Case Report
Getting stung by black scorpion Androctonus crassicauda: A case report
Human and Experimental Toxicology 2014, Vol. 33(10) 1081–1084 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0960327113515502 het.sagepub.com
A Aghabiklooei, N Zamani and H Hassanian-Moghaddam
Abstract 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 lifethreatening manifestations of scorpion envenomation if used early and in appropriate patients. Keywords Scorpion venoms, cholinergic agents, adrenergic agents, antivenom, antivenins, Androctonus crassicauda
Introduction The annual number of scorpion stings exceeds 1.2 million leading to 100,000 medically significant stings and more than 3,250 deaths (0.27%).1 Of the 650 known living species of scorpions, most of the lethal species are in the family Buthidae including Centruroides, Tityus, Leiurus, Androctonus, Buthus, and Parabuthus. The most important lethal species in the Middle East include Androctonus crassicauda, Androctonus australis, Buthus minax, Buthus occitanus, and Leiurus quinquestriatus.2 Local manifestations may exist in 90% of scorpion stings and 10% of cases can be life-threatening in a serious medical emergency situation.3 Scorpion stings produce a local reaction consisting of intense local pain, erythema, tingling or burning, and sometimes discoloration and necrosis. Depending on the scorpion species involved, systemic effects such as autonomic storm consisting of cholinergic and adrenergic effects may occur.1 Different cardiotoxic effects and electrocardiographic (ECG) abnormalities may be present, as well. Presence of different ECG changes as well as lung complications without a clear history of scorpion sting may mimic other diagnoses
including myocardial infarction and complicate the treatment plan.4 We present a case of scorpion sting in an old woman first diagnosed to be acute myocardial infarction who was successfully treated by low dose of antivenom.
Case report A 65-year-old woman travelling in an intercity bus had the sensation of being bitten in the left calf and left flank while she was still in the bus. After arrival to the destination (Tehran), she began to experience pain and swelling in the left calf and one episode of vomiting and referred to a general physician who Toxicological Research Center, Loghman Hakim Hospital, Department of Clinical Toxicology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran Corresponding author: H Hassanian-Moghaddam, Toxicological Research Center, LoghmanHakim Hospital, Department of Clinical Toxicology, Shahid Beheshti University of Medical Sciences, Tehran, 1445613131, Islamic Republic of Iran. Email: [email protected]
Downloaded from het.sagepub.com at Universidad de Sevilla. Biblioteca on May 27, 2015
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administered her hydrocortisone and intravenous (IV) promethazine with the diagnosis of hypersensitivity due to an unknown bite. She was brought to our emergency department (ED) 3.5 h later due to severe agitation and slurred speech. This was while the primary treatment had not been effective. In the first examination performed, the patient’s vital signs were as follow: respiratory rate: 32 breaths/ min, pulse rate: 160 beats/min, blood pressure: 120/80 mmHg, and temperature: 36.5 C. In ECG, tachycardia and tall T waves in precordial leads, stress test (ST) depression in V5–V6, and long QT interval (QT Corrected: 485 ms) were observed. In arterial blood gases analysis, a pH of 7.29, partial pressure of carbon dioxide (PCO2) of 37.6, and bicarbonate (HCO3) of 17.1 were detected (PaO2/fraction of inspired oxygen (FiO2) ¼ 247). O2 saturation was 81.5%. Lab tests including blood urea nitrogen, creatinine, and liver function tests as well as the electrolytes were within normal limits. Blood glucose was 258 mg/dL, creatine kinase-MB (CK-MB) and troponine I were checked and reported to be 35 U/L and 0.5 ng/ml, respectively (normal values:
Getting stung by black scorpion Androctonus crassicauda: A case report
Human and Experimental Toxicology 2014, Vol. 33(10) 1081–1084 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0960327113515502 het.sagepub.com
A Aghabiklooei, N Zamani and H Hassanian-Moghaddam
Abstract 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 lifethreatening manifestations of scorpion envenomation if used early and in appropriate patients. Keywords Scorpion venoms, cholinergic agents, adrenergic agents, antivenom, antivenins, Androctonus crassicauda
Introduction The annual number of scorpion stings exceeds 1.2 million leading to 100,000 medically significant stings and more than 3,250 deaths (0.27%).1 Of the 650 known living species of scorpions, most of the lethal species are in the family Buthidae including Centruroides, Tityus, Leiurus, Androctonus, Buthus, and Parabuthus. The most important lethal species in the Middle East include Androctonus crassicauda, Androctonus australis, Buthus minax, Buthus occitanus, and Leiurus quinquestriatus.2 Local manifestations may exist in 90% of scorpion stings and 10% of cases can be life-threatening in a serious medical emergency situation.3 Scorpion stings produce a local reaction consisting of intense local pain, erythema, tingling or burning, and sometimes discoloration and necrosis. Depending on the scorpion species involved, systemic effects such as autonomic storm consisting of cholinergic and adrenergic effects may occur.1 Different cardiotoxic effects and electrocardiographic (ECG) abnormalities may be present, as well. Presence of different ECG changes as well as lung complications without a clear history of scorpion sting may mimic other diagnoses
including myocardial infarction and complicate the treatment plan.4 We present a case of scorpion sting in an old woman first diagnosed to be acute myocardial infarction who was successfully treated by low dose of antivenom.
Case report A 65-year-old woman travelling in an intercity bus had the sensation of being bitten in the left calf and left flank while she was still in the bus. After arrival to the destination (Tehran), she began to experience pain and swelling in the left calf and one episode of vomiting and referred to a general physician who Toxicological Research Center, Loghman Hakim Hospital, Department of Clinical Toxicology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran Corresponding author: H Hassanian-Moghaddam, Toxicological Research Center, LoghmanHakim Hospital, Department of Clinical Toxicology, Shahid Beheshti University of Medical Sciences, Tehran, 1445613131, Islamic Republic of Iran. Email: [email protected]
Downloaded from het.sagepub.com at Universidad de Sevilla. Biblioteca on May 27, 2015
1082
Human and Experimental Toxicology 33(10)
administered her hydrocortisone and intravenous (IV) promethazine with the diagnosis of hypersensitivity due to an unknown bite. She was brought to our emergency department (ED) 3.5 h later due to severe agitation and slurred speech. This was while the primary treatment had not been effective. In the first examination performed, the patient’s vital signs were as follow: respiratory rate: 32 breaths/ min, pulse rate: 160 beats/min, blood pressure: 120/80 mmHg, and temperature: 36.5 C. In ECG, tachycardia and tall T waves in precordial leads, stress test (ST) depression in V5–V6, and long QT interval (QT Corrected: 485 ms) were observed. In arterial blood gases analysis, a pH of 7.29, partial pressure of carbon dioxide (PCO2) of 37.6, and bicarbonate (HCO3) of 17.1 were detected (PaO2/fraction of inspired oxygen (FiO2) ¼ 247). O2 saturation was 81.5%. Lab tests including blood urea nitrogen, creatinine, and liver function tests as well as the electrolytes were within normal limits. Blood glucose was 258 mg/dL, creatine kinase-MB (CK-MB) and troponine I were checked and reported to be 35 U/L and 0.5 ng/ml, respectively (normal values:
