rummage about in a hand wound in the emergency department, virtually looking for a needle in a haystack. If
the presence of a spine is in question, soft tissue density radiographic techniques for a radiopaque foreign
body may be diagnostic. Magnetic resonance imaging may be quite useful to locate spine fragments. Although
the calcium carbonate is relatively inert, it is accompanied by slime, bacteria, and organic epidermal debris.
Therefore secondary infections are not uncommon and deep puncture wounds are an indication for
prophylactic antibiotics.
Some sea urchin spines are phagocytosed in the soft tissues and ultimately dissolve. The granulomas
caused by retained sea urchin spine fragments have sarcoidal histologic features and generally appear as flesh-
or dye-colored surface or subcuticular nodules 2 to 12 months after the initial injury. In thin-skinned areas
these nodules are erythematous and rubbery, painless, and infrequently umbilicated. In thicker-skinned areas
(palms, soles, and knees) that are frequently abraded, they have a keratinized appearance. Although necrosis
and microabscess formation may be evident microscopically, suppuration is unusual. Rarely, the destructive
nature of the inflammatory process may be severe enough to necessitate amputation of a digit. If a spine
cannot be removed and becomes a nidus for cyst or granuloma formation, the lesion may be removed
surgically. Intralesional injection with a corticosteroid (triamcinolone hexacetonide 5 mg/ml) is less
efficacious but may be successful. Systemic antiinflammatory drugs may be minimally helpful but are not
substitutes for removal of the spine. A diffuse delayed reaction, consisting of cyanotic induration, fusiform
swelling in the digits, and focal phalangeal bony erosion, may be treated with a systemic corticosteroid and
antibiotics.
Sea Cucumbers
Life and Habits. Sea cucumbers are free-living worm- or sausage-shaped bottom feeders of diverse
external patterns and coloration that are essentially scavengers. They are cosmopolitan in distribution, found
in both shallow and deep waters. Cucumbers are harvested as a food (trepang, beche-de-mer) in the South
Pacific.
Venom and Venom Apparatus. Cucumbers produce in their body walls a visceral cantharidin-like
liquid toxin ("holothurin"). Holothurin is concentrated in the tentacular organs of Cuvier, which can be
projected and extended anally when the animal mounts a defense . Toxic genera include Actinopyga,
Stichopus, and Holothuria. Some cucumbers dine on nematocysts and thus can secrete coelenterate venom as
well.
Clinical Aspects. Holothurin may induce contact dermatitis when the tentacular organs directly contact
the skin. Generally the substance is diluted in the surrounding ocean water and the reaction is minimal.
However, persons who dissect sea cucumbers topside in the preparation of food products may inadvertently
handle the toxin and develop a papular skin irritation. The major risk underwater is to the corneas and
conjunctivae, which may become intensely inflamed if directly contacted by tentacular fragments or high
concentrations of the toxin. This may occur if the mask is cleared in the immediate vicinity of recent sea
cucumber manipulation. A severe reaction may lead to blindness. Holothurin is a potent cardiac glycoside and
may cause severe illness or death on ingestion.
Treatment. The management of holothurin-induced contact dermatitis is similar to that for starfish
dermatitis. A topical or systemic corticosteroid may be necessary to manage a severe reaction. Because
cucumbers that dine on nematocysts may secrete coelenterate venom, the initial skin detoxification should
include topical application of 5% acetic acid (vinegar), papain, or 40% to 70% isopropyl alcohol. If an eye is
involved, it should be anesthetized with 1 or 2 drops of proparacaine 0.5% and then irrigated with 100 to 250
ml of normal saline to remove any residual foreign matter. The cornea should then be stained with fluorescein
to identify corneal defects. A proper slit-lamp examination is optimal to determine whether inflammation
extends into the anterior chamber or involves the iris. If there is no sign of infection, a moderate approach to
the inflammatory keratitis includes regular instillation of cycloplegic, mydriatic, and corticosteroid
ophthalmic solutions. Prompt referral to an ophthalmologist is essential.
Annelid Worms
Life and Habits. There are 6200 species of segmented marine worms (phylum Annelida, class
Polychaeta), either free moving or sedentary. Some members of the former group are considered toxic and
may attain 1 foot in length. The worms are predominantly carnivorous and exist in the tidal zone to depths of
5000 m, mostly as bottom feeders. Each segment of the worm possesses paddlelike appendages (parapodia)
