Box-jellyfish cardiotoxin and i.v. verapamil

Australian venomous jellyfish, envenomation syndromes, toxins and therapy

The seas and oceans around Australia harbour numerous venomous jellyfish. Chironex fleckeri, the box jellyfish, is the most lethal causing rapid cardiorespiratory depression and although its venom has been characterised, its toxins remain to be identified. A moderately effective antivenom exists which is also partially effective against another chirodropid, Chiropsalmus sp. Numerous carybdeids, some unidentified, cause less severe illness, including Carybdea rastoni whose toxins CrTX-A and CrTX-B are large proteins. Carukia barnesi, another small carybdeid is one cause of the 'Irukandji' syndrome which includes delayed pain from severe muscle cramping, vomiting, anxiety, restlessness, sweating and prostration, and occasionally severe hypertension and acute cardiac failure. The syndrome is in part caused by release of catecholamines but the cause of heart failure is undefined. The venom contains a sodium channel modulator. Two species of Physalia are present and although one is potentially lethal, has not caused death in Australian waters. Other significant genera of jellyfish include Tamoya, Pelagia, Cyanea, Aurelia and Chyrosaora.

The effects of antivenom and verapamil on the haemodynamic actions of Chironex fleckeri (box jellyfish) venom

The efficacy of antivenom and verapamil against Chironex fleckeri (box jellyfish) venom was investigated in monitored mechanically ventilated piglets. Chironex fleckeri tentacle extract alone, a mixture of tentacle extract with antivenom, and verapamil before tentacle extract were administered intravenously to groups of animals. Tentacle extract caused severe systemic hypotension, cardiac dysrrhythmias, pulmonary hypertension, haemolysis and hyperkalaemia. These effects were prevented by pre-incubation of tentacle extract with antivenom. Verapamil did not prevent any effect of venom, exacerbated cardiovascular collapse and increased mortality. We conclude that antivenom neutralizes the cardiovascular, haemolytic and hyperkalaemic effects of box jellyfish venom. Verapamil does not prevent any of these effects and is contra-indicated for treatment of envenomation.

Clinical implications of research on the box-jellyfish Chironex fleckeri

Despite several decades of laboratory research, many anecdotal clinical publications and successful production of antivenom, the active components of Chironex fleckeri venom and their mechanisms of toxicity remain poorly elucidated. Conflicting results of animal experiments and venom studies and the lack of controlled clinical trials necessitate caution in formulating protocols of clinical management. Of particular note are that in severe envenomation (1) clinical deterioration can occur within minutes and cardiac support must be emphasised in addition to respiratory support; (2) larger doses of antivenom may be appropriate; and (3) recommendations of therapy with verapamil and other cardioactive drugs remain controversial.