Acute kidney injury and pancreatitis due to scorpion sting: case report and literature review

Albuquerque, Polianna Lemos Moura Moreira; Magalhaes, Karla do Nascimento; Sales, Tamiris de Castro; Paiva, José Hícaro Hellano Gonçalves Lima; Daher, Elizabeth de Francesco; Silva Junior, Geraldo Bezerra da

doi:10.1590/S1678-9946201860030

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Revista do Instituto de Medicina Tropical de São Paulo

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REVIEW • Rev. Inst. Med. trop. S. Paulo 60 • 2018 • https://doi.org/10.1590/S1678-9946201860030 copy

Acute kidney injury and pancreatitis due to scorpion sting: case report and literature review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Despite the high number of accidents due to scorpion stings in Brazil, severe cases in adults are seldomly reported. In the Northeast region of Brazil, Tityus stigmurus is the most prevalent species. A 69 year-old woman who was stung by a scorpion attended the emergency room 5 hours after envenomation. She got worse due to abdominal pain. Clinical findings were concordant with class III scorpion envenomation (major systemic manifestations), complicated by acute kidney injury and acute pancreatitis. Intensive supportive therapy was adopted. In the follow-up, 3 months later, she was completely recovered. This report is being brought to recommend the thorough management of victims of scorpion accidents, enabling early diagnosis of severe complications, which could lead to death if aggressive supportive measures are not early and adequately taken.

Scorpionism; Acute kidney injury; Tityus stigmurus; Acute pancreatitis

Variable	Admission	24 hours later	Discharge	3 months later	Normal range
Glucose (mg/dl)	281	235	**	**	74 - 106
Potassium (mmol/l)	3.24	3.92	3.06	4.13	3.5 - 5.3
Sodium (mmol/l)	140	141	133	142	135 - 148
Chloride (mmol/l)	100	106	93	96	96 - 109
Urea (mg/dl)	27	45	50	42	13 - 43
Creatinine (mg/dl)	0.8	1.4	1.0	0.8	0.6 - 1.1
AST (U/L)	85	240	**	20	< 32
ALT (U/L)	93	242	**	19	< 31
PT (s)	12.1	14.2	11.8	11.4	10 - 14
aPTT (s)	22.2	26.5	24.8	23.9	22 - 28
Lipase (U/L)	5442	2121	**	70	13 - 60
Amylase (U/L)	1914	1138	135	92	< 84
D-LDH (U/L)	474	**	**	319	230 - 460
CK (U/L)	91	**	**	102	< 170
Hemoglobin (g/dl)	14.2	15.6	9.9	13.6	11.3 - 15.2
Leukocytes (/mm³)	11470	7730	10110	5170	3600 - 10000
Platelets (/mm³)	164000	162000	218000	202000	150- 450 (10³)
Creatinine (mg/dl)	0.8	2.4	1.0	0.8	0.6 - 1.1
Urea (mg/dl)	27	115	50	42	13 - 43
MCP-1 (pg/mgCr)	1576.97	**	**	**	*
uNGAL (ng/mgCr)	7.97	**	**	**	*
KIM-1 (ng/mgCr)	1180	**	**	**	*
PH***	7.41	**	**	**	7.35
pCO₂ (mmHg)***	37.1	**	**	**	35 - 45
pO₂ (mmHg)***	161.3	**	**	**	85 - 100
HCO3 (mmol/L)***	23.6	**	**	**	22 - 26
BE (mmol/L)***	-1.6	**	**	**	-4 - +4
Lactate (mmol/L)***	2.54	**	**	**	<2.0

References	Number of cases	Age^a	Scorpion Specie	Initial presentation ^e	Antivenom	Complications ^f	Outcome	Pancreatic findings ^e
Bartholomew et al., 1970³⁵, Trinidad	30 (20 males)	9 – 57^c	Tityus trinitatis	Sialorrhea (16), abdominal pain (16), vomit (15), reddening and oedema in stung site	No	No	Discharge without symptoms	High amylase level (24), high transaminases levels (5)
Sofer et al., 1991¹⁷, Israel	15 (9 males)	1 – 14	Leiurus quinquestriatus and Buthotus judaicus	Abdominal pain (3), vomit (7), hematemesis (1), respiratory failure (1), hypertension (6), ventricular arrhythmias (1)	No	Respiratory failure (assisted ventilation) and Cardiac abnormalities	1 death (ventricular arrhythmia)	High level of serum immunoreactive cationic trypsin (13), hyperglycaemia
Otero et al., 2004³⁶, Colombia	1 (female)	3	Tityus asthenes	Vomit, tachypnoea	b	b	Discharge without symptoms	Acute oedematous pancreatitis
Sousa et al., 2007³⁷, Venezuela	2 (2 males)	8; 13	Tityus neoespartanas	Local pain in right foot (2), vomit (2), colic-like abdominal pain (2), sialorrhea (2), diaphoresis (2)	03 vials in the 13 year-old-patient	Cardiac abnormalities and pancreatic microcalcifications (abdominal ultrasound, 1 year later)	Discharge without symptoms	High levels of amylase and lipase, edematous pancreatic pattern (abdominal ultrasound)
Mouaffak et al., 2012³⁸, Africa	1	11	Androctonus mauretanicus	Abdominal pain, tachycardia, tachypnoea, agitation, fever	b	Priapism	Discharge without symptoms	Normal abdominal ultrasound
Kumar et al., 2012¹³, India	1 (male)	8	b	Autonomic dysfunctions, pulmonary oedema, stung site – right foot without abnormalities	b	Haemorrhagic pancreatitis, myocarditis and pulmonary oedema	Death	Extensive parenchymal pancreatic necrosis accompanied by interstitial haemorrhagic pancreatitis (post- mortem diagnosis)

References	Number of cases	Age ^a	Scorpion Specie	Initial presentation ^e	Antivenom	Pancreatic findings	Dialysis ^e	Outcome	Kidney findings ^e
Malhotra et al., 1978⁴¹, Iran	15 (9 males)	2.5 – 60^c	b	Local ulceration in stung site (3), hemoglobinuria, oliguria, edema, hemolytic anemia and hemolytic jaundice	No	b	Yes (5)	b	Hemoglobinuria, mesangial proliferation, variable degreed of tubular changes and mild interstitial infiltration (4)
Chadha et al., 1979⁴⁵, Iran	1 (female)	28	b	Bloody urine, breathless, severe hemolytic anemia, slight jaundice, puffy face, black necrotic area at the stung site, hypotension	Yes (dose did not report)		Yes	Discharge (skin grafting was performed later)	Hemoglobinuria, albuminuria, anuria (Not biopsied)
Naqvi et al., 1998⁴⁷, Pakistan	1 (male)	60	b	Severe local pain, swelling (foot), hematuria, torpor, cervical rigidity	No	Normal amylase	Yes	Death (Disseminated intravascular coagulation and shock)	Hematuria, albuminuria, acute tubular necrosis in renal tissue
Derakhshan et al., 2004⁴⁸, Iran	6	<16	b	Haemolysis	b	b	b	b	Acute tubular necrosis
Valavi et al., 2008⁴⁹, India	1 (female)	7	Hemiscorpius lepturus	Bloody urine, vomiting, agitation, restlessness, erythematic area with local oedema at the stung site	Yes	b	Yes	Discharge in dialysis program	Hemoglobinuria, microscopic haematuria, proteinuria and erythrocyte casts, clinical diagnosis of haemolytic uremic syndrome (Not biopsied)
Jalali et al., 2010⁴⁰, Iran	102	<10	Hemiscorpius lepturus	b	b	b	b	3 deaths (associated to AKI^d)	Hemoglobinuria isolated (28) or with renal failure ^d (73)
Naqvi, 2015⁴³, Pakistan	18 (7 males)	10.74 – 47.7 c	b	Main stung site – foot, severe local pain, tingling, numbness, burning sensation, oliguria- anuria (16), haematuria/ hematemesis (10)	b	b	Yes (18)	16 discharge (13 with complete and 3 with partial renal recovery) and 2deaths (cardiac arrhythmia and cardiomyopathy)	Haematuria (14), proteinuria (15), acute tubular necrosis and pigment casts without abnormal glomeruli (3)
Ranaweera et al., 2015²⁸, Sri-Lanka	1	53	b	Vomiting, abdominal pain, haemoglobinuria progressing to anuria	No	b	Yes	Discharge in dialysis program (death 4 months later)	Haemorrhagic glomerular infarction with AKI
Vazirianzadeh et al., 2017⁴², Iran	103	≤14	Hemiscorpius lepturus and Androctonus crassicauda	b	b	b	b	4 deaths	Hemoglobinuria in different rates

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[1] Correspondence to: Geraldo Bezerra da Silva Junior Universidade de Fortaleza, Curso de Medicina, Programas de Pós-Graduação em Saúde Coletiva e Ciências Médicas, Rua 25 de Março, 997, Bloco S, Sala S-01, CEP: 60811-905, Fortaleza, CE, Brazil Tel: +55 85 3477 3280, Fax: +55 85 85 3477 3424,pollylemos78@gmail.com, E-mail:geraldobezerrajr@unifor.br