Stingray Envenomation of the Foot: A case report
by Al Kline, DPM1
The Foot & Ankle Journal 1 (6): 4
Stingrays are docile marine animals that only strike their victim when provoked or startled. Lower extremity and foot envenomation is common when fishing in shallow waters off the beach. The stingray tail has a sharp, serrated barb along the proximal third of the tail that is usually hidden and encased in an integumentary sheath and can deliver painful enzymes causing tissue necrosis. Immediate treatment including rapid cleansing and heat submersion of the foot is recommended after injury. If treatment is delayed, infection from marine bacteria often requires hospitalization including intravenous antibiotics and surgical treatment.
Key words: Stingray envenomation
This is an Open Access article distributed under the terms of the Creative Commons Attribution License. It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)
Accepted: May 2008
Published: June 2008
ISSN 1941-6806
doi: 10.3827/faoj.2008.0106.0004
Stingray envenomation of the foot is a common marine injury. There is an estimated 1500 stingray injuries reported annually in the United States. [1] Usually, a person will be fishing in shallow water and accidentally step on the stingray. This causes an instinctive, defense mechanism of the stingray. The tail will lash upward like a scorpion and penetrate a sharp bard in the lower extremity or foot. The stingray tail has a sharp, serrated barb along the proximal third of the tail that is usually hidden and encased in an integumentary sheath. The stinger barb is made of cartilage and the serrations are directed proximally.
This means, that as the barb penetrates, the barb can rip tissue or even lacerate tendons, ligaments and other soft tissue as it pulls away from the puncture site. (Fig. 1) The integumentary sheath that encases the barb also contains a venomous protein that is released into a wound when the barb strikes and the sheath ruptures. This will cause intense pain and tissue necrosis. The barb can remain or break off in the wound. Fortunately, this only occurs in about 5% of reported cases. [2,6]
Figure 1 The serrated stingray barb. The barb is encased in an integumentary sheath. The serrated spines are directed proximally and can cause extensive tissue damage when pulled from a wound.
Envenomation occurs in up to 75% of reported stingray injuries. [6] The stingray venom contains the neurotransmitter serotonin and two enzymes; 5-nucleotidase, and phosphodiesterase. [2] Serotonin is responsible for the intense pain associated with the sting and the 5-nucleotidase and phosphodiesterase enzymes cause intense tissue necrosis.
Fatal envenomation is extremely rare and has recently come to light due to the death of “The Crocodile Hunter”, Steve Irwin, on September 4th, 2006. Steve Irwin was snorkeling in water and swam close to an Australian bull ray. (Fig. 2) The ray was startled and lashed its tail upward and pierced Steve Irwin’s heart. He died shortly after pulling the barb from his chest. It was reported at that time that only three fatal envenomations in Australia’s history had been reported before Irwin’s death.
Figure 2 The Australian bull ray or Southern eagle ray (Myliobatis australis).
Interestingly, one month later in October 2006, James Bertikas from Florida was stung by a ray as the barb also pierced his heart. However, he did not remove the barb, and survived his injury. In his case, a 2 ½ inch barb penetrated his left lung and migrated into his heart crossing both the left and right ventricle. [8] Most deaths occur from the actual laceration of a major artery or organ such as the heart from the barb and not the venomous effects.
However, in one report, a 12 year old boy died after envenomation from a freak accident when an ‘airborne’ ray slammed against his chest penetrating the barb into the boys left lung and piercing the pericardium.
The boy was relatively asymptomatic and initially treated for a puncture wound to the chest and knee, but he died six days later from sequestered venom and myocardial necrosis causing right ventricular rupture and fatal cardiac tamponade. [2,6] Another reported case involved a man who sustained a laceration to his femoral artery and bled to death. [2] In most cases, stingray injuries are not life-threatening, but can cause long-term complications. In one report, osteomyelitis of the malleolus resulted from an ankle strike seven months after injury. [6]
The effects of envenomation are not clearly understood as to reported systemic effects. Common reported symptoms can include diaphoresis, nausea, cardiac arrhythmias,tremors, skin rash, headache,delirium, fever, hypertension, syncope, anxiety and a host of other common allergic reactions.
Another complication from injury is the seawater and bacteria that can enter a wound on penetration during this injury.
We present the case of a 31 year old male who stepped on a stingray while fishing. He delayed initial treatment, continued to fish and developed cellulitis with a painful foot which required hospitalization and surgical treatment.
Case Report
A 31 year-old male presented to the emergency room with a hot, swollen foot. He was fishing in shallow water the day before and was stung by a stingray. He felt a sharp pain to the top of his foot. He continued to fish most of the day. In the evening, his foot swelling and pain got progressively worse. His wife went to the internet and realized that submerging the foot in hot water would eliminate the pain. He submerged the foot in water and his pain dissipated that evening. In the morning, he had a progressive increase in pain and presented to the emergency room for treatment.
Clinical evaluation revealed a small puncture wound to the dorsolateral aspect of the right foot. (Fig. 3) There was increased soft tissue swelling with slight tissue crepitus. His laboratory data revealed a 16,000 white count with a left shift. Routine radiographic evaluation showed an area of gas in the region of the puncture wound, but no sign of barb. (Fig. 4)
Figure 3 A small puncture wound is see to the dorsolateral aspect of the foot consistent with a stingray envenomation. The central puncture wound will have signs of tissue necrosis.
Figure 4 Radiographic evaluation reveals soft tissue gas formation in the subcutaneous tissues of the dorsal foot. No barb is seen on radiograph.
It was recommended he go directly to the operating room for incision and drainage with exploration of the wound.
Surgical exploration revealed soft tissue necrosis through the subcutaneous layer from the initial envenomation. All soft tissue was removed and sent for deep tissue culture. Some local debris was flushed from the wound, but no barb was located. The wound was thoroughly irrigated with Betadine solution and Bacitracin irrigation. The wound was then loosely packed and the edges of the incision were loosely approximated. (Fig. 5)
Figure 5 It is important to open the puncture site and remove any necrotic tissue and explore for foreign material that may cause continued infection. Necrotic tissue is removed, the edges of the wound can be loosely approximated and the central injury point may granulate and heal by secondary intention.
Tissue cultures revealed Staphylococcus aureus. He was placed on IV Levaquin. His initial infection took about a week to resolve and he was discharged from the hospital. He continued local wound care and within 2 weeks of his injury, the wound closed. (Fig. 6)
Figure 6 The wound is now closed and the patient has returned to work without incident.
Discussion
It is important to initially submerge the foot into hot water after the incident. Rapid application of heat will denature the enzymes causing the pain and limit the effects of tissue necrosis. It is recommended that immediate submersion into hot, but not scalding, water will also help to ease the pain of this injury.
It is recommended to submerge the foot into a water temperature of 42 to 45 degrees Celsius (108-113 degrees Fahrenheit) for 30 to 90 minutes, or until the pain resolves. [3] Infection of the wound can usually be avoided with aggressive wound cleansing and oral antibiotics.
In cases where cellulites results in delayed treatment or is not responsive to oral antibiotics, hospitalization and intravenous antibiotics is recommended. The most common pathogens to infect the wound include Staphylococcus aureus and streptococcus species. Water-borne pathogens of concern include Vibrios vulnificans in salt water and Aeromonas species in fresh water.
In more serious lacerations, it is important to immediately control hemorrhage from the laceration by applying direct pressure to the wound. Applying a tourniquet to the extremity is not recommended because swelling and systemic effects are rare in extremity wounds. [2] The wound should always be cleansed thoroughly with an antibacterial wound cleanser immediately after injury. Hexachlorophene in 70% alcohol (pHisoHex®) or Betadine solution will provide good antibacterial cleansing of the wound. [6]
Although there is no antidote or anti-venom , it has also been reported that direct injection of 1% lignocaine (or lidocaine) may have an anti-venomous affect to the venom that remains in the wound. [6] If the patient presents some time after injury to the emergency room with a hot, swollen foot, it is important to incise and open the puncture site, even if no barb is present. Intravenous antibiotic therapy is recommended until the cellulites has resolved. Hyperbaric oxygen in the treatment of stingray envenomation has also proved to be beneficial. [4]
Tetanus prophylaxis should also be current. Levofloxin or Levaquin is the drug of choice against Vibrio species and will cover Staphylococcus aureus and multi-drug, gram-negative organisms common to penetration injuries. Bactrim and Doxycyline are also good against Vibrio species, although the coverage is not as good for staph and strep species. [3]
Of course, antibiotic treatment can be tailored to the results of deep tissue samples taken at time of surgery to determine the infective organism. At time of surgery, it is recommended to inspect the wound for foreign material, remove any necrotic tissue, take deep tissue biopsy for culture and leave the wound packed open. Packing can include Betadine gauze or calcium alginate. Calcium alginate dressing or Kaltostat® has been reported to absorb toxin in one report. [7]
Conclusion
Stingrays belong the the class Chondrichthyes meaning cartilaginous fishes. These are usually docile creatures that only strike when provoked or feel threatened. In this case, medical treatment after initial injury was delayed which required surgical treatment and prolonged hospitalization. The delay in initial treatment caused progressive tissue necrosis and secondary infection after injury.
It is important to treat these injuries promptly. If the injury is not life-threatening, it is important to quickly cleanse the wound and submerge the foot in hot water to deactivate the tissue enzymes that cause pain and tissue necrosis. Ideally, medical treatment will consist of radiographs to eliminate the possibility of a barb that may remain in the wound. In the emergency room setting, the wound can be injected with 1% lidocaine and lanced at the puncture site. The wound should then be aggressively irrigated with Betadine. A calcium alginate dressing can then be applied to the open wound and allowed to heal by secondary intention. Oral antibiotics with coverage for gram positive and negative organisms are prescribed at discharge.
References
1. Perkins, A.R., Morgan, S.S.: Poisoning, Envenomation and Trauma from Marine Creatures. American Family Physician, February, 2004 [Online]
2. Ganard, S. Stingray Injuries, Envenomation, and Medical Mangement. [Online article]
3. Meade, J.L. Stingray Envenomations, Emedicine article [Online]
4. Rocca, A.F. Hyperbaric Oxygen Therapy in the treatment of soft tissue necrosis resulting from a stingray puncture wound. Foot Ankle Int. 22 (4): 318-323, April 2001. [PubMed]
5. Perkins, A.R., Morgan, S.S.: Poisoning, Envenomation and Trauma from Marine Creatures. American Family Physician, February, 2004 [Online]
6. Fenner, P.J. et al: Fatal and Non-Fatal Stingray Envenomation. Med Journal Australia : 151:621-625. 1989. [PDF]
7. Fenner, P.J.: Stingray Envenomation: A Suggested New Treatment. Med Journal Australia: 163: 665. 1995 [PDF]
8. St. Petersburg Times [Online news wire], October, 2006.
Address correspondence to: Dr. Al Kline, DPM, 3130 South Alameda, Corpus Christi, Texas 78404. E-mail: al@kline.net
1Adjunct Clinical Faculty, Barry University School of Podiatric Medicine. Private practice, Chief of Podiatry, Doctors Regional Medical Center. Corpus Christi, Texas, 78411.
© The Foot & Ankle Journal, 2008
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Yo Al-
Loved the piece. As I am a frequent surf fisher this is of great interest to me.
Rev. Bailey
June 1, 2008 at 9:26 pm
Very interesting facts since my better half is now undergoing medical treatment for a sting on the side of her foot! The scratch 1 inch away is now the problem as it has blistered and may now be nercrotic! In Huatulco her foot was not submersed in hot water at all but was flushed with peroxide, administered a pain releif about 45 min, later and antibiotics administered twice daily with pills in addition for the weeks stay. Now she is on IV drip for administering antibiotics here and samples of the tissue and blood are going to tell the rest of the story, and I hope it is for the best!
cliff
March 17, 2009 at 8:22 pm
It should be noted that the StingRay was aggresive in its attempt to sting Cathy! I have not found any evidence to suggest that they will attack but if startled will swim or sting! This Ray appeared to keep coming after Cathy and while she was avoiding the other Rays in the shallows it managed to sting her! Is this a breeding time or something where it was protecting young? It did happen to be near where a river/drainage outlet was situated from a sewage treatment plant which may explain warmer water and the abundance of these Rays there?
The treatment seems unsuccessful with the wound and area becoming sorer! The real culprit to all this may have been contamination in the water that entered the scratch as the penetration wound has all but healed, The docters may be treating for the wrong thing! Time will tell if time doesn’t make it worse to the point that the onset of the infection calls for more tissue removal!
cliff prystie
March 19, 2009 at 6:16 am
We have a local stingray sanctuary at our Aquarium. I suspect that rays are very territorial. I have seen this type of behavior when rays are in groups.
Al Kline DPM
May 9, 2009 at 9:01 am
I go to surgery thursday for a stingray attack that occurred on 4/13/09 while I was on vacation. It was not cleaned at all in the er, I was put on doxycycline and given a tetanus shot. I went to the er where I live on 4/16/09. It was obviously infected. I was put on bactrim ds. The wound was not opened and cleaned. I have some pretty gnarly pics. The barb went through my leg right above my ankle and then back out. After the incision and debridement the doc told me a skin graft will have to be done because you can see the tendon (the sheath has partially liquified) and the muscles. the hole is too big to close itself. aaarrrrggghhh. I am SO tired of this.
stacy
May 5, 2009 at 5:38 pm
Stacy,
Sorry to hear of your ordeal. Feel free to post your photos with us. You can send your pictures JPEG files to picomstaff@hotmail.com. I’ll then upload them to this page. Keep us informed on your outcome.
Al Kline DPM
May 6, 2009 at 7:06 am
Well, I went to the or today. The dr said that the tendon that moves my foot sideways (didn’t say the name, anyone know?) was dead and he had to remove it. He was very upset that it had never been debrided and says that is why the tendon died and the healing was so delayed. I am 100% non weight bearing at this time so it can heal. I go back to the wound care center tomorrow so they can check it. He said I will still need a skin graft. stay tuned……
stacy
May 7, 2009 at 5:10 pm
I have posted Stacy’s pictures of her injury. Feel free to comment here on what you think. Could this have been managed differently?
Stingray Injury Picture #1
Stingray Injury Picture #2
Stingray Injury Picture #3
Stingray Injury Picture #4
Stingray Injury Picture #5
FAOJ Editors
May 9, 2009 at 8:19 am
I must say the 5th picture looks much better! Needless to say, it’s pretty obvious that the following should have happened:
1. Heat submersion after initial injury-immediate trip to hospital ER for admission.
2. Immediate incision and drainage with aggressive debridement after injury. Open packing of injury with Calcium alginate or betadine solution soaked gauze. (This type of penetration injury should be opened from entry point to exit point)
3. Hospitalization (outpatient treatment of such an injury on oral antibiotics just won’t do it for this type of injury)
4. IV antibiotics
5. Sometimes these deep, muscular injuries require a secondary operation to remove additional necrotic tissue.
6. Whirlpool, wound care and hyperbarics also have indications in treatment.
Al Kline DPM
May 9, 2009 at 8:39 am
I went to the wound care center for the first post-surgery exam yesterday. The tentative plan is to put a wound vac on it as soon as possible and to maybe go back to surgery next thursday so they can attempt to close the wound. They will probably still have to do a skin graft at some point. I have already missed a month of work, and have a ways to go. I am a prison guard, so there are no “light duty” assignments. I cannot go back to work until I am cleared to be on my feet for 16 hours. This is killing me financially. I am also a very active person, so the cabin fever is driving me nuts! All this from a fish… I advise anyone to research what should be done for an injury and be very proactive and assertive so you do not wind up where I did. This could have been prevented.
Thank you, Stacy Williams
Stacy
May 9, 2009 at 9:13 am
Al-
Stacy is my mom and I was there when It happened. She was is HORRIBLE PAIN for about an hour and a half untill the nurse gave her some kind of pain relief. Thanks for all the advise and I dont see a vacation to the beach any time soon.
Robert
May 9, 2009 at 11:51 am
I went to the Dr. yesterday and I am scheduled for a skin graft next Thursday 5/21/09. Wish me luck…
stacy
May 15, 2009 at 9:59 am
GL, take some photos!
Al Kline DPM
May 16, 2009 at 6:42 am
Just thought I would update you. I had the skin graft on 5/21 as scheduled. No pictures of that because there was a compression dressing that stayed on for a week at a time and was changed at the docs. On june 18 was was given permission to put limited weight on the foot for balance and tranfers. On the 25th, I was told I could put weight on it as tolerated. I started physical therapy last week and saturday 7/4 was my first day crutch-free. Last Thursday they finally took the dreesing off permanently. I will get some pics and send them to you. I am hoping to go back to work next week, although I don’t know how well the 16 hours totally on my feet is going to go. It was the tibialis anterior tendon that had to partially be removed and I have problems picking my foot up correctly. The stairs at work should be loads of fun…..anyway, I’m hoping this adventure is almost over! Thank You, stacy
stacy williams
July 6, 2009 at 2:00 am
Dr. Kline,
My son was stung by what we believe to be a stingray on May 16, 2009 at Gulf Shores, AL. Pain was immediate and bled freely. Initial thought was jellyfish having never been stung by anything at the beach before. He drove back to Birmingham the following morning but swelling and redness increased and sooght treatment at ER. Placed on oral Levaquin and went home. Next morning redness and swelling had continued higher and admitted to hospital. Placed on IV antibiotics for 7 days. Checked out of hospital on 750 mg oral Levaquin 1/day and 100 mg doxycycline 2/day. Changing dressing every 12 hrs. Concerned if additional treatment needs to occur. Being monitored by plastic surgeon. I will send pictures. Please give feedback ASAP.
Bob
June 1, 2009 at 8:57 am
I got hit while gigging flounder 05-25-09 on my left ankle . It hurt. Got back to boat , squeezed the wound and flushed with peroxide and packed with neosporin. 45 minutes later I had it in hot water. Pain subsided immediately. It oozed for a few days on the 3 day it was beginning to get warm. And I thought I was about to get infected. It cooled off and started to heal. It has been 3 weeks today and it is almost closed up, for 1 ” gash to a 1/4″ . There is still swelling but it subsides if I elevate it. The skin feels hard around the wound but it doesnt hurt. The swilling is going away. I feel fortunate I didnt get any other infection.
mike
June 15, 2009 at 7:08 pm
I got stung in my knee while diving and taking care of some students. The students startled the ray but I was the one who got hit. I’m thankful for that as they were only 12 years old! I got quite a fright and I’ve never experienced so much pain before. I went straight to the hospital. The doctor injected me with local anesthetic and thoroughly flushed the wound with betadine solution. The had a poke around to see if there was any debris, but none seemed to be visible. They inserted a piece of gauze to stop the wound healing, then dressed it up and told me to go back the next day. I’m on 2000 mg amoxicillin daily and they told me not to walk on it unnecessarily. It’s now been almost 48 hours and I have no pain, a little swelling and feel some tightness around my knee area. I do have to say that I am a little worried about this tissue necrosis. But, I am sure that some pain or discoloration of my skin would be evident by now. I’m keeping my fingers crossed that all will be well.
Angie
June 30, 2009 at 11:27 pm
i was stung on 8/8/09 on the side of my foot by what i’m guessing was a very small sting ray. we called the local EMS, and they took vitals and told me to go home and soak it in hot water and clean it and it should be fine. they also recommended i get a tetanus shot, but i have not done so yet. my sting was completely painless the following day and the day after. then i had to get into a really hot car for about 30 minutes (104 degrees) and suddenly my ankle opposite of where i got stung and my calf swelled up. i have some very tender streaks going up my shin and from the swollen ankle, but the ankle itself is not red or painful. the swelling in my calf has gone down quite a bit, but i am concerned about the pain that i am having in my leg. i cannot put any weight on my leg or it feels as though someone is shoving a tiny cactus up the inside of my leg in those two tender areas. should i go to the ER? i live in a small town way away from the ocean, and i am just afraid that these doctors around here will have no idea what to do about this.
Kelly
August 11, 2009 at 10:03 am
Kelly – The streaks could be a sign of infection. I’d recommend going to the nearest metropolitan area for help. I live in somewhat small town 2 hours south of Washington, DC and had to go to the DC metro area to get help. Doctors in my area have bad reputations, but even the doctors at the beach told me I was fine. Now I’m spending a lot of time going to appointments with a plastic surgeon that is cutting open the wound to drain it frequently and I will need a skin graft because of dead tissue.
Erin
August 18, 2009 at 2:38 pm
another thing: does the venom get into your bloodstream or stay localized? i am pregnant and pretty concerned about the effects this might have on the baby.
Kelly
August 11, 2009 at 10:05 am
I also had an issue with neglect from doctors (no draining/debridement or hint that it might be needed; was told I was healing fine when I was concerned). Long story short, I had to go to a plastic surgeon Thursday, Friday and Monday (today is Tuesday) and my next appointment is Friday. I will need a skin graft as well.
A couple of questions:
- What’s the healing process for a skin graft on the ankle? I know the dressing stays on for awhile and is changed by the doctor, but can I walk on it? What sort of bandage or dressing should I expect? How long will it require me to take off work?
- Has anyone ever sought legal action for neglect from an emergency medical place? I went to the same place twice (day of sting and four days later – two different doctors). It was never drained or debrided thoroughly and at the second visit I was told I was fine when I was concerned (already showing the symptoms that six days later sent me to doctor in the DC area and then a surgeon).
Also, I posted a recount of what happened to me on my blog (though with an online medical information twist – I’m a web developer) if anyone is interested: http://blog.erinmstewart.com/2009/08/18/stingray-sting-and-online-medical-information/
Erin
August 18, 2009 at 2:46 pm
Hello,
I was hit with a stingray on 9/21/09 while on Ocracoke Island in North Carolina. I did go immediately to a physician there and he advised me to soak my foot in extremely hot water to help with the pain. I spent two hours in the office soaking my foot and also soaked it another hour after I left there. I also received a tetanus shot that day. After three weeks now, I was thinking that things were going to be okay with it, but it does have a swollen spot there where I was hit. I am wondering if this is normal or will I need to get it checked and have it drained? Any info would be helpful!
Kristen
Kristen
October 10, 2009 at 9:30 pm
hi kristen. i don’t know how big the stingray was that got you, but i got hit by a small one, and it DID swell, but i just kept soaking it. it never showed real signs of infection or anything, but it did swell right at the injection site. i saw a doctor about it, and he prescribed me some antibiotics, but he didn’t even LOOK at it, so i didn’t take them. anywya, after about a month it healed up just fine. i would watch out for redness that spreads, swelling that is more than just at the injection site, or streaks coming from it. those are all signs of an infection. otherwise, i would not worry about it too much.
Kelly
October 11, 2009 at 5:06 am
Thanks Kelly for your input. I really do appeciate it!
Kristen
October 11, 2009 at 6:20 pm
I originally posted in March 09 about my better halfs envenomation…to this day there is still an odd dark colour below the injury site. If you apply pressure on top of the spot it seems to puff up slightly. I have not received anymore flak in some months accusing me of trying to scare away tourists!!! Thankgod and I hope I have raised some awarness of the situation arising from a stingray sting, and what seems like a form of ignorance from the medical field when it comes to treating these things…by the way my better half also happens to be a Nurse. A bandage process called wet to day on the area after debridement of the wound will help greatly…
cliff
October 11, 2009 at 9:05 pm
Thanks for the input Cliff. It helps to know that I may be dealing with this for some time so I guess I won’t think that my foot will fall off any time soon. I sure do agree with you that unfortunately for whatever reason the medical field does not have much after treatment care. I do not live near the ocean and if I were to see a local doctor, they would have no idea how to provide post-treatment. Don’t worry about the flack of scaring the tourists away, because had I been made aware of the darn things being so close to the edge of the water, it would not have kept me from going to the beach for my vacation. It would have however made me more cautious of my surroundings. Thanks again!
Kristen
October 12, 2009 at 6:47 pm
I went to stingray city and got stung by a very large stingray (3-4ft) on the bottom of my foot. I did apply hot water, but not nearly hot enough. The terrible pain lasted 6 hrs. Then my foot went numb, after a week there is still about a 2 inch area still numb. The Island Doctor gave me Antibiotic pills to take and I am now back from the cruise and feel I need to go see a local doctor, can you give me a recommendation in the Orlando, Florida area?
William Brown
November 8, 2009 at 9:03 pm
My stingray encounter was back on September 21st and as of today I find that the side of my foot is still purple and it swells with certain shoes on. I was on an antibiotic for a skin disorder for a month and I do think that it helped me. The doctor that I saw on Hatteras also gave me a tetanus shot the day of the attack. I do not know of a physician to recommend in Florida unfortunately. I don’t think it would hurt to have someone look at it. It sounds like your wound is a lot larger than mine. Hope this info helps
Kristen
November 9, 2009 at 6:47 pm