Epidemiology of scorpionism: a global appraisal

Scorpion envenomation among children: clinical manifestations and outcome (analysis of 685 cases)

Our objective was to characterize both epidemiologically and clinically manifestations after severe scorpion envenomation and to define simple factors indicative of poor prognosis in children. We performed a retrospective study over 13 years (1990-2002) in the medical intensive care unit (ICU) of a university hospital (Sfax-Tunisia). The diagnosis of scorpion envenomation was based on a history of scorpion sting. The medical records of 685 children aged less than 16 years who were admitted for a scorpion sting were analyzed. There were 558 patients (81.5%) in the grade III group (with cardiogenic shock and/or pulmonary edema or severe neurological manifestation [coma and/or convulsion]) and 127 patients (18.5%) in the grade II group (with systemic manifestations). In this study, 434 patients (63.4%) had a pulmonary edema, and 80 patients had a cardiogenic shock; neurological manifestations were observed in 580 patients (84.7%), 555 patients (81%) developed systemic inflammatory response syndrome (SIRS), and 552 patients (80.6%) developed multi-organ failure. By the end of the stay in the ICU, evolution was marked by the death in 61 patients (8.9%). A multivariate analysis found the following factors to be correlated with a poor outcome: coma with Glasgow coma score ≤ 8/15 (odds ratio [OR] = 1.3), pulmonary edema (OR = 2.3), and cardiogenic shock (OR = 1.7). In addition, a significant association was found between the development of SIRS and heart failure. Moreover, a temperature > 39°C was associated with the presence of pulmonary edema, with a sensitivity at 20.6%, a specificity at 94.4%, and a positive predictive value at 91.7%. Finally, blood sugar levels above 15 mmol/L were significantly associated with a heart failure. In children admitted for severe scorpion envenomation, coma with Glasgow coma score ≤ 8/15, pulmonary edema, and cardiogenic shock were associated with a poor outcome. The presence of SIRS, a temperature > 39°C, and blood sugar levels above 15 mmol/L were associated with heart failure.

Specific activation of human neutrophils by scorpion venom: a flow cytometry assessment

Acute lung injury following envenomation by Tityus scorpion species is due in part to activation of the inflammatory response leading to release of cytotoxic leukocyte-derived products, including cytokines and possibly reactive oxygen species (ROS). Tityus zulianus envenomation in Venezuela produces cardiorespiratory complications and death by lung injury whereas stings by Tityus discrepans produce mainly gastrointestinal and pancreatic alterations. To ascertain the role played by granulocytes in the envenomation by T. zulianus (TzV) and T. discrepans (TdV), human peripheral blood neutrophils, eosinophils, and monocytes were exposed to scorpion venoms (0.001-5 μg/mL) and the kinetics (5-15 min) of peroxide production determined by flow cytometry, using 2',7'-dichlorodihydrofluorescein diacetate (succinimidyl ester) as a fluorescent substrate. TzV induced a significantly (p<0.01) more potent increase in peroxide production in neutrophils (for 5 and 10 min of incubation), and to a lesser extent in monocytes (5-15 min), compared to TdV. TzV induced necrosis in neutrophils at doses higher than 5 μg/mL. No effect was observed on eosinophils, suggesting that TzV specifically targets neutrophil intracellular ROS production. The TzV-stimulated pathway is protein kinase C-dependent because it was almost completely (>90%) abolished by staurosporine. The stimulatory effect is associated with the lowest molecular mass venom peptides as gel filtration fractions TzII and TzIII significantly enhanced peroxide production. The combined used of the intracellular ROS agonist, phorbol myristate acetate (PMA), and TzV produced a modest but significant increase in peroxide production suggesting the possibility of overlapping signaling cascades amongst PMA and TzV. Up-regulation of intracellular neutrophil ROS production may be an important in vivo target for TzV which could have a role to play in the cardiorespiratory complications elicited after envenomation by this species.

Molecular diversity of toxic components from the scorpion Heterometrus petersii venom revealed by proteomic and transcriptome analysis

Scorpion venoms contain a vast untapped reservoir of natural products, which have the potential for medicinal value in drug discovery. In this study, toxin components from the scorpion Heterometrus petersii venom were evaluated by transcriptome and proteome analysis.Ten known families of venom peptides and proteins were identified, which include: two families of potassium channel toxins, four families of antimicrobial and cytolytic peptides,and one family from each of the calcium channel toxins, La1-like peptides, phospholipase A2,and the serine proteases. In addition, we also identified 12 atypical families, which include the acid phosphatases, diuretic peptides, and ten orphan families. From the data presented here, the extreme diversity and convergence of toxic components in scorpion venom was uncovered. Our work demonstrates the power of combining transcriptomic and proteomic approaches in the study of animal venoms.

Scorpion stings in Turkey: epidemiological and clinical aspects between the years 1995 and 2004

The most important health-threatening scorpions found in Turkey are; Androctonus crassicauda, Leiurus quinquestriatus, Mesobuthus gibbosus and M. eupeus species, all of which belong to the Buthidae family. The epidemiological and clinical findings of scorpion stings in Turkey were evaluated between the years 1995 and 2004 based on data recorded in the National Poison Information Center (NPIC). A total of 930 cases were recorded. The cases mostly occurred in the month of July. The gender distribution was 50.22% female and 45.48% male. It was shown that the 20-29 age group presented more scorpion stings. Most of the stings occurred in Central Anatolia and Marmara regions of Turkey. Patients at the hospital showed signs of localized (pain, hyperemia, edema and numbness) and systemic effects (hyperthermia, nausea and vomiting, tachycardia, shivering and lethargy) but no lethality was notified. According to records, 33% of the poisoned patients were treated with antivenin in healthcare facilities.

[Emergency immunotherapy: snake and scorpion antivenoms]

Passive immunotherapy was discovered in 1894. It is the only etiological treatment of envenomations by snakes or scorpions. Immunotherapy is based on administration of antibodies produced by an animal hyperimmunised against venom. Improvement of whole antivenomous sera was obtained, first by separating the antibodies from other components of blood plasma, then by using enzyme digestion of immunoglobulins G and, finally, by purifying the final product. Efficacy and also tolerance were significantly increased. Antivenom administration should be performed through the intravascular route to ensure better diffusion and to facilitate the complexion with the venom. The sale of antivenoms, in particular in Africa, is considerably reduced since about thirty years and is not in adequacy with the epidemiologic needs. In addition to the high cost of the current products, the difficulties of supplying, storage and use seem at the origin of this rejection by both the health staff and the victims who resort massively to traditional medicine. Whereas WHO reminds the rules of production and use of the antivenoms to producers and authorities in charge of drug regulations, it appears that the accessibility of the antivenoms depends on a concerted effort from all the actors, coordinated by health authorities: producers, distributers, manufacturers and public. Beyond technological improvements necessary in antivenom production, the strategy to be implemented must include the strict evaluation of the needs based on epidemiologic studies, the share of cost recovery between all the actors, and the optimization of the therapeutic protocol to make it applicable in remote health centres. Once confidence towards immunotherapy will be restored, mortality will be significantly reduced.

[Impact of the environment on envenomation incidence and severity]

Envenomations constitute a serious public health problem in many developing countries. It is related to the hazards of the encounters of venomous animals and human explained by both the venomous animal behaviour and human activities. Severity depends on the toxicity or inoculated amount of the venom and, to a lesser extent, on the management of the envenomation. Man-induced alteration of the environment results in modifications of venomous animals populations both in proportion of species and abundance of specimens. Some species have a higher adaptation capacity and may grow up dramatically. In rural regions, plantations are at great risk of exposure to snakes whereas in suburban areas, scorpions may occur in high density. In some plantations or settlements, incidence may increase by two to ten folds. Local ecological and epidemiological studies allow taking measures to control the venomous animals, prevent the snakebites or scorpion stings and provide antivenoms and better management of the envenomations.

Effects of in utero exposure to Tityus bahiensis scorpion venom in adult rats

The toxicity of Tityus bahiensis scorpion venom is well known, but there are little data about the damage in offspring of dams that were exposed to the venom during pregnancy. The objective of this work was to determine the toxic effects of venom in adult offspring of Wistar rats exposed to venom in utero. Dams were divided into a control group, subcutaneously injected with saline solution on the 10th (GD10) and 16th (GD16) days, and two experimental groups, subcutaneously injected with venom (2.5mg/kg) on GD10 or GD16, respectively. Adult offspring were evaluated according to behavioral development and neuronal integrity in the hippocampus. Tests performed in the activity box and in the enriched environment demonstrated that males from GD10 had motor decrease. Females from GD10 showed a depressive-like state and were more anxious, as demonstrated by the forced swimming test and social interaction. The plus-maze discriminative avoidance task demonstrated that GD16 males had lower levels of anxiety. The number of neuronal cells was decreased in CA1, CA3 and CA4 hippocampal areas of males and females from GD10 group and in CA1 of females and CA4 of males from GD16 group. Thus, we conclude that venom exposure in pregnant dams causes subtle alteration in the behavioral and neuronal development of offspring in adult life in a gender-dependent manner.

Parabutoporin, a cationic amphipathic peptide from scorpion venom: much more than an antibiotic

Parabutoporin (PP) from the South African scorpion Parabuthus schlechteri is a 45-mer lysine-rich and cysteine-free peptide. At micromolar concentrations it has antimicrobial effects against G+ and G- bacteria and is antifungal as well. However, at submicromolar concentrations, parabutoporin also directly interferes with cellular functions of the human innate immune system, especially polymorphonuclear neutrophils (PMN): parabutoporin acts as a chemoattractant for neutrophils, induces their degranulation, while delaying constitutive neutrophil apoptosis. In addition, it potently inhibits induced superoxide production. Different signalling pathways regulating these biochemical processes were identified as targets of parabutoporin. Therefore, parabutoporin is a well documented scorpion venom peptide with immuno-regulatory properties beyond its antibiotic effects.

Severe scorpion envenomation in children: Management in pediatric intensive care unit

BACKGROUND

Scorpion envenomation is a common public health problem worldwide and children are at greater risk of developing severe cardiac, respiratory and neurological complications. The aim of this study was to evaluate the effects of antivenin and/or prazosin use on prognosis of scorpion-envenomed children admitted to pediatric intensive care unit (PICU).

METHODS

The standardized medical records of 45 children hospitalized with severe scorpion sting in PICU were retrospectively evaluated. General characteristics of the children, clinical and laboratory findings, treatment approaches and prognosis were evaluated.

RESULTS

The mean age of the patients were 6.1 +/- 4.1 years ranging between 4 month and 15 years. Male to female ratio was 1.8. Thirty-three (71.1%) cases of scorpion stings came from rural areas. Twenty-six (57.8%) of the patients were stung by Androctonus crassicauda. The most common sting localization was the foot-leg (55.6%). The mean duration from the scorpion sting to hospital admission was 4.5 +/- 2.6 hours. The most common findings at presentation were cold extremities (95.5%), excessive sweating (91.1%) and tachycardia (77.7%). The mean leukocyte count, and serum levels of glucose, lactate dehydrogenase, creatine phosphokinase and international normalized ratio were found above the normal ranges. Prazosin was used in all patients, dopamine in 11 (24.4%) and Na-nitroprusside in 4 (8.8%) patients. Two children died (4.4%) due to pulmonary oedema. These children, in poor clinical status at hospital admission, needed mechanical ventilation, and death occurred despite use of antivenin and prazosin in both of them.

CONCLUSION

The current management of children with severe scorpion envenomation consists of administration of specific antivenom and close surveillance in a PICU, where vital signs and continuous monitoring enable early initiation of therapy for life-threatening complications. The aggressive medical management directed at the organ system specifically can be effective. Our data indicated that when admission to hospital is late, the beneficial effect of antivenom and/or prazosin is questionable in severe scorpion stings.

Phylogeography of Androctonus species (Scorpiones: Buthidae) in Tunisia: Diagnostic characters for linking species to scorpionism

A fragment of the mitochondrial (mt) 16S ribosomal RNA gene was amplified by PCR and sequenced from individual adult scorpions of the genus Androctonus, which were sampled from central and southern Tunisia and identified using an explicit set of morphological characters. Phylogenetic analyses placed the mtDNA haplotypes in three well-supported monophyletic lineages, corresponding to the morphospecies Androctonusaeneas, Androctonusamoreuxi and Androctonusaustralis. The latter species was the most abundant and widespread, and it was characterized by two mtDNA sub-lineages each of which predominated only north or south of the Chott el Jerid, a seasonally flooded saline depression that divides non-Mediterranean Tunisia. The divergence of the two mtDNA lineages was dated by mtDNA molecular clocks, indicating that the formation of the Chott el Jerid is unlikely to have been the barrier generating the vicariant evolution of the two lineages of A. australis, although it may have impeded their mixing following secondary contact. Both regional mtDNA lineages were found in A. australis hector and A. australisgarzonii, indicating that these two morphological forms are neither monophyletic nor geographically isolated and, therefore, should not be treated as species or subspecies. It is recommended that no subspecies of A. australis should be recognized in North Africa and toxicologists should cease the taxonomic error of referring to a species "Androctonus australis Hector". The morphological form "hector" has no proven association with an increased risk of scorpionism compared with "garzonii". However, it might be prudent to produce anti-venom in Tunisia by using both morphological forms of A. australis collected each side of the Chott el Jerid, because of the evidence for regional variation in toxins. The highest risk for scorpion stings occurs in the central region, where the new diagnostic markers should be used to discover any association between Androctonus species and scorpionism.

Contextual analysis and epidemiology of spider bite in southern Santa Catarina State, Brazil

The aim of this work was to conduct an epidemiological and clinical review of 1126 cases of envenoming by spider recorded in the national notifiable diseases information system (SINAN) files of the Municipal Health Secretary of the Criciúma region, Santa Catarina State, Brazil from 1994 to 2006. This work presents a critical analysis carried out by the application of the chi(2) test, with different regional contextual parameters, including the incidence coefficient. Spider envenoming accounts for more than 50% of all cases recorded in the SINAN files for poisonous animals and is the main cause of human envenomation in the Criciúma region. The majority of the spider bites (57.4%) were reported in the hottest months, from December to May. The anatomic region that suffered the most bites was the hand. Nearly 50% of the accidents were recorded in the group aged 20-49 years. The spiders most frequently involved in accidents for all age groups were of the Loxosceles genus. Although the data collected lack further epidemiological and, especially, clinical details, this does not affect the conclusions of the study, which could be used in the planning of actions aimed at improving environmental health.

Escorpionismo por Tityus pusillus Pocock, 1893 (Scorpiones; Buthidae) no Estado de Pernambuco

Apresentamos neste trabalho os primeiros relatos de acidente escorpiônico causado pela espécie Tityus pusillus (Buthidae). Os acidentes ocorreram no ambiente doméstico, na área rural situada nas cidades de Paudalho e São Lourenço da Mata, Pernambuco, Brasil. Os dois casos descritos, uma criança e uma mulher grávida, foram classificados como leve e moderado, respectivamente. Os sintomas clínicos apresentados foram distúrbios locais (dor e parestesia) e distúrbios sistêmicos (calafrios, tontura, cefaléia e vômito). Esses registros permitem incluir Tityus pusillus como uma espécie de importância médica no Brasil.

Venoms, venomics, antivenomics

Venoms comprise mixtures of peptides and proteins tailored by Natural Selection to act on vital systems of the prey or victim. Here we review our proteomic protocols for uncoiling the composition, immunological profile, and evolution of snake venoms. Our long-term goal is to gain a deep insight of all viperid venom proteomes. Knowledge of the inter- and intraspecies ontogenetic, individual, and geographic venom variability has applied importance for the design of immunization protocols aimed at producing more effective polyspecific antivenoms. A practical consequence of assessing the cross-reactivity of heterologous antivenoms is the possibility of circumventing the restricted availability of species-specific antivenoms in some regions. Further, the high degree of target specificity makes toxins valuable scaffolds for drug development.