QJM Advance Access originally published online on October 12, 2006
QJM 2006 99(11):803-804; doi:10.1093/qjmed/hcl106
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Correspondence |
Response
Department of Emergency Medicine
Sir Charles Gairdner Hospital
Nedlands
Australia
email: angimark{at}iinet.net.au
Sir,
On behalf of the authors I am delighted in Drs Gershwin and Fenner's interest in our letter.
Dr Gershwin's work has importantly taxonomically defined a number of cubozoan jellyfish. In our table we inadvertedly misreferenced one of her papers; we should have referred to her Memoirs of Queensland Museum 2005 paper,1 not her Zootaxa 2005 paper,2 and we apologize for this oversight.
Our letter is the first report where the jellyfish stinging the patient that subsequently developed Irukandji syndrome were captured at the time of the sting and identified. Other than Barnes's original report, this has not been documented elsewhere.3 The evidence that Gershwin cites for Alatina mordens, Malo maxima, Carybdea alata and ‘fire jellies’ is based on jellyfish being seen or caught in the vicinity of the patient being stung (not invariably at the same time). These jellyfish often have a bell size of approximately 30–40 mm, and after reading Gershwin's detailed taxonomical reports,1,2 it seems doubtful that an eye-witness could accurately identify what sort of cubozoan he was seeing in the water.
In the case of Malo maxima, named after a patient that our toxicology service managed through his ICU and hospital stay, this cubozoan was captured on a pearling boat 3 months after and some kilometres from the beach the patient was stung,2 and the symptoms reported in our letter are significantly different to those of the patient this jellyfish is named after.
I sense that Gershwin may agree with our claim that Carybdea xaymacana causes Irukandji syndrome, although there are many jellyfish in the Perth waters, and the evidence she cites is circumstantial. The cubozoans we report were captured within metres and around the patients being stung, at the time they were being stung. It was our opinion that the patients were swimming in a swarm of C. xaymacana. The nets used have successfully captured many Carukia barnesi.
Well before the publication of Dr Fenner's excellent textbook,4 Barnes originally described a milder version of Irukandji syndrome, that he named ‘pseudo-Irukandji syndrome’.5 In Dr Fenner's report of Morbakka causing Irukandji syndrome, a 12-year-old girl was stung on her shoulder by a long tentacle that slid into the water.6 Her father saw a jellyfish in the water and identified it as Morbakka from photographs of this jellyfish. The child developed mild back pain that settled with paracetamol and antihistamine. Fenner and his colleagues subsequently described how they placed a tentacle from Morbakka on the arm of one of them, and the subject did not develop Irukandji syndrome, only symptoms around the welt. Again, this is not conclusive evidence of causation.
In our ‘fire jelly’ case, the nematocysts recovered from our patient's skin were identical to those from the cubozoan captured by the patient at the time of her sting. These nematocysts (and the cubozoan captured) are different from the Morbakka described by Fenner et al.6
Anyone involved in the regular management of envenomed patients in Australia will be aware of the distress that the Australian public and medical profession experienced with the white-tailed spider and its presumed association with necrotic ulcers. For this reason, accurate identification of envenoming creatures is essential.
Some of these cubozoans have previously been suspected of causing Irukandji syndrome, but much of the evidence has been circumstantial. We believe we have presented good evidence identifying five cubozoans that cause Irukandji syndrome. We know there is much that is unknown about Irukandji syndrome, however with collaborative work and sharing of expertise between scientists and clinicians we will slowly come to understand more of this condition.
References
1. Gershwin L. Carybdea alata auct. and Manokia stiasnyi, reclassification to a new family with description of a new genus and two new species. Memoirs of the Queensland Museum 2005; 51:501–23.[Medline]
2. Gershwin L. Two new species of jellyfishes (Cnidaria: Cubozoa: Carybdeida) from tropical Western Australia, presumed to cause Irukandji Syndrome. Zootaxa 2005; 1084:1–30.
3. Barnes JH. Cause and effect in Irukandji stingings. Med J Aust 1964; 14:897–904.[Medline]
4. In Williamson J, Fenner P, Burnett J, Rifkin J (Eds.). Venomous and Poisonous Marine Animals: a Medical and Biological Handbook1996;Sydney, Australia NSW Press.
5. Kinsey B. More Barnes on Box Jellyfish1988;Townsville, Australia James Cook University.
6. Fenner PJ, Fitzpatrick PF, Hardwick RJ, Skinner R. Morbakka another cubomedusan. Med J Aust 1985; 143:550–5.[ISI][Medline]
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