First report of death due to Hemiscorpius acanthocercus envenomation in Iran: Case report.

Scorpion stings are significant causes of death in the western and southern regions of Iran. To date, reports have indicated that the H. lepturus species is the main cause of mortality due to scorpion stings. One of the species that belongs to this genus is Hemiscorpius acanthocercus (H. acanthocercus). This scorpion's venom is cytotoxic, and it causes pathological changes in the blood and can cause severe damage to the kidneys. The pain of Hemiscorpius' sting is mild and asymptomatic in the early hours. Delays in the treatment of these victims can cause hemolysis, hematuria, kidney failure, and even death. In this paper, we report the first known death due to an H. acanthocercus' sting in Iran.

Introduction

Every year, more than one million cases of scorpion stings are reported in the world (1). Most of these cases are reported in Mexico, Tunisia, and Brazil (2). The Hemiscorpius genus of scorpions is distributed throughout Asia (Iran, Iraq, Oman, Pakistan, Saudi Arabia, Yemen, and the United Arab Emirates) and Africa (Eritrea, Somalia, and Egypt) (3–7). In Iran, about 40,000 to 50,000 scorpion sting cases are reported annually, resulting in about 19 deaths (8). To date, 1,500 species of scorpions have been identified throughout the world, and about 50 of these species can be dangerous to humans. These 50 species include Androctonus, Buthus, Mesobuthus, Tityus, Leiurus, and Hemiscorpius (9). The H. lepturus scorpion is the most venomous scorpion in Iran (10–13). The scorpion’s venom contains various toxins, including neurotoxin, cardiotoxin, nephrotoxin, and hemolytic toxin (14). Children and elderly patients are at increased risk of complications from scorpion envenomation (15). It is well known that the potent cytotoxin, venom in H. lepturus, causes cutaneous necrosis, necrotic ulcers, psychological problems, ankylosis of the joints, hemoglubinuria, fatal haemolysis, hematuria, renal failure, and even death (9, 11, 12, 16–18). In southern Iran, Hemiscorpius is responsible for 95% of deaths (10). This paper presents and discusses the first report of death as a result of H. acanthocercus envenomation in a 15-year-old male in southern Iran.

Case presentation

Clinical presentation

A 15-year-old male resident of a rural area in the Bandar Abbas district in southern Iran was stung by an H. acanthocercus scorpion on his right arm (Figure 1), and he was admitted to the hospital 12 hours later due to weakness, fever, chills, and pain at the site of the sting.

Figure 1.

Dorsal view of a female Hemiscorpius acanthocercus scorpion from Hormozgan Province in southern Iran: Original picture taken by M. Shahi (Scale, mm).

The patient was conscious at the time of admission, and he was not ill, icteric. On the first day, the clinical signs included fever, lethargy, abdominal pain, chills, active bleeding, and hematuria. The patient’s vital signs were BP (115/75 mm Hg), PR 68/min, RR (18/min), and body temperature (39.5 °C); his heart and lung functions were normal. Erythema and local necrosis were observed at the site of the sting. On the second day after admission, the patient’s fever increased to 40 °C, and active bleeding and hematuria continued. On the third day, there was no change in the clinical status of the patient.

Laboratory findings

Table 1 provides the results of the patient’s laboratory tests. On the second day, his data showed increases in PTT (56 sec), WBC (24×103/µl), Urea (86 mg/dl), Creatinine (2.1 mg/dl), SGOT (240 U/L), SGPT (180 U/L), Total and Direct Bilirubin (9 and 2 mg/dl, respectively), and there were decreases in his RBC (2.83×106/µl), HGB (8.8 g/dl), and PLT (20×103/µl).

Table 1.

Biochemistry and Complete Blood Count test results

Test (Units)	Results
	Day 1	Day 3
Urea (mg/dl)	44	164
BUN (mg/dl)	20	76
Creatinine (mg/dl)	1	4.2
LDH (U/L)	611	6538
Sodium (mEq/L)	139	149
Potassium (mEq/L)	4.3	5.6
PTT (Sec)	33	41
PT (Sec)	14.5	20
WBC (×103/µl)	7.6	24.9
RBC (×106/µl)	3.82	2.94
HGB (g/dl)	11.2	8.4
HCT (%)	34	26.1
MCV (fL)	89	88
MCH (pg)	29	28
MCHC (g/dl)	32	32
PLT (×103/µl)	38	150
RDW-SV (%)	17	22

Treatment and outcome

The patient received scorpion anti-venum and intravenous hydrocortisone and clemastine. The patient also received 400 mg of ciprofloxacin twice a day and 600 mg of clindamycin three times a day for treatment of cellulitis. Also, intravenous paracetamol was used to control the patient’s fever, and he received fresh frozen plasma (FFP), platelets, and cryoprecipitate for correction of coagulation factors. In spite of these treatments, the patients died due to his impaired coagulation status and hemodynamic status.

Discussion

H. lepturus envenomation has resulted in a significant number of mortalities in Iran (19, 20). The Hemiscorpius scorpion’s sting does not cause immediate or severe pain (1, 19), so most people who are stung do not get medical care. The delay in seeking medical care may be due to the fact that there are few early symptoms associated with H. lepturus envenomation, and those that do occur are mild (18). The patient did not seek medical care until 12 days after envenomation, and by that time he had developed severe complications. The severe symptoms of envenomation caused by H. lepturus venom in children are attributable to their low body mass and their limited physiological reserves (19). Very severe renal complications have been observed in children who had not sought medical care (21). In Rahmani & Jalali’s study, all patients who died also had been stung by H. lepturus scorpions and sought medical care days later (18), as was the case for the patient in our study. H. lepturus venom causes various symptoms, such as macular erythema, necrosis, ulcers, fever, and others (22). The clinical symptoms caused by H. acanthocercus envenomation were similar to those of H. lepturus. Therefore, this scorpion poses a significant risk for victims, especially children. Studies have shown that Hemiscorpius venom is highly cytotoxic and can cause cutaneous necrosis, severe hemolysis, hematuria, renal failure, and death (18, 23), and our observations in the case in question were similar to the findings of those studies.

Table 1 shows laboratory findings that indicate the changes in a patient’s hematology and biochemistry parametrics as the result of being stung by an H. acanthocercus scorpion. ed. These data were in good agreement with the findings of other similar studies in Iran (10, 16, 18, 24–26). The most severe hemoglobinuria, i.e., + 4, that has been observed in people stung by H. lepturus scorpions was reported in Mohseni’s study (27). Other studies has shown a rapid reduction in the level of HCT with acute hemolysis among patients who were referred to hospital emergency departments (16, 28). In addition, Emam’s report indicated that the measurement of hematologic parameters, such as PTT, Hb, RBC, and PLT, was important because they are important indicators in patients who have been stung by H. lepturus scorpions (29). In contrast to the above results, the results of Mohseni’s study indicated that the PTT and PT factors were not important indices in cases involving scorpion stings (27). Dehghani showed that the venom from the H. lepturus scorpion causes an increase in WBC count (30). The results of hematology tests and urine analyses in this case were similar to the above results. The results of this report showed that, when people are stung by Hemiscorpius scorpions, their laboratory test results change, including the results associated with hematology, biochemistry, and urine analysis. Therefore these tests can be useful in the early detection and treatment of victims. Anti-venom therapy is an available method for treating scorpion envenomation in Iran. The specific anti-venin made by the Razi Vaccine and Serum Research Institute is a polyvalent antivenom (5-ml ampoule) against six species of scorpions, i.e., H. lepturus, Androctonus crassicauda, Mesobuthus eupeus, Odonthobothus doriae, Hottentotta saulcyi and Hottentotta zagrozensis (31). In Iran, the current treatment of patients who have been stung by H. lepturus is the intravenous (IV) or intramuscular (IM) injection of anti-venom (12). The specific polyvalent anti-venom injection as early as possible after the sting is fundamentally important with respect to the effectiveness of the anti-venom (19). In severe cases following envenomation, death can occur as a result of delaying the administration of the anti-venom, especially in children and elderly patients (32).

Conclusions

The venom of H. acanthocercus such as H. lepturus venom represents serious clinical Symptom such as hemoglobinuria, proteinuria, hematuria, hemolysis of blood cells and increased creatinine excretion. Therefore the venom of H. acanthocercus had severe effects on the blood and kidneys. These toxic effects may be fatal for children. Urine analysis, hematology and biochemistry data are the most important factors in the follow-up of scorpion victims. This report showed that the anemia and hemoglobinuria in patients who stung by Hemiscorpius scorpions should be considered. Finally, the results of this report indicate that H. acanthocercus is one of the most dangerous scorpions in south of Iran. Further studies are recommended due to lack of sufficient information on the toxicology of these scorpions done.