Download a case report on scorpion bite induced myocarditis

Indo American Journal of Pharmaceutical Research, 2015
ISSN NO: 2231-6876
A CASE REPORT ON SCORPION BITE INDUCED MYOCARDITIS: A RARE CASE
REPORT
R Siddarama*, Gangula Amareswara Reddy, R Rohith, P Gowtham, Shaik kaleemulla, R Phanindra
Nayak, M Venkata Subbaiah
P Rami Reddy Memorial College of Pharmacy, India.
ARTICLE INFO
Article history
Received 16/04/2015
Available online
05/05/2015
Keywords
Scorpion Bite,
Myocarditis,
Salivation,
Shortness of Breath,
ECG Abnormalities,
Palpitations,
Prazosine.
ABSTRACT
Scorpion stings are more common in our India as well as other countries. 1.23 million
Scorpion bite cases are diagnosed per annum, among that 32,000 cases may be fatal. Majority
of scorpions proceeds similar cardiovascular effects. Scorpion venom contains number of
toxins like alpha and beta toxins etc., which activates both sympathetic and parasympathetic
neurotransmitters. Morbidity and mortality rate of scorpion envenomation is high in rural
areas due to the lack of medical facilities. Generally, scorpion stings are harmless but in some
times they have both local (pain, burning sensation at the site of sting and swelling, redness)
and systemic (pulmonary edema, myocardial damage, hypertension, hyperglycemia, priapism
and arrhythmias.) manifestations including death also. Prazosin is most important antidote for
scorpion sting. In our case, 45 years male patient was admitted in general medicine
department with scorpion sting, he was administered with parenteral hydrocortisone100 mg
and antihistamine Pheniramine maleate 22.7 mg after washing the site of sting. On 3 rd day we
observed abnormal heart sounds (S3) and ECG changes suggests early Myocarditis, after
considering the patient’s past medical history and social habits we confirmed that the patient
had developed Myocarditis due to scorpion sting. As there are very few cases of scorpion
sting induced Myocarditis, it is necessary to monitor closely the electrocardiographic changes
of the patient periodically.
Copy right © 2015 This is an Open Access article distributed under the terms of the Indo American journal of Pharmaceutical
Research, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
www.iajpr.com
Page
Please cite this article in press as R Siddarama et al. A Case Report on Scorpion Bite Induced Myocarditis: A Rare Case Report.
Indo American Journal of Pharm Research.2015:5(04).
1600
Corresponding author
R Siddarama
Department of Clinical Pharmacy,
P Rami Reddy Memorial College of Pharmacy,
Kadapa, Andhra Pradesh, India - 516001
[email protected]
+917306209795
Vol 5, Issue 04, 2015.
R Siddarama et al.
ISSN NO: 2231-6876
INTRODUCTION
There are about 1,500 species of scorpions worldwide, out of these 50 are dangerous to human. Among 86 species in India,
Palamnaeusswammerdami and Mesobuthus tumulus are of medical importance [1].Scorpion bites are common in rural India [2].
Almost all venomous scorpions, belong to the large family called Buthidae [3].They hunt during night and put out of sight in burrow
during the day to avoid light. Scorpion stings increase considerably in summer months and lesser in winter. Scorpion sting causes a
wide range of signs and symptoms from local skin reaction (severe pain and burning sensation at the site of sting) to cardiovascular
collapse, neurological and respiratory symptoms. Cardiovascular manifestations are more prominent with the sting of scorpion such as
Hypertension, Myocarditis, Cardiac arrhythmias etc. These occur due to more number of toxins (alpha & beta) [4].Cardiovascular
complications in scorpion stings: ECG abnormalities, Hypertension, Hypotension, Echocardiographic abnormalities, pulmonary
edema, LVF, Cardiopulmonary arrest, LVF, left ventricular failure [5]. Systemic complications following scorpion sting, Autonomic
storm, Dyselectrolytemia, Acute pancreatitis, Encephalopathy, Acute hepatic injury, Myocarditis with pulmonary edema, Acute renal
failure, Metabolic acidosis, cerebrovascular accidents[6].Local treatment of scorpion bite includes placing of ice bags at the site of
scorpion sting to reduce pain, immobilize the affected part to delay venom absorption, apply a topical or local anesthetic agent to the
wound to decrease paresthesia, prophylaxis administration of tetanus, administration of systemic antibiotics if signs of secondary
infection occur, muscle relaxants for severe muscle spasms (ie, benzodiazepines) oxygen inhalation, intravenous fluids to help prevent
hypovolemia, for hyperdynamic cardiovascular changes, administration of a combination of beta-blockers with sympathetic alphablockers is most effective in reversing this venom-induced effect. Such as prazosin, nifedipine, nitroprusside, hydralazine, or
angiotensin-converting enzyme inhibitors are better. Inotropic medications, such as digitalis have little effect, while dopamine
aggravates the myocardial damage through catecholamine like actions, administration of atropine to counter venom-induced
parasympathomimetic effects. The use of steroids to decrease shock and edema is of unproven benefit, Antivenom is the treatment of
choice after stabilization and supportive care for newer scorpion antivenom as follows: Non-Centruroides and Centruroides antivenom
[7].
CASE REPORT
A 45 years male patient was admitted in General Medicine department with scorpion bite and complained of Sweating,
Salivation, Redness and Swelling present at the site of the sting. On examination patient was conscious and coherent. On Physical
examination the vitals were: Body Temperature -1010F, P.R-94 bpm, B.P - 180/90 mm of Hg. Systemic examination shows CVS S1S2 and S3 sounds were observed, R.S - BLAE +ve, CNS - Pupils were not reacting to light. On laboratory examination, Hemoglobin
levels were found to be moderately decreased (11g/dl). On the 3 rd day, the patient complained of headache, drowsiness, dyspnea,
palpitations, and by these we suspected to have cardiovascular complications and advised for ECG examination. ECG showed
abnormal waves i.e., T-wave depression at aVL, aVF, V2 – V6 (Fig.1) ST segment inversion at V2, V3 (Fig.2)and after the observation
of the report he confirmed to have Myocarditis (Scorpion bite induced Myocarditis).
He was treated with Parenteral anti-ulcer drug (Pantop 40 mg IV OD), Parentral antibiotic (Ceftriaxone 1g IV BD), oralblood pressure
lowering drug(Prazosin 2.5 mg BD), Parentral anti histamine (Avil 22.7 mg IM BD), Parentral corticosteroid(Hydrocortisone 100 mg
IV BD), Parentralopiod analgesic (Tramadol 50 mg IM BD) andIntravenous electrolyte and fluid supplement Normal Saline (0.9 %
NaCl), Dextrose Sodium Chloride.
Page
1601
Fig.1: T-wave depression at aVL, aVF, V2 – V6.
www.iajpr.com
Vol 5, Issue 04, 2015.
R Siddarama et al.
ISSN NO: 2231-6876
Fig.2: ST Segment inversion at V2, V3.
DISCUSSION
When the scorpion bites, venom is deposited in the skin deep to subcutaneous tissue, almost entire absorption of the venom
from sting site would occur in 7-8 hours. 70% of maximum concentration of venom in the blood will be reached within 15 minutes
and then time needed to reach maximum venom blood concentration is 101± 8 minutes in experimental animals, half-life of
intravenously injected venom is between 4 to 7 minutes and takes 4.2 to 13.4 hours for elimination from blood [8]. The scorpion
venom is water soluble antigenic complex mixture of neurotoxins, nephrotoxins, hemolysins, cardiotoxins, phosphodiesterases,
hyaluronidases, phospholipases, histamine and other chemicals [9]. The venom can cause myocarditis by:Direct cardiotoxic effect of
the venom causing toxic myocarditis by reduction of Na-K-ATPase and adrenergic myocarditis by releasing noradrenaline and
adrenaline from neurons, ganglia and adrenals, thus increasing myocardial oxygen demand by direct chronotropic and inotropic effect
on already compromised myocardial blood supply[10]. The venom is a powerful arrhythmogenic agent. The actions of venom are
inhibited by prazosin, atropine, propranolol and phentolamine [11]. Successful management of scorpion sting includes tourniquette
and specific antivenin [12]. Supportive therapies consist of conventional management of left ventricular failure and pulmonary edema.
CONCLUSION
The patient reported in this case report had an evidence of myocarditis as electrocardiographic changes shows T-wave
depression at aVL, aVF, V2 – V6, ST segment inversion at V2, V3 , and clinically in the form of marked sinus tachycardia and a loud
S3 gallop. As there are very few cases of scorpion sting induced Myocarditis, it is necessary to monitor closely the
electrocardiographic changes of the patient periodically.
Page
1602
CONFLICT OF INTERESTS
The authors have declared that they have no conflict of interest.
www.iajpr.com
Vol 5, Issue 04, 2015.
R Siddarama et al.
ISSN NO: 2231-6876
REFERENCES
1. Erfati P. Epidemiology, symptomatology and treatment of buthinae stings. In Arthpod Venoms, Handbook of Experimental
Pharmacology, Bettini S (Ed.), Springer-Verlag: New York 1978:p.312-5.
2. Bisarya, B. N., Vasavada, J. P., Bhat, A., Nair, P. N. R. and Sharma, V. K: Hemiplegia and myocarditis following scorpion bite.
Indian Heart J., 29: 97-100, 1977.
3. Bawaskar HS. Personal communication, 1998.
4. Bawaskar HS, Bawaskar PH. Indian red scorpion envenoming. Indian J Pediatr 1998; 65(3):383-91.
5. Raza M. Soomro et al, Cardiovascular Complications of Scorpion Stings And The Effects of Antivenom, Journal of the Saudi
Heart Association, Vol. 10, No.1 , 1998
6. SR Gadwalkar et al Bilateral Cerebellar Infarction: A Rare Complication of Scorpion Sting. Japi, vol. 54, july2006
7.
David Cheng et al, Scorpion Envenomation May 16, 2013
8. Ismail M and Abd-el salam MA. Are the toxicological effects of scorpion envenomation related to tissue venom concentration?
Toxicon 1988; 233-56.
9. Bawaskar HS, Bawaskar PH. Scorpion sting. J Assoc Physicians India, 1998; 46:388–92.
10. Rahav G, Weiss T. Scorpion sting induced pulmonary
11. Ismail, M., El Asmar, M. F. and Osman, O. H. Pharmacological studies with scorpion venom; evidence for the presence of
histamine. Toxicon., 13: 49-56. 1975.
12.
Wallace, J. F. Disorders caused by venoms, bites and stings. In, "Harrison's Principles of Internal Medicine", Editors: Issel
bacher, K. J., Adams, R. D., Braunwald, E., Petersdorf, R. G. and Wilson, J. D. 9th edition, McGraw Hill International Book Co.,
Johannesburg, London, Tokyo etc., 1980, pp. 924-925.
Page
1603
54878478451150431
www.iajpr.com