Fatal and Severe Box Jellyfish Stings, Including Irukandji Stings, in Malaysia,

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1 275 Fatal and Severe Box Jellyfish Stings, Including Irukandji Stings, in Malaysia, John M. Lippmann, OAM, BSc, MAppSc, PeterJ.Fenner,AM,MD(London),FACTM, FRCGP, Ken Winkel, MBBS, BMedSci, PhD, FACTM, and Lisa-Ann Gershwin, PhD Divers Alert Network Asia-Pacific, Melbourne, Victoria, Australia; School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Queensland, Australia; Travel Medicine Mackay, North Mackay, Queensland, Australia; Australian Venom Research Unit, Department of Pharmacology, University of Melbourne, Victoria, Australia; Tasmanian Museum and Art Gallery, Hobart, Tasmania, Australia DOI: /j x Background. Jellyfish are a common cause of injury throughout the world, with fatalities and severe systemic events not uncommon after tropical stings. The internet is a recent innovation to gain information on real-time health issues of travel destinations, including Southeast Asia. Methods. We applied the model of internet-based retrospective health data aggregation, through the Divers Alert Network Asia-Pacific (DAN AP), together with more conventional methods of literature and media searches, to document the health significance, and clinical spectrum, of box jellyfish stings in Malaysia for the period January 1, 2000 to July 30, Results. Three fatalities, consistent with chirodropid envenomation, were identified for the period all tourists to Malaysia. Non-fatal chirodropid stings were also documented. During 2010, seven cases consistent with moderately severe Irukandji syndrome were reported to DAN and two representative cases are discussed here. Photographs of chirodropid (multi-tentacled), carybdeid (four-tentacled) box jellyfish, and of severe sting lesions were also submitted to DAN during this period. Conclusions. This study suggests that the frequency and severity of jellyfish stings affecting tourists in Southeast Asia have been significantly underestimated. Severe and fatal cases of chirodropid-type stings occur in coastal waters off Peninsular Malaysia and Sabah, Borneo. Indeed, the first Malaysian cases consistent with Irukandji-like syndrome are reported here. Reports to DAN, a provider of emergency advice to divers, offer one method to address the historic lack of formalized reporting mechanisms for such events, for photo-documentation of the possible culprit species and treatment advice. The application of marine stinger prevention and treatment principles throughout the region may help reduce the incidence and severity of such stings. Meanwhile travelers and their medical advisors should be aware of the hazards of these stings throughout the Asia-Pacific. Jellyfish are a common cause of marine injuries world-wide. Most cases are minor and without permanent sequelae. However, box jellyfish can cause major stings with fatalities or severe systemic symptoms. 1 4 Unfortunately, despite the development of many interventions to reduce this type of injury in Australia, 5 little documentation exists concerning the contemporary hazard represented by jellyfish stings in coastal regions of tropical developing countries. In a previous paper, 2 these authors drew attention to the presence, and associated morbidity and mortality, of potentially deadly jellyfish in the coastal waters of Thailand, including chirodropids (larger multitentacled box jellyfish similar to Australia s Chironex fleckeri) and carybdeids (smaller box jellyfish with one Corresponding Author: John M. Lippmann, OAM, BSc, MAppSc, Divers Alert Network Asia-Pacific, P.O. Box 384, Ashburton, Melbourne, VIC 3147, Australia. johnl@ danasiapacific.org tentacle in each corner), similar but distinct from the Australian jellyfish Carukia barnesi, 6 some of which may be associated with the Irukandji, or Irukandji-like, syndrome hereafter referred to as Irukandji jellyfish. With the proximity to Thailand, and in the region where chirodropids occur, including the Philippines, where some 20 to 50 sting deaths occur annually, 7 a similar problem is highly likely to occur in Malaysia, although such cases have been minimally documented. 7,8 The recent box jellyfish-related deaths of several international tourists in both Thailand and Malaysia 2,9 12 have emphasized these risks from marine stings in coastal areas of Southeast Asia. Unfortunately, it is very difficult to access detailed and timely reports enabling injury prevention recommendations to address these emerging health issues. One recent innovation to facilitate such access about the health status of travel destinations, for near real-time infectious and toxicdiseasesurveillance,hasbeeninternet-basedreporting. Entities such as ProMed ( and HealthMap ( provide a 2011 International Society of Travel Medicine, Journal of Travel Medicine 2011; Volume 18 (Issue 4):

2 276 Lippmann et al. Figure 1 Locations in Malaysia where fatal or serious stings have been reported since 1945 (indicated by dots). In some locations there have been multiple fatalities and/or serious stings. focal point for collection, presentation, and dissemination of geospatially sophisticated health data to optimize travel health outcomes. We therefore applied this model of internet-based health data aggregation, together with conventional methods, to increase knowledge of box jellyfish stings in Malaysia, a major tourist destination in the region. Methods Most case histories and images were obtained through Divers Alert Network Asia-Pacific (DAN AP) reports received since November 2007 from victims or witnesses; internet discussions from jellyfish discussion sites; Google Alerts (using the term jellyfish stings ); media sources (Thailand, Malaysia, and Singapore on-line newspapers); and contacts. Where possible, reports were verified by communication, photographic evidence, and/or telephone interview. Also, Google and PubMed searches were conducted using combinations of searching keywords Malaysia, jellyfish, Irukandji, fatal, and near fatal. Where possible, diagnoses of chirodropid box jellyfish sting and Irukandji syndrome were made by standard clinical definitions previously used in this journal. 2 Case F1: February s to DAN and Electronic Newspaper Reports A 45-year-old Swedish female tourist died after being stung by a jellyfish while taking an evening swim off a beach in Langkawi. She suddenly shrieked with pain and became unconscious within seconds. Lesions, reportedly consistent with a chirodropid sting, were visible on her legs. She was immediately taken ashore where cardiopulmonary resuscitation (CPR) was commenced. Her husband reported that an ambulance arrived 15 minutes later and the paramedics confirmed that she had been stung by a jellyfish. 12 Case F2: November Newspaper Report An 8-year-old South Korean girl was reported to have died after a jellyfish sting at Palau Sapi, near Kota Kinabalu, Sabah. She had lesions on both legs and collapsed within seconds and died shortly thereafter. 10 The lesions described were consistent with chirodropid lesions (photograph not available). However, photographs of lesions on another child at Palau Sapi 1 month later showed a pattern typical of a multi-tentacled box jellyfish, indicating that chirodropid jellyfish occur in the area. 11 Results Fatalities Three fatalities from jellyfish stings were reported in Malaysia since 2000 (locations shown in Figure 1). Case F3: June Newspaper Report A 26-year-old male tourist from Brunei reportedly died after a jellyfish sting at Palau Pangkor. He and several friends were stung and he collapsed and died on the

3 Box Jellyfish Stings in Malaysia 277 Figure 2 Chirodropic-type lesions on the leg of a British tourist stung at Kota Kinabalu, July way to hospital. The death was reported to be from an anaphylactic reaction to the sting. 9 Near-fatal Chirodropid Envenomation Kota Kinabalu, July Communications to DAN A 44-year-old female British tourist. The wound (Figure 2), together with the accompanying description, is typical of a chirodropid envenomation, such as from Chironex spp. The sea was calm, there were high tides, and the water was cloudy. As the victim walked from the sea she felt a light gripping sensation to her lower legs and knees. Within seconds she could not breathe or talk properly, and felt unwell. Transparent blue/gray/purple tentacles were stuck to her lower legs. After staggering a few meters she fell onto the sand, overcome by severe leg pains. Briefly everywhere felt painful, and then localized to excruciating pains in her lower legs. She reported dyspnoea and had a sore (not tight) chest. There was a period of altered (reduced) consciousness, after which she again became aware of leg pains and noticed the lifeguards applying ice. Sitting up caused a feeling of faintness. When told she had been stung by a box jellyfish she expressed disbelief as she had no warning of their potential presence (although a lifeguard later told another tourist that they occurred there). She elected to return to her hotel rather than hospital but had to be taken by wheelchair, as she could barely walk. Severe pain lasted a few hours despite the use of regular co-codamol (30 mg codeine/500 mg paracetamol) and 400 mg ibuprofen; pain persisted several days. The next day she had severe oedema below her thighs and developed cellulitis above the stung area, which appeared to clear with antibiotics. The wounds blistered and took 3 months to heal, although neuropathic pain and slight ankle swelling remained. 13 Many aspects of this case are highly consistent with severe chirodropid envenomation. Irukandji-like Syndrome Cases Pantai Tengah Mark, Langkawi, June 26, Communications to DAN Two British tourists were both stung. Lifeguards applied vinegar and a cream. Within half-an-hour, they developed unpleasant chest pains and severe waves of pain throughout their bodies and were taken to hospital by ambulance for a pain-killing injection (unknown) and IV serum (again, unknown). They reported severe on-going pain and tremors and re-presented for further analgesia but, despite this, it was another 2 days before they felt better. No warning signs were present at the beach and it was reported that at least two other people were stung that day, one reportedly remaining in hospital overnight with breathing difficulties. 14 Frida Beach, Langkawi, June 20, Telephone and Communications with DAN A 30-year-old Norwegian female, taking no medications and with no prior history of allergy or serious illness, was stung on her left leg and foot while walking in shallow, murky water. A jellyfish captured there shortly afterwards is shown in Figure 3. She initially had some skin pain and discomfort but was otherwise well. Bystanders scraped the wound site and flushed it with fresh water to remove the tentacles. A doctor was consulted and she was given an antihistamine (clemastinum) and 30 mg prednisolone. Some 50 minutes later, the sting area was edematous with an intense red color. Local pain had intensified and she became nauseous. Over the next 2 to 3 hours she developed generalized pain in her skin and subcutaneous tissues, spreading from the foot to the rest of her body. Her nausea increased but she did not vomit. She described regular waves of burning pain throughout her entire body almost like labor pains, as well as flu-like symptoms with muscle pain and generalized discomfort. She was given oral tramadol for analgesia. She was monitored until the following day and required further oral tramadol for generalized soft tissue pain. Her pain and other symptoms gradually disappeared over the next 3 to 4 days. 15 Discussion The DAN AP ( is a non-profit diving safety association that is part of an international network of similar organizations. DAN AP has been operating since 1994 and provides a contact point for the diving community in the Asia-Pacific concerning diverse regional health issues and events. It has become apparent, through numerous and persistent reports, through the Network and its affiliates, from affected individuals, concerned witnesses, as well as tour operators, that it is overwhelmingly likely the frequency and severity of jellyfish stings in Southeast Asian waters

4 278 Lippmann et al. Figure 3 Carybdeid captured at Frida Beach, Langkawi, June have been significantly underestimated. The lack of formalized reporting mechanisms for such patient-driven observations has precluded wider appreciation of this public health and travel medicine issue. In this context, the ubiquitous availability of digital cameras and internet access, even in remote localities, has provided a major advance in the ability to gather marine injury data in real time. Further, the scope of such information is now far more enriched than mere case demographics, allowing, as presented here, detailed first-hand patient descriptions of the event and its sequelae, including post-medical outcomes, geospatial and environmental referencing, together with unprecedented ability to record the natural history of the sting lesion itself, providing insight into the possible culprit species. The provision of an on-line focal point for such reports, such as through DAN, provides a rich resource to complement more traditional methods of data gathering. This in turn advances our understanding of marine stings in the region, allowing for development of improved safety assessment and delivery. Figure 4 Chirodropid photographed at Telaga Harbour, Langkawi, May 12, 2010 (T. Marinis photo). In this study, blending such methods, we have gathered compelling evidence of both lethal and severe box jellyfish and, for the first time, stings producing an Irukandji-like syndrome, currently affecting travelers swimming and diving in the coastal waters of Peninsula and mainland Malaysia. This builds on sporadic, isolated historic reports of lethal and near-lethal chirodropid stings out of Penang, Labuan Island, and the island of Borneo since the 1940s. 7,8,16 18 We believe that these are a significant underestimation of the true occurrence of fatal and severe stings in Malaysia. Cubozoan Jellyfish Species in Malaysian Waters To date, to our knowledge, no cubozoan jellyfish have been captured from Malaysian waters for taxonomic identification, so the current state of knowledge is based on photographs and sting reports. However, the case histories and sting lesion photographs demonstrate unequivocally that lethal box jellyfish species occur in these waters. This conclusion is not surprising considering that lethal species of box jellyfish are confirmed from the surrounding regions of Thailand, the Philippines, and northern Australia. 2,7 Preliminary morphological determination of jellyfish species is based on the examination of high-resolution versions of the photographs reproduced herein. However, thorough species identification will require examination of specimens and nematocysts. The carybdeid jellyfish species captured and photographed at Frida Beach, Langkawi, in June 2010 (Figure 3) is an Irukandji-like species, possibly in the genus Malo 19 or Gerongia. 20 The chirodropid jellyfish species photographed at Telaga Harbour, Langkawi, on May 12, 2010 (Figure 4) is in the genus Chiropsoides or an unknown close relative. 21 The total length was estimated to be 60 cm (including tentacles), considerably smaller than that normally expected for a mature lethal species. The carybdeid jellyfish species photographed at Rebak, Langkawi, on May 15, 2010 (Figure 5) is an Irukandji-type species, and probably new to science. The bell was estimated to be 3 to 4 cm and the tentacles 20 to 25 cm unusually large for the genus Carukia,andmore

5 Box Jellyfish Stings in Malaysia 279 Figure 5 Carybdeid jellyfish species photographed at Rebak, Langkawi, May 15, 2010 (T. Marinis photo). typical of the genus Malo. However, the conspicuous warts on the body are similar to a Carukia spp. 6 Although it is often difficult to match jellyfish stings to particular species, stings from chirodropid and Irukandji box jellyfish are considered the most reliable to diagnose in the field or in the clinical presentation and effects. Those reported here from these Malaysian jellyfish are very similar to those previously reported in Australia and in Thailand. 2,4,18 Despite our efforts to link the species in the photographs with Malaysian sting case reports, some questions remain unresolved. In particular, the chirodropid shown in Figure 4 may not be a lethal species although conditions favorable to the one chirodropid species would be favorable to another, lethal species. In neighboring Thailand, following decades of known lethal and sub-lethal stings, a suspected lethal chirodropid species has only recently been collected for formal identification. Indeed this species is new to science and has not yet been formally described and classified. Furthermore, the two Irukandji-like jellyfish presented here do not appear to be the same species and to date, to our knowledge, no Irukandji syndrome cases have been previously formally reported from Malaysia. This suggests that there probably are Irukandji stings in Malaysian waters that are not being recognized as such. This is common, and most instances are only reported through unusual circumstances. However, knowing that at least two carybeid species are present in Malaysian waters suggests that a heightened awareness of indicative ecological conditions and early clinical features of envenomation should be emphasized. Enquiries to the hospital about the most recent fatality (case F1) stated the cause of death was drowning ; in case F3, it was anaphylaxis ; and we do not have an actual cause of death in case F2. Unfortunately, the cause of death with jellyfish stings is often misunderstood and attributed to other factors, or played down, rather than being directly attributed to the venom effects of the jellyfish sting. 22 Whilst anaphylaxis was diagnosed, true anaphylaxis from jellyfish stings is extremely rare, having been confirmed only once 23 and extremely unlikely to have occurred without previous exposure to the venom. Misdiagnoses in the area render the task of instituting and promulgating appropriate public health measures more difficult and convey the message that deaths arise from individual predilection rather than severe envenomation from endemic jellyfish. Figure 6 A suitable warning sign of dangerous jellyfish with an attached bottle of vinegar for dousing stings (Cape Tribulation, Queensland, Australia). Preventative actions to reduce fatalities and severe cases from jellyfish stings cannot be implemented until the problem is accepted. Case F1 actually occurred shortly before a world championship round of a triathlon where the swim leg took place just off the beach in which many hundreds of competitors swam, likely with little or no idea of the danger present! Malaysia, like Thailand, northern Australia, and many other tropical destinations, is marketing strongly to draw international tourists. Many of these partake in aquatic activities such as swimming, snorkelling, scuba diving, and water skiing. As dangerous box jellyfish are present in Malaysian waters, this exposes participants to the risk of severe envenomation, especially if personal protective precautions are not undertaken. Travelers to this region need to have these aquatic risks and their mitigation addressed as part of pre-travel health education. It is imperative that government authorities, aquatic resorts, and aquatic operators warn clients of the potential threat so that they can make an informed decision prior to entering the sea in such areas. These warnings should ideally be included in pretrip information from travel agents and travel medicine advisors. However, it is also essential that adequate and appropriate warning signs are present in affected areas and multi-lingual brochures are provided to tourists by resorts and operators. Figure 6 shows a suitable sign, as well as vinegar access. Neither scraping the skin nor flushing with fresh water should be used on the sting site as both can trigger discharge of further nematocysts. Sea water can be used to wash off tentacles, or preferably vinegar, if available, which rapidly and effectively neutralizes cubozoan nematocysts. 24 Vinegar should be readily accessible to locals and tourists alike for prompt access in the event of a sting. Lifeguards trained in CPR should be provided by coastal

6 280 Lippmann et al. tourist resorts to increase the likelihood of survival from a severe chirodropid sting. Conclusions Potentially lethal chirodropid and Irukandji jellyfish are present in Malaysian waters with an associated incidence of morbidity and mortality in both tourists and Malay Nationals. It is essential that adequate preventative treatment and management strategies are implemented to minimize harm from these species. DAN AP provides one method to address the historic lack of knowledge about such stings to improve sting prevention. Preventative strategies must include education of travel medicine specialists, travel agents, local medical and ambulance personnel; governmentinitiated policies for education of tourist bodies and tourism operators; multi-lingual resources of educational literature; and signage with clear, accurate warnings for visitors to these areas; fenced walkways for entry to beaches with multi-lingual signs at their start and entrance to the beach; and vinegar bottles of up to 5 L quickly and easily accessible. Unfortunately, retaining the status quo by failing to embrace these solutions will inevitably lead to further deaths and severe envenomations, including Irukandji syndrome and, with internet access open to all, will likely lead to an increasing backlash from the international tourism community as the unaddressed risks of these marine stings become increasingly obvious. Limitations There are some inherent limitations in certain data collection methods employed in this study. Self-reporting has potential inaccuracy and bias unless followed up with careful questioning and assessment. Newspaper reports can be notoriously biased and inaccurate and great care must be taken in interpretation of these and supporting evidence gathered where possible. Calls to DAN for advice are much more likely to be assessed objectively and yield more credible reports. Acknowledgments We would like to acknowledge the efforts of Andrew Jones, whose young son was badly stung while on holiday in Thailand. In response to the sting, Mr Jones has personally spent much time and effort trying to make tropical beaches safer. Sincere thanks to all of those who submitted marine sting reports to DAN to facilitate this research. Declaration of Interests J. L. is the Executive Director of Divers Alert Network Asia-Pacific. P. F. was the Marine Stinger Advisor with Surf Life Saving Queensland from 1985 to 2005: the National Medical Officer, Surf Life Saving Australia He was a co-author on the textbook 3 and is a member of the Marine Stinger Advisory Group to the Queensland Government. K. W. is the Director of the Australian Venom Research Unit, and Senior Research Fellow, at the University of Melbourne. He is also a member of the Marine Stinger Advisory Group to the Queensland Government and is a consultant to CSL Limited, the manufacturer of Australia s antivenoms. K. W. is funded by the Australian Government Department of Health. L.-A. G. was the National Marine Stinger Advisor with Surf Life Saving Australia from 2005 to Since 2007, she has been on the Medical Advisory Panel for St John Ambulance Australia and the Director of the Australian Marine Stinger Advisory Services. References 1. Fenner PJ, Williamson JA. Worldwide deaths and severe envenomation from jellyfish stings. Med J Aust 1996; 165: Fenner PJ, Lippmann J, Gershwin LA. Fatal and nonfatal severe jellyfish stings in Thai waters. J Travel Med 2010; 17: Taylor DMcD, Pereira P, Seymour J, Winkel KD. A sting from an unknown jellyfish species associated with persistent symptoms and raised troponin I levels. Emerg Med 2002; 14: DePender AMG, Winkel KD, Ligthelm RJ. A probable case of Irukandji syndrome in Thailand. J Travel Med 2006; 13: Gershwin LA, Denardi D, Fenner PJ, Winkel KD. Marine stingers: review of an under-recognised global coastal management issue. Coast Manage J 2009; 38: Southcott RV. Revision of some Carybdeidae (Scyphozoa: Cubomedusae), including a description of the jellyfish responsible for the Irukandji syndrome. Aust J Zool 1967; 15: Williamson J, Fenner P, Burnett J, Rifkin J, Eds. Venomous and poisonous marine animals: a medical and biological handbook. Sydney: NSW University Press, Cleland JB, Southcott RV. Injuries to man from marine invertebrates in the Australian region. Special Report Series No 12. Canberra: National Health and Medical Research Council, New Strait Times. 16 June Available at: highbeam.com/doc/1p html. (Accessed 2010 Sept 15) 10. Daily Express. 21 Nov Available at: express.com.my/print.cfm?newsid= (Accessed 2010 Sept 15) 11. Daily Express. 22 Dec Available at: express.com.my/print.cfm?newsid= (Accessed 2010 Sept 15) 12. Phuket Wan. Feb Available at: com/tourism/alarm-box-jellyfish-kills-tourist-langkawi /. (Accessed 2010 Sept 15)

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