Catfish spine envenomation: a case report and literature review

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1 Wilderness and Environmental Medicine, 10, (1999) CASE REPORT Catfish spine envenomation: a case report and literature review ANDRA L. BLOMKALNS, MD, EDWARD J. OTTEN, MD From the Department of Emergency Medicine. University of Cincinnati College of Medicine. Cincinnati. OH. Catfish spine envenomations are common injuries, reported in both freshwater and saltwater. Such injuries are complex puncture wounds, often complicated by severe infection. Signs and symptoms range from simple local pain and bleeding to systemic manifestations with hemodynamic compromise. Care and treatment involve aggressive pain management, judicious wound cleansing, prophylactic antibiotics, and close follow-up. A case of catfish spine envenomation from a freshwater catfish is presented here. Key words: Aridae, catfish, envenomation, freshwater, Ictaluridae, saltwater Introduction Catfish spine envenomation is a frequent cause of morbidity among freshwater and saltwater anglers. Although these injuries are intensely painful, most such envenomations heal without sequelae. Serious complications result mostly from soft- tissue infections from a variety of organisms not typically encountered in the emergency department. A case of a freshwater catfish (lctalurus punctatus) spine envenomation is presented here. A review of the physiology and therapeutic and preventive measures of catfish spine envenomations is presented. Case report A 40-year-old recreational fisherman presented to the emergency department 3 hr after sustaining an injury to his nondominant hand while trying to unhook a freshwater channel catfish (I punctatus). The spine was imbedded in the volar aspect of the hand, and after numerous failed attempts to shake the offending fish loose, the patient cut the spine with a pair of pliers at the level of the skin. He presented complaining of severe left hand pain, numbness to the elbow, and slight dizziness. Initial examination revealed a 4 X 3-mm foreign body imbedded in the soft tissues midway between the fourth and fifth metacarpal bones. Motor and sensory functions Direct correspondence to Department of Emergency Medicine, University of Cincinnati College of Medicine. 231 Bethesda Avenue. PO Box Cincinnati. OH (Dr Blomkalns). were grossly normal and capillary refill was preserved. A plain radiograph of the hand showed a 2-cm-Iong foreign body with dense circumferential cortex with numerous 1-2-mm retroflexed barbs projecting perpendicular to the shaft (Fig I). Treatment consisted of warm water immersion for 30 min, tetanus prophylaxis, pain management with meperidine/promethazine, and I g intravenous cefazolin. Due to initial inability to easily extract the spine, a plastic surgerylband consult was obtained. The spine was successfully removed after a protracted 3-hr attempt, with eventual core excision. The patient was discharged on a 7-day course of cephalexin 500 mg four times a day and 48-hr outpatient clinic follow-up, One-, two-, and four-week clinic follow-ups showed that the wound was healing well but slowly. Wound cultures obtained on initial presentation grew no organisms. No residual deficits in motor or sensory functions were noted. At a 6-month telephone follow-up, the patient reported that the hand had healed completely without loss of function or further symptoms. Discussion The venomous catfish belong to the class Osteichthyes, order Cypriniformes, suborder Siluroidei. There are a number of families of both freshwater and marine catfish that have been implicated in venomous injuries to humans (Table). The Ictaluridae and Aridae represent the predominant freshwater and saltwater families of North American catfishes, respectively. catfish gen-

2 Catfish spine envenomation 243 Fig 1. Radiograph of catfish spine imbedded in hand. Catfish implicated in venomous injuries to humans [11 Family Habitat Distribution Examples Aridae Bagridae Claridae Doradidae Heteropneustidae Ictaluridae. Pimelodidae Plotosidae Siluridae Marine Marine Worldwide Asia Indo-Pacific South America Asia North America South America Indo-Pacific Africa, Asia, Europe Sea catfish (USA) Akaza (Japan) Ikan Keli (Malaysia) Bagre (Amazon) Pia Cheet (Thailand) Madtom (USA) Bagre (Amazon) Oriental catfish (USA) European catfish

3 244 Blomkalns and Otten Fig 2. Photograph of saltwater catfish with exposed pectoral spine. erally inhabit slow, still, and often dirty waters. Saltwater catfish travel in large schools and are always moving. Both species are nonselective omnivores, which probably accounts for their high frequency of being caught. Size can vary anywhere from a few grams to 200 kg. Characteristic perioral barbels account for their name, and these, contrary to popular opinion, are harmless and incapable of envenomation [1]. Besides the venomous properties that make catfish dangerous to humans, there are species that are attracted to urine and may swim into the human urethra and become lodged, thereby necessitating surgical removal (Urinophilus, Amazon). Other Egyptian species can create an electric current on the surface of their bodies intense enough to cause a fatal electric shock in humans (Malapterus, Egypt) [1]. Catfish stings are not an uncommon hazard of both recreational and commercial fishing [2,3]. Of the some 1000 species of catfish in the world, most can inflict venomous stings through their dorsal and pectoral spines [1]. These stings, in addition to being inoculating puncture wounds, are true envenomations [4] and most often occur in the hands during attempts to unhook catfish or in the feet while wading [5]. These wounds require judicious care and symptomatic relief, prophylactic antibiotic administration, and reliable follow-up from the emergency department. The dorsal and pectoral fins are associated with most of the morbidity resulting from catfish encounters [6]. These fins have cartilaginous, serrated spines that are held erect when the catfish is disturbed [5,7] (Fig 2 and 3). Venom glands are enclosed in a delicate integumentary sheath, and they release their contents when traumatized. The venom causes a severe local inflammatory reaction [8], with erythema, edema, local hemorrhage, and tissue necrosis in excess of that caused by the wound alone. Other systemic symptoms may be present as well, including tachycardia, weakness, hypotension, nausea and vomiting, paresthesias, dizziness, loss of consciousness, and respiratory distress. The venom is a complex composition of hemolytic, dermonecrotic, edema-producing, and vasospastic factors whose potency is largely inversely proportional to fish size and is a defensive mechanism. Exact venom constituents vary from species to species. Saltwater and tropical species generally produce the worst symptoms and, often, the worst infections [9,10]. A second toxic mechanism, crinotoxicity, has been identified in some catfish species, namely Arius thalassinus and Plotatus lineatus [11,12]. Crinotoxins are pro-

$Catfish spine envenomation.-.:.; I.' ;, " ',' ;,\ " f. ;.,, " Fig 3. Dorsal spine of Galeichthys felis [1].$

4 Catfish spine envenomation.-.:.; I.' ;, " ',' ;,\ " f. ;.,, " Fig 3. Dorsal spine of Galeichthys felis [1]. teinacous substances found in the epidermal secretions coating the entire catfish body surface, not just the spines, and are released when the catfish is excited or threatened. If exposed to open skin, these toxins can cause similar symptoms of throbbing pain, tissue necrosis, and, possibly, muscle fasciculation [13,14]. The most serious long-term complications of catfish spine envenomations involve infections. Since catfishinflicted wounds are most often puncture wounds rather than lacerations [15], these injuries are essentially bacterial inoculums set up for infection. One series of case reports [16] reported serious infections requiring ray amputations in two patients; another [15] reported wound progression to dry gangrene, necessitating digit amputation. Organisms in many reports included Klebsiella, Erysipelothrix, Nocardia, Chromobacterium, Sporothrix, 245 Actinomyces, Edwardsiella, Mycobacterium, Aeromonas, and Vibrio [17,18]. It was noted that patients with predisposing illnesses and in immunocompromised states are especially susceptible to infections from Vibrio [19], The microbiologies of freshwater and saltwater infections differ greatly, but the most worrisome organisms are the Vibrio species for saltwater infections and Aeromonas for freshwater infections [9,10,20]. Aeromonas infections can look very much like typical streptococcal or staphylococcal cellulitis [21], but are resistant to penicillins and cephalosporins [22,23]. Empiric therapy against gram-negative rods is suggested, with ciprofloxacin being the single most popular and effective agent against freshwater and saltwater bacterial isolates [14,17,24], Aminoglycosides have been advocated by others. However, in the absence of serious bacterial infection, oral cephalosporins are advocated by some authors [18]. Treatment should begin with careful cleansing of the surrounding skin surface, Symptomatic measures should include local infiltration of a long-acting local anesthetic without epinephrine and regional blocks when feasible after a careful neurologic exam. As the venoms are all heat-labile to some degree, immersion of the affected extremity in warm water may be the most beneficial and expeditious symptomatic treatment measure, Water temperatures from at least 45 C (l13 F) to as hot as can be tolerated without scalding have been advocated [18], Effectiveness, patient tolerance, and the necessity to manipulate the hand for treatment should dictate total immersion time. Although not all catfish spines are reliably radio-opaque, radiographs to inspect for foreign bodies should be included in all cases. These films require careful and meticulous examination to visualize free tiny serrations [8,25] (Fig 1). Tetanus prophylaxis should be given when indicated [5,8], After reasonable pain management, attempts should be made to irrigate, explore, and debride the wound if evidence of a foreign body is present on a plain radiograph, keeping in mind that smaller spine components and epidermal fragments may not be present on the radiograph at all. Due to the structural nature of the spine, spine extraction and debridement can be difficult, as was the case with the presenting patient. The angled serrated edges prevent easy retrograde extraction and often remain behind if the spine is extracted using excessive force [25]. If gentle traction fails to produce an intact spine, circumferential excision in the operating room may be necessary [6]. Antibiotic management is somewhat controversial and depends on several factors: freshwater or saltwater, age and immune status of the victim, time from injury to presentation, and presence of a foreign body, It is the recommendation of the authors that all patients receive

5 246 a course of oral antibiotics. The chosen antibiotic should at least cover gram-negative rods, and ciprofloxacin [14] or another flouroquinolone seems to be among the most popular and reasonable choices [9,10]. Antibiotic treatment should provide coverage for Aeromonas species in freshwater envenomations and Vibrio species in saltwater envenomations, respectively. Wound follow-up should be arranged within I week, or sooner if signs of infection are present. Patients with systemic signs and symptoms suggesting infection should be admitted for intravenous antibiotics [24]. Wound culture is indicated if initial treatment measures fail. Specialized culture media may be necessary in cases of suspected marine, halophilic organisms. Retained foreign body in wounds should be suspected with worsening erythema, drainage, pain, swelling, or cyanosis. Live or dead catfish are best handled carefully to avoid accidental encounters with spines. Gloves, while not foolproof, are suggested. One suggested method involves rubbing the fish's belly to "put it to sleep" and then gently grasping the fish in an anterior-to-posterior direction so that the erect dorsal spine fits safely between the second and third digits. A variety of commercial catfish-handling devices are available and are of questionable assistance. Barefoot wading, particularly in slowmoving waters, should be discouraged. Superficial scratches and lacerations can be washed with antibacterial soap, dressed with antibiotic ointment, and observed. Wounds that are more serious should be treated as described above. Acknowledgment The authors thank Andris Blomkalns for his cooperation, support, and photographic expertise. References 1. Halstead BW. Vertebrates, Class Osteichthyes. In: Halstead BW, Halstead LG, eds. Poisonous and Venomous Marine Animals ofthe World Revised Edition. Princeton, NJ: Darwin Press, Inc; 1978: Fredette SR, Derk FF, Nardozza AJ. Catfish spine injury of the foot. JAm Podiatr Med Assoc. 1997;87: Burnett JW, Calton GJ, Morgan RJ. Catfish poisoning. Cutis. 1985;35: Schultz KE. Dangerous marine organisms. In: Kravis, Warner, eds. Emergency Medicine: A Comprehensive Review. Rockville, MD: Aspen Publishing; 1983: Scoggin CH. Catfish stings. JAMA. 1975;231: Helm T. Dangerous Sea Creatures-A Complete Guide to Blomkalns and Otten Hazardous Marine Life. New York, NY: Funk and Wagnalls; 1976: Minton SA Jr. Venom Diseases. Springfield, IL: Charles C Thomas; 1974: Zeman MG. Catfish stings: A report of three cases. Ann Emerg Med. 1989;18: Auerbach PS, Yajko DM, Nassos PS, Kizer KW, Morris JA, Hadley WK. Bacteriology of the freshwater environment: Implications for clinical therapy. Ann Emerg Med. 1987;16: Auerbach PS, Yajko DM, Nassos PS, et al. Bacteriology of the marine environment: Implications for clinical therapy. Ann Emerg Med. 1987;16: Shiomi K, Takarnija M, Yamanaka H, Kikuchi T, Sizuki y. Toxins in the skin secretion of the oriental catfish (Plotosus lineatus): Immunological properties and immunochemical identification of producing cells. Toxicon. 1988; 26: AI-Hasson JM, Thomson M, Ali M, et al. Vasoconstrictor components in the Arabian Gulf catfish (Arius thalassinus) proteinaceous skin secretion. Toxicon. 1986;24: Shepherd S, Thomas SH, Stone K. Catfish envenomation. J Wild Med. 1994;5: Das SK, Johnson MB, Cohly HHP. Catfish stings in Mississippi. South Med J. 1995;88: Mann JW, Werntz JR. Catfish stings to the hand. J Hand Surg. 1991;16A: Baack BR, Kucan JO, Zook EG, Russell RC. Hand infections secondary to catfish spines: Case reports and literature review. J Trauma. 1991;31: Penman AD, Lanier DC, Avara WT, et al. Vibrio vulnificus wound infections from Mississippi Gulf Coast waters: June to August South Med J. 1995;88: Murphey DK, Septimus EJ, Waagner DC. Catfish-related injury and infection: Report of two cases and review of the literature. Clin Infect Dis. 1992;14: Bonner JR, Coker AS, Berryman CR, Pollock MH. Spectrum of Vibrio infections in a Gulf Coast community. Ann Intern Med. 1983;99: Mathur MN, Patrick WG, Unsworth Ip, Bennett FM. Cellulitis owing to Aeromonas hydrophila: Treatment with hyperbaric oxygen. Aust N Z J Surg. 1995;65: Grenga TE. Catfish spine envenomation of the hand. J Hand Surg. 1989;14: Katz D, Smith H. Aeromonas hydrophila of a puncture wound. Ann Emerg Med. 1980;9: Hanson PG, Standridge J, Jarrett F, Maki DG. wound infection due to Aeromonas hydrophila. JAMA. 1977;238: Caudell MJ, Kuhn WE Aeromonas hydrophila soft-tissue infection: A report of two cases. Acad Emerg Med. 1997; 4: Howard RI, Burgess GH. Surgical hazards posed by marine and freshwater animals in Florida. Am J Surg. 1993; 166:

What is a wound? An injury to the skin and some times other deeper soft tissues. Types:

1 Dr. Samer Sara What is a wound? An injury to the skin and some times other deeper soft tissues. Types: Open wounds: Skin is torn or cut, often leads to bleeding. Closed wounds: Skin is not affected and