Abstract

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 3^rd 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

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