|Year : 2019 | Volume
| Issue : 2 | Page : 182-185
Hazardous marine life: Stingray injury and its multimodal management
Bharat Khemji Jani1, Chandrashekhar Mohanty2
1 Classified Specialist Surgery, INHS Dhanvantari, Port Blair, Andaman and Nicobar Islands, India
2 Senior Advisor Marine Medicine, INHS Dhanvantari, Port Blair, Andaman and Nicobar Islands, India
|Date of Submission||04-May-2019|
|Date of Acceptance||05-Jun-2019|
|Date of Web Publication||07-Oct-2019|
Surg Cdr (Dr) Bharat Khemji Jani
INHS Dhanvantari, Minnie Bay, Port Blair, Andaman and Nicobar Islands
Source of Support: None, Conflict of Interest: None
Human existence is known for its phenomenon of expansion and extension in the various natural habitat over a period of time. This has always accompanied with more frequent encounter with the natural inhabitants of that territory. Marine environment is not an exception to this. With increasing encroachment in the marine life, the incidences of the injuries due to marine animals have increased by manifold. Herein we report a case of stingray injury to a diver, its presentation and management. Stingray injuries are one of the rare forms of marine injuries as the fish attacks on provocation or accidentally only. The stingray injury causes both local and systemic effects on humans however in our case the local effects were late. Moreover the local damage was much more as compared to the external appearance of the stinger injury. This is an important aspect of the clinical part of this report as the external appearance of the injury is very deceptive in comparison with the actual damage caused within. He was managed with IV antibiotics, supportive care, timely local wound debridement and hyperbaric oxygen therapy. The response to HBOT was superb and resulted in speedy recovery of the patient. It can be concluded that though the stingray injuries are rare but the disabilities caused by extensive venomous damage to soft tissue and time taken for complete recovery. Systemic effects though not seen in our case may cause sudden death as reported in some case reports.
Keywords: Hyperbaric oxygen therapy, stingray injury, tissue necrosis
|How to cite this article:|
Jani BK, Mohanty C. Hazardous marine life: Stingray injury and its multimodal management. J Mar Med Soc 2019;21:182-5
| Introduction|| |
With increased interaction among environmentalist and globalization, frequent encounters with venomous marine life have attracted the medical fraternity. Unfortunate death of the famous crocodile hunter  with stingray injury has suddenly brought stingray injuries into the limelight. There are about 150 species of ray fishes known worldwide and most of them live in shallow waters of tropical and subtropical coastlines. Venomous encounter with humans is commonly found with common stingray. Along the underside of a stingray's Spine there are two grooves which contain venom-secreting, glandular tissue [Figure 1]. The spine is covered with a thin layer of skin called the integumentary sheath, and toxin is concentrated in it. The stinger is bone hard spine as long as 14.5” sharp and serrated on both sides and pointed at the end. The typical retroserrated design on sides of the spine makes extraction from the human tissue very difficult and causes extensive damage  [Figure 2].
|Figure 1: Common stingray (Source – Wikipedia, scientific classification Kingdom – Animalia, phylum – Chordata, class – Chondrichthyes order – myliobatiformes, subo)|
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It was found that the toxic fractions of extremely heat-labile venom are soluble proteins of the average molecular weight. The constituent of venom was ten amino acids, and total nitrogen, carbohydrate, and protein for 100 mg of the venom have been calculated as 3.1, 3.3, and 24.9 mg, respectively. The intravenous LD50 of the lyophilized venom is estimated at 28 mg/kg of body weight. Two ventrolateral grooves of the sting contain the maximum portion of venom. During attack, the sheath dissolves, and venom is released along with the tissue damage. Most of the injuries are puncture wounds caused by the stinger with release of venom, and very few times the stinger is left inside the tissue.
A stingray injury has bimodal pattern of tissue damage; mechanical (injury due to stinger) and chemical component. Chemical component of envenomation is due to the toxin released into the wound. Envenomation occurs when the integumentary sheath surrounding the barb ruptures on penetration. Pieces of the toxin-containing sheath are usually deposited in the subcutaneous tissue. This deposited toxin releases over the next few hours, causing slow and progressive damage to the tissue.
The aim of this case report is to highlight the importance of overtly looking benign but potentially life- and limb-threatening stingray injury. This is especially important in case of marine divers and sea fearers who commonly encounter stingray and are far away from medical help. The potential of stingray injury to cause major damage is also related to site of injury.
Clinically, a stingray injury presents with immediate and intense pain at the site of the injury which is distinctly out of proportion to the wound signifies toxin-mediated tissue damage. Pain attains peak in 30–90 min and may last up to 48 h or more depending on the amount of toxin deposited, site of injury, and initial first aid management, i.e. immersion in hot water. This is followed by edema and discoloration soon appears at the wound site, tissue necrosis from venom may appear over 24–48 h. Local complications of a stingray wound include retained foreign body which can be soft tissue (retained integumentary sheath) or singer spine itself, acute infection, delayed infection, and delayed wound healing. Early secondary infection of the wound by bacteria of the genera Vibrio, Aeromonas, and Mycobacterium of marine origin, and delayed infection with bacteria and fungi can occur in few cases., Toxic systemic effects of envenomation can include nausea, vomiting, diarrhea, diaphoresis, weakness, headache, vertigo, muscle cramping, abdominal pain, syncope, seizures, respiratory distress, cardiac arrhythmias, convulsions, and hypotension.
The management starts with local treatment of the wound, debridement of open wound, removal of foreign body, and immersion in the hot water (43°C–45°C). Systemic effects of envenomation are managed with supportive care in a multidisciplinary approach toward systemic effects of envenomation such as cardiac arrhythmia, hypotension, and respiratory complications due to allergic reactions requiring intensive care in some of the cases.
| Case Report|| |
This is a case report of 35-year-old young diver who sustained a stab injury by stingray in the tropical region of South Asia. He presented with a puncture wound on the lateral aspect of right foot behind the lateral malleolus with a small induration around the puncture mark without any signs of erythema. He presented after 32 h of injury and was devoid of any signs of systemic envenomation; however, the injured extreme was treated with immersion in warm water at the site of injury. He was started on supportive care of limb elevation, prophylactic IV antibiotics, and cleaning of wound. However, on the 3rd day, an area of fluctuation has appeared around the puncture wound with no clinical signs of abscess formation. On the clinical suspicion, the wound was explored to drain small amount of pus and few necrosed tissue. There was an area of devitalizing soft tissue spreading across the subcutaneous plane [Figure 3].
|Figure 3: Image after the first surgical exploration of wound near the lateral malleolus of the right foot|
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He was thoroughly explored under anesthesia, and all the devitalized tissue was removed. This created a wound of 8 cm × 6 cm size exposing the muscle planes, Achilles tendon, and lateral malleolus [Figure 4].
Regular debridement of wound and intermittent negative pressure wound dressing supported by broad-spectrum antibiotics were used for 5 days. The wound started improving and started showing the granulation tissue. At this juncture, hyperbaric oxygen therapy (HBOT) was used for faster recovery. Table number 66 for a dry dive of 90 min was used. Oxygen was delivered at 2.4 Atmosphere/square meter (ATA) for a 10 sessions. The wound has shown rapid recovery. To be specific, the slough and devitalized tissue reduced significantly on the 3rd day of HBOT and appearance of the healthier granulation tissue. The wound could finally be closed without any disability. His hemodynamic and laboratory parameters remained under control throughout his complete treatment.
| Discussion|| |
The stinger is a retroserrated sharp spine which is used as a whiplash by the fish, while escaping from the potential predator. Although not much literature available on the site of injury, it can be claimed on the basis of few case reports , that the penetrating injury by stingray in the abdomen and cardiac region is potentially fatal injuries due to local and systemic effects of venom.
A recently conducted study by Santos et al. showed that the effects of stingray envenomation cause systemic issues due to the above-mentioned interleukin-33 (IL33) activation, and the mechanisms involved in neutrophil trafficking during acute injury with fish venoms are poorly characterized. The experiment was done over cremaster muscle of mice and peritoneum, and it was found that neutrophil mobilization required a contribution by IL33, while mast cells and inflammation-dependent IL-1β production are dispensable. Acute inflammation due to injury produces local warmth and this heat causes rapid denaturation of the venom and progressive tissue necrosis. This takes some time and may appear over next few hours to 48 h.
However, the mechanism of pain relief by hot water immersion and commonly used cold compress during acute injury is contradicting. It may be possible that the immersion in hot water may just help in alleviating the pain of stingray and do not have any effect in reducing the local effects of venom in the form of tissue destruction and the same can be claimed with experience in this case.
The wound showed encouraging response to HBOT which is one promising development in the management of the stingray injury. Local envenomation causes subfascial spread of soft-tissue necrosis without showing superficial signs of inflammation. High-pressure oxygen delivered in such patients creates an aerobic atmosphere in the tissue by attaining higher concentrations in serum levels rather than depending on the blood supply. Hence, HBOT in the early phase of injury may show better results and limit the scope of repeated debridement in certain cases.
| Conclusion|| |
Although rare, stingray injuries over the chest and abdomen can pose a challenge for the management. Injuries to extremities can be very deceptive in the initial phase and may not show standard signs of inflammation locally. A multidisciplinary approach with a high degree of clinical suspicion, thorough wound debridement, and involvement of hyperbaric therapy can expedite recovery from local and systemic effects of stingray injury.
We would like to thank the diving unit and HBOT therapy team at Port Blair.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was financially supported by the Armed Forces Medical and Health Services.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]