Marine Envenomation Postgraduate Course 2024 PDF

MARIEDEL A. TAN, RN Toxicology Nurse Poison Control Center Eastern Visayas Medical Center Region VIII MARINE ENVENOMATIONS  TOPIC OUTLINE MARINE ENVENOMATIONS I. INVERTEBRATE A. CNIDARIA (JELLYFISH and ANEMONE) B. MOLLUSCA...

MARIEDEL A. TAN, RN Toxicology Nurse Poison Control Center Eastern Visayas Medical Center Region VIII MARINE ENVENOMATIONS  TOPIC OUTLINE MARINE ENVENOMATIONS I. INVERTEBRATE A. CNIDARIA (JELLYFISH and ANEMONE) B. MOLLUSCA C. ECHINODERMATA & ANNELIDA II. VERTEBRATES A. SNAKES B. FISH III. FOODBORNE POISONING A.CIGUATERA POISONING B.SHELLFISH POISONING C.TETRODON POISONING D.SCOMBROID POISONING Objectives 1. Recognize the different kinds of marine toxins/envenomation and foodborne illness through marine toxins. 2. Understand the mechanism of toxic action, clinical manifestations and specific management in marine toxins and envenomation. 3. Determine the application of learning theories in approaches as a Toxicology Nurse in the Clinical setting. I.INVERTEBRATES A. CNIDARIA(JELLYFISH ) Jellyfish -Jellyfish are part of the phylum Cnidaria, which encompasses over 10,000 species of animals exclusively found in aquatic environments. Parts of Jellyfish Spotted jellyfish (Mastigias papua)-in Bucas Grande Islands of Socorro in Surigao del Norte Box jellyfish- in Bulalacao Island, Coron, Palawan Box jellyfish- in Bulalacao Island, Coron, Palawan. - is well known for the box jellyfish Chironex fleckeri (Greek cheiro means hand, Latin nex means murderer; therefore, “assassin’s hand”). - When full grown, its bell measures 25 to 30 cm in diameter, and 15 tentacles are attached at each “corner” of the bell. These tentacles may extend up to 3 m in length. Crown jellyfish (Cephea cephea)-in San Luis, Batangas Thimble jellyfish of genus Linuche -in Boracay Island, Malay, Aklan Tomato jellyfish (Crambione cf. mastigophora) labong- labong.-in El Nido, Palawan -Larvae of certain Linuche unguiculata cause sea bather’s eruption (SBE). Venom Apparatus of the Jellyfish All species possess microscopic cnidae(nematocyst) , which are highly specialized organelles consisting of an encapsulated hollow barbed thread bathed in venom. A trigger mechanism called a cnidocil regulates nematocyst discharge. -Pressure from contact with a victim’s skin, or chemical triggers such as osmotic changes, stimulates discharge of the thread and toxin from its casing.  Toxins Signs and symptoms Proteins disrupt cellular Local effects: processes. intense pain,redness, Enzymes:pro break down proteins and welts, swelling tease damage tissues Neurotoxin Affect the nervous Systemic effects: s system Cardiovascular collapse Cardiotoxin Impact the Respiratory distress s cardiovascular system. Cardiac arrest Dermonecro Cause skin necrosis and Severe pain and tic Toxins severe pain. anxiety Linear stings typically cause immediate itching, pain, stinging, or pricking at the site of contact, lasting for up to 10 days.  Blistering, wheal formation, numbness, paraesthesia and local oedema may occur,  Secondary infection may lead to ulceration, local necrosis and gangrene. Management 1. Maintain a clear airway and ensure adequate ventilation. 2. Management of anaphylaxis -Give epinephrine. -Give IV crystalloid such as 0.9% sodium chloride to correct hypotension. -Give hydrocortisone and an antihistamine such as chlorphenamine by slow IV injection -bronchospasm treat conventionally with nebulized bronchodilators and steroids 3. In vitro trials with C. fleckeri tentacles demonstrate complete irreversible inhibition of nematocyst discharge following a 30-second application of 5-8% of Acetic Acid. - In the Indo-Pacific region, where C. fleckeri and C. barnesi are of greatest concern, vinegar should be used. 4. Use a gloved or towel-covered hand, and gently remove the tentacles. 5. If painful, submerge the affected limb or wound in hot water but not scalding, water (42–45 °C) for 30– 90 minutes or until the pain resolves Needed equipment/materials for hot water immersion: -water bucket -water temperature thermometer -portable water heater 6. Give simple analgesics (e.g. paracetamol) to relieve residual pain. For severe pain, analgesia can be escalated to include parenteral analgesia, local infiltration of local anesthetic 7. Give anti-tetanus prophylaxis as required. 8. Monitor wounds for infection and treat as necessary. Use of prophylactic antibiotics should only be considered for grossly contaminated wounds 9. If a tentacle has been placed in the mouth, it may cause rapid intraoral swelling with the potential for airway obstruction. In such cases, an endotracheal tube should be considered. 10. Immediately irrigate the affected eye thoroughly with 1000 mL 0.9% saline or equivalent crystalloid for a minimum of 10-15 minutes  Box jellyfish antivenom is a sheep-derived whole IgG raised against the venom of C. fleckeri. Available in Australia since 1070.This prevents neurotoxicity and myotoxicity from C. fleckeri following pretreatment B.ANEMONE Cnidaria (Anemone) -Immobile marine creatures that sting on contact. -They are common inhabitants of reefs and tide pools and attach themselves to rock or coral. Armed with modified nematocysts known as sporocysts located on their tentacles, they produce stings like those of organisms from other Cnidaria classes. HELL’S fire sea anemone, locally called “garaban”  Toxins Signs and symptoms Neurotoxin Affect nerve cells, Local Effects: s causing pain and pain, swelling, paralysis. redness, blistering Cytolysins Destroy cell membranes, leading to cell death. Systemic Effects: nausea, vomiting, Hemolysins Cause the destruction of and in severe cases, red blood cells. respiratory distress Protease Inhibit the action of or cardiovascular Inhibitors proteases, which are symptoms enzymes that break down proteins. Case Report: A 37-year-old man with no underlying disease was admitted to our hospital. He presented with intense pain, a rash, and swelling in his right thigh. Two days prior, he had been stung by a sea anemone while scuba diving in Cebu, Philippines. His blood tests revealed renal dysfunction, and his platelet count was normal. However, on day three, the platelet count decreased rapidly. Hemolytic uremic syndrome (HUS) is a condition that affects the blood and blood vessels. It results in the destruction of blood platelets ,a low red blood cell count and kidney failure due to damage to the very small blood vessels of the kidneys Management 1. Wash with sea water, not fresh water. 2. Remove nematocysts by scraping off with a sharp edge. 3. Submerge affected limb or wound in water as hot as can be tolerated for 30-90 minutes or until pain is easing. 4. Supportive therapy: Pain control, wound care, antihistamines (oral and topical), topical steroids, antibiotics if necessary I.INVERTEBRATES B. MOLLUSCA Cone snails -There are over 900 different species of cone snails. Cone snails are typically found in warm and tropical seas and oceans worldwide, and they reach their greatest diversity in the Western Indo-Pacific region -There are over 900 different species of cone snails. Cone snails are typically found in warm and tropical seas and oceans worldwide, and they reach their greatest diversity in the Western Indo-Pacific region Cone snails Conus telatus Cone snails use a harpoon-like structure called a radula to inject venom into their prey. The venom is produced in a specialized venom gland located near the radula.  Toxins Signs and symptoms Conotoxins: Peptide toxins that target specific receptors and ion channels. α- Target nicotinic relaxation or paralysis, conotoxins acetylcholine impaired memory and receptors. attention. μ- prevents muscle Target voltage-gated conotoxins sodium channels. contraction, resulting in muscle paralysis. ω- Target voltage-gated reduce heart muscle conotoxins calcium channels. contractility and dilate blood vessels. Management 1.Primary intervention include maintenance of ABC 2.Hot water immersion (45-50 degrees Celsius) following cone snail stings for pain relief. 3.Pressure immobilization bandaging may blunt toxin distribution by decreasing lymphatic spread. 4.Local wound care and tetanus prophylaxis C.ECHINODERMATA & ANNELIDA Sea Urchins Sea urchins are animals that are typically small, spiny and round. They live in all the earth’s oceans, at depths ranging from the tide line to 15,000 feet. Because they cannot swim, they live on the sea floor. Their main defense against more agile predators like eels and otters is their hard, spiny test, or shell. Sea Urchin -The venom apparatus (pedicellaria) nestled among the spikes are tubular stalks topped with biting jaws known as pedicellariae;  Toxins Signs and symptoms Saponins Causes hemolysis (breaking pain, swelling, serotonin down of red blood cells), redness, and in some skin irritation, and mucous cases, allergic membrane irritation reactions or systemic Histamine Inflammation and allergic symptom. and Other reaction Biogenic Amines 1. Spine contact with the skin may be very painful ,bleeding, erythema, edema, and granulomas. If joints are penetrated, synovitis and arthritis may occur resulting in loss of movement/function. Management 1. Hot water immersion Remove Spines: - If spines are embedded in the skin, they should be removed promptly and carefully to avoid breaking them. Tweezers can be used for this purpose.antibiotics and tetanus should be considered; -spines are quite brittle and will usually be extruded within 3 days. 3. Use of prophylactic antibiotics should only be considered for grossly contaminated wounds. SNAKES Banded sea Krait Sea snakes are members of the class Reptilia and are divided into two subfamilies: Hydrophiinae and Laticaudinae. -They are close relatives of the cobra and krait. -Their tails are flattened, and their bodies often are brightly colored.  Toxins Signs and symptoms Neurotoxins disrupt the transmission of 1. Painful nerve signals muscles,paralysis, Myotoxins target muscle tissue, causing blurry vision, "Thick muscle damage. tongue" with Phospholip cell membrane damage difficulty swallowing ases A2 and inflammation. or speaking, Excessive saliva production, Vomiting, Droopy eyelids (ptosis) Management 1.Immobilization of the extremity and consideration of a pressure immobilization bandage to impede lymphatic drainage. 2.Tourniquets that impede venous or arterial flow are not recommended and may be detrimental. 3.Airway and respiratory effort require close monitoring because paralysis can develop rapidly. FISH -Families include Dasyatidae -(whip ray or stingray), - Urolophidae (round ray), -Myliobatidae (batfish or eagle ray), -Gymnuridae (butterfly ray) -Potamotrygonidae (river ray, freshwater). -Spiny fish of the family Scorpaenidae include a variety of venomous creatures.Fish of the genus Pterois are commonly called lionfish ( P. volitans and P. lunulata ). -Stingrays Stingrays are a group of sea rays, which are cartilaginous fish related to sharks. They are classified in the suborder Myliobatoidei of the order Myliobatiformes and consist of eight families Stingrays Stingrays have a sharp barb or spine located at the base of their tail. This spine is typically serrated and can reach several inches in length. The venom is housed in glands located around the base of this barb  Venom Signs and symptoms composition Toxins mixture of proteins, Intense pain. peptides, and enzymes Symptoms peak 30 to 90 minutes after injury and may persist for 48 hours Enzymes phospholipase A2 tissue damage and inflammation Neuropeptide affect nerve function Systemic s and can cause pain symptoms include and other neurological weakness, nausea, The barb on the stingray’s tail can cause lacerations and puncture wounds,. Management 1. Wounds inflicted by stingrays and spiny fish should be carefully examined for imbedded foreign material. -Radiographs may uncover retained spines. 2. Stingray wounds can be extensive and require surgical attention for vascular or tendonous disruption. 3. Tetanus immune status should be addressed. 4. Prophylactic antibiotics may decrease rates of wound infection. 5. In a series of 51 stings from P. pterois and S. guttata, 80% of patients had complete relief of local pain with hot water immersion. Hot water produces similar relief for pain. 6. Although patients occasionally required a single dose of oral or parenteral analgesia, clinicians rarely prescribed pain medication upon discharge. Stone fish They are known for their excellent camouflage, resembling rocks or coral, which makes them difficult to spot. Stonefish possess 13 sharp dorsal fin spines capable of delivering venom. Stone fish Stonefish store their venom in specialized glands located in the spines along their dorsal fin.  Venom Signs and symptoms composition Stonustoxin: A major protein toxin Causes pain, responsible for many swelling, muscle of the venom's effects. weakness, and potentially cardiovascular and respiratory issues. Veratridine- Compounds that affect Disrupt normal like Toxins sodium channels in nerve signaling, nerve cells. leading to pain and neurological symptoms.  Venom Signs and symptoms composition Cardiotoxins: Toxins that specifically Cause irregular affect the heart. heart rhythms (arrhythmias) and potentially cardiac arrest. Cytotoxins Toxins that cause cell Contribute to tissue damage and death. necrosis and severe local damage at the site of envenomation.  Venom Signs and symptoms composition Neurotoxins Toxins that interfere Lead to muscle with nervous system paralysis, difficulty function. breathing, and other severe systemic symptoms. Inflammatory Description: Cause redness, Mediators Compounds that swelling, and pain promote inflammation. at the site of the sting. Stings from stonefish produce immediate, severe pain with rapid wound cyanosis and edema that may progress up the injured extremity. Management 1. Pain relief or analgesia 2. Tetanus prophylaxis 3.Broad spectrum antibiotics directed at marine pathogens. Prophylactic antibiotics may decrease rates of wound infection Doxycycline 100 mg IV BID or Vibramycin 200mg BID plus Ceftazidime 2 grams IV q 8 hrs 3. Antidote: Antivenin for stonefish envenomation does exist (Commonwealth Serum Laboratories, Melbourne, Australia); CIGUATERA POISONING Ciguatera Fish Poisoning - is a type of seafood poisoning primarily caused by the ingestion of reef fishes contaminated with neurotoxins called Ciguatoxins (CTX). - More than 500 fish species have caused human cases of ciguatera poisoning, with the barracuda, sea bass, parrot fish. The common factor is the comparably large size of the fish(4–6 lb or more) involved barracuda sea bass parrot fish grouper red amber jack snapper History and Epidemiology The earliest case recorded was in Basilan, Province in 1988, implicating 19 patients from four families (Chan 2015). In Sibuyan Island, Romblon, 32 cases were suspected of CFP from September 1997 to January 1998, and these were caused by several reef fishes locally known as manambulao” (grunt fish), “isdang bato”, “ahaan” (grunt fish), “dayang -dayang”(grunt fish), “lampuyang” (parrot fish), “dugso” (grunt fish). The most recent case was reported in Zamboanga City in Mindanao last 2014, wherein 14 patients experienced shortness of breath, dizziness, and vomiting after eating barracuda fishes. Food chain transfer of CTX through the marine food web This process thus causes accumulation and an increase in lethality as it goes up the food chain. Experimental evidence of dietary ciguatoxin accumulation in an herbivorous coral reef fish Clinical Manifestations 1. Gastrointestinal (nausea, vomiting, diarrhoea, abdominal pain) 2. Neurological (paraesthesia, tingling lips, blurred vision, ataxia, tremor). 3. Temperature sensation reversal is a typical finding Management 1. Maintain a clear airway and ensure adequate ventilation. 2. In patients with significant GI fluid loss through vomiting and/or diarrhea, intravenous fluid, and electrolyte repletion are essential. 3. Intravenous mannitol (1gm/kg over 30 minutes)may alleviate neurologic and muscular dysfunctional symptoms associated with ciguatera. Should be used with caution because it may cause hypotension. The osmotic effect of mannitol is expected to reverse ciguatoxin-induced edema of the circumaxonal Schwann cells, which likely explains its beneficial action, along with potential neuroprotective effects. 4. Since sensitization occurs, for the next 6 to 12 months, the patient should avoid the following foods, chemicals, and medications that may contain polycyclic ether moieties that can trigger a recurrence of symptoms: fish, shellfish, alcoholic beverages, nuts, or nut products, seeds or seed products, mayonnaise, marijuana, opiates, barbiturates, solvents, glues, epoxies, ethers, resins, herbicides, insecticides, and cosmetics. Article -In this study, CFP cases involving 22individuals from 2 households in Iloilo province are reported. These individuals experienced a range of symptoms common to fish poisoning while one of them experienced a temperature reversal sensation. -Cigua-Check kit screening done by BFAR indicate the presence of CTX in remnant fish -The presence of CTX in blood samples of affected individuals were confirmed by electrospray ionization mass spectrometry. SHELLFISH POISONING Paralytic Shellfish - Is caused by eating shellfish which have bioaccumulated gonyautoxins (primarily saxitoxin) are produced by certain dinoflagellates. -Bivalve mollusks such as mussels, oysters, and clams are most associated with PSP, although it has been reported following ingestion of xanthid crabs and sea snails (Llewellyn et al, 2002; Barraza, 2009). Bivalve molluscan shellfish Xanthid Crabs Major categories of shellfish poisoning 1. Amnestic Shellfish Poisoning -Causative agent: Domoic acid -Clinical Manifestations: -Nausea and vomiting, abdominal cramps, diarrhea -headache -Memory loss(amnesia) -Seizures,coma , death 2. Diarrhetic Shellfish Poisoning -Causative agent: Okadaic Acid and Dinophysis Toxin -Clinical Manifestations: -Nausea ,vomiting -diarrhea, abdominal pain - headache 3. Neurotoxic Shellfish Poisoning -Causative agent: Brevetoxin -Clinical Manifestations: -Nausea , vomiting, diarrhea -hypotension, arrhythmias -numbness, tingling -cramps, paralysis -seizure,coma 4. Paralytic Shellfish Poisoning -Causative agent: Saxitoxin -Clinical Manifestations: -GI: diarrhea, nausea, vomiting, abdominal pain -Neurologic: paresthesias of the face, muscle paralysis (weakness, dysphagia, ataxia, respiratory paralysis) -In the Philippines, the species of dinoflagellates involved are Pyrodinium bahamense var. compressum and Gymnodinium catanella Saxitoxin is a voltage- gated sodium channel blocker, preventing action potential propagation and leaving nerve and muscle tissues non-functional Management: 1. GUT decontamination is recommended by doing gastric lavage with 1.5% sodium bicarbonate 1 tablespoon baking soda in 1 liter of water or 2 vials of 8.4% sodium bicarbonate in 1 liter of water. 2. After 5 min, do gastric lavage with activated charcoal Adult: 100 g in 200 mL water Pedia: 1 g/kg to make a slurry 3. After lavage, give sodium sulfate. 4. The lactic acidosis of unknown origin seen in experimental animals and possibly humans can be treated by assisted ventilation, fluid therapy and periodic monitoring of the blood pH. It is possible that the fluid therapy will also assist in the renal excretion of toxin. Give 8.4% sodium bicarbonate 1 mEq/kg IV q 6 hours until urine pH > 7.5 BFAR Advisories TETRODOTOXIN POISONING Tetrodotoxin Poisoning -Occurs after ingestion of fish belonging to the order Tetraodontiformes (e.g. Puffer fish) or after the bite of the blue-ringed octopus. -It is concentrated in the skin and viscera of fish. Representatives of the 10 extant Tetraodontiformes families: a Triacanthodidae, Triacanthodes anomalus; b Triacanthidae, Triacanthus biaculeatus; c Balistidae, Abalistes filamentosus; d Monacanthidae, Thamnaconus hypargyreus; e Aracanidae, Kentrocapros aculeatus; f Ostraciidae, Ostracion immaculatus; g Triodontidae Triodon macropterus; h Tetraodontidae, Arothron mappa; i Diodontidae, Diodon liturosus; j Molidae, Masturus lanceolatus Mechanism of Toxic Action -The toxin blocks voltage-gated sodium channels resulting in failure of action potential generation and propagation, autonomic effects and neuromuscular weakness. Clinical Manifestations : Paralyzed patients with fixed or dilated pupils may still be conscious, with implications for the decision to stop treatment. Patients in a deep coma with brainstem areflexia may also make a full recovery with supportive care Management: 1. Maintain a clear airway and ensure adequate ventilation. 2. Consider activated charcoal (charcoal dose: 50 g for adults; 1 g/kg for children) if the patient presents within 1 hour of ingestion 3. Ensure adequate fluid resuscitation if the patient is hypotensive. For symptomatic bradycardia give atropine IV. SCOMBROID POISONING Scombrotoxic fish poisoning - Histamine Fish Poisoning/Scombrotoxin - Occurs after ingestion of poorly stored dark meat marine fish. Mechanism of Toxic Action - Histidine decarboxylase is an enzyme produced by bacteria present in the gills and GI tracts of the fish or from bacterial contamination due to poor hygiene during handling and preparation. The enzyme converts the amino acid histidine into histamine -Histamine fish poisoning occurs after the ingestion of improperly refrigerated dark meat marine fish. Clinical Manifestations 1. Features closely resemble histamine reactions and include flushing, dizziness, headache, GI upset and palpitations. Affected areas are bright red, hot and itchy. The rash is a form of urticaria, but unlike an allergic reaction, there is no wealing (skin swelling). Management 1. Symptomatic patients should be treated with antihistamines e.g. chlorphenamine. In severe cases consider addition of an H2 blocker. Prevention 1. Fishes should be appropriately refrigerated or kept on ice at less than 38 Fahrenheit from the time they are caught to the time cooked to prevent spoilage. 2. Fish with a bad odor or a “honey-combed” appearance should not be consumed.  Patients may be reassured that they are not allergic to fish if other individuals experience a similar reaction to eating the same fish at the same time. References 1. National Poison Management and Control Center,Algorithms of Common Poisonings 4th Edition 2. Goldfrank,L et. Al ,Goldfranks`s Toxicologic Emergencies 9th Edition , Mc Graw Hill Companies 2011 3. LeikinJ and Paloucek F, Poisoning and Toxicology Handbook 4th Edition,. Informa Healthcare USA, Inc,2008 4. G.Palakrishnakone,Marine and Freshwater Toxins, 2016, P. Spinger Reference