Injuries caused by venomous and poisonous aquatic animals may provoke important morbidity in humans. The phylum Echinoderma include more than 6000 species of starfish, sea urchins, sand dollars, and sea cucumbers some of which have been found responsible for injuries to humans. Initial injuries by sea urchins are associated with trauma and envenomation, but later effects can be observed. Sea urchin granuloma is a chronic granulomatous skin disease caused by frequent and successive penetration of sea urchin spines which have not been removed from wounds. The authors report a typical case of sea urchin granuloma in a fisherman and its therapeutic implications.Os acidentes por animais aquáticos traumatizantes e venenosos podem provocar morbidez importante em humanos. Equinodermos marinhos incluem mais de 6000 espécies de estrelas-do-mar, ouriços-do-mar, "bolachas-de-praia" e pepinos-do-mar. Vários equinodermos têm sido responsabilizados por acidentes em humanos. Granulomas por ouriço-do-mar são lesões de caráter granulomatoso, crônicas, causada por acidentes com espículas de ouriço-do-mar. Os autores relatam um caso típico de granulomas por ouriço-do-mar ocorrido em um pescador e enfatizam as implicações terapêuticas aplicadas

Haddad Junior, Vidal

Mora, Jamesson de Macedo

Rossetto, André Luiz

English

Os acidentes por animais aquáticos traumatizantes e venenosos podem provocar morbidez importante em humanos. Equinodermos marinhos incluem mais de 6000 espécies de estrelas-do-mar, ouriços-do-mar, "bolachas-de-praia" e pepinos-do-mar. Vários equinodermos têm sido responsabilizados por acidentes em humanos. Granulomas por ouriço-do-mar são lesões de caráter granulomatoso, crônicas, causada por acidentes com espículas de ouriço-do-mar. Os autores relatam um caso típico de granulomas por ouriço-do-mar ocorrido em um pescador e enfatizam as implicações terapêuticas aplicadas.Injuries caused by venomous and poisonous aquatic animals may provoke important morbidity in humans. The phylum Echinoderma include more than 6000 species of starfish, sea urchins, sand dollars, and sea cucumbers some of which have been found responsible for injuries to humans. Initial injuries by sea urchins are associated with trauma and envenomation, but later effects can be observed. Sea urchin granuloma is a chronic granulomatous skin disease caused by frequent and successive penetration of sea urchin spines which have not been removed from wounds. The authors report a typical case of sea urchin granuloma in a fisherman and its therapeutic implications

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Rev. Inst. Med. trop. S. Paulo48(5):303-306, September-October, 2006(1) Faculdade de Medicina da UNIVALI (Universidade do Vale do Itajaí), Itajaí, SC, Brasil.(2) Hospital e Maternidade Marieta Konder Bornhausen, Itajaí, SC, Brasil.(3) Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brasil.(4) Hospital Vital Brazil, Instituto Butantan, SP, Brasil.Correspondence to: Vidal Haddad Junior, Departamento de Dermatologia, Faculdade de Medicina de Botucatu, Caixa Postal 557, 18618-000 Botucatu, SP, Brasil. E-mail: haddadjr@fmb.unesp.brCASE REPORTSEA URCHIN GRANULOMAAndré Luiz ROSSETTO(1,2), Jamesson de Macedo MORA(2) & Vidal HADDAD JUNIOR(3,4)SUMMARYInjuries caused by venomous and poisonous aquatic animals may provoke important morbidity in humans. The phylumEchinoderma include more than 6000 species of starfish, sea urchins, sand dollars, and sea cucumbers some of which have beenfound responsible for injuries to humans. Initial injuries by sea urchins are associated with trauma and envenomation, but latereffects can be observed. Sea urchin granuloma is a chronic granulomatous skin disease caused by frequent and successive penetrationof sea urchin spines which have not been removed from wounds. The authors report a typical case of sea urchin granuloma in afisherman and its therapeutic implications.KEYWORDS: Venomous aquatic animals; Traumatic aquatic animals; Echinoderms; Sea urchin; Sea urchin granuloma; Foreignbody granulomas.INTRODUCTIONSome aquatic animals can cause important morbidity in humans3,4,5.Nowadays man frequents aquatic ecosystems more and more for bothcommercial reasons (fishing) and recreation (bathing and aquaticsports). This increase also increases the number of accidents, which inturn increases the value given by the medical community to knowledgeof the clinical characteristics of these injuries and related therapies.Dermatologists must pay special attention to this subject as the skin iscompromised in practically all injuries caused by poisonous aquaticanimals3,4,5. The apparatus causing trauma and envenomations arediverse; severe trauma can be provoked by fish stings, teeth, or spines,and sea urchin spines. Allergic mechanisms can be seen after ingestingcrustaceans and mollusks, and poisonings by different fish andcnidarians are not rare. Often we can see associations between thesemechanisms.Echinoderms are part of a phylum of cosmopolite and commonanimals with radial symmetry which includes more than 6000 speciesof starfish, sea urchins, sand dollars, and sea cucumbers. Some seaurchins, starfish, and sea cucumbers are responsible for injuries tohumans3,4,5. Approximately 80 species of sea urchin are toxic to humans;they are slow moving non-aggressive marine bottom-dwellers and arefound in deep waters, rocky inclines, and tropical and temperate coralreefs. They have oval bodies with a rigid external skeleton of calciumcarbonate around one central body orifice. A fine epithelial layer oftegument covers the shell. Spines of calcium carbonate and pedicellaria(or tube foot) are attached to the tegument (Fig. 1). Some species donot have a tube foot that can contain poison glands. The spines can behollow or solid with toxins associated with them or their thin epitheliallayer. The spines can be short and thick, or fine and long which canpenetrate the skin through a victim’s footwear or bathing suit. Toxicsubstances which have so far been identified in the pedicellaria andspines include steroids, serotonin, glycosides, cholinergic substances,histamine, and substances similar to bradicinin5,7,8.The primary injury caused by sea urchins is from spine penetration.The most commonly compromised areas are the feet and ankles (if avictim steps on a sea urchin) and the hands from manipulation or as adefense mechanism when people are dragged on to rocky walls bywave action. Spine penetration causes intense and immediate pain,bleeding, erythema, edema, and local myalgia. When joints arepenetrated, synovitis can occur. Systemic symptoms are especiallycommon when toxin injection from fifteen or more spines occurs. Theseinclude paresthesia, radiated pain, hypotension, muscular weakness,dyspnea, aphonia, deafness, and even death4,5,7,8. Traumatic injuriesprovoke moderate pain expressed mainly by local compression. Thepurple and black pigment from the spines can mark the skin andsimulate fragment retention, although fragment retention iscommon3,4,7,8. These fragments can cause infections and foreign bodyreactions3,4,5,7. Pain and edema can last for a week3,4,5,7.As delayed complications we can observe formation of granulomas,chronic arthropathy, persistent neuropathy, local bone destruction and304ROSSETTO, A.L.; MORA, J.M. & HADDAD JUNIOR, V. - Sea urchin granuloma. Rev. Inst. Med. trop. S. Paulo, 48(5): 303-306, 2006.Fig. 4 - Surgical exeresis of the nodules. Note the small black spine fragment in the center ofthe surgery area.Fig. 5 - The patient’s hands seven days after treatment.Fig. 3 - Multiple painful nodules, edema and hyperkeratosis in the patient’s hands.Fig. 2 - Early lesions caused by sea urchin spines and their aspects in the Emergency Unit.Fig. 1 - Black sea urchin (Echinometra locunter), collected by the patient.a vesicular reaction for delayed hypersensitivity7. The possiblemechanism for the granulomatous reactions occurs due to foreign bodyreactions against the inorganic substances contained in the spines(calcium carbonate, magnesium carbonate, calcium sulphate,phosphates, and silica)8. Lesions are pink to blue papules and nodulesof 2-5 mm, which later turn brown. Edema and hyperkeratosis arecommon7. Symptoms are varied8.The histopathology of sea urchin granuloma has manymorphological variations2. A granulomatous inflammatory reaction ispredominant, with frequent foreign body and sarcoid patterns. Otherhistopathological patterns without granulomatous inflammation canalso be found. Another study described the presence of infection fromMycobacterium marinum associated with granulomatous chronicinjuries from sea urchins suggesting that it is necessary to look forinfections in these circumstances2.The sea urchins are part of the beach and rock fauna around theBrazilian coastline. The black sea urchin (Echinometra locunter) canROSSETTO, A.L.; MORA, J.M. & HADDAD JUNIOR, V. - Sea urchin granuloma. Rev. Inst. Med. trop. S. Paulo, 48(5): 303-306, 2006.305be found all along the coast and causes a great number of traumaticaccidents, about 50% of the injuries seen in coastal town emergencyunits3,4,5. The green or purple sea urchin (Lythechinus variegatus) isnot so common, but also causes accidents. Both species have poison intheir pedicellaria or tube foot, but worse problems come from thedifficulty of extracting spines in emergency units. A third genus(Diadema sp.) has poisonous spines that can cause seriousenvenomation, but it is found in deep waters and only divers are exposedto this kind of injury3,4. About 40% of patients who do not completelyremove the spines present with fever, local pain, painful nodules, andother complications4.Treatment for sea urchin spine injuries is by immersion of theaffected area in hot water (43 °C - 46 °C); this makes the toxins inactiveand relieves the pain. Pedicellaria and spines must be removed byirrigation with clean water and soft traction. The fragmentation of spinesis very common and occasionally radiological examination of softtissues is necessary to identify the fragments with surgical exploration,especially in cases of lesions in joints. Bacterial and fungal infectionsare possible after the trauma, so is tetanus. Irrigating the wound withurine or alcohol is a folklore remedy and does not have any scientificbasis. Difficult to extract spines can be destroyed with one or twoapplications of erbium: YAG laser ablation8.CASE DESCRIPTIONA 49-year-old male born in Blumenau and living in BalneárioCamboriú (Santa Catarina State, Brazil) for 40 years, who has been anunderwater fisherman for 25 years (free diving to catch fish, lobsters,and sea urchins on the coast). He sought medical attention two yearsafter the incident due to pain and edema in the back of the right hand,and again six months later with a similar manifestation in the back ofthe left hand. Dermatological examination revealed edema,hyperkeratosis and multiple hardened purple nodules of between 0.6and 2.0 cm diameter adhering to deep tissue; some were painful tomanipulation, and were located in the superior members in elbows,forearms, and mainly the hands. He also had some less painful nodulesin the knees (Fig. 2). General physical examination was normal (Height= 1.73 m. Weight = 62 kg) and radiological examination of the handsdid not reveal any foreign bodies. He reported weight loss (6 kg) duringthe period without apparent reason.With these manifestations and histopathological examdemonstrating compact granulomas in the nodules, he received an initialdiagnostic of borderline Hanseniasis and was treated with Dapsone,Rifampicin and Clofazimin for 12 months, without good outcome. Hereported later that the nodules appeared after traumas with sea urchinspines during dives on rocky underwater slopes. He denied looking formedical attention after these injuries and extracted the spines from thewounds himself, although some spines were not removed but hereported that they were expelled from the wounds after about two weeks.According to the patient, the trauma occurred with two species of seaurchin: the small “lesser black”, more common in rocky slopes andshallow waters and the less frequent larger “dark green”, found in deeperwaters. After the traumas, he felt strong pain at the spine penetrationsites which endured for a few hours. Pain was more intense and lastedlonger when the traumas were caused by the “dark green” sea urchin.He had had a surgery twelve years ago in the left knee to remove a seaurchin spine. He received antitetanus booster one year after theexamination.The patient was submitted to a new biopsy of one nodule from thehand and the histopathological exam found non-caseating compactgranulomas, with epithelioid cells and Langhans giant cells (sarcoidgranulomas) compatible with the sea urchin granuloma hypothesis.The patient was treated by surgical exeresis of multiple nodules andintralesional infiltration of triamcinolone immediately after surgeryin the left and right superior members (Fig. 3). After nodule extractionspine fragments were found in the nodules and adjacent tissue (Fig.4). The patient was also medicated with Paracetamol 750 mg every sixhours for pain and moved away from the sea until he was healed.Evolution one week after surgery showed reduced pain, and the areawhere nodules had been extracted were in a healing process and thenodules with infiltrated triamcinolone had partially decreased in sizeand were painless.DISCUSSIONThe history and clinical manifestations presented by this patient weretypical of the delayed granulomatous phase in sea urchin injuries.Sporadic accidents with removal of most spines do not seem to causegranulomas4,5. The most important factor in this manifestation seems tobe the frequent penetration of spines. Some species of sea urchin arefound along the entire length of the Brazilian coast. Man frequentingthis habitat will be subject to injury and poisoning from their spines andpedicellaria. In many countries, such as Italy, sea urchin ovaries areused as food; they are eaten raw or are ingredients in other manufacturedseafood. This means that many people catch them thus increasing theprobability of injuries3,5,6. In Brazil, some sea foods have become morepopular, which increases the risk of fishing accidents and gives this typeof accident an occupational character. Correct treatment in the acutephase is extremely important and should be performed by professionalsin Emergency Units so that immediate and longer term complicationsare prevented1,5. Therefore knowledge about diagnosis and treatmentare necessary. In this case, the authors used different therapeuticapproaches with good clinical results in both situations (Fig. 5).RESUMOGranulomas por ouriços-do-marOs acidentes por animais aquáticos traumatizantes e venenosospodem provocar morbidez importante em humanos. Equinodermosmarinhos incluem mais de 6000 espécies de estrelas-do-mar, ouriços-do-mar, “bolachas-de-praia” e pepinos-do-mar. Vários equinodermostêm sido responsabilizados por acidentes em humanos. Granulomaspor ouriço-do-mar são lesões de caráter granulomatoso, crônicas,causada por acidentes com espículas de ouriço-do-mar. Os autoresrelatam um caso típico de granulomas por ouriço-do-mar ocorrido emum pescador e enfatizam as implicações terapêuticas aplicadas.REFERENCES1. BERGER, L. & CAUMES, E. - Accidents cutanés provoqués par la fauna et la floresous-marines. Ann. Derm. Vénér., 131: 397-404, 2004.306ROSSETTO, A.L.; MORA, J.M. & HADDAD JUNIOR, V. - Sea urchin granuloma. Rev. Inst. Med. trop. S. Paulo, 48(5): 303-306, 2006.2. DE LA TORRE, C. & TORIBIO, J. - Sea-urchin granuloma histology profile. A pathologicstudy of 50 biopsies. J. cutan. Path., 28: 223-228, 2001.3. HADDAD JUNIOR, V. - Atlas de animais aquáticos perigosos do Brasil: guia médicode identificação e tratamento (Atlas of dangerous aquatic animals: a guide ofidentification and treatment). São Paulo, Editora Roca, 2000.4. HADDAD JUNIOR, V.; NOVAES, S.P.M.S.; MIOT, H.A. & ZUCCON, A. - Accidentscaused by sea urchins - the efficacy of precocious removal of the spines in theprevention of complications. An. bras. Derm., 76: 677-681, 2001.5. HADDAD JUNIOR, V. - Animais aquáticos de importância médica no Brasil. Rev. Soc.bras. Med. trop., 36: 591-597, 2003.6. HANEKE, E.; TOSTI, A. & PIRACCINI, B.M. - Sea urchin granuloma of the nailapparatus: report of 2 cases. Dermatology, 192: 140-142, 1996.7. ROCHA, G. & FRAGA, S. - Sea urchin granuloma of the skin. Arch. Derm., 85: 406-408, 1962.8. SMITH, M.L. - Skin problems from marine echinoderms. Derm. Ther., 15: 30-33, 2002.Received: 16 November 2005Accepted: 13 June 2006

Granulomas por ouriços-do-mar

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Sea urchin granuloma

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