Letters to the Editor Department of Dermatology, Thanjavur Medical College, Thanjavur, Tamil Nadu, India Address for correspondence: Dr. Parimalam Kumar, Old 33A, New 4/1, East Ellaiamman Koil Street, Dr. Radhakrishnan Nagar, Thiruvottiyur, Chennai - 60 0019, Tamil Nadu, India. E-mail: [email protected]
REFERENCES 1.
2.
Tamura A, Ohnishi K, Ishikawa O, Miyachi Y. Flow cytometric DNA content analysis on squamous cell carcinomas according to the preceding lesions. Br J Dermatol 1996;134:40-3. Ko T, Tada H, Hatoko M, Muramatsu T, Shirai T. Trichilemmal carcinoma developing in a burn scar: A report of two cases. J Dermatol 1996; 23:463-8.
Hypersensitivity reaction to scorpion antivenom Sir, A 21-year-old female patient was admitted to our hospital with generalized rash and severe itching since five days after being stung by a small yellow scorpion on her abdomen and receiving scorpion antivenom. According to her detailed history, on the day of the accident, she had presented to a local emergency department (ED) complaining fatigue and burning sensation at the site of the sting. The physician in the ED had intramuscularly administered one ampoule of polyvalent scorpion antivenin after skin test. However, the indication of the administration of antivenin was not clear. The antivenom used was purified polyvalent anti-scorpion serum produced by the Razi Vaccine and Serum Research Institute in Iran. The serum was prepared from the purified plasma of healthy horses immunized with venoms of the six dangerous scorpion species in Iran including Odontobuthus doriae, Mesobuthus eupeus, Androctonus crassicauda, Buthotus saulcyi, Buthotus sach and Hemiscorpius lepturus. This antivenin is usually presented in the 5-mL ampoules. Three hours after receiving the antivenom, she had developed the current symptoms which had improved with corticosteroids and antihistamines but had continued to relapse and remit. In our hospital, examination showed edematous, urticarial plaques intermixed with generalized flushing [Figures 1 and 2]. Neither lymphadenopathy nor discrete urticarial wheals were observed. The oral cavity and conjunctivae were not involved. The history, presentation and Naranjo adverse drug reaction probability score of nine[1] led to the diagnosis of immediate hypersensitivity reaction to scorpion antivenom. High doses of prednisolone and hydroxyzine were administered with sustained improvement of her signs and symptoms over 10 days. Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 1
3. 4.
5.
Das S, Roy AK, Maiti A. Marjolinulcer with multifocal origin. Indian J Dermatol 2009;54:14-5. Arons MS, Lynch JB, Lewis SR, Blocker TG Jr. Scar tissue carcinoma. I. A clinical study with special reference to burn scar carcinoma. Ann Surg 1965; 161:170-88. Phillips TJ, Salman SM, Bhawan J, Rogers GS. Burn scar carcinoma. Diagnosis and management. Dermatol Surg 1998;24:561-5.
Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.144534
Scorpion stings have local and systemic effects. [2-5] Mild envenomations can be managed by supportive care. However, severe and life-threatening envenomations should be treated with scorpion antivenoms although the use of these products has potential risk of immediate and a more delayed-onset form of hypersensitivity reactions. [2,6-8] This case shows that a hypersensitivity skin test is ineffective
Figure 1: Edematous, urticarial plaques and generalized flushing on the patient’s back
S51
Letters to the Editor Emergency Room/Division of Medical Toxicology, Hazrat Ali-Asghar (p) Hospital, Meshkinfam Street, 7143918796 Shiraz, Iran. E-mail: [email protected]
REFERENCES 1.
2.
3. 4. Figure 2: Edematous, urticarial plaques on the dorsum of the patient’s foot
in predicting immediate-type hypersensitivity reactions in patients given scorpion antivenom. [6] Furthermore, this case highlights that hypersensitivity reaction to scorpion antivenom can present in the form of debilitating, prolonged cutaneous manifestations that may develop several hours after antivenom administration. This form of immediate hypersensitivity (delayed-onset and protracted) reaction to scorpion antivenom has not yet been reported in the literature. It is to be noted that antivenom was not indicated in this case in view of the patient’s mild symptoms.[2,7]
5. 6.
7. 8.
Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239-45. Hoffman RS, Nelson LS, Howland MA, Lewin NA, Flomenbaum NE, Goldfrank LR. editors. Goldfrank’s Manual of Toxicologic Emergencies. 1st ed. New York: McGraw-Hill; 2007. p. 901-13. Dehghani R, Fathi B. Scorpion sting in Iran: A review. Toxicon 2012;60:919-33. Sagheb MM, Sharifian M, Moini M, Sharifian AH. Scorpion bite prevalence and complications: Report from a referral centre in southern Iran. Trop Doct 2012;42:90-1. Radmanesh M. Cutaneous manifestations of the Hemiscorpius lepturus sting: A clinical study. Int J Dermatol 1998;37:500-7. Cupo P, Azevedo-Marques MM, de Menezes JB, Hering SE. [Immediate hypersensitivity reactions after intravenous use of antivenin sera: Prognostic value of intradermal sensitivity tests]. Rev Inst Med Trop Sao Paulo 1991;33:115-22. Ismail M. Treatment of the scorpion envenoming syndrome: 12-years experience with serotherapy. Int J Antimicrob Agents 2003;21:170-4. Bond GR. Antivenin administration for Centruroides scorpion sting: Risks and benefits. Ann Emerg Med 1992;21:788-91.
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Hossein Sanaei-Zadeh Medical School, Shiraz University of Medical Sciences, Shiraz, Iran Address for correspondence: Dr. Hossein Sanaei-Zadeh, Medical School, Shiraz University of Medical Sciences,
Keraunographic tattoo Sir, Lightning injuries are common but uncommonly reported even though it strikes the earth >100 times each second or 8 million times/day.[1] It has been an enigma since antiquity. The brilliance, power, and destructive capacity of lighting have made it the subject for religion, superstition, politics, and most recently, scientific investigation. A 36-year-old male patient presented to the emergency department with history of a lightning strike about 8 h back. He was hiking in mountainous terrain in the open during evening hours. It started raining heavily, so he took shelter under a tree. He had an umbrella in his hand. Lightening flash initially struck the tree and later hit the patient. Patient had a brief period of unconsciousness and on regaining consciousness he felt pain in the upper limb.
S52
Website: www.idoj.in DOI: 10.4103/2229-5178.144536
Patient was confused and had bradycardia at the time of admission. Detailed examination including blood pressure, respiratory rate and systemic examination including ear and eye examination were normal. Dermatological examination revealed keraunographic markings, pathognomonic of lightning over the scapular region (left) [Figure 1]. He also suffered second-degree linear burns on the shin (right) due to rapid heating by electrical energy. Complete blood count, urine analysis including myoglobinuria, cardiac enzyme tests, serial electrocardiography monitoring, liver enzymes, and serum electrolytes were all normal. Patient was admitted and monitored for seven days. He was treated with analgesics for pain in the upper limb. Cutaneous lesions healed spontaneously in four days. He had an uneventful recovery after seven days. Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 1
Copyright of Indian Dermatology Online Journal is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
REFERENCES 1.
2.
Tamura A, Ohnishi K, Ishikawa O, Miyachi Y. Flow cytometric DNA content analysis on squamous cell carcinomas according to the preceding lesions. Br J Dermatol 1996;134:40-3. Ko T, Tada H, Hatoko M, Muramatsu T, Shirai T. Trichilemmal carcinoma developing in a burn scar: A report of two cases. J Dermatol 1996; 23:463-8.
Hypersensitivity reaction to scorpion antivenom Sir, A 21-year-old female patient was admitted to our hospital with generalized rash and severe itching since five days after being stung by a small yellow scorpion on her abdomen and receiving scorpion antivenom. According to her detailed history, on the day of the accident, she had presented to a local emergency department (ED) complaining fatigue and burning sensation at the site of the sting. The physician in the ED had intramuscularly administered one ampoule of polyvalent scorpion antivenin after skin test. However, the indication of the administration of antivenin was not clear. The antivenom used was purified polyvalent anti-scorpion serum produced by the Razi Vaccine and Serum Research Institute in Iran. The serum was prepared from the purified plasma of healthy horses immunized with venoms of the six dangerous scorpion species in Iran including Odontobuthus doriae, Mesobuthus eupeus, Androctonus crassicauda, Buthotus saulcyi, Buthotus sach and Hemiscorpius lepturus. This antivenin is usually presented in the 5-mL ampoules. Three hours after receiving the antivenom, she had developed the current symptoms which had improved with corticosteroids and antihistamines but had continued to relapse and remit. In our hospital, examination showed edematous, urticarial plaques intermixed with generalized flushing [Figures 1 and 2]. Neither lymphadenopathy nor discrete urticarial wheals were observed. The oral cavity and conjunctivae were not involved. The history, presentation and Naranjo adverse drug reaction probability score of nine[1] led to the diagnosis of immediate hypersensitivity reaction to scorpion antivenom. High doses of prednisolone and hydroxyzine were administered with sustained improvement of her signs and symptoms over 10 days. Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 1
3. 4.
5.
Das S, Roy AK, Maiti A. Marjolinulcer with multifocal origin. Indian J Dermatol 2009;54:14-5. Arons MS, Lynch JB, Lewis SR, Blocker TG Jr. Scar tissue carcinoma. I. A clinical study with special reference to burn scar carcinoma. Ann Surg 1965; 161:170-88. Phillips TJ, Salman SM, Bhawan J, Rogers GS. Burn scar carcinoma. Diagnosis and management. Dermatol Surg 1998;24:561-5.
Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.144534
Scorpion stings have local and systemic effects. [2-5] Mild envenomations can be managed by supportive care. However, severe and life-threatening envenomations should be treated with scorpion antivenoms although the use of these products has potential risk of immediate and a more delayed-onset form of hypersensitivity reactions. [2,6-8] This case shows that a hypersensitivity skin test is ineffective
Figure 1: Edematous, urticarial plaques and generalized flushing on the patient’s back
S51
Letters to the Editor Emergency Room/Division of Medical Toxicology, Hazrat Ali-Asghar (p) Hospital, Meshkinfam Street, 7143918796 Shiraz, Iran. E-mail: [email protected]
REFERENCES 1.
2.
3. 4. Figure 2: Edematous, urticarial plaques on the dorsum of the patient’s foot
in predicting immediate-type hypersensitivity reactions in patients given scorpion antivenom. [6] Furthermore, this case highlights that hypersensitivity reaction to scorpion antivenom can present in the form of debilitating, prolonged cutaneous manifestations that may develop several hours after antivenom administration. This form of immediate hypersensitivity (delayed-onset and protracted) reaction to scorpion antivenom has not yet been reported in the literature. It is to be noted that antivenom was not indicated in this case in view of the patient’s mild symptoms.[2,7]
5. 6.
7. 8.
Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239-45. Hoffman RS, Nelson LS, Howland MA, Lewin NA, Flomenbaum NE, Goldfrank LR. editors. Goldfrank’s Manual of Toxicologic Emergencies. 1st ed. New York: McGraw-Hill; 2007. p. 901-13. Dehghani R, Fathi B. Scorpion sting in Iran: A review. Toxicon 2012;60:919-33. Sagheb MM, Sharifian M, Moini M, Sharifian AH. Scorpion bite prevalence and complications: Report from a referral centre in southern Iran. Trop Doct 2012;42:90-1. Radmanesh M. Cutaneous manifestations of the Hemiscorpius lepturus sting: A clinical study. Int J Dermatol 1998;37:500-7. Cupo P, Azevedo-Marques MM, de Menezes JB, Hering SE. [Immediate hypersensitivity reactions after intravenous use of antivenin sera: Prognostic value of intradermal sensitivity tests]. Rev Inst Med Trop Sao Paulo 1991;33:115-22. Ismail M. Treatment of the scorpion envenoming syndrome: 12-years experience with serotherapy. Int J Antimicrob Agents 2003;21:170-4. Bond GR. Antivenin administration for Centruroides scorpion sting: Risks and benefits. Ann Emerg Med 1992;21:788-91.
Access this article online Quick Response Code:
Hossein Sanaei-Zadeh Medical School, Shiraz University of Medical Sciences, Shiraz, Iran Address for correspondence: Dr. Hossein Sanaei-Zadeh, Medical School, Shiraz University of Medical Sciences,
Keraunographic tattoo Sir, Lightning injuries are common but uncommonly reported even though it strikes the earth >100 times each second or 8 million times/day.[1] It has been an enigma since antiquity. The brilliance, power, and destructive capacity of lighting have made it the subject for religion, superstition, politics, and most recently, scientific investigation. A 36-year-old male patient presented to the emergency department with history of a lightning strike about 8 h back. He was hiking in mountainous terrain in the open during evening hours. It started raining heavily, so he took shelter under a tree. He had an umbrella in his hand. Lightening flash initially struck the tree and later hit the patient. Patient had a brief period of unconsciousness and on regaining consciousness he felt pain in the upper limb.
S52
Website: www.idoj.in DOI: 10.4103/2229-5178.144536
Patient was confused and had bradycardia at the time of admission. Detailed examination including blood pressure, respiratory rate and systemic examination including ear and eye examination were normal. Dermatological examination revealed keraunographic markings, pathognomonic of lightning over the scapular region (left) [Figure 1]. He also suffered second-degree linear burns on the shin (right) due to rapid heating by electrical energy. Complete blood count, urine analysis including myoglobinuria, cardiac enzyme tests, serial electrocardiography monitoring, liver enzymes, and serum electrolytes were all normal. Patient was admitted and monitored for seven days. He was treated with analgesics for pain in the upper limb. Cutaneous lesions healed spontaneously in four days. He had an uneventful recovery after seven days. Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 1
Copyright of Indian Dermatology Online Journal is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
