Jellyfish Envenomation Presenting with Delayed Identical Cutaneous Lesions in a Mother and Child

Abstract

Jellyfish envenomation can present with local cutaneous lesions both immediate and delayed. While the immediate reaction is toxin mediated, an immune mechanism is responsible for the delayed eruptions. This is a report of a mother and child who developed identical papular lesions in a bizarre, linear distribution after coming in contact with jellyfish almost simultaneously while on holiday. Histology showed focal basal cell degeneration along with peri-vascular and peri-appendageal lympho-mononuclear infiltrate. Both patients responded well to topical tacrolimus.

What was known?

• Jellyfish stings can cause immediate and delayed local skin reactions

• Histology usually shows a subacute dermatitis.

Introduction

Jellyfish are invertebrates found in the sea. Their stings can cause both immediate and delayed local reactions in the skin. A report of envenomation of a mother and child duo, who developed identical skin lesions a week later, is presented here.

Case Report

A 35-year-old lady and her son aged 9 years presented with itchy, red, bizarre linear lesions on the arms. Two weeks ago, while on holiday in the Bintan island of Indonesia, first the son and then the mother who were swimming closely, came in contact with unidentified jellyfish within minutes of each other. They described severe burning pain and immediate development of burn like lesions at the site of contact. The locals present on the beach, applied vinegar to the lesions and removed the thread-like jellyfish body parts. A local physician prescribed pain killers, antihistamine and topical ointments. Neither developed any systemic symptoms. A week later both patients noted that the skin lesions were palpable with peeling of skin and severe itching. Clinical examination showed mildly erythematous papules with superficial scaling, coalescing to form linear lesions arranged in a crisscross configuration, extensively involving the right forearm of the boy [Figure 1]. The mother had similar lesions but less extensive on the left forearm [Figure 2]. Histopathological examination of a biopsy done on the mother showed focal basal cell degeneration with upper dermal lympho-mononuclear infiltrate. In addition there was peri-vascular and peri-appendageal lympho-mononuclear infiltrate. Eosinophils, neutrophils or any foreign body parts were not seen [Figure 3]. Both patients responded well to topical tacrolimus 0.1% ointment, topical emollients and oral antihistamine. A review at 4 months showed post-inflammatory hyperpigmentation.

Figure 1.

Coalescing erythematous scaly papules in a crisscross fashion on the forearm of the boy

Figure 2.

Similar linear skin lesions in the mother

Figure 3.

Focal basal cell degeneration in addition to peri-vascular and peri-appendageal infiltrate [H and E, 100X]

Discussion

Jellyfish that belong to the phylum Cnidaria, have a world-wide distribution. They have an umbrella-like body with tentacles, the number, length and color of which are species-specific. All tentacles are lined by cnidocytes which contain specialized organelles called nematocysts. These are hollow capsules containing a tightly coiled thread immersed in venom. Mechanical stimuli activate the uncoiling of the thread which penetrates into tissues and the venom is discharged. Nematocyst discharge is a mechanical event and occurs within a fraction of a second. They can discharge when separated from the body of the jellyfish or even when the jellyfish is dead though the rate decreases. All Cnidarins are capable of envenomation but not all are dangerous to humans.[1]

Symptoms resulting from jellyfish envenomation can be immediate or delayed, local or systemic. Local immediate reactions that are toxin mediated may vary from intense burning pain, linear red wheals, edema, erythema to skin necrosis. Pain is perceived instantly, is maximal within 5 min and resolves over a period of time.[2] However, the skin lesions may sometimes be delayed for several hours, persist up to several months or recur without further stings.[3,4]

Delayed cutaneous eruptions or multiple recurrent eruptions following solitary envenomations by different subphyla of cnidarins are very well documented. Clinically, delayed eruptions have presented as eczematous lesions,[4] indurated lesions,[5] papules, plaques[6] and even widespread papulonodular lesions.[7] Histologically, most reports have described features of subacute dermatitis together with lympho-mononuclear infiltrate in peri-vascular and peri-appendageal locations. Eosinophils and neutrophils were also present. An immunologic reaction involving both B- and T-cell systems has been postulated in delayed reactions following jellyfish envenomation.[8]

It is known that the length of the toxin thread of the nematocyst determines the site of toxin injection in the skin—intraepidermal, intradermal or intravascular and probably in some cases even subcutaneous. It is thought that the initial site of toxin deposition together with the molecular size of the venom contribute to the ultimate clinical outcome.[1] The clinical presentation of the two patients in this report is identical with coalescing papules in a bizarre, linear configuration except that son who was stung first had more extensive involvement. Both mother and son were stung within a few moments of each other so it is possible that they came in contact with the same jellyfish. It is reasonable to surmise that the type of jellyfish together with their distinctive nematocyst and specific toxin dictates the subsequent clinical picture as well as the histology. The histology on the mother showed focal basal cell degeneration in addition to peri-vascular and peri-appendageal infiltrate, which is rarely reported in the literature.[9] Both the patients responded well to the higher strength of topical tacrolimus as in the case reported by Asztalos et al.

This case report is unique in its presentation of a mother and child pair who were stung by jellyfish almost simultaneously and presented with identical cutaneous lesions. The histology showed basal cell degeneration which is rarely reported.

What is new?

• Clinical lesions of jellyfish stings depend upon the species type

• Histology may show basal cell layer degeneration.