Clinic: Chironex sp., Chiropsalmus sp.

Examine for venom effects

Autopharmacological and allergic effects

• Nausea, vomiting, abdominal pain, diarrhoea,
• urtitcaria, angio-oedema,
• bronchospasm,
• arterial hypotension, shock (cause: systemic allergic reactions).

Local Effects

Skin

• Acute, within minuty painful linear or blotchy urticarial or papulovesicular skin lesions with typical ladder-like "cross-hatching pattern"  (see 'Morphological characteristics'),
• erythema,
• eye injury,
• acute vascular insufficiency distal to the sting,
• later: necrosis, ulceration.

Definition of a "major sting"

Decreased consciousness and/or >50% of an extremity affected.

Eyes

• Pain,
• conjunctival congestion,
• chemosis,
• corneal oedema,
• iridocyclitis.

Neurological effects

Current understanding is that cardiac effects are the main cause of systemic envenoming. However, there may also be neurotoxic effects involved. The mechanism of action of the venom components that may cause neurological effects is unclear.

Cardiac effects

With "major stings", cardiovascular failure may occur within minutes.

• Bradycardia, tachycardia, arrhythmias
• Arterial hypotension
• Myocardial failure, cardiogenic shock

Laboratory and physical investigations

ECG
Tachycardia, arrhythmias (Beadnell et al. 1992).
Scrapings of the skin
Identification of Chironex fleckeri envenoming by nematocyst recovery from skin (Currie and Wood 1995).
ELISA
Within a few days after the sting, specific IgG antibodies are formed that persist for many months. The species of jellyfish that caused the sting can be identified retrospectively using antibody detection with an ELISA test. However, there are problems with specificity (Burnett et al. 1988a). 

Species-specific envenoming pattern

The assessment of the envenoming pattern is based on the data from publication in which the identification of the snakes is clearly specified and in accordance with accepted criteria. 

Chironex sp.

General

The mechanism of action underlying Chironex fleckeri envenoming remain largely unknown for pain, respiratory failure, cardiotoxicity (autopsies reveal pulmonary oedema suggesting a cardiac death), blood pressure changes; for urticaria and scaring pore-forming toxins are proposed (D’Ambra et al. 2020, Piontek et al. 2020, Tibbals 2006).

¹Autopharmacological and allergic effects

Anaphylactic reactions, in particular anaphylactic shock, may be difficult to distinguish in differential diagnostic terms from systemic toxic effects (Tibballs 2006; Tibballs et al. 2011).
As in other cnidarian skin contact, delayed hypersensitivity is observed in survivors (O'Reilly et al. 2001; Tibballs et al. 2011). Itchy red maculopapular rash dotted along the initial tentacle contact points consistent with urticaria occurring 7-14 days after envenoming.

²Local effects

Immediate pain varying in intensity from mild to very severe, unbearable sharp or burning pain, the latter being a characteristic of box jellyfish stings. Multiple whip-like wheals on the skin or a “frosted ladder pattern” suggest a sting by a boxjellyfish corresponding to the transverse bands on the tentacles. The colour is red, purple or brown. The skin lesions pass through a blister stage then develop into necroses that affect the entire thickness of the skin. Scars, possibly also keloid scars (Barnes 1960, Bengston et al. 1991, Hartwig et al. 1980, O'Reilly et al. 2001, Strutton and Lumley 1988, ANZCOR Guidelines ‘Guideline 9.4.5 - First Aid Management of Marine Envenomation’). Paralysis of the ulnar nerve after tentacle contact in the region of the superficial course of the nerve on the elbow has been observed (Laing and Harrison 1991). Rare and unclear pathogenic mechanism: Acute regional vascular insufficiency in the affected extremity (Abu-Nema et al. 1988, Adiga 1984, Drury et al. 1980, Williamson et al. 1988).

Eye injury

Most stings affecting the eyes described to date were painful injuries with conjunctival congestion, chemosis, corneal oedema and mild iridocyclitis that resolved on their own or with local treatment within 48 h. However, there have also been reports of iritis, chronic unilateral glaucoma, mydriasis, accommodation disturbances, peripheral anterior synechia, iris depigmentation and blurred vision (Glasser et al. 1992, 1993, Mitchell 1962, Rapoza et al. 1986, Wong and Matoba 1985).

³Neurological effects

Current understanding is that cardiac effects are the main cause of systemic envenoming. However, there may also be neurotoxic effects involved. The mechanism of action of the venom components that may cause neurological effects is unclear.
Respiratory insufficiency/respiratory failure, and respiratory arrest (current understanding is that respiratory failure is most likely due to heart failure).
Severely bloated abdomen, urinary retention, erectile dysfunction, unchanged R-R interval on ECG during inspiration and expiration as well as carotid sinus massage.
Signs of respiratory insufficiency/respiratory failure, and respiratory arrest occur within minutes after severe envenoming (Lumley et al. 1988).
Parasympathetic effects are observed (Chand and Selliah 1984).

⁴Cardiac effects

• Hypertension followed by hypotension, tachycardia, arrhythmia, cardiac failure,
• physical collapse,
• difficulty or cessation of breathing (most likely secondary to heart failure),
• cardiac arrest.

Current understanding is that cardiac venom effects are the main cause of severe and fatal envenoming with impaired cardiac contraction, hypertension followed by hypotension, tachycardia, arrhythmias and decreased coronary flow , and cardiac failure occurring within minutes of the sting (e.g., Bengston et al. 1991, Beadnell et al. 1992, Lumley et al. 1988, Currie and Jacups 2005, Anziani Vente et al. 2022; see also ‘General’ above).
E.g., Anziani Vente et al. (2022) report on two children of which one felt intense burning pain on his legs while swimming in shallow waters. He immediately left the water and went into cardiac arrest with successful cardiopulmonary resuscitation.
The mechanism of action is, however, unclear (Piontek et al. 2020); mostly likely a direct effect of the venom on myocardial cells (Seymour et al. 2020). ANZCOR Guidelines ‘Guideline 9.4.5 - First Aid Management of Marine Envenomation’

Other signs & symptoms

Profuse sweating, sometimes only in the sting area.
Nausea and vomiting. 
Headache, restlessness and irrational behaviour. 
Generalised muscle pain; severe muscle cramps in the limbs, chest and abdomen.

Morbidity

Delayed hypersensitivity reactions (see above; O'Reilly et al. 2001).
Scarring and keloid formation after healing of the skin lesions.

Case fatality rate

Williamson et al. reported 1980 at least 55 confirmed fatalities in the Indo-Pacific region since 1884, 40 of which occurred in northern Australia (Williamson et al. 1980).
More recent data report overall 77 deaths in Australia. 

 Species-specific publications: see ‘References’ at the end of the file. 

Clinical management

See also Clinical Management: cnidarians

for advice on diagnosis (clinical, laboratory) and treatment (supportive, antivenom).

First Aid Measures for Jellyfish stings

The Cochrane review of 2023 came to the following conclusion (McGee et al. 2023):

“For people with symptoms and signs of jellyfish stings, and their first responders or treating clinicians, treatment will depend on the species of jellyfish, as the stings from different species produce symptoms of varying severity. However, we cannot be certain which is the best treatment for any species of jellyfish. Although our evidence was very uncertain, the data from the included studies evaluating heat application after non-box jellyfish stings in Australia and Hawaii are consistent with the ARC 2010 guideline, which suggests starting treatment with heat after stings in non-tropical Australia. We have found no evidence to refute heat application for non-box jellyfish stings in non-tropical Australia. For box jellyfish envenomation, the evidence is more limited, but both the ARC 2010 and ILSF 2000 guidelines recommend the application of vinegar to inactivate the nematocyst. Our review did not find sufficient evidence to support these recommendations, but the recommendations are consistent with evidence from in vitro studies (Yanagihara 2017)”. 

The review of Cunha et al. (2022) came by and large to the same conclusions: The first aid and treatment recommendation are based on individual cases and cases series and expert opinion.
Pek et al. (2025) conclude in their systematic review “There were very few studies and a significant risk of bias and heterogeneity, leading to very low-quality evidence on first aid treatment for jellyfish stings.”
Yanagihara et al. (2025) publishedadditional experimental observations.

The current uncertainty of recommendations is also reflected in the accompanying document ‘Research on Jellyfish Stings’ of the 2025 version of the ANZCOR Guidelines ‘Guideline 9.4.5 - First Aid Management of Marine Envenomation’

The ANZCOR Guidelines emphasize:
“The most important part of first aid for a potentially fatal jellyfish sting is to watch for cardiac arrest, treat with CPR (Refer to ANZCOR Guideline 8) if this occurs, and expedite transfer to definitive care including antivenom.”

Due to the high regional diversity of jellyfish, the unpredictable dynamics caused by global warming and the uncertainty of the evidence base for the various recommendations, we refer to regional/national guidelines. We recommend to follow-up developments of the evidence carefully.

Local treatment

• Pain control
• Wound management
  Tetanus prophylaxis
  Standard wound care (WHO 2010) 
• Eye injury
  Most stings affecting the eyes described to date were painful injuries with conjunctival congestion, chemosis, corneal oedema and mild iridocyclitis that resolved on their own or with local treatment within 48 h. However, there have also been reports of iritis, chronic unilateral glaucoma, mydriasis, accommodation disturbances, peripheral anterior synechia, iris depigmentation and blurred vision (Glasser et al. 1992, 1993, Mitchell 1962, Rapoza et al. 1986, Wong and Matoba 1985).

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

• Comprehensive ABCDE approach

• ICRC Basic Emergency Care: approach to the acutely ill and injured (SAMPLE  and ABCDE approach: first module)

Obey chironex sp., Chiropsalmus sp. - specific features

see 'Species-specific envenoming pattern above'. 

Key issues

Supportive treatment is lifesaving

Cardiocascular failure 

• Cardiovascular management

ABCDE-approch is lifesaving as supportive treatment until the antivenom applied acts or when antivenom is not available or fails. 

IMPORTANT
Cnidarian venoms are (thermo-)labile. It is assumed that they lose their activity within 15–20 min after absorption into the tissue or the blood circulation. Thus even if pharmacological /antivenom treatment fail, treatment success may still be possible if there are optimal resuscitation conditions. The patient's condition may deteriorate again after a temporary improvement of the circulatory condition due to renewed mobilisation of venom from the periphery (Williamson et al. 1984b).

Respiratory failure

• Airway management

• Breathing: Oxygen ⇨ assisted ventilation ⇨ mechanical ventilation

ABCDE-approch is lifesaving as supportive treatment until the antivenom applied acts or when antivenom is not available or fails.

Very rare

• acute regional vascular insufficiency distal to the sting (?).

Specific treatment (antivenoms)

Box jellyfish (Chironex fleckeri)

BOX JELLYFISH ANTIVENOM (AUST R 74891)(CSL, Parkville, Australia).

Efficacy
The efficacy is debated (e.g., Winter et al. 2009, Andreosso et al. 2014, Piontek et al. 2020).
Experience from treatment of individual cases:
Antivenom administration by trained ambulance personnel
The fact that the antivenom most probably only neutralises the lethal components of the venom if given immediately after the sting led to considerations regarding how to administer antivenom as quickly as possible on the beach. Thus, ambulance personnel were trained to administer antivenom and have already used this knowledge a number of times with success (Beadnell et al. 1992, Fenner et al. 1989).

Research is ongoing to identify venom mechanisms of actions and effective venom antidotes (Lau et al. 2019).

References

Reviews

• D'Ambra I, Lauritano C. A Review of Toxins from Cnidaria. Mar Drugs. 2020 Oct 6;18(10):507. PMID: 33036158; PMCID: PMC7600780. https://doi.org/10.3390/md18100507 
• Cegolon L, Heymann WC, Lange JH, Mastrangelo G. Jellyfish stings and their management: a review. Mar Drugs. 2013 Feb 22;11(2):523-50. PMID: 23434796; PMCID: PMC3640396. https://doi.org/10.3390/md11020523
• Cunha SA, Dinis-Oliveira RJ. Raising Awareness on the Clinical and Forensic Aspects of Jellyfish Stings: A Worldwide Increasing Threat. Int J Environ Res Public Health. 2022 Jul 10;19(14):8430. PMID: 35886286; PMCID: PMC9324653. https://doi.org/10.3390/ijerph19148430
• McGee RG, Webster AC, Lewis SR, Welsford M. Interventions for the symptoms and signs resulting from jellyfish stings. Cochrane Database Syst Rev. 2023 Jun 5;6(6):CD009688. PMID: 37272501; PMCID: PMC10240560. https://doi.org/10.1002/14651858.CD009688.pub3
• Pek JH, Lim SH, Ong GY, Djarv T, Douma M, Welsford M, Charlton NP. First Aid Treatment of Jellyfish Stings: A Systematic Review. Cureus. 2025 May 17;17(5):e84289. PMID: 40525026; PMCID: PMC12169498. https://doi.org/10.7759/cureus.84289

• Premmaneesakul H, Sithisarankul P. Toxic jellyfish in Thailand. Int Marit Health. 2019;70(1):22-26. PMID: 30931514. https://doi.org/10.5603/imh.2019.0004
• Tibbals J. Australian venomous jellyfish, envenomation syndromes, toxins and therapy. Toxicon. 2006 Dec 1;48(7):830-59. Epub 2006 Jul 15. PMID: 16928389. https://doi.org/10.1016/j.toxicon.2006.07.020
• Tibballs J, Yanagihara AA, Turner HC, Winkel K. Immunological and toxinological responses to jellyfish stings. Inflamm Allergy Drug Targets. 2011 Oct;10(5):438-46. PMID: 21824077; PMCID: PMC3773479. https://doi.org/10.2174/187152811797200650
• Ward NT, Darracq MA, Tomaszewski C, Clark RF. Evidence-based treatment of jellyfish stings in North America and Hawaii. Ann Emerg Med. 2012 Oct;60(4):399-414. Epub 2012 Jun 6. PMID: 22677532. https://doi.org/10.1016/j.annemergmed.2012.04.010

Images of tentacle prints

• Cunha SA, Dinis-Oliveira RJ. Raising Awareness on the Clinical and Forensic Aspects of Jellyfish Stings: A Worldwide Increasing Threat. Int J Environ Res Public Health. 2022 Jul 10;19(14):8430. PMID: 35886286; PMCID: PMC9324653. https://doi.org/10.3390/ijerph19148430

Overviews on broad topics

• Lau MT, Manion J, Littleboy JB, Oyston L, Khuong TM, Wang QP, Nguyen DT, Hesselson D, Seymour JE, Neely GG. Molecular dissection of box jellyfish venom cytotoxicity highlights an effective venom antidote. Nat Commun. 2019 Apr 30;10(1):1655. PMID: 31040274; PMCID: PMC6491561. https://doi.org/10.1038/s41467-019-09681-1 
• Piontek M, Seymour JE, Wong Y, Gilstrom T, Potriquet J, Jennings E, Nimmo A, Miles JJ. The pathology of Chironex fleckeri venom and known biological mechanisms. Toxicon X. 2020 Feb 24;6:100026. PMID: 32550582; PMCID: PMC7285912. https://doi.org/10.1016/j.toxcx.2020.100026 

Internet links providing general clinical guidance

• WHO (2010) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139
• WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured (2018)  https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured
• WHO ABCDE Approach  https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2

Internet links providing specific information

ANZCOR Guidelines ‘Guideline 9.4.5 - First Aid Management of Marine Envenomation’

Original publications by species

Alatina alata (Hawaiian box jellyfish)

• Yanagihara AA, Uyehara CFT, Kadler R, Del Rio SN, Hurwitz K, Wilcox CL, Alimboyoguen AL, Saguil N, Reed MC, Barnhill J, Morrison B. Evidence-Based Management of Box Jellyfish Stings. Mil Med. 2025 Sep 1;190(Supplement_2):589-598. PMID: 40984166; PMCID: PMC12448702. https://doi.org/10.1093/milmed/usaf278

Chironex fleckeri

• Andreosso A, Smout MJ, Seymour JE.Dose and time dependence of box jellyfish antivenom. J Venom Anim Toxins Incl Trop Dis. 2014 Aug 12;20:34. PMID: 25161664; PMCID: PMC4144694. https://doi.org/10.1186/1678-9199-20-34 
• Anziani Vente A, Jaloux C, Morand JJ, LE Bel S, Bosdure E, Dubus JC, Morand A. Severe box jellyfish envenomation in 2 children. Travel Med Infect Dis. 2022 Jan-Feb;45:102217. Epub 2021 Dec 30. PMID: 34973452. https://doi.org/10.1016/j.tmaid.2021.102217 
• BARNES JH. Observations on jellyfish stingings in North Queensland. Med J Aust. 1960 Dec 24;47(2):993-9. PMID: 13687108. https://doi.org/10.5694/j.1326-5377.1960.tb24003.x 
• Beadnell CE, Rider TA, Williamson JA, Fenner PJ. Management of a major box jellyfish (Chironex fleckeri) sting. Lessons from the first minutes and hours. Med J Aust. 1992 May 4;156(9):655-8. PMID: 1352619. https://doi.org/10.5694/j.1326-5377.1992.tb121467.x 
• Chand, R. P., K. Selliah (1984) Reversible parasympathetic dysautonomia following stinging attributed to the box jelly fish (Chironex fleckeri) .Aust. N. Z. J. Med. 14: 673-675 
• Currie BJ, Wood YK. Identification of Chironex fleckeri envenomation by nematocyst recovery from skin. Med J Aust. 1995 May 1;162(9):478-80. PMID: 7746205. https://doi.org/10.5694/j.1326-5377.1995.tb140010.x 
• Currie BJ, Jacups SP. Prospective study of Chironex fleckeri and other box jellyfish stings in the "Top End" of Australia's Northern Territory. Med J Aust. 2005 Dec 5-19;183(11-12):631-6. PMID: 16336157. https://doi.org/10.5694/j.1326-5377.2005.tb00062.x 
• Hartwick R, Callanan V, Williamson J. Disarming the box-jellyfish: nematocyst inhibition in Chironex fleckeri. Med J Aust. 1980 Jan 12;1(1):15-20.PMID: 6102347. 
• Laing JH, Harrison DH. Envenomation by the box-jellyfish--an unusual cause of ulnar nerve palsy. J R Soc Med. 1991 Feb;84(2):115-6. PMID: 1671879; PMCID: PMC1293105. https://doi.org/10.1177/014107689108400222 
• Lumley J, Williamson JA, Fenner PJ, Burnett JW, Colquhoun DM. Fatal envenomation by Chironex fleckeri, the north Australian box jellyfish: the continuing search for lethal mechanisms. Med J Aust. 1988 May 16;148(10):527-34PMID: 2897074. https://doi.org/10.5694/j.1326-5377.1988.tb99466.x 
• O'Reilly GM, Isbister GK, Lawrie PM, Treston GT, Currie BJ. Prospective study of jellyfish stings from tropical Australia, including the major box jellyfish Chironex fleckeri. Med J Aust. 2001 Dec 3-17;175(11-12):652-5. PMID: 11837877. https://doi.org/10.5694/j.1326-5377.2001.tb143765.x 
• Seymour J, Saggiomo S, Lam W, Pereira P, Little M. Non-invasive assessment of the cardiac effects of Chironex fleckeri and Carukia barnesi venoms in mice, using pulse wave doppler. Toxicon. 2020 Oct 15;185:15-25. Epub 2020 Jun 29. PMID: 32615183. https://doi.org/10.1016/j.toxicon.2020.06.018 
• Strutton G, Lumley J. Cutaneous light microscopic and ultrastructural changes in a fatal case of jellyfish envenomation. J Cutan Pathol. 1988 Aug;15(4):249-55. PMID: 2903186. https://doi.org/10.1111/j.1600-0560.1988.tb00554.x 
• Williamson JA, Callanan VI, Hartwick RF.Serious envenomation by the Northern Australian box-jellyfish (Chironex fleckeri). Med J Aust. 1980 Jan 12;1(1):13-6. PMID: 6102346. https://doi.org/10.5694/j.1326-5377.1980.tb134565.x 
• Winter KL, Isbister GK, Jacoby T, Seymour JE, Hodgson WC.An in vivo comparison of the efficacy of CSL box jellyfish antivenom with antibodies raised against nematocyst-derived Chironex fleckeri venom. Toxicol Lett. 2009 Jun 1;187(2):94-8. Epub 2009 Feb 20. PMID: 19429250. https://doi.org/10.1016/j.toxlet.2009.02.008 
• Yanagihara AA, Uyehara CFT, Kadler R, Del Rio SN, Hurwitz K, Wilcox CL, Alimboyoguen AL, Saguil N, Reed MC, Barnhill J, Morrison B. Evidence-Based Management of Box Jellyfish Stings. Mil Med. 2025 Sep 1;190(Supplement_2):589-598. PMID: 40984166; PMCID: PMC12448702. https://doi.org/10.1093/milmed/usaf278

Chiropsalmus sp.

• Bengtson K, Nichols MM, Schnadig V, Ellis MD.Sudden death in a child following jellyfish envenomation by Chiropsalmus quadrumanus. Case report and autopsy findings. JAMA. 1991 Sep 11;266(10):1404-6. Erratum in: JAMA 1991 Nov 27;266(20):2834. Bengston K [corrected to Bengtson K]. PMID: 1679136. https://doi.org/10.1001/jama.266.10.1404

Species-specific evidence

Chironex sp.,  Chiropsalmus sp., and other box jellyfish

Alatina sp.

Guadeloupe

• Bouyer-Monot D, Pelczar S, Ferracci S, Boucaud-Maitre D. Retrospective study of jellyfish envenomation in emergency wards in Guadeloupe between 2010 and 2016: When to diagnose Irukandji syndrome? Toxicon. 2017 Oct;137:73-77. Epub 2017 Jul 13. PMID: 28711467. https://doi.org/10.1016/j.toxicon.2017.07.011

 

Chironex fleckeri

Study

Australia

• O'Reilly et al. (2001) 
  Prospective study of patients (n=40) presenting with jellyfish stings at a teaching hospital in tropical Australia between August 1999 and July 2000. Identification (C. fleckeri): sticky tape sampling and microscopic identification of nematocysts (n=39). Presentations consistent with C. fleckeri  in 28 cases. Sticky tape sampling positive for C. fleckeri nematocysts in 23 cases. Nematocysts not detected in 10 cases. All microscopically confirmed C. fleckeri stings had typical clinical presentations.

Case reports (exemplary)

Criteria and scrutiny vary widely in the attribution of the culprit. It is advisable to always go back to the original sources cited. E.g., in the review of Cunha et al (2022), section Class Scyphozoa, it is stated „Lethal cases have been reported“. In the cited paper Kim et al (2022), the authors rather reported “Nemopilema nomurai was the suspected species of jellyfish encountered by the patient, although we are unable to confirm this.”

Australia

• Beadnell et al. (1992) 
  Identification: C. fleckeri; criteria: typical tentacle "prints" ("frosted ladder" pattern) on the skin.
• Boyd (1984)
  1 sting. Identification: C. fleckeri; criteria: typical tentacle "prints" ("frosted ladder" pattern) on the skin.
• Fenner et al (1989) 
  2 stings. Identification: C. fleckeri; criteria: typical tentacle "prints" ("frosted ladder" pattern) on the skin 2/2, tentacle adhering to the skin 1/2.
• Flecker (1952)
  1 sting. Identification: C. fleckeri (see also Williamson et al. 1980). 
• Horne 1988 
  1 sting. Identification: C. fleckeri; criteria: typical tentacle "prints" ("frosted ladder" pattern) on the skin; Chironex nematocysts.
• Kingston and Southcott (1960)
  2 stings. Identification: C. fleckeri or Chiropsalmus quadrigatus; criteria: nematocysts.
• Lumley et al. (1988)
  1 sting. Identification: C. fleckeri; criteria: typical tentacle "prints" ("frosted ladder" pattern) on the skin; Chironex nematocysts on the skin and in histological preparations.
• Maguire (1968)
  1 sting. Identification: C. fleckeri; criteria: typical tentacle "prints" ("frosted ladder" pattern) on the skin.
• Sutherland (1979)
  1 sting. Identification: C. fleckeri; criteria: typical tentacle "prints" ("frosted ladder" pattern) on the skin.
• Williamson et al. (1980)
  1 sting. Identification: C. fleckeri; criteria: typical tentacle "prints" ("frosted ladder" pattern) on the skin; tentacles adhering to the skin.
• Williamson et al. (1984)
  2 stings. Identification: C. fleckeri; criteria: typical tentacle "prints" ("frosted ladder" pattern) on the skin.

Thailand

• Vente et al. (2022)
  2 children. Identification: C. fleckeri; criteria: typical tentacle "prints" ("frosted ladder" pattern) on the skin. One child with cardiac arrest after leaving the water and successful cardiopulmonary resuscitation.
• Laing and Harrison (1991)
  1 sting. Identification: C. fleckeri; criteria: typical tentacle "prints" ("frosted ladder" pattern) on the skin.
• Thaikruea (2023)
  Dermatological effects 
• Thaikruea et al. (2015)
  Fatal and severe cases 

Chiropsalmus quadrumanus

Brazil

• Haddad et al. (2002)
  8 patients. Identification: confirmed and associated with C. quadrumanus.

USA 

Texas, Gulf of Mexico

• Bengtson et al. (1991)
  1 sting. Identification: nematocysts.

References

• Beadnell CE, Rider TA, Williamson JA, Fenner PJ. Management of a major box jellyfish (Chironex fleckeri) sting. Lessons from the first minutes and hours. Med J Aust. 1992 May 4;156(9):655-8. PMID: 1352619. https://doi.org/10.5694/j.1326-5377.1992.tb121467.x
• Bengtson K, Nichols MM, Schnadig V, Ellis MD.Sudden death in a child following jellyfish envenomation by Chiropsalmus quadrumanus. Case report and autopsy findings. JAMA. 1991 Sep 11;266(10):1404-6. Erratum in: JAMA 1991 Nov 27;266(20):2834. Bengston K [corrected to Bengtson K]. PMID: 1679136. https://doi.org/10.1001/jama.266.10.1404
• Boyd W. Sea-wasp antivenom in a toddler. Med J Aust. 1984 Apr 14;140(8):504. PMID: 6143242. https://doi.org/10.5694/j.1326-5377.1984.tb108191.x
• Fenner PJ, Williamson JA, Blenkin JA.Successful use of Chironex antivenom by members of the Queensland Ambulance Transport Brigade. Med J Aust. 1989 Dec 4-18;151(11-12):708-10.PMID: 2574410.
• FLECKER H. Fatal stings to North Queensland bathers. Med J Aust. 1952 Jan 12;1(2):35-8. PMID: 14909885. https://doi.org/10.5694/j.1326-5377.1952.tb83833.x
• Haddad V Jr, da Silveira FL, Cardoso JL, Morandini AC. A report of 49 cases of cnidarian envenoming from southeastern Brazilian coastal waters. Toxicon. 2002 Oct;40(10):1445-50. PMID: 12368114. https://doi.org/10.1016/s0041-0101(02)00162-9
• Kim JH, Han SB, Durey A. Fatal Pulmonary Edema in a Child After Jellyfish Stings in Korea. Wilderness Environ Med. 2018 Dec;29(4):527-530. Epub 2018 Oct 9. PMID: 30309824. https://doi.org/10.1016/j.wem.2018.07.002
• KINGSTON CW, SOUTHCOTT RV. Skin histopathology in fatal jellyfish stinging. Trans R Soc Trop Med Hyg. 1960 Jul;54:373-84. PMID: 14409218. https://doi.org/10.1016/0035-9203(60)90119-x
• Laing JH, Harrison DH. Envenomation by the box-jellyfish--an unusual cause of ulnar nerve palsy. J R Soc Med. 1991 Feb;84(2):115-6. PMID: 1671879; PMCID: PMC1293105. https://doi.org/10.1177/014107689108400222
• Lumley J, Williamson JA, Fenner PJ, Burnett JW, Colquhoun DM. Fatal envenomation by Chironex fleckeri, the north Australian box jellyfish: the continuing search for lethal mechanisms. Med J Aust. 1988 May 16;148(10):527-34. PMID: 2897074. https://doi.org/10.5694/j.1326-5377.1988.tb99466.x
• Maguire, E. J. (1968) Chironex fleckeri (“sea wasp”) sting.Med. J. Aust. 2: 1137-1138
• O'Reilly GM, Isbister GK, Lawrie PM, Treston GT, Currie BJ. Prospective study of jellyfish stings from tropical Australia, including the major box jellyfish Chironex fleckeri. Med J Aust. 2001 Dec 3-17;175(11-12):652-5. PMID: 11837877. https://doi.org/10.5694/j.1326-5377.2001.tb143765.x
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