CLINICALLY SPEAKING

Deep Soft-Tissue Necrosis of the Foot and Ankle Caused by Catfish Envenomation
A Case Report
Bryan J. Roth, DPM* Stephen M. Geller, DPM*

Catfish envenomations represent a relatively rare cause of complications in podiatric medicine. We report a case of an unusual event eliciting a severe soft-tissue necrosis in a 21-year-old man and his complicated wound-healing process. This case reviews the potential complications of catfish envenomations. (J Am Podiatr Med Assoc 100(6): 493496, 2010)

Worldwide, there are more than 3,000 different species of catfish, many of which are venomous to humans.1 Catfish have axillary venom glands and one dorsal and two pectoral fin barbels to inflict envenomation.2 The fins are composed of sharp retrorse teeth that can lacerate the skin, enhancing exposure and absorption of the venom.3, 4 Softtissue infections secondary to catfish envenomation are relatively uncommon pathologic conditions presenting to the daily podiatric medical office. A review of the current literature uncovered only seven articles that detail catfish injuries to the foot.3, 5-10 Many of the previous articles described the cases as unusual foreign bodies or wounds with minor complications. Zeman5 presented a patient who kicked a catfish and required removal of the embedded catfish spine but healed without complication. Arlen and Vartian7 described a patient with a unicameral bone cyst of the first metatarsal that was presumed to stem from a catfish spine puncture more than 25 years earlier. Banks8 reported on a patient with a plantar foot puncture wound after stepping on the dorsal spine of a catfish. An incision and drainage was performed, with cultures returning significant for Edwardsiella tarda. Most long-term complications associated with catfish envenomation involve infection. The severity of the infection varies with the species of the
*Department of Podiatric Medicine and Surgery, Maricopa Medical Center, Phoenix, AZ. Corresponding author: Stephen M. Geller, DPM, Department of Podiatric Medicine and Surgery, Maricopa Medical Center, 2601 E Roosevelt Ave, Phoenix, AZ 85008. (E-mail: desertfootdoc@hotmail.com)

catfish. Clinical symptoms of the envenomation process are typically associated with pain, erythema, edema, paleness, paresthesia, muscle fasciculations, and tissue necrosis.2-6, 11-17 Another presentation of catfish wounds is an advancing ring of erythema.16 Reported complications in the literature include puncture wounds and lacerations complicated by soft-tissue infections, tenosynovitis of the hands, bursitis, septic arthritis, osteomyelitis, bony cysts, and necrotizing fasciitis.2-8, 11-18 Owing to the large diversity of the species, there is no definitive treatment regimen for catfish stings. However, many advocate local wound care parameters, including irrigation and debridement, serial dressing changes, and topical and systemic antibiotics. An interesting concept includes the addition of soaking the affected area in the warmest water one can tolerate. The idea addresses the heat-labile attitude of the catfish venom.8 Warm water soaks (458C for 45 min) help with immediate pain relief better than do narcotics and local anesthesia.4, 19 Radiographic evaluation is warranted, but caution should be taken because not all catfish spines are radiopaque. Clinical evaluation for abscess or retained foreign body indicates a need for wound exploration. A quickly spreading cellulitis or tissue necrosis may require fasciotomy or amputation. Empirical antibiotic coverage is difficult considering the wide array of causative organisms. Edwardsiella tarda, Citrobacter freundii, Morganella morganii, Pseudomonas aeruginosa, Enterobacter cloacae, Aeromonas hydrophila, Vibrio vulnificus, Streptococcus, Staphylococcus aureus, and epidermis have all been identified.9 At a minimum,

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the administration of antibiotics should cover gramnegative organisms. In the literature, ciprofloxacin and other fluoroquinolones are popular choices for coverage of gram-negative organisms.11 The two concerning organisms are the Vibrio species for saltwater and the Aeromonas species for freshwater. The recommended regimen for coverage of most Vibrio species includes a combination of doxycycline and ceftazidime, and coverage of most Aeromonas species includes fluoroquinolones.20 As with any open wound, the patient should be given tetanus prophylaxis when indicated.

Case Report
A 21-year-old Hispanic man sustained a puncture wound from a catfish while working at a local farmer’s market. The puncture wound was sustained to the medial aspect of the right foot after dropping a catfish while stocking shelves. After piercing through his leather boots, the pectoral fin penetrated the skin overlying the medial aspect of the navicular. He presented to the emergency department 4 days later secondary to constitutional symptoms and intense pain in his right foot and ankle. On initial presentation, a small puncture wound was noted on the medial aspect of the right midfoot (Fig. 1). The puncture site was closed, with no sign

of associated wound infection. However, there was intense erythema noted along the proximal dorsum of the right foot and the anterior aspect of the right ankle. There was no evidence of a foreign body, eg, a catfish barb, on clinical or radiographic examination. The patient was taken to the operating room for incision and drainage of his right foot. A small foreign body was removed from the puncture site that was later identified as a catfish spine. Intraoperative findings revealed severe tissue necrosis of the superficial and deep fascia along the course of the anterior tibial tendon. The surrounding soft tissues and the anterior tibial tendon sheath were found to be necrotic (Fig. 2). Excision of all necrotic tissue was completed. After thorough irrigation of the wound, soft-tissue cultures were obtained and sent to the pathology laboratory. Intraoperative soft-tissue cultures later returned positive for coagulase-negative Staphylococcus. There was no associated growth of anaerobic or fungal species. A negative-pressure wound dressing (GranuFoam and V.A.C.; KCI, San Antonio, Texas) was then applied. Three days later, wound debridement was performed in the operating room. At this time, a sterile collagen bioimplant (OrthADAPT; Synovis Orthopedic and Woundcare Inc, Irvine, California) was used to cover the exposed tendon, and the V.A.C. was reapplied after partially closing the wound. After several weeks of wound care and a prolonged

Figure 1. Initial presentation of the right foot and ankle. Notice the hyperpigmented nodule on the medial aspect of the foot. A catfish spine was later identified from this site.

Figure 2. Initial intraoperative view depicting the extensive soft-tissue necrosis of the right foot and ankle along the course of the anterior tibial tendon.

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healing course intensified by patient noncompliance, the patient returned to the operating room for delayed primary closure. Once again, the patient walked on the affected extremity, and the wound returned. Nonetheless, after a complicated postoperative course intensified by patient noncompliance, the wound healed (Fig. 3). The patient was discharged from the clinic and has returned to normal activities.

Discussion
Catfish (class: Osteichthyes; subclass: Siluroidea) vary widely in shape and size.11 Currently, 3,000 species have been identified, with many more yet to be verified. Although they live in both freshwater and marine environments, the ability to cause envenomation is species dependent. Most injuries occur to the extremities of freshwater and marine fishermen who improperly handle the catfish.12 The stinging apparatus is composed of the dorsal and pectoral fins connected to the venom glands. When the fish is disturbed, the fins extend from their bodies, increasing the chance for puncture and envenomation. Not only does the catfish possess venom from the glands, but it also contains toxins in its epidermal cells that are secreted with excitation.5 Secretion of toxins from skin cells is known as crinotoxicity, and if exposed to open skin it can cause similar complications as the venom.12 Halstead was one of the first to report on toxic epidermal secretions of fish unrelated to the venom apparatus and popularized the term ichthyocrinotoxins.13 Thus, unlike venoms, epidermal secretions are not injected into other organisms. Composition catfish crinotoxins have been found to be identical

and typically are composed of at least one hemolysin, two lethal factors, and two edema-forming factors.14 Much of the available research coincides with the hypothesis that venoms evolved from catfish toxins.13 The mechanisms of action of the neurotoxic and hemotoxic effects of catfish toxin have yet to be completely described in the literature.15 We described a patient with a complicated wound stemming from a catfish spine puncture. There is no doubt that his delay in presentation hindered treatment and resulted in the need for prolonged and aggressive care. Moreover, if the patient had been compliant with postoperative management, he may have healed quicker. However, this was a significant injury to his lower extremity. The difference between this case and those previously reported is that the present patient required multiple surgical interventions and a prolonged postoperative course. The only organism obtained from the intraoperative cultures was coagulase-negative Staphylococcus. It is likely that the Staphylococcus was not the primary cause of the tissue necrosis, and we believe that the tissue necrosis was due solely to the spread of the toxins associated with the envenomation process, which is known to be potentially necrotic to the skin and soft-tissue structures.

Conclusions
In summary, catfish envenomations can progress through a wide array of complications varying from a simple wound to necrotizing fasciitis, to a gangrenous limb, and, ultimately, to death. This article should be a reminder to all physicians that if these wounds are left untreated, there is a high associated morbidity rate that can lead to devastating outcomes. This patient’s delayed presentation to the hospital eventually lead to his severe tissue necrosis and prolonged healing. Treatment was successful, and the patient returned to his normal activities. Financial Disclosure: None reported. Conflict of Interest: None reported.

References
1. FERRARIS C JR: Checklist of catfishes, recent and fossil (Osteichthyes: Siluriformes), and catalogue of siluriform primary types. Zootaxa 1418: 4, 2007. 2. SINGLETARY EM, ROCHMAN AS, BODMER JCA, ET AL: Envenomations. Med Clin North Am 89: 1203, 2005.

Figure 3. Final presentation of the healed site 4 months after initial presentation.

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3. BAKER DH: An unusual foreign body: catfish spine. Pediatr Radiol 27: 585, 1997. 4. BLOMKALNS AL, OTTEN EJ: Catfish spine envenomation: a case report and literature review. Wilderness Environ Med 10: 242, 1999. 5. ZEMAN MG: Catfish stings: a report of three cases. Ann Emerg Med 18: 212, 1989. 6. FREDETTE S, DERK F, NARDOZZA A: Catfish spine injury of the foot. JAPMA 87: 187, 1997. 7. ARLEN DI, VARTIAN CV: Bone cyst of fishy origin: from an old catfish spine puncture wound to the foot. J Foot Ankle Surg 38: 68, 1999. 8. BANKS AS: A puncture wound complicated by infection with Edwardsiella tarda. JAPMA 82: 529, 1992. 9. EILAND LS, SALAZAR ML: Polymicrobial catfish spine infection in a child. Pediatr Infect Dis J 25: 282, 2006. 10. MIDANI S, RATHORE MH: Vibrio species infection of a catfish spine puncture wound. Pediatr Infect Dis J 13: 333, 1994. 11. AJMAL N, NANNEY LB, WOLFORT SF: Catfish spine envenomation: a case of delayed presentation. Wilderness Environ Med 14: 101, 2003. 12. HADDAD V JR, MARTINS IA: Frequency and gravity of human envenomation caused by marine catfish (subor-

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der siluroidei): a clinical and epidemiological study. Toxicon 47: 840, 2006. CAMERON AM, ENDEAN R: Epidermal secretions and the evolution of venom glands in fishes. Toxicon 11: 401, 1973. SHIOMI K, TAKAMIYA M, YAMANAKA H, ET AL: Toxins in the skin secretion of the oriental catfish (Plotosus lineatus): immunological properties and immunocytochemical identification of producing cells. Toxicon 26: 353, 1988. SHEPHERD S, THOMAS S, STONE CK: Catfish envenomation. J Wilderness Med 5: 67, 1994. BAACK BR, KUCAN JO, ZOOK EG, ET AL: Hand infections secondary to catfish spines: case reports and literature review. J Trauma 31: 1433, 1991. MURPHEY DK, SEPTIMUS EJ, WAAGNER DC: Catfish-related injury and infection: report of two cases and review of the literature. Clin Infect Dis 14: 690, 1992. ASHFORD RU, SARGEANT PD, LUM GD: Septic arthritis of the knee caused by Edwardsiella tarda after a catfish puncture wound. Med J Aust 168: 443, 1998. SATORA L, PACH J, TARGOSZ D, ET AL: Stinging catfish poisoning. Clin Toxicol (Phila) 43: 893, 2005. NOONBURG GE: Management of extremity trauma and related infections occurring in the aquatic environment. J Am Acad Orthop Surg 13: 244, 2005.

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