Venomous Creatures: Stonefish and Lionfish Envenomation

Scorpionfish are a family of fish that sting victims with sharp spines covered in venom. Venom glands, located at the base of the spine, inject venom once the spines are embedded in the victim. While the location and composition of venom vary by species, all scorpionfish envenomations cause extremely painful wounds, and in rare cases, can cause systemic symptoms. Although hundreds of species exist, the most commonly encountered scorpionfish that cause human injury are stonefish and lionfish.

Stonefish

Stonefish venom contains stonustoxin, a potent cytotoxin leading to local cell death, verrucotoxin, a calcium channel agonist that causes cardiotoxicity, and trachynilysin which stimulates acetylcholine release from nerve endings resulting in neurotoxicity. Wounds are typically localized and necrotic with regional lymphadenopathy. Systemic effects from stonefish envenomation include anxiety, paralysis, and seizures from neurotoxicity or pericarditis, heart failure, and pulmonary edema from cardiotoxicity. 

ED Management:

• Hot water immersion at 42-45°C for 30-90 minutes for venom deactivation
• Analgesia
• Local wound care (including tetanus)
• Antibiotics to cover for Vibrio species
  • Cephalosporin (ceftazidime) + tetracycline (doxycycline)
  • Fluoroquinolone (ciprofloxacin)
  • Pediatrics: Aminoglycoside + TMP-SMX
• Anti-venom for refractory pain, cardiotoxicity, or neurotoxicity

Stonefish Anti-venom (not FDA-approved, available in aquariums):

• Horse IgG
• Dosing
  • 1-2 punctures: 1 vial IM
  • 3-4 punctures: 2 vials IM
  • 5+ punctures: 3 vials IM
  • Repeat if refractory pain
• Risk: anaphylaxis, serum sickness

Disposition:

• Admit: Requiring anti-venom, parenteral analgesia, or surgical wound management
• Discharge: Pain controlled and observed 6-12 hours

Lionfish

Lionfish envenomations typically present with milder symptoms than those from stonefish, however, they are more frequently encountered. Lionfish venom is cytotoxic leading to localized edema, plasma extravasation, and thrombotic skin lesions. The severity of stings is graded from 1 to 3 (see table below). Rarely, systemic symptoms such as nausea/vomiting, diaphoresis, dizziness, palpitations, and syncope can occur.

Lionfish Sting Grading

Grade	Description	Image
I	Local erythema, edema, and ecchymosis
II	Vesicle or blister formation
III	Necrotic ulceration

Emergency Department Management:

• Hot water immersion at 42-45°C x 30-90 minutes is indicated for venom deactivation, given the toxin is heat-labile
• Analgesia
• Wound care (including tetanus)
  • All blisters should be drained because the fluid can contain a high concentration of venom
• Consider antibiotics
  • Superficial wounds: no antibiotics
  • Penetrating wounds: antibiotics covering Vibrio
    • Cephalosporin (ceftazidime) + tetracycline (doxycycline)
    • Fluoroquinolone (ciprofloxacin)
    • Pediatrics: Aminoglycoside + TMP-SMX

Disposition:

• Admit: Requiring parenteral analgesia or surgical wound management
• Discharge: Pain controlled and observed 6-12 hours

Resources:

• Atkinson PRT, Boyle A, Hartin D, McAuley D.  Is hot water immersion an effective treatment for marine envenomation?  Emerg Med J.  2006;23:503-508.
• Auerbach PS, ed. Wilderness Medicine. 6thed. Philadelphia, PA: Mosby, Inc; 2012:1628-1645.
• Balhara KS, Stolbach A.  Marine Envenomations. Emerg Med Clin N Am.  2014;32:223-243.
• Diaz, JH.  Marine Scorpaenidae Envenomation in Travelers: Epidemiology, Management, and Prevention.  Journal of Travel Medicine.  2015;22(4):251-258
• Fernandez I, Valladolid G, Varon J, Sternbach G.  Encounters with Venomous Sea LIfe. The Journal of Emergency Medicine.  2011;40(1):103-112.
• Hornbeak KB, Auerbach, PS.  Marine Envenomation. Emerg Med Clin N Am.  2017;35:321-337.
• Tomlinson H, Elston DM.  Aquatic Antagonists: Lionfish (Pterois volitans).  Cutis.  2018;102(4)232-234.

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