A comparative study of severe scorpion envenomation in children caused by Tityus bahiensis and Tityus serrulatus

Bucaretchi, Fábio; Baracat, Emílio CE; Nogueira, Roberto J.N.; Chaves, Aniel; Zambrone, Flávio A.D.; Fonseca, Márcia R.C.C.; Tourinho, Francis S

doi:10.1590/S0036-46651995000400008

Abstracts

From January 1984 to May 1994, 17 of 239 children under 15 years old stung by Tityus serrulatus (15.1%) or Tityus bahiensis (84.9%) presented severe envenoming. Of these 17 patients (1-11 years old; median=2 yr) 14 were stung by T.serrulatus and three by T.bahiensis. All of them received scorpion antivenom i.v. at times ranging from 45 min. to 5 h after the accident (median=2h). On admission, the main clinical manifestations and laboratory and electrocardiographic changes were: vomiting (17), diaphoresis (15), tachycardia (14), prostration (10), tachypnea (8), arterial hypertension (7), arterial hypotension (5), tremors (5), hypothermia (4), hyperglycemia (17), leukocytosis (16/16), hypokalemia (13/17), increased CK-MB enzyme activity (>6% of the total CK, 11/12), hyperamylasemia (11/14), sinusal tachycardia (16/17) and a myocardial infarction-like pattern (11/17). Six patients stung by T.serrulatus had depressed left ventricular systolic function assessed by means of echocardiography. Of these, five presented pulmonary edema and four had shock. A child aged two-years old presented severe respiratory failure and died 65 h after being stung by T.serrulatus. Severe envenomations caused by T.serrulatus were 26.2 times more frequent than those caused by T.bahiensis (p<0.001).

Scorpion envenomation; Tityus serrulatus; Tityus bahiensis

No período de janeiro de 1984 a maio de 1994, de 239 crianças com até 15 anos de idade, picadas por escorpiões pertencentes às espécies T.bahiensis (84,9%) e T.serrulatus (15,1%), 17 apresentaram envenenamento grave. Destes 17 pacientes, cuja idade variou de 1 a 11 anos (mediana=2anos), 14 foram picados por T.serrulatus e 3 por T.bahiensis. Todos receberam anti-veneno escorpiônico i.v. entre 45 min. e 5 hs após o acidente (mediana=2 horas). À admissão, as principais manifestações clínicas, alterações laboratoriais e eletrocardiográficas observadas foram: vômitos(17), sudorese profusa(15), taquicardia(14), prostração(10), taquipnéia (8), hipertensão arterial(7), hipotensão arterial(5), tremores(5), hipotermia(4), hiperglicemia(17), leucocitose (16/16), hipocaliemia(13/17), aumento da CK-MB (>6% da CK total)(11/12), hiperamilasemia(11/14), taquicardia sinusal(16/17) e padrão semelhante ao infarto do miocárdio(11/17). A ecocardiografia, observou-se depressão da função sistólica ventricular esquerda em 6 pacientes, todos picados por T.serrulatus. Destes, 5 apresentaram edema pulmonar e 4 choque. Uma criança de 2 anos de idade, picada por T. serrulatus, faleceu 65 horas após o acidente devido insuficiência respiratória grave. Conclui-se que os acidentes graves determinados por T.serrulatus foram 26,2 vezes mais freqüentes que os determinados por T.bahiensis (p<0,001).

ANIMAL ENVENOMATION

A comparative study of severe scorpion envenomation in children caused by Tityus bahiensis and Tityus serrulatus

Estudo comparativo do envenenamento escorpiônico grave em crianças provocado por Tityus bahiensis e Tityus serrulatus

Fábio Bucaretchi^I,II; Emílio CE. Baracat^I,III; Roberto J.N. Nogueira^I,IV; Aniel Chaves^V; Flávio A.D. Zambrone^II; Márcia R.C.C. Fonseca^II; Francis S. Tourinho^II

^IDepartment of Pediatrics; Faculty of Medical Sciences, Campinas State University - UNICAMP, Campinas, SP, Brazil

^IIPoison Control Center - Universitary Hospital - UNICAMP, Campinas, SP, Brazil

^IIIPediatric Emergency Unit - Universitary Hospital - UNICAMP, Campinas, SP, Brazil

^IVPediatric Intensive Care Unit - Universitary Hospital - UNICAMP, Campinas, SP, Brazil

^VEchocardiography Unit - Universitary Hospital - UNICAMP, Campinas, Brazil

^{Correspondence to} Correspondence to: Prof. Dr. Fábio Bucaretchi Centro de Controle de Intoxicações, Hospital das Clínicas, 4º andar UNICAMP, Cidade Universitária "Zeferino Vaz" 13081-970 Campinas, SP, Brasil FAX - FONE 55-192-398670

SUMMARY

From January 1984 to May 1994, 17 of 239 children under 15 years old stung by Tityus serrulatus (15.1%) or Tityus bahiensis (84.9%) presented severe envenoming. Of these 17 patients (1-11 years old; median=2 yr) 14 were stung by T.serrulatus and three by T.bahiensis. All of them received scorpion antivenom i.v. at times ranging from 45 min. to 5 h after the accident (median=2h). On admission, the main clinical manifestations and laboratory and electrocardiographic changes were: vomiting (17), diaphoresis (15), tachycardia (14), prostration (10), tachypnea (8), arterial hypertension (7), arterial hypotension (5), tremors (5), hypothermia (4), hyperglycemia (17), leukocytosis (16/16), hypokalemia (13/17), increased CK-MB enzyme activity (>6% of the total CK, 11/12), hyperamylasemia (11/14), sinusal tachycardia (16/17) and a myocardial infarction-like pattern (11/17). Six patients stung by T.serrulatus had depressed left ventricular systolic function assessed by means of echocardiography. Of these, five presented pulmonary edema and four had shock. A child aged two-years old presented severe respiratory failure and died 65 h after being stung by T.serrulatus. Severe envenomations caused by T.serrulatus were 26.2 times more frequent than those caused by T.bahiensis (p<0.001).

Keywords: Scorpion envenomation; Tityus serrulatus, Tityus bahiensis.

RESUMO

No período de janeiro de 1984 a maio de 1994, de 239 crianças com até 15 anos de idade, picadas por escorpiões pertencentes às espécies T.bahiensis (84,9%) e T.serrulatus (15,1%), 17 apresentaram envenenamento grave. Destes 17 pacientes, cuja idade variou de 1 a 11 anos (mediana=2anos), 14 foram picados por T.serrulatus e 3 por T.bahiensis. Todos receberam anti-veneno escorpiônico i.v. entre 45 min. e 5 hs após o acidente (mediana=2 horas). À admissão, as principais manifestações clínicas, alterações laboratoriais e eletrocardiográficas observadas foram: vômitos(17), sudorese profusa(15), taquicardia(14), prostração(10), taquipnéia (8), hipertensão arterial(7), hipotensão arterial(5), tremores(5), hipotermia(4), hiperglicemia(17), leucocitose (16/16), hipocaliemia(13/17), aumento da CK-MB (>6% da CK total)(11/12), hiperamilasemia(11/14), taquicardia sinusal(16/17) e padrão semelhante ao infarto do miocárdio(11/17). A ecocardiografia, observou-se depressão da função sistólica ventricular esquerda em 6 pacientes, todos picados por T.serrulatus. Destes, 5 apresentaram edema pulmonar e 4 choque. Uma criança de 2 anos de idade, picada por T. serrulatus, faleceu 65 horas após o acidente devido insuficiência respiratória grave. Conclui-se que os acidentes graves determinados por T.serrulatus foram 26,2 vezes mais freqüentes que os determinados por T.bahiensis (p<0,001).

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ACKNOWLEDGEMENTS

We thank the medical and the nursing staff of the pediatric emergency and the intensive care units, of the Hospital das Clínicas, Universidade Estadual de Campinas (UNICAMP), for their dedication in the treatment of patients with scorpion envenomation. We also thank to Flavia S.F. Gellert and Stephen Hyslop for reviewing the English of the manuscript.

Recebido para publicação em 02/01/1995

Aceito para publicação em 11/07/1995

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2. AMARAL, C.F.S.; REZENDE, N.A. & FREIRE-MAIA, L. - Acute pulmonary edema after Tityus serrulatus scorpion sting in children. Amer. J. Cardiol., 71: 242-245, 1993.
3. AMARAL, C.F.S.; DIAS, M.B.; CAMPOLINA, D.; PROIETTI, F.A. & REZENDE, N.A. - Children with adrenergic manifestations of envenomation after Tityus serrulatus scorpion sting are protected from early anaphylatic antivenom reactions. Toxicon, 32: 211-215, 1994.
4. AMARAL, C.F.S.; BARBOSA, A.J.A.; LEITE, V.O.R. et al. - Scorpion sting - induced pulmonary acute oedema: evidence of increased alveolocapillary membrane permeability. Toxicon, 32: 999-1003, 1994.
5. AMITAI, Y.; MINES, Y.; AKER, M. & GOITEIN, K. - Scorpion sting in children. A review of 51 cases. Clin. Pediat., 24: 136-140, 1985.
6. BARTHOLOMEW, C. - Acute scorpion pancreatitis in Trinidad. Brit. med. J., 1: 668-670, 1970.
7. BAWASKAR, H.S. - Diagnostic cardiac premonitory signs and symptoms of red scorpion sling. Lancet, 1: 552-554, 1982.
8. BAWASKAR, H.S. & BAWASKAR, P.H. - Prazosin in management of cardiovascular manifestations of scorpion sting. Lancet, 1: 510-511, 1986.
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10. BUCARETCHI, F. - Análise das principais diferenças clínicas e epidemiológicas dos acidentes por escorpiőes das espécies Tityus bahiensis e Tityus serrulatus e, por aranhas do gęnero Phoneutria, atendidos no CCI-HC-UNICAMP, no período de janeiro de 1984 a julho de 1988. Campinas, 1990. (Dissertaçăo de Mestrado - Faculdade de Ciências Médicas da Universidade Estadual de Campinas).
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15. CHAVES, A.; LEME, C.; BUCARETCHI, F. et al. - Alteraçőes ecodopleicardiográficas no acidente escorpiônico grave. Rev. bras. Ecocardio., 16(supl.): 31, 1993. (res.59)
16. CUPO, P.; JURCA, M.; AZEVEDO-MARQUES, M.M. et al. - Severe scorpion envenomation in Brazil. Clinical, laboratory and anatomopathological aspects. Rev. Inst. Med. trop. S. Paulo, 36: 67-76, 1994.
17. DEHESA-DÁVILA, M. & POSSANI, L.D. - Scorpionism and serotherapy in Mexico. Toxicon., 32: 1015-1018, 1994.
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19. FREIRE-MAIA, L.; PINTO, G.I. & FRANCO, J. - Mechanism of the cardiovascular effect produced by scorpion purified toxin in the rat. J. Pharmacol. exp. Ther., 188: 207-213, 1974.
20. FREIRE-MAIA, L. & CAMPOS, J.A. - On lhe treatment of the cardiovascular manifestations of scorpion envenomation. Toxicon, 25: 125-130, 1987.
21. FREIRE-MAIA, L. & CAMPOS, J.A. - Pathophysiology and treatment of scorpion poisoning. In: OWNBY, C.H. & ODELL, G.V., ed. Natural toxins. Oxford, Pergamon, 1989-p. 139-159.
22. FREIRE-MAIA, L.; CAMPOS, J.A. & AMARAL, C.F.S. - Approaches to the treatment of scorpion envenoming. Toxicon, 32: 1009-1014, 1994.
23. GUERON, M.; ADOLPH, R.V.; GRUPP, J.L. et al. - Hemodynamic and myocardial consequences of scorpion venom. Amer J. Cardiol., 45: 979-986, 1980.
24. GUERON, M. & OVSYSHCHER, I. - What is the treatment for the cardiovascular manifestations of scorpion envenomation? Toxicon, 25: 121-124, 1987.
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26. GUERON, M.; MARGULIS, G. & SOFER, S. - Echocardiographic and radionuclide angiographic observations following scorpion envenomation by Leiurus quinquestriatus. Toxicon, 28: 1005-1009, 1990.
27. GUERON, M.; MARGULIS, G.; ILIA, R. & SOFER, S. - The management of scorpion envenomation. Toxicon, 31: 1071-1076, 1993.
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Correspondence to:

Prof. Dr. Fábio Bucaretchi

Centro de Controle de Intoxicações, Hospital das Clínicas, 4º andar

UNICAMP, Cidade Universitária "Zeferino Vaz"

13081-970 Campinas, SP, Brasil

FAX - FONE 55-192-398670

Publication Dates

Publication in this collection
21 Sept 2006
Date of issue
Aug 1995

History

Accepted
11 July 1995
Received
02 Jan 1995

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. AMARAL, C.F.S.; LOPES, J.A.; MAGALHĂES, R.A. & REZENDE, N.A. - Electrocardiographic, enzymatic and echocardiographic evidence of myocardial damage after Tityus serrulalus scorpion poisoning. Amer.J. Cardiol., 67: 655-657, 1991.

[2] 2. AMARAL, C.F.S.; REZENDE, N.A. & FREIRE-MAIA, L. - Acute pulmonary edema after Tityus serrulatus scorpion sting in children. Amer. J. Cardiol., 71: 242-245, 1993.

[3] 3. AMARAL, C.F.S.; DIAS, M.B.; CAMPOLINA, D.; PROIETTI, F.A. & REZENDE, N.A. - Children with adrenergic manifestations of envenomation after Tityus serrulatus scorpion sting are protected from early anaphylatic antivenom reactions. Toxicon, 32: 211-215, 1994.

[4] 4. AMARAL, C.F.S.; BARBOSA, A.J.A.; LEITE, V.O.R. et al. - Scorpion sting - induced pulmonary acute oedema: evidence of increased alveolocapillary membrane permeability. Toxicon, 32: 999-1003, 1994.

[5] 5. AMITAI, Y.; MINES, Y.; AKER, M. & GOITEIN, K. - Scorpion sting in children. A review of 51 cases. Clin. Pediat., 24: 136-140, 1985.

[6] 6. BARTHOLOMEW, C. - Acute scorpion pancreatitis in Trinidad. Brit. med. J., 1: 668-670, 1970.

[7] 7. BAWASKAR, H.S. - Diagnostic cardiac premonitory signs and symptoms of red scorpion sling. Lancet, 1: 552-554, 1982.

[8] 8. BAWASKAR, H.S. & BAWASKAR, P.H. - Prazosin in management of cardiovascular manifestations of scorpion sting. Lancet, 1: 510-511, 1986.

[9] 9. BAWASKAR, H.S. & BAWASKAR, P.H.- Vasodilators: scorpion envenoming and the heart (an Indian experience). Toxicon, 32: 1031-1040, 1994.

[10] 10. BUCARETCHI, F. - Análise das principais diferenças clínicas e epidemiológicas dos acidentes por escorpiőes das espécies Tityus bahiensis e Tityus serrulatus e, por aranhas do gęnero Phoneutria, atendidos no CCI-HC-UNICAMP, no período de janeiro de 1984 a julho de 1988. Campinas, 1990. (Dissertaçăo de Mestrado - Faculdade de Ciências Médicas da Universidade Estadual de Campinas).

[11] 11. BUCARETCHI, F.; DOUGLAS, J.; FONSECA, M.R.C.C. et al. - Envenenamento ofídico em crianças: freqüęncia de reaçőes precoces ao antiveneno em pacientes que receberam pré-tratamento com antagonistas H1 e H2 da histamina e hidrocortisona. Rev. Inst. Med. trop. S. Paulo, 36: 451-457, 1994.

[12] 12. BÜCHERL, W. - Escorpionismo no Brasil. Mem. Inst. Butantan, 34: 9-24, 1969.

[13] 13. BROWN, M.J.; BROWN, C.D. & MURPHY, M.B. - Hypokalemia from beta2-receptor stimulation by circulating epinephrine. New Engl. J. Med., 309: 1414-1419, 1983.

[14] 14. CAMPOS, J.A.; LOPEZ, M. & FREIRE-MAIA, L. - Signs, symptoms and treatment of severe scorpion poisoning in children. In: EAKER, D. & WADSTROM, T., ed. Natural toxins. Oxford, Pergamon, 1980. p.61-68.

[15] 15. CHAVES, A.; LEME, C.; BUCARETCHI, F. et al. - Alteraçőes ecodopleicardiográficas no acidente escorpiônico grave. Rev. bras. Ecocardio., 16(supl.): 31, 1993. (res.59)

[16] 16. CUPO, P.; JURCA, M.; AZEVEDO-MARQUES, M.M. et al. - Severe scorpion envenomation in Brazil. Clinical, laboratory and anatomopathological aspects. Rev. Inst. Med. trop. S. Paulo, 36: 67-76, 1994.

[17] 17. DEHESA-DÁVILA, M. & POSSANI, L.D. - Scorpionism and serotherapy in Mexico. Toxicon., 32: 1015-1018, 1994.

[18] 18. FAYET, G.; COURAND, F.; MIRANDA, F. & LISSITZKY, S. - Electro-optical-system for monitoring activity of heart cells in culture. Application to the study of several drugs and scorpion toxins. Europ. J. Pharmacol., 27: 165-174, 1974.

[19] 19. FREIRE-MAIA, L.; PINTO, G.I. & FRANCO, J. - Mechanism of the cardiovascular effect produced by scorpion purified toxin in the rat. J. Pharmacol. exp. Ther., 188: 207-213, 1974.

[20] 20. FREIRE-MAIA, L. & CAMPOS, J.A. - On lhe treatment of the cardiovascular manifestations of scorpion envenomation. Toxicon, 25: 125-130, 1987.

[21] 21. FREIRE-MAIA, L. & CAMPOS, J.A. - Pathophysiology and treatment of scorpion poisoning. In: OWNBY, C.H. & ODELL, G.V., ed. Natural toxins. Oxford, Pergamon, 1989-p. 139-159.

[22] 22. FREIRE-MAIA, L.; CAMPOS, J.A. & AMARAL, C.F.S. - Approaches to the treatment of scorpion envenoming. Toxicon, 32: 1009-1014, 1994.

[23] 23. GUERON, M.; ADOLPH, R.V.; GRUPP, J.L. et al. - Hemodynamic and myocardial consequences of scorpion venom. Amer J. Cardiol., 45: 979-986, 1980.

[24] 24. GUERON, M. & OVSYSHCHER, I. - What is the treatment for the cardiovascular manifestations of scorpion envenomation? Toxicon, 25: 121-124, 1987.

[25] 25. GUERON, M. & SOFER, S. - Vasodilators and calcium blocking agents as treatment of cardiovascular manifestations of human scorpion envenomation. Toxicon, 28: 127-128, 1990.

[26] 26. GUERON, M.; MARGULIS, G. & SOFER, S. - Echocardiographic and radionuclide angiographic observations following scorpion envenomation by Leiurus quinquestriatus. Toxicon, 28: 1005-1009, 1990.

[27] 27. GUERON, M.; MARGULIS, G.; ILIA, R. & SOFER, S. - The management of scorpion envenomation. Toxicon, 31: 1071-1076, 1993.

[28] 28. GUERON, M. & SOFER, S. - The role of the intensivist in the treatment of the cardiovascular manifestations of scorpion envenomation. Toxicon, 32: 1027-1029, 1994.

[29] 29. GOYFFON, M.;VACHON, M. & BROGLIO, N. - Epidemiological and clinical characteristics of the scorpion envenomation in Tunisia. Toxicon, 20: 337-344, 1982.

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