Clinical Toxicology (2010) 48, 390–392 Copyright © Informa UK, Ltd. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563651003662675 LCLT SHORT REPORT Intracerebral hemorrhage and death after envenoming by the jellyfish Carukia barnesi Death due to Irukandji syndrome PETER PEREIRA 1 , JANE BARRY 1 , MICHAEL CORKERON 2 , PIP KEIR 3 , MARK LITTLE 4 , and JAMIE SEYMOUR 5 1 Department of Emergency Medicine, Cairns Base Hospital, Cairns, Australia 2 Intensive Care Unit, Townsville Hospital, Townsville, Australia 3 Emergency Department, Gosford Hospital, Gosford, Australia 4 Emergency Department, Royal Perth Hospital, Perth, Australia 5 Marine and Tropical Biology, James Cook University, Cairns, Australia Introduction. Irukandji syndrome is because of envenoming by a number of small jellyfish. It results in a delayed onset of generalized pain, sweating hypertension, and tachycardia. There is no antivenom. Case report. A 44-year-old healthy male was stung while swimming in NE Australia. He rapidly developed Irukandji syndrome. He had a rapid deterioration in conscious level because of an intracerebral hemorrhage. He developed left ventricular failure with an elevated troponin (34 mcg/L, N < 0.4) requiring inotropic support. He progressed to brain death and died on day 13 poststing. Nematocysts recovered from the patient skin were consistent with a large Carukia barnesi. Discussion. This is the first case of a death because of Irukandji syndrome where the jellyfish Carukia barnesi has been demonstrated to the causative creature. Keywords Jellyfish; Irukandji syndrome; Envenoming; Death Case presentation A fit and healthy 44-year-old male American tourist was transferred by helicopter to the Emergency Department at Cairns Base Hospital, northeastern Australia (CBHED) at 15:30 on March 31, 2002. He was stung on the right side of his chest while snorkel- ing at Low Isles Reef, 25 km north of Cairns at 13:00 that day. Vinegar was applied soon after the sting but within 15 min the patient developed dyspnea, headache, and pain in his back and lower limbs. Irukandji syndrome was diagnosed and a rescue helicopter attended the patient at 14:30. The patient was experiencing severe generalized pain and dry retching. His pulse rate (PR) was 96/min, NIBP 230/90 mmHg, and SPO2 at 99% on room air at sea level. He was administered a total 25 mg morphine, 10 mg metoclopramide, and 12.5 mg promethazine intravenously. The flight para- medic recorded purposeless movements of his right arm and leg and eyes moving to the “right and back.” On arrival at the CBHED, the patient was in significant distress. His initial observations were GCS 14, PR 95/min, NIBP 150/110 mmHg, R/R 15/min, and SPO 2 of 100% on oxygen at 4l/min by Hudson mask. He was incoherent, severely agitated, and demonstrated a left hemiparesis, marked neck stiffness, and persistent right gaze with normal papillary reflexes. His BSL was 12 and his ECG was unremarkable. He was intubated utilizing an RSI and an urgent cranial CT was performed, which revealed a large R frontal intrace- rebral hemorrhage (ICH), with blood in all ventricles. His R anterior chest demonstrated a conspicuously prominent pur- ple lesion of 5 cm × 2 cm, corresponding to the initial sting site reported by the patient to paramedic. The site was scraped with a scalpel blade for microscopic examination. He was transferred to the neurosurgical ICU unit at The Townsville Hospital, a tertiary hospital 350 km south of Cairns. At Townsville ICU, the patient had a normal CT angio- gram, following which he underwent a craniotomy for the evacuation of clot and placement of an ICP monitor. Early severe hypertension was followed by left ventricular failure requiring inotropic support and a cardiac troponin rise to 34 mcg/L (N < 0.4) at 48 h post envenomation. However, by day 4 his cardiovascular function normalized, supported by an unremarkable echocardiogram. Despite the above neurosurgical interventions, he devel- oped persistent intracranial hypertension refractory to medi- cal therapy. He progressed to brain death and organ donation on day 13 (April 12, 2002). Received 11 December 2009; accepted 29 January 2010. Address correspondence to Mark Little, Emergency Department, Royal Perth Hospital, Perth, Australia. E-mail: mark.little@health. wa.gov.au Clinical Toxicology Downloaded from informahealthcare.com by James Cook University on 07/14/10 For personal use only.