Scorpion Sting Syndrome in Eastern Riyadh
1990; King Faisal Specialist Hospital and Research Centre; Volume: 10; Issue: 4 Linguagem: Inglês
10.5144/0256-4947.1990.383
ISSN0975-4466
Autores Tópico(s)Mosquito-borne diseases and control
ResumoOriginal ArticlesScorpion Sting Syndrome in Eastern Riyadh John R. NealeMD John R. Neale Address reprint requests and correspondence to Dr. Neale: P.O. 727, Pescadero, California 94060, USA. From the Emergency Department, King Fahad Hospital, Riyadh Search for more papers by this author Published Online:1 Jul 1990https://doi.org/10.5144/0256-4947.1990.383SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractThe emergency department log at the King Fahad Hospital was reviewed for the five-year period 1983 through 1987 and 205 cases of “scorpion sting syndrome” were found. Specimens brought in by patients were preliminarily identified as Androctonus crassicauda, Apistobuthus pterygocercus, and Leiurus quinquestriatus. Only 13 cases (6%) occurred in the winter months of December, January, and February. Fifty cases (24%) occurred in the daylight hours between 0600 and 1800. There were two hospitalizations and a third patient refused hospitalization. The records of 173 cases were analyzed and all but one had a Saudi surname. One hundred thirty-six patients presented within one hour of the sting. Males were affected twice as often as females, six of whom were pregnant. Twenty-nine (17%) of the patients were children. Pain was the most common symptom but was not always present. Hypertension and redness at the site of the sting were the most common signs. Although frequently benign, cases of scorpion sting as observed in Eastern Riyadh may not be innocuous. Severity is likely to be greater in children and in adults with preexisting hypertension.IntroductionScorpions (order Scorpionidae) have not changed noticeably in form over 400 million years. As a group, they are easily recognized but individual species can be difficult to identify. There are at least 700 different species. They exist on all continents but are characteristic of desert areas, semiarid grasslands, and the tropics. The venom injected by the sting apparatus, which is located in the scorpion's tail, has been found to be primarily neurotoxic.The family Buthidae contains most of the world's dangerous scorpions. Toxicity is variable, but in certain areas scorpions represent a significant medical problem: in the Middle East and North Africa (Leiurus, Androctonus, Buthus, and others), India (B. famulus, Palamneus), the Americas (Centruroides), and Brazil and Trinidad (Tityus).The practitioner faced with a patient who complains of a scorpion sting is in a dilemma. Details of the injury are frequently vague and the clinical course is uncertain. Venom composition is variable, related in part to habitat and diet,1 and the pathophysiological mechanism is incompletely understood. This paper presents the range of experience with a large series of emergency room patients treated for “scorpion sting syndrome.”MATERIAL AND METHODSThe King Fahad Hospital is located approximately 30 kilometers east of the center of Riyadh and deals with over 40,000 emergency cases a year.Emergency department records for 1983 through 1987 were examined for cases of scorpion sting. (Records from 27 April to 14 July 1983 were missing.)Independent computerized hospital records were used to review the charts of patients who were hospitalized.The medical records of 173 patients were then examined by a single physician and the following data recorded: patient name, age, sex, time of sting, prior treatment, signs and symptoms of the patient, single or multiple sting, location of the sting, prior sting history, coexisting medical conditions, treatment, and outcome.Six scorpion specimens from the Riyadh vicinity were examined. These were preliminarily identified by Dr. M. Ismail of the Department of Pharmacology, King Saud University, and also with the help of the manual of Vachon.2RESULTSDuring the study period, 305 patients with animal bites and stings were seen in the emergency room. Of these, 205 were treated for scorpion stings. The average incidence of scorpion sting syndrome was 1.3 cases per 1000 patients, with no significant annual variation over the five-year period despite the increasing population and urbanization of the area.Six specimens were brought to the emergency room by the patients and these were identified as Androctonus crassicauda (4 specimens), Apistobuthus pterygocercus (1 specimen), and Leiurus quinquestriatus (1 specimen) (Figures 1 to 3).Figure 1. Androctonus crassicauda.Download FigureFigure 2. Apistobuthus pterygocercus.Download FigureFigure 3. Leiurus quinquestriatus.Download FigureFifteen (9%) patient records contained a description of the stinging creature. In 11 it was described as black or dark brown and this probably represents Androctonus. It was described as light, white, yellow, or beige in the others and this would fit the description of both Leiurus and Apistobuthus.Between May and October, 155 (76%) of the 205 cases were seen, and only 13 cases (6%) were seen during December, January, and February. The greatest frequency of cases (N=149; 73%) occurred between 1800 and 0600. The peak hours for the appearance of patients in the emergency room was between 2000 and 0200 hours (N=109; 53%).One hundred thirty-six patients (79%) were seen within one hour of the sting. The longest interval between the sting and presentation in the emergency department was 10½ hours. This same patient reported that he had been stung by the same scorpion which had stung and killed his 3-month-old child, who was not seen at our institution.All but one of the 173 patients whose records were analyzed had familiar Saudi Arabian surnames. Average age was 22 years (range, 5 months to 80 years). Twice as many men as women had been stung and this ratio was also observed in the pediatric group (N=29; 17%).Six of the patients were pregnant. Four were in the second trimester and two in the third trimester. The two patients who subsequently delivered at King Fahad Hospital had normal children without complications. Follow-up is not available for the others.One hundred fifty-seven (91%) had a single sting. An extremity was involved in 90% (162 of 181 sting sites noted) of the cases, and the lower extremity was involved in 116 cases (64%) with 89 (49%) involving the foot. The testicle was involved in one case and the buttocks in six. The left side of the body was affected more frequently than the right (99 versus 72 cases). Ten sites were on the torso or an undetermined location.The signs and symptoms of the scorpion sting syndrome are given in Tables 1 to 3. Pain is the most common symptom (94%) but is not always present. Redness at the sting site (49%) and systemic hypertension (46%) were the most common signs.Table 1. Pattern of clinical findings in 173 cases of scorpion sting syndrome.Table 1. Pattern of clinical findings in 173 cases of scorpion sting syndrome.Table 2. Local clinical findings reported in 173 cases of scorpion sting syndrome.Table 2. Local clinical findings reported in 173 cases of scorpion sting syndrome.Table 3. Systemic clinical findings reported in 173 cases of sting syndrome.Table 3. Systemic clinical findings reported in 173 cases of sting syndrome.Six patients had had previous stings but there was no instance of an allergic reaction. Forty patients (23%) were referred from other medical facilities. Forty-seven (27%) had had some form of prior treatment, including antivenom in 19, tourniquets in 17, and self-inflicted lacerations over the sting site in four. The other seven had miscellaneous forms of prior treatment such as topical powders. In one case the patient is reported to have suffered an allergic response with syncope to the skin test for the antivenom. None of the treatments was observed to be effective.Treatment of the scorpion sting syndrome in the emergency department yielded variable results. No specific treatment was given in eight cases (5%). Tetanus prophylaxis was given in 37 (21%); antihistamines, pain medications, or a combination of the two was given in 138 (80%). Topical ice was applied in 90 (52%) and local infiltration of anesthetic was carried out in 15 (9%) of the cases. Sedatives, steroids, and antibiotics were administered in two to three cases each.The patients were observed in the emergency department for an average of one hour, though this ranged from 5 minutes to 9 hours. Ten patients returned after discharge, mainly because of continued pain. One patient returned twice, at 3 and at 6 hours, and another returned 24 hours after the first visit.Two patients were hospitalized and one patient refused hospitalization. Their cases are summarized as follows:Patient 1A 4½-year-old girl was stung while camping in the desert. She was initially treated at an outside clinic with what was described to be an antivenom agent. On presentation in the emergency room she was shivering and restless, with blood pressure 130/40, pulse 108, respirations 30, and temperature 37.2°C. She was admitted to the intensive care unit (ICU). Complete blood count, electrolytes, coagulation profile, and subsequent amylase activity were normal. She had an uncomplicated hospital course, including return of blood pressure to 90/60, and was discharged in good condition after 36 hours.Patient 2A 13-month-old boy was seen in the emergency room 1 hour after being stung by a black scorpion while he was lying on the ground. The only findings were a pulse of 120 and a small area of erythema on the abdomen. He was given 12.5 mg of diphenhydramine hydrochloride and discharged. He returned one hour later after having had an apparent seizure. Findings at physical examination included generalized rigor, periorbital swelling, and cold clammy skin. His pulse was 112, respirations 28, temperature 36.2°C; blood pressure was not recorded. He was admitted to the ICU. Initial white blood cell count in the ICU was 16.4 109/L with 76 polys and 6 bands. Serum electrolytes and coagulation studies were normal. Urinalysis revealed 3 to 6 red cells per high power field. He continued to improve and was discharged in good condition after 4 days.Patient 3A 50-year-old woman with a history of diabetes and hypertension was stung twice on the torso by a light-colored scorpion. She complained of pain and “pins and needles” sensation at the sites; redness, swelling, and tenderness were noted at one site. Blood pressure was 232/116, pulse 108, respirations 40, and temperature 37°C. White blood cell count was 9.5 109/L, sodium 134 mmol/L, potassium 4.1 mmol/L, CO2 19 mmol/L, and glucose 24.6 mmol/L. Electrocardiogram showed a sinus tachycardia without S-T segment changes. Nine hours later her blood pressure was 178/100. She signed out against medical advice, on NPH and regular insulin.DISCUSSIONI have used the term scorpion sting syndrome to refer to the varied manifestations of presumed scorpion envenomation. It is a not uncommon reason for emergency room visits in Eastern Riyadh.Vachon2 found fourteen species of scorpions on the Arabian peninsula. Nine were in the Riyadh area. Table 4 lists the species found by Vachon and also notes the three species for which locally available Pasteur scorpion antivenom is made.Table 4. Scorpions found in Saudi Arabia.Table 4. Scorpions found in Saudi Arabia.The marked seasonal and diurnal pattern of incidence of scorpion sting syndrome is related to its behavior as a night predator and a poikilotherm.The experience reported here bears out the contention that “a scorpion sting is not generally fatal to healthy adults in Africa and the Mid-East.”3 In other parts of Saudi Arabia, such as Al-Baha, there have been reports of more frequent hospitalizations, with a mortality as high as 8%.4 The more toxic species Leiurus is common in that area and this may account for the difference in severity.A typical case of scorpion sting syndrome can, perhaps, be summarized as follows: immediately after the sting there is local pain with proximal radiation, followed shortly by local redness and swelling. During an intermediate period of one to two hours, the patient will appear anxious and in moderate discomfort with nausea and epigastric pain. Tenderness is noted over the site and there is moderate hypertension and tachycardia. Usually this picture resolves within an hour or two, during which time an analgesic or antihistamine may be given. The local pain can persist for up to 24 hours.In the present series, local and systemic signs and symptoms occurred together in only 16 cases (9%) (Table 1).The clinical presentation and course are quite variable. For example, pain has been considered a hallmark of scorpion stings and was present in all 24 of the patients in the series reported by El Naggar et al.5 In the present series, 30 (17%) had no pain at the time of the emergency room visit. Of these, however, 25 had other signs or symptoms of a scorpion sting.Hypertension is the most common systemic sign, presumably because the venom releases catecholamines from the sympathetic nervous system. It has been shown in animal studies that venom-induced arterial hypertension is due to the effect of catecholamines released by toxin from adrenal glands and postganglionic nerve endings on alpha adrenergic receptors. By contrast, tachycardia, which did not appear without hypertension, is due to the effect of toxin-released catecholamines on beta adrenergic receptors.6Apprehension and restlessness are a significant component of scorpion sting syndrome, suggesting that dysphoria is a direct chemical effect of envenomation. Because of their small size, children may be more severely affected than adults; they may also have more difficulty localizing and describing symptoms. A constant restlessness may be particularly common in patients under 10 years of age.7Both of the two pregnant patients with scorpion sting syndrome about whom we know the outcome of pregnancy had a normal delivery, and this agrees with the findings of Ismail,8 who reported that, in the rat, only a small fraction of injected venom was found in the fetus or placenta. The fetus appeared to be affected only indirectly through metabolic and electrolyte abnormalities in the mother, rather than by any direct toxicity.Five of our patients (3%) had no local or systemic signs or symptoms, and there was little doubt among any of the patients that they had been stung by a scorpion. It is possible that envenomation does not always occur. Ismail observed that, during the electric milking of the venom apparatus in the laboratory, a venom droplet could not always be extracted. This may be due to inspissation of the venom apparatus. It is also possible that a scorpion hysteria exists, whereby an actual sting does not occur. At least one case in the present series could qualify as such.The role of antivenom treatment is not clearly established. A World Health Organization publication states that “antivenoms are among the few pharmacological agents in widespread use today whose therapeutic value remains largely untested by clinical trial.”9 Current concern about the safety and effectiveness of antivenom is quite legitimate. Because the clinical picture was not considered severe enough to warrant the risk of antivenom treatment in any of the patients in the present series, none were treated with it. In one animal experiment, antivenom was noted to prevent cardiac toxicity if given before envenomation but not if given afterwards.10 An interesting exchange of letters in Toxicon6,11 voiced uncertainty about the use of antivenom even in cases with serious cardiovascular manifestations.Because of the variety of treatments used in the patients in this study, it is not possible to draw conclusions about the value of any particular treatment. A useful treatment algorithm has been proposed for more serious cases.12 Conservative symptomatic management is the most desirable. Some claim that meperidine hydrochloride is contraindicated in the treatment of pain resulting from a scorpion sting. However, the doses used by Stahnke and Dengler,13 who sought to prove this, far exceeded those normally used. Routine doses of meperidine hydrochloride have been used for pain control both in our patients and those of others, with no ill effect.In the Arizona study of Centruroides, the most common sting site was the hand.14 In the current series, the most common site was the foot. At present, it may be as difficult to prevent scorpion stings by advocating the use of shoes while camping in the desert as it is to give physicians a rational treatment protocol. However, physicians should observe children and other high-risk patients such as hypertensives for several hours after a sting, paying particular attention to restlessness in children and to cardiovascular parameters in all.ARTICLE REFERENCES:1. Zlotkin E, Miranda F, Rachat H. In: Bettini S, ed. Handbook of Experimental Pharmacology. New York, Springer Verlag; 1978;:323–30. Google Scholar2. Vachon M. Arachnids of S.A.: scorpiones. In Wittmer W, ed. Fauna of Saudi Arabia, Vol 1, Basle, Ciba-Geigy, 1979;:30–66. Google Scholar3. Scorpion venom antiserum. In: Martindale W, ed. The extra pharmacopoeia, ed 28. London: Pharmaceutical Press, 1982;1607. Google Scholar4. Fatani AJ. "Propsosal for the M.Sc. dissertation, submitted to Dr. Ismail" ., Dept. of Pharmacology, King Saud University, 1987. Some pharmacological studies of the cardiovascular and related effects of scorpion envenomation: the setting up of an experimental treatment protocol. Google Scholar5. El Naggar MK, Wahab AA, Montasser MF. "Clinical patterns of scorpion stings in Saudi Arabia" . J Egypt Soc Parasitol. 1985; 15:135. Google Scholar6. Freire-Maia L, Campos JA. "Response to the letter by Gueron and Ousysoysben on the treatment of the cardiovascular manifestations of scorpion envenomation" . Toxicon. 1987; 25(2):125–30. Google Scholar7. Rimsza ME, Zimmerman R. "Scorpion envenomation" . Pediatrics. 1980; 66(2):298–302. Google Scholar8. Ismail M, Abdulsalam MA. "Are the toxicological effects of scorpion envenomation related to tissue venous concentration?" Toxicon. 1988; 26(3):33–56. Google Scholar9. World Health Organization. Progress in the characterization of venoms and standardization of antivenoms. Geneva, WHO; 1981. Google Scholar10. Ismail M, Shibl AM, Morad AM, Abdullah ME. "Pharmacokinetics of 125I-labelled antivenin to the venom from the scorpion Androctonus amoreuxi" . Toxicon. 1983; 21(1):47–56. Google Scholar11. Gueron J, Ousysoysben I. "What is the treatment for the cardiovascular manifestations of scorpion envenomation?" Toxicon. 1987; 25(2):121–4. Google Scholar12. Hershkovich Y, Elitsur Y, Margolis CZ, et al.. "Criteria map audit of scorpion envenomation in the Negev, Israel" . Toxicon. 1985; 23(5):845–54. Google Scholar13. Stahnke H, Hance Dengler A. "The effect of morphine and related substances on the toxicity of venoms" . Am J Trop Med. 1964; 13:346–51. Google Scholar14. Findlay RE. 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Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byJarrar B and Al-Rowaily M (2019) Epidemiological aspects of scorpion stings in Al-Jouf Province, Saudi Arabia, Annals of Saudi Medicine , 28:3, (183-187), Online publication date: 1-May-2008.Dittrich K, Ahmed R and Ahmed Q (2019) Cardiac Arrest Following Scorpion Envenomation, Annals of Saudi Medicine , 22:1-2, (87-90), Online publication date: 1-Jan-2002.Dittrich K, Power A and Smith N (1994) Scorpion Sting Syndrome — A Ten Year Experience, Annals of Saudi Medicine , 15:2, (148-155), Online publication date: 1-Mar-1995.Rashid A and Hossain M (2019) Scorpion Envenomation in the Children of Northwestern Saudi Arabia, Annals of Saudi Medicine , 13:2, (205-206), Online publication date: 1-Mar-1993.Izuora G, Syed A and Almahdi A (2019) Reply, Annals of Saudi Medicine , 13:2, (206-207), Online publication date: 1-Mar-1993.Izuora G, Syed A and Al-Hindi A (2019) Scorpion Envenomation in Marjadah Children, Annals of Saudi Medicine , 12:3, (322-323), Online publication date: 1-May-1992. Volume 10, Issue 4July 1990 Metrics History Accepted5 September 1989Published online1 July 1990 InformationCopyright © 1990, Annals of Saudi MedicinePDF download
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