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  • marine drugs

    Review

    To Pee, or Not to Pee: A Review on Envenomation andTreatment in European Jellyfish Species

    Louise Montgomery 1,2,*, Jan Seys 1 and Jan Mees 1,3

    1 Flanders Marine Institute, InnovOcean Site, Wandelaarkaai 7, Ostende 8400, Belgium;jan.seys@vliz.be (J.S.); jan.mees@vliz.be (J.M.)

    2 College of Medical, Veterinary & Life Sciences, Graham Kerr Building, University of Glasgow,Glasgow G12 8QQ, UK

    3 Ghent University, Marine Biology Research Group, Krijgslaan 281, Campus Sterre-S8, Ghent B-9000, Belgium* Correspondence: loubudhram@gmail.com; Tel.: +32-059-342130; Fax: +32-059-342131

    Academic Editor: Kirsten BenkendorffReceived: 13 May 2016; Accepted: 30 June 2016; Published: 8 July 2016

    Abstract: There is a growing cause for concern on envenoming European species because of jellyfishblooms, climate change and globalization displacing species. Treatment of envenomation involves theprevention of further nematocyst release and relieving local and systemic symptoms. Many anecdotaltreatments are available but species-specific first aid response is essential for effective treatment.However, species identification is difficult in most cases. There is evidence that oral analgesics,seawater, baking soda slurry and 4245 C hot water are effective against nematocyst inhibitionand giving pain relief. The application of topical vinegar for 30 s is effective on stings of specificspecies. Treatments, which produce osmotic or pressure changes can exacerbate the initial stingand aggravate symptoms, common among many anecdotal treatments. Most available therapiesare based on weak evidence and thus it is strongly recommended that randomized clinical trialsare undertaken. We recommend a vital increase in directed research on the effect of environmentalfactors on envenoming mechanisms and to establish a species-specific treatment. Adequate signageon jellyfish stings and standardized first aid protocols with emphasis on protective equipment andavoidance of jellyfish to minimize cases should be implemented in areas at risk.

    Keywords: jellyfish; European; cnidarians; nematocyst; stings; envenomation; pain; treatment; relief

    1. Introduction

    Over the past few decades, jellyfish blooms have caused a great deal of disturbance acrossthe world with the perception that their increasing numbers are damaging fishing gear, blockingpower plants and impacting on fragile fish stocks. This may be due to climatic changes, overfishing,eutrophication and habitat alteration [15]. Due to this increase, jellyfish envenomation has becomean increasing problem not only for public health, tourists, and fishermen, but also indirect impacton the economy [6]. Globally, approximately 10,000 species make up the Cnidarian phylum, with 1%recognized as a threat to human health. Within the Cnidarian phylum most health problems arisefrom the representatives of scyphozoans (true jellyfish), cubozoans (box jellyfish) and hydrozoans(siphonophores and hydroids) [710].

    Jellyfish stings have become a familiar summer hazard in Europe with an increase in marineactivities taking place at this time of year [11]. It is thought that as many as 150 million jellyfishstings take place annually worldwide emphasizing the need for more conclusive research on thistopic [7,12]. Envenomation mainly causes cutaneous reactions such as pain and itching, however,systemic symptoms including cardiac and neurological complications can result from venom enteringthe circulatory system. Such serious reactions, which can occasionally be fatal, are most commonly

    Mar. Drugs 2016, 14, 127; doi:10.3390/md14070127 www.mdpi.com/journal/marinedrugs

    http://www.mdpi.com/journal/marinedrugshttp://www.mdpi.comhttp://www.mdpi.com/journal/marinedrugs

  • Mar. Drugs 2016, 14, 127 2 of 21

    consequences of stings inflicted by venomous jellyfish such as the Australian species Chironex fleckeri.However death, although rare, can occur from species that are found in Europe, such as fromCyanea capillata and Physalia physalis associated with an allergic response or aggravating prior healthconcerns [10,13,14].

    Although jellyfish seem relatively simple and have existed since the Pre-Cambrian era, theyare sophisticated organisms with complex life cycles and advanced envenoming mechanisms [1,15].Little is known about the factors that affect their lifecycles with regard to the true composition oftheir toxins and how to treat their stings. There is much confusion among the public on the first aidprotocol for jellyfish envenomation, which is further complicated by the portrayal of quick treatmentssuch as urine and meat tenderizer as suitable therapeutic agents from extrapolated results withoutdiscussing the limitations of the findings [16,17]. There is a great deal of literature on the treatment ofjellyfish envenomation, which is contradictive, uncertain and unjustified, and thus reflects knowledgeat this time [15,17]. With no universal therapeutic available, there is a need to develop species orgenus specific therapies, as the nature of the venom is organism dependent [13]. Individuals canreact differently to the venom depending on their health, where they are stung both anatomically andgeographically, the surface area of the sting site, and the rate of peripheral circulation, which maybe dependent on sex, age and size [15,18,19]. Anecdotal treatment is accepted due to the scarcity ofstatistically significant findings of evidence-based medicine (EBM). However, many currently acceptedanecdotal treatments can exacerbate symptoms through further nematocyst release [1517].

    We reviewed first aid treatments and health problems associated with European jellyfishenvenomation and compiled the most reliable treatments available for stings of the 41 Europeanspecies. The envenomation process and an accord of the most reliable treatments for general andcommon envenoming species are provided, as well as recommendations for further research.

    2. Methods

    79 publications on European jellyfish species envenomation, toxicology and treatment wereidentified through Web of Knowledge (WoK) [20]. The term jellyfish was defined as all Europeanscyphozoan and cubozoan species, and frequent envenoming hydrozoan species. All Europeanscyphozoan and cubozoan species were identified with the aid of the World Register of Marine Species(WoRMS) [21] and based upon a publication search that stated species found in European watersthat were not recorded in WoRMS. Hydrozoan species were chosen through the identification ofrecurring species in envenomation cases on WoK, and with reference to hydrozoan species selectedby MED-jellyrisk, an integrated monitoring program of jellyfish outbreaks in the MediterraneanSea [22]. Forty one species were considered: all 37 scyphozoans, the single cubozoan, and threehydrozoan species.

    The following terms were searched: jellyfish AND envenomation AND Europe; jellyfishAND toxicology AND Europe; jellyfish AND envenomation; jellyfish AND toxicology AND* species name (* out of the 41 species identified in Europe); jellyfish AND sting AND treatment;* species name. The papers were selected after skim reading the document. The full papers werethen examined and the papers selected met at least one of the following criteria: (a) the publicationwas related to European jellyfish; (b) the publication was about species in other continental watersbut is also regarded as a European species; (c) the paper discussed innovative first aid treatments oninternational jellyfish envenomation; (d) the paper referred to species of the same genus as a Europeanspecies. Further relevant articles were also selected from referenced papers due to a lack of papersavailable from the WoK search.

    Publications on laboratory studies, field studies, case studies with randomized andnonrandomized controlled trials, letters to the editor, observational case studies with and withoutcontrols, literature reviews, books and expert opinions were all used. Some publications presentedindividual case studies while others presented larger scale investigations. Some had poor experimentalprotocol suggesting why anecdotal treatments are greatly accepted.

  • Mar. Drugs 2016, 14, 127 3 of 21

    The relevant information on jellyfish species: markings induced cutaneous symptoms andsystemic symptoms suffered upon immediate envenomation as well as long-term medical problemswere extracted. Associated treatments were recorded with the effect of the treatment noted on whethersymptoms improved, had no effect or exacerbate the sting and related symptoms. Cross-reactivespecies, the reaction between two different species, were also documented.

    3. The Organisms

    3.1. Anatomy and Physiology of the Stinging Mechanism

    Cnidarians have epithelial stinging cells (Figure 1), called cnidocytes, which house cnidocysts(also known as cnidae) and are clustered into batteries along the tentacles and in some species onthe bell. Nematocysts are one of three categories of cnidocysts found in cnidaria. Nematocysts areenclosed within cnidocytes. Jellyfish tentacles contain these specialized nematocyst structures, whichallow envenomation due to highly coiled tubules armed with spines and is species dependent [2326].

    Mar. Drugs 2016, 14, 127 3 of 21

    The relevant information on jellyfish species: markings induced cutaneous symptoms and systemic symptoms suffered upon immediate envenomation as well as long-term medical problems were extracted. Associated treatments were recorded with the effect of the treatment noted on whether symptoms improved, had no effect or exacerbate the sting and related symptoms. Cross-reactive species, the reaction between two different species, were also documented.

    3. The Organisms

    3.1. Anatomy and Physiology of the Stinging Mechanism

    Cnidarians have epithelial stin