Objective Envenomation by Mesobuthus tamulus scorpion sting can result in serious cardiovascular effects. Scorpion antivenom is a specific treatment for scorpion sting. Evidence for the benefit of scorpion antivenom and its efficacy compared with that of commonly used vasodilators, such as prazosin, is scarce. We assessed the efficacy of prazosin combined with scorpion antivenom, compared with prazosin alone, in individuals with autonomic storm caused by scorpion sting.
Design Prospective, open label randomised controlled trial.
Setting General hospital inpatients (Bawaskar Hospital and Research Centre Mahad Dist-Raigad Maharashtra, India).
Participants Seventy patients with grade 2 scorpion envenomation, older than six months, with no cardiorespiratory or central nervous system abnormalities.
Intervention Scorpion antivenom plus prazosin (n=35) or prazosin alone (n=35) assigned by block randomisation. Treatment was not masked. Analysis was by intention to treat.
Main outcome measures The primary end point was the proportion of patients achieving resolution of the clinical syndrome (sweating, salivation, cool extremities, priapism, hypertension or hypotension, tachycardia) 10 hours after administration of study drugs. Secondary end points were time required for complete resolution of clinical syndrome, prevention of deterioration to higher grade, doses of prazosin required overall and within 10 hours, and adverse events. The study protocol was approved by the independent ethics committee of Mumbai.
Results Mean (SD) recovery times in hours for the prazosin plus scorpion antivenom group compared with the prazosin alone groups were: sweating 3 (1.1) v 6.6 (2.6); salivation 1.9 (0.9) v 3 (1.9); priapism 4.7 (1.5) v 9.4 (1.5). Mean (SD) doses of prazosin in the groups were 2 (2.3) and 4 (3.5), respectively. 32 patients (91.4%, 95% confidence interval 76.9% to 97.8%) in the prazosin plus antivenom group showed complete resolution of the clinical syndrome within 10 hours of administration of treatment compared with eight patients in the prazosin group (22.9%, 11.8% to 39.3%). Patients from the antivenom plus prazosin group recovered earlier (mean 8 hours, 95% CI 6.5 to 9.5) than those in the control group (17.7 hours, 15.4 to 19.9; mean difference −9.7 hours, −6.9 to −12.4). The number of patients whose condition deteriorated to a higher grade was similar in both groups (antivenom plus prazosin four of 35, prazosin alone five of 35). Hypotension was reported in fewer patients in the antivenom plus prazosin group (12 of 35, 34.3%) than in the prazosin group (19 of 35, 54.3%), but the difference was not statistically significant. No difference was noted in change in blood pressure and pulse rate over time between two groups.
Conclusion Recovery from scorpion sting is hastened by simultaneous administration of scorpion antivenom plus prazosin compared with prazosin alone.
Trial registration number CTRI/2010/091/000584 (Clinical Trials Registry India).
Scorpion venoms consist of a complex of several toxins that exhibit a wide range of biological properties and actions, as well as chemical compositions, toxicity, and pharmacokinetic and pharmacodynamic characteristics. These venoms are associated with high morbility and mortality, especially among children. Victims of envenoming by a scorpion suffer a variety of pathologies, involving mainly both sympathetic and parasympathetic stimulation as well as central manifestations such as irritability, hyperthermia, vomiting, profuse salivation, tremor, and convulsion. The clinical signs and symptoms observed in humans and experimental animals are related with an excessive systemic host inflammatory response to stings and stings, respectively. Although the pathophysiology of envenomation is complex and not yet fully understood, venom and immune responses are known to trigger the release of inflammatory mediators that are largely mediated by cytokines. In models of severe systemic inflammation produced by injection of high doses of venom or venoms products, the increase in production of proinflammatory cytokines significantly contributes to immunological imbalance, multiple organ dysfunction and death. The cytokines initiate a cascade of events that lead to illness behaviors such as fever, anorexia, and also physiological events in the host such as activation of vasodilatation, hypotension, and increased of vessel permeability.
Scorpion sting is common in villages, and is an important public health problem in India. The clinical symptoms of envenomation by scorpion sting are by sympathetic and parasympathetic stimulation, causing a variety of symptoms. The leading causes of death are cardiac dysfunction and pulmonary edema. We present herein a case of scorpion sting in a 9-year-old boy who developed pulmonary edema and gradually developed cytotoxic cerebral edema with infarct leading to motor aphasia with upper motor neuron facial palsy.
Cerebral infarct; motor aphasia; scorpion sting
Scorpion stings are common in many tropical countries. Although most scorpion stings cause only localized pain without life-threatening envenoming, about one third of stings cause systemic envenoming which can result in death. Children are particularly sensitive to scorpion envenoming. The severity of scorpion stings is related to the presence of neurotoxins in the venom that cause a sudden release of neurotransmitters from the autonomic nervous system, predominantly sympathetic. There is also a strong inflammatory response that worsens symptoms, including those of a respiratory nature. Several vital functions may be directly affected, including the cardiovascular, respiratory, and neuromuscular systems. Hypertension is constant at the beginning of systemic envenoming and sometimes has a severe cardiac and respiratory impact. Although controversial, immunotherapy is the only etiological treatment. Administered early, it prevents many complications and improves the outcome. New antivenoms are highly purified immunoglobulin fragments, the efficacy and safety of which are excellent. As a consequence, adverse reactions to antivenoms are now very rare and usually mild, which should limit any reluctance regarding their routine use. Symptomatic treatment is still necessary to support immunotherapy, especially in cases of delayed arrival at hospital. A combination of both approaches should be considered, based on local resources and constraints.
scorpion; envenoming; treatment; antivenom
A retrospective survey of 1,135 telephone calls during 1980 and 1981, reporting scorpion envenomation to the Arizona Poison and Drug Information Center, was reviewed. Of these, 438 calls identified Centruroides exilicauda as the offending scorpion on the basis of description of the arthropod and consistency of physical findings and clinical course. Envenomation by C exilicauda occurred primarily in adults during the summer and early fall months of the year. Although most patients (92%) were treated at home with conservative therapy, 8% of patients either came to or were referred to a medical facility. Children younger than 5 years were frequently brought or were referred to either emergency care or inpatient hospital care. We conclude on the basis of this series that despite the historical reputation of lethality associated with envenomation by C exilicauda, most envenomations by this scorpion are relatively minor. The other important observation was that children younger than 5 years appear to be particularly prone to severe toxicity.
Scorpion envenomations are a public health problem in many countries. Scorpions are second only to snakes in causing human fatalities from envenomation. Species of scorpions capable of inflicting fatal stings are living in North and South Africa, the Middle East, India, America, Trinidad, and Tobago. Hemiscorpius lepturus (from the Hemiscorpiidae family) is the most medically important scorpion in Iran which accounts for 92% of all hospitalized scorpion sting cases. The venom from H. lepturus is primarily a cytotoxic agent and has hemolytic, nephrotoxic, and to some extent, hepatotoxic activities. We found a combination of microangiopatic hemolytic anemia, thrombocytopenia, and acute renal failure in a seven year-old female child who was referred to us with a 12 h history of bloody urine following a H. lepturus sting. Her blood smear showed fragmented erythrocytes and burr cells, leading us to a diagnosis of hemolytic uremic syndrome (HUS). This report highlights the importance of acceptable prophylaxis and therapeutic protocols for HUS in these patients.
Hemolytic uremic syndrome; microangiopathic hemolytic anemia; scorpion sting
Scorpion sting is a public health problem in Khuzestan, South-West Iran. The aims of the current study were to monitor the hospitalized children, due to scorpion sting, and releasing more clinical and epidemiologic data related to scorpionism in this Province.
In this retrospective study, the data of scorpion sting victims, among the hospitalized children in Abuzar Children Hospital of Ahvaz Jundi Shapur University of Medical Sciences, was analyzed from the points of epidemiological and clinical aspects in 2006.
The scorpion species of 18 files out of 57 were recognized accurately, using Farzanpay’s keyof Iranian scorpions, as Androctonus crassicauda (Scorpionida: Buthidae) and Hemiscorpious lepturus (Scorpionida: Hemiscorpiidae).
The most scorpionism emergencies among the children in the Khuzestan should be paid to those species. However, H. lepturus sting emergencies are in the top of attention among the children.
Scorpion; Androctonus crassicauda; Hemiscorpius lepturus; Scorpionism; Children; Iran
A patient with electrocardiographic abnormalities after scorpion sting, simulating early myocardial infarction, is reported here. Pulmonary edema and congestive heart failure accompanied these electrocardiographic changes. The etiology of the cardiovascular manifestations in severe scorpion sting is related to the venom effects on the sympathetic nervous system and the adrenal secretion of catecholamines as well as to the toxic effects of the venom on the myocardium.
Myocardial damage; pulmonary edema; scorpion bite
Cerebrovascular manifestations are uncommon presentations of scorpion sting in the Indian subcontinent. A prospective study was carried out on 42 patients with scorpion sting in the intensive care unit (ICU) of the Institute of Medical Sciences, Banaras Hindu University, Varanasi-05, INDIA, during the period of May 2005 to October 2007. In all the patients detailed history, physical examination with a specific neurological examination and routine biochemical testing and fundus examination were done. Computerized tomography and magnetic resonance imaging were done in cases with neurological deficit. All these patients also underwent a complete hematological, rheumatologic and cardiovascular work-up for stroke. Cerebrovascular involvement was noted in three patients (7.15%). Hemorrhagic stroke was noted in two patients (4.77%) and thrombotic stroke was noted in one patient (2.39%). The mean time of presentation of neurological symptoms was 3 days. Contrary to world literature, there have been no reports of cranial nerve palsies or neuromuscular involvement in our series.
Disseminated intravascular coagulation; scorpion sting; stroke
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.
Objective—To study cardiovascular haemodynamics following scorpion envenomation.
Setting—Intensive care unit of a university hospital.
Patients—Eight patients with Indian red scorpion (Mesobuthus tamulus) stings.
Intervention—Captopril (6.25 to 12.5 mg orally) every 30 minutes until pulmonary oedema resolved.
Main outcome measures—Haemodynamic data obtained by pulmonary artery catheterisation.
Results—Two haemodynamic patterns were seen. There was a predominant vascular effect in one patient, with severe hypertension, tachycardia, increased systemic vascular resistance index (SVRI = 5893 dyn.s.cm-5), and normal cardiac index (2.73 l/m2). A predominant myocardial effect with left ventricular dysfunction and normal right ventricular function was seen in the other seven patients, with tachycardia, pulmonary oedema, mild hypotension, reduced stroke volume (mean (SD), 25.9 (8.3) ml/m2), normal SVRI (1812 (831) dyn.s.cm−5), and increased pulmonary artery wedge pressure (PAWP = 25 (4.4) mm Hg). Following mild dehydration pulmonary oedema subsided (PAWP = 14 (8.5) mm Hg) in three of these patients, but hypovolaemic shock developed (right atrial pressure (RAP) = 1.3 (2.1) mm Hg); pulmonary oedema recurred with rehydration. One patient developed fatal cardiogenic shock with raised PAWP (27 mm Hg) and RAP (11 mm Hg), and vasodilatation (SVRI = 1129 dyn.s.cm−5). Stroke volume (30.5 (8.7) ml/m2) and cardiac output (4.3 (1.5) l/m2) improved with resolution of pulmonary oedema (PAWP = 14.4 (4.2) mm Hg) following afterload reduction with captopril.
Conclusions—Mild envenomation causes severe vasoconstriction and hypertension. Severe envenomation produces predominant left ventricular dysfunction with normal systemic vascular resistance manifesting as pulmonary oedema or severe hypotension depending on the fluid balance. Shock due to biventricular dysfunction and vasodilatation occurs terminally.
Keywords: scorpion sting; myocarditis; pulmonary oedema; animal toxin
Bark scorpion envenomation is potentially life threatening in children and traditionally treated with antivenom (AV). We sought to describe the clinical course, management, complications and outcome of children with severe scorpion envenomation treated with supportive care during a period when AV was unavailable. A retrospective chart review was performed, all children presenting to a referral hospital between September 1, 2004 and July 31, 2006 with severe scorpion envenomation not receiving AV, were included. A standardized data abstraction form was used to record time of symptom onset, time to healthcare facility (HCF), clinical findings, treatment, complications, and length of stay. Eighty-eight patients were included with mean age of 3.7 years (0.33–12). Mean time to symptom onset was 20 min (0–130) and mean time to HCF was 79 min (10–240). Incidence of clinical manifestations include: neuromuscular agitation, 100 %; opsoclonus, 97 %; hypersalivation, 81 %; tachycardia, 82 %; hypertension, 49 %; vomiting, 38 %; fever, 28 %; respiratory distress, 33 %; and hypoxia, 18 %. Complications included rhabdomyolysis in 18 (20 %) and aspiration in 12 (13 %) patients. Intubation was required in 24 % of patients. The most frequently used agents to control symptoms were benzodiazepines (98 %) followed by opioids (69 %). Intravenous fluids were given to 84 %. Mean length of stay was 29 h (range, 6–73 h). There were no deaths. In addition to the classic findings of neuromuscular hyperactivity, opsoclonus, and hypersalivation, a high incidence of hyperadrenergic findings and respiratory compromise are noted in this series. A significant number of patients required mechanical ventilation. Benzodiazpines and opioids were the most common medications used to control symptoms.
Scorpion envenomation; Centruroides sculpturatus; Respiratory failure; Motor hyperactivity; Hyperadrenergic effects
Objective: This study was to evaluate the levels of NT-proBNP in patients with myocarditis which occurred after a scorpion sting envenomation.
Material and Methods: A total of 30 patients with scorpion sting envenomation and 21 patients with heart failure which was caused by cardiomyopathy, were prospectively studied. The data included the patient demographics, clinical features, echocardiography and the NT-proBNP levels.
Results: An echocardiographic evidence of myocarditis with a left ventricular ejection fraction of less than 50%, was found in 22 patients. In all the 22 patients, NT-proBNP was significantly elevated. The NT-proBNP levels were very high in the patients with severe LV dysfunction. However, it was in the normal range in the patients without an evidence of myocarditis. The elevated NT-proBNP levels were correlated with the LV dysfunction and myocarditis. When they were compared with the patients with heart failure which was caused by cardiomyopathy, the NTproBNP levels were found to be significantly more elevated in scorpion sting myocarditis.
Conclusions: The NT-proBNP levels were significantly elevated in myocarditis which occurred after a scorpion sting envenomation.
Scorpion; Myocarditis; Envenomation; Echocardiography; NT-pro BNP
Previous works had shown that scorpion venom induced neurotransmitter elevation and an inflammatory response associated with various anatomo-pathological modifications. The most dangerous scorpions species in Algeria responsible for these effects are Androctonus australis hector (Aah) and Androctonus amoreuxi (Aam).
Comparison of the physiopathological effects induced by the two venoms showed differences in the kinetic of cytokine release and in lung injury.
The lung edema was only observed in response to Aah venom and it was correlated with cell infiltration. In order to better understand the involved mechanism in inflammatory response, we used two antagonists, atropine (non-selective muscarinic antagonist) and propranolol (β adrenergic antagonist), which lead to a decrease of cell infiltration but has no effect on edema forming.
These results suggest another pathway in the development of lung injury following envenomation with Aam or Aah venom.
Scorpion venoms; Cytokines; Lung inflammation; Acetylcholine; Atropine; Propranolol
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.
biochemical analysis data; epidemiological; hematological analysis data; scorpion sting; urine analysis data
Scorpion envenomation is common among desert dwellers, affecting several systems and resulting in multiple organ dysfunction (MOD) or failure (MOF), mainly due to their action on Na+ channels. Although scorpion venoms toxins do not pass the blood brain barrier, their CNS effects are prominent, occurring in conjunction with, or as an aftermath of peripheral actions of the venom.
To determine the ability of venom of the common scorpion Leiurus quinquestriatus (LQQ) to induce MOD or MOF when injected into rabbits in micro quantities centrally (intracerebroventricularly, i.c.v.) or macro amounts peripherally (s.c. or i.v.). Also, to assess if the Na+ channel blocker lidocaine can protect rabbits from the resultant manifestations.
Rabbits were injected with LQQ venom centrally or peripherally, in either sublethal or lethal doses, and MOD or MOF determined by assessing: cardiac output (CO), estimated hepatic blood flow (EHBF), biochemical parameters indicative of cardiac/hepatic/renal and pancreatic functions, blood pressure (BP), survival, lung/body index (LBI, indicative of pulmonary edema), and/or histological changes in hearts, lungs, livers plus kidneys. In pre-treatment experiments, lidocaine was injected 40 min before venom and protective ability examined.
LQQ venom in sublethal doses caused comparable significant reductions (vs control) in CO and EHBF when injected i.c.v. (2 μg kg−1) or s.c. (0.2 mg kg−1). Both routes caused gradual dose-related enhanced levels of creatine kinase, lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, creatinine, glucose and amylase, indicating MOD. Also, characteristic venom-induced changes in BP were evident after lethal doses of venom i.v. (0.5 mg kg−1) or i.c.v. (3 μg kg−1). Histological changes in the organs plus LBI were comparable after i.c.v. and i.v. venom injection, with animals ultimately exhibiting MOF. Lidocaine (1 mg kg−1 i.v., then infusion 50 μg kg−1 min−1, 30 min before venom), protected the animals from MOF evoked by lethal doses of the venom (whether injected centrally or peripherally), as evidenced by the amelioration of the venom’s effects on blood pressure, LBI, survival and multiple organ histopathological manifestations.
LQQ venom, whether injected centrally or peripherally caused comparable systemic dose-dependent MOD or MOF, with the latter attenuated by the Na+ channel blocker lidocaine, indicating a role for Na+ channels.
Leiurus quinquestriatus; Scorpion venom; Cardiac output; Estimated hepatic blood flow; Blood pressure; Lidocaine; Pulmonary index; Histopathological manifestations
As a rule, bites and stings in travellers are merely a nuisance. But it is sensible to be informed about the more serious possibilities which can result. Systemic diseases can be transmitted, the skin lesions from insects can be troublesome and finally, some bites and stings can cause envenoming. Thus, the bather may be harmed by venomous fish stings, sea urchins, jellyfish and in Asian-Pacific waters by sea-snakes. Land hazards include bites or stings by scorpions, spiders, ticks, centipedes, bees, wasps, caterpillars and snakes. The main clinical features of such bites and stings, including treatment and prevention, are outlined.
We hypothesized that the edema fluid-to-plasma protein (EF/PL) ratio, a non-invasive measure of alveolar capillary membrane permeability, can accurately determine the etiology of acute pulmonary edema.
390 mechanically ventilated patients with acute pulmonary edema were enrolled. A clinical diagnosis of acute lung injury (ALI), cardiogenic pulmonary edema, or a mixed etiology was based on expert medical record review at the end of hospitalization. The EF/PL ratio was measured from pulmonary edema fluid and plasma samples collected at intubation.
209 patients had a clinical diagnosis of ALI, 147 had a diagnosis of cardiogenic pulmonary edema and 34 had a mixed etiology. The EF/PL ratio had an area under the receiver-operating curve of 0.84 for differentiating ALI from cardiogenic pulmonary edema. Using a predefined cutoff of 0.65, the EF/PL ratio had a sensitivity of 81% and a specificity of 81% for the diagnosis of ALI. An EF/PL ratio ≥ 0.65 was also associated with significantly higher mortality and fewer ventilator free days.
Non-invasive measurement of the EF/PL ratio is a safe and reliable bedside method for rapidly determining the etiology of acute pulmonary edema that can be used at the bedside in both developed and developing countries.
acute pulmonary edema; acute lung injury; acute respiratory distress syndrome; alveolar capillary membrane permeability; diagnosis
Recurrences of clinical or laboratory manifestations of North American pit viper envenomation may happen despite control of the envenomation syndrome by prompt and adequate antivenom therapy. Recurrences of coagulopathy in victims of Eastern diamondback rattlesnake envenomation are generally regarded as benign. The vast majority suffer no actual bleeding despite florid coagulation laboratory abnormalities due to selective defibrinogenation.
We report what we believe to be the first fatality following successful control of the envenomation syndrome following ovine antivenom treatment resulting from envenomation by a bite from the Eastern diamondback rattlesnake. This case raises the question of whether such recurrences are in fact benign, causal, or coincidental. This patient sustained significant brain hemorrhage and death ensued due to generalized cerebral edema. Defibrinogenation occurred 4 days after treatment with ovine antivenom.
Coagulation abnormalities following Eastern diamondback rattlesnake envenomation are due to selective defibrinogenation. This is separate from disseminated intravascular coagulation (DIC). Thrombin generation, thus hemostasis, are generally considered normal. This case may cause reexamination of this belief.
rattlesnake envenomation; defibrinogenation; hemorrhage; recurrence syndrome
Differentiating cardiogenic pulmonary edema from other bilateral lung diseases such as pneumonia is frequently difficult. We conducted a retrospective study to identify predictors for cardiogenic pulmonary edema and non-cardiogenic causes of bilateral lung infiltrates in chest radiographs.
The study included patients who had newly developed bilateral lung infiltrates in chest radiographs and patients who underwent echocardiography. Cases were divided into two groups based on the echocardiographic findings: the cardiogenic pulmonary edema group and the non-cardiogenic group. Clinical characteristics and basic laboratory findings were analyzed to identify predictors for differential diagnosis between cardiogenic and non-cardiogenic causes of bilateral chest infiltrates.
We analyzed 110 subjects. Predictors of cardiogenic pulmonary edema were higher brain natriuretic peptide (BNP) levels, lower C-reactive protein (CRP) levels on the day of the event (<7 mg/dL), age over 60 years, history of heart disease, and absence of fever and sputum. CRP on the day of the event was an independent factor to differentiate cardiogenic and non-cardiogenic causes of newly developed bilateral chest infiltrates. Also, the validity was comparable to BNP.
Clinical symptoms (sputum and fever), medical history (dyslipidemia and heart disease), and laboratory findings (BNP and CRP) could be helpful in the differential diagnosis of patients with acute bilateral lung infiltrates in chest radiographs.
C-Reactive Protein; Natriuretic Peptide, Brain; Pulmonary Edema
Distinguishing pulmonary edema due to acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS) from hydrostatic or cardiogenic edema is challenging in critically ill patients. B-type natriuretic peptide (BNP) can effectively identify congestive heart failure in the emergency room setting but, despite increasing use, its diagnostic utility has not been validated in the intensive care unit (ICU).
We performed a prospective, blinded cohort study in the medical and surgical ICUs at the University of Chicago Hospitals. Patients were eligible if they were admitted to the ICU with respiratory distress, bilateral pulmonary edema and a central venous catheter suggesting either high-pressure (cardiogenic) or low-pressure (ALI/ARDS) pulmonary edema. BNP levels were measured within 48 hours of ICU admission and development of pulmonary edema and onward up to three consecutive days. All levels were drawn simultaneously with the measurement of right atrial or pulmonary artery wedge pressure. The etiology of pulmonary edema – cardiogenic or ALI/ARDS – was determined by three intensivists blinded to BNP levels.
We enrolled a total of 54 patients (33 with ALI/ARDS and 21 with cardiogenic edema). BNP levels were lower in patients with ALI/ARDS than in those with cardiogenic edema (496 ± 439 versus 747 ± 476 pg/ml, P = 0.05). At an accepted cutoff of 100 pg/ml, specificity for the diagnosis of ALI/ARDS was high (95.2%) but sensitivity was poor (27.3%). Cutoffs at higher BNP levels improved sensitivity at considerable cost to specificity. Invasive measures of filling pressures correlated poorly with initial BNP levels and subsequent day BNP values fluctuated unpredictably and without correlation with hemodynamic changes and net fluid balance.
BNP levels drawn within 48 hours of admission to the ICU do not reliably distinguish ALI/ARDS from cardiogenic edema, do not correlate with invasive hemodynamic measurements, and do not track predictably with changes in volume status on consecutive daily measurements.
The scorpion Tityus stigmurus is widely distributed in Northeastern Brazil and known to cause severe human envenoming, inducing pain, hyposthesia, edema, erythema, paresthesia, headaches and vomiting. The present study uses a transcriptomic approach to characterize the gene expression profile from the non-stimulated venom gland of Tityus stigmurus scorpion.
A cDNA library was constructed and 540 clones were sequenced and grouped into 153 clusters, with one or more ESTs (expressed sequence tags). Forty-one percent of ESTs belong to recognized toxin-coding sequences, with transcripts encoding antimicrobial toxins (AMP-like) being the most abundant, followed by alfa KTx- like, beta KTx-like, beta NaTx-like and alfa NaTx-like. Our analysis indicated that 34% of the transcripts encode “other possible venom molecules”, which correspond to anionic peptides, hypothetical secreted peptides, metalloproteinases, cystein-rich peptides and lectins. Fifteen percent of ESTs are similar to cellular transcripts. Sequences without good matches corresponded to 11%.
This investigation provides the first global view of gene expression of the venom gland from Tityus stigmurus under resting conditions. This approach enables characterization of a large number of venom gland component molecules, which belong either to known or non yet described types of venom peptides and proteins from the Buthidae family.
India is a thickly populated country; apart from having biodiversity among people, climate does change from place to place. Western Ghats of South India harbors variety of plantations and diverse creatures. Agriculture is the primary occupation of the people and some tribes living in these regions. Here majority are callous/ ignorant in employing neither advanced farming techniques nor safety precautions, hence are exposed to bites and stings by animals. Of these, snake bites cause significant mortality and morbidity. Proper care for some of these individuals is out of reach. Identification of offending snake, snake bite injury or findings of envenomation is a key not only for the administration of antisnake venom but also for the victim to realize that he needs an expert care. Unless he believes it to be a critical snake bite and not a thorn prick, scorpion sting or a spider bite he will not approach a health care provider. To know about these dangerous signs that may help the victim to realize it as a case of snake bite, current study is employed on fatal cases in this region.
60 fatal snakebite cases were studied retrospectively for 5 years with an objective to know the socio-demography, latency and pattern of injuries in rural Southern India.
Most of the victims were males, in the age group of 31-50 years and were at risk of snake bites while farming. Large sample of subjects approached traditional therapists and were deprived of essential care in the critical first few hours after snake bite. Fang marks (90%), local ecchymoses (50%) and internal hemorrhage (28.3%), were the frequent demonstrable signs appreciated at autopsy.
Snakebite is a neglected, endemic, occupational (farming) disease of the poor and there is need for National Snakebite Prevention Programme for curtailing this menace.
Snake bite; Agriculturist; Poverty; Bite-admission time; Fang marks
In Iran intramuscular (IM) administration of antivenoms is used for the treatment of human scorpion envenoming of six medically dangerous scorpion species, including Odonthubuthus doriae (O. doriae). The purpose of the current study is to investigate the efficiency of the intramuscular route and the delay of injection on the neutralizing effect of the available polyvalent antivenom. We compared the pharmacokinetics parameters of O. doriae venom and its antivenom. 5µg 131I-labeled venom and 0.2µl of antivenom were administered via subcutaneous (SC) or IM into rats. Blood samples were taken at various predetermined time intervals during a 24hr period for the venom and a 360min period for the antivenom. The radio-iodination was carried out using the chloramin-T method. The results showed that pharmacokinetic parameters of the venom were T1/2 = 496.53min; Vd = 1522ml/kg; Cl = 2.12 ml/kg/min; mean resident residual time (MRT) = 555.77min, and for the antivenom T1/2 = 902.13min, Vd = 666.66 ml/kg , Cl = 0.512 ml/kg/min and MRT = 1292min. The total body clearance of the venom is relatively low in agreement with a high mean residence time. Higher AUC and Cmax values for the antivenom as well as its longer residence time indicate that the venom and antivenom are expected to have enough opportunity to interact in the tissue compartments. Over, this study suggests that the intramuscular administration of a single dose of antivenom (2 vials each of 5ml) based on current protocol in Iran is a suitable route for the treatment of envenomation with O. doriae. Prudently, further clinical studies with similar aims need to be carried out to confirm these findings in human victims.
Iranian scorpion; Odonthubuthus doriae; Razi polyvalent antivenom; pharmacokinetic parameters; venom
To determine predictive factors of mortality among children after isolated traumatic brain injury.
Materials and Methods:
In this retrospective study, we included all consecutive children with isolated traumatic brain injury admitted to the 22-bed intensive care unit (ICU) of Habib Bourguiba University Hospital (Sfax, Tunisia). Basic demographic, clinical, biochemical, and radiological data were recorded on admission and during ICU stay.
There were 276 patients with 196 boys (71%) and 80 girls, with a mean age of 6.7 ± 3.8 years. The main cause of trauma was road traffic accident (58.3%). Mean Glasgow Coma Scale score was 8 ± 2, Mean Injury Severity Score (ISS) was 23.3 ± 5.9, Mean Pediatric Trauma Score (PTS) was 4.8 ± 2.3, and Mean Pediatric Risk of Mortality (PRISM) was 10.8 ± 8. A total of 259 children required mechanical ventilation. Forty-eight children (17.4%) died. Multivariate analysis showed that factors associated with a poor prognosis were PRISM > 24 (OR: 10.98), neurovegetative disorder (OR: 7.1), meningeal hemorrhage (OR: 2.74), and lesion type VI according to Marshall tomographic grading (OR: 13.26).
In Tunisia, head injury is a frequent cause of hospital admission and is most often due to road traffic injuries. Short-term prognosis is influenced by demographic, clinical, radiological, and biochemical factors. The need to put preventive measures in place is underscored.
Acute head injury; children; intensive care unit; motor-vehicle crash; prognosis; trauma