European Journal of Echocardiography Advance Access published online on September 17, 2008
European Journal of Echocardiography, doi:10.1093/ejechocard/jen246
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Irukandji syndrome, catecholamines, and mid-ventricular stress cardiomyopathy
Keith Tiong*
Department of Medicine, Cairns Base Hospital, The Esplanade, Queensland 4870, Australia
Received 22 May 2008; accepted after revision 31 August 2008.
* Corresponding author. Tel: +61 740506118; fax: +61 40506113. E-mail address: keithtiong{at}aol.com
 |
Abstract
|
|---|
We present here the first reported case of mid-ventricular stress
cardiomyopathy secondary to ‘Irukandji syndrome’,
following envenomisation from a jellyfish.
Carukia barnesi is
a cubozoan or box jellyfish found in Far North Queensland, Australia
prevalent during the warmer months of the year. It has been
associated with ‘Irukandji syndrome’ as characterized
by a sympathetic overdrive secondary to an excess of endogenous
catecholamines release. There have been previous cases of sudden
onset of left ventricular dysfunction and jellyfish. The author
believes that this case is important because it highlights the
possible association between the sudden release in catecholamines
and stress cardiomyopathy.
Keywords: Mid-ventricular; Stress cardiomyopathy; Irukandji syndrome; Carukia barnesi; Catecholamines
|
Case report
|
|---|
A 26-year-old man was admitted to a local hospital in Far North
Queensland, 2 h following a sting on his body trunk from a jellyfish
similar in description to
Carukia barnesi, a small transparent
jelly fish. The subject remembers contact, while diving, with
a small transparent jelly fish, similar in size and character
to
Carukia barnesi. This occurs near the waters of Cooktown,
a seaside resort in Far North Queensland in December, during
summer, a peak period for
Carukia barnesi.
On admission to hospital, the subject developed symptoms consistent with ‘Irukandji syndrome’ which included pain, restlessness, agitation, and palpitations. His serial ECGs at 4.5 h and 19 h following envenomisation revealed a persistent generalized hyperacute T waves. His physical examination was consistent with a sudden catecholamines release with persistent tachycardia and hypertension (Figure 1).1,2 There were minimal effects from the sting itself with no detectable envenomisation rash which is consistent with Carukia barnesi. There were minimal abrasions on his body trunk which were not attributed to envenomisation. A rise in troponin was detected with a peak troponin I of 5.5 µg, 14 h later. His chest X-ray and cardiovascular examination at this stage were consistent with a mild degree of transient pulmonary oedema which responded to 20 mg of iv frusemide and glyceryl trinitrate infusion. The differential white cell counts were normal with an isolated thrombocytopenia. For Irukandji syndrome, the subject was initially treated with high flow oxygen, repeated doses of morphine, and 10 mmol of intravenous magnesium sulfate. Magnesium decreases the release of catecholamines and attenuates the receptor sensitivities.3 His telemetry recordings revealed heart rate variabilities which could be stigmata of sympathetic overdrive secondary to catecholamines release.4 He was also previously well with no past medical history. He was subsequently discharged from hospital 3 days after admission.
Serial transthoracic echocardiograms were performed on admission
which confirms mid-ballooning stress cardiomyopathy with poor
mid-regional wall motions. His systolic and diastolic cardiac
functions were assessed by B mode, M mode, and the Simpson's
method which confirm the diagnosis of mid-ventricular stress
cardiomyopathy with apical sparing. No invasive cardiac investigations
were performed (
Figures 2–7).
I believe that this case is important because it highlights
the possible mechanism behind the stress cardiomyopathy. This
is a transient event with an acute compromise in cardiac function
secondary to sympathetic overdrive. Previous
in vivo studies
have confirmed the rise in catecholamines level with envenomisation
from
Carukia barnesi.
2 This is the first documented case of
mid-ventricular stress cardiomyopathy secondary to contact with
venom from a jelly fish. Although no skin scrapping was performed
to determine the presence of nematocytes, the author and his
colleagues believe the description and the presentation was
consistent with envenomisation from
Carukia barnesi.
|
Discussion
|
|---|
Irukandji syndrome derives its name from the indigenous population
who resided in the region between Cairns and Port Douglas in
Far North Queensland.
5 Carukia barnesi is a transparent small
box like jellyfish with its bell up to 2 cm in size with four
tentacles, each measuring up to 1 cm. It utilizes its nematocysts
(stinging organelles) for capturing prey and defence. The release
of its venom or contact with its tentacle's extract is associated
with ‘Irukandji syndrome’, characterized by a sympathetic
overdrive.
In vitro and
in vivo animal studies have confirmed
its cardiovascular association with sympathetic overdrive with
direct pressor effects and tachycardia secondary to the sudden
release of endogenous noradrenaline and adrenaline.
1,2,6 In
animal models, catecholamines have direct toxic effect on cardiac
muscles by the activation of
- and β-receptors.
7,8 Similar
phenomenon has been confirmed in case reports involving human
subjects with this syndrome characterized by clinical findings
similar to sympathetic overdrive with diaphoresis, persistent
tachycardia, and hypertension.
4 There has been association between
jellyfish and deaths secondary to intracranial haemorrhage presumed
secondary to the sudden rise in blood pressure.
9 Currently,
there is no unequivocal data to confirm the hypothesis of a
direct toxic effect from the venom released as a direct cause
of cardiomyopathy.
6 Mid-ventricular ballooning syndrome is a
variant form of stress cardiomyopathy with transient mid-ventricular
weakening with apical sparing.
10 Mid-ventricular stress cardiomyopathy
may also present a continuum in the evolvement of stress cardiomyopathy.
Recently, the Queensland Irukandji Taskforce has recently published
their guidelines in the management of this condition which includes
the use of vasodilator agents such as magnesium and phentolamines.
11 Magnesium also directly inhibits the action catecholamines in
the peripheral circulation, and phentolamine is an alpha adrenergic
receptor blocker.
|
References
|
|---|
- Tibballs J, Hawdon G, Winkel K. Mechanism of cardiac failure in Irukandji syndrome and first aid treatment for stings. Anaesth Intensive Care (2001) 29:552.[Web of Science][Medline]
- Winkel KD, Tibballs J, Molenaar P, Lambert G, Coles P, Ross-Smith M, et al. Cardiovascular actions of the venom from the Irukandji (Carukia barnesi) jellyfish: effects in human, rat and guinea-pig tissues in vitro and in pigs in vitro. Clin Exp Pharmacol Physiol (2005) 32:777–88.[CrossRef][Web of Science][Medline]
- Corkeron MA. Magnesium infusion to treat Irukandji syndrome. The Med J Aust (2003) 178:411.
- Huynh TT, Seymour J, Pereira P, Mulcahy R, Cullen P, Carrette T, et al. Severity of Irukandji syndrome and nematocyst identification from skin scrapings. The Med J Aust (2003) 178:38–41.
- Flecker H. Irukanji sting to North Queensland bathers without production of wheals and with severe general symptoms. Med J Aust (1952) 2:89–91.[Medline]
- Ramasamy S, Isbister GK, Seymour JE, Hodgson WC. The in vivo cardiovascular effects of the Irukandji jellyfish (Carukia barnesi) nematocyst venom and a tentacle extract in rats. Toxicol Lett (2005) 155:135–41.[CrossRef][Web of Science][Medline]
- Hurst RT, Askew JW, Reuss CS, Lee RW, Sweeney JP, Fortuin FD, et al. Transient midventricular ballooning syndrome: a new variant. J Am Coll Cardiol (2006) 48:579–83.[Abstract/Free Full Text]
- Mann DL, Kent RL, Parsons B, Cooper Gt. Adrenergic effects on the biology of the adult mammalian cardiocyte. Circulation (1992) 85:790–804.[Abstract/Free Full Text]
- Fenner PJ, Hadock JC. Fatal envenomation by jellyfish causing Irukandji syndrome. Med J Aust (2002) 177:362–3.[Web of Science][Medline]
- Yasu T, Tone K, Kubo N, Saito M. Transient mid-ventricular ballooning cardiomyopathy: a new entity of Takotsubo cardiomyopathy. Int J Cardiol (2006) 110:100–1.[CrossRef][Web of Science][Medline]
- Pereira P, et al. Irukandji Taskforce Guidelines for the Emergency Management of Irukandji Syndrome. (2007) Prevention and Response Working Group of the Queensland Irukandji Taskforce.
CiteULike 
Connotea 
Del.icio.us What's this?
Top
Abstract
Case report
