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In this issue of the MJA, Isbister and colleagues report that hot water immersion was no more effective than ice packs for treating the pain of stings by the box jellyfish (Chironex fleckeri).1 This finding is surprising, as jellyfish venoms are heat-labile,2 but unsurprising, given that heat treatment for some patients did not begin until 4 hours after the patient was stung. Managing jellyfish stings is generally subject to confusion, and official advice needs revising to make it clear, consistent and effective. The current Australian Resuscitation Council (ARC) guidelines for treating jellyfish envenoming3 encourage this confusion by suggesting that people stung while swimming in temperate waters (south of Bundaberg) should use heat immersion to reduce pain (based on a randomised controlled trial of treatment for bluebottle stings4), but those envenomed in tropical waters (north of Bundaberg) should be treated with ice. The guidelines also advise that vinegar should be used to minimise envenoming only in tropical areas — unless it is clear that the patient has been stung by a bluebottle, in which case vinegar should never be used. Which treatment should you use if you are stung while swimming at Bundaberg? The answer is, at present, uncertain, and urgently requires investigation.

Australian bat lyssavirus (ABLV) infection in humans is rare but fatal, with no proven effective therapy. ABLV infection can be prevented by administration of a post-exposure prophylaxis regimen of human rabies immunoglobulin and rabies vaccine. All Australian bats (flying foxes and microbats) should be considered to be carrying ABLV unless proven otherwise. Any bat-related injury (bite, scratch or mucosal exposure to bat saliva or neural tissue) should be notified immediately to the relevant public health unit - no matter how small the injury or how long ago it occurred. Human-to-human transmission of ABLV has not been reported but is theoretically possible. Standard infection control precautions should be employed when managing patients with suspected or confirmed ABLV infection.

Objective: To investigate the effectiveness of hot water immersion for the treatment of Physalia sp. (bluebottle or Portuguese Man-of-War) stings. Design: Open-label, randomised comparison trial. Primary analysis was by intention to treat, with secondary analysis of nematocyst-confirmed stings. One halfway interim analysis was planned. Setting: Surf lifesaving first aid facilities at two beaches in eastern Australia from 30 December 2003 to 5 March 2005. Participants: 96 subjects presenting after swimming in the ocean for treatment of an apparent sting by a bluebottle. Interventions: Hot water immersion (45° C) of the affected part versus ice pack application. Main outcome measures: The primary outcome was a clinically important reduction in pain as measured by the visual analogue scale (VAS). Secondary outcomes were the development of regional or radiating pain, frequency of systemic symptoms, and proportion with pruritus or rash on follow-up. Results: 49 patients received hot water immersion and 47 received ice packs. The two groups had similar baseline features, except patients treated with hot water had more severe initial pain (VAS [mean ± SD]: 54 ±22 mm versus 42 ±22 mm). After 10 minutes, 53% of the hot water group reported less pain versus 32% treated with ice (21%; 95% CI, 1%– 39%; P = 0.039). After 20 minutes, 87% of the hot water group reported less pain versus 33% treated with ice (54%; 95% CI, 35%–69%; P = 0.002). The trial was stopped after the halfway interim analysis because hot water immersion was shown to be effective (P = 0.002). Hot water was more effective at 20 minutes in nematocyst-confirmed stings (95% versus 29%; P = 0.002). Radiating pain occurred less with hot water (10% versus 30%; P = 0.039). Systemic effects were uncommon in both groups. Conclusions: Immersion in water at 45° C for 20 minutes is an effective and practical

Objective: To describe the epidemiology and clinical features of box jellyfish envenoming in the Top End of the Northern Territory and, in particular, confirmed stings from the major Australian box jellyfish, Chironex fleckeri. Design: Prospective collection of clinical data and skin scrapings or sticky-tape tests for nematocyst identification from patients presenting to Royal Darwin Hospital and remote coastal community health clinics in the Northern Territory, spanning 10 950km of coastline; analysis of tidal, weather and seasonal data. Patients: All patients with jellyfish sting details recorded between 1 April 1991 and 30 May 2004. Main outcome measures: Demographic and clinical features, use of C. fleckeri antivenom, and associations between weather, seasonal and tidal factors and confirmed C. fleckeri stings. Results: Of 606 jellyfish stings documented, 225 were confirmed to have been caused by C. fleckeri. 37% of C. fleckeri stings were in children, 92% occurred during the “stinger season” (1 October to 1 June), 83% occurred in water 1 m or less deep, and 17% occured while victims were entering the water. Stings were least common on outgoing tides (P < 0.001) and commonest between 15:00 and 18:00 (P < 0.001) and on days with wind speed less than that month’s average (P < 0.001). Nearly all victims experienced immediate pain, but this could often be controlled with ice; only 30% required parenteral narcotics and 8% required hospital admission. Cardiorespiratory arrest occurred within several minutes of the sting in the one fatal case, involving a 3-year-old girl with only 1.2 m of visible tentacle contact. C. fleckeri antivenom was given to another 21 patients, none of whom had life-threatening features at the time they were given antivenom. Conclusions: Most C. fleckeri stings are not life-threatening; patients who die usually have cardiopulmonary arrest within minutes of the sting. The potential benefit of antivenom and magnesium under these circumstances remains to be shown, but a protocol with their rapid use is recommended if cardiopulmonary arrest has occurred. Unfortunately, this is unrealistic for many rural coastal locations, and the priority remains prevention of stings by keeping people, especially children, out of the sea during the

Interest in envenoming syndromes caused by Australian jellyfish has been intense since the deaths in early 2002 of two tourists in Queensland, attributed to the Irukandji syndrome. We review current knowledge of these envenoming syndromes, mechanisms of venom action and therapy, focusing on the deadly box jellyfish, Chironex fleckeri, and the array of jellyfish thought to cause the Irukandji syndrome. Current understanding of jellyfish venom activity is very limited, and many treatments are unproven and based on anecdote.

To determine the immediate and delayed effects of jellyfish stings, and correlate these with microscopic identification of jellyfish nematocysts.Prospective study of patients presenting with jellyfish stings.40 people presenting with jellyfish stings to the emergency department of a teaching hospital in tropical Australia between 1 August 1999 and 31 July 2000.Clinical diagnosis (sting by Chironex fleckeri, "Darwin carybdeid" or other jellyfish, or "Irukandji" syndrome); clinical severity; delayed hypersensitivity; and sticky-tape sampling and microscopic identification of nematocysts.Patients were aged 2-50 years, with eight aged under 15 years; 23 were male. Presentations were consistent with C. fleckeri sting in 28 cases, Darwin carybdeid sting in five, and Irukandji syndrome in four. Sticky-tape sampling was done in 39 patients and was positive for C. fleckeri nematocysts in 23 and for non-C. fleckeri nematocysts in six, with nematocysts not detected in 10 (including all four with Irukandji syndrome). All microscopically confirmed C. fleckeri stings had typical clinical presentations. None of the stings were life-threatening, and no antivenom was given. Delayed hypersensitivity reactions were seen in 11 of the 19 patients (58%) followed up after stings positive for C. fleckeri nematocysts.Although most jellyfish stings presenting to Royal Darwin Hospital I were caused by C. fleckeri, severe envenomation was rare. There was a strong association between clinical features and sticky-tape identification of nematocysts. Delayed hypersensitivity was common after C. fleckeri stings.

OBJECTIVE To examine crocodile attacks in the Northern Territory with particular reference to risk factors, range of injuries, microorganisms isolated from wounds, and surgical management; and to make recommendations for optimal treatment. DESIGN AND SETTING The case notes of patients treated at the Royal Darwin Hospital within the last decade were reviewed retrospectively. Autopsy and newspaper reports for the same period were also reviewed. RESULTS There were 16 reported crocodile attacks in Northern Territory waters from June 1981 to June 1991. Four of these were fatal. Most attacks resulted from swimming or wading in shallow water (13/16). Half the victims were known to be affected by alcohol. The majority of attacks occurred in failing light or at night (10/16). Injuries in survivors ranged from minor lacerations and puncture wounds to major abdominal, chest and limb trauma. Death in fatal attacks was caused by transection of the torso or decapitation. Microorganisms isolated from wound swabs included Pseudomonas, Enterococcus, Aeromonas and Clostridium species. CONCLUSIONS Most attacks in this series could have been prevented by taking adequate precautions. The treatment of crocodile injuries must include (i) adequate wound cultures, (ii) antitetanus prophylaxis, (iii) meticulous wound debridement, (iv) appropriate broad spectrum prophylactic antibiotics and (v) allowing healing by secondary intention or delayed primary closure where appropriate.

OBJECTIVE: To report the management of a serious box jellyfish (Chironex fleckeri) envenomation from the first minutes of bystander first aid and treatment by ambulance personnel to subsequent treatment in hospital. CLINICAL FEATURES: A 14-year-old girl sustained a serious Chironex fleckeri sting. There was no loss of consciousness, but the patient suffered severe pain, myocardial irritability, acute pulmonary oedema and mild systemic hypotension, due to the direct toxic effects of the venom. Thirst was a dominant symptom. INTERVENTION AND OUTCOME: Management involved rapid bystander action and call for ambulance assistance; and early intervention with oxygen/nitrous oxide administration, compression bandaging, antivenom administration and electrocardiographic monitoring at the site by ambulance personnel. Echocardiography in hospital three hours after the sting showed a normal myocardium. In hospital management resulted in recovery. Nocturnal itching of the sting persisted for six weeks. CONCLUSIONS: (i) Vinegar dousing may irritate freshly stung skin, but as a nematocyst inhibitor vinegar remains an essential part of the first aid treatment for cubozoan jellyfish stings. (ii) Compression/immobilisation bandaging was not associated with long-term harm to the sting area. (iii) The pain of an intramuscular antivenom injection may not be felt by a chirodropid sting victim, so safe injection protocols must be strictly observed. (iv) Ambulance services in other States whereas there is a risk of box jellyfish (Chironex fleckeri or Chiropsalmus quadrigatus) stings should be similarly trained and equipped to deal with serious jellyfish envenomations. Language: en

To attribute a cause and quantify allergic-like symptoms observed among island residents. Skin prick tests and intradermal injections with ultraviolet-irradiated, filtered (0.22 microns) whole-body homogenates of the soft tick, Ornithodoros capensis, were used to reproduce experimentally the symptoms observed. Heron Island, Great Barrier Reef, Australia. Island residents were designated as such after having spent more than 1 month on the island during the summer seabird breeding season. Control measures were instigated using a residual insecticide, delta-methrin, sprayed inside sleeping quarters. Acaricide spraying reduced (X2 = 4.42; P less than 0.05) the number of island residents complaining of having been bitten by ticks, yet was considered an inefficient control measure as 67% reported being attacked by ticks after spraying. Among 97 island residents, elevated total IgE levels were associated with reaction to tick bite in 11 cases (X2 = 27.17; P less than 0.001), but were not of reliable diagnostic value. Symptoms included intense pruritus, blistering (a major feature), erythema, weeping lesions, lymphangitis, dull ache, rheumatic pain and general lassitude, and intense discomfort. Sera from two of four volunteers with known reactions to O. capensis and one of four others with reactions to the Australian paralysis tick, Ixodes holocyclus, cross-reacted with antigens from a total of four of six biting/stinging and non-biting arthropods (radioallergosorbent tests). Symptoms associated with reactions to tick bite peaked in severity at 35-40 hours and thus the response was most likely delayed type IV hypersensitivity.

A new focus of spotted fever group rickettsial infection has been recognised in East Gippsland, Victoria. Seven cases have been identified among Melbourne residents after they holidayed in the area. The infections were confirmed serologically. The precise identity of the Rickettsia has not been determined.

Twenty six cases of a spotted-fever-like illness have been identified over a 17 year period in the population of about 1000 of Flinders Island, Tasmania. The usual features were high fever, headache, myalgia, slight cough, arthralgia without joint swelling and a maculopapular rash which did not resemble the common exanthems. Twelve cases had a focal skin lesions. Available evidence implicates ticks as the vector.

Australia has the most potent collection of venomous land and sea creatures in the world--something that settlers to this country discovered by bitter experience. Fortunately, today victims of bites from such animals may benefit from more effective and rational treatment than is available in most other countries.

Twenty-five patients living in a tick-endemic region of Sydney, New South Wales developed red meat allergy after experiencing large local reactions to tick bites. This represents a potentially novel cross-reaction between an arthropod and a food protein. (MJA 2009; 190: 510-511).

This paper presents a case of Irukandji syndrome (envenomation by the jellyfish, Carukia barnesi) with pulmonary oedema and hypokinetic cardiac failure. This case highlights the need for victims (and operators of tours venturing into the waters of North Queensland) to treat even apparently innocuous stings with vinegar and to avoid freshwater bathing and rubbing of stings immediately after such incidents. It also reinforces the use of phentolamine to treat the symptoms of catecholamine release associated with the syndrome. This patient required inotropic support and further underlines the need for practitioners to be aware that the syndrome can have severe sequelae and that central venous monitoring and inotropic management should be available when treating Irukandji stings.

To evaluate whether applying pressure equivalent to that of pressure immobilisation bandages (PIB) causes release of additional venom from discharged jellyfish nematocysts.In-vitro experiment--the venom beads released from electrically activated Chiropsalmus sp. nematocysts were viewed under direct microscopy before and after applying 40 mmHg pressure (replicating the pressure of PIB); and saline washings of discharged nematocysts before and after applying pressure were tested for toxicity (time to ventricular standstill after injecting into live prawns).Applying 40 mmHg pressure caused the venom beads to visibly increase in size, consistent with pressure expressing further venom from the discharged nematocysts. First washings of the nematocyst shafts before compression produced ventricular standstill in prawns within 60 seconds (n=3); second washings did not produce standstill during 540 seconds of observation (n=3); and washings after applying 40 mmHg pressure showed a return of toxicity, with ventricular standstill in all prawns within 180 seconds (n=3).Discharged nematocysts are by no means empty and harmless. Applying pressure results in further release of nematocyst venom. The currently recommended practice of applying PIB in the initial treatment of patients stung by a jellyfish may exacerbate the envenomation, and thus should not be recommended.

[Extract] To the Editor: In 1964 the Journal published an article by Barnes which solved the mystery of a distressing illness that was affecting many Queensland beachgoers — Irukandji syndrome.1 In a remarkable piece of detective work, Barnes had captured a small (25 mm bell) jellyfish and demonstrated, by allowing it to sting himself, his 9-year-old son and the on-duty lifeguard, that this jellyfish caused Irukandji syndrome. All required inpatient care. This jellyfish was named Carukia barnesi in his honour, and has been known as the "Irukandji jellyfish". Many now believe that more than one jellyfish is responsible for Irukandji syndrome. Significantly, in the 40 years since Barnes' discovery, no other jellyfish causing Irukandji syndrome has been identified.

OBJECTIVE To present two cases of Mondor's disease of the breast resulting from jellyfish stings in Western Australia. CLINICAL FEATURES A 30-year-old Caucasian woman presented with a palpable thickened cord in her right breast. The straightness of the cord suggested a thrombosed lymphatic. A 50-year-old Caucasian woman presented with an obvious palpable cord extending most of the length of her left breast. Mammography demonstrated no abnormality. Both women reported having been stung by jellyfish a month earlier. INTERVENTION AND OUTCOME As Mondor's disease is a benign, self-limiting disease, the patients were reassured and reviewed routinely. In each case, the condition settled spontaneously over a period of several weeks. CONCLUSION Jellyfish stings should be recognised as an unusual variant of the numerous causes which have been described for Mondor's disease.

A child with severe envenomation by Chironex fleckeri presented in cardiac arrest at a hospital between 15 and 20 min after the sting was sustained. Resuscitation was not successful. Objective confirmation of C. fleckeri as the cause of death is described. Four metres of tentacle contact in this case represents the smallest-measured fatal C. fleckeri sting that has been recorded so far. The mechanism of this death was toxic and not allergic. The available clinical information suggests direct myocardial interference, but does not exclude a respiratory hypoxic element. A more widespread venom-induced functional disruption of the cell membrane is postulated, with a resultant dysfunction in several vital organ systems that were acting in concert. Early, vigorous and sustained resuscitation that is performed as a first-aid measure offers the best hope of prehospital survival after a massive C. fleckeri sting, which is the most explosive envenomation process that is presently known to humans. In-hospital resuscitation from unresponsive circulatory arrest should now involve intravenously-administered verapamil (or its equivalent) and additional box-jellyfish antivenom, while the patient is being monitored.

A brief analysis is presented of the large recorded numbers of swimmers who have been stung by the "Irukandji" (Carukia barnesi) jellyfish during the 1985-1986 summer season in north Queensland, and the results are discussed. Many of the victims may suffer from symptoms of overstimulation of the sympathetic system, and hypertension is shown to be another complication of this syndrome. This hypertension seems to respond well to intravenously-administered phentolamine, an alpha-adrenergic receptor blocking drug. Phentolamine also reduces the excessive shaking and sweating that appears to be part of the "Irukandji syndrome". Diazepam relieves the anxiety which is part of the syndrome, but antihistamine agents and hydrocortisone seem to have no beneficial effect.

I report two cases of life-endangering respiratory failure after envenomation by a blue-ringed octopus (Hapalochlaena maculosa). Early and efficient support of respiratory function is vital in such cases. Cardiac asystole occurred in one patient. Both patients recovered completely after the vigorous application of routine resuscitation techniques.

We report observations on infestations with the lick, Amblyomma triguttatum, in soldiers who were bivou- acked in two areas near Perth; 34% ol 175 persons were infested with varying stages of the ectoparasite. Most persons were infested with only one tick but some troops had multiple infestations. Local skin reactions to tick-bites were frequent; they usually developed 24-48 h atter removal of the tick and may indicate delayed hypersensitivity reactions. A small number of persons developed secondary bacterial infections. Management and prevention of these infestations is reviewed briefly. (Med J Aust 1987; 1$t 238-240) ick-bite is a common problem in eastern Australia, particularly among persons who live in the tropics and subtropics.' In most reported instances, infestation has occurred with the Australian scrub-tick, Ixodes holocyclus, which is distributed from Normanton in the Gulf of Carpentaria, Queensland to Bairnsdale, Victoria.'?'3 This ectoparasite has been reported to cause local allergic reactions, secondary skin infections, anaphylaxis, and neuromuscular paralysis, as well as the trans- mission of organisms such as Rickettsia ouStralis, the aetiological agent of Queensland tick typhus. Ixodes holocyclus is not found in the southern parts of Western Australia, but infestation may occur with other species of ticks. Persons who are particularly at risk are bushwalkers and those who camp in the countryside. This paper reports the incidence of infestation in troops who were encamped at two sites near Perth and describes the clinical manifestations of infestation with the hard-tick, Amblyomma triguttatum, which is commonly known as the "kangaroo-tick".

Two cases of serious envenomation by the northern Australian box-jellyfish (Chironex fleckeri) are reported. The first-aid measures and the subsequent management and follow-up of patients are discussed. In addition to its known life-saving effects, the early administration of the specific antivenom appears to be the best treatment for the savage pain of the sting, and may also result in a reduction of subsequent skin scarring.

Serious envenomation of an adult pregnant woman by a box-jellyfish (Chironex flecteri) in North Queensland is reported. Quick thinking and resuscitation by bystanders which was followed by early hospital treatment resulted in a successful outcome both for mother and for fetus. A brief review of the historic background of box-jellyfish envenomation is given, and some specific problems concerning the management and prevention of envenomation from this unique animal are described. On-the-spot resuscitation takes absolute priority, and the advent of specific antivenom is a major advance. Avoidance of fetal stings in the future is possible by simple preventive measures. The role of the Surf Life Saving Association of Australia in the prevention and treatment of such problems is highlighted, and, as a result of recent research, possible changes in the management of box-jellyfish envenomations are predicted. Language: en