Журнал клинической токсикологии
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Hepatotoxic Effects of Acanthaster planci Envenomation: A Rare Case with Review of Literature on Crown-of-Thorns Starfish Sting

Muhammad Z Arif, Dania Afzal, Sebastian Hernandez, James F Holmes, Timothy E Albertson

Introduction: Acanthaster planci (crown-of-thorns starfish) is a known coral reef predator found in tropical waters. Despite increasing human encounters, there is limited documentation on the hepatotoxic effects of Acanthaster planci (A. planci) envenomation. We present a rare case of hepatotoxicity following envenomation, contributing to the scarce literature.

Case summary: A 70-year-old male presented with immediate sharp pain after brushing against the crown of an A. planci during a scuba diving trip in Moorea Island, French Polynesia. Initial evaluation in a local Emergency Department (ED) revealed febrile convulsive episodes, and the patient was subsequently discharged. He was readmitted with elevated liver enzymes Alanine Aminotransferase (ALT) 650 U/L, Aspartate Aminotransferase (AST) 550 U/L), and was treated with antibiotics and tetanus prophylaxis. On returning to the USA, further labs showed persistent hepatotoxicity (ALT 607 U/L, AST 310 U/L) and retained spines in his left leg. The patient was managed with N-Acetyl Cysteine (NAC) and antibiotics (doxycycline, and trimethoprim-sulfamethoxazole), with improvement in liver function, but Alkaline Phosphatase (ALP) remained elevated. Surgical debridement was deferred. The patient is under outpatient follow-up with no residual symptoms.

Discussion: The venom of A. planci contains asterosaponins, toxins with known hepatotoxic effects in animal models. While only two human cases have been reported, this case further highlights the potential for hepatotoxicity and the challenges in managing retained spines and systemic effects. Surgical debridement may not always be required if significant clinical improvement is seen.

Conclusion: A. planci envenomation can lead to significant hepatotoxicity. Proper wound care, antibiotic coverage, and monitoring of liver function are essential. Further studies are needed to determine the role of NAC, surgical intervention, and long-term follow-up in these patients.