Case Report

We present the case of a healthy 13 years old boy, who was attacked by a jellyfish at a Caribbean beach. The patient had burning and pain in the left half of the face and left shoulder and linear lesions with erythema and swelling. The tentacles were removed one minute after the attack by irrigating seawater, and two minutes after the attack the father applied 30 seconds directly his urine by direct urination.

One hour after the attack, the patient receives general medical attention, all the lesions were washed with soap and water applying a topical antibiotic (neomycin / polymyxin / bacitracin) and all the symptoms and lessons disappeared two hours after the urine application. The patient required analgesics by mouth for only 12 hours. (Ibuprofen 400 mgs each 6 hours two doses)

The species of jellyfish responsible for the injury was not determined.

Figure 1

FIGURE 1: Jellyfish sting in a boy, pictures on the left side 2 minutes after attack and pictures on the right two hours after urine application.

Discussion

In 2011, Avelino published a report that outlined the treatment of jellyfish stings they used glucocorticoids, antihistamines and antibiotics for one week. Blisters and pruritus disappeared until the tenth day and 8 months after the skin surrounding the lesion area was still abnormal, with hyperchromia and a slightly rough texture.(1)

The local and systemic symptoms that develop after being bitten by a jellyfish depend on such factors as the type of toxin, the variety of jellyfish, the duration and magnitude of exposure, host reaction to the sting of chemistry and initial treatment administered.(1)

The nematocysts are individual cells on the outer surface of the jellyfish that serve in defense or capturing prey species by injecting toxins.(2)

Jellyfish do not release all their venom in a sting, but continue for an extended period of time when the nematocyst gradually is breaking spikes that penetrate the skin and release more toxins. (2)

In the 2010 American Heart Association and American Red Cross Guidelines for First Aid published a review on this theme and recommended two important actions: preventing further discharge of the nematocyst and pain relief. (3), This paper recommend that jellyfish stings should be washed thoroughly with vinegar (4% to 6% solution of acetic acid) as soon as possible at least 30 seconds or if the vinegar is not available, a suspension of sodium bicarbonate can be used, this recommendation is based on two old articles (4) (5).

There is evidence that local heating is effective for pain control after the nematocysts are removed or deactivated, so jellyfish stings should be treated with immersion in hot water when possible (Class IIa, Level of evidence B). The victim should be instructed to take a hot shower or immerse the affected part in warm water (45 ° C or at a temperature as hot as tolerated and as soon as possible, at least for 20 minutes or for as long as pain persists (6), (7). If hot water is not available hot wet or dry compresses can be used as a second choice, and cold application could be useful to reduce pain, but these are not as effective as hot water (Class IIb, LOE B (6), (10), (11), a recent paper reported that the use of ammonia, acetic acid and sodium bicarbonate have similar effects on the discharge of nematocysts (12). The use of other solutions such as urine or alcohol have been reported and have not been scientifically evaluated and in some works have been disqualified and regarded as harmful without explanation. (13)

The transmission of infections, bacterial and viral including HIV is a potential theoretical risk with the use of urine, however, the concentration of virus in the urine is very low and the risk of infection in the urine, tears and sweat is considered not clinically relevant. (14) the potential risk of bacterial infection if the donor's urine is contaminated can be lesser if we use urine of a relative apparently healthy. We believe that ideal like in blood transfusion is to use “safe urine “ to reduce this risk, after improvement of symptoms should wash the area with water and soap and apply a local antibiotic.

The benefits of urine as an emergency treatment for jellyfish stings mitigates the potential harm of a UTI and offer benefits compared to other existing modes of treatment, which are not accessible immediately.

Conclusions

Initial therapy should be directed to remove the tentacles as soon as possible, before they break nematocysts and introduce the toxin into the skin. The use of hot solutions and acid has been proven effective, but start time of treatment is important. Urine is an accessible solution, as it is a hot acid with a high content of ammonium, probably the solution that can be applied most rapidly. Perhaps it is time to reassess these treatments and produce controlled studies with an open mind to assess whether this popular treatment can be useful.

Jellyfish stings are common and potentially dangerous, especially in children and if urine proves to be an acceptable treatment, it can be applied immediately at the beach by healthy parents and is a good treatment accessible immediately.