Crown-of-Thorns starfish envenomation

Background

Crown-of-thorns starfish in Fiji.

Short-spined form from Gulf of California.

Spines at closeup view.

• A central disk with radiating arms
  • More than 15 arms
• Densely covered with spines
• Adults are often dull brown to green colored
  • some may have bright colors to warn predators
• Range from 9-14 inches in diameter

Mechanism

• Spines pierce the skin and cause severe pain
  • Lasting <3 hours
• Spines are coated with a slime that is extremely toxic

Clinical Features

• In severe cases can cause paralysis, hemolysis, & hepatotoxicity
• Paresthesia
• Nausea & vomiting
• Secondary infection

Differential Diagnosis

Marine toxins, envenomations, and bites

• Toxins
  • Ciguatera
  • Scombroid
  • Tetrodotoxin (e.g. pufferfish)
  • Shellfish poisoning
    • Amnesic shellfish poisoning
    • Diarrheal shellfish poisoning
    • Neurotoxic shellfish poisoning
    • Paralytic shellfish poisoning
• Stingers
  • Stingray injury
• Venomous fish
  • Cone shell
  • Lionfish
  • Sea urchins
  • Crown-of-Thorns Starfish
  • Stonefish
  • Other: Catfish, zebrafish, scorpion fish
• Nematocysts
  • Coral reef
  • Fire coral
  • Jellyfish (Cnidaria)
    • Box jellyfish
      • Irukandji syndrome
    • Sea wasp
  • Portuguese man-of-war
  • Sea anemones
  • Seabather's eruption
• Phylum porifera (sponges)
• Bites
  • Alligator and crocodile attacks
  • Octopus bite
  • Shark bite
• Infections
  • Vibrio species in saltwater
  • Aeromonas species in freshwater

Management

• Emersion in non-scalding water up to 45°C & Local lidocaine for pain control
• Remove spines/foreign bodies
  • If spines are intraarticular or near neurovascular structures they need to be carefully removed in the OR
• Thorough irrigation
• Update tetanus vaccination if needed
• Prophylactic antibiotics for deep puncture wounds

Disposition

• If hemodynamically stable, patient may be discharged home

See Also

• Marine toxins and envenomations