24 y/o male working at the local aquarium presents with right hand redness, pain, and swelling after handling an exotic fish. He is able to snap a picture of the fish before presenting to the ED. What’s your diagnosis?

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Stonefish (genus Synanceja) is a spiny bottom-feeding fish disguised to blend in with the rocky sea bottom. Found in the Pacific and Indian oceans, the spines of the fish are connected to venom filled glands at the bases.

Immediate, severe pain with rapid wound cyanosis and edema that may progress up the injured extremity. Pain reaches a maximum after 30 to 90 minutes and usually resolves over 6 to 12 hours, although pain may persist for days. May be associated with seizures, limb paralysis, hypertension, respiratory distress, or hypotension in systemic toxicity.

The wound should be cleaned and immersed in warm water. Stonefish antivenom can be given IV or IM. Anecdotal reports suggest it provides effective relief from pain. Administration is indicated for systemic toxicity or refractory pain.