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Am Fam Physician. 2006;73(3):391

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

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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