A painful swollen thumb Dr. Law chi yin PYNEH A&E

A painful swollen thumbA painful swollen thumb

Dr. Law chi yinDr. Law chi yin

PYNEH A&EPYNEH A&E


A lady age around 60 A lady age around 60

Sudden severe thumb pain for one hour Sudden severe thumb pain for one hour after stung by a fish spine while preparing after stung by a fish spine while preparing the fish for dinnerthe fish for dinner

The fish was caught by her son in the The fish was caught by her son in the nearby piernearby pier

Her son said that the fish was a stonefishHer son said that the fish was a stonefish


Would you believe him?Would you believe him?

Could he catch a stonefish near a pier in Could he catch a stonefish near a pier in Hong Kong?Hong Kong?

Was the severe thumb pain due to Was the severe thumb pain due to stonefish envenomation?stonefish envenomation?


On examination:On examination:– Blood pressure and pulse were stableBlood pressure and pulse were stable– Marked swelling of her left thumb and hand Marked swelling of her left thumb and hand

notednoted– Mild redness and hot onlyMild redness and hot only– No foreign body found in the woundNo foreign body found in the wound

The lady’s injury hand The lady’s injury hand

The lady’s injury handThe lady’s injury hand

The lady’s injury handThe lady’s injury hand

Treatment given in A&ETreatment given in A&E

ATT ATT Analgesic injection Analgesic injection Warm water bath Warm water bath Kept in observation wardKept in observation ward– SymptomsSymptoms– Vital signs Vital signs – Monitoring size of swellingMonitoring size of swelling

Asked her son to bring back the fish body Asked her son to bring back the fish body for examinationfor examination


Two hours laterTwo hours later

The fish body was brought to A&EThe fish body was brought to A&E

The size was just as the length of a tongue The size was just as the length of a tongue depressordepressor

The fish body looked like a stone The fish body looked like a stone

The secret fishThe secret fish



The color was brown and grey The color was brown and grey

Mouth and eyes point upwardMouth and eyes point upward

The dorsal spines were cut by the ladyThe dorsal spines were cut by the lady

What was the secret fish?What was the secret fish?

stonefishstonefish

Identification Guide to Identification Guide to Fishes in the Live Fishes in the Live Seafood Trade of the Seafood Trade of the Asia-Pacific Region. Asia-Pacific Region.

Published by Published by – WWF Hong KongWWF Hong Kong– Agriculture, Fisheries and Agriculture, Fisheries and

Conservation Department. Conservation Department. Hong KongHong Kong

stonefish stung injurystonefish stung injury

Swelling and pain persisting despite warm Swelling and pain persisting despite warm water bathwater bath

Skin blister found near puncture siteSkin blister found near puncture site

Swelling extend up to forearmSwelling extend up to forearm

no muscle weakness, dyspnea and no muscle weakness, dyspnea and hypotensionhypotension


Blister was clear, no pusBlister was clear, no pus

Aspiration done in observation, Aspiration done in observation,

Oral ciprofloxacin started Oral ciprofloxacin started


Pros and cons of Stonefish antivenom Pros and cons of Stonefish antivenom discussed discussed

She refused antivenom for fear of possible She refused antivenom for fear of possible allergic reactionallergic reaction


Pain and swelling static during observationPain and swelling static during observation

She was discharged with oral antibioticShe was discharged with oral antibiotic

Follow up 3 days laterFollow up 3 days later


She came back 10 hours later after She came back 10 hours later after leaving A&Eleaving A&E

pain and size of bulla increasing pain and size of bulla increasing

No evidence of tendinosynovitis No evidence of tendinosynovitis

Distal pulse and capillary circulation was Distal pulse and capillary circulation was goodgood

She was admitted to orthopedic ward for She was admitted to orthopedic ward for puncture site cellulitis puncture site cellulitis


Management in orthopedic wardManagement in orthopedic ward– Wound dressingWound dressing– IV antibioticIV antibiotic– Patch of superficial skin necrosis noted on Patch of superficial skin necrosis noted on

day 3, no debridement doneday 3, no debridement done– Pain and swelling subsided with conservative Pain and swelling subsided with conservative

treatmenttreatment– No antivenom givenNo antivenom given

What is stonefish and its What is stonefish and its venom?venom?

Venomous marine fishVenomous marine fish

Family Scorpaenidae Family Scorpaenidae – PteroisPterois - lionfish - lionfish – ScorpaenaScorpaena – scorpionfish – scorpionfish– SynanceiaSynanceia - stonefish - stonefish

stonefishstonefish

The most venomous The most venomous fish in the worldfish in the world

13 dorsal spines 13 dorsal spines contains venom. contains venom.

The severity of the The severity of the envenomation envenomation depends on the depth depends on the depth and number of and number of penetrationpenetration

stonefishstonefish

stonefish envenomation killed many stonefish envenomation killed many Pacific and Indian Ocean islanders in pre-Pacific and Indian Ocean islanders in pre-antivenom period.antivenom period.

1st antivenom developed in 1959 1st antivenom developed in 1959

stonefish venomstonefish venom

3 deaths reported in the literature3 deaths reported in the literature

1 case direct intravascular envenomation 1 case direct intravascular envenomation (Mozambique, 1957) (Mozambique, 1957)

2 other deaths occurring days or months 2 other deaths occurring days or months after envenomation, ? wound infection or after envenomation, ? wound infection or tetanustetanus

stonefish venomstonefish venom

The venom heat-labile proteinsThe venom heat-labile proteins4 biologically active factors: 4 biologically active factors:

1.1. hyaluronidase fraction hyaluronidase fraction 2.2. capillary permeability factorcapillary permeability factor3.3. a toxic or lethal fraction (Stonustoxin)a toxic or lethal fraction (Stonustoxin)4.4. pain producing factorpain producing factor

The 1&2 factors cause edemaThe 1&2 factors cause edemaThe Stonustoxin is myo- and neurotoxic The Stonustoxin is myo- and neurotoxic and cause shock and cause shock

What are the clinical features of What are the clinical features of stonefish envenomation and stonefish envenomation and

treatment?treatment?

Symptoms of envenomationSymptoms of envenomation

Systemic effects Systemic effects – NauseaNausea– muscle weaknessmuscle weakness– DyspneaDyspnea– hypotensionhypotension

Symptoms of envenomationSymptoms of envenomation

PainPain– Immediately localized painImmediately localized pain– spread to involve limb in 90 minutesspread to involve limb in 90 minutes– lasting up to 12 hours if untreatedlasting up to 12 hours if untreated– Mild subsequent pain may persist for days to Mild subsequent pain may persist for days to

weeks.weeks.

Signs of envenomed woundSigns of envenomed wound

Discolored by a surrounding ring of bluish Discolored by a surrounding ring of bluish cyanotic tissuecyanotic tissueSubsequent edema, erythema, and Subsequent edema, erythema, and warmth may involve the entire limbwarmth may involve the entire limbtissue necrosis in the absence of tissue necrosis in the absence of secondary infection (rarely)secondary infection (rarely)Vesicle formation (hands) may be followed Vesicle formation (hands) may be followed by rapid tissue sloughing and cellulitisby rapid tissue sloughing and cellulitis

Tissue reaction of envenomationTissue reaction of envenomation

Patel and Wells describe 3 grades of tissue Patel and Wells describe 3 grades of tissue reaction in Lionfish envenomation (reaction in Lionfish envenomation (Pterosis Pterosis volitansvolitans, Family , Family Scorpaenidae)Scorpaenidae)– erythematous reactionerythematous reaction– blister formation blister formation – dermal necrosisdermal necrosis

They have recommended early blister excision They have recommended early blister excision to prevent tissue necrosis to prevent tissue necrosis The blister fluid contain residual active venomThe blister fluid contain residual active venom

Goal of treatmentGoal of treatment

Control painControl pain– Warm water bathWarm water bath– AnalgesicAnalgesic– Local anesthesiaLocal anesthesia– AntivenomAntivenom

Goal of treatmentGoal of treatment

Wound managementWound management– Removal of foreign bodiesRemoval of foreign bodies– DebridementDebridement

Prevent infections in high-risk woundsPrevent infections in high-risk wounds– ATTATT– IV or oral board spectrum antibioticsIV or oral board spectrum antibiotics

Singapore experienceSingapore experience

8 cases of stonefish (8 cases of stonefish (Synanceia sp.Synanceia sp.) ) envenomation in 1.25 years time envenomation in 1.25 years time – Ann Acad Med Singapore 2004;33:515-20Ann Acad Med Singapore 2004;33:515-20

50% cases fish was identify by direct 50% cases fish was identify by direct visualization (fish body was brought to visualization (fish body was brought to A&E )A&E )

Caused severe pain and gross edema Caused severe pain and gross edema of the affected limb of the affected limb


Treatment givenTreatment given– hot water (45ºC) bathhot water (45ºC) bath– analgesiaanalgesia– tetanus prophylaxistetanus prophylaxis– broad-spectrum antibioticsbroad-spectrum antibiotics– Specific antivenom is available but not Specific antivenom is available but not

usedused– Surgical debridementSurgical debridement


Length of hospital stay averaged 3.9 Length of hospital stay averaged 3.9 daysdays

no deaths or systemic morbidityno deaths or systemic morbidity

1 case required surgical debridement 1 case required surgical debridement for local necrosis for local necrosis

Average time for complete resolution Average time for complete resolution was 8.2 days was 8.2 days


ConclusionsConclusions– majority of stonefish envenomations do majority of stonefish envenomations do

not result in significant or protracted not result in significant or protracted morbidity morbidity

– supportive treatment is adequatesupportive treatment is adequate– Systemic morbidity and mortalities are Systemic morbidity and mortalities are

rare. rare.

Is antivenom useful?Is antivenom useful?

Stonefish antivenomStonefish antivenom

Has beneficial effect in relieving the pain oHas beneficial effect in relieving the pain of envenomation f envenomation

40 years of unpublished experience and c40 years of unpublished experience and cases report ases report

Effect of stonefish antivenom other venomEffect of stonefish antivenom other venomous fish sting remains uncertain ous fish sting remains uncertain

J Toxicol Clin Toxicol. 2003;41(3):301-8J Toxicol Clin Toxicol. 2003;41(3):301-8

Australia's Commonwealth Serum Australia's Commonwealth Serum Laboratories (CSL Ltd)Laboratories (CSL Ltd)

The sole manufacturer of antivenoms for The sole manufacturer of antivenoms for human use in Australia. human use in Australia.

Australian antivenoms are amongst the Australian antivenoms are amongst the best in the world, in terms of purity and best in the world, in terms of purity and adverse reaction rate adverse reaction rate

stonefish antivenomstonefish antivenom

It produced by immunizing horses against It produced by immunizing horses against the stonefish venom the stonefish venom The horse’s serum antibodies is purified The horse’s serum antibodies is purified and fragmented by a series of digestion and fragmented by a series of digestion and processing stepsand processing stepsIt neutralise the effects of the stonefish It neutralise the effects of the stonefish envenomation envenomation – http://www.pharmacology.unimelb.edu.au/http://www.pharmacology.unimelb.edu.au/

avruweb/Venoms.htmavruweb/Venoms.htm

Ingredients of the antivenomIngredients of the antivenom

It contains 2,000 units of antivenom in 1.5 It contains 2,000 units of antivenom in 1.5 to 3 mL of liquid. to 3 mL of liquid.

It also contains It also contains – phenol as a preservativephenol as a preservative– sodium chloridesodium chloride– substances found in horse blood.substances found in horse blood.

IndicationsIndications for antivenom for antivenom

Severe pain Severe pain

Systemic featuresSystemic features– Shock, weakness, paralysisShock, weakness, paralysis

large amount of venom large amount of venom – multiple punctures multiple punctures

Contra-indication for Contra-indication for antivenomantivenom

those who have no serious effects of those who have no serious effects of envenomationenvenomation

Severe allergy reaction to skin test or Severe allergy reaction to skin test or horse serum producthorse serum product

Dosage of antivenomDosage of antivenom

same for both adults and children same for both adults and children

It depends on the number of puncture sites from It depends on the number of puncture sites from the spines on the stonefish:the spines on the stonefish:– 1 - 2 punctures the dose is 1 vial (2,000 units)1 - 2 punctures the dose is 1 vial (2,000 units)– 3 - 4 punctures the dose is 2 vials (4,000 units)3 - 4 punctures the dose is 2 vials (4,000 units)– 5 or more punctures the dose is 3 vials (6,000 units). 5 or more punctures the dose is 3 vials (6,000 units).

Dosage of antivenomDosage of antivenom

The injection is intramuscularly and can be The injection is intramuscularly and can be repeated if necessary. repeated if necessary.

It is occasionally diluted and injected into a It is occasionally diluted and injected into a vein. vein.

Adverse reactionAdverse reaction

Anaphylaxis Anaphylaxis

Serum sicknessSerum sickness

Serum sickness of antivenomSerum sickness of antivenom

Clinical featuresClinical features– RashRash– swollen glandsswollen glands– joint painsjoint pains– fever may fever may

occur anytime in the first 2 weeks after occur anytime in the first 2 weeks after injectioninjection2 cases had been reported after stonefish 2 cases had been reported after stonefish antivenomantivenom

Prevention of serum sicknessPrevention of serum sickness

Pretreatment is advocatedPretreatment is advocated– Adrenaline SC/IMIAdrenaline SC/IMI– AntihistamineAntihistamine– CorticosteroidCorticosteroid

Skin testing for allergy to antivenom is not Skin testing for allergy to antivenom is not recommended, as it is unreliable and may recommended, as it is unreliable and may delay urgent therapy delay urgent therapy

Prevention of serum sicknessPrevention of serum sickness

Corticosteroids delay both the incidence Corticosteroids delay both the incidence and severity of serum sicknessand severity of serum sickness

should be considered if a large volume of should be considered if a large volume of antivenom givenantivenom given

Marine wound infections Marine wound infections

All marine injuries are at risk of secondary infection, antibiotics are recommended High risk wound– deep puncture wounds– grossly contaminated wounds, – hand and foot (high incidence of ulceration

necrosis)– persons who are chronically ill or

immunocompromised

Marine wound infectionsMarine wound infections

Common bacteria– erysipelothrix rhusiopathiae – mycoplasma marinum – vibrio and aeromonas

Erysipelothrix rhusiopathiaeErysipelothrix rhusiopathiae(( 紅斑丹毒絲菌紅斑丹毒絲菌 ))

Fish handler's diseaseFish handler's disease

acquired through skin abrasion and minor wound acquired through skin abrasion and minor wound while handling marine animalswhile handling marine animals

especially fish and shellfishespecially fish and shellfish

It appears as a well-demarcated cellulitis It appears as a well-demarcated cellulitis characterized by erythema, edema, and warmth.characterized by erythema, edema, and warmth.

Erythromycin, cephalexin, and penicillin VK are Erythromycin, cephalexin, and penicillin VK are all referenced as appropriate first-line treatmentall referenced as appropriate first-line treatment

Mycoplasma marinum Mycoplasma marinum (( 海魚分枝桿菌海魚分枝桿菌 ))

Present with chronic suppurative and Present with chronic suppurative and granulomatous lesions granulomatous lesions

After contact contaminated seawaterAfter contact contaminated seawater

Local debridement, adequate drainage, Local debridement, adequate drainage, and a prolonged antibiotic course and a prolonged antibiotic course (doxycycline, clotrimazole) are essential(doxycycline, clotrimazole) are essential

Vibrio and Aeromonas species

Vibrio Vibrio speciesspecies– VulnificusVulnificus– ParahaemolyticusParahaemolyticus– damseladamsela

AeromonasAeromonas species species– ParahaemolyticusParahaemolyticus– alginolyticusalginolyticus


The most serious marine infections The most serious marine infections

may result in the loss of a limb or deathmay result in the loss of a limb or death– Necrotizing fasciitisNecrotizing fasciitis– CellulitisCellulitis– MyositisMyositis– gas gangrenegas gangrene– SepsisSepsis


Vibrio vulnificusVibrio vulnificus septicemia has a 20-50% septicemia has a 20-50% mortality mortality

Require IV antibiotic and ICU careRequire IV antibiotic and ICU care

AeromonasAeromonas infections may mimic infections may mimic clostridial gangrene. clostridial gangrene.

Antibiotic therapy should be guided by Antibiotic therapy should be guided by wound swab culture resultswound swab culture results

Stonefish sting: Stonefish sting: an occupational hazard in an occupational hazard in

Hong KongHong Kong

Chan TY, Tam LS, Chan LY Chan TY, Tam LS, Chan LY Department of Clinical Pharmacology, CUHKDepartment of Clinical Pharmacology, CUHK

–Ann Trop Med Parasitol. 1996 Dec;90(6):675-6.Ann Trop Med Parasitol. 1996 Dec;90(6):675-6.

Reference websitesReference websites

http://www.emedicine.com/emerg/topic300.htmhttp://www.emedicine.com/emerg/topic300.htmhttp://annals.edu.sg/pdf200408/V33N4p515.pdfhttp://annals.edu.sg/pdf200408/V33N4p515.pdfhttp://www.wwf.org.hk/eng/pdf/conservation/wl_trade/idmhttp://www.wwf.org.hk/eng/pdf/conservation/wl_trade/idm_popularfish/idm19_S_verrucosa.pdf_popularfish/idm19_S_verrucosa.pdfhttp://www.csl.com.au/http://www.csl.com.au/http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrihttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=22691281eve&db=PubMed&dopt=Abstract&list_uids=22691281http://www.pharmacology.unimelb.edu.au/avruweb/Venohttp://www.pharmacology.unimelb.edu.au/avruweb/Venoms.htmms.htmhttp://www.pharmacology.unimelb.edu.au/avruweb/creathttp://www.pharmacology.unimelb.edu.au/avruweb/creatable.htmlable.html

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A painful swollen thumb Dr. Law chi yin PYNEH A&E