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Re: Jellyfish Foot Injury—Vasospasm
LETTERS TO THE EDITOR
Re: Jellyfish Foot Injury—Vasospasm Dear Editor: I read with interest the unique case report of Giordano et al (1) entitled “Complication of a Portuguese Man-of-War Envenomation to the Foot: A Case Report” published in the July/August 2005 issue. This severe injury to a 35-year-old healthy woman brought to mind two points. Jellyfish stings produce instantaneous pain as the nematocysts penetrate deep into the nerve-rich dermis and the stage is set at that time with maximal pain. There is no reliable detoxification procedure available to the treating physician because of the rapidity of the damage and its depth in the skin. However, topical measures to relieve pain, although controversial, have been studied (2). The only randomized clinical control investigation suggests that cold packs were ineffective and hot packs were only minimally effective (3). The use of vinegar for disarming intact unfired nematocysts adhering to the skin surface was probably ineffective because the patient had no visible tentacles on her skin and the rapid painful tissue damage had already occurred. I suggest an additional mechanism to account for this degree of tissue loss–vasospasm. The shape of her ischemic tissue in an inverted teardrop places the apex near the dorsalis pedis artery as it crosses the ankle. I cannot account for a puncture wound but her primary physician noticed a cool, cyanotic, and indurated foot with diminished arterial pulses. Vasospasm with possible subsequent thrombosis has been reported several times after jellyfish stings to the upper arm and is more prevalent in the upper extremities because jellyfish float and bathers move their arms more than legs (4, 5). These cases often require surgical procedures but one responded well to an intra-arterial urokinase infusion (6). In my opinion these authors have reported the first case of severe ischemia of the foot caused by vasospasm after a jellyfish sting. An abbreviated clinical course might have been achieved, not by detoxification, but by focusing therapy on the injured arterial blood supply. Joseph W. Burnett, MD Department of Dermatology University of Maryland School of Medicine Baltimore, MD 58
THE JOURNAL OF FOOT & ANKLE SURGERY
References 1. Giordano AR, Vita L, Sardella PJ. Complication of a Portuguese manof-war evenomation to the foot: a case report. J Foot Ankle Surg 44:297–300, 2005. 2. Exton DR, Fenner PJ, Williamson JAH. Ice packs: an effective first aid treatment for Physalia and other painful jellyfish stings. Med J Aust 151:54, 1989. 3. Thomas CS, Scott ST, Galanis DJ, Goto RS. Box jellyfish (Carybdea alata) in Waikiki: their influx cycle plus the analgesic effect of hot and cold packs in their stings to swimmers at the beach; a randomized, placebo-controlled clinical trial. Hawaii Med J 60:100 –107, 2001. 4. Williamson JA, Burnett JW, Fenner PJ, Hach-Wunderle V, Hoe LY, Adiga KM. Acute regional vascular insufficiency after jellyfish envenomation. Med J Aust 149:698 –708, 1988. 5. Drury JK, Noonon JD, Pollack JG, Reid WH. Jellyfish sting with serious hand complications. Injury 12:66 – 68, 1980. 6. Taiseer A-N, Agyash K, Wafaii IK, Al-Hassan J, Thulesius O. Jellyfish stings resulting in severe hand ischemia successfully treated with intra-arterial urokinase. Injury: Br J Accident Surg 19:294 –296, 1988.
Dear Editor: We read with some interest the article by Zgonis et al in the July/August issue (Journal of Foot and Ankle Surgery 44:276 –280, 2005). Although we have great respect for the authors and their respective and collective insight, we are somewhat perplexed by the conclusions drawn from this study. Ostensibly, the aim (as quoted by the authors) was “to explore the relationship between hyperbaric oxygen therapy and the outcome of partial foot amputations in patients with diabetes mellitus.” All patients received hyperbaric oxygen therapy in this study. It seems rather difficult for the reader to draw conclusions about a relationship when there is no basis for comparison. This is, at best, a small survey of results from what appears to be one center during a 10-year period. Unfortunately, this aspect of study does not add appreciably to the literature, which is littered with small surveys in this area. The point that was most astonishing involved the attempted correlation between revascularization and postsurgical outcomes. The study’s results reported that, “revascularization was not associated with postsurgical outcome.” With 68% of the 40 wounds (in 35 patients) studied having received a bypass of some sort, it would be highly improbable to be able to address this question with any degree of certainty. The later qualification of-
Re: Jellyfish Foot Injury—Vasospasm Dear Editor: I read with interest the unique case report of Giordano et al (1) entitled “Complication of a Portuguese Man-of-War Envenomation to the Foot: A Case Report” published in the July/August 2005 issue. This severe injury to a 35-year-old healthy woman brought to mind two points. Jellyfish stings produce instantaneous pain as the nematocysts penetrate deep into the nerve-rich dermis and the stage is set at that time with maximal pain. There is no reliable detoxification procedure available to the treating physician because of the rapidity of the damage and its depth in the skin. However, topical measures to relieve pain, although controversial, have been studied (2). The only randomized clinical control investigation suggests that cold packs were ineffective and hot packs were only minimally effective (3). The use of vinegar for disarming intact unfired nematocysts adhering to the skin surface was probably ineffective because the patient had no visible tentacles on her skin and the rapid painful tissue damage had already occurred. I suggest an additional mechanism to account for this degree of tissue loss–vasospasm. The shape of her ischemic tissue in an inverted teardrop places the apex near the dorsalis pedis artery as it crosses the ankle. I cannot account for a puncture wound but her primary physician noticed a cool, cyanotic, and indurated foot with diminished arterial pulses. Vasospasm with possible subsequent thrombosis has been reported several times after jellyfish stings to the upper arm and is more prevalent in the upper extremities because jellyfish float and bathers move their arms more than legs (4, 5). These cases often require surgical procedures but one responded well to an intra-arterial urokinase infusion (6). In my opinion these authors have reported the first case of severe ischemia of the foot caused by vasospasm after a jellyfish sting. An abbreviated clinical course might have been achieved, not by detoxification, but by focusing therapy on the injured arterial blood supply. Joseph W. Burnett, MD Department of Dermatology University of Maryland School of Medicine Baltimore, MD 58
THE JOURNAL OF FOOT & ANKLE SURGERY
References 1. Giordano AR, Vita L, Sardella PJ. Complication of a Portuguese manof-war evenomation to the foot: a case report. J Foot Ankle Surg 44:297–300, 2005. 2. Exton DR, Fenner PJ, Williamson JAH. Ice packs: an effective first aid treatment for Physalia and other painful jellyfish stings. Med J Aust 151:54, 1989. 3. Thomas CS, Scott ST, Galanis DJ, Goto RS. Box jellyfish (Carybdea alata) in Waikiki: their influx cycle plus the analgesic effect of hot and cold packs in their stings to swimmers at the beach; a randomized, placebo-controlled clinical trial. Hawaii Med J 60:100 –107, 2001. 4. Williamson JA, Burnett JW, Fenner PJ, Hach-Wunderle V, Hoe LY, Adiga KM. Acute regional vascular insufficiency after jellyfish envenomation. Med J Aust 149:698 –708, 1988. 5. Drury JK, Noonon JD, Pollack JG, Reid WH. Jellyfish sting with serious hand complications. Injury 12:66 – 68, 1980. 6. Taiseer A-N, Agyash K, Wafaii IK, Al-Hassan J, Thulesius O. Jellyfish stings resulting in severe hand ischemia successfully treated with intra-arterial urokinase. Injury: Br J Accident Surg 19:294 –296, 1988.
Dear Editor: We read with some interest the article by Zgonis et al in the July/August issue (Journal of Foot and Ankle Surgery 44:276 –280, 2005). Although we have great respect for the authors and their respective and collective insight, we are somewhat perplexed by the conclusions drawn from this study. Ostensibly, the aim (as quoted by the authors) was “to explore the relationship between hyperbaric oxygen therapy and the outcome of partial foot amputations in patients with diabetes mellitus.” All patients received hyperbaric oxygen therapy in this study. It seems rather difficult for the reader to draw conclusions about a relationship when there is no basis for comparison. This is, at best, a small survey of results from what appears to be one center during a 10-year period. Unfortunately, this aspect of study does not add appreciably to the literature, which is littered with small surveys in this area. The point that was most astonishing involved the attempted correlation between revascularization and postsurgical outcomes. The study’s results reported that, “revascularization was not associated with postsurgical outcome.” With 68% of the 40 wounds (in 35 patients) studied having received a bypass of some sort, it would be highly improbable to be able to address this question with any degree of certainty. The later qualification of-