Elevated specific anti-jellyfish IgG and IgE may persist for several years, recurrence of
the clinical cutaneous reaction to jellyfish stings may occur within a few weeks without additional contact
with the tentacles, and serologic cross-reactivity between the sea nettle (Chrysaora quinquecirrha) and
Physalia physalis occurs. In a case of significant envenomation by the moon jellyfish Aurelia aurita, the
patient developed significant cross-reacting antibodies to Chrysaora quinquecirrha antigens.
Persons with extracutaneous or anaphylactoid responses to a coelenterate sting have been noted to
have higher specific IgG and IgE antibody levels. However, elevated persistent specific anti-jellyfish serum
IgG concentrations are not protective against the cutaneous pain resulting from a natural sting. A false-
positive ELISA serologic test to venom may occur, as demonstrated by negative skin testing.
A person recently stung by Physalia physalis may have recurrent cutaneous eruptions for 2 to 3 weeks
after the initial episode, without repeated exposure to the animal. This may take the form of lichenification,
hyperhidrosis, angioedema, vesicles, large bullae, nodules that resemble erythema nodosum, granuloma
annulare, or a more classic linear urticarial eruption. Recurrent eruptions have also followed a solitary
envenomation by the cnidarian Stomolophus meleagris. In a histological study of delayed reaction to a
Mediterranean Sea coelenterate, skin biopsy demonstrated grouping of human leukocyte antigen-DR-positive
cells with Langerhans cells and helper/inducer T lymphocytes, which indicates the possibility of a type IV
immunoreaction.
Venom-specific IgG antibodies appear to persist for longer periods than IgM antibodies. The binding
of brown recluse spider venom and purified cholera toxin to anti-Chrysaora and anti-Physalia monoclonal
antibodies indicates that there may be a common or cross-reacting antigenic site or sites between these toxic
substances and certain coelenterate venoms.
Acute regional vascular insufficiency of the upper extremity has been reported after jellyfish
envenomation. It can be manifested by acral ischemia, signs and symptoms of compartment syndrome, and
massive edema.
Treatment
Therapy is directed at stabilizing major systemic decompensation, opposing the venom's multiple
effects, and alleviating pain.
Systemic Envenomation. Generally, only severe Physalia or Cubomedusae stings result in rapid
decompensation. In both cases supportive care is based on the signs and symptoms. Hypotension should be
managed with the prompt intravenous administration of crystalloid, such as lactated Ringer's solution. This
must be done in concert with detoxification of any nematocysts (particularly those of Chironex or
Chiropsalmus) that are still attached to the victim, to limit the perpetuation of envenomation. Hypotension is
usually limited to very young or elderly victims who suffer severe and multiple stings, the effects of which are
worsened by fluid depletion that accompanies protracted vomiting. Hypertension is an occasional side effect
