A randomized, controlled field trial for the prevention of jellyfish stings with a topical sting inhibitor

Jellyfish Stings: A Review of Skin Symptoms, Pathophysiology, and Management

With the surge in the human coastal population and the increasing frequency of human activities along the coast, cases of marine envenomation, particularly jellyfish envenomation, have notably risen. Jellyfish stings can induce a spectrum of symptoms that vary in severity, encompassing skin injuries, acute systemic venom effects, delayed indirect sequelae, and even fatality, causing significant distress to patients. Among these manifestations, the occurrence of skin lesions following jellyfish stings is prevalent and substantial. These lesions are characterized by evident blister formation, development of bullae, subcutaneous hemorrhage, erythema, papules, wheal, ecchymosis, and ulceration or skin necrosis. Local cutaneous manifestations may persist for several weeks or even months after the initial sting. Despite aggressive treatment, many skin injuries still result in significant pigmentation or scarring after recovery. To address this issue effectively, it is imperative to conduct comprehensive evidence-based medical research, elucidate various components within jellyfish venom, and elucidate its pathogenic mechanism to develop targeted treatment programs. This article aims to review the skin symptoms, pathophysiology, and management of jellyfish stings. Such considerations can provide comprehensive guidance to medical professionals and the public and minimize the harm caused by jellyfish stings.

Toxin metalloproteinases exert a dominant influence on pro-inflammatory response and anti-inflammatory regulation in jellyfish sting dermatitis

Toxin metalloproteinases are the primary components responsible for various toxicities in jellyfish venom, and there is still no effective specific therapy for jellyfish stings. The comprehension of the pathogenic mechanisms underlying toxin metalloproteinases necessitates further refinement. In this study, we conducted a differential analysis of a dermatitis mouse model induced by jellyfish Nemopilema nomurai venom (NnNV) samples with varying levels of metalloproteinase activity. Through skin tissue proteomics and serum metabolomics, the predominant influence of toxin metalloproteinase activity on inflammatory response was revealed, and the signal pathway involved in its regulation was identified. In skin tissues, many membrane proteins were significantly down-regulated, which might cause tissue damage. The expression of pro-inflammatory factors was mainly regulated by PI3K-Akt signaling pathway. In serum, many fatty acid metabolites were significantly down-regulated, which might be the anti-inflammation feedback regulated by NF-κB p65 signaling pathway. These results reveal the dermatitis mechanism of toxin metalloproteinases and provide new therapeutic targets for further studies. SIGNIFICANCE: Omics is an important method to analyze the pathological mechanism and discover the key markers, which can reveal the pathological characteristics of jellyfish stings. Our research first analyzed the impact of toxin metalloproteinases on jellyfish sting dermatitis by skin proteomics and serum metabolomics. The present results suggest that inhibition of toxin metalloproteinases may be an effective treatment strategy, and provide new references for further jellyfish sting studies.

Identification and characterization of the key lethal toxin from jellyfish Cyanea nozakii

Jellyfish Cyanea nozakii venom is a complex mixture of various toxins, most of which are proteinous biological macromolecules and are considered to be responsible for clinical symptoms or even death after a severe sting. Previous transcriptome and proteome analysis identified hundreds of toxins in the venom, including hemolysins, C-type lectin, phospholipase A₂, potassium channel inhibitor, metalloprotease, etc. However, it is not clear which toxin in the venom plays the most important role in lethality. Herein, we isolated the key lethal toxin (Letoxcn) from jellyfish Cyanea nozakii using anion exchange chromatography, size-exclusion chromatography, and cation exchange chromatography. The molecular weight of Letoxcn is ∼50 kDa with the N-terminal sequences of QADAEKVNLPVGVCV. Peptide mass fingerprinting analysis of Letoxcn shows that it may have some motifs of phospholipase, metalloproteinase, thrombin-like enzyme, potassium channel toxin, etc. However, only metalloproteinase activity but no hemolytic, PLA₂, or blood coagulation activity was observed from in vitro toxicity analysis. Overall, this study uncovered and characterized the key lethal toxin in the venom of jellyfish Cyanea nozakii, which will not only help to reveal the molecule mechanism of the lethality, but also develop effective treatment like antivenom for this jellyfish sting in the future.

Effect of Rinse Solutions on Rhizostoma pulmo (Cnidaria: Scyphozoa) Stings and the Ineffective Role of Vinegar in Scyphozoan Jellyfish Species

Rhizostoma pulmo is a widely distributed scyphozoan in the Mediterranean Sea. Their stings result mainly in erythema, small vesicles, or/and pain, and cause a high number of bathers to seek assistance from first-aid services during the summer season. Despite the threat that jellyfish stings represent to public health, there is disagreement in the scientific community on first-aid protocols, with the dispute largely centered around the effectiveness of vinegar. In the present research, we investigated the effect of commonly used rinse solutions on nematocyst discharge in R. pulmo and the effect of vinegar on three more scyphozoans (Aurelia sp., Cassiopea sp., and Rhizostoma luteum). Scented ammonia, vinegar, and acetic acid triggered nematocyst discharge in R. pulmo. Vinegar also caused nematocyst discharge in Aurelia sp., Cassiopea sp., and R. luteum. In contrast, seawater, baking soda, freshwater, urine, and hydrogen peroxide were considered neutral solutions that did not induce nematocyst discharge. These results indicate that the use of vinegar, acetic acid, or commercial products based on these compounds is counterproductive. Their use can worsen pain and discomfort caused not only by R. pulmo stings but also by those of any scyphozoan. The use of seawater is recommended for cleaning the R. pulmo sting site until an inhibitor solution that irreversibly prevents nematocyst discharge is discovered.

Comparative Study of Toxic Effects and Pathophysiology of Envenomations Induced by Carybdea brevipedalia (Cnidaria: Cubozoa) and Nemopilema nomurai (Cnidaria: Scyphozoa) Jellyfish Venoms

Jellyfish stings can result in local tissue damage and systemic pathophysiological sequelae. Despite constant occurrences of jellyfish stings in oceans throughout the world, the toxinological assessment of these jellyfish envenomations has not been adequately reported in quantitative as well as in qualitative measurements. Herein, we have examined and compared the in vivo toxic effects and pathophysiologic alterations using experimental animal models for two representative stinging jellyfish classes, i.e., Cubozoa and Scyphozoa. For this study, mice were administered with venom extracts of either Carybdea brevipedalia (Cnidaria: Cubozoa) or Nemopilema nomurai (Cnidaria: Scyphozoa). From the intraperitoneal (IP) administration study, the median lethal doses leading to the deaths of mice 24 h post-treatment after (LD₅₀) for C. brevipedalia venom (CbV) and N. nomurai venom (NnV) were 0.905 and 4.4697 mg/kg, respectively. The acute toxicity (i.e., lethality) of CbV was much higher with a significantly accelerated time to death value compared with those of NnV. The edematogenic activity induced by CbV was considerably (83.57/25 = 3.343-fold) greater than NnV. For the evaluation of their dermal toxicities, the epidermis, dermis, subcutaneous tissues, and skeletal muscles were evaluated toxinologically/histopathologically following the intradermal administration of the venoms. The minimal hemorrhagic doses (MHD) of the venoms were found to be 55.6 and 83.4 μg/mouse for CbV and NnV, respectively. Furthermore, the CbV injection resulted in extensive alterations of mouse dermal tissues, including severe edema, and hemorrhagic/necrotic lesions, with the minimum necrotizing dose (MND) of 95.42 µg/kg body weight. The skin damaging effects of CbV appeared to be considerably greater, compared with those of NnV (MND = 177.99 µg/kg). The present results indicate that the toxicities and pathophysiologic effects of jellyfish venom extracts may vary from species to species. As predicted from the previous reports on these jellyfish envenomations, the crude venom extracts of C. brevipedalia exhibit much more potent toxicity than that of N. nomurai in the present study. These observations may contribute to our understanding of the toxicities of jellyfish venoms, as well as their mode of toxinological actions, which might be helpful for establishing the therapeutic strategies of jellyfish stings.

Inhibition of Nematocyst Discharge from Pelagia noctiluca (Cnidaria: Scyphozoa)—Prevention Measures against Jellyfish Stings

Pelagia noctiluca stings are common in Mediterranean coastal areas and, although the venom is non-lethal, they are painful. Due to its high toxicity and abundance, P. noctiluca is considered a target species for the focus of research on active ingredients to reduce the symptoms of its sting. To determine the effect of 31 substances and formulations on nematocyst discharge, we performed three tests: (1) screening of per se discharge activator solutions, (2) inhibitory test with nematocyst chemical stimulation (5% acetic acid) and (3) inhibitory test quantifying the hemolytic area. Ammonia, barium chloride, bleach, scented ammonia, carbonated cola, lemon juice, sodium chloride and papain triggered nematocyst discharge. All of them were ruled out as potential inhibitors. Butylene glycol showed a reduction in nematocyst discharge, while the formulations of 10% lidocaine in ethanol, 1.5% hydroxyacetophenone in distilled water + butylene glycol, and 3% Symsitive® in butylene glycol inhibited nematocyst discharge. These last results were subsequently correlated with a significant decrease in hemolytic area in the venom assays versus seawater, a neutral solution. The presented data represent a first step in research to develop preventive products for jellyfish stings while at the same time attempting to clarify some uncertainties about the role of various topical solutions in P. noctiluca first-aid protocols.

Raising Awareness on the Clinical and Forensic Aspects of Jellyfish Stings: A Worldwide Increasing Threat

Jellyfish are ubiquitous animals registering a high and increasing number of contacts with humans in coastal areas. These encounters result in a multitude of symptoms, ranging from mild erythema to death. This work aims to review the state-of-the-art regarding pathophysiology, diagnosis, treatment, and relevant clinical and forensic aspects of jellyfish stings. There are three major classes of jellyfish, causing various clinical scenarios. Most envenomations result in an erythematous lesion with morphological characteristics that may help identify the class of jellyfish responsible. In rare cases, the sting may result in delayed, persistent, or systemic symptoms. Lethal encounters have been described, but most of those cases happened in the Indo-Pacific region, where cubozoans, the deadliest jellyfish class, can be found. The diagnosis is mostly clinical but can be aided by dermoscopy, skin scrapings/sticky tape, confocal reflectance microscopy, immunological essays, among others. Treatment is currently based on preventing further envenomation, inactivating the venom, and alleviating local and systemic symptoms. However, the strategy used to achieve these effects remains under debate. Only one antivenom is currently used and covers merely one species (Chironex fleckeri). Other antivenoms have been produced experimentally but were not tested on human envenomation settings. The increased number of cases, especially due to climate changes, justifies further research in the study of clinical aspects of jellyfish envenoming.

Wilderness Medicine: Impacts from the Weather, Water, and World

Pediatricians play an important role in the prevention of injuries and provide families with anticipatory guidance regularly. As more families are traveling and spending time outdoors, we must be adept at providing them with knowledge and resources to set them up for success on their adventures. Prevention and preparation frequently can help limit injuries sustained in the wilderness. This article will focus specifically on injuries related to the environment (eg, cold weather injuries, heat-related illnesses) and travel location (eg, high-altitude illness, marine-related injuries, diving medicine). [Pediatr Ann. 2022;51(6):e212-217.].

Differing Effects of Vinegar on Pelagia noctiluca (Cnidaria: Scyphozoa) and Carybdea marsupialis (Cnidaria: Cubozoa) Stings-Implications for First Aid Protocols

The jellyfish species that inhabit the Mediterranean coastal waters are not lethal, but their stings can cause severe pain and systemic effects that pose a health risk to humans. Despite the frequent occurrence of jellyfish stings, currently no consensus exists among the scientific community regarding the most appropriate first-aid protocol. Over the years, several different rinse solutions have been proposed. Vinegar, or acetic acid, is one of the most established of these solutions, with efficacy data published. We investigated the effect of vinegar and seawater on the nematocyst discharge process in two species representative of the Mediterranean region: Pelagia noctiluca (Scyphozoa) and Carybdea marsupialis (Cubozoa), by means of (1) direct observation of nematocyst discharge on light microscopy (tentacle solution assay) and (2) quantification of hemolytic area (tentacle skin blood agarose assay). In both species, nematocyst discharge was not stimulated by seawater, which was classified as a neutral solution. In P. noctiluca, vinegar produced nematocyst discharge per se, but inhibited nematocyst discharge from C. marsupialis. These results suggest that the use of vinegar cannot be universally recommended. Whereas in case of a cubozoan C. marsupialis sting, the inhibitory effect of vinegar makes it the ideal rinse solution, in case of a scyphozoan P. noctiluca sting, vinegar application may be counterproductive, worsening the pain and discomfort of the stung area.

Protective effect of epigallocatechin-3-gallate (EGCG) on toxic metalloproteinases-mediated skin damage induced by Scyphozoan jellyfish envenomation

Jellyfish stingings are currently raising serious public health concerns around the world. Hence, the search for an effective first aid reagent for the envenomation has been the goal of many investigators in the field. There have been a few previous reports of in vivo as well as in vivo studies suggesting the metalloproteinase activity of scyphozoan jellyfish venom, such as N. nomurai venom (NnV), plays a major role in the pathogenesis. These results have inspired us to develop a metalloproteinase inhibitor as a candidate for the treatment of Scyphozoan jellyfish envenomation. It has been previously demonstrated that the major polyphenol component in green tea, epigallocatechin-3-gallate (EGCG), can inhibit metalloproteinase activity of snake venoms. In fact, plant polyphenols as potential therapeutics have been shown to exert positive effects on neutralizing snake venoms and toxins. In the present study, we found that EGCG significantly inhibits the toxic proteases of NnV in a concentration-dependent manner. Human keratinocyte (HaCaT) and Human dermal fibroblast (HDF) cell culture studies showed that EGCG treatment can protect the cells from NnV-induced cytotoxicity which has been accompanied by the down-regulation of human matrix metalloproteinase (MMP)-2 and -9. Simulated rat NnV envenomation study disclosed that topical treatments with EGCG considerably ameliorated the progression of the dermonecrotic lesions caused by NnV. EGCG also reduced the activitions of tissue MMP-2 and MMP-9, which seem to be crucial players in the dermal toxic responses induced by NnV. Therefore, we propose that EGCG might be an effective therapeutic agent for the treatment of cutaneoous jellyfish symptoms.

Epidemiology of the cnidarian Pelagia noctiluca stings on Moroccan Mediterranean beaches

An epidemiological study on the stings of Pelagia noctiluca was carried out on four Mediterranean beaches in Morocco. Data were retrieved from patients seeking medical treatment after a jellyfish sting. A total of 1321 patients presented with P. noctiluca stings during the summer of 2018. Most of the injuries were observed in persons aged 11-20 years. The stings were located more on the lower (53%) than on the upper limbs (27%). A total of 61% of those seeking treatment were Moroccan tourists, 29% were local residents and 9% were foreign tourists. The main medications provided were antiseptics (54%), non-pharmacological treatments (41%) and antibiotics (4%). The continuing presence of P. noctiluca in the Moroccan Mediterranean makes it necessary to set effective strategies to prevent and minimise their impact.

Combined Proteome and Toxicology Approach Reveals the Lethality of Venom Toxins from Jellyfish Cyanea nozakii

Jellyfish are a type of poisonous cnidarian invertebrate that secrete lethal venom for predation or defense. Human beings often become victims of jellyfish stings accidentally while swimming or fishing and suffer severe pain, itching, swelling, inflammation, shock, and even death. Jellyfish venom is composed of various toxins, and the lethal toxin is the most toxic and hazardous component of the venom, which is responsible for deaths caused by jellyfish stings and envenomation. Our previous study revealed many toxins in jellyfish venom, including phospholipase A2, metalloproteinase, and protease inhibitors. However, it is still unknown which type of toxin is lethal and how it works. Herein a combined toxicology analysis, proteome strategy, and purification approach was employed to investigate the lethality of the venom of the jellyfish Cyanea nozakii. Toxicity analysis revealed that cardiotoxicity including acute myocardial infarction and a significant decrease in both heart rate and blood pressure is the primary cause of death. Purified lethal toxin containing a fraction of jellyfish venom was subsequently subjected to proteome analysis and bioinformation analysis. A total of 316 and 374 homologous proteins were identified, including phospholipase A2-like toxins and metalloprotease-like toxins. Furthermore, we confirmed that the lethality of the jellyfish venom is related to metalloproteinase activity but without any phospholipase A2 activity or hemolytic activity. Altogether, this study not only provides a comprehensive understanding of the lethal mechanism of jellyfish venom but also provides very useful information for the therapeutic or rescue strategy for severe jellyfish stings.

β adrenergic receptor/cAMP/PKA signaling contributes to the intracellular Ca2+ release by tentacle extract from the jellyfish Cyanea capillata

Background

Intracellular Ca²⁺ overload induced by extracellular Ca²⁺ entry has previously been confirmed to be an important mechanism for the cardiotoxicity as well as the acute heart dysfunction induced by jellyfish venom, while the underlying mechanism remains to be elucidated.

Methods

Under extracellular Ca²⁺-free or Ca²⁺-containing conditions, the Ca²⁺ fluorescence in isolated adult mouse cardiomyocytes pre-incubated with tentacle extract (TE) from the jellyfish Cyanea capillata and β blockers was scanned by laser scanning confocal microscope. Then, the cyclic adenosine monophosphate (cAMP) concentration and protein kinase A (PKA) activity in primary neonatal rat ventricular cardiomyocytes were determined by ELISA assay. Furthermore, the effect of propranolol against the cardiotoxicity of TE was evaluated in Langendorff-perfused rat hearts and intact rats.

Results

The increase of intracellular Ca²⁺ fluorescence signal by TE was significantly attenuated and delayed when the extracellular Ca²⁺ was removed. The β adrenergic blockers, including propranolol, atenolol and esmolol, partially inhibited the increase of intracellular Ca²⁺ in the presence of 1.8 mM extracellular Ca²⁺ and completely abolished the Ca²⁺ increase under an extracellular Ca²⁺-free condition. Both cAMP concentration and PKA activity were stimulated by TE, and were inhibited by the β adrenergic blockers. Cardiomyocyte toxicity of TE was antagonized by β adrenergic blockers and the PKA inhibitor H89. Finally, the acute heart dysfuction by TE was antagonized by propranolol in Langendorff-perfused rat hearts and intact rats.

Conclusions

Our findings indicate that β adrenergic receptor/cAMP/PKA signaling contributes to the intracellular Ca²⁺ overload through intracellular Ca²⁺ release by TE from the jellyfish C. capillata.

Combined proteomics and transcriptomics identifies sting-related toxins of jellyfish Cyanea nozakii

Jellyfish sting has become a worldwide issue of critical concern to human health and safety in coastal areas in recent decades. Cyanea nozakii is one of the dominant blooming species and dangerous stingers in China. However, it remains unclear how many and what types of toxins are present in the venom. So, we used a combined transcriptomics and proteomics approach to investigate the venom composition of jellyfish C. nozakii. In total 4,608,524 Illumina valid reads were obtained to de novo assemble to 40,434 unigenes in the transcriptomics analysis. And, a total of 311,635 MS/MS spectra with 12,247 unique MS/MS spectra were generated to 1556 homologous proteins in the proteomics analysis. 174 potential toxin proteins were identified, with 27 proteins homology to the toxins from venomous animals, including phospholipase A2, zinc metalloproteinase-disintegrin agkistin, serine protease inhibitor, plancitoxin-1, alpha-latrocrustotoxin-Lt1a, etc. This study described the transcriptomics and venom proteomics of jellyfish C. nozakii for the first time. Our findings provide a comprehensive understanding of the venom composition of C. nozakii. Furthermore, the results may also be very helpful for the discovery of novel bioactive proteins, as well as the development of effective treatments for jellyfish sting in the future.

BIOLOGICAL SIGNIFICANCE

Jellyfish Cyanea nozakii is one of the most dangerous stingers in the coast of china. Hundreds of thousands of people would be stung every year and victims suffered a severe pain, itch, swelling, inflammation, wheal and even more serious consequence. However, it remains unclear how many and what types of toxins are present as well as the relationship between the clinical symptoms and toxins. Our combined transcriptomics and proteomics findings can provide a comprehensive understanding of the venom composition of C. nozakii and will also be helpful for the development of effective treatments for jellyfish sting in the future.

A Survey of Jellyfish Sting Knowledge among Naval Personnel in Northeast China

BACKGROUND

Jellyfish envenomation is common along the coastal area, and can cause severe consequences. Naval personnel are among the high-risk population for this injury. The aim of this study was to assess knowledge regarding jellyfish envenomation among naval personnel in a navy unit in northeast China.

METHODS

A predesigned questionnaire was distributed to 120 naval members in January 2015. The data of 108 respondents were included in the statistical analysis.

RESULTS

We found that 38.0% of the respondents selected jellyfish sting as the common wound in their units, and 13.0% had experienced or observed this injury. In addition, 63.0% of the participants rated their own knowledge as "low" or "none". The average score they got was 5.77 ± 2.50, with only 16.7% getting a score above 60% of the full score. The correct rates of five questions were below 60%. No statistical differences existed in the knowledge score among different groups of respondents defined by socio-demographic variables.

CONCLUSIONS

Jellyfish sting is common in this navy unit, but personnel got a low score on the knowledge assessment. They also lacked confidence in first aid. Medical education and training should be implemented to address this issue.

Experimental Assays to Assess the Efficacy of Vinegar and Other Topical First-Aid Approaches on Cubozoan (Alatina alata) Tentacle Firing and Venom Toxicity

Despite the medical urgency presented by cubozoan envenomations, ineffective and contradictory first-aid management recommendations persist. A critical barrier to progress has been the lack of readily available and reproducible envenomation assays that (1) recapitulate live-tentacle stings; (2) allow quantitation and imaging of cnidae discharge; (3) allow primary quantitation of venom toxicity; and (4) employ rigorous controls. We report the implementation of an integrated array of three experimental approaches designed to meet the above-stated criteria. Mechanistically overlapping, yet distinct, the three approaches comprised (1) direct application of test solutions on live tentacles (termed tentacle solution assay, or TSA) with single image- and video-microscopy; (2) spontaneous stinging assay using freshly excised tentacles overlaid on substrate of live human red blood cells suspended in agarose (tentacle blood agarose assays, or TBAA); and (3) a “skin” covered adaptation of TBAA (tentacle skin blood agarose assay, or TSBAA). We report the use and results of these assays to evaluate the efficacy of topical first-aid approaches to inhibit tentacle firing and venom activity. TSA results included the potent stimulation of massive cnidae discharge by alcohols but only moderate induction by urine, freshwater, and “cola” (carbonated soft drink). Although vinegar, the 40-year field standard of first aid for the removal of adherent tentacles, completely inhibited cnidae firing in TSA and TSBAA ex vivo models, the most striking inhibition of both tentacle firing and subsequent venom-induced hemolysis was observed using newly-developed proprietary formulations (Sting No More™) containing copper gluconate, magnesium sulfate, and urea.

Protective effects of batimastat against hemorrhagic injuries in delayed jellyfish envenomation syndrome models

Previously, we established delayed jellyfish envenomation syndrome (DJES) models and proposed that the hemorrhagic toxins in jellyfish tentacle extracts (TE) play a significant role in the liver and kidney injuries of the experimental model. Further, we also demonstrated that metalloproteinases are the central toxic components of the jellyfish Cyanea capillata (C. capillata), which may be responsible for the hemorrhagic effects. Thus, metalloproteinase inhibitors appear to be a promising therapeutic alternative for the treatment of hemorrhagic injuries in DJES. In this study, we examined the metalloproteinase activity of TE from the jellyfish C. capillata using zymography analyses. Our results confirmed that TE possessed a metalloproteinase activity, which was also sensitive to heat. Then, we tested the effect of metalloproteinase inhibitor batimastat (BB-94) on TE-induced hemorrhagic injuries in DJES models. Firstly, using SR-based X-ray microangiography, we found that BB-94 significantly improved TE-induced hepatic and renal microvasculature alterations in DJES mouse model. Secondly, under synchrotron radiation micro-computed tomography (SR-μCT), we also confirmed that BB-94 reduced TE-induced hepatic and renal microvasculature changes in DJES rat model. In addition, being consistent with the imaging results, histopathological and terminal deoxynucleotidyl transferase-mediated UTP end labeling (TUNEL)-like staining observations also clearly corroborated this hypothesis, as BB-94 was highly effective in neutralizing TE-induced extensive hemorrhage and necrosis in DJES rat model. Although it may require further clinical studies in the near future, the current study opens up the possibilities for the use of the metalloproteinase inhibitor, BB-94, in the treatment of multiple organ hemorrhagic injuries in DJES.

Jellyfish Stings: A Practical Approach

Jellyfish have a worldwide distribution. Their stings can cause different reactions, ranging from cutaneous, localized, and self-limited to serious systemic or fatal ones, depending on the envenoming species. Several first aid treatments are used to manage such stings but few have evidence behind their use. This review of the literature describes and discusses the different related first aid and treatment recommendations, ending with a summarized practical approach. Further randomized controlled trials in this field are needed.

Water envenomations and stings

Marine envenomations are an important part of sports medicine. Marine sport is practiced widely, and many aquatic envenomations require quick recognition and timely action to ensure the safety and recovery of victims. Even a basic knowledge of treatments of various envenomations could help clinicians be more effective in acute treatment. The purpose of this article is to review known literature and expand on recent progress in the field of aquatic envenomations.

Impact of stinging jellyfish proliferations along south Italian coasts: human health hazards, treatment and social costs

Stinging jellyfish outbreaks represent a health hazard, causing contact dermatitis and systemic reactions. This study investigated the epidemiology, severity, and treatment protocols of jellyfish stings in a coastal area with high tourist development and frequent stinging jellyfish outbreaks of the central Mediterranean (Salento, Southern Italy), and the associated costs for the Italian National Health Service. In 2007–2011, 1,733 bathers (mostly children and females) sought medical assistance following jellyfish stings, the main cause of human pathologies due to contact with marine organisms. The majority of events were reported in the years 2007–2009, whereas the occurrence of cnidarian jellyfish outbreaks has been increasingly reported in the same area since summer 2010. Most symptoms were limited to local and cutaneous reactions; conversely, 8.7% of cases evoked complications, mainly due to allergic reactions. The main drugs used were corticosteroids, locally applied and systemic (46% and 43%, respectively), and with ammonia (74%) as the main non-pharmacological treatment. The estimated cost of jellyfish-related first-aid services along the Salento coastline over the 5-year period was approximately 400,000 Euros. Therefore the management of jellyfish outbreak phenomena need coordinated research efforts towards a better understanding of underlying ecological mechanisms, together with the adoption of effective prevention policy, mitigation strategies, and appropriate planning of health services at tourist hot spots.

Interventions for the symptoms and signs resulting from jellyfish stings

BACKGROUND

Jellyfish envenomations are common amongst temperate coastal regions and vary in severity depending on the species. Stings result in a variety of symptoms and signs, including pain, dermatological reactions and, in some species, Irukandji syndrome (including abdominal/back/chest pain, tachycardia, hypertension, sweating, piloerection, agitation and sometimes cardiac complications). Many treatments have been suggested for the symptoms and signs of jellyfish stings. However, it is unclear which interventions are most effective.

OBJECTIVES

To determine the benefits and harms associated with the use of any intervention, in both adults and children, for the treatment of jellyfish stings, as assessed from randomised trials.

SEARCH METHODS

We searched the following electronic databases in October 2012 and again in October 2013: the Cochrane Central Register of Controlled Trials (CENTRAL;The Cochrane Library, Issue 9, 2013); MEDLINE via Ovid SP (1948 to 22 October 2013); EMBASE via Ovid SP (1980 to 21 October 2013); and Web of Science (all databases; 1899 to 21 October 2013). We also searched reference lists from eligible studies and guidelines, conference proceedings and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and contacted content experts to identify trials.

SELECTION CRITERIA

We included randomised controlled trials that compared any intervention(s) to active and/or non-active controls for the treatment of symptoms and signs of jellyfish sting envenomation. No language, publication date or publication status restrictions were applied.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted study selection and data extraction and assessed risk of bias using a standardised form. Disagreements were resolved by consensus with a third review author when necessary.

MAIN RESULTS

We included seven trials with a total of 435 participants. Three trials focused on Physalia (Bluebottle) jellyfish, one trial on Carukia jellyfish and three on Carybdea alata (Hawaiian box) jellyfish. Two ongoing trials were identified.Six of the seven trials were judged as having high risk of bias. Blinding was not feasible in four of the included trials because of the nature of the interventions. A wide range of interventions were assessed across trials, and a wide range of outcomes were measured. We reported results from the two trials for which data were available and reported the effects of interventions according to our definition of primary or secondary outcomes.Hot water immersion was superior to ice packs in achieving clinically significant (at least 50%) pain relief at 10 minutes (one trial, 96 participants, risk ratio (RR) 1.66, 95% confidence interval (CI) 1.01 to 2.72; low-quality evidence) and 20 minutes (one trial, 88 participants, RR 2.66, 95% CI 1.71 to 4.15; low-quality evidence). No statistically significant differences between hot water immersion and ice packs were demonstrated for dermatological outcomes.Treatment with vinegar or Adolph's meat tenderizer compared with hot water made skin appear worse (one trial, 25 participants, RR 0.31, 95% CI 0.14 to 0.72; low-quality evidence).Adverse events due to treatment were not reported in any trial.

AUTHORS' CONCLUSIONS

This review located a small number of trials that assessed a variety of different interventions applied in different ways and in different settings. Although heat appears to be an effective treatment for Physalia (Bluebottle) stings, this evidence is based on a single trial of low-quality evidence. It is still unclear what type of application, temperature, duration of treatment and type of water (salt or fresh) constitute the most effective treatment. In addition, these results may not apply to other species of jellyfish with different envenomation characteristics. Future research should further assess the most effective interventions using standardised research methodology.

Jellyfish stings and their management: a review

Jellyfish (cnidarians) have a worldwide distribution. Despite most being harmless, some species may cause local and also systemic reactions. Treatment of jellyfish envenomation is directed at: alleviating the local effects of venom, preventing further nematocyst discharges and controlling systemic reactions, including shock. In severe cases, the most important step is stabilizing and maintaining vital functions. With some differences between species, there seems to be evidence and consensus on oral/topical analgesics, hot water and ice packs as effective painkillers and on 30 s application of domestic vinegar (4%-6% acetic acid) to prevent further discharge of unfired nematocysts remaining on the skin. Conversely, alcohol, methylated spirits and fresh water should be carefully avoided, since they could massively discharge nematocysts; pressure immobilization bandaging should also be avoided, as laboratory studies show that it stimulates additional venom discharge from nematocysts. Most treatment approaches are presently founded on relatively weak evidence; therefore, further research (especially randomized clinical trials) is strongly recommended. Dissemination of appropriate treatment modalities should be deployed to better inform and educate those at risk. Adequate signage should be placed at beaches to notify tourists of the jellyfish risk. Swimmers in risky areas should wear protective equipment.

Prophylactic treatment of jellyfish stings--a randomised trial

BACKGROUND

Contact with jellyfish can cause skin irritation and manifestations. We wanted to investigate the prophylactic effect of a sun cream containing an inhibitor against jellyfish stings.

MATERIAL AND METHOD

We recruited 38 persons who were randomised such that each received two of three possible treatments, one on each underarm. Prophylactic treatment with sun cream containing jellyfish sting inhibitor, ordinary sun cream, and no cream. Their underarms were exposed to wet jellyfish tentacles in a watchglass. The following were recorded: time before pain, skin changes after four minutes, and pain intensity after 10 minutes, registered on a VAS scale.

RESULTS

Thirteen of 25 subjects who had the sun cream with jellyfish sting inhibitor did not register any pain after 4 minutes' exposure, compared with two of 25 and two of 26 who had received pre-treatment with ordinary sun cream (p &equals; 0.32) and no pre-treatment (p < 0.001), respectively. On average, subjects who had received prophylactic treatment with sun cream containing jellyfish sting inhibitor recorded a lower VAS score for pain/discomfort after 10 minutes. The difference was 10.6 mm (95 % CI 3.1-17.9) compared with ordinary sun cream and 14.2 mm (95 % CI 6.9-21.5) compared with no pre-treatment. A smaller number of subjects were found to have underarms with inflamed skin when prophylactic cream containing jellyfish sting inhibitor was used (6 of 25) than when ordinary sun cream was used (11 of 25) or no pre-treatment (12 of 26). There were no statistically significant differences between ordinary sun cream and no pre-treatment for any of the three outcomes.

INTERPRETATION

Prophylactic treatment with jellyfish sting inhibitor reduces the risk of subjects developing symptoms after exposure to jellyfish tentacles.

Seabather's eruption: a clinical and epidemiological study of 38 cases in Santa Catarina State, Brazil

Seabather's eruption (SBE) is an intensely itchy, papule-erythematous dermatitis that occurs predominantly in regions of the body covered by bathing costumes, after exposure to marine water. The planulae larvae of Linuche unguiculata scyphomedusae (thimble jellyfish) are the etiologic agent of the dermatitis, which is frequent in waters of Caribbean, Gulf of Mexico and Florida. The authors report 38 cases of SBE in the State of Santa Catarina (Southern region of Brazil), with emphasis on their clinical and epidemiological aspects, such as profile of victim, topography of the papules and conditions predisposing to the accident.

Active nematocyst isolation via nudibranchs

Cnidarian venoms are potentially valuable tools for biomedical research and drug development. They are contained within nematocysts, the stinging organelles of cnidarians. Several methods exist for the isolation of nematocysts from cnidarian tissues; most are tedious and target nematocysts from specific tissues. We have discovered that the isolated active nematocyst complement (cnidome) of several sea anemone (Cnidaria: Anthozoa) species is readily accessible. These nematocysts are isolated, concentrated, and released to the aqueous environment as a by-product of aeolid nudibranch Spurilla neapolitana cultures. S. neapolitana feed on venomous sea anemones laden with stinging nematocysts. The ingested stinging organelles of several sea anemone species are effectively excreted in the nudibranch feces. We succeeded in purifying the active organelles and inducing their discharge. Thus, our current study presents the attractive possibility of using nudibranchs to produce nematocysts for the investigation of novel marine compounds.

Skin and systemic manifestations of jellyfish stings in iraqi fishermen

BACKGROUND

Jellyfish stings are common worldwide with an estimated 150 million cases annually, and their stings cause a wide range of clinical manifestations from skin inflammation to cardiovascular and respiratory collapse. No studies on jellyfish stings have been carried out in Basra, Iraq.

OBJECTIVES

To describe the immediate and delayed skin reactions to White Jellyfish (Rhizostoma sp.) stings and the types of local treatment used by fishermen.

METHODS AND MATERIALS

150 fishermen were enrolled at three Marine stations in Basra, Iraq. Demographic data, types of skin reactions, systemic manifestations and kinds of treatments were collected.

RESULTS

Overall, 79% of fishermen in all three Marine stations gave a history of having been stung. The common sites of sings were the hands and arms followed by the legs. Most fishermen claimed that stings led to skin reactions within 5 minutes. The presenting complaints were itching, burning sensation, and erythematic wheals. A few days after the sting, new groups of painless and itchy erythematous monomorphic papular rashes developed at the site of the sting in 62% of cases as a delayed type of skin reaction that resolved spontaneously. The local remedies commonly used by the fishermen were seawater, tap water and ice. A few fishermen considered stings as insignificant and did not think there was a need to seek medical help.

CONCLUSIONS

We conclude that jellyfish causes many stings among fishermen in the Basra region. Their stings lead to immediate and delayed skin reactions. Self-treatment by topical remedies is common.