Serum levels of IL-6 and its soluble receptor, TNF-α and chemokine RANTES in scorpion envenomed children: Their relation to scorpion envenomation outcome

Venomics of Leiurus abdullahbayrami, the most lethal scorpion in the Levant region of the Middle East

The scorpion Leiurus abdullahbayrami has been associated with severe/lethal envenomings throughout the Levant region of the Middle East, encompassing Turkey, Syria, and Lebanon, and only scarce information is available on its venom composition, activity, and antigenicity. We report on the composition of L. abdullahbayrami venom collected from Lebanese specimens using nESI-MS/MS, MALDI-TOF MS, SDS-PAGE and RP-HPLC. Venom lethality, through LD50 determination in mice (intraperitoneal), was also assessed (0.75 (0.16-1.09) mg/kg), confirming L.abdullahbayrami venom vertebrate toxicity. Fifty-four peaks were detected using RP-HPLC, half of which eluted in the gradient region between 20 and 40% acetonitrile. In reducing SDS-PAGE, most predominant components were <10 kDa, with minor components at higher molecular masses of 24.4, 43.1, and 48.9 kDa. Venom mass fingerprint by MALDI-TOF detected 21 components within the 1000-12,000 m/z range. Whole venom 'shotgun' bottom-up nLC-MS/MS approach, combined with in-gel tryptic digestion of SDS-PAGE bands, identified at least 113 different components belonging to 15 venom families and uncharacterized proteins, with ion channel-active components (K+ channel toxins (28); Na+ channel toxins (42); Cl- channel toxins (4); Ca+2 toxins (2)) being predominant. A single match for a L. adbullahbayrami NaTx was found in the UniProt database with other congeneric species, toxin h3.1 from Leiurus hebraeus, suggesting this might be an indication of venom divergence within Leiurus, eventhough this warrants further investigation involving venom proteomics and transcriptomics of relevant species. Considering such potential interspecific venom variation, future work should address whether preparation of a specific anti-L. abdullahbayrami antivenom is justified.

Amazonian scorpions and scorpionism: integrating toxinological, clinical, and phylogenetic data to combat a human health crisis in the world's most diverse rainfores

Venom from Amazonian scorpions of the genus Tityus contains components capable of eliciting a distinct clinical, mostly neurological, syndrome. This contrasts with the mainly autonomic manifestations produced after envenomation by congeneric southern and northern South American species. Herein, we summarize Pan-Amazonian scorpionism by synthesizing available toxinological, clinical, and molecular data gathered from all affected areas in Amazonia, including Brazil, Ecuador, Colombia, Peru, Venezuela, and French Guiana. We searched multiple databases, as well as our own records, for reports of scorpion envenomations in Amazonia by confirmed Tityus spp., and compared the clinical manifestations. To help uncover clinical and venom relationships among problematic species, we explored phylogenetic relationships with a rate-calibrated analysis of mitochondrial COI data from available species. The possible existence of diversity gradients for venom toxic and immunogenic components despite the predicted strong phylogenetic association among species is underscored by discussed clinical and toxinological findings. A multicentric effort, involving all nations affected by this neglected disease, is urgently needed to offer alternatives for treating and understanding this pathology, including the preparation of neutralizing antibodies with a broad range of efficacy.

Evaluation of systemic inflammatory response and lung injury induced by Crotalus durissus cascavella venom

This study investigated the systemic inflammatory response and mechanism of pulmonary lesions induced by Crotalus durissus cascavella venom in murine in the state of Bahia. In order to investigate T helper Th1, Th2 and Th17 lymphocyte profiles, we measured interleukin (IL) -2, IL-4, IL-6, IL-10, IL-17, tumor necrosis factor (TNF) and interferon gamma (IFN-γ) levels in the peritoneal fluid and macerated lungs of mice and histopathological alterations at the specific time windows of 1h, 3h, 6h, 12h, 24h and 48h after inoculation with Crotalus durissus cascavella venom. The data demonstrated an increase of acute-phase cytokines (IL-6 and TNF) in the first hours after inoculation, with a subsequent increase in IL-10 and IL-4, suggesting immune response modulation for the Th2 profile. The histopathological analysis showed significant morphological alterations, compatible with acute pulmonary lesions, with polymorphonuclear leukocyte (PMN) infiltration, intra-alveolar edema, congestion, hemorrhage and atelectasis. These findings advance our understanding of the dynamics of envenomation and contribute to improve clinical management and antiophidic therapy for individuals exposed to venom.

Serotherapy against Voltage-Gated Sodium Channel-Targeting αToxins from Androctonus Scorpion Venom

Because of their venom lethality towards mammals, scorpions of the Androctonus genus are considered a critical threat to human health in North Africa. Several decades of exploration have led to a comprehensive inventory of their venom components at chemical, pharmacological, and immunological levels. Typically, these venoms contain selective and high affinity ligands for the voltage-gated sodium (Na_v) and potassium (K_v) channels that dictate cellular excitability. In the well-studied Androctonus australis and Androctonus mauretanicus venoms, almost all the lethality in mammals is due to the so-called α-toxins. These peptides commonly delay the fast inactivation process of Na_v channels, which leads to increased sodium entry and a subsequent cell membrane depolarization. Markedly, their neutralization by specific antisera has been shown to completely inhibit the venom’s lethal activity, because they are not only the most abundant venom peptide but also the most fatal. However, the structural and antigenic polymorphisms in the α-toxin family pose challenges to the design of efficient serotherapies. In this review, we discuss past and present accomplishments to improve serotherapy against Androctonus scorpion stings.

Immune drug discovery from venoms

This review catalogues recent advances in knowledge on venoms as standalone therapeutic agents or as blueprints for drug design, with an emphasis on venom-derived compounds that affects the immune system. We discuss venoms and venom-derived compounds that affect total immune cell numbers, immune cell proliferation, immune cell migration, immune cell phenotype and cytokine secretion. Identifying novel compounds that 'tune' the system, up-regulating the immune response during infectious disease and cancer and down-regulating the immune response during autoimmunity, will greatly expand the tool kit of human immunotherapeutics. Targeting these pathways may also open therapeutic options that alleviate symptoms of envenomation. Finally, combining recent advances in venomics with progress in low cost, high-throughput screening platforms will no doubt yield hundreds of prototype immune modulating compounds in the coming years.

Role of some vasoactive mediators in scorpion envenomed children: Possible relation to envenoming outcome

Scorpion envenomation causes an autonomic storm resulting in changes in the vasoactive mediators' levels which lead to myocardial damage, cardiovascular disturbances, peripheral circulatory failure, pulmonary edema, multi-system-organ-failure and death. The study aimed to determine the circulating levels of adrenaline, noradrenaline, angiotensin converting enzyme (ACE), Angiotensin II (Ang II), kallikrein enzyme, nitric oxide (NO), aldosterone, and electrolytes Na⁺, K⁺ and Ca⁺² in scorpion envenomed children and to evaluate the potential relation between these vasoactive mediators, the severity of scorpion envenoming and the clinical outcome of envenomed children. Forty envenomed children (22 mild and 18 severe cases) along with 10 healthy control children were enrolled in the study. The circulating levels of adrenaline, noradrenaline, Ang II, ACE, kallikrein enzyme, and NO were determined by ELISA, and spectrophotometric assays on admission and 24 h later. On admission, serum aldosterone, and electrolytes; Na⁺, K⁺ and Ca⁺² were determined by RIA, Flame photometer and Flame atomic absorption respectively. All envenomed children showed significant surge of adrenaline, noradrenaline, ACE, Ang II, aldosterone, NO and Na⁺, that concomitantly faced by significant reduction in kallikrein, K⁺ and Ca⁺² on admission. Twenty four hours later, all envenomed children continued to show significant elevation of ACE, Ang II and NO. The severely envenomed children showed considerable reduction in circulating levels of adrenaline, noradrenaline, ACE and Ang II, while dramatic increase in kallikrein activity was reported in comparison to mildly envenomed children after 24 h of medical care. Also, NO exhibited considerable accumulation in non survivors, on admission, that was persistent for the subsequent 24 h and was accompanied by high kallikrein, low catecholamines and Ang II levels compared to survivors. Finally, the hypertensive cases showed substantial higher levels of catecholamine, ACE and Ang II, 24 h after admission. These findings indicated that, disturbances of the studied vasoactive mediators were common in scorpion envenomed children and may account for several inflammatory manifestations and clinical outcome. ACE inhibitors could be considered as possible therapeutic agent in victims with prominent increase in ACE and Ang II while kallikrein inhibitor and antioxidants may be effective in the treatment of late hypotensive ones.

Hemiscorpius lepturus venom induces expression and production of interluckin-12 in human monocytes

The objective of this study was to evaluate the capacity of the venom from Hemiscorpius lepturus to induce expression and production of interleukin-12 (IL-12) on isolated human monocytes. For this purpose, isolated human monocytes (250,000-300,000 cells/ml) were exposed to different concentrations of the venom (0.625, 1.25, 2.5, 5, 10 and 20 μg/ml) in 96-well plates for varying incubation periods (6, 12, and 24 h). The end point of assessment included LDH cytotoxicity assay, measurement of expression of IL-12,p40 mRNA by real-time PCR, and quantification of IL-12 release using sandwich ELISA technique. The results showed that this venom produced concentration- and time of incubation-dependent cytotoxicity. The level of enhancement of expression and production of IL-12 were found significantly higher with lowest concentration and after 6 h of incubation. The findings demonstrated that the venom from this scorpion contains active constituents which can direct the immune system to produce IL-12.

Clinical comparison of scorpion envenomation by Androctonus mauritanicus and Buthus occitanus in children

The clinical results of scorpion stings by Androctonus mauritanicus (Am) and Buthus occitanus (Bo) (main sources of scorpionism in Morocco) were evaluated in this work. The objective was to compare the clinical manifestations of envenoming from these species by investigating possible correlations among symptoms/signs and laboratory abnormalities of envenomed patients. 41 children (25 males, 18 months - 11 years) were admitted at the Provincial Hospital of El Jadida-Morocco. Their minor (18 children) or severe (23 children) systemic signs such as pallor (48.8%), pulmonary edema (APE) (36.6%), convulsion (26.8%), coma (7.3%) were more frequent in children envenomed by Am than Bo, but angioedema (Quincke's edema) (4.9%) was particularly developed in the latter group. The laboratory blood abnormalities (hyperglycemia, high levels of aspartate aminotransferase (AST), lactate dehydrogenase (LDH), creatinine, bilirubin, leukocytes, neutrophils, monocytes, platelets and low levels of lymphocytes and hemoglobin) were significantly higher (p < 0.05) in patients envenomed by Am than Bo, and in all population in comparison to control group. The correlation among these biological analyzes and clinical status showed that higher levels of LDH and value of leukocytes ≥19 × 10(3)/mm(3) were indices of cardiac dysfunction with APE. Pallor sign was correlated with a state of shock and/or low level of hemoglobin, associated or not to bilirubin increase. Fatalities (7.3%), presenting toxic myocarditis, had lowest count of lymphocytes (≤4.2%) in comparison to survivors. This is the first report on lymphopenia which may be useful for forecast the fatal outcome in scorpion envenomation.

Effects of atropine and propranolol on lung inflammation in experimental envenomation: comparison of two buthidae venoms

Background

Previous works had shown that scorpion venom induced neurotransmitter elevation and an inflammatory response associated with various anatomo-pathological modifications. The most dangerous scorpions species in Algeria responsible for these effects are Androctonus australis hector (Aah) and Androctonus amoreuxi (Aam).

Results

Comparison of the physiopathological effects induced by the two venoms showed differences in the kinetic of cytokine release and in lung injury.

The lung edema was only observed in response to Aah venom and it was correlated with cell infiltration. In order to better understand the involved mechanism in inflammatory response, we used two antagonists, atropine (non-selective muscarinic antagonist) and propranolol (β adrenergic antagonist), which lead to a decrease of cell infiltration but has no effect on edema forming.

Conclusion

These results suggest another pathway in the development of lung injury following envenomation with Aam or Aah venom.

Emerging options for the management of scorpion stings

Scorpion stings are common in many tropical countries. Although most scorpion stings cause only localized pain without life-threatening envenoming, about one third of stings cause systemic envenoming which can result in death. Children are particularly sensitive to scorpion envenoming. The severity of scorpion stings is related to the presence of neurotoxins in the venom that cause a sudden release of neurotransmitters from the autonomic nervous system, predominantly sympathetic. There is also a strong inflammatory response that worsens symptoms, including those of a respiratory nature. Several vital functions may be directly affected, including the cardiovascular, respiratory, and neuromuscular systems. Hypertension is constant at the beginning of systemic envenoming and sometimes has a severe cardiac and respiratory impact. Although controversial, immunotherapy is the only etiological treatment. Administered early, it prevents many complications and improves the outcome. New antivenoms are highly purified immunoglobulin fragments, the efficacy and safety of which are excellent. As a consequence, adverse reactions to antivenoms are now very rare and usually mild, which should limit any reluctance regarding their routine use. Symptomatic treatment is still necessary to support immunotherapy, especially in cases of delayed arrival at hospital. A combination of both approaches should be considered, based on local resources and constraints.

Scorpion envenomation and antivenom therapy

Scorpion envenomation is a dangerous and common global event that can result in a variety of toxic clinical effects. These are typically managed with supportive care or antivenom. Antivenom use is controversial because of conflicting evidence of effectiveness for adrenergic toxicity. However, both controlled and uncontrolled studies have shown that antivenom is effective in resolving neuromotor toxicity associated with envenomations by the scorpions of genus Centruroides.

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.

Comparative study between the protective effects of Saudi and Egyptian antivenoms, alone or in combination with ion channel modulators, against deleterious actions of Leiurus quinquestriatus scorpion venom

This study compared efficacy of two polyvalent antivenoms (Saudi Arabian and Egyptian), against lethality and pathophysiological changes of Leiurus quinquestriatus quinquestriatus (LQQ) scorpion venom in mice. Additionally, the study examined whether treatment with selected ion channel modulators, lidocaine, nimodipine or amiodarone would be effective, alone or combined with the antivenoms. The protein concentration of the Saudi antivenom was 1/3 of Egyptian, indicating lesser immunogenicity, while both preservative contents were within limits. In immunodiffusion experiments, both exhibited prominent precipitin bands indicating high concentrations of specific antibodies. Neutralizing capacities (60-70 LD(50)) stated on labels were confirmed. Both antivenoms significantly (P < 0.001) prolonged survival time (from 26.9 +/- 1.18 min, 100% dead with venom to 224-300 min, 0-30% dead) of envenomed mice, whether injected iv before or 5 min after venom. Injection of either antivenom plus ion channel modulators, gave comparable results to that observed in mice treated with antivenoms alone. The Na(+) channel blocker lidocaine and the Ca(2+) channel blocker nimodipine on their own significantly protected the animals (P < 0.05), but to a lesser extent. The two antivenoms, significantly ameliorated the venom-evoked changes in serum LDH (P < 0.001) and CKMB (P < 0.01) plus cardiac TNFalpha and nitrate/nitrite levels (P < 0.001). When combined with lidocaine or nimodipine, the effects were not greater than antivenom alone. Moreover, the antivenoms ameliorated characteristic venom-evoked changes in the isolated perfused Langendorff hearts. Lidocaine and amiodarone were more effective than nimodipine. In Conclusion both Saudi and Egyptian antivenoms protected mice from the pathological and lethal effects of LQQ scorpion. Sodium and calcium channel blockers, lidocaine and nimodipine, may be useful when antivenoms are not available.

Epidemiology of scorpionism: a global appraisal

The scorpionism is an actual public health problem in several parts of the world because, either incidence, or severity of envenomations is high and managed with difficulty by health services, or for these two reasons at the same time. The treatment of scorpion envenomation is complex and controversial, in particular regarding the utility of the antivenoms and symptomatic treatments that must be associated. The authors reviewed the literature of last 30 years to discuss the epidemiologic importance of scorpionism and to point out the principal therapeutic or preventive measures. According to the most recent studies, seven areas were identified as at risk: north-Saharan Africa, Sahelian Africa, South Africa, Near and Middle-East, South India, Mexico and South Latin America, east of the Andes. These involve 2.3 billion at risk population. The annual number of scorpion stings exceeds 1.2 million leading to more than 3250 deaths (0.27%). Although adults are more often concerned, children experience more severe envenomations and among them, mortality is higher. Improvement of therapeutic management would reduce the lethality very significantly.