Correspondence

Stonefish Envenomation

N Engl J Med 1993; 329:510-511August 12, 1993

Article

To the Editor:

The stonefish (synanceja) is a member of the scorpion fish family and lives in shallow waters of the Indo-Pacific region. Its length averages 15 cm, with 13 venomous spines located on the dorsal surface. Although stonefish envenomation is believed to be potentially lethal, actual reports of life-threatening illness largely reflect information obtained secondhand1,2. In most cases, symptoms are limited to severe local manifestations in the involved extremity. Some have entirely dismissed the idea that stonefish envenomations may cause serious systemic toxicity3,4. Pulmonary edema has been reported to occur after jellyfish stings5. We report a patient in whom radiographically documented pulmonary edema developed after a stonefish envenomation.

A previously healthy 34-year-old man was wading barefoot in 2 ft (0.6 m) of water on a coral reef when he felt a sharp pain in his foot. A stonefish was sighted by his companion. At no time did his head go under the water. Over the next 15 minutes, he became severely dyspneic.

In the emergency room, about 35 minutes after the injury, the physical examination revealed a man in severe distress, spewing blood-tinged sputum. He had a respiratory rate of 60 and a pulse of 140 per minute. Six puncture wounds were present on the sole of his left foot (Figure 1Figure 1The Foot of a Man with Stonefish Envenomation.). The area immediately surrounding the puncture sites had a dusky appearance, with edema and erythema extending to the ankle. The partial pressure of oxygen was 61 mm Hg while he was breathing 100 percent oxygen through a nonrebreathing mask. A chest film showed diffuse, fluffy, bilateral infiltrates (Figure 2Figure 2Chest Film of a Man after Stonefish Envenomation.). Radiographs of the foot did not reveal evidence of retained spines.

The patient was intubated and mechanically ventilated. Antivenom (6000 units of horse serum hyperimmunized with synanceja; Commonwealth Serum Labs, Melbourne, Australia) was given parenterally. Tetanus prophylaxis was administered. The foot was immersed in hot water for about 45 minutes, and the wound was debrided. The ventilation tube was removed the next morning. The lungs were clear on auscultation; the patient was breathing normally with a room-air oxygen saturation of 93 percent. One week later, the foot had mild residual soft-tissue edema, but the wound was clean and dry. No permanent impairment was anticipated.

Stonefish venom causes marked increases in vascular permeability,6 resulting in pulmonary edema in laboratory animals7. Pulmonary edema due to this venom has been suspected previously in humans on the basis of the clinical examination3 or secondhand testimony4. This case suggests that stonefish envenomation can indeed cause serious systemic illness, which can be promptly reversed by the administration of antivenom.

David F. Lehmann, M.D., Pharm.D.
John C. Hardy, D.O.
Commonwealth Health Center, Saipan, MP 96950

7 References

1. 1

   Wiener S. Stone-fish sting and its treatment. Med J Aust 1958;2:218-222
   

2. 2

   Smith JLB. Two rapid fatalities from stonefish stabs. Copeia 1957;3:249-249
   CrossRef

3. 3

   Flecker H. Injuries from stone fish. Med J Aust 1956;2:371-373
   

4. 4

   Sorokin M. Medical hazards of the coral reef. Trans R Soc Trop Med Hyg 1975;69:94-98
   CrossRef | Web of Science | Medline

5. 5

   Fenner PJ, Williamson JA, Burnett JW, et al. The “Irukandji syndrome” and acute pulmonary edema. Med J Aust 1988;149:150-156
   Web of Science | Medline

6. 6

   Khoo HE, Yuen R, Poh CH, Tan CH. Biological activities of Synanceja horrida (stonefish) venom. Natural Toxins 1992;1:54-60
   CrossRef | Medline

7. 7

   Kreger AS. Detection of a cytolytic toxin in the venom of the stonefish (Synanceia trachynis). Toxicon 1991;29:733-743
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   Gregory P. Wedin, Daniel E. Keyler, Elisabeth F. Bilden. 2009. Poisons of Animal Origin. .
   CrossRef

2. 2

   Douglas Boletini-Santos, Evilin Naname Komegae, Suely G. Figueiredo, Vidal Haddad, Mônica Lopes-Ferreira, Carla Lima. (2008) Systemic response induced by Scorpaena plumieri fish venom initiates acute lung injury in mice. Toxicon 51:4, 585-596
   CrossRef

3. 3

   M.C.E. Gwee, P. Gopalakrishnakone, R. Yuen, H.E. Khoo, K.S.Y. Low. (1994) A review of stonefish venoms and toxins. Pharmacology & Therapeutics 64:3, 509-528
   CrossRef