A common Kiwi presentation.

 I recently saw a patient for an off work certificate who was somewhat unusual for New Zealand.

He worked on a mine in Queensland and had been having a holiday before returning to NZ. Whilst wandering in the shallows he stood on something sharp and had severe pain in his foot. Lifting his foot he had four puncture marks and assumed he had stood on some coral.

He then describes ascending pain,  spreading erythema and severe oedema and pre-syncopal symptoms.

His mates loaded him into the Ute and rushed him to the local hospital.

On arrival he was mildly hypotensive BP 100/60 with a relative bradycardia of 50bpm for a patient in severe pain.

He was treated with a combination of oral, IV analgesia and hot water immersion (which he reports no effect from) and was kept for observation. Discharged with oral antibiotics and returned to NZ.

Discharge diagnosis of “Fish envenomation NOS”

He was kind enough to share his photos from the “holiday from hell”

 

foot 1

24 hours post injury.

foot 3

 Impressive oedema.

foot 4

 72 hours post injury.

When seen in clinic (2 weeks post injury) the patients oedema was resolving but he couldn’t get his boot on yet. The blistered areas had sloughed off and good granulation tissue in the bases. As he was working for a rich Aussie mining company I put him off for another week 😉

So I went looking for some info on fish envenomation’s. The Team at LITFL did a great review in 2009 so I chased about to see what the literature has come up with since then.

http://lifeinthefastlane.com/2009/04/scorpionfish-stonefish-lionfish/ (LITFL discussion of management)

Published at the exact same time as the LITFL review was a case series from Singapore hospital of 30 patients, showing most did very well and antivenom was not used very often.

http://www.ncbi.nlm.nih.gov/pubmed/19495521

 An article in French which discusses a case leading to cardiovascular collapse:

 http://www.ncbi.nlm.nih.gov/pubmed/20099677

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