Curbside Consults

VOL 107 / NO 4 / APRIL 2000 / POSTGRADUATE MEDICINE

Best treatment of jellyfish stings?

Family physician, Texas

A: Tranquil coastal waters beckon innocents from inland on their summer vacations, but too often, the unwary human interlopers face the dual perils of jellyfish envenomization and well-meaning but injudicious therapeutic advice.

With more than 100 potentially hazardous species, jellyfish and their stings represent one of the most common sources of marine toxin exposure. Jellyfish claim a vast region as home, including the popular waters of the US eastern seaboard from Florida to north of the Chesapeake Bay as well as those of Hawaii, Australia, the Caribbean, and the Indo-Pacific region. Varieties of these creatures are often known by descriptive local appellations (eg, sea nettles, Portuguese man-of-war, box jellyfish, blue bottles, sea wasps) rather than by their scientific names.

Jellyfish have sinewy, easily detachable tentacles that are often several meters long and extend from a central bell. As many as 500,000 stinging capsules, or nematocysts, stud the almost invisible excrescences and are ready to discharge at lightning speed. Contact of these capsules with the skin results in almost instantaneous discomfort or pain, typically referred to as burning, throbbing, itching, or shocklike. Within minutes, characteristic zigzag or whiplike urticarial wheals appear, sometimes with a reddish hue. Systemic toxicity develops only in unusual circumstances and almost never complicates jellyfish stings in US domestic waters.

Avulsed tentacles with competent stinging capsules almost always adhere to the victim's skin and should be immediately inactivated. The tentacle may be removed by simple digital extraction, shaving the affected area, or scraping the skin with the edge of a plastic card.

Cutaneous manifestations usually resolve spontaneously within an hour or two, leaving temporary discoloration at most, so almost any sensible therapy suffices. (Suggested therapies have ranged from the bizarre to the ludicrous, including application of hot sand, aloe vera, kerosene, ammonia, onion extract, and urine.) One seemingly innocuous method that should be avoided is the application of fresh water, because osmotic shock triggers an instantaneous discharge of any remaining toxin into the upper dermis, further compounding the patient's discomfort.

Acceptable first aid for stings of Portuguese man-of-war and box jellyfish is soaking the area in diluted vinegar. For stings of the more common domestic sea nettle, applying a slurry of baking soda may be helpful. Use of papain or powdered meat tenderizer offers limited benefits. The most effective symptomatic treatment is simple and inexpensive: application of ice to the affected areas. Neither oral analgesics nor any form of corticosteroids seems warranted.

Acute conjunctivitis occasionally follows transfer of unruptured capsules from the sting area to the eye by unwary victims responding to the almost universal desire to rub the wounds. Even beached jellyfish should be avoided, since toxin-containing capsules continue to pose a threat.

With all this in mind, perhaps we physicians should suggest vacationing at a mountain retreat.

Ken Landow, MD
Clinical Professor of Dermatology
University of Southern California School of Medicine
Los Angeles

Corticosteroids for tuberculosis?

Family physician, Malaysia

A: Use of adjunctive corticosteroids in management of pulmonary and extrapulmonary tuberculosis is both a contentious and an important clinical issue. Theoretical bases for such therapy include prevention of chronic fibrosis and resultant organ dysfunction, diminution of tissue destruction and inflammation caused by the host's inflammatory response, and limitation of the systemic wasting resulting from release of inflammatory mediators. However, it is well known that in the absence of effective antituberculous therapy, corticosteroids enhance the virulence of Mycobacterium tuberculosis.

Unfortunately, many of the applicable studies have been uncontrolled, inadequately powered, and insufficiently followed, or conducted with what today would be considered suboptimal antituberculous therapy. Nevertheless, a critical appraisal of available data suggests that in patients with pulmonary or pleural tuberculosis, corticosteroid therapy results in more rapid resolution of symptoms, particularly in severe disease. However, corticosteroids have not been shown to have any beneficial long-term effects on morbidity or mortality in pulmonary or pleural tuberculosis (1) and therefore are not currently recommended for use in these cases.

Adjunctive corticosteroid therapy has been shown to decrease morbidity and mortality in patients with tuberculous meningitis, pericarditis, and peritonitis. Girgis and colleagues (2) randomized 280 patients with suspected tuberculous meningitis to receive antituberculous chemotherapy with or without dexamethasone. In the 160 patients whose cerebrospinal fluid cultures were positive for M tuberculosis, the mortality rate was significantly lower in those who received dexamethasone (43%) than in those receiving antituberculous chemotherapy alone (59%). In addition, neurologic complications and permanent sequelae occurred significantly less often in the dexamethasone-treated group.

Similarly, in two randomized studies, Strang and colleagues (3,4) found that an 11-week course of prednisolone reduced mortality and the need for pericardiocentesis or pericardiectomy in patients with both active tuberculous pericardial effusion and tuberculous constrictive pericarditis. In a retrospective review of 35 patients with peritoneal tuberculosis, Alrajhi and coworkers (5) reported that adjuvant treatment with corticosteroids reduced the incidence of recurrent abdominal pain and intestinal obstruction.

Therefore, adjunctive corticosteroid treatment should be considered in patients with tuberculous meningitis, pericarditis, or peritonitis. Data are inadequate to recommend such therapy in other sites of extrapulmonary tuberculosis.

Because adjunctive corticosteroids are used for their immunosuppressive effects, it is essential that antituberculous chemotherapy be adequate to clear the infection. Consequently, adjunctive corticosteroid therapy should be avoided in localities where multidrug-resistant strains of M tuberculosis are endemic.

Joseph Varon, MD
Baylor College of Medicine, Houston
Paul Marik, MD
Washington Hospital Center, Washington, DC

References

1. Lee CH, Wang WJ, Lan RS, et al. Corticosteroids in the treatment of tuberculous pleurisy: a double-blind, placebo-controlled, randomized study. Chest 1988;94(6):1256-9
2. Girgis NI, Farid Z, Kilpatrick ME, et al. Dexamethasone adjunctive treatment for tuberculous meningitis. Pediatr Infect Dis J 1991;10(3):179-83
3. Strang JI, Kakaza HH, Gibson DG, et al. Controlled clinical trial of complete open surgical drainage and of prednisolone in treatment of tuberculous pericardial effusion in Transkei. Lancet 1988;2(8614):759-64
4. Strang JI, Kakaza HH, Gibson DG, et al. Controlled trial of prednisolone as adjuvant in treatment of tuberculous constrictive pericarditis in Transkei. Lancet 1987;2(8573):1418-22
5. Alrajhi AA, Halim MA, al-Hokail A, et al. Corticosteroid treatment of peritoneal tuberculosis. Clin Infect Dis 1998;27(1):52-6

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Wish you could nab an expert at the curbside, or some other handy spot, for a quick consult on a clinical problem? Curbside Consults brings the consultant to you. In this Q&A column, members of our Editorial Board and other consultants offer general advice on handling those thorny situations that crop up in everyday practice.

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