Factors associated with pulmonary edema in severe scorpion sting patients--a multivariate analysis of 428 cases

Use of point-of-care ultrasound to assess the severity of scorpion stings in hospitalized patients

INTRODUCTION

Scorpionism is a public health problem, especially in tropical regions. In Brazil, the prevalence of envenomation by scorpions is high, and the average national lethality is around 0.16 percent. The Tityus serrulatus scorpion is the primary species of medical importance. However, objective tools to predict and define the severity of these envenomations are lacking.

MATERIALS AND METHODS

This was an observational study conducted among patients aged 0-19 years with scorpionism. Patients were admitted to a reference hospital between December 2020 and May 2022. Point-of-care ultrasound was performed within 24 hours of the scorpion sting.

RESULTS

Forty-nine patients were included, with a median age of 3.6 (interquartile range 2.3-5.3) years and a predominance of females (51 percent). Fifteen patients (30.6 percent) presented major life-threatening signs, 32 (65.3 percent) minor systemic manifestations, and two (4.1 percent) only local manifestations. Left ventricular dysfunction was identified in 13 patients (26.5 percent). Ten patients (20.4 percent) presented pattern B (visualization of three or more B lines in the evaluated quadrant) in at least one lung window. The sensitivity and specificity of cardiac and pulmonary ultrasound to identify the most severely ill patients were 86 percent and 94 percent, respectively.

DISCUSSION

The changes found on point-of-care ultrasound were associated with life-threatening signs. All patients with class III envenomation were referred to the intensive care unit, showing the importance of early identification of this subgroup. The main limitations were the small sample size and the fact that admission to intensive care was not based on systematic criteria.

CONCLUSIONS

Point-of-care ultrasound is able to identify early signs of pulmonary congestion and heart failure in scorpionism. It can be useful for the objective selection of patients who are at a higher risk of complications and death and who require intensive support; it may also be valuable for periodic reassessments. Point-of-care ultrasound is a valuable tool for identifying and monitoring severe cases of scorpionism.

A Novel Therapeutic Formulation for the Improved Treatment of Indian Red Scorpion (Mesobuthus tamulus) Venom-Induced Toxicity-Tested in Caenorhabditis elegans and Rodent Models

Indian Red Scorpion (Mesobuthus tamulus) stings are a neglected public health problem in tropical and sub-tropical countries, including India. The drawbacks of conventional therapies using commercial anti-scorpion antivenom (ASA) and α1-adrenoreceptor antagonists (AAA) have prompted us to search for an adequate formulation to improve treatment against M. tamulus stings. Novel therapeutic drug formulations (TDF) of low doses of commercial ASA, AAA, and ascorbic acid have remarkably improved in neutralising the in vivo toxic effects of M. tamulus venom (MTV) tested in Caenorhabditis elegans and Wistar strain albino rats in vivo models. The neutralisation of MTV-induced production of free radicals, alteration of the mitochondrial transmembrane potential, and upregulated expression of genes involved in apoptosis, detoxification, and stress response in C. elegans by TDF surpassed the same effect shown by individual components of the TDF. Further, TDF efficiently neutralized the MTV-induced increase in blood glucose level within 30 to 60 min post-treatment, organ tissue damage, necrosis, and pulmonary oedema in Wistar rats, indicating its clinical application for effecting treating M. tamulus envenomation. This study demonstrates for the first time that C. elegans can be a model organism for screening the neutralization potency of the drug molecules against a neurotoxic scorpion venom.

Echocardiographic Evaluation of the Response to Prazosin Treatment in Scorpion Sting

BACKGROUND

Scorpion envenomation is a major public health problem in children that can induce lethal neurological, respiratory and cardiovascular complications. We aimed to evaluate cardiovascular complications with a follow-up of envenomed children for 1 month for possibility of incomplete recovery.

METHODS

This was a prospective study conducted for children who presented with scorpion sting to Emergency and Intensive Care units. Demographic, clinical and laboratory findings of patients were recorded. Cases with suspected clinical and electrocardiographic manifestations of myocarditis were subjected to bedside echocardiography with follow-up at the end of the first week and the first month.

RESULTS

Scorpion sting cases presented to our hospital were 81 cases during 1-year study; of them, 17 cases were stable without systemic manifestations after 12 h observation and discharged. Sixty-four cases suffered systemic organic complications and needed ICU admission; their mean age was 11.52 ± 3.74 and 64% of them were males. Twenty-eight of admitted cases showed manifestations of myocarditis and by echocardiography, all of them had evidence of left ventricular dysfunction. On follow-up, there was significant improvement at the end of first week and complete improvement at the end of first month except three cases who died due to pulmonary edema and cardiogenic shock.

CONCLUSION

Acute toxic myocarditis is a common and an important cause of morbidity and mortality following scorpion envenomation that necessitates early and aggressive management. High index of suspicion, serial electrocardiogram monitoring and echocardiography are three integrative lines required to recognize this serious complication. Lay summaryAcute toxic myocarditis is a common cause of morbidity and mortality following scorpion envenomation that necessitates rapid medical treatment. We aimed to evaluate cardiovascular complications after scorpion sting with a follow-up of envenomed children for 1 month for possibility of incomplete recovery. Tachycardia was the most frequent observed cardiac sign followed by hypotension, while the least was bradycardia and hypertension. All cases with manifestations suggestive of myocarditis were evaluated by bedside two-dimensional echocardiography and showed evidence of left ventricular dysfunction, that begin to regress within 1 week of treatment unless progressive pulmonary edema and resistant cardiogenic shock occurred. On follow-up for survivors, complete improvement at the end of first month was noticed. Clinical suspicion, serial ECG monitoring and echocardiography are required for rapid and early diagnosis. Early use of prazosin therapy can prevent long-term residual damage as evidenced by echocardiographic evaluation.

Levosimendan treatment in a child with treatment-resistant left ventricular systolic dysfunction after scorpion sting

Background:

Scorpion stings are common in countries dominated by rural and coastal settlements with temperate climate. Scorpion stings are usually harmless and can be seen in local findings, but in some cases, systemic, neurotoxic, and cardiotoxic findings can be seen.

Case report:

A 3 year 7 month old girl was referred to pediatric emergency care 2 h after yellow scorpion (species of Leiurus abdullahbayrami) sting. In our case, cardiac function insufficiently progressed in spite of the standard inotropic and milrinone treatment. On the third day of hospitalization, levosimendan was initiated with good clinical effect.

Conclusion:

In the literature, the use of levosimendan in pediatric patients has been limited to those with low cardiac output syndrome after cardiovascular surgery. The use of levosimendan in children with scorpion sting has been previously reported only in Banille et al.’s study. Scorpion antivenom should be administered intravenously as soon as possible in cases of systemic findings that develop after scorpion stings. This report suggests that levosimendan is temporally associated with improvement in patients who have severe cardiac dysfunction due to scorpion sting and refractory to current treatment.

Incidence, mechanisms and impact outcome of hyperglycaemia in severe scorpion-envenomed patients

Hyperglycaemia is often observed in severe scorpion-envenomed patients. It is due to a severe autonomic storm with a massive release of catecholamines, increased glucagon levels, cortisol levels, and either decreased insulin levels or insulin resistance. The presence of hyperglycaemia is an indicator of severity in this specific condition. Indeed, hyperglycaemia was associated with the severity of clinical manifestations of severe scorpion envenomation requiring intensive care unit (ICU) admission. In fact, the presence of hyperglycaemia was associated with the presence of respiratory failure, pulmonary oedema, haemodynamic instability, neurological failure, multisystem organ failure, and an increased mortality and ICU length of stay. As a consequence, we think the presence of hyperglycaemia in scorpion-envenomed patients at the emergency department prompts searching for presence of systemic manifestations or cardiorespiratory manifestations. As a consequence, the presence of hyperglycaemia can help screen severe patients at the emergency department. The current management of severe scorpion envenomation involves the admission and close surveillance in the ICU, where vital signs and continuous monitoring enable early initiation of therapy for life-threatening complications. The use of antivenom for scorpion stings remains controversial. All patients with pulmonary oedema should receive prazosin and possibly dobutamine, according the scorpion's species. Mechanical ventilation is usually used in severe cases. Insulin should be reserved for severe cases with confirmed excessive hyperglycaemia (>10 mmol/l).

Scorpion envenoming in Morona Santiago, Amazonian Ecuador: Molecular phylogenetics confirms involvement of the Tityus obscurus group

Scorpion envenoming by species in the genus Tityus is hereby reported from rural locations in the Amazonian province of Morona Santiago, southeastern Ecuador. Twenty envenoming cases (18 patients under 15 years of age) including one death (a 4-year-old male) were recorded at the Macas General Hospital, Morona Santiago, between January 2015 and December 2016 from the counties of Taisha (n=17), Huamboyo (n=1), Palora (n=1), and Logroño (n=1). An additional fatality from 2014 (a 3-year-old female from Nayantza, Taisha county) is also reported. Leukocytosis and low serum potassium levels were detected in most patients. We observed a significant negative correlation between leukocytosis and hypokalemia. Scorpions involved in three accidents from Macuma, Taisha County, were identified as genetically related to Tityus obscurus from the Brazilian Amazonian region based on comparison of mitochondrial DNA sequences encoding cytochrome oxidase subunit I. These cases, along with previously reported envenoming from northern Manabí, reinforce the notion that scorpionism is a health hazard for children in Ecuador and emphasizes the need to supply effective antivenoms against local species, which are not currently available. The genetic affinity of the Ecuadorian specimens with T. obscurus may underlay toxinological, clinical, and venom antigenic relationships among Amazonian scorpions that deserves further exploration for designing therapeutic strategies to treat scorpionism in the region.

Neurologic Complications in Children With Scorpionism: A Retrospective Study in Upper Egypt

Scorpion envenomation is a life-threatening health problem in tropical and subtropical regions, particularly among children. The aim of this study was to describe the epidemiologic characteristics, clinical profile, and prognosis of neurologic complications among children with scorpionism in Upper Egypt. In this retrospective study, the neurologic complications of scorpionism in 2 university hospitals were analyzed from the points of epidemiologic and clinical picture and outcomes. The neurologic manifestations were found at a high percentage (85%). Irritability was the main manifestation (83.4%), followed by sweating (81.5%), hyperthermia (33.6%), and priapism (48.2% of males). Moreover, convulsion and coma were found in 14.7% and 11% of children, respectively. Neurologic manifestations were common in children with scorpionism and they correlated with poor outcome. Identification of epidemiologic and clinical features of central nervous system complications of scorpionism in children provide important data, helping in development of management policies aiming at preventive control of scorpionism and decrease its mortality.

Predictive Factors for Determining the Clinical Severity of Pediatric Scorpion Envenomation Cases in Southeastern Turkey

OBJECTIVE

The aim of this study was to define the epidemiological, clinical, and laboratory manifestations of scorpion envenomation and to identify factors that are predictive of severe cases.

METHODS

The medical files of 41 scorpion envenomation cases were reviewed retrospectively. The cases were classified as mild-moderate or severe. The epidemiological, clinical, and laboratory findings of patients were recorded.

RESULTS

There were 27 patients (65.9%) in the mild-moderate group and 14 patients (34.1%) in the severe group. The median age of all patients was 48 months. The most common systemic finding was cold extremities (41.5%). In all patients, the most commonly observed dysrhythmia was sinus tachycardia (34.1%). Two patients (4.9%) had pulseless ventricular tachycardia and died. Pulmonary edema and myocarditis were observed in 9 patients (22%). Median values of leukocyte and glucose levels were markedly increased in the severe group. Additionally, the mean thrombocyte level (540,857 ± 115,261 cells/mm(3)) in the severe group was significantly increased compared with the mild-moderate group (391,365 ± 150,017 cells/mm(3)). Thrombocyte levels exhibited a positive correlation with leukocyte and glucose values and a negative correlation with patient left ventricular ejection fraction. Multivariate analysis of laboratory parameters indicated that the most predictive factor for clinical severity is thrombocytosis (odds ratio 23.9; 95% CI: 1.6-353.5, P = .021).

CONCLUSIONS

Although our results share some similarities with those of other reports, thrombocytosis was markedly increased in the severe group and served as the most predictive laboratory factor of clinical severity.

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.

Elevated Cardiac Troponin (cTnI) Levels Correlate with the Clinical and Echocardiographic Evidences of Severe Myocarditis in Scorpion Sting Envenomation

OBJECTIVE

This study was to evaluate the predictive value of the cardiac troponins in scorpion sting myocarditis at a tertiary care hospital in Raichur, (Karnataka state) India.

METHODS

A total of 84 consecutive patients were prospectively studied. The data included the demographics, the time of presentation to the hospital, the clinical features, the cardiac troponin levels and the echocardiographic findings.

RESULTS

12 patients with only local symptoms had troponin levels of less than 0.01μg/L. 12 patients with local and systemic symptoms without an echocardiac evidence of myocarditis had troponin values of 0.01 to 0.11 μg/L. 60 patients with an echocardiographic evidence of myocarditis had troponin levels of above 0.11 μg/L. 6 patients with severe myocarditis who required ventilator support or which led to death had troponin values which were higher than 10 μg/L.

CONCLUSIONS

High cardiac troponin levels predict myocarditis in scorpion sting envenomation and they can be a useful tool in guiding the therapy early.

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.

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.

Asymmetric pulmonary edema after scorpion sting: a case report

A 12-year-old boy was referred with acute asymmetric pulmonary edema (APE) four-hour after scorpion sting to Emergency department. On admission, the main clinical manifestations were: dyspnea, tachypnea, and tachycardia. Chest x-ray revealed APE predominantly on the right hemithorax. The patient was treated with oxygen, intravenous frusemide and digoxin and discharged on the sixth hospital day in a good condition. This case report emphasizes the occurrence of asymmetric pulmonary edema after severe scorpion envenomation within few hours immediately after the sting.

Epidemiological, clinical characteristics and outcome of severe scorpion envenomation in South Tunisia: multivariate analysis of 951 cases

The aim of this retrospective descriptive study was to describe both epidemiologically and clinically manifestations following severe scorpion envenomation and to define simple predictive factors which can be used in routine practice in general Intensive Care Units (ICU) as an indicator of poor prognosis. Cases were collected from hospital patients' files during 13-year (1990-2002) period in the medical Intensive Care Unit of a university hospital (Sfax - Tunisia). The diagnosis of scorpion envenomation was based on a history of scorpion sting. Nine hundred fifty-one patients, who were admitted for a scorpion sting, were analyzed. There were 769 patients (80.8%) in the grade III group (with cardiogenic shock and/or pulmonary edema or severe neurological manifestation (coma and/or convulsion)) and 182 patients (19.2%) in the grade II group (with systemic manifestations). Scorpion envenomation is more frequent in summer; indeed 82.3% of our patients were admitted between June and September. The mean age (+/-SD) was 14.7 +/- 17.4 years, ranging from 0.5 to 90 years. In this study 739 patients (77.8%) had neuromuscular signs, 700 patients (73.6%) had gastrointestinal signs and 585 patients (61.5%) had a pulmonary edema, while 195 patients (20.5%) had a cardiogenic shock. The mean blood sugar on admission was at 11.32 +/- 5.66 mmol/l, a high blood sugar level (>11 mmol/l) was observed in 39% of cases. The mean blood urea was at 7.1 +/- 3.2 mmol/l, it was above 10 mmol/l in 10.7% of cases. The mean of leucocytes was at 17 418 +/- 7833 cells/mm(3), it was above 11 000/mm(3) in 80% of cases. In the end of the stay in ICU, evolution was marked by the improvement of 879 patients (92.5%) while 72 patients (7.5%) died. A multivariate analysis found the following factors to be correlated with a poor outcome: age less than 5 years (OR = 2.27), fever >38.5 degrees C (OR = 2.79), coma with Glasgow coma score < or =8/15 (OR = 9.87), pulmonary edema (OR = 8.46), leucocytes >25 000 cells/mm3 (OR = 2.35) and blood urea >8 mmol/l (OR = 4.02). Moreover, in children group, a significant association was found between PRISM score and mortality rate, this model had a high discriminative power with an area under the ROC curve at 0.93. In the adult patients a significant association was found between SAPS II score and mortality rate, this model had a high discriminative power with an area under the ROC curve at 0.82. In summary, in severe scorpion envenomation, age less than 5 years, fever >38.5 degrees C, coma with Glasgow coma score < or =8/15, pulmonary edema, leucocytes >25 000 cells/mm3 and blood urea >8 mmol/l were associated with a poor outcome.