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PubMed1994

The role of the intensivist in the treatment of the cardiovascular manifestations of scorpion envenomation.

The following report summarizes the role of the intensivist in the treatment of the cardiovascular manifestations of scorpion envenomation within the intensive care unit. It emphasizes the need for a clear understanding the mechanisms involved behind the manifestations of myocardial damage and the rational approach of aggressive treatment of the overstimulated autonomic nervous system. The report emphasizes the complexity of the clinical picture and the intensivist approach based on clinical and experimental evidence, with excellent results.

Animals↗
PubMed1994

Vasodilators: scorpion envenoming and the heart (an Indian experience).

Our aim was to assess clinically whether there was any benefit in adding a single dose of sublingual nifedipine (a slow calcium channel blocker) to prazosin in the management of the cardiovascular manifestations of envenoming by the Indian red scorpion (Mesobuthus tamulus). A total of 163 patients stung by this species was admitted to hospital at Mahad between January 1991 and October 1993. Cardiovascular abnormalities were hypertension (59), of whom 42 had bradycardia and 17 had tachycardia; pulmonary oedema (14), of whom eight had hypertension and six hypotension; supraventricular tachycardia (eight), of whom three had hypotension and one died. Of the remaining patients, 78 demonstrated severe excruciating local pain at the site of sting but had no systemic involvement. Nineteen patients with hypertension and tachycardia were given a single dose of sublingual nifedipine plus prazosin on admission, then prazosin alone repeated 6 hourly. Five patients with massive life-threatening pulmonary oedema recovered after being given intravenous sodium nitroprusside. Prazosin alone helped to alleviate cardiovascular manifestations in the remaining 52 victims. One patient was admitted in a deep coma, 12 hr after the sting, and died. Eight victims whose blood pressure had been controlled in hospital by nifedipine plus prazosin developed acute pulmonary oedema necessitating additional doses of prazosin for recovery. Fifty-two victims treated with prazosin alone did not develop pulmonary oedema and the drug appeared to hasten the recovery. In the presence of high blood pressure, tachycardia, a murmur and impending myocardial failure, nifedipine appeared to contribute to cardiopulmonary instability and to augment myocardial oxygen consumption. In this situation calcium channel blockers should probably be avoided.

Adolescent↗
PubMed1999

Evaluation of antivenom therapy in children severely envenomed by Androctonus australis garzonii (Aag) and Buthus occitanus tunetanus (Bot) scorpions.

One hundred and forty-seven cases of envenomed children under 15 years old presenting local and general symptoms without failure in vital functions (clinical grade II) or presenting serious general symptoms with failure in vital functions (clinical grade III) were collected during the summer seasons of 1993-1997. They were classified in six groups according to the use or not of antivenom, the route and the frequency of antivenom administration. The determination, by a sensitive ELISA, of blood venom concentration before and until 6 h after antivenom therapy, allowed the establishment of the venom toxicokinetic curve for each group. The intramuscular administration of antivenom did not show significant effects on venom toxicokinetic curves and on patients recovery time. However, the same amount of antivenom administered by intravenous route clear rapidly the blood free venom toxins. Also, the patient recovery time was significantly shortened. These data are in favor of intravenous application of an adequate dose of an efficient antivenom in order to treat successfully severe scorpion envenoming cases.

Animals↗
PubMed2005

[Cardiovascular dysfunction following severe scorpion envenomation. Mechanisms and physiopathology].

The seriousness of scorpion envenomation results essentially from left cardiac function with pulmonary oedema and/or a state of shock. Adrenergic myocarditis, toxic myocarditis and myocardial ischemia are the 3 mechanisms that explain the cardiac dysfunction. Myocardial ischemia is not only due to the release of catecolamines but also the effect of the cytokines and/or neuropeptide Y on the coronary vessels. The cardiac damage can be due or enhanced by the depressive effect of the cytokines on the myocardial cells. The frequently observed hyperglycaemia only enhances the state of the already damaged myocardium.

Acidosis↗
PubMed1994

Serotherapy in the management of scorpion sting in children in Saudi Arabia.

A total of 780 children with scorpion stings were admitted to a referral hospital in Saudi Arabia over a 7-year period. A similar number was managed in the outpatient department. The mortality was 4.8% initially, but no death occurred in the last 2 years of the study period. The reduction in mortality is attributed to the use of antivenom and improvement in case management.

Adolescent↗
PubMed1996

Severe envenoming by the Indian red scorpion Mesobuthus tamulus: the use of prazosin therapy.

We describe the clinical course and outcome in 46 victims of severe scorpion envenoming treated with prazosin (P), and compare them with earlier patients treated with conventional therapy (C) (n = 45) and nifepidine (N) (n = 28). The incidence of complicating left ventricular failure was 29% for C, 35% for N and 6.5% for P; that of acute pulmonary oedema was 46% for C, 14% for N and zero for P; mortality was 25% for C, 3.5% for N and zero for P. Although this is a historical study, prazosin appears to significantly reduce morbidity and shorten recovery time. Experience in other countries suggests that antivenom is helpful in controlling many of these problems, but in rural India serotherapy remains largely unavailable, and prazosin is a mainstay of treatment.

Adolescent↗
PubMed1959

Actions of scorpion venom on skeletal muscle.

A protein-like constituent of scorpion venom produced effects on the skeletal muscle fibre resembling those of citrate, lack of calcium or veratrine. These effects could be diminished by the addition of calcium. They do not appear to be due to the formation of a non-ionized complex with calcium.

Animals↗
PubMed2005

Best evidence topic report. Scorpion envenomation: does administration of antivenom alter outcome?

A short cut review was carried out to establish the clinical utility of antivenom in scorpion poisoning. Using the reported search, 69 papers were found, of which four presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Animals↗
PubMed1992

Management of the cardiovascular manifestations of poisoning by the Indian red scorpion (Mesobuthus tamulus).

OBJECTIVE: The efficacy of nifedipine and prazosin in combination or alone in the management of cardiovascular manifestations caused to Mesobuthus tamulus poisoning was investigated. DESIGN: Observation and study. SETTING: Hospital at Mahad, Maharashtra, India. SUBJECTS: 62 patients who had been stung by a red scorpion were admitted from January to December 1990: 18 with hypertension, 15 with supraventricular tachycardia, 11 with pulmonary oedema, and 18 with local pain at the site of sting but no systemic involvement. Two patients with massive life-threatening pulmonary oedema were given intravenous sodium nitroprusside. RESULTS: The combination of nifedipine and prazosin was more successful in preventing myocardial damage in 16 patients with hypertension than was nifedipine alone in two other patients with hypertension. Prazosin alone helped to alleviate the cardiovascular manifestations in eight patients with pulmonary oedema and 15 with supraventricular tachycardia. One patient with pulmonary oedema died and two recovered after they were given intravenous sodium nitroprusside. CONCLUSION: Nifedipine alone did not prevent myocardial damage unless the peripheral action of venom was blocked by prazosin.

Adult↗
PubMed2000

Triage for Leiurus quinquestriatus scorpion envenomation in children--is routine ICU hospitalization necessary?

(1) Leiurus quinquestriatus scorpion (LQS) envenomation is a common public health problem with a similar clinical presentation in the Middle East and worldwide: localized reactions occur in up to 97% of the victims. (2) LQS envenomation in children is potentially fatal since the severity of symptoms is weight-dependent. (3) A common policy is to hospitalize all children stung by the LQS-regardless of clinical severity-in the pediatric intensive care unit (PICU). (4) Seventeen of 18 children treated at two Israeli medical centers during an 8-year period developed mild to moderate clinical manifestations (antivenin was given in the one severe case; all children survived): all 18 had been transferred to an ICU for surveillance. Since patient care in PICUs is far more costly and manpower-intense than in general emergency rooms, we propose that a protocol of 6 h of surveillance in the emergency department is adequate and safe for most children who had been stung by LQS. Only children who develop systemic manifestations should be hospitalized and transferred to the intensive care unit. (5) Further prospective studies should be conducted to define specific subgroups that may benefit from these recommendations.

Adolescent↗
PubMed1991

Cardiac dysfunction and pulmonary edema following scorpion envenomation.

Cardiac dysfunction with pulmonary edema following scorpion envenomation (SE) has been documented only in a few isolated case reports. We conducted a systematic hemodynamic study in five consecutive patients (mean age, 21.6 +/- 8 years) presenting with pulmonary edema occurring a few hours (9.6 +/- 5.2 hours) after SE. All patients had increased pulmonary capillary wedge pressure (mean, 25 +/- 1.8 mm Hg) while the systemic vascular resistance was elevated only in one. The stroke volume index was markedly depressed (21.7 +/- 3.6 ml/sq m) whereas cardiac index was normal or slightly decreased (2.5 +/- 0.4 L/min/sq m). Cerebral infarct and sudden cardiac arrest were the cause of death in two patients. In the three survivors, all the hemodynamic disturbances and respiratory abnormalities disappeared within a few days. We conclude that cardiac dysfunction was found in all five patients and this was reversible in the three surviving the acute episode.

Adult↗
PubMed1994

Response to specific Centruroides sculpturatus antivenom in 151 cases of scorpion stings.

Review was made of the symptoms, treatment and outcome of 151 cases of severe envenomation by the scorpion Centruroides sculpturatus treated with antivenom, 1988-1989. The most frequent symptoms were restlessness, nystagmus, paresthesiae, hypersalivation, fasciculation, blurred vision and dysphagia with an average of four symptoms. Medications before antivenom, given to about half of the subjects, included antihistamines, sedatives, analgesics and epinephrine. In 71% of patients, symptoms were relieved within 30 minutes of receiving one vial. Immediate hypersensitivity reactions occurred in 8%, but were generally mild. Skin tests had a sensitivity of 96% and specificity of 68%. Delayed reactions were not addressed. In conclusion, the antivenom appears safe and effective.

Adolescent↗
PubMed1995

Efficacy of antivenom therapy for neutralizing circulating venom antigens in patients stung by Tityus serrulatus scorpions.

Enzyme-linked immunosorbent assays for detection of Tityus serrulatus venom antigen and of horse anti-T. serrulatus venom antibodies were carried out before antivenom treatment and at 1, 6, 12, and 24 hr after antivenom therapy in 18 patients with systemic manifestations following T. serrulatus scorpion sting. Increased levels of circulating venom antigens were detected in the patients before antivenom treatment, but were no longer detected 1 hr after specific antivenom therapy. High titers of antivenom persisted for at least 24 hr after treatment with antivenom. The evolution of clinical and laboratory manifestations of envenoming showed that vomiting and local pain decreased within 1 hr and hyperglycemia was no longer detected 12 hr after antivenom therapy. The cardiorespiratory manifestations disappeared 6-24 hr after the administration of antivenom and all patients recovered completely. This study demonstrates the efficacy of antivenom therapy in neutralizing circulating venom antigens and supports the prompt administration of a potent antivenom to patients with systemic manifestations of envenoming.

Adolescent↗
PubMed2002

[Theoretical and experimental bases for treatment of scorpion envenomations].

Improving the efficacy of envenomation treatment depends on what is known about active molecules present in venoms. Regarding scorpions, studies carried out mainly on the most poisonous species have shown that the toxicity and mortality were due to small proteins-toxins--able to interfere with the normal process of the ionic channels. In certain cases, using the mouse model, it has been shown that over 90% of mortality was due to toxins operating on the sodium channels implicated in the action potential of the excitable cells. Pharmacokinetic studies have shown the diversity of their mode of action implying an adaptation of the means and tools intended to neutralise them. The toxins active on the sodium channels represent a family of proteins from 60 to 65 amino acids linked by 4 disulphide bridges with a very strong antigenic polymorphism; this has certain implications in terms of paraspecificity of antivenoms. The problem is even more complicated when one considers the variation of toxin quantity from one animal to another of the same species. Another approach is to identify the most active and represented toxins in venoms for each antigenic group and to develop a means of neutralizing them. It would also be possible to define toxoids for use either in the production of the antivenoms or as immunological protection for individuals at risk. Lastly, where symptomatic treatment is concerned, certain drugs such as aspirin, quinine or dandrolene have been shown definitely to increase the value of the LD50 in the mouse.

Action Potentials↗
PubMed1992

The effect of scorpion envenomation on the different organs of albino mice.

The effect of sublethal doses of scorpion venom (Buthus quinquestriatus) on the hepatic vascular bed and hepatic parenchyma were studied. The main toxic effect of the venom was primarily on the vascular bed of the liver as manifested by dilatation of branches of the hepatic artery, portal vein together with intravascular thrombi and subcapsular haemorrhages. Apart from mild hydropic degeneration some cells of the hepatic parenchyma showed focal necrosis and Kupffer cells were frequently hypertrophied and contained pigment. In the lung, dilated thrombosed vessels were observed. In the kidney, the vessels showed the same changes. The epithelial and endothelial cells of the glomeruli appeared normal except for slight swelling with intact basement membrane. The tubular cells were swollen with increased granularity and attenuation of the tubular lumen, a picture compatible with hydropic degeneration. The possible mechanisms in inducing such lesions were discussed.

Animals↗
PubMed2001

[Study of the protective capacity of scorpion venom Buthus occitanus tunetanus polymerised to glutaraldehyde in mice strains with different haplotypes].

The immune response obtained against the toxic fraction of the scorpion venom Buthus occitanus tunetanus detoxified by polymerisation with glutaraldehyde, was analysed for low inbred mice having different haplotypes: C57BL/6 (H-2b) et BALB/c (H-2d) and the SWISS outbred mouse. This three strains of mice, immunized with the polymeric form of Bot-G50 are able to induce an immune response with bumoral mediation. The anti-polymers antibodies obtained from immunized mice, cross-react with the native Bot-G50 fraction. Indeed, in vitro protection experiments demonstrated that immune sera were neutralizing (between 150 and 235 micrograms of Bot-G50 ml). The in vivo protection assays showed that immunized mice could resist the challenge by high amount of toxic fraction (between 70 and 80 micrograms of Bot-G50). This protection was found to be long-lived, since immunized SWISS mice could resist the challenge by 4 DL50 of the toxic fraction (80 micrograms) six month after the start of the immunized program.

Animals↗
PubMed2005

[Recombinant antibodies: a new application in scorpion envenomation?].

Serotherapy is the only specific treatment for envenomation. The antibodies are obtained after the purification of serum from hyperimmunised horses and are used after fragmentation in the form of polyclonal Fab or F(ab)'2. The anti-venom sera are heterogeneous, and their protective effect is often weak. The administration of these preparations induces risks of immediate or delayed side effects: hypersensitivity reactions, anaphylactic shock and serum sickness. This observation led us to develop new forms of antibodies produced by molecular engineering, capable of specifically neutralizing the neurotoxins responsible for the toxicity of the venom of Androctonus australis Hector. The recombinant antibody fragments are more homogeneous than conventional antivenoms and perfectly characterized in terms of specific activity. The method used to obtain them eliminates the risk of transmission by non-conventional transmissible agents. The earliest results confirm the importance of these new molecules (scFv recombinant Fab, diabody, triabody) and their ability to neutralize the action of scorpion neurotoxins. They could open the path to a new generation of more homogeneous antivenoms that are better tolerated and have well-characterized intrinsic properties.

Animals↗
PubMed2000

Structural and functional differences of two toxins from the scorpion Pandinus imperator.

The Pandinotoxins, PiTX-K alpha and PiTX-K beta, are members of the Charybdotoxin family of scorpion toxins that can be used to characterize K+ channels. PiTX-K alpha differs from PiTX-K beta, another peptide from Pandinus imperator, by one residue (P10E). When the two toxins are compared in a physiological assay, the affinity of PiTX-K beta for voltage-gated, rapidly inactivating K+ channels in dorsal root ganglia (DRG) neurons is 800-fold lower than that of PiTX-K alpha (K alpha-IC50 = 8.0 nM versus K beta-IC50 = 6,500 nM). To understand this difference, the three-dimensional structure of PiTX-K beta was determined by nuclear magnetic resonance (NMR) spectroscopy and compared to that of PiTX-K alpha. This comparison shows that structural differences between the two toxins occur at a residue that is critical for blocking K+ channels (K27) as well as at the site of the natural mutation (P10E). In PiTX-K beta, the negatively charged carboxylate oxygen of E10 can approach the positive charge of K27 and presumably reduces the net positive charge in this region of the toxin. This is likely the reason why PiTX-K beta binds K+ channels from DRG neurons with a much lower affinity than does PiTX-K alpha.

Amino Acid Sequence↗