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Case report
Pulmonary Edema in Scorpion Bite
M. P.Gorkhaly*, D. M. Joshi**
Abstract
A patient after 3 days of scorpion bite at the
lateral aspect of right lower limb presented with
a feature of pulmonary edema and cardiac
arrhythmias and was treated at ICU set-up with
diuretics and other supportive therapy. The
patient
recovered
fully
symptomatically,
radiological finding and ECG came normal.
Usually scorpion bites are not toxic but few
species are toxic because of its massive release
of catecholamine and direct toxic effect of the
venom on cardiac fibers.
Key Words
Insulin, Pulmonary edema, Captopril, Scorpion
bite
Introduction
Scorpions are crablike arachnids that feed on
ground-dwelling arthropods and small lizards.
Painful but relatively harmless scorpion stings
need to be distinguished from the potentially
lethal envenomations that are produced by about
30 of the ~1000 known species.
Scorpion bites are common in Terai (plains)
region of eastern Nepal. They are mainly Indian
red scorpion (Mesobuthus tamulus). It is one of
the most toxic envenomation in animal kingdom.
Scorpion venom is a species-specific complex
mixture of short neurotoxin proteins, appreciable
quantities of serotonin, hyaluronidase and
various enzymes that act on trypsinogen 1,2 The
toxins bind at cell membrane level to the
voltage-dependent potassium channels, the
_______________________________________________________
*Associate Professor, NAMS, Bir Hospital
**Resident, Internal Medicine, NAMS
calcium activated potassium channel, as well as
sodium channels.2 Autonomic storm, presenting
as hypertension, tachycardia and biventricular
dysfunction with left ventricular predominance,
pulmonary edema and cool extremities3 is thus
initiated due to alpha receptor stimulation by
the toxin. Terminal hypotension could represent
catecholamine depletion syndrome or activation
of kinin/prostaglandin pathway.
Mild envenomation causes severe vasoconstriction
and hypertension. Severe envenomation produces
predominant left ventricular dysfunction with
normal systemic vascular resistance manifesting
as pulmonary oedema or severe hypotension
depending on the fluid balance. Shock due to
biventricular dysfunction and vasodilatation
occurs terminally. 4
Some calcium channel drug like nifedipine also
has some benefit for the treatment but it alone
did not prevent myocardial damage unless the
peripheral action of venom was blocked by
prazosin. 5
Severe envenomation produces predominant left
ventricular dysfunction with normal systemic
vascular resistance manifesting as pulmonary
oedema improved with following afterload
reduction with captopril. 6 Captopril 12.5-25 mg
thrice daily also has very good outcome in
mortality during pulmonary edema.7
Tityus serrulatus in Brazil cause massive release
of endogenous catecholamine with hypertensive
crises, arrhythmias, pulmonary edema, and
myocardial damage. Acute pancreatitis occurs
with stings of Tityus trinitatis in Trinidad, and
central nervous toxicity complicates stings of
Parabuthus and Buthotus scorpions of South
Africa. Tissue necrosis and hemolysis may follow
stings of the Iranian Hemiscorpius lepturus. It is
one of the causes of reversible cordiomyopathy
which is being proved by one study done in Brazil
which is because of sting by Tityus serrulatus.8
Random blood sugar was 141mg, Urea-37mg%,
Creatinine-0.9mg%, Na- 140meq/l, and K5meq/l, Bilirubin total- 0.9mg%, conjugated
-0.3mg%, SGPT- 34u/l, Alkaline phosphates186u/l, SGOT-44u/l.
Case Reporting
ECG with sinus rate of 100/min with multiple
ectopics and few bigeminy.
Mr. TPA, 50 years gentleman from Sarlahi,
farmer by profession, non-smoker and nonalcoholic, without any significant illness in the
past, admitted in our hospital after four days of
scorpion bites at the right lateral aspect of the
foot while working in his farm.
At the time of admission, he was severely
dyspneic with presence of othopnoea.He also
complained about cough with pinkish frothy
sputum but however there was no chest pain, no
history of loss of consciousness, fever and
abdominal pain. According to the patient,
initially there was mild swelling at the bite site
which gradually subsided.
On examination he was conscious, oriented but
on respiratory distress with vitals maintained
with BP 130/82 mm of Hg.
Chest X-ray showed bilateral fluffy shadow at the
middle and lower zone.
Echocardiographic findings were as follows:
All chambers are normal,
MR Grade II
Fair LV systolic function
Patient was treated at ICU in the line of
Pulmonary Edema for three days with Diuretics,
captopril 12.5 mg 4 times (6 hrly) daily, insulin
infusion and other symptomatic measurements.
As he started to improve symptomatically along
with radiological finding, he was shifted to ward.
And there he was kept for another seven days
with the same treatment and from where he was
discharged and while on discharge , he was
without any symptoms and all the investigation,
even chest x-ray, ECG were normal.
Oxygen Saturation was only 82% without oxygen,
and he was having central cyanosis.
Cardiovascular, central nervous and abdominal
examination revealed no gross abnormality.
Chest-vesicular breathing with bilateral diffuse
fine inspiratory crackles upto to the level of
middle part of interscapular region.
At time of admission, total count was 11,700 per
cmm, with Neutrophil-55%, Lymphocyte-43% and
Eoisinophil-02%.
Hb-12.8% ESR- 40 mm in first hour.
Fig. 1: 1st x-ray at the arrival at emergency
(21st 04.64)
Fig. 2: 2nd day of admission (22ND 04.64)
Fig. 3: 29th.04.64 (At the time of discharge)
Fig. 4: ECG with multiple ectopics
Discussion
The patient presented to our hospital was in
respiratory distress (tachypnea), hypoxemia and
pulmonary edema with arrhythmias. It has been
reported that scorpion envenoming results in a
severe autonomic storm with a massive release
of catecholamine, increased angiotensin II and
inhibition of insulin secretion.2 These hormonal
alterations could be responsible for the
pathogenesis
of
a
variety
of
clinical
manifestations. Under these conditions, Scorpion
envenoming essentially undergo fuel-energy
deficits and an inability to utilize the existing
metabolic substrates by vital organs and
consequence is multiple system failure and the
death. Regular insulin was infused at the rate of
0.3U/ Gm of glucose and glucose at the rate of
0.1 gm/Kg/Hr and Potassium supplement was
given accordingly. Based on animal experiments
where insulin administration reversed the
metabolic and ECG changes induced by scorpion
envenoming and treating the poisonous scorpion
sting victims with insulin, they consider that
insulin has a primary metabolic role in preventing
and reversing the cardiovascular, haemodynamic,
and neurological manifestations and pulmonary
oedema induced by scorpion envenoming9. If
patient present after 4-8 hours of bite, usually
they present with complication and our patient
presented after three days of bite. It ‘s been
reported that 25-30% fatality due to acute
pulmonary oedema in victims of Indian red
scorpion (Mesobuthus tamulus) sting have been
reported from Western Maharashtra, India. The
advent of prazosin in recent years has
revolutionized the management of severe
scorpion sting cases. Prazocin prevents and cures
the cardio-vascular complications. However one
report showed majority of cases developed acute
pulmonary oedema in 4-8 hours in a hospital
setting irrespective of control of their arterial
blood pressure with six hourly oral prazosin.10
After-load reduction with oral Captopril is safe
and effective in Scorpion envenom CVS
manifestations. Results are similar to those with
other vasodilators.
In our patient, Antivenom therapy was not used
due to non-availability. However, recent reports
have disfavored its use in preventing
cardiovascular manifestations for Indian species
of scorpion venom.11
5)
Bawaskar HS, Bawaskar PH. Management
of the cardiovascular manifestations of
poisoning by the Indian red scorpion
(Mesobuthus tamulus).Br Heart J; 1992;
68(5):478-80.
6)
Bawaskar HS, Bawaskar PH. Management
of the cardiovascular manifestations of
poisoning by the Indian red scorpion
(Mesobuthus tamulus).Br Heart J; 1992;
68(5):478-80
7)
Krishnan A, Sonawane RV, Karnad DR
Captopril
in
the
treatment
of
cardiovascular manifestations of Indian
red
scorpion
(Mesobuthus
tamulus
concanesis Pocock) envenomation.JAssoc
Physicians India. 2007; 55:22-6
8)
Hering SE, Jurca M, Vichi FL, AzevedoMarques MM, Cupo P. ‘Reversible
cardiomyopathy’ in patient with severe
scorpion envenoming by Tityus serrulatus:
evolution of enzymatic, electrocardiography
and
echocardiographic
alterations. Ann Trop Paediatr. 1993;
13(2): 173-82.
9)
Ismail M. The scorpion envenoming
syndrome. Toxicon 1995; 33:825-58.
Murthy KR, Hase NK. Scorpion envenoming
and the role of insulinToxicon. 1994;
32(9):1041-4.
10)
Karnad DR. Haemodynamic patterns in
patients with scorpion envenomation.
Heart 1998 ; 79(5):485-9.
Bawaskar HS, Bawaskar PH. Prazosin
therapy and scorpion envenomation. J
Assoc Physicians India 2000; 48:1175-80.
11)
Bawaskar HS, Bawaskar PH. Clinical profile
of severe scorpion sting in children at
rural setting. Ind Pediatr 2003; 40:1072-5.
Our patient was referred from villages situated
far away from the Katmandu and since majority
of scorpion sting present with intense local pain
and are non fatal, the victims get symptomatic
treatment and usually get better after initial
sting. But unfortunately our patient developed
respiratory distress and was referred late to our
center. But fortune enough, our patient
recovered completely with injectable diuretics,
insulin infusion, captopril and other supportive
management.
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