J Ayub Med Coll Abbottabad 2017;29(2)
CASE REPORT
MULTI-ORGAN DYSFUNCTION SECONDARY TO YELLOW
SCORPION STING
Muhammad Faisal Khan, Hameed Ullah
Department of Anaesthesiology, Aga Khan University Hospital, Karachi-Pakistan
Scorpion stings are common in tropical and subtropical regions. The history and clinical
manifestation warrant urgent recognition and treatment. The incidence of scorpion stings in
Pakistan is not known as there is no published data available in literature. We report our
experience of a yellow scorpion sting victim who required intensive care admission after
developing multi-organ dysfunction.
Keywords: Multi-organ dysfunction; Scorpion sting; ICU; Renal replacement
J Ayub Med Coll Abbottabad 2017;29(1):347–9
INTRODUCTION
Scorpionism is the second most common cause of
human envenomation after snake bites in published
literature.1 The leading cause of death related to
scorpion sting is cardiac dysfunction with pulmonary
oedema.2 Renal dysfunction is also not uncommon
that may require extracorporeal support.3 Toxicity of
scorpion venom varies between species and within
the same species of scorpion in different geographic
region.2 There is abundant literature available that
describes the epidemiology and regional distribution
of different species of scorpion but so far Pakistani
literature is almost non-existent.
CASE REPORT
A 30-year-old woman, resident of Lasbella,
Balochistan, had a witnessed yellow scorpion bite on
left thigh in early hours of morning whilst seated on
the ground for feeding her child. She complained of
pain in the left flank. Initially a poultice of kitchen
ingredients was placed on the bite area, but by the
late afternoon she developed shortness of breath. She
was taken to a general practitioner where she was
given intravenous hydrocortisone and was discharged
home. In the same evening, she passed black
coloured urine. She went to local doctor and then
referred to our hospital for further management. She
reached our hospital around 18 hours after sting.
On arrival in the emergency room, she was
agitated but responsive with time, place and person.
Her vitals were as follows: non-invasive blood
pressure (NIBP) 210/100, heart rate 130/minute and
respiratory rate 40/min. She was requiring 10 litter of
oxygen thru face mask with peripheral oxygen
saturation 89–90%. On clinical exam, she was
dehydrated and had generalized erythematous rash
with blister formation over the left lower flank.
Respiratory examination revealed bilateral coarse
crackles up to the mid zones. Arterial blood gas
showed 7.30/24/49/16 on 50% fractional inspired
oxygen concentration (FiO2). There was no history of
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bleeding except that she poured a small quantity of
black urine. Her haematological and biochemical data
are mentioned in table-1. Her chest X-ray revealed
bilateral alveolar infiltrates. She was intubated for
progressive respiratory failure and shifted to
intensive care unit.
In the intensive care unit, her respiratory
condition deteriorated further and required high
ventilator parameters. She was managed with lung
protective ventilatory strategy with high positive endexpiratory pressure (PEEP). Patient was sedated with
propofol and morphine infusion. She was managed
with labetalol infusion to keep the systolic blood
pressure below 140 mmHg and intermittent doses of
injection Lasix. Packed cell and fresh frozen plasma
were transfused. Patient was initially started with
broad spectrum antibiotic (Tazocin) that was
subsequently de-escalated when septic screen result
was reported negative.
On day 3rd in ICU, her course was
complicated with acute coronary syndrome. Three
sets of troponin I was mildly elevated (0.9, 0.6 & 0.2
ng/ml respectively). Transthoracic Echo showed
moderate left ventricular dysfunction. She was
managed
conservatively.
Continuous
renal
replacement therapy was started due to worsening
renal failure and acidosis.
On 4th day in ICU, she started to improve
clinically, labetalol was tapered down and closed.
She was gradually weaned off on 7th day and then
successfully extubated. Patient remained admitted in
the hospital for a month for intermittent
haemodialysis and then shifted to home.
DISCUSSION
The available data relating to scorpion bites and its
epidemiology in Pakistan is very scarce. Only one
study4, we could have searched in the “PakMedinet”
(Medical Database) that describe the use of prazocin
in scorpion sting. The author illustrated that they
received 24 cases of scorpion (detail not mentioned
http://www.jamc.ayubmed.edu.pk
J Ayub Med Coll Abbottabad 2017;29(2)
and we also could not find the full text) sting and all
were treated with Prazocin.
The hypothetical reason of rarity of
available literature in Pakistan is either health care
workers have less awareness about this native or it
has never been shared in the national literature. The
incidence may be high in remote villages or towns,
but most of the time these patients are managed either
by local Hakim or with traditional herbs or medicine
at home.
Scorpion envenomation are the most
important cause of arachnid envenoming and are
responsible for significant morbidity and paediatric
mortality in many parts of Central and South
America, Middle East, Asia, and other northern and
south Africa.5 Out of 1500 scorpion species, 30 are
dangerous to human.6 About 250 000 scorpion events
are registered in the Mexico every year, with the
highest mortality rate in the world.1 121 cases were
reported in India from 1986–1989.7 Poisonous fauna
is also prevalent in Iran and Saudi Arabia.2,8 There
are 18 families in order Scorpionidae; while Buthidae
family is the largest and is more toxic to human.5
Yellow scorpion (Leiurus quinquestriatus) is one of
the members of Buthidae family and is considered as
venomous scorpion. It is prevalent in this
Subcontinent and Middle-East region.2 Scorpion
venom contains neurotoxin, haemolysin, agglutinins,
haemorrhagins, leucocytolysins, coagulins, ferments
lecithin and cholseterin9. Substance P stimulates the
cutaneous pain fibers3. The systemic manifestations
of scorpion bite are a result of the intracellular influx
of Na+ and Ca++ ions through sodium channels that
lead to autonomic storm.10
Severity of symptoms depends upon the size
of victim, season and the time lapse between sting
and hospitalization.2 Patient may present with
hypertensive crises due to excessive sympathetic
stimulation and adrenaline release from nerve
endings
at
adrenal
medulla10,
myocardial
11
hypoperfusion, arrythmya , cerebellar infarct12 and
death. It is suggested that mechanism of acute cardiac
dysfunction caused by scorpion sting is due to
transient myocardial ischemia13 which is related to
micro vascular spasm that may cause myocardial
perfusion imbalance. Pulmonary oedema may
develop between 30 minutes to four hours’ post sting.
The nephropathy following sting is not rare and it can
be due to pigment nephropathy, interstitial nephritis,
rhabdomyolyisis, vasculitis or direct toxin effect.14
Scorpion anti-venom has been advocated as specific
treatment for scorpion bite but its role is
controversial.15 None of the report in literature
showed that antivenom is effective in prevention or
abolition of the cardiovascular morbidity16. Alphareceptors play vital role in the pathogenesis of
cardiac failure and pulmonary oedema due to
scorpion sting. Prazocin is a selective alpha-1
adrenergic receptor blocker, it dilates veins and
arteriole. It also inhibits sympathetic outflow in
central venous system.15
Pulmonary oedema is a lethal and life
threatening complication which need rapid
intervention. The severity of pulmonary oedema is
directly related to the dose of toxins, duration of
intoxication, and perhaps to the velocity of rise of
systemic arterial pressure following injection of
scorpion toxins.17 The management is supportive
therapy that includes Ca++ channel blocker, diuretic
and sodium nitroprusside.
Table-1: Haematological and biochemical data
Haemoglobin (Hb)
Haematocrit (HCT)
White blood cell (WBC)
Platelet
Creatinine
Lactate dehydrogenase
(LDH)
Creatinine phosphokinase
Haptoglobin
Prothrombin time
Activated partial
thromboplastin time
INR
Measured value
Normal value
6.0
12.5–15.5g/dl
18.6
37–48%
51000 with left shift 4500–10000
96X109
150–450X109/L
4.1
0.6–1.2mg/dl
17488
140–280 U/L
28813
20
16
45
22–128 U/L
41–165 mg/dl
12–13 second
25–35 second
1.53
1.1
CONCLUSION
Awareness of the scorpion envenomation need to be
highlighted particularly in Pakistan as this is a lifethreatening condition. Also, prompt and appropriated
treatment approach can save human life from major
catastrophe.
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Revised: 26 November, 2016
Accepted: 29 December, 2016
Address for Correspondence:
Hameed Ullah, Department of Anaesthesiology, P.O. Box 3500, Stadium Road, Aga Khan University Hospital,
Karachi-74800-Pakistan
Cell: +92 333 231 3134
Email: [email protected]
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http://www.jamc.ayubmed.edu.pk