Extensive Ischemic Stroke Following Scorpion Sting In A Young During Hospital Stay In A Tertiary Care Hospital: A Rare Case Report

Complication following scorpion sting are common in India and can be fatal. Stroke following scorpion sting is a rare complication and can occur by various mechanisms such as autonomic storm, hypertension, hypotension, toxic myocarditis, disseminated intravascular coagulation, venom induced vasculitis. We present a rare case of multiple brain infarcts following scorpion sting which has rarely been reported in medical literature. In our case non-contrast CT head showed multiple infarcts involving bilateral cerebellar hemisphere, bilateral occipital lobes, medulla and Pons on right side, right temporal lobe, and right thalamus, left parietal lobe. He was investigated for other possible cause of stroke in young without positive results such as cardiac, hematological, rheumatological workup. In view of normal CT cerebral angiography and lack of other cause of stroke in young and the temporal relation and progression of events we concluded that stroke in this patient is likely as result of severe vasospasm due to autonomic storm resulting in low flow infarct. Close observation of the patient for a period of hospital stay is required. During this period an hourly check of the patient should be done as assessing the level of consciousness, pulse rate and rhythm, blood pressure, respiratory rate and new symptoms or signs such as focal neurological deficits.

Mesenteric hypoperfusion and inflammation induced by brain death are not affected by inhibition of the autonomic storm in rats

OBJECTIVES: Brain death is typically followed by autonomic changes that lead to hemodynamic instability, which is likely associated with microcirculatory dysfunction and inflammation. We evaluated the role of the microcirculation in the hemodynamic and inflammatory events that occur after brain death and the effects of autonomic storm inhibition via thoracic epidural blockade on mesenteric microcirculatory changes and inflammatory responses. METHODS: Male Wistar rats were anesthetized and mechanically ventilated. Brain death was induced via intracranial balloon inflation. Bupivacaine (brain death-thoracic epidural blockade group) or saline (brain death group) infusion via an epidural catheter was initiated immediately before brain death induction. Sham-operated animals were used as controls (SH group). The mesenteric microcirculation was analyzed via intravital microscopy, and the expression of adhesion molecules was evaluated via immunohistochemistry 180 min after brain death induction. RESULTS: A significant difference in mean arterial pressure behavior was observed between the brain death-thoracic epidural blockade group and the other groups, indicating that the former group experienced autonomic storm inhibition. However, the proportion of perfused small vessels in the brain death-thoracic epidural blockade group was similar to or lower than that in the brain death and SH groups, respectively. The expression of intercellular adhesion molecule 1 was similar between the brain death-thoracic epidural blockade and brain death groups but was significantly lower in the SH group than in the other two groups. The number of migrating leukocytes in the perivascular tissue followed the same trend for all groups. CONCLUSIONS: Although thoracic epidural blockade effectively inhibited the autonomic storm, it did not affect mesenteric hypoperfusion or inflammation induced by brain death. .

Autonomic dysfunctions in patients with scorpion sting: early predictors of severe disease.

Scorpion sting envenomation is a common medical emergency accounting for nearly 2.8% of annual intensive cardiac care unit admissions and much more outpatient visits. Symptomatology and severity of envenomation varies greatly. Autonomic storm may end up in loss of life. Methods: This is a clinical study conducted between April 2011 and February 2013. Patients with moderate to severe envenomation were examined at frequent intervals for various autonomic manifestations. Various demographic, clinical and electrocardiogram (ECG) changes were studied for their association with severity of envenomation. Results were statistically evaluated for their significance. Results: A total of 106 patients were studied with a mean age of 27.25 years and peak incidence between 11 and 30 year age groups. 91% reached the hospital within 12 h. 7.55% of the patients had Grade 2, 74.53% had Grade 3 and 17.92% had Grade 4 disease, all grades were common in 11-30 age group. Autonomic disturbances; profuse sweating seen in 72.6% of the patients that showed a strong correlation with pulmonary edema and ECG manifestations (p ≤ 0.0001). Pulmonary edema was present in 37.7% of the patients. Excessive salivation was seen in 28.3%, and persistent nausea and vomiting were seen in 24.5%, both were associated with severe cardio-pulmonary manifestations. Hypotension was present in 14.2% of patients that was associated with poor prognosis (p ≤ 0.0001). Conclusions: Scorpion sting envenomation is a life-threatening problem requiring immediate attention. Presence of autonomic dysfunctions; profuse sweating, excessive salivation, persistent nausea and vomiting, hypotension at presentation are poor prognostic factors.

Acute Pancreatitis in Scorpion Envenoming Syndrome: Insulin-Glucose Administration Reverses Haemodynamic Changes, Pulmonary Edema and Other Clinical Manifestations Due to Scorpion (Mesobuthus tamulus Concanesis, Pocock [Buthidae family]) Stings

Death due to poisonous scorpion (Buthidae family) stings is a common event in the developing countries. Scorpion envenoming syndrome results in autonomic storm, release of catecholamines, angiotensin II, glucagon, glucocorticoids, either suppressed insulin secretion or hyperinsulinemia; hyperglycemia, lipolysis – sudden increase in free fatty acids (FFA), acute myocarditis, disseminated intravascular coagulation, cardiovascular disturbances, pulmonary oedema, acute pancreatitis, and many clinical manifestations. Under these altered hormonal mileu, insulin administration reversed the metabolic and ECG changes induced by scorpion envenoming in the experimental animals and in scorpion sting victims. Insulin has a primary metabolic role in preventing, counter-acting and reversing the metabolic, cardiovascular, haemodynamic, and neurological manifestations and pulmonary oedema induced by scorpion envenoming and reversing all the deleterious effects of FFA by inhibiting the catecholamine induced lipolysis, and increase intra-cellular K+, facilitating glucose transport to the myocardium and glucose metabolism through different pathways. Profuse sweating, excessive salivation and abdominal pain are the triad of symptoms of ominous significance in scorpion sting victims with acute pancreatitis. Laryngeal spasm and respiratory failure are more common with acute pancreatitis. Continuous infusion of regular crystalline insulin should be given at the rate of 0.3 U/g glucose and glucose at the rate of 0.1 g/kg body weight/hour, for 48–72 hours, with supplementation of potassium as needed and maintenance of fluid, electrolytes and acid-base balance.

Laryngeal Spasm in Scorpion Envenoming Syndrome

Death due to scorpion envenoming syndrome is a common event all over the world in tropical and sub-tropical countries. Scorpion envenoming syndrome results in a severe autonomic storm with a massive release of catecholamines, increased levels of angiotensin II, glucagon, cortisol, thyroid hormones, either hypoinsulinemia or hyperinsulinemia, hyperglycemia and increased free fatty acid levels. Under these conditions, scorpion envenoming syndrome with laryngeal spasm, fasciculations, clonus and tetany like skeletal muscle contractions, myocardial damage, disseminated intravascular coagulation, cardiovascular disturbances, peripheral circulatory failure, cardiac pulmonary oedema, adult respiratory distress syndrome, and many other clinical manifestations cause multi-systemorgan-failure and death. Under these altered conditions, scorpion envenoming essentially results in a syndrome of fuel – energy deficits and an inability to use the existing metabolic substrates by vital organs causing MSOF and death. Based on our animal experiments in which insulin administration reversed the metabolic and ECG changes induced by scorpion envenoming and treating the poisonous scorpion sting victims with insulin, we consider that insulin has a primary metabolic role in preventing and reversing laryngeal spasm, fasciculations, clonus and tetany like contractions, the cardiovascular, neurological manifestations and pulmonary oedema. Administration of insulinglucose infusion to scorpion sting victims is the physiological basis for the control of the metabolic response when that has become a determinant to survival. Continuous infusion of regular crystalline insulin at the rate of 0.3 U/g glucose and glucose at the rate of 0.1 g/kg body weight/hour, for 48–72 hours, potassium supplementation and maintenance of fluid, electrolytes and acid–base balance.