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Neurodegenerative diseases are one of the major causes of death worldwide, characterized by neurite atrophy, neuron apoptosis, and synapse loss. No effective treatment has been indicated for such diseases so far, and the search for new drugs is being increased in the last years. Animal venoms’ secretion/venom can be an alternative for the discovery of new molecules, which could be the prototype for a new treatment. Here, we present the biochemical characterization and activity of the extract from the box jellyfish Chiropsalmus quadrumanus (Cq) on neurites. The Cq methanolic extract was obtained and incubated to human SH-SY5Y neurons, and neurite parameters were evaluated. The extract was tested in other cell types to check its cytotoxicity and was submitted to biochemical analysis by mass spectrometry in order to check its composition. We could verify that the Cq extract increased neurite outgrowth length and branching junctions, amplifying the contact between SH-SY5Y neurons, without affecting cell body and viability. The extract action was selective for neurons, as it did not cause any effects on other cell types, such as tumor line, nontumor line, and red blood cells. Moreover, mass spectrometry analysis revealed that there are no proteins but several low molecular mass compounds and peptides. Three peptides, characterized as cryptides, and 14 low molecular mass compounds were found to be related to cytoskeleton reorganization, cell membrane expansion, and antioxidant/neuroprotective activity, which act together to increase neuritogenesis. After this evaluation, we conclude that the Cq extract is a promising tool for neuronal connection recovery, an essential condition for the treatment of neurodegenerative diseases.

Both Chironex fleckeri venom (CFV) and Carukia barnesi venoms (CBV) are known to cause significant cardiac morbidity and mortality. Many animal studies have demonstrated cardiac dysfunction with these venoms. This study specifically examines the systolic and diastolic cardiac functions using non-invasive pulse wave doppler. Mitral and aortic doppler sonograms of anaesthetised mice were obtained utilising a 10 MHz doppler probe. These continuous sonograms were analysed to ascertain changes in cardiac function before and after the parenteral administration of the test venoms. We found that CFV administration causes rapid cardiac dysfunction without a change in heart rate. Analysis of the resulting sonograms shows both systolic and diastolic dysfunction which together is suggestive of a progressively poorly compliant, contracted left ventricle. Additionally, the rapidity of cardiac dysfunction suggests a direct effect of CFV on myocardial cells. In contrast CBV showed a moderate immediate inotropic and chronotropic effect that was sustained until precipitous cardiac decompensation. This is consistent with the hypotheses of a toxin induced stress cardiomyopathy from sustained catecholaminergic activity.

Special issue Cnidarian Venom.-- 11 pages, 3 figures, 3 tables.-- Data Availability Statement: Data sharing not applicable. No new data were created or analyzed in this study, The jellyfish species that inhabit the Mediterranean coastal waters are not lethal, but their stings can cause severe pain and systemic effects that pose a health risk to humans. Despite the frequent occurrence of jellyfish stings, currently no consensus exists among the scientific community regarding the most appropriate first-aid protocol. Over the years, several different rinse solutions have been proposed. Vinegar, or acetic acid, is one of the most established of these solutions, with efficacy data published. We investigated the effect of vinegar and seawater on the nematocyst discharge process in two species representative of the Mediterranean region: Pelagia noctiluca (Scyphozoa) and Carybdea marsupialis (Cubozoa), by means of (1) direct observation of nematocyst discharge on light microscopy (tentacle solution assay) and (2) quantification of hemolytic area (tentacle skin blood agarose assay). In both species, nematocyst discharge was not stimulated by seawater, which was classified as a neutral solution. In P. noctiluca, vinegar produced nematocyst discharge per se, but inhibited nematocyst discharge from C. marsupialis. These results suggest that the use of vinegar cannot be universally recommended. Whereas in case of a cubozoan C. marsupialis sting, the inhibitory effect of vinegar makes it the ideal rinse solution, in case of a scyphozoan P. noctiluca sting, vinegar application may be counterproductive, worsening the pain and discomfort of the stung area, This research was mainly funded by ISDIN company (Barcelona, Spain) and with the collaboration of the CaixaResearch by “la Caixa” Foundation through the project “Repercusiones Clínicas y Socioeconómicas de las Medusas en el Mediterráneo” (RECLAIME).-- This work acknowledges the ‘Severo Ochoa Centre of Excellence’ accreditation (CEX2019-000928-S)

Cubozoan jellyfish are classified as plankton despite the strong swimming and orientation abilities of cubomedusae. How these capabilities could affect cubozoan population structures is poorly understood. Medusae of the cubozoan Copula sivickisi can uniquely attach to surfaces with the sticky pads on their bells. Biophysical modelling was used to investigate the spatial scales of connectivity in a C. sivickisi population. When the medusae were active at night they could maintain their observed distribution on fringing reef if they attached to the reef when the current speed exceeded a moderate threshold. This behaviour facilitated the isolation of a C. sivickisi population on reefs fringing Magnetic Island, Queensland, Australia. Within this distribution, there was considerable within bay retention and medusae rarely travelled > 3 km. The few (C. sivickisi could contain incipient or cryptic species given the small scales of connectivity demonstrated here.

Box jellyfish have an elaborate visual system and perform advanced visually guided behaviors. However, the rhopalial nervous system (RNS), believed to be the main visual processing center, only has 1000 neurons in each of the four eye carrying rhopalia. We have examined the detailed structure of the RNS of the box jellyfish Tripedalia cystophora, using immunolabeling with antibodies raised against four putative neuropeptides (T. cystophora RFamide, VWamide, RAamide, and FRamide). In the RNS, T. cystophora RF-, VW-, and RAamide antibodies stain sensory neurons, the pit eyes, the neuropil, and peptide-specific subpopulations of stalk-associated neurons and giant neurons. Furthermore, RFamide ir+ neurites are seen in the epidermal stalk nerve, whereas VWamide antibodies stain the gastrodermal stalk nerve. RFamide has the most widespread expression including in the ring and radial nerves, the pedalium nerve plexus, and the tentacular nerve net. RAamide is the putative neurotransmitter in the motor neurons of the subumbrellar nerve net, and VWamide is a potential marker for neuronal differentiation as it is found in subpopulations of undifferentiated cells both in the rhopalia and in the bell. The results from the FRamide antibodies were not included as only few cells were stained, and in an unreproducible way. Our studies show hitherto-unseen details of the nervous system of T. cystophora and allowed us to identify specific functional groups of neurons. This identification is important for understanding visual processing in the RNS and enables experimental work, directly addressing the role of the different neuropeptides in vision.

Background: Irukandji syndrome definition is still widely misunderstood. Irukandji-like syndrome is more unclear than Irukandji syndrome. This study aimed to describe Irukandji-like syndrome in cases involving stinging by single-tentacle box jellyfish species in Thailand. Materials and methods: Surveillance system and networks of toxic jellyfish incidents were established to enable case detection. In the period 2007 to 2019, all cases of stinging by single - tentacle box jellyfish resulting in collapse, hospital attendance or death were investigated. Results: The majority of the 19 Irukandji-like syndrome cases were male (68.2%), median age 35.0 years (range 6.0–60.0), and Thai nationality (52.3%). Clinical manifestations of Irukandji - like syndrome were categorised as severe wound pain with immediate systemic reaction (66.7%), moderate wound pain with gradual systemic reaction (16.7%), and moderate wound pain with the immediate systemic reaction after a physical/chemical trigger (16.7%). The pain occurring when being stung differed from the pain occurring during the systemic reaction. The five most common symptoms were pain (100.0%), high blood pressure (100.0%), palpitations (86.7%), respiratory distress (52.6%), and near collapse/collapse (31.6%). The pain occurs when being stung was excruciating or burning pain at the wounds, felt like an electric shock, and rapidly expanded to heart pain. While the pain occurring during the systemic reaction was back pain, muscle pain, joint pain, abdominal pain, and body aches. The marks from the tentacles appeared similar in appearance to the caterpillar tracks of tanks. In 6 cases the species could be identified and all of them involving the Morbakka spp. Conclusions: This was the largest study of Irukandji-like syndrome cases involving stings by single - tentacle box jellyfish in Thailand and the different clinical manifestations might be caused by different species of single - tentacle box jellyfish.

The diploblastic cnidarian body plan comprising the epidermis and gastrodermis has remained largely unchanged since it evolved roughly 600 Ma. The origin of muscle from the mesoderm in triploblastic lineages is a central evolutionary question in higher animals. Triploblasts have three embryonic germ layers: the endoderm, mesoderm, and ectoderm, which develop into organs, muscle, and skin, respectively. Diploblasts lack the mesoderm, the layer thought to give rise to the skeletomuscular system. However, phyla such as Cnidaria and Ctenophora, which are typically classified as diploblasts, possess striated musculature. Within phylum Cnidaria, class Cubozoa includes carnivorous box jellyfish, which are capable of extending and contracting their tentacles for predation and defense mechanisms, thus suggesting a well-organized system of muscles. Here, the tentacle musculature of the cubomedusae Carybdea marsupialis is investigated using transmission electron microscopy in conjunction with light microscopy to further understand the arrangement of musculature in these primitive animals. Cross sections of tentacles confirmed that the gastrodermis is separated from the epidermis by a collagenous mesogleal layer containing numerous longitudinal muscle cells arranged in fascicles. Longitudinal muscles permit the tentacle to retract toward the bell during fast tentacle shortening and crumpling behavioral responses. Circular muscle cells were found in the gastrodermis and epidermis, encircling the layer of longitudinal muscle. These circular muscles likely enable the elongation process that allows the tentacles to return to a resting state after contraction. The presence of a definitive muscle cell layer within the mesoglea suggests that C. marsupialis has an advanced muscle morphology that is similar to triploblastic animals.

This case report describes the typical features of the dermatological progression of a patient stung by a (probable) box jellyfish. The purpose is to guide clinicians and patients to an understanding of what to expect after such a sting using the clinical narrative and unique sequential photographs of the injury. With knowledgeable consultation from experienced physicians and meticulous care, this envenomation healed without the need for skin grafting.

Biological investigations on free ranging marine species are regarded as challenging throughout the scientific community. This is particularly true for 'logistically difficult species' where their cryptic natures, low abundance, patchy distributions and difficult and/or dangerous sampling environments, make traditional surveys near impossible. What results is a lack of ecological knowledge on such marine species. However, advances in UAV technology holds potential for overcoming these logistical difficulties and filling this knowledge gap. Our research focused on one such logistically difficult species, the Australian box Jellyfish (Chironex fleckeri), and we investigated the capacity of consumer grade UAV technology to detect this, highly venomous, target species in the inshore waters of Northern Queensland Australia. At two sites in the Weipa area, we utilized video analysis, visual count comparisons with a netted animal tally, and evaluated the role of associated environmental conditions, such as wind speed, water visibility and cloud cover on jellyfish detection rates. In total fifteen, 70 meter transects were completed between two sites, with 107 individuals captured. Drone success varied between the two sites with a significant difference between field and post-field (laboratory) counts. Animal size and cloud cover also had significant effects on detection rates with an increase in cloud cover and animal size enhancing detection probability. This study provides evidence to suggest drone surveys overcome obstacles that traditional surveys can't, with respect to species deemed logistically difficult and open scope for further ecological investigations on such species.

Cubozoans have the most intricate visual apparatus within Cnidaria. It comprises four identical sensory structures, the rhopalia, each of which holds six eyes of four morphological types. Two of these eyes are camera-type eyes that are, in many ways, similar to the vertebrate eye. The visual input is used to control complex behaviors, such as navigation and obstacle avoidance, and is processed by an elaborate rhopalial nervous system. Several studies have examined the rhopalial nervous system, which, despite a radial symmetric body plan, is bilaterally symmetrical, connecting the two sides of the rhopalium through commissures in an extensive neuropil. The four rhopalia are interconnected by a nerve ring situated in the oral margin of the bell, and together these structures constitute the cubozoan central nervous system. Cnidarians have excellent regenerative capabilities, enabling most species to regenerate large body areas or body parts, and some species can regenerate completely from just a few hundred cells. Here we test whether cubozoans are capable of regenerating the rhopalia, despite the complexity of the visual system and the rhopalial nervous system. The results show that the rhopalia are readily regrown after amputation and have developed most, if not all, neural elements within two weeks. Using electrophysiology, we investigated the functionality of the regrown rhopalia and found that they generated pacemaker signals and that the lens eyes showed a normal response to light. Our findings substantiate the amazing regenerative ability in Cnidaria by showing here the complex sensory system of Cubozoa, a model system proving to be highly applicable in studies of neurogenesis.

Cnidarian venom research has lagged behind other toxinological fields due to technical difficulties in recovery of the complex venom from the microscopic nematocysts. Here we report a newly developed rapid, repeatable and cost effective technique of venom preparation, using ethanol to induce nematocyst discharge and to recover venom contents in one step. Our model species was the Australian box jellyfish (Chironex fleckeri), which has a notable impact on public health. By utilizing scanning electron microscopy and light microscopy, we examined nematocyst external morphology before and after ethanol treatment and verified nematocyst discharge. Further, to investigate nematocyst content or “venom” recovery, we utilized both top-down and bottom-up transcriptomics–proteomics approaches and compared the proteome profile of this new ethanol recovery based method to a previously reported high activity and recovery protocol, based upon density purified intact cnidae and pressure induced disruption. In addition to recovering previously characterized box jellyfish toxins, including CfTX-A/B and CfTX-1, we recovered putative metalloproteases and novel expression of a small serine protease inhibitor. This study not only reveals a much more complex toxin profile of Australian box jellyfish venom but also suggests that ethanol extraction method could augment future cnidarian venom proteomics research efforts.

Cnidarian envenomations are the leading cause of severe and lethal human sting injuries from marine life. The total amount of venom discharged into sting-site tissues, sometimes referred to as “venom load”, has been previously shown to correlate with tentacle contact length and sequelae severity. Since

Stinging jellyfish outbreaks represent a health hazard, causing contact dermatitis and systemic reactions. This study investigated the epidemiology, severity, and treatment protocols of jellyfish stings in a coastal area with high tourist development and frequent stinging jellyfish outbreaks of the central Mediterranean (Salento, Southern Italy), and the associated costs for the Italian National Health Service. In 2007–2011, 1,733 bathers (mostly children and females) sought medical assistance following jellyfish stings, the main cause of human pathologies due to contact with marine organisms. The majority of events were reported in the years 2007–2009, whereas the occurrence of cnidarian jellyfish outbreaks has been increasingly reported in the same area since summer 2010. Most symptoms were limited to local and cutaneous reactions; conversely, 8.7% of cases evoked complications, mainly due to allergic reactions. The main drugs used were corticosteroids, locally applied and systemic (46% and 43%, respectively), and with ammonia (74%) as the main non-pharmacological treatment. The estimated cost of jellyfish-related first-aid services along the Salento coastline over the 5-year period was approximately 400,000 Euros. Therefore the management of jellyfish outbreak phenomena need coordinated research efforts towards a better understanding of underlying ecological mechanisms, together with the adoption of effective prevention policy, mitigation strategies, and appropriate planning of health services at tourist hot spots.

Identification of potentially harmful cubomedusae is difficult due to their gelatinous nature. The only hard structure of medusae, the statolith, has the potential to provide robust measurements for morphometric analysis. Traditional morphometric length to width ratios (L: W) and modern morphometric Elliptical Fourier Analysis (EFA) were applied to proximal, oral and lateral statolith faces of 12 cubozoan species. EFA outperformed L: W as L: W did not account for the curvature of the statolith. Best discrimination was achieved with Canonical Discriminant Analysis (CDA) when analysing proximal + oral + lateral statolith faces in combination. Normalised Elliptical Fourier (NEF) coefficients classified 98% of samples to their correct species and 94% to family group. Statolith shape agreed with currently accepted cubozoan taxonomy. This has potential to assist in identifying levels of risk and stock structure of populations in areas where box jellyfish envenomations are a concern as the severity of envenomation is family dependent. We have only studied 12 (27%) of the 45 currently accepted cubomedusae, but analyses demonstrated that statolith shape is an effective taxonomic discriminator within the Class.

The pharmacology of Australian box jellyfish, Chironex fleckeri, unpurified (crude) nematocyst venom extract (CVE) was investigated in rat isolated cardiac and vascular tissues and in anaesthetised rats. In small mesenteric arteries CVE (0.01-30 μg/ml) caused contractions (EC(50) 1.15±0.19 μg/ml) that were unaffected by prazosin (0.1 μM), bosentan (10 μM), CGRP(8-37) (1 μM) or tetrodotoxin (1 μM). Box jellyfish antivenom (5-92.6 units/ml) caused rightward shifts of the CVE concentration-response curve with no change in the maximum. In the presence of l-NAME (100 μM) the sensitivity and maximum response to CVE were increased, whilst MgSO(4) (6 mM) decreased both parameters. CVE (1-10 μg/ml) caused inhibition of the contractile response to electrical sympathetic nerve stimulation. Left atrial responses to CVE (0.001-30 μg/ml) were bi-phasic, composed of an initial positive inotropy followed by a marked negative inotropy and atrial standstill. CVE (0.3 μg/ml) elicited a marked decrease in right atrial rate followed by atrial standstill at 3 μg/ml. These responses were unaffected by 1 μM of propranolol, atropine or CGRP(8-37). Antivenom (54 and 73 units/ml) caused rightward shifts of the CVE concentration-response curve and prevented atrial standstill in left and right atria. The effects of CVE do not appear to involve autonomic nerves, post-synaptic α(1)- or β(1)-adrenoceptors, or muscarinic, endothelin or CGRP receptors, but may occur through direct effects on the cardiac and vascular muscle. Box jellyfish antivenom was effective in attenuating CVE-induced responses in isolated cardiac and vascular tissues.

BACKGROUND: The Toxic Jellyfish Network and its surveillance system were set up in 2008 and in 2009, respectively. Case investigations detected 3 cases with severe cutaneous injuries described in this article. CASES: There were 57 probable cases of box jellyfish stings between 2008 and 2013. Three of these injuries resulted in dermal necrosis, and 2 were associated with severe wound complications. A Thai man aged 21 years sustained wounds on his left knee and thigh. He received oral antibiotics and daily wet dressings; he did not receive steroids. He subsequently developed blisters, swelling of the lower left leg, neuritis, and severe itching in the later stages. Nevertheless, his wounds did not become infected and there was no keloid scarring. An American woman aged 25 years sustained stings on her right hand and arm. She received antibiotic ointment and a tape that was placed directly on the wound without any gauze or padding underneath. She developed a wound infection 2 weeks postinjury. Surgical debridement was required twice to remove necrotic tissue; keloid scars persisted on evaluation at 4 months. An American woman aged 33 years received stings on her left upper thigh. Initial treatment was provided by local residents, who crushed morning glory leaves to extract the juice and then applied the juice (mixed with water) to her wounds. She received intravenous steroids, oral antihistamines, oral analgesics, and antibiotic cream at the hospital. Despite this aggressive treatment, the wounds became gangrenous and surgical debridement was required to remove necrotic tissue. CONCLUSION: Clinicians need to be knowledgeable regarding the potentially serious wounds that can develop following jellyfish stings. Additional research is needed to identify best management approaches. Language: en

Just over a century ago, animal responses to injections of jellyfish extracts unveiled the phenomenon of anaphylaxis. Yet, until very recently, understanding of jellyfish sting toxicity has remained limited. Upon contact, jellyfish stinging cells discharge complex venoms, through thousands of barbed tubules, into the skin resulting in painful and, potentially, lethal envenomations. This review examines the immunological and toxinological responses to stings by prominent species of jellyfish including Physalia sp. (Portuguese Man-o-War, Blue-bottle), Cubozoan jellyfish including Chironex fleckeri, several Carybdeids including Carybdea arborifera and Alatina moseri, Linuche unguiculta (Thimble jellyfish), a jellyfish responsible for Irukandji syndrome (Carukia barnesi) and Pelagia noctiluca. Jellyfish venoms are composed of potent proteinaceous porins (cellular membrane pore-forming toxins), neurotoxic peptides, bioactive lipids and other small molecules whilst the tubules contain ancient collagens and chitins. We postulate that immunologically, both tubular structural and functional biopolymers as well as venom components can initiate innate, adaptive, as well as immediate and delayed hypersensitivity reactions that may be amenable to topical anti-inflammatory-immunomodifier therapy. The current challenge for immunotoxinologists is to deconstruct the actions of venom components to target therapeutic modalities for sting treatment.

Box jellyfish (Cubomedusae) are visually orientating animals which possess a total of 24 eyes of 4 morphological types; 2 pigment cup eyes (pit eye and slit eye) and 2 lens eyes [upper lens-eye (ule) and lower lens-eye (lle)]. In this study, we use electroretinograms (ERGs) to explore temporal properties of the two lens eyes. We find that the ERG of both lens eyes are complex and using sinusoidal flicker stimuli we find that both lens eyes have slow temporal resolution. The average flicker fusion frequency (FFF) was found to be approximately 10 Hz for the ule and 8 Hz for the lle. Differences in the FFF and response patterns between the two lens eyes suggest that the ule and lle filter information differently in the temporal domain and thus are tuned to perform different visual tasks. The data collected in this study support the idea that the visual system of box jellyfish is a collection of special purpose eyes.

SUMMARY Like all other cnidarian medusae, box jellyfish propel themselves through the water by contracting their bell-shaped body in discrete swim pulses. These pulses are controlled by a swim pacemaker system situated in their sensory structures, the rhopalia. Each medusa has four rhopalia each with a similar set of six eyes of four morphologically different types. We have examined how each of the four eye types influences the swim pacemaker. Multiple photoreceptor systems, three of the four eye types, plus the rhopalial neuropil, affect the swim pacemaker. The lower lens eye inhibits the pacemaker when stimulated and provokes a strong increase in the pacemaker frequency upon light-off. The upper lens eye, the pit eyes and the rhopalial neuropil all have close to the opposite effect. When these responses are compared with all-eye stimulations it is seen that some advanced integration must take place.

Although CSL box jellyfish antivenom (AV) remains the primary treatment for Chironex fleckeri envenoming, there has been considerable debate regarding its clinical effectiveness. Animal studies have shown that AV is largely ineffective in preventing C. fleckeri-induced cardiovascular collapse. This study examined the effectiveness of CSL box jellyfish AV (ovine IgG), raised against ‘milked’ venom, and polyclonal rabbit IgG antibodies (Ab) raised against nematocyst-derived venom. A venom dose of 30 μg/kg, i.v., which causes an initial presser response (34 ± 5 mmHg; n = 7) followed by cardiovascular collapse, was used in all experiments. A bolus dose of AV (3000 U/kg, i.v.) or Ab (12 mg; i.e. an equivalent protein ‘load’ to 3000 U/kg AV), administered 15 min prior to a bolus dose of venom, did not significantly attenuate the effects of venom. The venom response was also not significantly attenuated when AV (3000 U/kg) was given as a bolus dose 10–60 min prior to venom infusion. However, when the venom was incubated with either AV (3000 U/kg) or Ab (12 mg) for 3 h prior to infusion, the effect of the venom was almost abolished. The results of this study demonstrate that antibodies raised against both ‘milked’ and nematocyst-derived venom are able to neutralise the cardiovascular collapse produced by the venom. However, large amounts of AV are required and must be preincubated with the venom to be protective. This indicates a very rapid action of the toxin(s) and that AV is unlikely to be clinically effective because it cannot be administered early enough.

Introduction: Chironex fleckeri is a large box jellyfish that has been labelled the ‘most venomous animal’ in the world. We have recently shown that the primary effect of C. fleckeri venom in vivo is cardiovascular collapse. This study utilised a cell-based assay to examine the effects of C. fleckeri venom on the proliferation of a rat aortic smooth muscle cell line. In addition, the ability of CSL box jellyfish antivenom and/or various potential treatment strategies to neutralise the effects of the venom was examined. Methods: A7r5 cells were cultured in media containing venom. The effect of CSL box jellyfish antivenom (5 U/mL), CSL polyvalent snake antivenom (5 U/mL), lanthanum (5 µM), MgSO4 (50 mM), verapamil (5 µM) or felodipine (5 µM) was examined. Cell viability was determined using a Cell titer 96 AQueous One Solution cell proliferation assay. Results: Incubation of A7r5 cells with serially diluted venom (2–0.004 µg/mL) caused a concentration-dependent inhibition of cell proliferation with an IC50 value of 0.056 µg/mL. This response was not affected by the absence of calcium or the presence of lanthanum in the media. Box jellyfish antivenom (5 U/mL) prevented the inhibition of cell proliferation caused by the venom. Verapamil (5 µM) had no significant effect on the inhibition. In contrast, felodipine (5 µM) or MgSO4 (50 mM) potentiated the effects of the venom and partially negated the protective effect of the antivenom. Discussion: This study displayed the ability to utilise a cell-based assay to determine the effects of C. fleckeri venom on vascular cell viability. It showed that CSL box jellyfish can neutralise the effects of the venom but only if added prior to the venom. In addition, potential adjunct therapies verapamil, felodipine and MgSO4 were found to be ineffective, with felodipine and MgSO4 potentiating the detrimental effects of the venom.

Cubomedusae have a total of 24 eyes of four morphologically different types. Two of these eye types are camera-type eyes (upper and lower lens-eye), while the other two eye types are simpler pigment pit eyes (pit and slit eye). Here, we give a description of the visual system of the box jellyfish species Chiropsella bronzie and the optics of the lens eyes in this species. One aim of this study is to distinguish between general cubozoan features and species-specific features in the layout and optics of the eyes. We find that both types of lens eyes are more severely under-focused in C. bronzie than those in the previously investigated species Tripedalia cystophora. In the lower lens-eye of C. bronzie, blur circles subtend 20 and 52 degrees for closed and open pupil, respectively, effectively removing all but the coarsest structures of the image. Histology reveals that the retina of the lower lens-eye, in addition to pigmented photoreceptors, also contains long pigment-cells, with both dark and white pigment, where the dark pigment migrates on light/dark adaptation. Unlike the upper lens-eye lens of T.cystophora, the same eye in C.bronzie did not display any significant optical power.

Irukandji stings may be lethal to humans, and yet, until late 2005, only one of the many suspected Irukandji stingers had been formally named and classified. This paper describes Malo kingi, n. sp., which is apparently responsible for a recent fatality. This species differs from all other cubozoans in having halo-like rings of tissue encircling the tentacles, with club-shaped Type 4 microbasic mastigophores inserted end-on around the periphery of the rings. It further differs from its only current congener, Malo maxima, in having: a much smaller, more rounded body; different tubule winding patterns in the undischarged nematocysts; spines confined to the distal-most portion of the shaft in the discharged nematocysts; relatively broader pedalia; somewhat less well defined rhopalial horns; and perradial lappets with a greater number of nematocyst warts and nipple-like terminal extensions. Much additional work is needed to better understand the general biology of this and other dangerous species so as to prevent further fatalities, debilitating illnesses, and threats to the tourism industry resulting from the marine stinger problem. Treatment of envenomations, management issues regarding sting prevention, and the related implications for tourism, all rely on being able to consistently and accurately identify public health hazards. The need still exists for an aggressive awareness campaign aimed at residents and visitors regarding education and prevention of Irukandji stings.

Venom profiles of two age groups of the medically important Australian box jellyfish Carukia barnesi [Southcott, R.V., 1967. Revision of some Carybdeidae (Scyphozoa, Cubomedusae), including description of jellyfish responsible for the 'Irukandji' syndrome. Aust. J. Zool. 15, 651-657] were compared. Sodium dodecyl sulphate-polyacrylamide gel electrophoresis revealed differences in protein banding of tentacular venom between immature and mature animals. This correlates to a change in diet from invertebrate prey in immature C. barnesi medusae to vertebrate prey in mature medusae. Unlike other cubozoan studies, a change in venom did not equate to a change in nematocyst types or their relative frequencies. Additionally, comparison of tentacle structure and bell wart number showed developmental differences between the two age classes. Observations of prey capture in mature individuals and differences in bell warts between immature and mature medusae suggest different methods of prey capture are employed at different life stages of C. barnesi.

Box jellyfish have the most elaborate sensory system and behavioural repertoire of all cnidarians. Sensory input largely comes from 24 eyes situated on four club-shaped sensory structures, the rhopalia, and behaviour includes obstacle avoidance, light shaft attractance and mating. To process the sensory input and convert it into the appropriate behaviour, the box jellyfish have a central nervous system (CNS) but this is still poorly understood. The CNS has two major components: the rhopalial nervous system and the ring nerve. The rhopalial nervous system is situated within the rhopalia in close connection with the eyes, whereas the ring nerve encircles the bell. We describe the morphology of the ring nerve of the box jellyfish Tripedalia cystophora as ascertained by normal histological techniques, immunohistochemistry and transmission electron microscopy. By light microscopy, we have estimated the number of cells in the ring nerve by counting their nuclei. In cross sections at the ultrastructural level, the ring nerve appears to have three types of neurites: (1) small "normal"-looking neurites, (2) medium-sized neurites almost completely filled by electron-lucent vacuoles and (3) giant neurites. In general, only one giant neurite is seen on each section; this type displays the most synapses. Epithelial cells divide the ring nerve into compartments, each having a tendency to contain neurites of similar morphology. The number and arrangement of the compartments vary along the length of the ring nerve.

Clinical observations suggest a primary cardiotoxic role in fatal Chironex fleckeri stings. The limited research available indicates that Chiropsella bronzie venom acts in a similar manner although appears to be less potent. The aim of the present study was to elucidate the vascular effects of C. fleckeri and C. bronzie venoms using rat isolated aorta. Both venoms produced a sustained contraction of endothelium-denuded aorta which was not significantly affected by prazosin or box jellyfish antivenom. Felodipine significantly reduced the contractile response to C. fleckeri venom but not C. bronzie venom. Both venoms produced an initial relaxation (Phase 1), followed by a sustained contraction (Phase 2), in pre-contracted endothelium-intact aorta. Removal of the endothelium significantly inhibited both phases of the response. NOLA significantly inhibited Phase 1, but not Phase 2, of the response to both venoms. Atropine, HOE 140 or BQ 123 did not have any significant inhibitory effect on either phase. In conclusion, neither C. fleckeri nor C. bronzie venoms appear to contain components with activity at alpha(1)-adrenoceptors. Antivenom was ineffective in reversing the effects of the venom suggesting it is incapable of completely neutralising nematocyst-derived venom. Determining the mechanism of action of these venoms will allow for the development of better treatment strategies.

3 pages, 2 figures, A woman stung by the box jellyfish Carybdea marsupialis (Cnidaria, Cubozoa) at a Spanish Mediterranean beach showed systemic manifestations over several months [pain far from the inoculation point, arthralgia, paresthesia, hyperesthesia, increase in eosinophils and immunoglobulin E (IgE)] in addition to the skin condition, This research was carried out under contract LIFE 08 NAT ES 0064 (to C. B., J. M. G., and V. F.) co-financed by the European Commission (www.cubomed.eu), the Ministerio de Agricultura, Alimentación y Medio Ambiente, Fundación Biodiversidad, and the Dirección General del Agua of the Regional Government of Valencia

Background. Jellyfi sh stings are a common occurrence among ocean goers worldwide with an estimated 150 million envenomations annually. Fatalities and hospitalizations occur annually, particularly in the Indo-Pacifi c regions. A new topical jellyfi sh sting inhibitor based on the mucous coating of the clown fi sh prevents 85% of jellyfi sh stings in laboratory settings. The fi eld effectiveness is unknown. The objective is to evaluate the fi eld effi cacy of the jellyfi sh sting inhibitor, Safe Sea ™ . Methods. A double-blind, randomized, placebo-controlled trial occurred at the Dry Tortugas National Park, FL, USA and Sapodilla Cayes, Belize. Participants were healthy volunteers planning to snorkel for 30 to 45 minutes. Ten minutes prior to swimming, each participant was directly observed applying a blinded sample of Safe Sea (Nidaria Technology Ltd, Jordan Valley, Israel) to one side of their body and a blinded sample of Coppertone ® (ScheringPlough, Kenilworth, NJ, USA) to the contralateral side as placebo control. Masked 26 g samples of both Safe Sea SPF15 and Coppertone ® SPF15 were provided in identical containers to achieve 2 mg/cm 2 coverage. Sides were randomly chosen by participants. The incidence of jellyfi sh stings was the main outcome measure. This was assessed by participant interview and examination as subjects exited the water. Results. A total of 82 observed water exposures occurred. Thirteen jellyfi sh stings occurred during the study period for a 16% incidence. Eleven jellyfi sh stings occurred with placebo, two with the sting inhibitor, resulting in a relative risk reduction of 82% (95% confi dence interval: 21% – 96%; p = 0.02). No seabather ’ s eruption or side effects occurred. Conclusions. Safe Sea is a topical barrier cream effective at preventing >80% jellyfi sh stings under real-world conditions.

Objective: To describe the epidemiology and clinical features of box jellyfish envenoming in the Top End of the Northern Territory and, in particular, confirmed stings from the major Australian box jellyfish, Chironex fleckeri. Design: Prospective collection of clinical data and skin scrapings or sticky-tape tests for nematocyst identification from patients presenting to Royal Darwin Hospital and remote coastal community health clinics in the Northern Territory, spanning 10 950km of coastline; analysis of tidal, weather and seasonal data. Patients: All patients with jellyfish sting details recorded between 1 April 1991 and 30 May 2004. Main outcome measures: Demographic and clinical features, use of C. fleckeri antivenom, and associations between weather, seasonal and tidal factors and confirmed C. fleckeri stings. Results: Of 606 jellyfish stings documented, 225 were confirmed to have been caused by C. fleckeri. 37% of C. fleckeri stings were in children, 92% occurred during the “stinger season” (1 October to 1 June), 83% occurred in water 1 m or less deep, and 17% occured while victims were entering the water. Stings were least common on outgoing tides (P < 0.001) and commonest between 15:00 and 18:00 (P < 0.001) and on days with wind speed less than that month’s average (P < 0.001). Nearly all victims experienced immediate pain, but this could often be controlled with ice; only 30% required parenteral narcotics and 8% required hospital admission. Cardiorespiratory arrest occurred within several minutes of the sting in the one fatal case, involving a 3-year-old girl with only 1.2 m of visible tentacle contact. C. fleckeri antivenom was given to another 21 patients, none of whom had life-threatening features at the time they were given antivenom. Conclusions: Most C. fleckeri stings are not life-threatening; patients who die usually have cardiopulmonary arrest within minutes of the sting. The potential benefit of antivenom and magnesium under these circumstances remains to be shown, but a protocol with their rapid use is recommended if cardiopulmonary arrest has occurred. Unfortunately, this is unrealistic for many rural coastal locations, and the priority remains prevention of stings by keeping people, especially children, out of the sea during the

Cubozoans differ from other cnidarians by their body architecture and nervous system structure. In the medusa stage they possess the most advanced visual system within the phylum, located in sophisticated sensory structures, rhopalia. The rhopalium is a club-shaped structure with paired pit-shaped pigment cup eyes, paired slit-shaped pigment cup eyes, and two complex camera-type eyes: one small upper lens eye and one large lower lens eye. The medusa carries four rhopalia and visual processing and locomotor rhythm generation takes place in the rhopalia. We show here a bilaterally symmetric organization of neurons, with commissures connecting the two sides, in the rhopalium of the cubozoan Tripedalia cystophora. The fortuitous observation that a subset of neurons is strongly immunoreactive for a PCNA (proliferating cell nuclear antigen)-like epitope allowed us to analyze the organization of these neurons in detail. Distinct PCNA-immunoreactive (PCNA-ir) nuclei form six bilateral pairs that are associated with the slit eyes, pit eyes, upper lens eye, and the posterior wall of the rhopalium. Three commissures connect the clusters of the two sides and all clusters in the rhopalium have connections to the area around the base of the stalk. This neuronal system provides an anatomical substrate for integration of visual signals from the different eyes.

Cubozoans, or box jellyfish, each have twenty-four eyes of four types, but no central brain for information processing. An investigation of these eyes reveals optics as sophisticated as in vertebrates. Despite this, the retina is out of focus and the sharp image is not used to provide acute vision, but as a way of processing visual information. ‘Blurred’ vision may be perfect for avoiding large stationary objects without focusing on small floating objects and plankton. This may also be a pointer to a missing link in the early evolution of animal visual systems, likely to have involved eyes performing a single visual task only. The cover shows the two lens eyes and two pairs of pigment pit eyes in the bizarre sensory club of Chiropsalmus sp., larger but similar to those of Tripedalia cystophora used in the optical study. Cubozoans, or box jellyfish, differ from all other cnidarians by an active fish-like behaviour and an elaborate sensory apparatus1,2. Each of the four sides of the animal carries a conspicuous sensory club (the rhopalium), which has evolved into a bizarre cluster of different eyes3. Two of the eyes on each rhopalium have long been known to resemble eyes of higher animals, but the function and performance of these eyes have remained unknown4. Here we show that box-jellyfish lenses contain a finely tuned refractive index gradient producing nearly aberration-free imaging. This demonstrates that even simple animals have been able to evolve the sophisticated visual optics previously known only from a few advanced bilaterian phyla. However, the position of the retina does not coincide with the sharp image, leading to very wide and complex receptive fields in individual photoreceptors. We argue that this may be useful in eyes serving a single visual task. The findings indicate that tailoring of complex receptive fields might have been one of the original driving forces in the evolution of animal lenses.

The administration of magnesium sulphate is a proposed novel therapy for Irukandji syndrome1. In this non-randomized, unblinded case series, data from ten patients who received magnesium salts are reviewed. Magnesium sulphate boluses of 10 to 20 mmol, in the six patients for which there was adequate data, reduced pain scores immediately after administration from 8.7±1.5 to 2.8±2.8 (Wilcoxon rank-sum test, P=0.03). In ten patients blood pressure decreased with a mean difference of −18 mmHg in mean arterial pressure. Magnesium requirements in individual patients varied markedly. Pain on injection occurred in four patients, three of whom had received peripherally administered magnesium chloride, and one patient reported transient ptosis after administration of magnesium sulphate 166 mmol over 18 hours in the setting of severe Irukandji syndrome. Magnesium sulphate administration appears to attenuate pain and hypertension in Irukandji syndrome and warrants further evaluation in this setting.

Using a new technique to extract venom from the nematocysts, the efficacy of CSL box jellyfish antivenom (AV) and adjunct therapies, verapamil and magnesium sulfate (MgSO(4)), were investigated against the in vivo cardiovascular effects of Chironex fleckeri venom in anaesthetised rats. C. fleckeri venom (30 microg/kg; i.v.) produced a transient hypertensive response followed by hypotension and cardiovascular collapse within 4 min of administration. Prophylactic treatment of anaesthetised rats with CSL box jellyfish AV (3000 U/kg; i.v.) did not have any effect on the venom-induced pressor response, but prevented cardiovascular collapse in four out of 10 animals. Administration of verapamil (20mM@0.25 ml/min; i.v.) either alone or in combination with AV, did not have any effect on the C. fleckeri venom-induced pressor response nor the consequent hypotension or cardiovascular collapse of animals. However, the administration of verapamil negated the partially protective effects of AV. Concurrent artificial respiration of animals with the above treatments did not attenuate the C. fleckeri venom-induced cardiovascular effects. MgSO(4) (0.05-0.07M@0.25 ml/min; i.v.) alone did not have any effect on the venom-induced pressor response nor the consequent cardiovascular collapse of animals. However, although combined AV and MgSO(4) administration could not inhibit the transient pressor effect following the administration of C. fleckeri venom, it prevented cardiovascular collapse in all animals. We show for the first time, the cardiovascular effects of a C. fleckeri venom sample free of tentacular contamination and the potential of MgSO(4) as an adjunct therapy for the treatment of potentially fatal C. fleckeri envenomings.

Objective. To determine the knowledge, beliefs, and behavior of local residents and visitors to North Queensland who may be at risk of contact with ‘‘Irukandji’’ jellyfish. Methods. Structured interviews were conducted with 208 ferry passengers (92.9% response) traveling between Magnetic Island and Townsville (19 deg S). Results. A total of 88.1% of the locals, 69.8% of the domestic tourists, and 34% of the international tourists knew what an Irukandji was (P < 0.001). Half of the international tourists, 20% of the domestic tourists, and 3.9% of the locals with this knowledge incorrectly assumed it was safe to swim inside stinger-resistant enclosures or were unsure (P < 0.001). Visitors to Magnetic Island who had swum or intended to swim in the sea (47%) knew less about Irukandji than other visitors (P = 0.05). Only 42.3% of the respondents realized that Irukandji posed a risk to swimmers on the outer reefs, and only 33.1% knew that Irukandji were also found outside North Queensland. Conclusions. International tourists had little knowledge about Irukandji. Thus, accurate educational messages may need to be targeted at this group. Offshore water sport and reef tour operators should be encouraged to provide clients with protective clothing to minimize the risk of stings. A coordinated educational response across northern Australia may be necessary to inform the public about both the box jellyfish (Chironex fleckeri) and Irukandji.

Irukandji syndrome is a constellation of delayed severe local and systemic symptoms occurring after a Carukia barnesi box jellyfish sting involving any exposed skin. These cases are limited to Australia, the habitat of that animal. Numerous other cases of an Irukandji-like syndrome after other small Carybdeid genus envenomations have been reported elsewhere in the world. There have yet been no reports of Irukandji-like syndrome occurring in continental US coastal waters. We describe 3 cases of marine envenomation causing such a symptom complex in US military combat divers off Key West, FL. It is unclear what species caused the injuries, but a member of the Carybdeid genus seems most likely.

We conducted two studies to determine whether the minimum clinically significant difference in the visual analog scale (VAS) for nearly simultaneous and brief-interval serial assessments of pain is less than that for pain assessment at 20- to 30-minute intervals, using a 10-cm VAS. The first study was a blinded, randomized, placebo-controlled paired trial comparing the pain of intravenous cannulation in both hands (20-minute application of a eutectic mixture of local anesthetics v placebo) of study subjects. The second study was a non-blinded, randomized, paired trial of different treatments for jellyfish stings. In the first study, 37 of 40 subjects indicated that one hand experienced more pain than the other. Eleven of these 37 subjects (30%) indicated differences in VAS values of 1.0 cm or less, with a minimum value of 0.5 cm. In the second study, for all the VAS-based pain comparisons, VAS differences ofor=0.5 cm (other than zero) occurred 183 times, and in 171 of these instances (93%) subjects were able to recognize that there was a difference. On the basis of these findings, the minimum clinically significant VAS difference for paired comparisons that are simultaneous or occur within 5 minutes of each other is about 0.5 cm or less. This value is less than the 1.3-cm value determined for serial 20- to 30-minute pain comparisons. It is likely that other types of pain comparisons may have different minimum clinically significant VAS differences.

Haemodynamic effects of saline-extracted venom from nematocysts isolated from tentacles of the box-jellyfish Chiropsalmus quadrigatus (Habu-kurage) were investigated. In anaesthetized rabbits, i.v. injections of the venom produced hypotension following a transient hypertension. Mean femoral arterial blood flow markedly decreased immediately after the injection and femoral vascular resistance increased. Left ventricular dP/dt remarkably decreased after a transient and small increase, and heart rate decreased. Left ventricular end-diastolic pressure markedly elevated. All of the above changes by 0.2-5 microg/kg of the venom expressed as the amount of protein were seen dose-dependently and occurred without tachyphylaxis. In five of seven animals received an injection of the venom at 10 microg/kg, irreversible cardiac arrest occurred. Changes produced by 1 or 2 microg/kg of the venom were significantly attenuated either by heating the venom at 40 degrees C for 10min or by pretreatment with diltiazem. These results indicate that the venom from Habu-kurage has both vasoconstrictor and cardiodepressive effects, and suggest that these thermolabile actions may be due partly to activation of voltage-dependent calcium channels and probably subsequent calcium-overload.

Interest in envenoming syndromes caused by Australian jellyfish has been intense since the deaths in early 2002 of two tourists in Queensland, attributed to the Irukandji syndrome. We review current knowledge of these envenoming syndromes, mechanisms of venom action and therapy, focusing on the deadly box jellyfish, Chironex fleckeri, and the array of jellyfish thought to cause the Irukandji syndrome. Current understanding of jellyfish venom activity is very limited, and many treatments are unproven and based on anecdote.

Rationale: Although anaphylaxis caused by jellyfish stings is common in coastal areas, an allergic shock caused by cooked jellyfish ingestion has never been reported in China. In this paper, we report a case of allergic shock being caused by ingestion of cooked salt-preserved jellyfish shortly after being stung by a live jellyfish. Patient concerns: A 26-year-old Chinese man presented with dizziness, pruritus, dyspnea, hypotension, and tachycardia after eating cooked salted jellyfish. The patient had been stung twice by jellyfish half a year ago. Diagnoses: Allergic shock caused by ingestion of cooked jellyfish. Interventions: The patient was treated with phenergan (25 mg, intramuscular injection), 250 mL normal saline (NS) and 10 mg dexamethasone (intravenous drip), 500 mL NS and 0.4 g cimetidine (intravenous drip), and 500 mL NS for rapid fluid infusion (intravenous drip). Outcomes: After the treatment, the main clinical symptoms of the patient improved quickly. Five days later, the patient's urticaria had dissipated. Lessons: A history of jellyfish contact or sting might be an important allergic factor for individuals who consume any kind of jellyfish.

The potentially fatal Irukandji syndrome is relatively common in tropical waters throughout the world. It is caused by the sting of the Irukandji jellyfish, a family of box jellyfish that are almost impossible to detect in the water owing to their small size and transparency. Using collated medical records of stings and local weather conditions, we show that the presence of Irukandji blooms in coastal waters can be forecast on the basis of wind conditions. On the Great Barrier Reef, blooms largely coincide with relaxation of the prevailing southeasterly trade winds, with average conditions corresponding to near zero alongshore wind on the day prior to the sting. These conditions are consistent with hypotheses long held by local communities and provide a basis for designing management interventions that have the potential to eliminate the majority of stings.

At least two conducting systems are well documented in cubomedusae. A variably diffuse network of large neurons innervates the swim musculature and can be visualized immunohistochemically using antibodies against α- or β-tubulin. Despite the non-specificity of these antibodies, multiple lines of evidence suggest that staining highlights the primary motor networks. These networks exhibit unique neurite distributions among the muscle sheets in that network density is greatest in the perradial frenula, where neurites are oriented in parallel with radial muscle fibers. This highly innervated, buttress-like muscle sheet may serve a critical role in the cubomedusan mechanism of turning. In scyphomedusae, a second subumbrellar network immunoreactive to antibodies against the neuropeptide FMRFamide innervates the swim musculature, but it is absent in cubomedusae. Immunoreactivity to FMRFamide in cubomedusae is mostly limited to a small network of neurons in the pacemaker region of the rhopalia, the pedalial apex at the nerve ring junction, and a few neuron tracts in the nerve ring. However, FMRFamide-immunoreactive networks, as well as tubulin-immunoreactive networks, are nearly ubiquitous outside of the swim muscle sheets in the perradial smooth muscle bands, manubrium, pedalia, and tentacles. Here we describe in detail the peripheral nerve nets of box jellyfish on the basis of immunoreactivity to the antibodies above. Our results offer insight into how the peripheral nerve nets are organized to produce the complex swimming, feeding, and defensive behaviors observed in cubomedusae.

Introduction. Irukandji syndrome is because of envenoming by a number of small jellyfish. It results in a delayed onset of generalized pain, sweating hypertension, and tachycardia. There is no antivenom. Case report. A 44-year-old healthy male was stung while swimming in NE Australia. He rapidly developed Irukandji syndrome. He had a rapid deterioration in conscious level because of an intracerebral hemorrhage. He developed left ventricular failure with an elevated troponin (34 mcg/L, N < 0.4) requiring inotropic support. He progressed to brain death and died on day 13 poststing. Nematocysts recovered from the patient skin were consistent with a large Carukia barnesi. Discussion. This is the first case of a death because of Irukandji syndrome where the jellyfish Carukia barnesi has been demonstrated to the causative creature.

Background Jellyfish envenomations are common amongst temperate coastal regions and vary in severity depending on the species. Stings result in a variety of symptoms and signs, including pain, dermatological reactions and, in some species, Irukandji syndrome (including abdominal/back/chest pain, tachycardia, hypertension, sweating, piloerection, agitation and sometimes cardiac complications). Many treatments have been suggested for the symptoms and signs of jellyfish stings. However, it is unclear which interventions are most effective. Objectives To determine the benefits and harms associated with the use of any intervention, in both adults and children, for the treatment of jellyfish stings, as assessed from randomised trials. Search methods We searched the following electronic databases in October 2012 and again in October 2013: the Cochrane Central Register of Controlled Trials (CENTRAL;The Cochrane Library, Issue 9, 2013); MEDLINE via Ovid SP (1948 to 22 October 2013); EMBASE via Ovid SP (1980 to 21 October 2013); and Web of Science (all databases; 1899 to 21 October 2013). We also searched reference lists from eligible studies and guidelines, conference proceedings and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and contacted content experts to identify trials. Selection criteria We included randomised controlled trials that compared any intervention(s) to active and/or non-active controls for the treatment of symptoms and signs of jellyfish sting envenomation. No language, publication date or publication status restrictions were applied. Data collection and analysis Two review authors independently conducted study selection and data extraction and assessed risk of bias using a standardised form. Disagreements were resolved by consensus with a third review author when necessary. Main results We included seven trials with a total of 435 participants. Three trials focused on Physalia (Bluebottle) jellyfish, one trial on Carukia jellyfish and three on Carybdea alata (Hawaiian box) jellyfish. Two ongoing trials were identified. Six of the seven trials were judged as having high risk of bias. Blinding was not feasible in four of the included trials because of the nature of the interventions. A wide range of interventions were assessed across trials, and a wide range of outcomes were measured. We reported results from the two trials for which data were available and reported the effects of interventions according to our definition of primary or secondary outcomes. Hot water immersion was superior to ice packs in achieving clinically significant (at least 50%) pain relief at 10 minutes (one trial, 96 participants, risk ratio (RR) 1.66, 95% confidence interval (CI) 1.01 to 2.72; low-quality evidence) and 20 minutes (one trial, 88 participants, RR 2.66, 95% CI 1.71 to 4.15; low-quality evidence). No statistically significant differences between hot water immersion and ice packs were demonstrated for dermatological outcomes. Treatment with vinegar or Adolph's meat tenderizer compared with hot water made skin appear worse (one trial, 25 participants, RR 0.31, 95% CI 0.14 to 0.72; low-quality evidence). Adverse events due to treatment were not reported in any trial. Authors' conclusions This review located a small number of trials that assessed a variety of different interventions applied in different ways and in different settings. Although heat appears to be an effective treatment for Physalia (Bluebottle) stings, this evidence is based on a single trial of low-quality evidence. It is still unclear what type of application, temperature, duration of treatment and type of water (salt or fresh) constitute the most effective treatment. In addition, these results may not apply to other species of jellyfish with different envenomation characteristics. Future research should further assess the most effective interventions using standardised research methodology.

We read with interest the article entitled “Anaphylaxis caused by ingestion of jellyfish” by Imamura et al. in this journal [1]. They stated that their case subject was sensitized through the skin by jellyfish stings and that subsequent jellyfish intake induced anaphylaxis. However, we experienced a case of anaphylaxis after jellyfish ingestion without any history of jellyfish contact or sting.A 14-year-old boy developed a cough, urticaria and dyspnea 30 minutes after he ate a breakfast that [...]

The vertebrate cardiotoxic components of the venom produced by the Australian box jellyfish, Chironex fleckeri, have not previously been isolated. We have uncovered for the first time, three distinct cytotoxic crude fractions from within the vertebrate cardiotoxic peak of C. fleckeri venom by monitoring viability of human muscle cells with an impedance based assay (ACEA xCELLigence system) measuring cell detachment as cytotoxicity which was correlated with a reduction in cell metabolism using a cell proliferation (MTS) assay. When the effects of the venom components on human cardiomyocytes and human skeletal muscle cells were compared, two fractions were found to specifically affect cardiomyocytes with distinct temporal profiles (labelled Crude Toxic Fractions (CTF), α and β). A third fraction (CTF-γ) was toxic to both muscle cell types and therefore not cardio specific. The vertebrate, cardio specific CTF-α and CTF-β, presented distinct activities; CTF-α caused rapid but short term cell detachment and reduction in cell metabolism with enhanced activity at lower concentrations than CTF-β. This activity was not permanent, with cell reattachment and subsequent increased metabolism of heart muscle cells observed when exposed to all but the highest concentrations of CTF-α tested. The cytotoxic effect of CTF-β took twice as long to act on the cells compared to CTF-α, however, the activity was permanent. Furthermore, we showed that the two fractions combined have a synergistic effect causing a much stronger and faster cell detachment (death) when combined than the sum of the individual effects of each toxin. These data presented here improves the current understanding of the toxic mechanisms of the Australian box jellyfish, C. fleckeri, and provides a basis for in vivo research of these newly isolated toxic fractions.

Although Chironex fleckeri and Carukia barnesi cause significant human envenomation, research into their effects in human models or human cells has been limited. In this in vitro study we have presented data that shows that although C. fleckeri is highly cytotoxic to human cardiac and skeletal muscle cells, C. barnesi is not cytotoxic at all concentrations tested to both cardiac and skeletal muscles cells. We also demonstrate that in vitro C. fleckeri venom cardiocytotoxic activity is significantly attenuated when heated to 44 °C for 20 min. There is a similar attenuation with skeletal cells at 46 °C.