Octopus Envenomation

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Background

Octopuses, which are organisms of the class Cephalopoda in the phylum Mollusca, are generally harmless and unlikely to be aggressive unless provoked.

Their bites are rarely life threatening, except for the bite of the greater blue-ringed octopus, Hapalochlaena lunulata and the southern blue-ringed octopus (also known as the Australian spotted octopus) Hapalochlaena maculosa, which are found in coastal waters and tide pools around Australia and other Western Pacific tidal pools.[1, 2] A third species, the blue-lined octopus Hapalochlaena fasciata, has also been described. These octopuses grow up to 20 cm in length with tentacles extended. They are normally light-colored with dark brown bands and blue rings or patches. When disturbed, their bodies darken, and the blue circles turn iridescent blue. Their venom can be released into the water to paralyze their prey, but its effects on humans primarily occur by injection of the venom upon biting.[3, 4, 5, 6, 7]

The blue-ringed octopus is shown below.


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Blue-ringed octopus. Image courtesy of Simon Dubbin.

Pathophysiology

There are many fractions in the venom secreted from the salivary glands of the blue-ringed octopus, one of which is identical to tetrodotoxin. This substance has also been found in multiple other tissues in H lunulata and H fasciata through fluorescent light microscopy.[8] Tetrodotoxin blocks voltage-gated fast sodium channel conduction, blocking peripheral nerve conduction, which can lead to paralysis and death from respiratory failure. Nerve conduction studies in tetrodotoxin-poisoned (puffer fish) persons have demonstrated reduced motor and sensory conduction velocities consistent with inhibition of sodium currents at the node of Ranvier.[9] Reported central nervous system effects of tetrodotoxin in humans have included nausea and emesis, miosis, diabetes insipidus, and depressed cortical activity.

Other fractions of the venom include 5-hydroxytryptamine, hyaluronidase, tyramine, histamine, tryptamine, octopamine, taurine, acetylcholine, and dopamine.[10]

Epidemiology

Frequency

United States

The blue-ringed octopus does not naturally dwell in the coastal waters of the US.

International

Rare cases of octopus envenomation occur in the Indo-Pacific region.

Mortality/Morbidity

Mortality is rare. Full recovery is expected when appropriate measures are undertaken.

Age

Individuals bitten by a blue-ringed octopus would have to be old enough and mobile enough to be able to walk or swim in the tide pools and coastal waters of Australia.

History

Any octopus can bite with its parrot-like chitinous beak.

The bite of the blue-ringed octopus is usually painless; however, the individual may experience a reaction similar to a bee sting.

If envenomation has occurred, symptoms are likely to start within 10 minutes of being bitten.

If a significant envenomation has occurred, the individual will rapidly progress from perioral and peripheral paresthesias through the following signs and symptoms.

Anaphylactoid or anaphylactic reactions have rarely been reported.

Physical

The individual is usually bitten on an extremity and sustains 1-2 small puncture wounds.

Local reaction may be minimal, but it can progress to include pain, edema, and erythema of the entire extremity.

The patient becomes flaccid once paralyzed.

Causes

Envenomations usually occur when an individual picks up a blue-ringed octopus or accidentally steps on one.

Laboratory Studies

Laboratory studies for octopus envenomation are noncontributory.

A general workup for a critically ill patient is recommended to rule out other etiologies for acute paralysis and respiratory failure.

Imaging Studies

Imaging studies are generally not helpful.

A plain film of the puncture site may be indicated to rule out a foreign body.

Prehospital Care

Cardiopulmonary support, including endotracheal intubation and cardiopulmonary resuscitation (CPR), as clinically indicated.

What constitutes proper wound care for octopus envenomation is controversial. Options include the following:

Emergency Department Care

Treatment of octopus envenomation is supportive.

Provide endotracheal intubation and ventilatory support until the venom has worn off, usually within 4-10 hours.

Confirm that the patient's tetanus status is current.

No antivenin is available.

Neostigmine and edrophonium have shown benefit in restoring muscular strength in some cases of tetrodotoxin intoxication (eg, puffer fish), but have not undergone clinical trials in blue-ringed octopus envenomations.

4-Aminopyridine (Neurelan - US, Pymadine), a drug utilized as an antagonist to nondepolarizing neuromuscular blocking agents (available in the US as an orphan drug for multiple sclerosis), has been shown to reverse tetrodotoxin toxicity in animal experiments.[11]

Consultations

A general surgery consult may be indicated for wide excision of the wound. However, this has not proven to improve outcome.

A medical toxicologist (certified by the American Board of Medical Toxicology or the American Board of Emergency Medicine), or a poison control center certified by the American Association of Poison Control Centers, should be contacted regarding this uncommon intoxication.

Medication Summary

The goal of pharmacotherapy is to reduce morbidity and prevent complications. Administration of nondepolarizing neuromuscular blocking antagonists may be beneficial. 4-Aminopyridine (Neurelan) is utilized as an antagonist to nondepolarizing neuromuscular blocking agents (available in the US as an orphan drug for multiple sclerosis), has been shown to reverse tetrodotoxin toxicity in animal experiments.[11, 2] The dosing regimen for use in octopus envenomation is not yet established.

Further Inpatient Care

The patient with octopus envenomation should be admitted to an intensive care unit until the venom has worn off, usually in 4-10 hours.

If significant hypoxia has not occurred, recovery is usually rapid.

Further Outpatient Care

Local wound care follow up is prudent.

Complications

If acute paralysis and respiratory arrest is not immediately recognized and appropriately treated, anoxic brain injury or death will result.

Prognosis

The prognosis for octopus envenomation is generally excellent, unless significant hypoxia has occurred.

Patients should be warned that anaphylactic reactions may result in ongoing symptoms (eg, joint pains, effusions) for up to several weeks.

Author

Jon Mark Hirshon, MD, MPH, Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine

Disclosure: Nothing to disclose.

Specialty Editors

Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor of Surgery, Harvard Medical School

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

Disclosure: Nothing to disclose.

James Steven Walker, DO, MS, Clinical Professor of Surgery, Department of Surgery, University of Oklahoma College of Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Scott H Plantz, MD, FAAEM, Associate Clinical Professor of Emergency Medicine, Department of Emergency Medicine, University of Louisville School of Medicine

Disclosure: Nothing to disclose.

References

  1. Walker DG. Survival after severe envenomation by the blue-ringed octopus (Hapalochlaena maculosa). Med J Aust. Dec 10-24 1983;2(12):663-5. [View Abstract]
  2. Flachsenberger WA. Respiratory failure and lethal hypotension due to blue-ringed octopus and tetrodotoxin envenomation observed and counteracted in animal models. J Toxicol Clin Toxicol. 1986-87;24(6):485-502. [View Abstract]
  3. Kizer KW. Marine envenomations. J Toxicol Clin Toxicol. 1983-84;21(4-5):527-55. [View Abstract]
  4. Auerbach PS. Marine envenomations. N Engl J Med. Aug 15 1991;325(7):486-93. [View Abstract]
  5. McGoldrick J, Marx JA. Marine envenomations. Part 2: Invertebrates. J Emerg Med. Jan-Feb 1992;10(1):71-7. [View Abstract]
  6. Nimorakiotakis B, Winkel KD. Marine envenomations. Part 2--Other marine envenomations. Aust Fam Physician. Dec 2003;32(12):975-9. [View Abstract]
  7. Fernandez I, Valladolid G, Varon J, Sternbach G. Encounters with venomous sea-life. J Emerg Med. Jan 2011;40(1):103-12. [View Abstract]
  8. Williams BL, Stark MR, Caldwell RL. Microdistribution of tetrodotoxin in two species of blue-ringed octopuses (Hapalochlaena lunulata and Hapalochlaena fasciata) detected by fluorescent immunolabeling. Toxicon. Dec 1 2012;60(7):1307-13. [View Abstract]
  9. Oda K, Araki K, Totoki T, et al. Nerve conduction study of human tetrodotoxication. Neurology. May 1989;39(5):743-5. [View Abstract]
  10. Watters MR, Stommel EW. Marine Neurotoxins: Envenomations and Contact Toxins. Curr Treat Options Neurol. Mar 2004;6(2):115-123. [View Abstract]
  11. Chang FCT, Spriggs DL, Benton BJ, et al. 4-Aminopyridine reverses saxitoxin (STX)- and tetrodotoxin (TTX)- induced cardiorespiratory depression in chronically instrumented guinea pigs. Fundam Appl Toxicol. Jul 1997;38(1):75-88. [View Abstract]

Blue-ringed octopus. Image courtesy of Simon Dubbin.

Blue-ringed octopus. Image courtesy of Simon Dubbin.