Letters to the Editor
Jellyfish Species Distinction Has Treatment Implications
TO THE EDITOR: The article, "Health Issues for Surfers,"1 by Dr. Zoltan and colleagues was an interesting reminder that certain activities may be associated with particular exposures and health risks. I would like to comment on several points covered in the article.
In the discussion of wounds, the authors indicate the potential for infection with halophilic microorganisms, particularly Vibrio species. Indeed, Vibrio vulnificus infection can be a life- or limb-threatening complication of marine wounds. A tetracycline has long been considered the antibiotic of choice against V. vulnificus,2 although several other antibiotics also are effective. Therefore, I propose including the relatively inexpensive and effective drugs doxycycline (Vibramycin) and tetracycline among the recommended antibiotics for initial empiric prophylaxis for outpatients with infection-prone wounds or immunocompromised status. It also may be provident to mention tetanus prophylaxis.
The article cites a potential harmful effect of fresh water irrigation of jellyfish stings. However, it seems that stings by different species of coelenterates may respond differently to various treatments. There are reports of adverse reactions to fresh water in patients with apparent Chironex fleckeri sting and to hot water immersion in Atlantic Physalia sting.3 In contrast, our clinical experience in Hawaii (with presumed Carybdea alata stings) has been that hot, fresh water immersion or irrigation is helpful.3 Thomas and colleagues found no effect in Hawaii (beneficial or harmful) with ambient temperature fresh water irrigation of presumed C. alata stings.4 Other investigators3 have used fresh water on stings of other coelenterate species without discernible adverse effects.
The authors1 note
the particular threat of box jellyfish to surfers. Figure 3 is labeled as a box jellyfish
(C. alata), commonly found in Hawaii, but
actually seems to illustrate C. fleckeri,
the potentially deadly box jellyfish of northern Australia. More
importantly,
this apparent confusion of species is reflected in the text,
which notes that in the United States, box jellyfish are found only in Hawaii,
but recommends the use of antivenom, which is available only for the Australian
C. fleckeri. The distinction is important
because different jellyfish species pose different risks to humans and may
require different treatment. Specific C. fleckeri
antivenom may be lifesaving in severe envenomations by that species5 and also may benefit stings by other closely
related chirodropid jellyfish (Chiropsalmus species). There is no evidence that
it helps with stings from carybdeid jellyfish such as
C. alata. Furthermore, if specific
antivenom for C. alata would become
available, it rarely would be required because
C. alata envenomations in Hawaii are generally
self-limited, whereas antivenom itself poses a limited risk of anaphylaxis
(C. fleckeri antivenom is prepared by
hyperimmunizing sheep). In our experience in Hawaii, even patients who sought
emergency department treatment for more severe C.
alata stings could be managed successfully with simple measures such as
a hot water shower.3
REFERENCES
1. Zoltan TB, Taylor KS, Achar SA. Health issues for surfers. Am Fam Physician 2005;71:2313-7.
2. Abramowicz M. Handbook of antimicrobial therapy. New Rochelle, N.Y.: Medical Letter, 2000:49.
3. Yoshimoto CM, Yanagihara AA. Cnidarian (coelenterate) envenomations in Hawaii improve following heat application. Trans R Soc Trop Med Hyg 2002;96:300-3.
4. Thomas CS, Scott SA, Galanis DJ, Goto RS. Box jellyfish (Carybdea alata) in Waikiki. The analgesic effect of sting-aid, Adolph's meat tenderizer and fresh water on their stings: a double-blinded, randomized, placebo-controlled clinical trial. Hawaii Med J 2001;60:205-7, 210.
5. Williamson J, Burnett J. Clinical toxicology of marine coelenterate injuries. In: Meier J, White J, eds. Handbook of clinical toxicology of animal venoms and poisons. Boca Raton, Fla.: CRC Press, 1995:89-115.
editor's note: This letter was sent to the authors of "Health Issues for Surfers," who declined to reply.
Dysmorphic Findings in Persons with Fragile X Syndrome
TO THE EDITOR: The article, "Diagnosis and Management of Fragile X Syndrome,"1 in the July 1, 2005, issue of American Family Physician by Drs. Wattendorf and Muenke was concise and enlightening. However, I was perplexed by the photo in Figure 1 of the article,1 which intended to portray the "dysmorphic findings" of this syndrome. After having noted nothing out of the ordinary about the young man in the picture, I covered the caption and showed the photo to a number of colleagues. Not one thought there was anything remarkable about the young man's appearance; even upon reading of the features purported to be depicted, not one colleague concurred that the photo portrayed anything that we would consider dysmorphic. All agreed that he is a typical young male in appearance.
REFERENCES
1. Wattendorf DJ, Muenke M. Diagnosis and management of fragile X syndrome. Am Fam Physician 2005;72:111-3.
IN REPLY: We were pleased with Dr. Reynolds' response to our article, "Diagnosis and Management of Fragile X Syndrome."1 The boy in Figure 1 of our article1 has classic facial findings of fragile X syndrome. As with other articles in this series, we tried to include photos of patients with genetic syndromes who have subtle dysmorphic findings. These are patients whose diagnosis has been missed because they do not have the "typical" findings (i.e., the most severe) shown in photographs in older genetic textbooks. The goal of this series of short reviews is to familiarize the family physician with the diagnosis and management of patients with various genetic syndromes. Many of these are not obvious at birth or in early childhood, and delayed diagnosis may lead to missed opportunities for early interventions. Patients with various degrees of developmental and cognitive differences who have only mildly to moderately abnormal facial features require a detailed work-up to arrive at the specific diagnosis.2 We will be delighted if further articles in this series also will be discussed among readers and their colleagues.
REFERENCES
1. Wattendorf DJ, Muenke M. Diagnosis and management of fragile X syndrome. Am Fam Physician 2005;72:111-3.
2. Wattendorf DJ, Muenke M. The human genome project and its impact on developmental disabilites. In: Butler MG. Genetics of developmental diabilities. Marcel Dekker, Inc., 2005.
The article "Health Issues for Surfers" (June 15, 2005, page 2313) contained an error in the figure legend for Figure 3, which described a jellyfish. The figure legend incorrectly described the jellyfish depicted in the figure as a box jellyfish (Carybdea alata), which is indigenous to American waters. However, the jellyfish shown was a Chironex fleckeri, which is indigenous to the South Pacific. The correct figure legend should have been, "A number of different types of box jellyfish exist, all displaying a characteristic bell with tentacles arising from the corners. Although Carybdea alata may be encountered in Hawaii, an even more venemous variety, Chironex fleckeri, shown here, is found in the South Pacific." The online version of this article has been corrected.
The "Clinical Quiz" in the July 1, 2005, issue (page 28) gave incorrect options for Question 2, pertaining to the article "Prevention of Falls in Older Persons," on page 81. The correct answer to this rewritten question is A. Multifactorial risk assessment and management. The question is reprinted below and the online version has been corrected. n
Q2. Which one of the following is the most effective strategy for preventing falls?
A. Multifactorial risk assessment and
management.
B. Cognitive behavioral approaches.
C. Massage therapy.
D. Use of specific shoes.
Send letters to Kenny Lin, M.D., Assistant Editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent (on disk) to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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