Asthma Exacerbation and Erythematous Papules in a Traveler

A 32-year-old man with asthma developed wheezing while swimming in the sea of Florida, USA. The patient was evaluated at a hospital the next day for his unresolved respiratory distress. The patient was hemodynamically stable without signs of anaphylactic shock. On a physical examination, his lungs revealed scattered wheezing, and erythematous papular skin lesions were observed on his upper extremities (Picture). Chest X-ray was unrevealing. Physalia physalis, also known as the Portuguese man of war, is a marine creature resembling a jellyfish mainly found in the coastal areas of the Atlantic Ocean. Our patient retrospectively, but not convincingly, recalled coming across a jellylike mass while swimming in the sea. His respiratory distress rapidly improved with systemic glucocorticoids only, and his skin lesions resolved in few weeks with residual minor skin pigmentation. P. physalis is a coelenterate possessing numerous tentacles lined with nematocysts that can inject venom toxin into humans. The toxin contains multiple allergic biochemical agents that can induce bronchospasm/ asthma-like hypersensitivity reactions. The injection site generally erupts into localized linear, erythematous papules. Increased awareness of P. physalis is warranted for individuals with a history of asthma, since severe systemic manifestations leading to a fatal outcome, such as anaphylaxis and cardiovascular collapse, have been described in the literature (1, 2).