Coral Toxicity

Etiology

PTX exposure, and resulting toxicity via coral, is mostly associated with inhalation of vapors during cleaning, scrubbing, or eradicating the coral from home/public aquariums. Due to the rapid growth of zoanthids, it requires regular removal from specific unwanted areas of the aquarium. The removal process is mostly by boiling in water and/or scrubbing out from rocks. This process may result in inhalation of steam or aerosolized droplets. Also, instances of dermal absorption from prolonged and unprotected handling of PTX-containing coral have been reported. It can occur via both intact and broken skin. PTX toxicity can occur due to the consumption of seafood capable of producing PTX or seafood contaminated with corals. Also, reports of corneal toxicity have been reported caused by PTX.[1][3][4][5]

Epidemiology

Zoanthids are common in oceans of tropics and subtropics; this includes coastlines of Hawaii, Florida, Brazil, Australia, Japan, and many Atlantic islands. They usually live in the shallow, hard-bottom floors of the ocean up to 12 meters deep. However, zoanthids can be easily purchased online so that the toxicity can occur at any place. The majority of the cases of Coral toxicity are among aquarium enthusiasts. In recent times, an increasing number of cases of inhalational exposures have been reported among aquarium handlers during the cleaning or handling of coral for a prolonged time.[6]

Pathophysiology

Poisonings associated with PTX-contaminated soft corals are mostly through inhalation or dermal absorption. However, the ingestion of corals or surrounding seawater is a less probable, but not impossible event. The exact in vivo mechanism of the toxicity of PTX is not established. PTX is known to be a potent vasoconstrictor. The neurotoxic, cardiotoxic, and metabolic effects are mainly due to the dysregulation of sodium/potassium adenosine triphosphatase (ATPase), a transmembrane pump. PTX locks into the pump in α-β ATPase heterodimer leading to a sequence of conformational changes and thereby allowing passive transport of both ions (sodium and potassium), which in turn destroys the ion gradient which is the very essence of cellular homeostasis. Therefore, PTX can affect any cell line depending upon the mode of exposure.[1][5][7][8][9]

History and Physical

There is increasing evidence of inhalational and/or cutaneous exposure to PTX after handling PTX-contaminated soft corals. Coral toxicity due to palytoxin depends on the duration of exposure, the route of exposure, and the distance from the location where the coral was being handled. The patient may seek medical attention minutes to hours after the maintenance of home aquaria. A detailed history of patient activity before the symptoms and also patient hobbies and occupation would yield useful information.

The patient usually describes an event of handling corals, mostly by pouring boiling water and scrubbing coral out of the rocks. The resultant vapor exposure may present with symptoms. The most common presentations are:

Respiratory system

• Rhinorrhoea
• Cough
• Dyspnea

Musculoskeletal System

• Weakness
• Myalgia
• Muscle cramps
• Rhabdomyolysis

Nervous System

• Paresthesia
• Convulsions
• Dizziness
• Numbness
• Restlessness

Other systemic symptoms

• Fever
• Nausea/vomiting
• Tachycardia
• Hypotension

Handling of corals with intact or damaged skin for a prolonged period may result in dermal absorption of the toxin and present with:

• Local (edema, erythema, pruritus)
• Perioral paresthesia
• Dysgeusia
• Other non-specific systemic symptoms.

Instances of ocular contamination result in symptoms of keratoconjunctivitis and are non-specific. The symptoms also include severe ocular pain, red eye, decreased visual acuity, photophobia, foreign body sensation, and metallic taste. The patient may present with severe respiratory distress and cyanosis, which can result in progressive respiratory failure and death.[1][3][4][9][10][11][12][13]

Evaluation

The diagnosis of coral toxicity has no confirmatory study or imaging, as it is a clinical diagnosis based mostly on a clear history of preceding exposure to PTX-containing coral species and the symptomatology that follows. There is a wide variety of possible presentations; therefore, a strong history and clinical suspicion make the foundation for an accurate diagnosis. PTX has been successfully isolated by the use of high-performance liquid chromatography in some public health cases. However, there is no qualitative or quantitative test used to assess human toxicity, and  PTX is not isolated for diagnosis in patients. Results from recent reports indicate a negative culture for an infectious cause and a temporal relationship to palytoxin exposure. The evaluation of the patient depends upon the mode of exposure and the clinical presentations. This assessment may include an electrocardiogram and respiratory monitoring.[4][10][12]

Treatment / Management

So far, no antidote has been developed against PTX toxicity. Additionally, there is no defined and harmonized medical protocol for the treatment of PTX associated with corals. In general, the management is mainly symptomatic and focused on reducing or limiting the signs and symptoms of toxicity and limiting further damage. Hence, they are defined case by case. Following dermal and ocular exposure, rinsing the affected area with water is useful to reduce the toxicity.  

Many approaches regarding inhalational exposure to PTX have been under study. One approach focuses on the usage of nebulized β-agonists or corticosteroids and/or systemic corticosteroids. Another approach is based on the association of non-steroidal anti-inflammatory drugs and nebulized β-agonists or a combination of corticosteroids and antihistamines. For cutaneous exposure, treatment with supportive intravenous fluids infusion, corticosteroids, and antihistamines is mandatory. For ocular exposure and limited toxicity, artificial tears, steroid drops, and/or antibiotics are common choices. More serious damage to the eye like keratitis and ulcers may require surgical exploration and management, such as amniotic membrane transplantation. 

For patients arriving at the emergency department with dyspnea, cyanosis, and respiratory difficulties, progression to respiratory failure should be anticipated, and intensive care should be made available. Also, the toxic effects of PTX on the heart should receive proper attention, using an electrocardiogram. Animal studies using vasodilators, papaverine, and isosorbide dinitrate have shown that these can serve as antidotes. However, the animal experiments showed benefits only after the injection of these agents directly into the heart immediately after exposure.[14][15][16](B3)

Differential Diagnosis

The differential diagnosis of coral toxicity includes the following:

• Acute anemia
• Acute gastritis
• Aspiration syndromes
• Congenital anomalies of the lungs
• Hematologic problems
• Intestinal perforation
• Metabolic problems
• Portal hypertension
• Pulmonary air leaks
• Renal artery aneurysm
• Small intestinal diverticulosis
• Upper gastrointestinal bleeding

Prognosis

Patients with mild exposure and minimal symptoms may just require symptomatic treatments and recover well. In cases of serious presentations, including respiratory failure, cardiotoxicity, keratoconjunctivitis, rhabdomyolysis, and kidney failure, there is a significant increase in morbidity and mortality.[14][15][16]

Complications

Coral toxicity due to PTX may have various effects and complications depending upon the mode and duration of exposure. Mild toxicities have local and non-specific systemic symptoms. More severe cases can result in hemolysis, cardiotoxicity and myocardial damage, severe respiratory distress, pulmonary edema, rhabdomyolysis, kidney failure, coma, and death resulting from cardiac or respiratory failure. Also, ocular exposure can be severe enough to result in corneal ulceration and even perforation.[14][15][16]