Epidemiology of scorpionism: a global appraisal

Why do we study animal toxins?

Venom (toxins) is an important trait evolved along the evolutionary tree of animals. Our knowledges on venoms, such as their origins and loss, the biological relevance and the coevolutionary patterns with other organisms are greatly helpful in understanding many fundamental biological questions, i.e., the environmental adaptation and survival competition, the evolution shaped development and balance of venoms, and the sophisticated correlations among venom, immunity, body power, intelligence, their genetic basis, inherent association, as well as the cost-benefit and trade-offs of biological economy. Lethal animal envenomation can be found worldwide. However, from foe to friend, toxin studies have led lots of important discoveries and exciting avenues in deciphering and fighting human diseases, including the works awarded the Nobel Prize and lots of key clinic therapeutics. According to our survey, so far, only less than 0.1% of the toxins of the venomous animals in China have been explored. We emphasize on the similarities shared by venom and immune systems, as well as the studies of toxin knowledge-based physiological toxin-like proteins/peptides (TLPs). We propose the natural pairing hypothesis. Evolution links toxins with humans. Our mission is to find out the right natural pairings and interactions of our body elements with toxins, and with endogenous toxin-like molecules. Although, in nature, toxins may endanger human lives, but from a philosophical point of view, knowing them well is an effective way to better understand ourselves. So, this is why we study toxins.

Study of severe scorpion envenoming following subcutaneous venom injection into dogs: Hemodynamic and concentration/effect analysis

To evaluate the dose-effects of Androctonus australis hector (Aah) venom injected subcutaneously on hemodynamics and neurohormonal secretions, 10 anesthetized and ventilated mongrel dogs, were split in two groups (n = 5/group). Subcutaneous injection was done with either 0.2 mg/kg or 0.125 mg/kg of the purified G50 scorpion toxic fraction. Hemodynamic parameters using right heart catheter were recorded and plasma concentrations of catecholamine, troponin, and serum toxic fraction were measured sequentially from baseline to 120 min. We identified the dose of toxic fraction evoking characteristic hemodynamic perturbation of severe envenomation, the time-lapse to envenomation, and the associated plasma level. The injection of 0.125 mg/kg toxic fraction was not associated with significant variations in hemodynamic parameters, whereas the 0.2 mg/kg dose caused envenomation characterized by significant increase in plasma catecholamines, increased pulmonary artery occluded pressure, mean arterial pressure, and systemic vascular resistance (p < 0.05), in association with sustained decline in cardiac output (p < 0.001). Envenomation occurred by the 30th minute, and the corresponding concentration of toxic fraction was 1.14 ng/ml. The current experiment allowed the identification of the sub-lethal dose (0.2 mg/kg) of the toxic fraction of Aah administered by the subcutaneous route. Two parameters with potential clinical relevance were also uncovered: the time-lapse to envenomation and the corresponding concentration of toxic fraction.

Revealing the Function and the Structural Model of Ts4: Insights into the "Non-Toxic" Toxin from Tityus serrulatus Venom

The toxin, previously described as a "non-toxic" toxin, was isolated from the scorpion venom of Tityus serrulatus (Ts), responsible for the most severe and the highest number of accidents in Brazil. In this study, the subtype specificity and selectivity of Ts4 was investigated using six mammalian Nav channels (Nav1.2→Nav1.6 and Nav1.8) and two insect Nav channels (DmNav1 and BgNav). The electrophysiological assays showed that Ts4 specifically inhibited the fast inactivation of Nav1.6 channels, the most abundant sodium channel expressed in the adult central nervous system, and can no longer be classified as a "non-toxic peptide". Based on the results, we could classify the Ts4 as a classical α-toxin. The Ts4 3D-structural model was built based on the solved X-ray Ts1 3D-structure, the major toxin from Ts venom with which it shares high sequence identity (65.57%). The Ts4 model revealed a flattened triangular shape constituted by three-stranded antiparallel β-sheet and one α-helix stabilized by four disulfide bonds. The absence of a Lys in the first amino acid residue of the N-terminal of Ts4 is probably the main responsible for its low toxicity. Other key amino acid residues important to the toxicity of α- and β-toxins are discussed here.

The Scorpion Toxin Tf2 from Tityus fasciolatus Promotes Nav1.3 Opening

We identified Tf2, the first β-scorpion toxin from the venom of the Brazilian scorpion Tityus fasciolatus. Tf2 is identical to Tb2-II found in Tityus bahiensis. We found that Tf2 selectively activates human (h)Na_v1.3, a neuronal voltage-gated sodium (Na_v) subtype implicated in epilepsy and nociception. Tf2 shifts hNa_v1.3 activation voltage to more negative values, thereby opening the channel at resting membrane potentials. Seven other tested mammalian Na_v channels (Na_v1.1-1.2; Na_v1.4-1.8) expressed in Xenopus oocytes are insensitive upon application of 1 μM Tf2. Therefore, the identification of Tf2 represents a unique addition to the repertoire of animal toxins that can be used to investigate Na_v channel function.

Severity of Scorpion Stings in the Western Brazilian Amazon: A Case-Control Study

BACKGROUND

Scorpion stings are a major public health problem in Brazil, with an increasing number of registered cases every year. Affecting mostly vulnerable populations, the phenomenon is not well described and is considered a neglected disease. In Brazil, the use of anti-venom formulations is provided free of charge. The associate scorpion sting case is subject to compulsory reporting. This paper describes the epidemiology and identifies factors associated with severity of scorpions stings in the state of Amazonas, in the Western Brazilian Amazon.

METHODOLOGY/PRINCIPAL FINDINGS

This study included all cases of scorpion stings in the state of Amazonas reported to the Brazilian Diseases Surveillance System from January 1, 2007 to December 31, 2014. A case-control study was conducted to identify factors associated with scorpions sting severity. A total of 2,120 cases were reported during this period. The mean incidence rate in the Amazonas was 7.6 per 100,000 inhabitants/year. Scorpion stings showed a large spatial distribution in the state and represent a potential occupational health problem for rural populations. There was a positive correlation between the absolute number of cases and the altimetric river levels in the Central (p<0.001; Rs = 0.479 linear) and Southwest (p = 0.032; linear Rs = 0.261) regions of the state. Cases were mostly classified as mild (68.6%), followed by moderate (26.8%), and severe (4.6%). The overall lethality rate was 0.3%. Lethality rate among children ≤10 years was 1.3%. Age <10 years [OR = 2.58 (95%CI = 1.47-4.55; p = 0.001)], stings occurring in the rural area [OR = 1.97 (95%CI = 1.18-3.29; p = 0.033) and in the South region of the state [OR = 1.85 (95%CI = 1.17-2.93; p = 0.008)] were independently associated with the risk of developing severity.

CONCLUSIONS/SIGNIFICANCE

Scorpion stings show an extensive distribution in the Western Brazilian Amazon threatening especially rural populations, children ≤10 in particular. Thus, the mapping of scorpions fauna in different Amazon localities is essential and must be accompanied by the characterization of the main biological activities of the venoms. Urban and farming planning, in parallel with awareness of workers at risk for scorpion stings on the need for personal protective equipment use should be considered as public policies for preventing scorpionism.

Biochemical and physiological characterization of a new Na(+)-channel specific peptide from the venom of the Argentinean scorpion Tityus trivittatus

A new peptide with 61 amino acids cross-linked by 4 disulfide bridges, with molecular weight of 6938.12Da, and an amidated C-terminal amino acid residue was purified and characterized. The primary structure was obtained by direct Edman degradation and sequencing its gene. The peptide is lethal to mammals and was shown to be similar (95% identity) to toxin Ts1 (gamma toxin) from the Brazilian scorpion Tityus serrulatus; it was named Tt1g (from T. trivittatus toxin 1 gamma-like). Tt1g was assayed on several sub-types of Na(+)-channels showing displacement of the currents to more negative voltages, being the hNav1.3 the most affected channel. This toxin displays characteristics typical to the β-type sodium scorpion toxins. Lethality tests and physiological assays indicate that this peptide is probably the most important toxic component of this species of scorpion, known for causing human fatalities in the South American continent.

Scorpion sting nephropathy

Scorpion envenomations are ubiquitous, but nephropathy is a rare manifestation, reported mainly from the Middle East and North Africa. Rapid venom redistribution from blood, delayed excretion from the kidneys, direct toxicity of venom enzymes, cytokine release and afferent arteriolar constriction have been seen in experimental animals. Haemoglobinuria, acute tubular necrosis, interstitial nephritis and haemolytic–uraemic syndrome have been documented in human victims of scorpion envenomation. Epidemiology, venom components and toxins, effects on the laboratory mammals especially the kidneys and reports of renal failure in humans are reviewed in this article.

Epidemiology of envenomations by terrestrial venomous animals in Brazil based on case reporting: from obvious facts to contingencies

Background

Envenomation remains a neglected public health issue in most tropical countries. A better understanding of the epidemiology of bites and stings by venomous animals should facilitate their prevention and management. This study aimed to explore the benefits that could be derived from the compulsory notification of cases as it is now routinely practiced in Brazil.

Methods

The Brazilian Notifiable Diseases Information System (SINAN) was consulted online for the 2001–2012 period on all envenomations by venomous terrestrial animals. We studied the incidence, severity, number of deaths, gender, season of accident and time between the accident and hospital consultation.

Results

In total, 1,192,667 accidents and 2,664 deaths from terrestrial venomous animals (snakes, scorpions, spiders, bees and caterpillars) were reported in Brazil during these 12 years, the circumstances of which are detailed in this study. Most envenomations and deaths were caused by snakebites and scorpion stings. However, incidence and mortality showed high regional variations. During this period, the steady and parallel increase of the cases from all the species resulted from several factors including the human population increase, gradual improvement of data collection system and, probably, environmental and socioeconomic factors affecting in a different way the incidence of envenomation by each zoological group and by region.

Conclusion

Mandatory reporting of cases appears to be a useful tool to improve the management of envenomations. However, local studies should be continued to account for the variability of accident circumstances and refine measures necessary for their management.

Biochemical, transcriptomic and proteomic analyses of digestion in the scorpion Tityus serrulatus: insights into function and evolution of digestion in an ancient arthropod

Scorpions are among the oldest terrestrial arthropods and they have passed through small morphological changes during their evolutionary history on land. They are efficient predators capable of capturing and consuming large preys and due to envenomation these animals can become a human health challenge. Understanding the physiology of scorpions can not only lead to evolutionary insights but also is a crucial step in the development of control strategies. However, the digestive process in scorpions has been scarcely studied. In this work, we describe the combinatory use of next generation sequencing, proteomic analysis and biochemical assays in order to investigate the digestive process in the yellow scorpion Tityus serrulatus, mainly focusing in the initial protein digestion. The transcriptome generated database allowed the quantitative identification by mass spectrometry of different enzymes and proteins involved in digestion. All the results suggested that cysteine cathepsins play an important role in protein digestion. Two digestive cysteine cathepsins were isolated and characterized presenting acidic characteristics (pH optima and stability), zymogen conversion to the mature form after acidic activation and a cross-class inhibition by pepstatin. A more elucidative picture of the molecular mechanism of digestion in a scorpion was proposed based on our results from Tityus serrulatus. The midgut and midgut glands (MMG) are composed by secretory and digestive cells. In fasting animals, the secretory granules are ready for the next predation event, containing enzymes needed for alkaline extra-oral digestion which will compose the digestive fluid, such as trypsins, astacins and chitinase. The digestive vacuoles are filled with an acidic proteolytic cocktail to the intracellular digestion composed by cathepsins L, B, F, D and legumain. Other proteins as lipases, carbohydrases, ctenitoxins and a chitolectin with a perithrophin domain were also detected. Evolutionarily, a large gene duplication of cathepsin L occurred in Arachnida with the sequences from ticks being completely divergent from other arachnids probably due to the particular selective pressures over this group.

Scorpion-related cardiomyopathy: Clinical characteristics, pathophysiology, and treatment

CONTEXT

Scorpion envenomation is a threat to more than 2 billion people worldwide with an annual sting number exceeding one million. Acute heart failure presenting as cardiogenic shock or pulmonary edema, or both is the most severe presentation of scorpion envenomation accounting for 0.27% lethality rate.

OBJECTIVE

The purpose of this review is to characterize the scorpion-related cardiomyopathy, clarify its pathophysiological mechanisms, and describe potentially useful treatments in this particular context.

METHODS

We searched major databases on observational or interventional studies (whether clinical or experimental) on the cardiorespiratory consequences of scorpion envenomation and their treatment. No limit of age or language was imposed. A critical appraisal of the literature was conducted in order to provide a pathophysiological scheme that reconciles reported patterns of cardiovascular toxicity and hypotheses and assumptions made so far.

RESULTS

Early cardiovascular dysfunction is related to the so-called "vascular phase" of scorpion envenomation, which is related to a profound catecholamine-related vasoconstriction leading to a sharp increase in left ventricular (LV) afterload, thereby impeding LV emptying, and increasing LV filling pressure. Following this vascular phase, a myocardial phase occurs, characterized by a striking alteration in LV contractility (myocardial stunning), low cardiac output, and hypotensive state. The right ventricle involvement is symmetric to that of LV with a profound and reversible alteration in right ventricular performance. This phase is unique in that it is reversible spontaneously or under inotropic treatment. Scorpion myocardiopathy combines the features of takotsubo myocardiopathy (or stress myocardiopathy) which is linked to a massive release in catecholamines leading to myocardial ischemia through coronary vasomotor abnormalities (epicardial coronary spasm and/or increase in coronary microvascular resistance). Treatment of pulmonary edema due to scorpion envenomation follows the same principles as those applied for the treatment of cardiogenic pulmonary edema in general: this begins with oxygen supplementation targeting an oxygen saturation of 92% or more, by oxygen mask, continuous positive airway pressure, noninvasive ventilation, or conventional mechanical ventilation. Dobutamine effectively improves hemodynamic parameters and may reduce mortality in severe scorpion envenomation.

CONCLUSION

Scorpion cardiomyopathy is characterized by a marked and reversible alteration in biventricular performance. Supportive treatment relying on ventilatory support and dobutamine infusion is a bridge toward recovery in the majority of patients.

Evolution of alternative methodologies of scorpion antivenoms production

Scorpionism represents a serious public health problem resulting in the death of children and debilitated individuals. Scorpion sting treatment employs various strategies including the use of specific medicines such as antiserum, especially for patients with severe symptoms. In 1909 Charles Todd described the production of an antiserum against the venom of the scorpion Buthus quinquestriatus. Based on Todd's work, researchers worldwide began producing antiserum using the same approach i.e., immunization of horses with crude venom as antigen. Despite achieving satisfactory results using this approach, researchers in this field have developed alternative approaches for the production of scorpion antivenom serum. In this review, we describe the work published by experts in toxinology to the development of scorpion venom antiserum. Methods and results describing the use of specific antigens, detoxified venom or toxins, purified toxins and or venom fractions, native toxoids, recombinant toxins, synthetic peptides, monoclonal and recombinant antibodies, and alternative animal models are presented.

Transcriptome analysis of scorpion species belonging to the Vaejovis genus

Scorpions belonging to the Buthidae family have traditionally drawn much of the biochemist's attention due to the strong toxicity of their venoms. Scorpions not toxic to mammals, however, also have complex venoms. They have been shown to be an important source of bioactive peptides, some of them identified as potential drug candidates for the treatment of several emerging diseases and conditions. It is therefore important to characterize the large diversity of components found in the non-Buthidae venoms. As a contribution to this goal, this manuscript reports the construction and characterization of cDNA libraries from four scorpion species belonging to the Vaejovis genus of the Vaejovidae family: Vaejovis mexicanus, V. intrepidus, V. subcristatus and V. punctatus. Some sequences coding for channel-acting toxins were found, as expected, but the main transcribed genes in the glands actively producing venom were those coding for non disulfide-bridged peptides. The ESTs coding for putative channel-acting toxins, corresponded to sodium channel β toxins, to members of the potassium channel-acting α or κ families, and to calcium channel-acting toxins of the calcin family. Transcripts for scorpine-like peptides of two different lengths were found, with some of the species coding for the two kinds. One sequence coding for La1-like peptides, of yet unknown function, was found for each species. Finally, the most abundant transcripts corresponded to peptides belonging to the long chain multifunctional NDBP-2 family and to the short antimicrobials of the NDBP-4 family. This apparent venom composition is in correspondence with the data obtained to date for other non-Buthidae species. Our study constitutes the first approach to the characterization of the venom gland transcriptome for scorpion species belonging to the Vaejovidae family.

Echocardiologic evaluation and follow-up of cardiovascular complications in children with scorpion sting in coastal South India

Introduction and Objective:

Scorpion stings are a common emergency in India and many other tropical countries. In India, the red scorpions are more prevalent, and their venom is more likely to cause myocardial dysfunctions. There are very few studies conducted on this problem. The following study was done in Andhra Pradesh and aimed to identify cardiovascular complications of scorpion stings in children with a follow-up of 6 months

Study Design:

Prospective observational study.

Setting:

Children admitted with scorpion sting in a tertiary care hospital between December 2009 and November 2010 and followed-up till May 2011.

Results:

Scorpion stings account for 1 in every 36 admissions. Maximum cases were in 0–3 years age group. Electrocardiogram changes were seen in 76% cases and myocarditis in 42% cases. Echocardiography revealed decreased ejection fraction (EF), transient mitral regurgitation and wall motion abnormalities were observed. Average EF improved from 16% on day 1 to 47.94% and 59% on day 5 and 14 respectively, which was highly statistically significant. By the end of 1 month, all the survivors had normal EF and no residual cardiac dysfunction was observed at 6 months.

Conclusion:

Scorpion stings, a common and fatal medical emergency in India, produce echocardiographic changes without any long term residual damage on myocardial activity.

Scorpion venom components as potential candidates for drug development

Scorpions are well known for their dangerous stings that can result in severe consequences for human beings, including death. Neurotoxins present in their venoms are responsible for their toxicity. Due to their medical relevance, toxins have been the driving force in the scorpion natural compounds research field. On the other hand, for thousands of years, scorpions and their venoms have been applied in traditional medicine, mainly in Asia and Africa. With the remarkable growth in the number of characterized scorpion venom components, several drug candidates have been found with the potential to tackle many of the emerging global medical threats. Scorpions have become a valuable source of biologically active molecules, from novel antibiotics to potential anticancer therapeutics. Other venom components have drawn attention as useful scaffolds for the development of drugs. This review summarizes the most promising candidates for drug development that have been isolated from scorpion venoms.

Acute cerebellar dysfunction with neuromuscular manifestations after scorpionism presumably caused by Tityus obscurus in Santarém, Pará / Brazil

Scorpionism is a public health problem in many tropical countries, especially in North Africa, South India, Latin America and the Middle East. In Brazil, patients with severe scorpion envenoming have mainly cardiovascular events, including acute heart failure, acute respiratory distress syndrome and shock, death is rare. We described 58 accidents presumably caused by Tityus obscurus in Brazilian Amazonia. Patients reported a sensation of "electric shocks" which could last hours. The vast majority of patients presented a clinical picture compatible with acute cerebellar dysfunction, beginning minutes and lasting up to 2 days after the accident. They presented cerebellar ataxia, dysdiadochokinesia, dysmetry, dysarthria, dyslalia, nausea and vomiting. Besides, some patients presented myoclonus and fasciculation which can also be attributed to cerebellar dysfunction or maybe the result of direct action on skeletal muscle. Two patients had evidence of intense rhabdomyolysis and acute kidney injury. The clinical picture in this scorpion envenoming is mainly characterized by an acute dysfunction of cerebellar activities and abnormal neuromuscular manifestations and in some cases muscle injury which are not described in any other region of the world. This work presents clinical, epidemiologic, laboratory and treatment aspects of this unmatched scorpion envenoming in the state of Pará, northern Brazil.

Quo vadis venomics? A roadmap to neglected venomous invertebrates

Venomics research is being revolutionized by the increased use of sensitive -omics techniques to identify venom toxins and their transcripts in both well studied and neglected venomous taxa. The study of neglected venomous taxa is necessary both for understanding the full diversity of venom systems that have evolved in the animal kingdom, and to robustly answer fundamental questions about the biology and evolution of venoms without the distorting effect that can result from the current bias introduced by some heavily studied taxa. In this review we draw the outlines of a roadmap into the diversity of poorly studied and understood venomous and putatively venomous invertebrates, which together represent tens of thousands of unique venoms. The main groups we discuss are crustaceans, flies, centipedes, non-spider and non-scorpion arachnids, annelids, molluscs, platyhelminths, nemerteans, and echinoderms. We review what is known about the morphology of the venom systems in these groups, the composition of their venoms, and the bioactivities of the venoms to provide researchers with an entry into a large and scattered literature. We conclude with a short discussion of some important methodological aspects that have come to light with the recent use of new -omics techniques in the study of venoms.

Scorpionism in Brazil in the years 2000 to 2012

Background

Scorpionism is a serious public health problem in Brazil. Nationwide epidemiological analyses of scorpion stings are scarce. In this context, the present study aims to provide an epidemiological analysis of accidents involving scorpions in Brazil.

Methods

An analytical epidemiological study of the scorpion accidents reported in the Information System for Notifiable Diseases (SINAN) was conducted from 2000 to 2012 in Brazil.

Results

During this period, 482,616 accidents and 728 deaths were reported. The annual average incidence and mortality rates per 100,000 inhabitants were 19.6 and 0.030, respectively, with annual average lethality rate of 0.16%. The highest accident frequency was recorded in male subjects, aged 20–49 years, from September to December and in urban areas, except in the northern region of the country, where accidents were most frequent in June and July, and in rural areas. Males up to age 9 and rural areas were defined as an age group and area for greatest death risk, respectively.

Conclusions

Scorpionism in Brazil is a predominantly urban health problem that mostly affects people at an economically active age. The Northeast and Southeast hold the majority of cases and deaths, as well as the highest annual incidence and mortality averages, but the Central West and North presented the highest average annual lethality rates. The epidemiological changes described in this study highlight the need for intensifying health surveillance actions to prevent scorpion accidents in Brazil.

A randomized trial comparing intravenous paracetamol, topical lidocaine, and ice application for treatment of pain associated with scorpion stings

OBJECTIVE

Appropriate treatment for scorpion-associated pain was not previously studied in detail in the literature. The aim of this study was to compare the efficacy of three treatment modalities in patients with painful scorpion stings using visual analog scale (VAS) scores.

MATERIALS AND METHODS

A randomized study was carried out during a 1-year period in patients with scorpion stings who did not have any systemic signs or symptoms. Patients were treated with intravenous paracetamol, topical lidocaine, or ice application. Pain intensity was evaluated using VAS score at the time of presentation to emergency department and at 30th, 60th, 120th, and 240th minutes. Changes in VAS scores from baseline were recorded.

RESULTS

A total of 130 patients were included in the statistical analysis. Significant reduction in pain intensity was observed with topical lidocaine group when compared with the ice application group (p < 0.001) and paracetamol group (p < 0.001) in all selected time intervals. The median reduction in scores at 30 min after therapeutic intervention was 25.0 mm for topical lidocaine, 14.5 mm for ice application, and 10.0 mm for intravenous paracetamol. No adverse events were reported.

DISCUSSION

Our results revealed that topical lidocaine is superior to both intravenous paracetamol and local ice application and its effect lasts several hours after envenomation.

CONCLUSION

Topical lidocaine is an effective and safe treatment in scorpion sting associated with pain in patients with nonsystemic signs and symptoms.

Getting stung by black scorpion Androctonus crassicauda

Importance of the correct diagnosis in the correct early management of a scorpion stung patient by using antivenom is not emphasized, particularly when there are little evidences. A 65-year-old female was brought to our emergency department with the chief compliant of being stung by an unknown object 3 h earlier while traveling in an intercity bus. She became agitated and simultaneously experienced tachycardia, very severe generalized sweating, cold and wet extremities, bilateral diffuse crackle in the base of lungs, tachypnea, and lethargy. With the primitive diagnosis of myocardial infarction, scorpion sting was documented as the cause of this combined cholinergic and adrenergic syndrome after the scorpion was found in the patient’s bed clothes. She dramatically responded to the administration of low dose of scorpion antivenom. This case dramatically responded to the antivenom administration, especially the cholinergic and sympathetic signs, pulmonary edema, and electrocardiographic changes were fully and almost immediately recovered. Scorpion antivenom may reverse life-threatening manifestations of scorpion envenomation if used early and in appropriate patients.

[Scorpion envenomation treated in the Infectious and Tropical Diseases at the Donka National Hospital, Guinea]

A retrospective descriptive study was conducted from 1(st) October 2010 to 30 November 2012 on the records of patients admitted for scorpion envenomation in the Department of Infectious and Tropical Diseases at the Donka National Hospital. The objective of this study is to describe the epidemiological profile and clinical characteristics of scorpion envenomation in Maritime Guinea, from scorpion stings recently covered in this service. We collected 75 cases of scorpion envenomation. The median age was 21.5 with interquartile 8 and 20 and sex ratio was 1.29. The upper limbs were involved in 55% of cases, followed by the lower limbs (35%), trunk (6%), head and neck (4%). We observed 63% of patients with local signs, 30% mild and general clinical signs of 7% severe systemic symptoms. All patients received an analgesic and a heterologous antitoxin, associated with an antibiotic (87% of patients), a corticosteroid (72%), diazepam (13%) and furosemide (34.6%). The incidence of scorpion envenomation is not negligible despite underreporting of cases, most often treated in traditional medicine.

Engineering venom's toxin-neutralizing antibody fragments and its therapeutic potential

Serum therapy remains the only specific treatment against envenoming, but anti-venoms are still prepared by fragmentation of polyclonal antibodies isolated from hyper-immunized horse serum. Most of these anti-venoms are considered to be efficient, but their production is tedious, and their use may be associated with adverse effects. Recombinant antibodies and smaller functional units are now emerging as credible alternatives and constitute a source of still unexploited biomolecules capable of neutralizing venoms. This review will be a walk through the technologies that have recently been applied leading to novel antibody formats with better properties in terms of homogeneity, specific activity and possible safety.

Wheat germ in vitro translation to produce one of the most toxic sodium channel specific toxins

Envenoming following scorpion sting is a common emergency in many parts of the world. During scorpion envenoming, highly toxic small polypeptides of the venom diffuse rapidly within the victim causing serious medical problems. The exploration of toxin structure-function relationship would benefit from the generation of soluble recombinant scorpion toxins in Escherichia coli. We developed an in vitro wheat germ translation system for the expression of the highly toxic Aah (Androctonus australis hector)II protein that requires the proper formation of four disulphide bonds. Soluble, recombinant N-terminal GST (glutathione S-transferase)-tagged AahII toxin is obtained in this in vitro translation system. After proteolytic removal of the GST-tag, purified rAahII (recombinant AahII) toxin, which contains two extra amino acids at its N terminal relative to the native AahII, is highly toxic after i.c.v. (intracerebroventricular) injection in Swiss mice. An LD₅₀ (median lethal dose)-value of 10 ng (or 1.33 pmol), close to that of the native toxin (LD₅₀ of 3 ng) indicates that the wheat germ in vitro translation system produces properly folded and biological active rAahII. In addition, NbAahII10 (Androctonus australis hector nanobody 10), a camel single domain antibody fragment, raised against the native AahII toxin, recognizes its cognate conformational epitope on the recombinant toxin and neutralizes the toxicity of purified rAahII upon injection in mice.

A wheat germ embryo derived cell-free translation system expresses a biologically active, highly toxic scorpion venom protein that is fully neutralized by a camel single domain antibody fragment raised against the native scorpion toxin.

Scorpions: a presentation

Scorpions, at least the species of the family Buthidæ whose venoms are better known, appear as animals that have evolved very little over time. The composition of their venoms is relatively simple as most toxins have a common structural motif that is found in other venoms from primitive species. Moreover, all the scorpion venom toxins principally act on membrane ionic channels of excitable cells. The results of recent works lead to the conclusion that in scorpions there is a close relationship between venomous function and innate immune function both remarkably efficient.

Ischemic infarction of cerebral cortex in a child with scorpion sting envenomation

Ischemic infarction in scorpion sting envenomation is rare and only few cases have been reported in adults. A 3-y-old child is reported who developed recurrent generalized tonic-clonic seizures 2 h after admission and hemiparesis on third day of admission following scorpion sting. Cranial tomography showed infarction in right and left frontoparietal lobes. The child was managed conservatively with prazosin, lorazepam and phenytoin sodium and made a complete recovery.

A camelid antibody candidate for development of a therapeutic agent against Hemiscorpius lepturus envenomation

Hemiscorpius lepturus scorpionism poses one of the most dangerous health problems in many parts of the world. The common therapy consists of using antivenom antibody fragments derived from a polyclonal immune response raised in horses. However, this immunotherapy creates serious side effects, including anaphylactic shock sometimes even leading to death. Thus, many efforts have been made to introduce new replacement therapeutics that cause less adverse reactions. One of the most attractive approaches to replacing the available therapy is offered by single-domain antibody fragments, or nanobodies (Nbs). We immunized dromedaries with H. lepturus toxin and identified a functional recombinant Nb (referred to as F7Nb) against heminecrolysin (HNc), the major known hemolytic and dermonecrotic fraction of H. lepturus venom. This Nb was retrieved from the immune library by phage display selection. The in vitro neutralization tests indicated that 17.5 nmol of the F7Nb can inhibit 45% of the hemolytic activity of 1 EC100 (7.5 μg/ml) of HNc. The in vivo neutralization tests demonstrated that F7Nb had good antihemolytic and antidermonecrotic effects against HNc in all tested mice. Surprisingly, F7Nb (8.75 nmol) neutralized 1 LD100 of HNc (10 μg) via an intracerebroventricular route or 1 LD100 (80 μg) via a subcutaneous route. All of the control mice died. Hence, this Nb is a potential leading novel candidate for treating H. lepturus scorpionism in the near future.

Distribuição espacial de acidentes escorpiônicos em Belo Horizonte, Minas Gerais, 2005 a 2009

Acidentes por escorpião constituem problema de saúde pública em Belo Horizonte. Realizou-se um estudo epidemiológico observacional retrospectivo para analisar a frequência e distribuição espacial dos acidentes escorpiônicos em Belo Horizonte, entre 2005 e 2009, e associá-las às categorias de risco classificadas pelo Índice de Vulnerabilidade à Saúde (IVS), um índice socioeconômico regional composto. Foram utilizados dados de notificação do Sistema Nacional de Agravos de Notificação (SINAN) e Sistema de Vigilância Epidemiológica (SISVE), referentes aos anos de 2008 e 2009. Para o período de 2005 a 2007, foi necessário o resgate de dados das fichas clínicas do Hospital João XXIII (HPSJXXIII) correspondentes às variáveis encontradas no SINAN e SISVE, uma vez que os mesmos não estavam digitalizados nos referidos sistemas de informação. Para georreferenciamento e análise espacial, foi utilizada a base geográfica EndGeo, o aplicativo de mapeamento MapInfo versão 10.0 e os programas Hotspot Detective e SatScan. Entre 2005 e 2009, ocorreram em Belo Horizonte 2.769 casos de acidentes por escorpião, o que representa uma incidência média de 22,4 casos por 100.000 habitantes. Do total de casos, 1.924 (69,5%) foram georreferenciados e houve predomínio de incidência em dois Distritos Sanitários (DS), com grande concentração de casos nas regiões de cemitérios do município. Foram detectados dois "clusters" no período, sendo um em 2005, nos DS Noroeste e Oeste, e outro entre 2006 e 2007, nos DS Noroeste e Nordeste. Não houve associação entre as áreas de maior incidência de escorpionismo e as áreas de maior risco à saúde classificadas pelo IVS. Com base nos resultados, conclui-se que há necessidade de melhorias no processo de notificação do agravo e que o mapeamento dos casos é uma ferramenta relevante capaz de embasar o direcionamento das ações educativas de controle para as áreas prioritárias de Belo Horizonte.

Clinical characteristics and outcome of children stung by scorpion

Scorpion envenomation is a health problem in children in tropical and subtropical regions. The aim of this study was to evaluate demographic and clinical characteristics as well as outcomes in referred children to Assiut University Children Hospital during the year 2012 with a history of scorpion sting. The medical files of these patients were reviewed retrospectively for demographic data, time and site of biting, and clinical manifestations. Laboratory investigations of the patients were reviewed for complete blood count (CBC), liver function tests, creatinine phosphokinase (CPK), lactate dehydrogenase (LDH), arterial blood gases, and serum electrolytes. Results showed 111 children with a history of scorpion sting; 69 males and 42 females with a median age of 5 years. Out of the studied patients, 53.2 % were classified as class III of clinical severity with recorded pulmonary edema in 33.3 %, cardiogenic shock in 46.8 %, and severe neurological manifestations in 22.8 %. Twelve patients (10.8 %) were classified as class II with mild systemic manifestations, and 36 % of the patients were classified as class I with only local reaction. Outcomes of these patients were discharge without sequelae in 55.8 %, discharge with sequelae in 26.1 %, and death in 18.1 %.

CONCLUSION

more than half of stung children had a severe clinical presentation and about one fifth died. Aggressive treatment regimens are recommended for such patients to improve the outcome.

Deep intraspecific divergences in the medically relevant fat-tailed scorpions (Androctonus, Scorpiones)

The genus Androctonus, commonly known as fat-tailed scorpions, contains 22 species distributed from Togo and Mauritania in the west, North Africa, through the Middle East and to as far east as India. With 13 species, a substantial amount of this genus' diversity occurs in North Africa, which is a major hotspot of scorpion sting incidents. Androctonus are among the most medically relevant animals in North Africa. Since venom composition within species is known to vary regionally, the improvement of therapeutic management depends on a correct assessment of the existing regional specific and sub-specific variation. In this study, we assessed the phylogeographical patterns in six species of Androctonus scorpions from North Africa using mitochondrial DNA markers. We sequenced COX1, 12S, 16S and ND1 genes from 110 individuals. Despite lacking basal resolution in the tree, we found taxonomical and geographically coherent clades. We discovered deep intraspecific variation in the widespread Androctonus amoreuxi and Androctonus australis, which consisted of several well-supported clades. Genetic distances between some of these clades are as high as those found between species. North African A. australis have a deep split in Tunisia around the Chott el-Djerid salt-lake. A novel split between A. amoreuxi scorpions was found in Morocco. We also found deep divergences in Androctonus mauritanicus, corresponding to areas attributed to invalidated subspecies. In addition we uncovered a clade of specimens from coastal south Morocco, which could not be ascribed to any know species using morphological characters. Based on these findings we recommend a reassessment of venom potency and anti-venom efficacy between these deep intraspecific divergent clades.

Efficacy of scorpion antivenom plus prazosin versus prazosin alone for Mesobuthus tamulus scorpion sting envenomation in children: a randomised controlled trial

OBJECTIVE

To assess the efficacy of combined use of scorpion antivenom (SAV) with prazosin, compared with prazosin alone in children with Mesobuthus tamulus scorpion envenomation.

STUDY DESIGN

Randomised controlled trial.

SETTING

A tertiary care hospital in south India.

PATIENTS

50 children with definite history and/or systemic manifestations of scorpion envenomation were recruited from the paediatric emergency or outpatient department from February 2012 to July 2013.

INTERVENTIONS

The children were randomised into two groups. In 25 children, SAV was administrated as a slow intravenous bolus combined with prazosin (group A). Others received prazosin alone (group B). Results were analysed by Student t test and χ(2) test.

MAIN OUTCOME MEASURES

Time required for resolution of autonomic symptoms, total dose of prazosin, adverse events.

RESULTS

Children in group A recovered earlier than those in group B (mean difference 9.1 h, 95% CI 6.0 to 12.2). 23 children (92%) in group A were clear of autonomic symptoms within 10 h, compared with 10 children (40%) in group B (mean difference 52%, 95% CI 29% to 75%). The proportion of children deteriorating to clinical grade 3 or 4 was 8% in group A as against 44% in group B (p<0.01). The mean dose of prazosin required was 54 µg/kg versus 130.8 µg/kg in group A and B, respectively (p<0.01). SAV was not associated with severe adverse reactions.

CONCLUSIONS

Usage of SAV led to faster recovery and reduced the incidence of myocardial dysfunction. Combined therapy with SAV and prazosin is beneficial for children with M tamulus scorpion envenomation.

TRIAL REGISTRATION NUMBER

CTRI/2013/09/004002 (Clinical Trials Registry of India).

The genome of Mesobuthus martensii reveals a unique adaptation model of arthropods

Representing a basal branch of arachnids, scorpions are known as ‘living fossils’ that maintain an ancient anatomy and are adapted to have survived extreme climate changes. Here we report the genome sequence of Mesobuthus martensii, containing 32,016 protein-coding genes, the most among sequenced arthropods. Although M. martensii appears to evolve conservatively, it has a greater gene family turnover than the insects that have undergone diverse morphological and physiological changes, suggesting the decoupling of the molecular and morphological evolution in scorpions. Underlying the long-term adaptation of scorpions is the expansion of the gene families enriched in basic metabolic pathways, signalling pathways, neurotoxins and cytochrome P450, and the different dynamics of expansion between the shared and the scorpion lineage-specific gene families. Genomic and transcriptomic analyses further illustrate the important genetic features associated with prey, nocturnal behaviour, feeding and detoxification. The M. martensii genome reveals a unique adaptation model of arthropods, offering new insights into the genetic bases of the living fossils.

Scorpions have maintained the primary anatomical features of their Paleozoic arthropod ancestors. Here, the authors report the genome sequence of Mesobuthus martensii and highlight evidence of genetic and morphological evolution that represents a unique adaptation model of arthropods.

Scorpion venoms as a potential source of novel cancer therapeutic compounds

Scorpions and their venoms have been used in traditional medicine for thousands of years in China, India and Africa. The scorpion venom is a highly complex mixture of salts, nucleotides, biogenic amines, enzymes, mucoproteins, as well as peptides and proteins (e.g. neurotoxins). One of the recently observed biological properties of animal venoms and toxins is that they possess anticancer potential. An increasing number of studies have shown that scorpion venoms and toxins can decrease cancer growth, induce apoptosis and inhibit cancer progression and metastasis in vitro and in vivo. Several active molecules with anticancer activities, ranging from inhibition of proliferation and cell cycle arrest to induction of apoptosis and decreasing cell migration and invasion, have been isolated from scorpion venoms. These observations have shed light on the application of scorpion venoms and toxins as potential novel cancer therapeutics. This mini-review focuses on the anticancer potential of scorpion venoms and toxins and the possible mechanisms for their antitumor activities.

Overview of scorpion species from China and their toxins

Scorpions are one of the most ancient groups of terrestrial animals. They have maintained a steady morphology over more than 400 million years of evolution. Their venom arsenals for capturing prey and defending against predators may play a critical role in their ancient and conservative appearance. In the current review, we present the scorpion fauna of China: 53 species covering five families and 12 genera. We also systematically list toxins or genes from Chinese scorpion species, involving eight species covering four families. Furthermore, we review the diverse functions of typical toxins from Chinese scorpion species, involving Na⁺ channel modulators, K⁺ channel blockers, antimicrobial peptides and protease inhibitors. Using scorpion species and their toxins from China as an example, we build the bridge between scorpion species and their toxins, which helps us to understand the molecular and functional diversity of scorpion venom arsenal, the dynamic and functional evolution of scorpion toxins, and the potential relationships of scorpion species and their toxins.

Mild reproductive effects of the Tityus bahiensis scorpion venom in rats

Background

Scorpion envenoming is a public health problem in Brazil, where Tityus serrulatus and T. bahiensis are considered the most dangerous scorpions. They are well adapted to urbanized environments, and there is an increasing probability of human exposure to these venoms, including during pregnancy. Not much is known about the effects of prenatal exposure to the venom, and no information is available to aid in the rational treatment of victims stung during pregnancy. Thus, this study aimed to investigate whether venom from the scorpion T. bahiensis administered once to pregnant female rats at a dose that causes a moderate envenomation may lead to deleterious effects on the reproductive performance of the dams and on the development of their offspring. This is the first work demonstrating that T. bahiensis venom, when administered experimentally to rats, alters maternal reproductive performance and the morphological development of fetuses. The venom was given to dams on the 5th (GD5) or on the 10th (GD10) gestational day. After laparotomy, on GD21, fetuses and placentas were counted, weighed and externally analyzed. The corpora lutea were counted. The sex and vitality of fetuses were evaluated, and each litter was then randomly divided for visceral or skeletal analyses. Data were analyzed by ANOVA followed by the Tukey-Kramer test and Fisher’s exact test. The significance level for all tests was set at p < 0.05.

Results

GD5 group presented an increased number of pre-implantation losses. Weight gains in fetuses and placentas were observed in the GD5 and GD10 groups. Weights of the heart and lungs were elevated in GD5 and GD10 and liver weight in GD10.

Conclusions

Moderate envenomation by T. bahiensis scorpion venom alters maternal reproductive performance and fetal development. However, these are preliminary results whose causes should be investigated more carefully in future studies.

Pediatric epidemiological aspects of scorpionism and report on fatal cases from Tityus stigmurus stings (Scorpiones: Buthidae) in State of Pernambuco, Brazil

INTRODUCTION

Envenomation by scorpion stings is a major public health problem in numerous tropical countries because of its frequent incidence and potential severity. Approximately 1,900 species of scorpions are known in the world, and at least 130 of these have been described in Brazil.

METHODS

This work reports on 3 child deaths caused by Tityus stigmurus stings and characterizes epidemiological and clinical surveys on pediatric cases of scorpionism recorded in the Centro de Assistência Toxicológica de Pernambuco (Ceatox-PE).

RESULTS

Scorpion stings accounted for more than 60% of all cases recorded for venomous animals. The children were from 37 cities of the State of Pernambuco and accounted for 28.8% of the victims treated for scorpion stings, with the highest incidence in the metropolitan area of Recife. Stings occurred throughout the year and slightly increased during the rainy season. Independent of the elapsed time for a prognosis, most cases showed mild symptoms. Three moderate cases that resulted in death featured cardiogenic shock and/or pulmonary edema or severe neurological symptoms. For the fi rst time, death attributed to T. stigmurus was confirmed by the presence of the scorpion.

CONCLUSIONS

These results suggest that scorpionism in Pernambuco is a public health problem that needs to be monitored carefully throughout the year by the government.