Unique report details the dermatological progression and effective treatment of a severe jellyfish sting

Experts describe in Wilderness & Environmental Medicine what patients and clinicians should expect after a severe jellyfish sting and recommend how to manage this for best results in the field and throughout follow-up treatment

Philadelphia, September 4, 2019

A detailed case report and comprehensive sequence of photographs in Wilderness & Environmental Medicine, published by Elsevier, document the dermatological progression of a patient stung by a jellyfish off the coast of Cambodia. The aim of this report is to guide clinicians and patients to understand what to expect after such a sting and steps to increase the probability of a full recovery.

Jellyfish stings (envenomations) are a common affliction of ocean goers worldwide. Although many are simply a nuisance, some can be very severe or even fatal. The most severe non-anaphylactic reactions are caused by jellyfish species that inhabit Indo-Pacific waters. Examples of species known to be clinically dangerous include the box jellyfish (Chironex fleckeri), sea nettle (Chrysaora quinquecirrha), and Irukandji (Carukia barnesi).

“In this report, we provide written and visual details of the natural progression of a probable box jellyfish envenomation that originated in waters off Cambodia,” explained lead author Paul S. Auerbach, MD, Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA, USA. “We document a comprehensive visual demonstration of what patients and clinicians should expect after a severe sting by box jellyfish or similarly injurious species.”

The patient (a co-author of this report) was a 21-year-old woman in good health at the time of injury in early June 2019. She was stung while swimming off the coast of Koh Ta Kiev, Cambodia, in chest-deep water. She experienced immediate and intense burning pain to her right leg that gradually subsided over the next 10 hours, bright red and swollen streaks where tentacles had contacted the skin of the right thigh, and lightheadedness with a brief loss of consciousness after leaving the water within 20 minutes of the sting. She did not see the jellyfish well enough to identify precisely the species, but multiple species of box-type jellyfish are known to live in these waters.

Envenomation, Day 2

With worsening symptoms, the patient travelled to Siem Reap where she was admitted to Royal Angkor International Hospital overnight. She then travelled to Bali. Dr. Auerbach telephoned the patient and recommended that she return to California promptly to receive the medical care necessary to attempt healing without complications and gave her detailed advice for managing the wound during the journey.

After arriving in the United States, the patient was seen by a dive medicine specialist physician and a plastic surgeon. Physical examination was consistent with superficial and deep partial thickness burns, possibly with near full thickness injury in some areas. She was advised to continue washing the wounds and to clean and dress the wounds using silver sulfadiazine topical cream in the deeper areas and Leptospermum honey (Medihoney) in the shallower areas. The immediate goals were to keep the wounds clean, prevent infection, maintain moisture to facilitate healing, and allow for serial examinations to determine the best method for wound closure.

After 60 days the wound was fully closed and healed. Moisturizing lotion and sun protection measures were continued to optimize scar maturation. The patient was counseled that she might be a candidate for elective scar revision, steroid treatment, and/or laser therapy in the future.

“With knowledgeable consultation from experienced physicians and meticulous care, this injury healed without the need for skin grafting,” reported Dr. Auerbach.

"The authors have provided an exceptionally detailed photographic timeline of the case,” added Neal W. Pollock, PhD, Department of Kinesiology, Laval University, Quebec, QC, Canada, and Editor-in-Chief of Wilderness & Environmental Medicine. “It provides excellent documentation of the evolution that will rarely be seen."


Notes for editors
The article is “Dermatological Progression of a Probable Box Jellyfish Sting,” by Paul S. Auerbach, MD; Deepak Gupta, MD; Karen Van Hoesen, MD; and Adriana Zavala, BSN (https://doi.org/10.1016/j.wem.2019.05.004). It appears in Wilderness & Environmental Medicine, volume 30, issue 3 (September 2019) published by Elsevier.

It is openly available at www.wemjournal.org/article/S1080-6032(19)30099-7/fulltext.

Full text of this article is also available to credentialed journalists upon request. Contact Theresa Monturano at +1 215 239 3711 or hmsmedia@elsevier.com to obtain copies. Journalists wishing to interview the authors should contact Paul S. Auerbach, MD, at paul.auerbach@gmail.com.

About Wilderness & Environmental Medicine
Wilderness & Environmental Medicine
(WEM), the official journal of the Wilderness Medical Society, is a peer-reviewed international journal for physicians practicing medicine in austere environments. It is devoted to original scientific and technical contributions on the practice of medicine defined by isolation, extreme natural environments, and limited access to medical help and equipment. Examples of topics covered include high altitude and climbing; hypothermia and cold-induced injuries; drowning and near-drowning; hazardous plants, reptiles, insects, and marine animals; animal attacks; search and rescue. www.wemjournal.org

About the Wilderness Medical Society
Founded in 1983, the Wilderness Medical Society (WMS) is the world's leading organization devoted to wilderness medical challenges. Wilderness medicine topics include expedition and disaster medicine, dive medicine, search and rescue, altitude illness, cold- and heat-related illness, wilderness trauma, and wild animal attacks. WMS explores health risks and safety issues in extreme situations such as mountains, jungles, deserts, caves, marine environments, and space. For more information on the WMS, please visit us at www.wms.org.

About Elsevier
Elsevier is a global information analytics business that helps scientists and clinicians to find new answers, reshape human knowledge, and tackle the most urgent human crises. For 140 years, we have partnered with the research world to curate and verify scientific knowledge. Today, we’re committed to bringing that rigor to a new generation of platforms. Elsevier provides digital solutions and tools in the areas of strategic research management, R&D performance, clinical decision support, and professional education; including ScienceDirect, Scopus, SciVal, ClinicalKey and Sherpath. Elsevier publishes over 2,500 digitized journals, including The Lancet and Cell, 39,000 e-book titles and many iconic reference works, including Gray's Anatomy. Elsevier is part of RELX, a global provider of information-based analytics and decision tools for professional and business customers. www.elsevier.com

Media contact
Theresa Monturano
+1 215 239 3711