275
Fatal and Severe Box Jellyfish Stings, Including Irukandji Stings,
in Malaysia, 2000–2010
John M. Lippmann, OAM, BSc, MAppSc,∗ Peter J. Fenner, AM, MD (London), FACTM,
FRCGP,†‡ Ken Winkel, MBBS, BMedSci, PhD, FACTM,§ and Lisa-Ann Gershwin, PhD
∗
Divers Alert Network Asia-Pacific, Melbourne, Victoria, Australia; † School of Public Health, Tropical Medicine and
Rehabilitation Sciences, James Cook University, Townsville, Queensland, Australia; ‡ Travel Medicine Mackay, North Mackay,
Queensland, Australia; § Australian Venom Research Unit, Department of Pharmacology, University of Melbourne, Victoria,
Australia; Tasmanian Museum and Art Gallery, Hobart, Tasmania, Australia
DOI: 10.1111/j.1708-8305.2011.00531.x
Background. Jellyfish are a common cause of injury throughout the world, with fatalities and severe systemic events not uncommon
after tropical stings. The internet is a recent innovation to gain information on real-time health issues of travel destinations,
including Southeast Asia.
Methods. We applied the model of internet-based retrospective health data aggregation, through the Divers Alert Network
Asia-Pacific (DAN AP), together with more conventional methods of literature and media searches, to document the health
significance, and clinical spectrum, of box jellyfish stings in Malaysia for the period January 1, 2000 to July 30, 2010.
Results. Three fatalities, consistent with chirodropid envenomation, were identified for the period—all tourists to Malaysia.
Non-fatal chirodropid stings were also documented. During 2010, seven cases consistent with moderately severe Irukandji
syndrome were reported to DAN and two representative cases are discussed here. Photographs of chirodropid (multi-tentacled),
carybdeid (four-tentacled) box jellyfish, and of severe sting lesions were also submitted to DAN during this period.
Conclusions. This study suggests that the frequency and severity of jellyfish stings affecting tourists in Southeast Asia have been
significantly underestimated. Severe and fatal cases of chirodropid-type stings occur in coastal waters off Peninsular Malaysia and
Sabah, Borneo. Indeed, the first Malaysian cases consistent with Irukandji-like syndrome are reported here. Reports to DAN, a
provider of emergency advice to divers, offer one method to address the historic lack of formalized reporting mechanisms for
such events, for photo-documentation of the possible culprit species and treatment advice. The application of marine stinger
prevention and treatment principles throughout the region may help reduce the incidence and severity of such stings. Meanwhile
travelers and their medical advisors should be aware of the hazards of these stings throughout the Asia-Pacific.
J
ellyfish are a common cause of marine injuries
world-wide. Most cases are minor and without
permanent sequelae. However, box jellyfish can
cause major stings with fatalities or severe systemic
symptoms.1 – 4 Unfortunately, despite the development
of many interventions to reduce this type of injury in
Australia,5 little documentation exists concerning the
contemporary hazard represented by jellyfish stings in
coastal regions of tropical developing countries.
In a previous paper,2 these authors drew attention to
the presence, and associated morbidity and mortality,
of potentially deadly jellyfish in the coastal waters
of Thailand, including chirodropids (larger multitentacled box jellyfish similar to Australia’s Chironex
fleckeri) and carybdeids (smaller box jellyfish with one
Corresponding Author: John M. Lippmann, OAM, BSc,
MAppSc, Divers Alert Network Asia-Pacific, P.O. Box 384,
Ashburton, Melbourne, VIC 3147, Australia. E-mail: johnl@
danasiapacific.org
tentacle in each corner), similar but distinct from the
Australian jellyfish Carukia barnesi,6 some of which
may be associated with the Irukandji, or Irukandji-like,
syndrome—hereafter referred to as Irukandji jellyfish.
With the proximity to Thailand, and in the region
where chirodropids occur, including the Philippines,
where some 20 to 50 sting deaths occur annually,7
a similar problem is highly likely to occur in
Malaysia, although such cases have been minimally
documented.7,8 The recent box jellyfish-related deaths
of several international tourists in both Thailand and
Malaysia2,9 – 12 have emphasized these risks from marine
stings in coastal areas of Southeast Asia.
Unfortunately, it is very difficult to access detailed and
timely reports enabling injury prevention recommendations to address these emerging health issues. One recent
innovation to facilitate such access about the health status
of travel destinations, for near real-time infectious and
toxic disease surveillance, hasbeen internet-based reporting. Entities such as ProMed (www.promedmail.org/)
and HealthMap (www.healthmap.org/en/) provide a
© 2011 International Society of Travel Medicine, 1195-1982
Journal of Travel Medicine 2011; Volume 18 (Issue 4): 275–281
276
Lippmann et al.
Figure 1 Locations in Malaysia where fatal or serious stings have been reported since 1945 (indicated by dots). In some locations
there have been multiple fatalities and/or serious stings.
focal point for collection, presentation, and dissemination of geospatially sophisticated health data to optimize
travel health outcomes. We therefore applied this model
of internet-based health data aggregation, together with
conventional methods, to increase knowledge of box jellyfish stings in Malaysia, a major tourist destination in
the region.
Methods
Most case histories and images were obtained through
Divers Alert Network Asia-Pacific (DAN AP) reports
received since November 2007 from victims or
witnesses; internet discussions from jellyfish discussion
sites; Google Alerts (using the term ‘‘jellyfish stings’’);
media sources (Thailand, Malaysia, and Singapore
on-line newspapers); and email contacts. Where
possible, reports were verified by email communication,
photographic evidence, and/or telephone interview.
Also, Google and PubMed searches were conducted
using combinations of searching keywords ‘‘Malaysia,’’
‘‘jellyfish,’’ ‘‘Irukandji,’’ ‘‘fatal,’’ and ‘‘near fatal.’’
Where possible, diagnoses of ‘‘chirodropid box
jellyfish sting’’ and ‘‘Irukandji syndrome’’ were made
by standard clinical definitions previously used in this
journal.2
Results
Fatalities
Three fatalities from jellyfish stings were reported in
Malaysia since 2000 (locations shown in Figure 1).
J Travel Med 2011; 18: 275–281
Case F1: February 2010. Emails to DAN
and Electronic Newspaper Reports
A 45-year-old Swedish female tourist died after being
stung by a jellyfish while taking an evening swim
off a beach in Langkawi. She suddenly shrieked
with pain and became unconscious within seconds.
Lesions, reportedly consistent with a chirodropid
sting, were visible on her legs. She was immediately
taken ashore where cardiopulmonary resuscitation
(CPR) was commenced. Her husband reported that
an ambulance arrived 15 minutes later and the
paramedics confirmed that she had been stung by a
jellyfish.12
Case F2: November 2006. Newspaper Report
An 8-year-old South Korean girl was reported to
have died after a jellyfish sting at Palau Sapi,
near Kota Kinabalu, Sabah. She had lesions on
both legs and collapsed within seconds and died
shortly thereafter.10 The lesions described were
consistent with chirodropid lesions (photograph not
available). However, photographs of lesions on
another child at Palau Sapi 1 month later showed
a pattern typical of a multi-tentacled box jellyfish,
indicating that chirodropid jellyfish occur in the
area.11
Case F3: June 2000. Newspaper Report
A 26-year-old male tourist from Brunei reportedly died
after a jellyfish sting at Palau Pangkor. He and several
friends were stung and he collapsed and died on the
277
Box Jellyfish Stings in Malaysia
Figure 2 Chirodropic-type lesions on the leg of a British
tourist stung at Kota Kinabalu, July 2009.
way to hospital. The death was reported to be from an
‘‘anaphylactic reaction’’ to the sting.9
Near-fatal Chirodropid Envenomation
Kota Kinabalu, July 2009. Email Communications to
DAN
A 44-year-old female British tourist. The wound
(Figure 2), together with the accompanying description,
is typical of a chirodropid envenomation, such as from
Chironex spp.
The sea was calm, there were high tides, and the
water was cloudy. As the victim walked from the sea
she felt a light gripping sensation to her lower legs and
knees. Within seconds she could not breathe or talk
properly, and felt unwell. Transparent blue/gray/purple
tentacles were stuck to her lower legs. After staggering a
few meters she fell onto the sand, overcome by severe leg
pains. Briefly everywhere felt painful, and then localized
to excruciating pains in her lower legs. She reported
dyspnoea and had a sore (not tight) chest. There was a
period of altered (reduced) consciousness, after which
she again became aware of leg pains and noticed the
lifeguards applying ice. Sitting up caused a feeling of
faintness. When told she had been stung by a box
jellyfish she expressed disbelief as she had no warning of
their potential presence (although a lifeguard later told
another tourist that they occurred there). She elected to
return to her hotel rather than hospital but had to be
taken by wheelchair, as she could barely walk.
Severe pain lasted a few hours despite the
use of regular co-codamol (30 mg codeine/500 mg
paracetamol) and 400 mg ibuprofen; pain persisted
several days. The next day she had severe oedema below
her thighs and developed cellulitis above the stung
area, which appeared to clear with antibiotics. The
wounds blistered and took 3 months to heal, although
neuropathic pain and slight ankle swelling remained.13
Many aspects of this case are highly consistent with
severe chirodropid envenomation.
Irukandji-like Syndrome Cases
Pantai Tengah Mark, Langkawi, June 26, 2010. Email
Communications to DAN
Two British tourists were both stung. Lifeguards
applied vinegar and a cream. Within half-an-hour, they
developed unpleasant chest pains and severe ‘‘waves of
pain’’ throughout their bodies and were taken to hospital
by ambulance for a ‘‘pain-killing injection’’ (unknown)
and IV ‘‘serum’’ (again, unknown).
They reported severe on-going pain and tremors and
re-presented for further analgesia but, despite this, it
was another 2 days before they felt better. No warning
signs were present at the beach and it was reported
that at least two other people were stung that day,
one reportedly remaining in hospital overnight with
breathing difficulties.14
Frida Beach, Langkawi, June 20, 2010. Telephone and
Email Communications with DAN
A 30-year-old Norwegian female, taking no medications
and with no prior history of allergy or serious illness,
was stung on her left leg and foot while walking in
shallow, murky water. A jellyfish captured there shortly
afterwards is shown in Figure 3.
She initially had some skin pain and discomfort but
was otherwise well. Bystanders scraped the wound site
and flushed it with fresh water to remove the tentacles. A
doctor was consulted and she was given an antihistamine
(clemastinum) and 30 mg prednisolone.
Some 50 minutes later, the sting area was edematous
with an intense red color. Local pain had intensified and
she became nauseous. Over the next 2 to 3 hours she
developed generalized pain in her skin and subcutaneous
tissues, spreading from the foot to the rest of her
body. Her nausea increased but she did not vomit. She
described regular waves of burning pain throughout
her entire body ‘‘almost like labor pains,’’ as well as
‘‘flu-like’’ symptoms with muscle pain and generalized
discomfort. She was given oral tramadol for analgesia.
She was monitored until the following day and required
further oral tramadol for generalized soft tissue pain.
Her pain and other symptoms gradually disappeared
over the next 3 to 4 days.15
Discussion
The DAN AP (www.danasiapacific.org) is a non-profit
diving safety association that is part of an international
network of similar organizations. DAN AP has been
operating since 1994 and provides a contact point for
the diving community in the Asia-Pacific concerning
diverse regional health issues and events. It has become
apparent, through numerous and persistent reports,
through the Network and its affiliates, from affected
individuals, concerned witnesses, as well as tour operators, that it is overwhelmingly likely the frequency
and severity of jellyfish stings in Southeast Asian waters
J Travel Med 2011; 18: 275–281
278
Lippmann et al.
Figure 4 Chirodropid photographed at Telaga Harbour,
Langkawi, May 12, 2010 (T. Marinis photo).
In this study, blending such methods, we have
gathered compelling evidence of both lethal and severe
box jellyfish and, for the first time, stings producing an
Irukandji-like syndrome, currently affecting travelers
swimming and diving in the coastal waters of Peninsula
and mainland Malaysia. This builds on sporadic, isolated
historic reports of lethal and near-lethal chirodropid
stings out of Penang, Labuan Island, and the island of
Borneo since the 1940s.7,8,16 – 18 We believe that these
are a significant underestimation of the true occurrence
of fatal and severe stings in Malaysia.
Figure 3 Carybdeid captured at Frida Beach, Langkawi, June
2010.
have been significantly underestimated. The lack of formalized reporting mechanisms for such patient-driven
observations has precluded wider appreciation of this
public health and travel medicine issue.
In this context, the ubiquitous availability of digital
cameras and internet access, even in remote localities,
has provided a major advance in the ability to gather
marine injury data in real time. Further, the scope
of such information is now far more enriched than
mere case demographics, allowing, as presented here,
detailed first-hand patient descriptions of the event
and its sequelae, including post-medical outcomes,
geospatial and environmental referencing, together with
unprecedented ability to record the natural history of
the sting lesion itself, providing insight into the possible
culprit species. The provision of an on-line focal point
for such reports, such as through DAN, provides a rich
resource to complement more traditional methods of
data gathering. This in turn advances our understanding
of marine stings in the region, allowing for development
of improved safety assessment and delivery.
J Travel Med 2011; 18: 275–281
Cubozoan Jellyfish Species in Malaysian Waters
To date, to our knowledge, no cubozoan jellyfish have
been captured from Malaysian waters for taxonomic
identification, so the current state of knowledge is
based on photographs and sting reports. However, the
case histories and sting lesion photographs demonstrate
unequivocally that lethal box jellyfish species occur
in these waters. This conclusion is not surprising
considering that lethal species of box jellyfish are
confirmed from the surrounding regions of Thailand,
the Philippines, and northern Australia.2,7
Preliminary morphological determination of jellyfish
species is based on the examination of high-resolution
versions of the photographs reproduced herein.
However, thorough species identification will require
examination of specimens and nematocysts.
The carybdeid jellyfish species captured and
photographed at Frida Beach, Langkawi, in June 2010
(Figure 3) is an Irukandji-like species, possibly in the
genus Malo19 or Gerongia.20
The chirodropid jellyfish species photographed at
Telaga Harbour, Langkawi, on May 12, 2010 (Figure 4)
is in the genus Chiropsoides or an unknown close
relative.21 The total length was estimated to be 60 cm
(including tentacles), considerably smaller than that
normally expected for a mature lethal species.
The carybdeid jellyfish species photographed at
Rebak, Langkawi, on May 15, 2010 (Figure 5) is an
Irukandji-type species, and probably new to science. The
bell was estimated to be 3 to 4 cm and the tentacles 20 to
25 cm—unusually large for the genus Carukia, and more
Box Jellyfish Stings in Malaysia
279
Figure 5 Carybdeid jellyfish species photographed at Rebak,
Langkawi, May 15, 2010 (T. Marinis photo).
typical of the genus Malo. However, the conspicuous
warts on the body are similar to a Carukia spp.6
Although it is often difficult to match jellyfish
stings to particular species, stings from chirodropid and
Irukandji box jellyfish are considered the most reliable
to diagnose in the field or in the clinical presentation
and effects. Those reported here from these Malaysian
jellyfish are very similar to those previously reported in
Australia and in Thailand.2,4,18
Despite our efforts to link the species in the photographs with Malaysian sting case reports, some questions remain unresolved. In particular, the chirodropid
shown in Figure 4 may not be a lethal species although
conditions favorable to the one chirodropid species
would be favorable to another, lethal species. In neighboring Thailand, following decades of known lethal and
sub-lethal stings, a suspected lethal chirodropid species
has only recently been collected for formal identification. Indeed this species is new to science and has not
yet been formally described and classified.
Furthermore, the two Irukandji-like jellyfish presented here do not appear to be the same species and
to date, to our knowledge, no Irukandji syndrome cases
have been previously formally reported from Malaysia.
This suggests that there probably are Irukandji stings in
Malaysian waters that are not being recognized as such.
This is common, and most instances are only reported
through unusual circumstances. However, knowing that
at least two carybeid species are present in Malaysian
waters suggests that a heightened awareness of indicative ecological conditions and early clinical features of
envenomation should be emphasized.
Enquiries to the hospital about the most recent
fatality (case F1) stated the cause of death was
‘‘drowning’’; in case F3, it was ‘‘anaphylaxis’’; and
we do not have an actual cause of death in case F2.
Unfortunately, the cause of death with jellyfish
stings is often misunderstood and attributed to other
factors, or ‘‘played down,’’ rather than being directly
attributed to the venom effects of the jellyfish sting.22
Whilst anaphylaxis was diagnosed, true anaphylaxis
from jellyfish stings is extremely rare, having been
confirmed only once23 and extremely unlikely to have
occurred without previous exposure to the venom.
Misdiagnoses in the area render the task of instituting
and promulgating appropriate public health measures
more difficult and convey the message that deaths
arise from individual predilection rather than severe
envenomation from endemic jellyfish.
Figure 6 A suitable warning sign of dangerous jellyfish with an
attached bottle of vinegar for dousing stings (Cape Tribulation,
Queensland, Australia).
Preventative actions to reduce fatalities and severe
cases from jellyfish stings cannot be implemented until
the problem is accepted. Case F1 actually occurred
shortly before a world championship round of a triathlon
where the swim leg took place just off the beach in which
many hundreds of competitors swam, likely with little
or no idea of the danger present!
Malaysia, like Thailand, northern Australia, and
many other tropical destinations, is marketing strongly
to draw international tourists. Many of these partake in
aquatic activities such as swimming, snorkelling, scuba
diving, and water skiing. As dangerous box jellyfish are
present in Malaysian waters, this exposes participants to
the risk of severe envenomation, especially if personal
protective precautions are not undertaken. Travelers
to this region need to have these aquatic risks and
their mitigation addressed as part of pre-travel health
education.
It is imperative that government authorities, aquatic
resorts, and aquatic operators warn clients of the
potential threat so that they can make an informed
decision prior to entering the sea in such areas.
These warnings should ideally be included in pretrip information from travel agents and travel medicine
advisors. However, it is also essential that adequate and
appropriate warning signs are present in affected areas
and multi-lingual brochures are provided to tourists by
resorts and operators. Figure 6 shows a suitable sign, as
well as vinegar access.
Neither scraping the skin nor flushing with fresh
water should be used on the sting site as both can
trigger discharge of further nematocysts. Sea water can
be used to wash off tentacles, or preferably vinegar,
if available, which rapidly and effectively neutralizes
cubozoan nematocysts.24
Vinegar should be readily accessible to locals and
tourists alike for prompt access in the event of a sting.
Lifeguards trained in CPR should be provided by coastal
J Travel Med 2011; 18: 275–281
280
tourist resorts to increase the likelihood of survival from
a severe chirodropid sting.
Conclusions
Potentially lethal chirodropid and Irukandji jellyfish
are present in Malaysian waters with an associated
incidence of morbidity and mortality in both tourists
and Malay Nationals. It is essential that adequate
preventative treatment and management strategies are
implemented to minimize harm from these species.
DAN AP provides one method to address the historic
lack of knowledge about such stings to improve
sting prevention. Preventative strategies must include
education of travel medicine specialists, travel agents,
local medical and ambulance personnel; governmentinitiated policies for education of tourist bodies
and tourism operators; multi-lingual resources of
educational literature; and signage with clear, accurate
warnings for visitors to these areas; fenced walkways
for entry to beaches with multi-lingual signs at their
start and entrance to the beach; and vinegar bottles of
up to 5 L quickly and easily accessible. Unfortunately,
retaining the status quo by failing to embrace these
solutions will inevitably lead to further deaths and
severe envenomations, including Irukandji syndrome
and, with internet access open to all, will likely lead to
an increasing backlash from the international tourism
community as the unaddressed risks of these marine
stings become increasingly obvious.
Limitations
There are some inherent limitations in certain data collection methods employed in this study. Self-reporting
has potential inaccuracy and bias unless followed up
with careful questioning and assessment. Newspaper
reports can be notoriously biased and inaccurate and
great care must be taken in interpretation of these and
supporting evidence gathered where possible. Calls to
DAN for advice are much more likely to be assessed
objectively and yield more credible reports.
Acknowledgments
We would like to acknowledge the efforts of Andrew
Jones, whose young son was badly stung while on holiday
in Thailand. In response to the sting, Mr Jones has
personally spent much time and effort trying to make
tropical beaches safer. Sincere thanks to all of those who
submitted marine sting reports to DAN to facilitate this
research.
Declaration of Interests
J. L. is the Executive Director of Divers Alert Network
Asia-Pacific.
J Travel Med 2011; 18: 275–281
Lippmann et al.
P. F. was the Marine Stinger Advisor with Surf Life
Saving Queensland from 1985 to 2005: the National
Medical Officer, Surf Life Saving Australia 1995–2005.
He was a co-author on the textbook3 and is a member of
the Marine Stinger Advisory Group to the Queensland
Government.
K. W. is the Director of the Australian Venom
Research Unit, and Senior Research Fellow, at the
University of Melbourne. He is also a member of the
Marine Stinger Advisory Group to the Queensland
Government and is a consultant to CSL Limited,
the manufacturer of Australia’s antivenoms. K. W. is
funded by the Australian Government Department of
Health.
L.-A. G. was the National Marine Stinger Advisor
with Surf Life Saving Australia from 2005 to 2007. Since
2007, she has been on the Medical Advisory Panel for
St John Ambulance Australia and the Director of the
Australian Marine Stinger Advisory Services.
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