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The Anaphylaxis Blues Jellyfish strikes back

The Anaphylaxis Blues Jellyfish strikes back. Dr Daniel Khamoudes Toxicology Service Prince Of Wales Hospital. Outline. Case History Facts. Case. 38M Otherwise well Hx of anaphylaxis to bee stings Blue Bottle Sting at Maroubra 1730 First aid with water to remove

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The Anaphylaxis Blues Jellyfish strikes back

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  1. The Anaphylaxis BluesJellyfish strikes back Dr Daniel Khamoudes Toxicology Service Prince Of Wales Hospital

  2. Outline • Case • History • Facts

  3. Case • 38M • Otherwise well • Hx of anaphylaxis to bee stings • Blue Bottle Sting at Maroubra 1730 • First aid with water to remove • Presented POW ED 1800 with pain • Primary sting L lateral ankle • Pain locally and L groin 8/10

  4. Case • In ambulance bay, hot water submersion • 1830 sudden onset tongue angioedema • Moved to resus • Nil respiratory or haemodynamic compromise • Adrenaline 0.5mg IM at 1855 • Rapid resolution within 5 minutes • Hydrocortisone 200mg IV • Ranitidine 50mg IV • Fexofenadine 180mg po • Fentanyl 150mcg, in 50mcg aliquots

  5. Case • Return of angioedema 2000 • Nil respiratory or haemodynamic compromise • Second dose Adrenaline 0.5mg IM 2010 • Resolution of symptoms over 10 minutes • Further boluses of Fentanyl as groin pain an issue • Creatinekinase and UEC NAD • HDU admission for observation re angioedema • Nil further episodes • Pain settled overnight

  6. History • Discovered 19031 • Richet and Portier • Dogs vs Jellyfish toxin • Second exposure lower dose lethal • 1913 Nobel Prize • Origin • Greek –ana (against) –phylaxis (protection) • Originally aphylaxis (publicist) 1. Wikipedia

  7. Mechanism • Nematoblasts->Nematocysts • Spring loaded syring • Discharge within 700ns of contact • 18m/s 5.4x106g • Pressure 7.7GPa • Local and systemic injury

  8. Mechanism

  9. Mechanism • Toxin2 • Local and systemic • Tubule • Collagens, glycoproteins and polysaccharides • Innate and adaptive cellular and humoral responses 2. J Tibballs, A Yanagihara, H Turner, K Winkel. Immunological and Toxinological Responses to Jellyfish Stings. Inflammation & Allergy - Drug Targets, 2011, 10, 438-446.

  10. Mechanism

  11. PhysaliaUtriculus • PhysaliaphysalisvsPhysaliautriculus • Float and Tail • Nematocysts remain active

  12. Local effects • Immediate pain and erythema • Progressive pain to draining lymph nodes • Long term scarring unlikely but occurs

  13. Local Effects

  14. Systemic Effects • Venom • Pore forming in plasma membrane, Ca influx/swelling/lysis2,3 • Neuro/cardio toxicity2,4 • Potential deaths with Physaliaphysalis5,6 • Immune Response – immediate and delayed • Hypersensitivity reaction • Previous exposure • Cross reactivity 3. Edwards, L.P.; Whitter, E.; Hessinger, D.A. Apparent membrane pore-formation by Portuguese Man-of-war (Physaliaphysalis). Toxicon, 2002, 40(9), 1299-1305. 4. Burnett, J.W. Treatment of Atlantic cnidarianenvenomations. Toxicon, 2009, 54(8), 1201-1205.5. 5. Tibballs, J. Australian venomous jellyfish, envenomation syndromes, toxins and therapy. Toxicon, 2006, 48(7), 830-859. 6. L Cegolon, W Heymann, G Mastrangelo. Jellyfish Stings and Their Management: A Review. Marine Drugs, Feb 2013. 11(2):523-550

  15. Treatment • Supportive • Analgesia • Consider regional • Hot water submersion3 • Anaphylaxis APP • ALS • IgG production noted8 7. C Loten, B Stokes, D Worsley, J Seymour, S Jiang, G Isbister. A randomised controlled trial of hot water (45°C) immersion versus ice packs for pain relief in bluebottle stings. MJA April 2006. 184(7):329-333. 8. Russo, A.J.; Calton, G.J.; Burnett, J.W. The relationship of the possible allergic response to jellyfish envenomation and serum antibody titers. Toxicon, 1983, 21(4), 475-480.

  16. Summary • Local and systemic symptoms • Treatment supportive +/- specific • ?Steroid topical • ?Sun exposure

  17. References • Wikipaedia • 2. J Tibballs, A Yanagihara, H Turner, K Winkel. Immunological and Toxinological Responses to Jellyfish Stings. Inflammation & Allergy - Drug Targets, 2011, 10, 438-446. • 3. Edwards, L.P.; Whitter, E.; Hessinger, D.A. Apparent membrane pore-formation by Portuguese Man-of-war (Physaliaphysalis). Toxicon, 2002, 40(9), 1299-1305. • 4. Burnett, J.W. Treatment of Atlantic cnidarianenvenomations. Toxicon, 2009, 54(8), 1201-1205.5. • 5. Tibballs, J. Australian venomous jellyfish, envenomation syndromes, toxins and therapy. Toxicon, 2006, 48(7), 830-859. • 6. L Cegolon, W Heymann, G Mastrangelo. Jellyfish Stings and Their Management: A Review. Marine Drugs, Feb 2013. 11(2):523-550 • 7. C Loten, B Stokes, D Worsley, J Seymour, S Jiang, G Isbister. A randomised controlled trial of hot water (45°C) immersion versus ice packs for pain relief in bluebottle stings. MJA April 2006. 184(7):329-333. • 8. Russo, A.J.; Calton, G.J.; Burnett, J.W. The relationship of the possible allergic response to jellyfish envenomation and serum antibody titers. Toxicon, 1983, 21(4), 475-480.

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