Case Report
Volume 5 Issue 9 - 2022
“From Dinner to Death” Fish Envenomation Presenting as Acute Fulminant Necrotizing Fasciitis in an Adult Filipino. A Case Report
Jose Eduardo Duya1*, Ruel A dela Cruz2, Bernardino B Alpuerto2, Marvin Karlo T Lugue2, Justiniano B Bai2, Jose Maria D Bautista2 and Carissa Paz Dioquino3
1Department of Medicine, University of the Philippines, Philippine General Hospital, Philippines
2Department of Orthopedics, University of the Philippines, Philippine General Hospital, Philippines
3National Poison Control and Management Center, University of the Philippines, Philippine General Hospital, Philippines
*Corresponding Author: Jose Eduardo Duya, Department of Medicine, University of the Philippines, Philippine General Hospital, Philippines.
Received: July 22, 2022; Published: August 05, 2022


Introduction: The Philippines is home to an array of marine animals and as such, marine stings and deadly envenomations are not uncommon. Despite this, there is a scarcity of locally published literature discussing its frequency, natural course of disease and the appropriate management.

Case Description: We present the case of EL, a 35/M previously diagnosed with Grave’s Disease, controlled on Methimazole. Patient has good baseline functional capacity prior to envenomation. 33 hours prior to admission, while preparing a fish for dinner (Local Name: Bugao/Burog, Synanceia verrucosa), the patient accidentally punctured his left thumb with one of its spine. Brisk bleeding was noted on the puncture site. 12 hours after the incident there was erythema with progressive swelling and violaceous discoloration of the thumb progressing to involve the pulp of the digits, all the fingers, forearm and arm. There were multiple tensed bullae with brownish, foul smelling fluid, progressive numbness (50% sensory loss) and progressive motor weakness as well. 37 hours post injury, the patient consulted at the emergency room, hypotensive (BP 70/40 mmHg), tachycardic at 110 bpm and tachypneic. On physical examination, he had pink conjunctivae, flat neck veins, no visible anterior neck mass, bronchovesicular breath sounds, distinct heart sounds, with no bipedal edema. The left upper extremity is marked swollen, erythematous, with areas of multiple bullae formation. After vigorous fluid challenge with 3L of PNSS with minimal blood pressure response, vasopressor support with Norepinephrine and Dopamine was started. He was diagnosed with Acute Necrotizing Fasciitis of the left upper extremity probably from Fish Envenomation. Shock, was multifactorial likely from hypovolemic from 3rd spacing and Sepsis Induced. Patient was given tetanus prophylaxis and was started on broad-spectrum antibiotics (Piperacillin, Tazobactam and Vancomycin). Since no antidote was locally available, patient was stabilized to undergo emergency debridement and fasciotomy of the left hand and forearm. Extensive necrosis of the fascia and foul smelling grayish discharge were seen intra-operatively. Post operatively, the patient succumbed from multiple organ dysfunction syndrome. Blood samples and bullae fluid samples were obtained and a heat labile protein toxin was identified. The potent toxin is found in the species of stonefish.

Discussion: Stonefish venom consists of 4 biologically active factors: (1) hylauronidase fraction, (2) capillary permeability factor, (3) toxic or lethal fraction, and (4) pain producing factor. The capillary permeability factor is a potent hypotensive agent which has direct myotoxic and neurotoxic activity. Combination of these factors resulted into refractory hypotension leading to demise of our patient. A high index of suspicion is warranted to prevent mortality and morbidity associated with fish envenomation. While no stonefish antivenom is locally available, simple management consists of removal of protruding spines, aggressive fluid hydration, adequate analgesia, hot water immersion techniques and adequate empiric antibiotics can be instituted. The role of early surgical debridement cannot be overemphasized as well. This case report aims to increase the awareness about local fish envenomation. Locally published guidelines for the prevention and treatment protocols for local fish envenomations should be developed and distributed locally.

Keywords: Fish Envenomation; Acute Fulminant Necrotizing Fasciitis; Adult Filipino


  1. The Philippine Marine Biodiversity; A Unique World Treasure.
  2. Carpenter KE and VG Springer. Environmental Biology (2005).
  3. Fenner PJ., et al. “Australian and World Marine Envenomation”. A Basic Diagnostic and Therapeutic Guide.
  4. Fenner PJ., et al. Clinical Aspects of Envenomation by Marine Animals.
  5. Lee JYL., et al. “Stonefish Envenomations of the Hand – A local Marine Hazard. A series of 8 Cases and Review of Literature”. Annals of the Academy of Medicine 33 (2004): 515-520.
  6. Samuel KK Ling., et al. “Stonefish envenomation with acute carpal tunnel syndrome”. Hong Kong Medical Journal 6 (2009): 471-473.
  7. Atkinson PR., et al. “Is hot water immersion an effective treatment for marine envenomation?” Emergency Medicine Journal 23 (2006): 503-508.
  8. Lau FL. “Emergency management of poisoning in Hong Kong”. Hong Kong Medical Journal 6 (2000): 288-292.
  9. Stonefish antivenom consumer product information”. Victoria, Australia: CSL Limited (2000).
  10. Adeline Ngo Su-Yin., et al. “Envenomation presenting to a Singapore hospital”. Singapore General Hospital.
  11. JYL Lee., et al. “Stonefish envenomation of the Hand. A Local Marine Hazard”. Annals of the Academy of Medicine 33 (2004): 315-320.
  12. Ryo Yamamoto., et al. “Stonefish “Okoze” Envenomation during Food Preparation”. The Keio Journal of Medicine 1 (2010): 19-22.
  13. HY Chan., et al. “Venomous fish sting cases reported to Hong Kong Poison Information Centre: a three-year retrospective study on epidemiology and management”. Hong Kong Journal of Emergency Medicine 17 (2010): 40-44.
Citation: Jose Eduardo Duya., et al. ““From Dinner to Death” Fish Envenomation Presenting as Acute Fulminant Necrotizing Fasciitis in an Adult Filipino. A Case Report”. EC Clinical and Medical Case Reports 5.9 (2022): 10-15.

PubMed Indexed Article

EC Pharmacology and Toxicology
LC-UV-MS and MS/MS Characterize Glutathione Reactivity with Different Isomers (2,2' and 2,4' vs. 4,4') of Methylene Diphenyl-Diisocyanate.

PMID: 31143884 [PubMed]

PMCID: PMC6536005

EC Pharmacology and Toxicology
Alzheimer's Pathogenesis, Metal-Mediated Redox Stress, and Potential Nanotheranostics.

PMID: 31565701 [PubMed]

PMCID: PMC6764777

EC Neurology
Differences in Rate of Cognitive Decline and Caregiver Burden between Alzheimer's Disease and Vascular Dementia: a Retrospective Study.

PMID: 27747317 [PubMed]

PMCID: PMC5065347

EC Pharmacology and Toxicology
Will Blockchain Technology Transform Healthcare and Biomedical Sciences?

PMID: 31460519 [PubMed]

PMCID: PMC6711478

EC Pharmacology and Toxicology
Is it a Prime Time for AI-powered Virtual Drug Screening?

PMID: 30215059 [PubMed]

PMCID: PMC6133253

EC Psychology and Psychiatry
Analysis of Evidence for the Combination of Pro-dopamine Regulator (KB220PAM) and Naltrexone to Prevent Opioid Use Disorder Relapse.

PMID: 30417173 [PubMed]

PMCID: PMC6226033

EC Anaesthesia
Arrest Under Anesthesia - What was the Culprit? A Case Report.

PMID: 30264037 [PubMed]

PMCID: PMC6155992

EC Orthopaedics
Distraction Implantation. A New Technique in Total Joint Arthroplasty and Direct Skeletal Attachment.

PMID: 30198026 [PubMed]

PMCID: PMC6124505

EC Pulmonology and Respiratory Medicine
Prevalence and factors associated with self-reported chronic obstructive pulmonary disease among adults aged 40-79: the National Health and Nutrition Examination Survey (NHANES) 2007-2012.

PMID: 30294723 [PubMed]

PMCID: PMC6169793

EC Dental Science
Important Dental Fiber-Reinforced Composite Molding Compound Breakthroughs

PMID: 29285526 [PubMed]

PMCID: PMC5743211

EC Microbiology
Prevalence of Intestinal Parasites Among HIV Infected and HIV Uninfected Patients Treated at the 1o De Maio Health Centre in Maputo, Mozambique

PMID: 29911204 [PubMed]

PMCID: PMC5999047

EC Microbiology
Macrophages and the Viral Dissemination Super Highway

PMID: 26949751 [PubMed]

PMCID: PMC4774560

EC Microbiology
The Microbiome, Antibiotics, and Health of the Pediatric Population.

PMID: 27390782 [PubMed]

PMCID: PMC4933318

EC Microbiology
Reactive Oxygen Species in HIV Infection

PMID: 28580453 [PubMed]

PMCID: PMC5450819

EC Microbiology
A Review of the CD4 T Cell Contribution to Lung Infection, Inflammation and Repair with a Focus on Wheeze and Asthma in the Pediatric Population

PMID: 26280024 [PubMed]

PMCID: PMC4533840

EC Neurology
Identifying Key Symptoms Differentiating Myalgic Encephalomyelitis and Chronic Fatigue Syndrome from Multiple Sclerosis

PMID: 28066845 [PubMed]

PMCID: PMC5214344

EC Pharmacology and Toxicology
Paradigm Shift is the Normal State of Pharmacology

PMID: 28936490 [PubMed]

PMCID: PMC5604476

EC Neurology
Examining those Meeting IOM Criteria Versus IOM Plus Fibromyalgia

PMID: 28713879 [PubMed]

PMCID: PMC5510658

EC Neurology
Unilateral Frontosphenoid Craniosynostosis: Case Report and a Review of the Literature

PMID: 28133641 [PubMed]

PMCID: PMC5267489

EC Ophthalmology
OCT-Angiography for Non-Invasive Monitoring of Neuronal and Vascular Structure in Mouse Retina: Implication for Characterization of Retinal Neurovascular Coupling

PMID: 29333536 [PubMed]

PMCID: PMC5766278

EC Neurology
Longer Duration of Downslope Treadmill Walking Induces Depression of H-Reflexes Measured during Standing and Walking.

PMID: 31032493 [PubMed]

PMCID: PMC6483108

EC Microbiology
Onchocerciasis in Mozambique: An Unknown Condition for Health Professionals.

PMID: 30957099 [PubMed]

PMCID: PMC6448571

EC Nutrition
Food Insecurity among Households with and without Podoconiosis in East and West Gojjam, Ethiopia.

PMID: 30101228 [PubMed]

PMCID: PMC6086333

EC Ophthalmology
REVIEW. +2 to +3 D. Reading Glasses to Prevent Myopia.

PMID: 31080964 [PubMed]

PMCID: PMC6508883

EC Gynaecology
Biomechanical Mapping of the Female Pelvic Floor: Uterine Prolapse Versus Normal Conditions.

PMID: 31093608 [PubMed]

PMCID: PMC6513001

EC Dental Science
Fiber-Reinforced Composites: A Breakthrough in Practical Clinical Applications with Advanced Wear Resistance for Dental Materials.

PMID: 31552397 [PubMed]

PMCID: PMC6758937

EC Microbiology
Neurocysticercosis in Child Bearing Women: An Overlooked Condition in Mozambique and a Potentially Missed Diagnosis in Women Presenting with Eclampsia.

PMID: 31681909 [PubMed]

PMCID: PMC6824723

EC Microbiology
Molecular Detection of Leptospira spp. in Rodents Trapped in the Mozambique Island City, Nampula Province, Mozambique.

PMID: 31681910 [PubMed]

PMCID: PMC6824726

EC Neurology
Endoplasmic Reticulum-Mitochondrial Cross-Talk in Neurodegenerative and Eye Diseases.

PMID: 31528859 [PubMed]

PMCID: PMC6746603

EC Psychology and Psychiatry
Can Chronic Consumption of Caffeine by Increasing D2/D3 Receptors Offer Benefit to Carriers of the DRD2 A1 Allele in Cocaine Abuse?

PMID: 31276119 [PubMed]

PMCID: PMC6604646

EC Anaesthesia
Real Time Locating Systems and sustainability of Perioperative Efficiency of Anesthesiologists.

PMID: 31406965 [PubMed]

PMCID: PMC6690616

EC Pharmacology and Toxicology
A Pilot STEM Curriculum Designed to Teach High School Students Concepts in Biochemical Engineering and Pharmacology.

PMID: 31517314 [PubMed]

PMCID: PMC6741290

EC Pharmacology and Toxicology
Toxic Mechanisms Underlying Motor Activity Changes Induced by a Mixture of Lead, Arsenic and Manganese.

PMID: 31633124 [PubMed]

PMCID: PMC6800226

EC Neurology
Research Volunteers' Attitudes Toward Chronic Fatigue Syndrome and Myalgic Encephalomyelitis.

PMID: 29662969 [PubMed]

PMCID: PMC5898812

EC Pharmacology and Toxicology
Hyperbaric Oxygen Therapy for Alzheimer's Disease.

PMID: 30215058 [PubMed]

PMCID: PMC6133268

News and Events

March Issue Release

We always feel pleasure to share our updates with you all. Here, notifying you that we have successfully released the March issue of respective journals and the latest articles can be viewed on the current issue pages.

Submission Deadline for Upcoming Issue

ECronicon delightfully welcomes all the authors around the globe for effective collaboration with an article submission for the upcoming issue of respective journals. Submissions are accepted on/before April 14, 2023.

Certificate of Publication

ECronicon honors with a "Publication Certificate" to the corresponding author by including the names of co-authors as a token of appreciation for publishing the work with our respective journals.

Best Article of the Issue

Editors of respective journals will always be very much interested in electing one Best Article after each issue release. The authors of the selected article will be honored with a "Best Article of the Issue" certificate.

Certifying for Review

ECronicon certifies the Editors for their first review done towards the assigned article of the respective journals.

Latest Articles

The latest articles will be updated immediately on the articles in press page of the respective journals.