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“From Dinner to Death” Fish Envenomation Presenting as Acute Fulminant Necrotizing Fasciitis of the Arem in an Adult Filipino

Background: The Philippines is home to a variety of
marine animals and as such, marine stings and envenomations
are not uncommon. Despite this, there is scarcity
of locally published literature discussing its natural
course and management. Case: We present the case of
EL, a 35/M diagnosed with Grave’s Disease, controlled.
Patient has good baseline functional capacity prior to
envenomation. 33 hours prior to admission, while preparing
a fish for dinner (Local Name: Bugao / Burog,
Synanceia verrucosa), the patient accidentally punctured
his left thumb with its spine. Brisk bleeding was noted on
the puncture site. A few hours after, patient felt pain involving
the entire upper extremity with progressive swelling,
bluish discoloration, and bullae formation. 37 hours
post injury, the patient consulted at the ER, hypotensive
and tachycardic. After vigorous hydration and vasopressor
support, he was stabilized to undergo immediate debridement
and fasciotomy of the left hand and forearm.
Extensive necrosis of the fascia and foul smelling grayish
discharge were seen. IV antibiotics and tetanus prophylaxis
were given. Post operatively, the patient succumbed
from multiple organ dysfunction syndrome. Blood samples
and bullae fluid samples were obtained and a heat
labile protein toxin was identified. The potent toxin is
found in the species of stonefish. Discussion: Stonefish
venom consists of 4 biologically active factors: (1) hylauronidase
fraction, (2) capillary permeability factor, (3)
toxic or lethal fraction, and (4) pain producing factor.
The capillary permeability factor is a potent hypotensive
agent which has myotoxic and neurotoxic activity. Combination
of these factors resulted into the rapid demise
of our patient. A high index of suspicion is warranted
to prevent mortality and morbidity associated with fish
envenomation. While no stonefish antivenom is locally
available, simple management consists of removal of
protruding spines, aggressive fluid hydration, adequate
analgesia, hot water immersion techniques and adequate
empiric antibiotics can be instituted. Conclusions: In this
light, increased awareness programs discussing prevention
and treatment protocols should be made.