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 Three fatalities from jellyfish stings were reported in Malaysia since 2000 (locations shown in Figure 1). 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 An 8-year-old South RO4929097 in vivo 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 Navitoclax clinical trial 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 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 way to hospital. The death was reported to be from an “anaphylactic reaction” to the sting.9 A 44-year-old female British Dimethyl sulfoxide 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.