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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. 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