American Journal of Emergency Medicine (2008) 26, 972.e1–972.

e2

www.elsevier.com/locate/ajem

Case Report

Stonefish envenomation knowledge of local fauna. Travel and exposures to increas-

ingly diverse environs will undoubtedly lead to more
Abstract numerous and exotic envenomations.
Stonefish (eg, Synanceia verrucosa, Synanceia hornium,
and Synanceia nana) are members of the Synanceiidae
As more Americans travel in greater numbers in search of
family but have also been classified by some as part of the
exotic destinations, they may encounter dangerous marine life
Scorpaenidae family (Fig. 1). Stonefish can be found in reefs
that hide in reefs and shallow marine waters. In this case report,
and shallow marine waters of the Indian and Pacific oceans
we describe a case of stonefish envenomation and provide a
[1]. Local names include Rockfish, Goblinfish, Devilfish,
review of the literature on management and prevention.
Warty-ghoul, Dornorn, Sherovea, and “Nofu” (The Waiting
As Americans travel abroad and engage in marine sports One). These names reflect the stonefish's spiny appearance
with increasing frequency, previously rare envenomations and its tendency to burrow under sand or mud in shallow
may become more common. Patients may present with acute water to surprise small passing fish upon which it preys.
or delayed sequelae of injury upon returning home. Many Human envenomation typically occurs when an unsuspect-
clinical presentations will benefit from specific treatments ing individual either jumps out of a boat into shallow water
with which an emergency provider may be unfamiliar. or wades into a reef and steps onto the spiny dorsal fins of a
An otherwise healthy 27-year-old man was transported to hidden stonefish [1]. In Guam, stonefish tend to have a sandy
a hospital by emergency medical services after suddenly brown appearance and blend into the shore shallows.
developing severe pain in his left foot while walking on the The pain of envenomation is notoriously intense and
surf at a local beach in Guam. The patient complained of immediate, increasing over the first 10 minutes after
severe distress due to pain described as constant, throbbing, exposure. Swelling follows the pain and may be severe,
and crushing with a sensation of numbness surrounding the spreading proximally from the injection site. Patients
painful area on the plantar aspect of his left foot. describe numbness in the center of the swollen area and
Physical examination revealed redness along the bottom severe pain at the edges. Affected area may become
of the patient's left foot, with bruising surrounding a puncture discolored with a bluish or blanched appearance. Although
site in the center of the left heel. The affected area was
immediately placed in a basin of hot water. The patient's pain
was unchanged by intravenous morphine sulfate. An x-ray of
the patient's left heel was unremarkable and did not reveal
any retained foreign body. Based on the patient's history,
physical examination findings, the severity of the patient's
pain, and the emergency provider's knowledge of local fauna,
a diagnosis of stonefish envenomation was made.
The patient received an additional dose of morphine, as
well as methylprednisolone 125 mg IV, after which the pain
was controlled. At no point did the patient note symptoms
such as confusion, shortness of breath, chest pain, nor focal
weakness or numbness, apart from the area surrounding the
puncture site. Vital signs were normal throughout the visit.
The patient was discharged home with prescriptions for
prednisone, acetaminophen/oxycodone, and levofloxacin.
Discharge instructions included use of hot soaks, elevation,
and criteria for returning to emergency department. Fig. 1 Stonefish (http://en.wikipedia.org/wiki/Image:Stone _
In any suspected envenomation, an emergency provider Fish _ at _ AQWA _ SMC2006.jpg#filelinks, accessed December
must combine a careful history, physical examination, and 19, 2007; with appreciation to Sean Mack, photographer).

0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
972.e2 Case Report

sensation and normal muscular functioning of the affected Owen Prentice MD

area may return, hypersensitivity and edema of the affected Department of Emergency Medicine
area may last for weeks. This may result in repeated visits to Boston University School of Medicine
the emergency department or primary care physician for Boston, MA, USA
continued management. Healing of puncture wounds is often
delayed, and ulcerations may develop and persist for several William G. Fernandez MD, MPH
months [1]. There are rare reported cases of mortality from Department of Emergency Medicine
paralysis of the chest muscles, heart failure, and/or cardiac Boston University School of Medicine
arrest due to stonefish envenomation, possibly secondary to Boston, MA, USA
the systemic effects of increased capillary permeability and Department of Emergency Medicine
hypotension or even hysteria due to pain leading to drowning. US Naval Hospital Guam
However, morbidity and mortality are mainly because of local E-mail address: william.fernandez@bmc.org
tissue necrosis and secondary infection [2-5].
After a patient is removed from danger of drowning or Todd J. Luyber MD
further envenomation, care should be focused on treating any Tracy L. McMonicle PA
systemic effects of envenomation. Laboratory studies have Department of Emergency Medicine
shown that stonefish poison has cardiovascular, neuromus- US Naval Hospital Guam
cular, and cytolytic properties [6,7]. The venom consists of a
potent neurotoxin (trachynilysin), as well as a catecholamine Marc D. Simmons MD
cardiotoxin (cardioleputin) [7]. Antivenom is available from Department of Emergency Medicine
Australia's CSL Limited but should be reserved for severe Lawrence General Hospital
systemic cases because it presents a risk of severe adverse Laurence, MA, USA
reaction such as anaphylactic shock or serum sickness [8]. Department of Emergency Medicine
Stonefish venom is heat labile, and immersion of the US Naval Hospital Guam
affected area in hot water should provide pain relief. The water
should be as hot as can be tolerated without scalding (42°C- doi:10.1016/j.ajem.2008.01.055
45°C), and immersion should be continued until pain resolves,
often for several hours, and repeated with return of pain. Along
The views expressed in this work are those of the individuals, and
with hot water immersion, oral or parenteral opioid analgesics do not reflect the official policy or position of the Department of the Navy,
may be required to control the severe pain. In addition, some Department of Defense, or the U.S. Government.
have advocated infusing lidocaine locally for additional pain
control [9]. Because the envenomated area may be numb,
inclusion of the unaffected limb in hot water bath may help to
avoid burning the patient. Previous reports have suggested that References
hot water immersion may increase the risk of developing a
severe secondary infection and recommend providing an [1] Edmonds C. Dangerous marine creatures. Flagstaff (Ariz): Best
Publishing Co; 1995.
antibiotic that covers marine organisms, especially Vibrio [2] Lee JY, Teoh LC, Leo SP. Stonefish envenomations of the hand—a local
vulnificus, before or during hot soaks [3]. Antibiotic therapy is marine hazard: a series of eight cases and a review of the literature. Ann
recommended for all puncture wounds of the hand and foot Acad Med Singapore 2004;33(4):515-20.
because of high incidence of infection [2]. [3] Tang WM, Fung KK, Cheng VC, et al. Rapidly progressive necrotising
Any retained spines should be removed as early as fasciitis following a stonefish sting: a report of two cases. J Orthop Surg
2006;14(1):67-70.
possible because they may continue to envenomate and [4] Dall GF, Barclay KL, Knight D. Severe sequelae after stonefish
increase risk of secondary infection. Radiographs and envenomation. Surgeon 2006;4(6).
ultrasound should be used to identify possible retained [5] Lyon RM. Stonefish poisoning. Wilderness Environ Med 2004;15:
foreign bodies, and surgical exploration may be necessary. 284-8.
Elevation of the affected area should be done to reduce [6] Church JE, Hodgson WC. The pharmacological activity of fish venoms.
Toxicon 2002;40:1083-93.
inflammation. All patients must be followed closely to [7] Chen D, Kini RM, Yuen R, Khoo HE. Haemolytic activity of
ensure that they do not develop a severe infection. stonustoxin from stonefish (Synanceja horrida) venom: pore formation
Prevention of stonefish envenomation may be possible and the role of cationic amino acid residues. Biochem J 1997;325:
with the use of tough, thick-soled shoes in endemic areas 685-91.
(spines have been known to penetrate tennis shoes). A [8] Stonefish antivenom [product information]. CSL Limited 45 Poplar
Road, Parkville, Victoria 3052, Australia. Amended September 20, 2004
shuffling gait is also said to reduce risk of injury as it may [9] Atkinson PRT, Boyle A, Hartin D, McAuley D. Is hot water immersion
alert a stonefish to one's presence before stepping on its an effective treatment for marine envenomation? Emerg Med J 2006;23:
spiny dorsal fin [1]. 503-8.