Informe especial: Envenenamiento por animal ponzoñoso: Alacranismo / Special report: Poisonous by venomous animal: Scorpions

Presentación de un caso, notificado el 9 de enero de 2017, a la Gerencia Operativa de Epidemiología del Gobierno de la Ciudad de Buenos Aires por un efector privado de la Ciudad, de envenenamiento por animal ponzoñoso (Alacranismo) en un paciente residente en la Ciudad de Buenos Aires. Se describen el cuadro clínico y el tratamiento recibido, la evolución del caso, la importancia de distintas acciones de vigilancia epidemiológica, el procedimiento de notificación, medidas de protección, y medidas de prevención y control de accidentes. Incluye datos de centros públicos nacionales y de la Ciudad de Buenos Aires especializados en asistencia y/o in-formación sobre animales venenosos

Scorpion envenomation and inflammation: Beyond neurotoxic effects.

Scorpion envenomation results in a wide range of clinical manifestations that are mostly attributed to the activation of the autonomic nervous system by venom toxins. In fact, sympathetic and parasympathetic disturbances play important roles during poisoning. However, scorpion venom also induces a complex hyperinflammatory state that occurs parallel to systemic inflammatory response syndrome and acute sepsis. After a scorpion sting, innate immune cells are exposed to the venom molecules, which bind to pattern recognition receptors and activate pro-inflammatory pathways that contribute toward the promotion of severe symptoms, such as pulmonary edema, and eventually lead to death. In this review, we highlight studies that pointed out inflammation as a major pathological facet of scorpion envenomation, so as to provide novel targets to improve therapeutics for scorpionism.

Myocardial injury induced by scorpion sting envenoming and evidence of oxidative stress in Egyptian children.

In the present study, 45 children in Upper Egypt (less than 16 years old) were admitted to the Pediatric Intensive Care Unit for scorpion envenomation (SE). They were compared with 30 apparently healthy children of matching age and sex as controls. Out of the studied victims, 35 children (78%) showed signs of severe envenomation, while 10 victims (22%) showed signs of mild envenomation. The case fatality was 33%. The serum levels of cardiac markers, cardiac troponin T (cTnT) and I (cTnI), as well as the enzymatic activities of creatine kinase-MB (CPK-MB) and lactate dehydrogenase (LDH) were determined for both victims and controls. In addition, the serum levels of oxidative stress markers, nitric oxide (NO), malondialdehyde (MDA), superoxide dismutase (SOD), reduced glutathione (GSH) and zinc (Zn) were measured. Electrocardiography and echocardiography were done. All the envenomed victims showed significantly higher mean values of cTnT, cTnI, CPK-MB and LDH than control group. These cardiac markers were elevated in severe cases and in non survivors in comparison with mild cases and survivors respectively. Furthermore, the serum levels of NO and MDA were significantly higher while the serum levels of SOD, GSH and Zn were significantly lower in all envenomed victims than the controls (p < 0.05 for all). There were no significant differences in the serum levels of oxidative stress markers among severe and mild cases or between survivors and non survivors victims. There were no significant correlations between the serum levels of cardiac markers and the oxidative stress markers in envenomed victims. In conclusions, oxidative stress occurs in scorpion envenomed children, but does not determine prognosis. Cardiac markers, but not the oxidative stress, remain the most important determining factor for the severity and the outcome of SE.

New and safe formulation for scorpion immunotherapy: Comparative study between saponin and FCA adjuvants associated to attenuated venom.

Envenoming by scorpion is a major health problem in Maghreb regions as well as in several regions of the world. Immunotherapy is the only effective treatment for scorpion stings. The immune sera are obtained from hyper-immunized animals with a formulation of venom associated to Freund's Complete Adjuvant (FCA). This formulation seems to protect against several alterations in immunized animals leading to worsening of their health due to added toxicity of native venom and FCA adjuvant. This study aims to provide a more efficient and non-toxic alternative to this formulation. Two formulations of saponin or FCA associated to irradiated venom of Androctonus australis hector (Aah) were used to compare their safety and their efficiency to better enhance the antibody titers against toxic antigens. Both of these formulations were used in immunization schedule of three months. Blood samples were collected every week, cell count, myeloperoxydase (MPO) and eosinophil peroxidase (EPO) activities and specific antibody titers were evaluated. Four months after the last immunization, rabbits were challenged with increased doses of native Aah venom. Results showed that immunization with saponin formulation induced lower inflammatory cell activation as well as reduced MPO and EPO activities compared to that using FCA. The formulation of irradiated venom with saponin seems also to be more efficient in the activation of lymphocytes resulting in higher titers of specific IgG. The immunoprotective effect evaluation showed that the formulation using saponin seems to protected animals until 3 LD50 of native venom compared to that using FCA which protected only until 2 LD50. These results indicate that saponin formulation with irradiated antigen could be more efficient and safe immunizing preparation for the production of sera against scorpion envenomation.

Age-Related Changes in Inflammatory Response after Experimental Envenomation: Impact on the Susceptibility to Androctonus australis hector Venom.

In regions at risk of scorpion envenomation, children remain the principal victims; they exhibit severe symptoms and represent a higher mortality rate compared to adults. The pathophysiology of envenomation is related to an excessive inflammatory response; however, no studies have identified the differences in immune responses to scorpion stings and mainly the mechanisms of inflammation between children and adults, which may be a determinant key of the susceptibility of children to scorpion envenomation. In this study, we compared the systemic (blood and lung) and the central (brain) inflammatory responses after injection of Androctonus australis hector (Aah) venom to 7 and 21 postnatal days (pnds) and adult mice by subcutaneous route. Results revealed that 7 and 21 pnd mice were more sensitive to Aah venom than adults and presented also severe systemic and central inflammatory responses characterized by a high activation of immune cells, NO liberation, and lipid peroxidation. Lymphocyte levels were much lower in young animals than in adults; however, neutrophil levels seemed to be higher in immature mice. The antioxidant GSH and catalase levels were more reduced in 7 and 21 pnd mice compared to adults leading to more pronounced tissular alterations and edema formation in lung and brain. These findings show a relationship between the severity of the pathophysiological effects of Aah venom and the age. The vulnerability of immature animals to Aah venom might result from uncontrolled inflammatory response and central nervous system alterations. Data from the present study emphasize the need for the development of age-specific therapeutic modalities.

Tityus serrulatus venom--A lethal cocktail.

Tityus serrulatus (Ts) is the main scorpion species of medical importance in Brazil. Ts venom is composed of several compounds such as mucus, inorganic salts, lipids, amines, nucleotides, enzymes, kallikrein inhibitor, natriuretic peptide, proteins with high molecular mass, peptides, free amino acids and neurotoxins. Neurotoxins are considered the most responsible for the envenoming syndrome due to their pharmacological action on ion channels such as voltage-gated sodium (Nav) and potassium (Kv) channels. The major goal of this review is to present important advances in Ts envenoming research, correlating both the crude Ts venom and isolated toxins with alterations observed in all human systems. The most remarkable event lies in the Ts induced massive releasing of neurotransmitters influencing, directly or indirectly, the entire body. Ts venom proved to extremely affect nervous and muscular systems, to modulate the immune system, to induce cardiac disorders, to cause pulmonary edema, to decrease urinary flow and to alter endocrine, exocrine, reproductive, integumentary, skeletal and digestive functions. Therefore, Ts venom possesses toxins affecting all anatomic systems, making it a lethal cocktail. However, its low lethality may be due to the low venom mass injected, to the different venom compositions, the body characteristics and health conditions of the victim and the local of Ts sting. Furthermore, we also described the different treatments employed during envenoming cases. In particular, throughout the review, an effort will be made to provide information from an extensive documented studies concerning Ts venom in vitro, in animals and in humans (a total of 151 references).

Development of protective agent against Hottentotta saulcyi venom using camelid single-domain antibody.

Hottentotta saulcyi, medically important scorpion species, causes some of harmful toxic exposure in Iran. Administrated, conventional antivenom-based immunotherapy is still limited and hardly meet ideal characteristic of effective treatment for scorpion envenomation. In this study we aimed to develop a neutralizing agent directed against scorpion venom based on VHH, variable domain of the Camelidae heavy chain antibody or Nanobody. This promising biomolecule is well-established as an advantageous tool for therapeutic purposes due to its small size, stability, monomeric performance and less immunogenicity. In this study, a large Nb library was constructed and phage displayed after successful camel immunization using H. saulcyi scorpion crude venom. After a series of biopanning rounds on Sephadex G50 purified venom fraction and screening by monoclonal phage ELISA, the best reactive Nb was retrieved and designated Nb12. The selected Nb was then expressed as soluble protein in Escherichia coli, purified and confirmed by SDS-PAGE analysis and western blotting. The lead candidate Nb12 bound scorpion venom with Kaff value of 5×10(7)M(-1). Nb12 was shown to be capable of neutralizing 2 LD50 of whole venom of scorpion toxin when injected in the ratio of the Nb/toxin of 1.4:1 into C57BL/6 mice. In challenge experiment, Nb succeeded to rescue all i.p. lethal dose injected mice even when administrated i.v., 20min after envenoming. These results with ease of production and superior neutralizing activity make Nb a suitable anti-toxin candidate for treatment of scorpion envenoming.

Serological, biochemical and enzymatic alterations in rodents after experimental envenomation with Hadruroides lunatus scorpion venom.

Toxic effects of Peruvian Hadruroides lunatus scorpion venom on different biochemical and enzymatic parameters in blood serum of Wistar rats and Swiss mice were determined after experimental envenomation. An increase in enzymatic activities of Aspartate Aminotransferase (AST), Lactate Dehydrogenase (LDH) and levels of serum protein and albumin were observed while a decrease in creatinine level in serum was perceived after 30 min of envenomation. No alterations in urea levels and in kidney histology were detected in the envenomed rats. The global leukocytes count was diminished, with decrease in lymphocytes, eosinophils and neutrophils levels in the bloodstream, while no alterations were found in hematological parameters of red series in rats injected with H. lunatus venom. IL-2, IL-4, IL-6, INF-γ, TNF, IL-17A and IL-10 levels were evaluated 0.5, 3 and 6 h after experimental envenomation of mice with H. lunatus venom. From all the analyzed cytokines, only IL-6 showed an increase in serum levels. Taken together, these results point out that envenomation by H. lunatus can impair hematological and immunological parameters and therefore might be monitored in accidents involving this species.

Study of severe scorpion envenoming following subcutaneous venom injection into dogs: Hemodynamic and concentration/effect analysis.

To evaluate the dose-effects of Androctonus australis hector (Aah) venom injected subcutaneously on hemodynamics and neurohormonal secretions, 10 anesthetized and ventilated mongrel dogs, were split in two groups (n = 5/group). Subcutaneous injection was done with either 0.2 mg/kg or 0.125 mg/kg of the purified G50 scorpion toxic fraction. Hemodynamic parameters using right heart catheter were recorded and plasma concentrations of catecholamine, troponin, and serum toxic fraction were measured sequentially from baseline to 120 min. We identified the dose of toxic fraction evoking characteristic hemodynamic perturbation of severe envenomation, the time-lapse to envenomation, and the associated plasma level. The injection of 0.125 mg/kg toxic fraction was not associated with significant variations in hemodynamic parameters, whereas the 0.2 mg/kg dose caused envenomation characterized by significant increase in plasma catecholamines, increased pulmonary artery occluded pressure, mean arterial pressure, and systemic vascular resistance (p < 0.05), in association with sustained decline in cardiac output (p < 0.001). Envenomation occurred by the 30th minute, and the corresponding concentration of toxic fraction was 1.14 ng/ml. The current experiment allowed the identification of the sub-lethal dose (0.2 mg/kg) of the toxic fraction of Aah administered by the subcutaneous route. Two parameters with potential clinical relevance were also uncovered: the time-lapse to envenomation and the corresponding concentration of toxic fraction.

Posterior Reversible Encephalopathy Syndrome in a Child Stung by Androctonus mauretanicus Scorpion.

Posterior reversible encephalopathy syndrome (PRES) after scorpion sting was very rarely reported in literature. This is an authenticated report of PRES occurring, in a 3-year-old previously healthy girl, as a complication of the Moroccan Androctonus mauretanicus sting. According to the available and recent data, we attempt to discuss the potential mechanisms leading to this neurologic disorder and to determine the possible cause-effect relationship between scorpion venom and its development.

Clinical consequences of Tityus bahiensis and Tityus serrulatus scorpion stings in the region of Campinas, southeastern Brazil.

Scorpion stings account for most envenomations by venomous animals in Brazil. A retrospective study (1994-2011) of the clinical consequences of Tityus scorpion stings in 1327 patients treated at a university hospital in Campinas, southeastern Brazil, is reported. The clinical classification, based on outcome, was: dry sting (no envenoming), class I (only local manifestations), class II (systemic manifestations), class III (life-threatening manifestations, such as shock and/or cardiac failure requiring inotropic/vasopressor agents, and/or respiratory failure), and fatal. The median patient age was 27 years (interquartile interval = 15-42 years). Scorpions were brought for identification in 47.2% of cases (Tityus bahiensis 27.7%; Tityus serrulatus 19.5%). Sting severity was classified and each accounted for the following percentage of cases: dry stings - 3.4%, class I - 79.6%, class II - 15.1%, class III - 1.8% and fatal - 0.1%. Pain was the primary local manifestation (95.5%). Systemic manifestations such as vomiting, agitation, sweating, dyspnea, bradycardia, tachycardia, tachypnea, somnolence/lethargy, cutaneous paleness, hypothermia and hypotension were detected in class II or class III + fatal groups, but were significantly more frequent in the latter group. Class III and fatal cases occurred only in children <15 years old, with scorpions being identified in 13/25 cases (T. serrulatus, n = 12; T. bahiensis, n = 1). Laboratory blood abnormalities (hyperglycemia, hypokalemia, leukocytosis, elevations in serum total CK, CK-MB and troponin T, bicarbonate consumption and an increase in base deficit and blood lactate), electrocardiographic changes (ST segment) and echocardiographic alterations (ventricular ejected fraction <54%) were frequently detected in class III patients. Seventeen patients developed pulmonary edema, 16 had cardiac failure and seven had cardiogenic shock. These results indicate that most scorpion stings involved only local manifestations, mainly pain; the greatest severity was associated with stings by T. serrulatus and in children <15 years old.

Diagnosis of Mesobuthus eupeus envenomation by skin test: reverse passive Arthus reaction.

While being stung by two large families of scorpions, Buthidae and Scorpionidae have different symptoms and complications, a similar maintenance treatment usually considers as the scorpion species could not be identified easily. Therefore, this study was an attempt to develop an immunologic response for designing a skin sensitivity test that can be used to determine the poisoning. The sensitivity and the specificity of RPA reaction for detecting experimental envenomated mice were evaluated. The inflammatory response for detection of envenomation was obtained by the injection of a solution containing complement, polyelectrolytes and purified monovalent antibodies. As the result, 84.44% sensitivity and 100% specificity recorded 15 min after challenge. Macroscopic findings were also confirmed histologically. No cross-reactions were observed with other species of scorpions and snake venoms. Designed Skin test induced obvious inflammatory reaction without any histological lesions. Besides adding the complement components and polyelectrolyte to the monovalent antibody leads to an increased susceptibility of inflammatory cells in this reaction, resulting in forming a visible inflammation in a short time. According to satisfactory specificity and sensitivity and visible results in about 15 min, non-harmful and cost benefity of reverse passive Arthus test can be used for diagnosis of scorpion envenomation.

Brainstem structures are primarily affected in an experimental model of severe scorpion envenomation.

Severe scorpion envenoming (SSE) is more frequent in children and is characterized by systemic dysfunctions with a mortality rate of up to 9%. Recent evidence shows that the central nervous system (CNS) plays a key role in triggering the cascade of symptoms present in SSE. The age-dependent role of the CNS in SSE lethality may be summarized in 3 hypotheses: (1) the shown increased blood brain barrier permeability of infants to the toxins would especially and primarily compromise neurovegetative control areas, (2) the neurons within these areas have high affinity to the toxins, and (3) the neurovascular interaction is such that SSE metabolically compromises proper function of toxin-targeted areas. A pharmacological magnetic resonance imaging paradigm was used to evaluate localized hemodynamic changes in relative cerebral blood volume (rCBV) for 30 min after the injection of TsTX, the most lethal toxin from the venom of the Tityus serrulatus scorpion. The brainstem showed significant rCBV reduction 1 min after TsTX administration, whereas rostral brain areas had delayed increase in rCBV (confirmed by laser Doppler measurements of cortical cerebral blood flow). Moreover, metabolic activity by 14C-2-deoxyglucose autoradiography showed the highest relative increase at the brainstem. To test whether TsTX has high affinity to brainstem neurons, the lateral ventricle was injected with Alexa Fluor 568 TsTX. Although some neurons showed intense fluorescence, the labeling pattern suggests that specific neurons were targeted. Altogether, these results suggest that brainstem areas involved in neurovegetative control are most likely within the primary structures triggering the cascade of symptoms present in SSE.

The roles of some scorpions, Hemiscorpius lepturus and Androctonus crassicauda, in a scorpionism focus in Ramhormorz, southwestern Iran.

Scorpion stings are a common and important health problem in Iran, particularly in south and southwestern Iran, including the province of Khuzestan. In the area of Khuzestan near the city of Ramhormoz, Hemiscorpius lepturus (Scorpionida: Hemiscorpioiidae) and Androctonus crassicauda (Buthidae) are present. Ramhormoz is in southwestern Iran and is one of the most important foci of the scorpion sting problem. The current study was carried out to gain both epidemiological and medical information about scorpion stings in and around the city of Ramhormoz. In total, 179 people who were admitted to the Emergency Department of Ramhormoz Imam Khomeini Hospital during 2008 and 2009 after being stung by scorpions were monitored. Epidemiological and medical parameters including sex of the victim; the part of the body stung; the month when stung; the biochemical parameters comprising blood sugar (BS), blood urea nitrogen (BUN), and creatinine (CR); hematological parameters including white blood cells (WBC), count blood cells (CBC), red blood cells (RBC), hemoglobin (Hb), hematocrit (HCT), platelet (PLT); and urine analysis including hemoglobinuria were recorded. The current study showed that most of the victims were stung by H. lepturus, while very few were stung by A. crassicaud, but in over half of the cases the species was not known. Stings were most common from May to Aguust. 73% of the victims were female. The limbs were the part of the body most likely to be stung. Hemogobinuria was very common in H. lepturus victims.

Epidemiological and clinical study on scorpionism in French Guiana.

UNLABELLED: Scorpion envenomation is a poorly explored problem in French Guiana. The aim of our study was to describe the epidemiological and clinical features of scorpion stings. METHODS: Our study is retrospective. It was conducted in the emergency department (ED) of Cayenne General Hospital, over an 8-year period (2003-2010). RESULTS: During the study period, 253 patients presented to the emergency department with a history of a scorpion sting. The mean incidence was 32 ± 8 cases per year. The peak of incidence was observed in April and May which are the rainiest months in the year. In most cases, the envenomation occurred between 6:00 and 11:00 am. The site of the sting was on the extremities (hand or foot) in 81% of cases. The scorpion was identified or brought to the hospital in 113 cases. It was described as a slim pincers scorpion in 97 cases. The mean time elapsed between the scorpion sting and admission was 4 ± 5 h. The main clinical symptoms at admission to the ED were local signs in 178 cases (70.4%), digestive disorders in 13 cases, neurologic manifestations in 18 cases, and respiratory manifestations in 7 cases. Adrenergic syndrome was found in 117 cases (46.2%), and cholinergic syndrome in 5 cases (2%). Hypertension was found in 80 patients, 14 of them had already a history of chronic hypertension. Overall, a total of 118 patients (46.6%) had Class I envenoming, 131 patients (51.8%) had Class II envenoming, and 4 patients (1.6%) experienced Class III envenoming. The evolution was favorable in all cases and no death was recorded. However, 42 patients (18.2%) were hospitalized in a medical unit and 4 patients were hospitalized in ICU without needing mechanical ventilation, inotropes or vasoactive drugs. CONCLUSION: Scorpion envenomation is an increasing accident in French Guiana. Symptoms vary from mild to severe and can require ICU admission. Practitioners have to be made aware of severe cases found mainly in children.

Posterior reversible encephalopathy syndrome following a scorpion sting.

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic entity not yet understood, that is present with transient neurologic symptoms and particular radiological findings. The most common imaging pattern in PRES is the presence of edema in the white matter of the posterior portions of both cerebral hemispheres. The cause of PRES is unclear. We report a case of 13-year-old male who was stung by a scorpion and developed a severe headache, visual disturbance, and seizures and had the diagnosis of PRES with a good outcome. Numerous factors can trigger this syndrome, most commonly: acute elevation of blood pressure, abnormal renal function, and immunosuppressive therapy. There are many cases described showing the relationship between PRES and eclampsia, transplantation, neoplasia and chemotherapy treatment, systemic infections, renal disease acute, or chronic. However, this is the first case of PRES following a scorpion sting.

Scorpion stings presenting to an emergency department in Singapore with special reference to Isometrus maculatus.

OBJECTIVE: We describe the epidemiology and clinical features of scorpion stings presenting to an emergency department in Singapore, including that of the venomous species Isometrus maculatus. A management approach to scorpion stings is proposed. METHODS: A retrospective study was done for patients from 2004 to 2009. Cases were identified by searching through emergency department records with ICD code E905, inpatient records, and the hospital toxicology service records. Identification of species was assisted by the Venom and Toxin research program at the National University of Singapore. RESULTS: A total of 13 cases of scorpion stings were identified. Eleven stings occurred locally, and the remaining 2 stings occurred in neighboring countries. The most common presenting symptoms were pain (92%), numbness (31%), and weakness (23%) confined to the region of the sting. The most common clinical signs recorded were redness (77%), tenderness (77%), and swelling (46%). Only 2 patients had significant alterations of vital signs: 1 had hypertension and the other had hypotension from anaphylaxis. Three patients experienced complications (abscess formation, anaphylaxis, cellulitis) requiring inpatient management. There were no fatalities, and all patients made a good recovery. Three cases were identified to be stings from I maculatus. These cases occurred locally, and mainly had clinical features of pain, redness, and mild regional numbness. CONCLUSIONS: Scorpion stings are uncommon presentations to the emergency department. Most stings cause local reactions that can be managed with supportive treatment. Stings by I maculatus were observed to cause mild, self-limiting effects.

Lung immunoreactivity and airway inflammation: their assessment after scorpion envenomation.

Release and activation of pro-inflammatory mediators are among the most important induced factors that are involved in the scorpion envenomation pathogenesis. Inflammatory response and lung reactivity were studied in mice following subcutaneous injection with Androctonus australis hector (Aah) venom. Venom immunodetection in lungs and sequestered cell population in the airways were determined. Cytokines, cellular peroxidase activities (eosinophil peroxidase, myeloperoxydase), and IgE antibodies were also assessed. Immunohistochemical study revealed a positive detection of the Aah venom in the alveolar wall, venule lumens, and inside inflammatory cells. Severe lung edema associated with rapid inflammatory response was observed after animal envenomation. Lung neutrophilia and eosinophilia were accompanied with IL-4, IL-5 release, and IgE synthesis. In conclusion, high cytokine levels, recruitment of inflammatory cells (eosinophils and neutrophils), and increased IgE concentration may contribute to the exacerbation and maintenance of the induced inflammatory response in lungs by scorpion venom. These results lead to the better understanding of this induced pathogenesis and could help the physicians to take care of envenomed patients.