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SCORPIONS

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) This management deals with general or unknown stings from scorpions, as well as stings from certain specific scorpions. The most common stinging scorpions in the United States are members of the genera Vejovis, Hadrurus, Androctonus, and Centruroides. Only the Centruroides is a serious medical problem.
    B) There are at least 650 types of scorpions, divided into 6 families. In the United States, the dangerous family is the Buthidae, which contains the Centruroides species (Likes et al, 1984).

Specific Substances

    A) C. EXILICAUDA
    1) C. sculpturatus
    2) C. ertschi
    3) Bark scorpion
    4) Yellow scorpion
    5) Whip scorpion
    6) Lethal scorpion
    CERCOPHONIUS
    1) Cercophonius squama
    EUSCORPIIDAE
    1) Euscorpius carpathicus
    2) Euscorpius candiota
    3) Small wood scorpions
    HADRURUS HIRSUTUS (WOOD)
    1) Giant Hairy Scorpion
    HETEROMETRUS
    1) Heterometrus bengalensis (CL Koch)
    ISOMETROIDES
    1) Isometroides vescus
    ISOMETRUS
    1) Isometrus acanthurus
    2) Isometrus assamensis
    3) Isometrus basilicus
    4) Isometrus besucheti
    5) Isometrus brachycentrus
    6) Isometrus corbeti
    7) Isometrus fomosus
    8) Isometrus heimi
    9) Isometrus isadensis
    10) Isometrus krasenskyi
    11) Isometrus kurkai
    12) Isometrus maculatus
    13) Isometrus melanodactylus
    14) Isometrus navaiae
    15) Isometrus rigidulus
    16) Isometrus sankeriensis
    17) Isometrus thurstoni
    18) Isometrus thwaitesi
    19) Isometrus vittatus
    20) Isometrus zideki
    LYCHAS
    1) Lychas marmoreus
    2) Lychas variatus
    PARUROCTONUS
    1) Paruroctonus boreus
    2) Northern scorpion
    URODACUS
    1) Urodacus armatus
    2) Urodacus novaehollandiae
    3) Urodacus planimanus
    GENERAL TERMS
    1) Scorpion
    2) Scorpion sting

Available Forms Sources

    A) FORMS
    1) ARIZONA: There are over 20 species of scorpions found in Arizona (Likes et al, 1984). Stahnke (1971) estimates that over 2500 people are stung by scorpions in Arizona each year (Stahnke, 1971). Over one 10 month period, there were 1553 cases of scorpionism treated in this state (Stahnke, 1950). Sixty-four deaths were recorded in the 20 years between 1929 and 1948 (Stahnke, 1950).
    2) CALIFORNIA: There are at least 37 species of scorpions, which belong to 7 genera of 3 families found in California (Russell & Madon, 1984). In California, the Centruroides species C exilicauda is concentrated in its distribution to the land bordering the Colorado River, except when specimens are inadvertently transported to other sites (such as residential areas of Los Angeles, Riverside, or Orange County) (Russell & Madon, 1984).
    3) ALBERTA: The northern scorpion (Paruroctonus boreus) is found in 12 states in the US (from northern Arizona to southwestern California) and Alberta, Canada. It is purportedly the only species of true scorpion found in Canada (Johnson, 2004).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) DEFINITION: Scorpions are the oldest and most primitive members of the terrestrial arachnids. They sting, but do not bite. They are found in warm climates throughout the world.
    B) TOXICOLOGY: Scorpion venoms are complex and the components are species specific. They can include phospholipase, acetylcholinesterase, hyaluronidase, serotonin and neurotoxins.
    C) EPIDEMIOLOGY: It is estimated that over 100,000 medically significant scorpion stings occur annually, primarily in the tropics and North Africa. Serious envenomation is generally limited to young children.
    D) WITH POISONING/EXPOSURE
    1) Most of the medically important scorpions belong to the family Buthidae. Clinical manifestations vary with the specific species.
    2) THE AMERICAS
    a) CENTRUROIDES SPECIES: Found in the US, Mexico, Central America and the West Indies. Sympathetic effects include increased heart rate and blood pressure, hyperglycemia, dilated pupils, piloerection, sweating, and hypertension. Parasympathetic effects include salivation, tearing, urination, defecation, bradycardia, hypertension, and gastric distension. Other effects include pain, hyperactivity, restlessness, paresthesias, hyperesthesia near the sting site, respiratory difficulties, increased secretions, stridor, irritability, prosthotonos and opisthotonos accompanied by muscle twitching, fasciculations, roving eye movements, blurred vision, difficulty swallowing, slurred speech, dysrhythmias, and nystagmus. In severe cases, respiratory failure may develop. Effects are most severe in infants and toddlers. See the SCORPIONS-CENTRUROIDES SPECIES management for further information.
    b) TITYUS: Found throughout South America except Chile. Local effects include pain, erythema, edema and burning. Common clinical effects in cases of human envenomation include local pain, vomiting, headache, dizziness, diaphoresis, agitation, tachypnea, tachycardia, somnolence, hyperglycemia, and leukocytosis. Less common effects include hypertension, pulmonary edema, dysrhythmias, hyperthermia, cardiac failure, confusion, seizures, and hyperamylasemia. Children under age 10 are more likely to develop systemic envenomation. See the SCORPIONS-TITYUS management for more information.
    3) THE MIDDLE EAST AND AFRICA
    a) ANDROCTONUS SPECIES: Native to North Africa. A australis, is responsible for about 80% of the accidents and 95% of the deaths. Clinical effects reported with A crassicauda envenomation include pain, tachycardia, tachypnea, agitation, irritability, seizures, coma, salivation, diaphoresis, vomiting, hypotension, leukocytosis, hyponatremia, and elevated serum amylase, creatine phosphokinase, and lactate dehydrogenase. Pulmonary edema may develop in severe cases. See the SCORPIONS-ANDROCTONUS SPECIES management for further information.
    b) LEIURUS QUINQUESTRIATUS: Native to the Middle East. Sympathetic effects include increased heart rate, hypertension, dilated pupils, and sweating. Parasympathetic effects include bradycardia, excessive secretions (like tearing), priapism, constricted pupils, and hypotension. CNS effects that may be seen are coma, seizures, hyperpyrexia, agitation, and restlessness. Other effects reported include paresthesias (local and generalized), hypothermia, fever, tachypnea, lethargy, irritability, vomiting, abdominal pain, ventricular dysrhythmias, respiratory failure, hematemesis, seizures, coma, hyperglycemia, pancreatitis, pulmonary edema, and cardiogenic shock. Systemic envenomation is most common in children.
    c) GROSPHUS SPECIES: Native to Madagascar. Little clinical information, but can cause pain, swelling, paresthesias, hyperventilation, lacrimation, sweating, and dysphagia.
    d) PARABUTHUS SPECIES: Found in southern Africa. Causes local pain, can cause hypersalivation, sweating, subjective neurologic complaints and in severe cases pulmonary edema.
    4) ASIA
    a) BUTHUS TAMULUS: Native to India. Common clinical findings include tachycardia, sweating, pain at the sting site, dysrhythmias, mydriasis, vomiting, breathlessness, priapism, and pulmonary edema.
    b) HETEROMETRUS BENGALENSIS: Native of eastern India, especially around West Bengal. This scorpion produced an irreversible neuromuscular blockade in animals. Deaths have been reported in infants and children stung by this scorpion.
    c) MESOBUTHUS TAMULUS: Native to India. Causes initial transient cholinergic stimulation followed by prolonged adrenergic hyperactivity. Tachycardia, local pain, paresthesias and hypertension are common. Bradycardia, vomiting, diaphoresis, excessive salivation, hemoptysis, prolonged QRS and QTc intervals, and ST and T wave changes have also been reported. Pulmonary edema and hypotension can develop in severe cases. See the SCORPIONS-MESOBUTHUS TAMULUS management for further information.
    d) PALAMNAEUS SPECIES: Native to India. May cause local pain, paresthesias, signs of mild autonomic nervous system excitation, pulmonary infiltrates, eosinophilia, excessive salivation, nausea, perspiration, malaise, and mild hypotension.
    5) AUSTRALIA
    a) CERCOPHONIUS SQUAMA: Native to Australia. Causes primarily local pain; can also cause nausea, headache, and malaise.
    b) ISOMETROIDES SPECIES: Native to Australia. Little clinical data, appears to cause local pain only.
    c) LYCHUS SPECIES: Native to Australia. Causes severe pain, may also cause nausea, headache, and malaise.
    d) URODACUS SPECIES: Native to Australia. Little clinical data, but appears to cause only local pain.
    0.2.5) CARDIOVASCULAR
    A) WITH POISONING/EXPOSURE
    1) Tachycardia and hypertension are common with most species. Bradycardia, hypotension, dysrhythmias, left ventricular dysfunction, cardiomyopathy, and ECG changes are less common but occur with species from Northern Africa, the Middle East, and India.
    0.2.6) RESPIRATORY
    A) WITH POISONING/EXPOSURE
    1) Respiratory distress and insufficiency may develop with most species secondary to increased secretions, CNS depression, and neuromuscular effects. Pulmonary edema may occur with North African, Indian, and Middle Eastern species.
    0.2.7) NEUROLOGIC
    A) WITH POISONING/EXPOSURE
    1) Agitation, movement disorders, CNS depression, and paresthesias are common with most species. Fasciculations, nystagmus, and slurred speech are common with Centruroides stings. Seizures may occur with species from Brazil, Northern Africa, the Middle East, and India.
    0.2.8) GASTROINTESTINAL
    A) WITH POISONING/EXPOSURE
    1) Nausea, vomiting, and excessive salivation are common with most species. Pancreatitis may develop with species from Northern Africa, the Middle East, and Brazil.
    0.2.10) GENITOURINARY
    A) WITH POISONING/EXPOSURE
    1) Priapism has been reported with Leiurus stings.
    0.2.14) DERMATOLOGIC
    A) WITH POISONING/EXPOSURE
    1) Diaphoresis develops with most species.
    0.2.15) MUSCULOSKELETAL
    A) WITH POISONING/EXPOSURE
    1) Local pain is common with most scorpion stings.
    0.2.16) ENDOCRINE
    A) WITH POISONING/EXPOSURE
    1) Hyperglycemia is common with most species.

Laboratory Monitoring

    A) Monitor blood pressure, ECG, heart rate, and respiratory status. Monitor electrolytes in patients with clinical evidence of dehydration. If Leiurus quinquestriatus or Tityus serrulatus envenomation is suspected, or there is clinical suspicion of pancreatitis, monitor blood glucose and serum amylase.

Treatment Overview

    0.4.7) BITES/STINGS
    A) SUMMARY
    1) MILD TO MODERATE ENVENOMATION: Administer opioids for pain control. Treat agitation with benzodiazepines.
    2) SEVERE ENVENOMATION: Monitor vital signs and mental status carefully. Administer antivenom if available. Administer oxygen. Pulmonary edema may develop; dry excessive secretions with atropine. Treat severe hypertension with nitroglycerine or nitroprusside. Treat agitation or seizures with benzodiazepines.
    B) AIRWAY MANAGEMENT
    1) Endotracheal intubation may be necessary in patients with excessive secretions and respiratory distress, severe pulmonary edema or those requiring sedation for psychomotor agitation.
    C) HYPERTENSIVE EPISODE
    1) Monitor vital signs regularly. For mild/moderate asymptomatic hypertension (no end organ damage), pharmacologic treatment is generally not necessary. For severe hypertension nitroprusside or nitroglycerin may be used. Labetalol and phentolamine are alternatives. Prazosin has also been used successfully for severe hypertension induced by scorpion sting.
    D) PSYCHOMOTOR AGITATION
    1) May be treated with IV benzodiazepines, monitor carefully for respiratory depression.
    E) CHOLINERGIC CRISIS
    1) Administer atropine to dry excessive secretions.
    F) PULMONARY EDEMA
    1) Treat with oxygen and nitroglycerin. Bilevel positive airway pressure or endotracheal intubation may be necessary in severe cases.
    G) HYPOTENSIVE EPISODE
    1) Infuse 10 to 20 mL/kg isotonic fluid. If hypotension persists, administer dopamine (5 to 20 mcg/kg/min) or norepinephrine (ADULT: Begin infusion at 0.5 to 1 mcg/min; CHILD: Begin infusion at 0.1 mcg/kg/min); titrate to desired response. Add dobutamine if there is evidence of left ventricular failure, myocardial depression or cardiogenic shock.
    H) SEIZURE
    1) Administer a benzodiazepine IV: DIAZEPAM (ADULT: 5 to 10 mg, repeat every 10 to 15 min as needed. CHILD: 0.2 to 0.5 mg/kg, repeat every 5 min as needed) or LORAZEPAM (ADULT: 2 to 4 mg; CHILD: 0.05 to 0.1 mg/kg). Consider phenobarbital or propofol if seizures recur after diazepam 30 mg (adults) or 10 mg (children greater than 5 years). Monitor for hypotension, dysrhythmias, respiratory depression, and the need for endotracheal intubation. Evaluate for hypoglycemia, electrolyte disturbances, and hypoxia.
    I) ANTIVENOM
    1) Antivenoms are available for some scorpion species. Efficacy has not been clearly established for many of them, and all carry a risk of acute and delayed allergic reactions.
    2) CENTRUROIDES SPECIES
    a) US: Centruroides (scorpion) Immune F(ab')2 (Anascorp(R)) is an equine-derived antivenom indicated for the treatment of patients with clinical signs of scorpion envenomation. Initiate treatment as soon as possible after envenomation. INITIAL DOSE: 3 vials: Reconstitute each vial with 5 mL of sterile normal saline. Combine the contents of all 3 reconstituted vials and further dilute to a total volume of 50 mL with sterile normal saline. Inspect solution; do NOT use if turbid. Infuse over 10 minutes. Monitor patient closely for up to 60 min after completion of the infusion for evidence of clinical improvement. ADDITIONAL DOSING: Infuse 1 vial at a time at 30 to 60 minute intervals. Reconstitute the vial as described above. Infuse over 10 minutes. Monitor patient for up to 60 minutes for clinical improvement.
    b) MEXICO: One antivenom is available from Laboratorios BIOCLON SA. Usual dose 1 to 4 vials as an IV infusion or IM injection.
    c) See SCORPIONS-CENTRUROIDES SPECIES management for further information.
    3) LEIURUS SPECIES
    a) SAUDI ARABIA: An antivenom to Leiurus quinquestriatus is available in Saudi Arabia. The manufacturer's recommended dose is 1 mL ampule subQ, IM or IV. One study found that doses of 5 to 20 mL as an IV infusion were needed to control venom effects.
    b) ISRAEL: An antivenom to Leiurus quinquestriatus is available from Hebrew University in Jerusalem. Usual dose is 5 to 15 mL diluted in 5% dextrose and 0.33% sodium chloride and given as an IV infusion. In 1 study, children who received antivenom did no better than those who did not.
    c) EGYPT: A polyvalent anti-scorpion serum is available and has been used.
    4) MESOBUTHUS TAMULUS
    a) ANTIVENOM: Anti-scorpion venom serum (AScVS) produced as a F(ab')2 fraction from Haffkine Biopharma, Mumbai, India is available to treat M. tamulus envenomations. Each vial is diluted in 10 mL distilled water and administrated by slow (5 to 7 minutes) intravenous injection; the dose (approximately 2 to 8 vials) is dependent on the clinical symptoms present and age of the patient. Signs of recover may noted within an hour of scorpion antivenom therapy.
    5) TITYUS SPECIES
    a) BRAZIL: A Fab2 antivenom to Tityus serrulatus is available from FUNED, Belo Horizonte, Brazil. Usual dose is 20 mL as an intravenous infusion.
    J) PRIAPISM
    1) Priapism has been reported in male children envenomated by Leirus scorpions. Priapism has also occurred following envenomation by Androctonus australis and Buthus occitanus scorpions.
    2) An immediate urological consult is necessary. Clinical history should include the use of other agents (ie, antihypertensives, antidepressants, illegal agents) that may also be contributing to priapism. In a patient with ischemic priapism the corpora cavernosa are often completely rigid and the patient complains of pain, while nonischemic priapism the corpora are typically tumescent, but not completely rigid and pain is not typical. Aspirate blood from the corpus cavernosum with a fine needle. Blood gas testing of the aspirated blood may be used to distinguish ischemic (typically PO2 less than 30 mmHg, PCO2 greater than 60 mmHg, and pH less than 7.25) and nonischemic priapism. Color duplex ultrasonography may also be useful. If priapism persists after aspiration, inject a sympathomimetic. PHENYLEPHRINE: Dose: Adult: For intracavernous injection, dilute phenylephrine with normal saline for a concentration of 100 to 500 mcg/mL and give 1 mL injections every 3 to 5 minutes for approximately 1 hour (before deciding that treatment is not successful). For children and patients with cardiovascular disease: Use lower concentrations in smaller volumes. NOTE: Treatment is less likely to be effective if done more than 48 hours after the development of priapism. Distal shunting (NOT first-line therapy) should only be considered after a trial of intracavernous injection of sympathomimetics.
    K) PATIENT DISPOSITION
    1) HOME CRITERIA: Healthy adults and children older than 5 years with local symptoms of a scorpion sting can usually be managed at home (with telephone follow-up) with ice at the site and other supportive measures for pain relief.
    2) OBSERVATION CRITERIA: Any patient with systemic effects and children younger than 5 years should be referred to a medical facility for evaluation. Children are more likely to develop signs and symptoms of severe envenomation following a scorpion sting.
    3) ADMISSION CRITERIA: Patients with symptoms of systemic envenomation should be admitted and may require intensive supportive care including intubation and ventilation and aggressive management including antivenom if available and other therapies to maintain cardiac output, stabilize hemodynamic function or treat pulmonary edema.
    4) CONSULT CRITERIA: A clinician skilled in the management of scorpion envenomations should be involved in the care of severely envenomated patients. A regional center should also be consulted in such cases.
    L) PREDISPOSING CONDITIONS
    1) The very young (ie, infants and toddlers) and those with underlying disease predispose individuals to more severe outcomes.
    M) PITFALLS
    1) Monitor airway carefully in patients with systemic manifestations who are treated with opioids, benzodiazepines, or other sedating agents.
    N) DIFFERENTIAL DIAGNOSIS
    1) It may be difficult to obtain an accurate history in young children or in patients who collapse secondary to underlying conditions or seizures. An envenomation may produce symptoms similar to an anaphylactic reaction, a primary seizure disorder or an overdose of a sympathomimetic or cholinergic agent. Attempt to find the site of scorpion sting. It will likely appear as a punctuate red mark surrounded by a small area of blanching and very tender to touch. The typical clinical presentation in very young children in endemic areas may include sympathetic or parasympathetic activity, severe agitation, along with a negative toxicology screen can assist with making the diagnosis.

Range Of Toxicity

    A) A single scorpion sting may be fatal for a child or debilitated or hypertensive adult. Although scorpion stings that produced fatalities were not uncommon years ago, good supportive care has made this a rare outcome.

Clinical Effects

Summary Of Exposure

    A) DEFINITION: Scorpions are the oldest and most primitive members of the terrestrial arachnids. They sting, but do not bite. They are found in warm climates throughout the world.
    B) TOXICOLOGY: Scorpion venoms are complex and the components are species specific. They can include phospholipase, acetylcholinesterase, hyaluronidase, serotonin and neurotoxins.
    C) EPIDEMIOLOGY: It is estimated that over 100,000 medically significant scorpion stings occur annually, primarily in the tropics and North Africa. Serious envenomation is generally limited to young children.
    D) WITH POISONING/EXPOSURE
    1) Most of the medically important scorpions belong to the family Buthidae. Clinical manifestations vary with the specific species.
    2) THE AMERICAS
    a) CENTRUROIDES SPECIES: Found in the US, Mexico, Central America and the West Indies. Sympathetic effects include increased heart rate and blood pressure, hyperglycemia, dilated pupils, piloerection, sweating, and hypertension. Parasympathetic effects include salivation, tearing, urination, defecation, bradycardia, hypertension, and gastric distension. Other effects include pain, hyperactivity, restlessness, paresthesias, hyperesthesia near the sting site, respiratory difficulties, increased secretions, stridor, irritability, prosthotonos and opisthotonos accompanied by muscle twitching, fasciculations, roving eye movements, blurred vision, difficulty swallowing, slurred speech, dysrhythmias, and nystagmus. In severe cases, respiratory failure may develop. Effects are most severe in infants and toddlers. See the SCORPIONS-CENTRUROIDES SPECIES management for further information.
    b) TITYUS: Found throughout South America except Chile. Local effects include pain, erythema, edema and burning. Common clinical effects in cases of human envenomation include local pain, vomiting, headache, dizziness, diaphoresis, agitation, tachypnea, tachycardia, somnolence, hyperglycemia, and leukocytosis. Less common effects include hypertension, pulmonary edema, dysrhythmias, hyperthermia, cardiac failure, confusion, seizures, and hyperamylasemia. Children under age 10 are more likely to develop systemic envenomation. See the SCORPIONS-TITYUS management for more information.
    3) THE MIDDLE EAST AND AFRICA
    a) ANDROCTONUS SPECIES: Native to North Africa. A australis, is responsible for about 80% of the accidents and 95% of the deaths. Clinical effects reported with A crassicauda envenomation include pain, tachycardia, tachypnea, agitation, irritability, seizures, coma, salivation, diaphoresis, vomiting, hypotension, leukocytosis, hyponatremia, and elevated serum amylase, creatine phosphokinase, and lactate dehydrogenase. Pulmonary edema may develop in severe cases. See the SCORPIONS-ANDROCTONUS SPECIES management for further information.
    b) LEIURUS QUINQUESTRIATUS: Native to the Middle East. Sympathetic effects include increased heart rate, hypertension, dilated pupils, and sweating. Parasympathetic effects include bradycardia, excessive secretions (like tearing), priapism, constricted pupils, and hypotension. CNS effects that may be seen are coma, seizures, hyperpyrexia, agitation, and restlessness. Other effects reported include paresthesias (local and generalized), hypothermia, fever, tachypnea, lethargy, irritability, vomiting, abdominal pain, ventricular dysrhythmias, respiratory failure, hematemesis, seizures, coma, hyperglycemia, pancreatitis, pulmonary edema, and cardiogenic shock. Systemic envenomation is most common in children.
    c) GROSPHUS SPECIES: Native to Madagascar. Little clinical information, but can cause pain, swelling, paresthesias, hyperventilation, lacrimation, sweating, and dysphagia.
    d) PARABUTHUS SPECIES: Found in southern Africa. Causes local pain, can cause hypersalivation, sweating, subjective neurologic complaints and in severe cases pulmonary edema.
    4) ASIA
    a) BUTHUS TAMULUS: Native to India. Common clinical findings include tachycardia, sweating, pain at the sting site, dysrhythmias, mydriasis, vomiting, breathlessness, priapism, and pulmonary edema.
    b) HETEROMETRUS BENGALENSIS: Native of eastern India, especially around West Bengal. This scorpion produced an irreversible neuromuscular blockade in animals. Deaths have been reported in infants and children stung by this scorpion.
    c) MESOBUTHUS TAMULUS: Native to India. Causes initial transient cholinergic stimulation followed by prolonged adrenergic hyperactivity. Tachycardia, local pain, paresthesias and hypertension are common. Bradycardia, vomiting, diaphoresis, excessive salivation, hemoptysis, prolonged QRS and QTc intervals, and ST and T wave changes have also been reported. Pulmonary edema and hypotension can develop in severe cases. See the SCORPIONS-MESOBUTHUS TAMULUS management for further information.
    d) PALAMNAEUS SPECIES: Native to India. May cause local pain, paresthesias, signs of mild autonomic nervous system excitation, pulmonary infiltrates, eosinophilia, excessive salivation, nausea, perspiration, malaise, and mild hypotension.
    5) AUSTRALIA
    a) CERCOPHONIUS SQUAMA: Native to Australia. Causes primarily local pain; can also cause nausea, headache, and malaise.
    b) ISOMETROIDES SPECIES: Native to Australia. Little clinical data, appears to cause local pain only.
    c) LYCHUS SPECIES: Native to Australia. Causes severe pain, may also cause nausea, headache, and malaise.
    d) URODACUS SPECIES: Native to Australia. Little clinical data, but appears to cause only local pain.

Vital Signs

    3.3.3) TEMPERATURE
    A) WITH POISONING/EXPOSURE
    1) HYPOTHERMIA may occur after stings from the following species:
    a) LEIURUS QUINQUESTRIATUS
    1) A number of victims experienced hypothermia 48 hours after being stung (Ismail et al, 1990).
    2) In a series of 104 patients with L quinquestriatus sting, 33 developed hypothermia (Sofer et al, 1994).
    b) TITYUS SERRULATUS
    1) In a series of 168 children with severe T serrulatus envenomation, approximately 10% developed hypothermia (Freire-Maia et al, 1994).
    2) HYPERTHERMIA has been reported after stings from the following species:
    a) BUTHUS OCCITANUS
    1) Hyperthermia is an important diagnostic sign when evaluating stings from members of this species (Goyffon et al, 1982).
    b) LEIURUS QUINQUESTRIATUS
    1) Victims of stings by this scorpion have exhibited rectal temperatures above 41 degrees C (Amitai et al, 1985). Not all victims became hyperthermic (Ismail et al, 1990).
    c) TITYUS SERRULATUS
    1) In a series of 168 children with severe T serrulatus envenomation, approximately 15% developed hyperthermia (Freire-Maia et al, 1994).
    d) Hyperthermia was reported in 42.3% of the patients (n=951) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion (Bahloul et al, 2005).

Heent

    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) LACRIMATION has been reported after stings from the following species:
    a) GROSPHUS SPECIES
    1) A sting on the finger from Grosphus palpator caused excessive lacrimation (Wilson, 1987).
    2) MIOSIS AND MYDRIASIS: Bilateral miosis and bilateral mydriasis were reported in 4.5% and 1.7% of the patients (n=951) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The presence of miosis and mydriasis was associated with a poor outcome of the patient as demonstrated by the significant correlation between miosis and mydriasis and subsequent mortality (p less than 0.001) (Bahloul et al, 2005). The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion.
    3) SQUINT was reported in 12.5% of the patients (n=951) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion (Bahloul et al, 2005).
    4) ANISOCORIA was reported in 4 of 951 patients (0.4%) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion (Bahloul et al, 2005).

Cardiovascular

    3.5.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Tachycardia and hypertension are common with most species. Bradycardia, hypotension, dysrhythmias, left ventricular dysfunction, cardiomyopathy, and ECG changes are less common but occur with species from Northern Africa, the Middle East, and India.
    3.5.2) CLINICAL EFFECTS
    A) HYPOTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) LEIURUS SPECIES
    1) Children stung by Leiurus quinquestriatus who developed serious cardiovascular problems also developed hypotension. Blood pressure readings on admission were 80/50, 90/50, and 80/40 mmHg (Sofer & Gueron, 1988).
    2) In another study, late hypotension was seen after stings, and was refractory to dopamine infusions (Ismail et al, 1990).
    b) PALAMNAEUS SPECIES
    1) Mild hypotension was observed in a patient stung by Palamnaeus bengalensis (Shah et al, 1989).
    B) HYPERTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) LEIURUS SPECIES
    1) Children stung by Leiurus quinquestriatus who developed serious cardiovascular problems also developed hypertension. Blood pressure readings on admission were 140/90, 172/125, 150/110, 150/120, and 120/60 mmHg (Sofer & Gueron, 1988). The venom of Leiurus quinquestriatus has been shown to elevate plasma renin levels (LaGrange, 1977).
    2) In a series of 14 children stung by Leiurus quinquestriatus, 6 developed severe hypertension (Sofer et al, 1991).
    b) MESOBUTHUS SPECIES
    1) Hypertension was reported in 45% of 526 stings. Another 5% had hypertension and pulmonary edema (Bawaskar & Bawaskar, 1992b).
    2) In other series, hypertension developed in 29% to 38% of cases (Bawaskar & Bawaskar, 1992b; Bawaskar & Bawaskar, 1994).
    c) TITYUS SERRULATUS
    1) In 2 series of patients with severe T serrulatus envenomation, approximately 8% to 35% developed hypertension (De Rezende et al, 1995; Freire-Maia et al, 1994).
    C) CONDUCTION DISORDER OF THE HEART
    1) WITH POISONING/EXPOSURE
    a) LEIURUS SPECIES
    1) Four of 9 patients with serious respiratory difficulties after stings by Leiurus quinquestriatus developed cardiac dysrhythmias. All developed various degrees of atrioventricular (AV) block and premature ventricular contractions. One patient developed ventricular tachycardia and fibrillation, and another also had ventricular tachycardia. All showed electrocardiographic evidence of myocardial damage. Inverted T waves were seen in the precordial leads in 1 patient, while others showed changes in the S-T segments (Sofer & Gueron, 1988).
    2) In a series of 14 children stung by Leiurus quinquestriatus, 1 developed severe ventricular dysrhythmias and cardiorespiratory arrest (Sofer et al, 1991).
    3) In a series of 9 children with fatal Leiurus quinquestriatus stings, 7 developed asystole and 1 had ventricular fibrillation (Ismail et al, 1992). All had significant cardiovascular (tachycardia, hypertension, hypotension) or CNS (seizures, coma, agitation) manifestations prior to the onset of dysrhythmias.
    b) TITYUS SERRULATUS
    1) In a series of 168 children with severe T serrulatus envenomation, approximately 18% developed dysrhythmias, including ventricular ectopic beats, complete AV block, sinus arrest, and wandering pacemakers (Freire-Maia et al, 1994).
    2) In this series, approximately 5% of patients sustained cardiac arrest (Freire-Maia et al, 1994).
    D) CARDIOMYOPATHY
    1) WITH POISONING/EXPOSURE
    a) LEIURUS SPECIES
    1) A serial echocardiographic study was done on a 7-year-old girl who was stung by a Leiurus quinquestriatus. She initially had signs of myocarditis that improved in the first 24 hours. Fourteen echocardiograms and electrocardiograms done over the next 4 months showed a gradually thickening left ventricular wall (maximal on the 12th day) associated with subsequent gradual improvement in contractility. Four months after the sting, the left ventricular wall thickness and overall size had returned to normal (Brand et al, 1988).
    2) Four patients with dysrhythmias also had elevated cardiac enzymes after stings by Leiurus quinquestriatus. The CPK levels ranged between 277 and 3000 units/liter (normal less than 100 units/liter). SGOT levels were 64 to 240 units/liter (normal less than 40 units/liter) (Sofer & Gueron, 1988).
    b) TITYUS SERRULATUS
    1) Stings by this scorpion have produced reversible depressed left ventricular systolic function and mitral regurgitation. ECG patterns were consistent with acute myocardial infarction-like changes and lasted 24 hours (Amaral et al, 1991).
    E) TACHYARRHYTHMIA
    1) WITH POISONING/EXPOSURE
    a) LEIURUS SPECIES
    1) In a series of 14 children stung by Leiurus quinquestriatus, 2 developed tachycardia (Sofer et al, 1991).
    2) In a series of 104 patients with L quinquestriatus sting, 69 developed tachycardia (Sofer et al, 1994).
    b) MESOBUTHUS SPECIES
    1) Tachycardia was seen in 18% of 526 stings (Bawaskar & Bawaskar, 1992b).
    2) In other series, tachycardia developed in at least 10% of patients (Bawaskar & Bawaskar, 1992b; Bawaskar & Bawaskar, 1994).
    c) TITYUS SERRULATUS
    1) Sinus tachycardia was seen in all children studied by Amaral et al after Tityus serrulatus stings(Amaral et al, 1991).
    2) In 2 large series of patients with severe T serrulatus envenomation, approximately 50% to 75% developed tachycardia (Freire-Maia et al, 1994; De Rezende et al, 1995). .
    F) HEART FAILURE
    1) WITH POISONING/EXPOSURE
    a) Cardiac failure was reported in 77.5% of the patients (n=951) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion (Bahloul et al, 2005)
    b) LEIURUS/BUTHUS SPECIES
    1) In a series of 33 Saudi Arabian children with stings from Leiurus quinquestriatus or Buthus occitanus, 12 had evidence of compromised left ventricular function on echocardiography (Kumar et al, 1992).
    c) TITYUS SERRULATUS
    1) In a series of 168 children with severe T serrulatus envenomation, approximately 15% developed heart failure (Freire-Maia et al, 1994).
    G) BRADYCARDIA
    1) WITH POISONING/EXPOSURE
    a) LEIURUS SPECIES
    1) In a series of 104 patients with L quinquestriatus sting, 14 developed bradycardia (Sofer et al, 1994).
    b) MESOBUTHUS SPECIES
    1) In a series of 163 patients, bradycardia developed in 26% (Bawaskar & Bawaskar, 1992b; Bawaskar & Bawaskar, 1994).
    c) TITYUS SERRULATUS
    1) In a series of 168 children with severe T serrulatus envenomation, approximately 10% developed bradycardia (Freire-Maia et al, 1994).
    H) MYOCARDIAL INFARCTION
    1) WITH POISONING/EXPOSURE
    a) SPECIES UNIDENTIFIED/CASE REPORT: In Turkey, a 55-year-old man was stung by a scorpion (species not identified) while sleeping and he developed immediate localized pain of his right leg and flank. He also experienced vomiting and dizziness. He was admitted to the ED and treated for general pain and 2 hours later was transferred to the cardiology department for severe angina. An initial ECG showed a sinus rhythm with ST segment elevation in leads DII, DIII, aVF, and V6 and a transthoracic echocardiogram showed hypokinesia of the inferior and posterior walls with mild mitral regurgitation and a left ventricular ejection fraction of 42%. Findings were consistent with an acute inferior wall myocardial infarction. The patient was given scorpion antivenom and sent emergently to the catheterization laboratory; total occlusion of the left circumflex artery was found (all other arteries were normal). A thrombus was aspirated from the artery followed by antiplatelet (glycoprotein llb/llla inhibitor) therapy. A repeat study the following day showed normal coronary arteries with no restenosis and a normal ECG. By day 5, all symptoms resolved and the patient was discharged to home (Baykan et al, 2016).
    I) ELECTROCARDIOGRAM ABNORMAL
    1) WITH POISONING/EXPOSURE
    a) MESOBUTHUS SPECIES
    1) ECG changes reported in patients with mesobuthus tamulus stings include left anterior hemiblock, ST and T wave changes, QRS prolongation, QTC prolongation, and low voltage (Bawaskar & Bawaskar, 1992b; Bawaskar & Bawaskar, 1994).
    3.5.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) DYSRHYTHMIA
    a) The venom of Leiurus quinquestriatus, Buthus judaicus, and Androctonus amoreuxi were studied in animals. Researches found that the dysrhythmias and infarcts occurred at a time when the tissue concentration of the venom in the heart was very low, suggesting these cardiac abnormalities might be a result of indirect factors (Ismail & Abd-Elsalam, 1988).
    2) BRADYCARDIA
    a) BUTHUS SPECIES: The venom of Buthus occitanus was tested on isolated hearts. It induced initial bradycardia, then tachycardia, followed by a prolonged bradycardia that led to death. Although there was some direct action, much of the cardiac effect seemed to be mediated by stimulation of the autonomic nervous system with predominately sympathetic stimulation and release of catecholamines (Ismail et al, 1980b).

Respiratory

    3.6.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Respiratory distress and insufficiency may develop with most species secondary to increased secretions, CNS depression, and neuromuscular effects. Pulmonary edema may occur with North African, Indian, and Middle Eastern species.
    3.6.2) CLINICAL EFFECTS
    A) PULMONARY EDEMA
    1) WITH POISONING/EXPOSURE
    a) SUMMARY
    1) In Tunisia, the Androctonus australis and Buthus occitanus scorpions are likely to produce severe envenomation. Pulmonary edema is the most severe respiratory effect of envenomation and can be the leading cause of death. Although the exact mechanism is unknown, the development of acute left ventricular failure has been associated with severe envenomation including pulmonary edema. Clinical manifestations usually associated with pulmonary edema include: young age, tachypnea, diaphoresis from excess catecholamine release and from sympathic and parasympathic nervous system stimulation, agitation which may be associated with seizures and coma. In addition, pulmonary edema is often preceded by high blood pressure that may lead to the neurologic effects observed (Bahloul et al, 2013).
    2) Acute lung injury (pulmonary edema) was reported in 61.5% of the patients (n=951) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion (Bahloul et al, 2005).
    b) BITHUS SPECIES
    1) Over 50% of the patients in 1 case series of Bithus tamulus stings developed pulmonary edema (Gaitonde et al, 1978).
    c) LEIURUS SPECIES
    1) Five of 51 children stung by scorpions assumed in most cases to be Leiurus quinquestriatus developed pulmonary edema (Amitai et al, 1985). Three of 9 children who developed respiratory difficulties of some sort associated with stings by Leiurus quinquestriatus had pulmonary edema.
    a) One of these patients developed metabolic acidosis and died 4 days after admission to the hospital in shock (Sofer & Gueron, 1988).
    b) These authors demonstrated pulmonary hypertension and elevated capillary pressure in the envenomation of these children, suggesting that the pulmonary edema is cardiogenic in origin (Gueron et al, 1980; Gueron & Ovsyshcher, 1984; Gueron & Ovsyshcher, 1987).
    d) MESOBUTHUS SPECIES
    1) In 1 series, 27% of 526 stings had pulmonary edema, while another series reported hypertension in 5% of patients (Bawaskar, 1982). Pulmonary edema may be due to myocarditis. Onset is 0.5 to 10 hours post sting (Bawaskar, 1982).
    2) In other series, pulmonary edema developed in 9% to 18% of patients (Bawaskar & Bawaskar, 1992b; Bawaskar & Bawaskar, 1994).
    e) PARABUTUS SPECIES
    1) A 5-year-old girl died 1 hour after being stung by a scorpion in southern Africa that was identified as Parabutus granulosus. An autopsy revealed severe pulmonary edema with intra-alveolar hemorrhage (Peterson, 1987).
    f) TITYUS SPECIES
    1) Pulmonary edema developed in approximately 12% to 15% of patients with Tityus serrulatus envenomation in 2 series (Freire-Maia et al, 1994; De Rezende et al, 1995).
    B) APNEA
    1) WITH POISONING/EXPOSURE
    a) Respiratory failure was reported in 62.7% of the patients (n=951) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion (Bahloul et al, 2005).
    b) LEIURUS SPECIES
    1) Several children (9 of 61) stung by scorpions (assumed in most cases to be Leiurus quinquestriatus) developed respiratory difficulties.
    a) One of the 9 developed cardiopulmonary arrest, 3 had cardiovascular failure associated with pulmonary edema and cardiac dysrhythmias, 1 was bradypneic with an inspiratory stridor and wheezing, and 4 were deeply CNS depressed with cyanosis, dyspnea, and/or a gasping breathing pattern (Sofer & Gueron, 1988).
    2) In a series of 104 patients with Leiurus quinquestriatus envenomation, 15 developed respiratory failure (Sofer et al, 1994). In 13, this was due to coma with respiratory depression, and in 2 to subglottic edema.
    3) Cyanosis may also be seen (Sofer & Gueron, 1988; Elitsur et al, 1984).
    C) HYPERVENTILATION
    1) WITH POISONING/EXPOSURE
    a) TITYUS SPECIES
    1) Tachypnea is common after Tityus serrulatus sting, occurring in approximately 55% to 75% of patients in 2 series (Freire-Maia et al, 1994; De Rezende et al, 1995).
    D) PNEUMONITIS
    1) WITH POISONING/EXPOSURE
    a) PALAMNAEUS SPECIES
    1) Pulmonary infiltrates with peripheral eosinophilia was noted in a man stung by Palamnaeus bengalensis. This was thought to be a manifestation of an allergic reaction (Shah et al, 1989).

Neurologic

    3.7.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Agitation, movement disorders, CNS depression, and paresthesias are common with most species. Fasciculations, nystagmus, and slurred speech are common with Centruroides stings. Seizures may occur with species from Brazil, Northern Africa, the Middle East, and India.
    3.7.2) CLINICAL EFFECTS
    A) PSYCHOMOTOR AGITATION
    1) WITH POISONING/EXPOSURE
    a) Agitation was reported in 74.6% of the patients (n=951) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion (Bahloul et al, 2005).
    b) LEIURUS SPECIES
    1) Children stung by Leiurus quinquestriatus showed signs of agitation and confusion on admission to the hospital (Sofer & Gueron, 1988).
    2) In a series of 14 children stung by Leiurus quinquestriatus, 10 developed agitation (Sofer et al, 1991).
    3) In another series of 104 patients, 93 (89%) developed restlessness (Sofer et al, 1994).
    c) TITYUS SPECIES
    1) In 2 large series of patients with Tityus serrulatus envenomation, 35% to 65% developed restlessness or agitation (Freire-Maia et al, 1994; De Rezende et al, 1995).
    B) HEADACHE
    1) WITH POISONING/EXPOSURE
    a) According to a prospective study involving Australian scorpion stings in 95 patients, minor systemic effects, including nausea, headache, and malaise, were reported in 11% of the patients (Isbister et al, 2003).
    C) CENTRAL NERVOUS SYSTEM DEFICIT
    1) WITH POISONING/EXPOSURE
    a) According to a prospective study involving Australian scorpion stings in 95 patients, minor systemic effects, including nausea, headache, and malaise, were reported in 11% of the patients (Isbister et al, 2003).
    b) A retrospective study was conducted, involving 951 patients admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. Impaired consciousness (Glasgow coma score [GCS] of 14 or less) and coma (GCS of 12 or less) were reported in 21.9% and 15.4% of the patients, respectively. There also appeared to be a significant correlation between the presence of coma (GCS of 12 or less) and the young age of the patients (p less than 0.001), the development of hyperthermia (p less than 0.05), seizures (p less than 0.001), pulmonary edema (p less than 0.001), liver failure (p less than 0.001), cardiac failure (p less than 0.001), respiratory failure (p less than 0.001), and subsequent mortality (p less than 0.0001) (Bahloul et al, 2005). In this study, the species of scorpion involved was not identified; however, it is believed that the 2 groups of patients (those with or without neurological manifestations) were envenomed by 2 or more different scorpion species. In Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion.
    c) LEIURUS SPECIES
    1) Several patients stung by Leiurus quinquestriatus developed CNS depression, including malaise, stupor, lethargy, and coma (Sofer & Gueron, 1988; Elitsur et al, 1984).
    2) In a series of 14 children stung by Leiurus quinquestriatus, 6 developed stupor or somnolence (Sofer et al, 1991).
    3) In another series of 104 patients, 37 (35%) developed a decreased level of consciousness (Sofer et al, 1994).
    d) TITYUS SPECIES
    1) In a series of 168 patients with Tityus serrulatus envenomation, approximately 25% developed somnolence (Freire-Maia et al, 1994).
    D) PARESTHESIA
    1) WITH POISONING/EXPOSURE
    a) According to a prospective study involving Australian scorpion stings in 95 patients, paresthesias and numbness were reported in 11% and 12% of the patients, respectively (Isbister et al, 2003)
    b) GROSPHUS SPECIES
    1) A sting on the right index finger by Groshus palpator caused paresthesias of both hands and feet. Swallowing was like "swallowing hot pins and needles" (Wilson, 1987).
    c) LEIURUS SPECIES
    1) In a series of 22 patients with Leiurus quinquestriatus sting, 11 (50%) had local paresthesias and 4 had widespread paresthesias (Bogomolski-Yahalom et al, 1995).
    d) PALAMNAEUS SPECIES
    1) A sting on the foot of a man caused severe local pain and paresthesias all over his body (Shah et al, 1989).
    E) SEIZURE
    1) WITH POISONING/EXPOSURE
    a) Seizures were reported in 5.9% of the patients (n=951) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The presence of seizures was associated with a poor outcome of the patient as demonstrated by the significant correlation between seizures and subsequent mortality (p less than 0.001) (Bahloul et al, 2005). The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion.
    b) LEIURUS SPECIES
    1) Seizures were seen in 5 of 51 children stung by scorpions (assumed in most cases to be Leiurus quinquestriatus) (Amitai et al, 1985).
    2) Out of 9 children with fatal Leiurus quinquestriatus envenomation, 5 developed seizures and 1 exhibited extreme agitation (Ismail et al, 1992).
    c) BUTHUS JUDAICUS
    1) A 10-month-old infant stung on 3 different sites by this species had generalized seizures (Amitai et al, 1984).
    d) TITYUS SPECIES
    1) In a series of 168 patients with Tityus serrulatus envenomation, approximately 5% developed seizures (Freire-Maia et al, 1994).
    F) NEUROLOGICAL FINDING
    1) WITH POISONING/EXPOSURE
    a) A retrospective study was conducted, involving 951 patients admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. Brain CT scans were performed on 10 patients. The CT scans revealed brain ischemia in 5 patients, brain edema in 2 patients, and brain atrophy in 2 patients (Bahloul et al, 2005).
    G) DISORDER OF AUTONOMIC NERVOUS SYSTEM
    1) WITH POISONING/EXPOSURE
    a) PALAMNAEUS SPECIES
    1) Signs and symptoms of mild autonomic nervous system excitation were noted after a sting by Palamnaeus bengalensis (Shah et al, 1989).
    H) CEREBRAL HEMORRHAGE
    1) WITH POISONING/EXPOSURE
    a) UNIDENTIFIED
    1) Intracerebral hemorrhage is a rare effect. It was reported in an adult after a sting of an unidentified scorpion. The patient also had hypertension (160/110 mmHg) immediately after the sting, and a BP of 140/96 mmHg approximately 30 minutes after the sting (Rai et al, 1990).
    I) CEREBRAL ARTERY OCCLUSION
    1) WITH POISONING/EXPOSURE
    a) LEIURUS SPECIES
    1) One child stung by a Leiurus quinquestriatus developed several brain infarcts observed by CT scan. Seven days after the sting he developed a right popliteal artery occlusion necessitating the amputation of his right lower leg (Sofer & Gueron, 1988).
    J) DYSKINESIA
    1) WITH POISONING/EXPOSURE
    a) PARABUTHUS SPECIES
    1) A 17-year-old stung by this species developed severe muscle weakness in the extremities, with increased rigidity of the abdominal wall and opisthotonus (Smith et al, 1983).
    K) HALLUCINATIONS
    1) WITH POISONING/EXPOSURE
    a) LEIURUS SPECIES
    1) A 7-year-old boy who was stung on the eyelid was seen in the emergency department about 24 hours postenvenomation. He was confused and hallucinating (Elitsur et al, 1984).
    L) MYOCLONUS
    1) WITH POISONING/EXPOSURE
    a) Myoclonus was reported in 11.2% of the patients (n=951) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The presence of myoclonus was associated with a poor outcome of the patient as demonstrated by the significant correlation between myoclonus and subsequent mortality (p =0.05) (Bahloul et al, 2005). The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion.
    3.7.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) PARALYSIS FLACCID
    a) Heterometrus bengalensis: This scorpion of eastern India has toxin-Hb in its venom. This is a toxic antigenic protein that produces irreversible neuromuscular blockade (Dasgupta et al, 1990).

Gastrointestinal

    3.8.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Nausea, vomiting, and excessive salivation are common with most species. Pancreatitis may develop with species from Northern Africa, the Middle East, and Brazil.
    3.8.2) CLINICAL EFFECTS
    A) NAUSEA AND VOMITING
    1) WITH POISONING/EXPOSURE
    a) According to a prospective study involving Australian scorpion stings in 95 patients, minor systemic effects, including nausea, headache, and malaise, were reported in 11% of the patients (Isbister et al, 2003).
    b) LEIURUS SPECIES
    1) Vomiting was seen in children stung by Leiurus quinquestriatus (Sofer & Gueron, 1988; Amitai et al, 1985).
    2) In a series of 14 patients with Leiurus quinquestriatus envenomation, 7 developed vomiting and 1 of these developed severe hematemesis (Sofer et al, 1991).
    3) In another series of 104 patients, 74 (71%) developed vomiting (Sofer et al, 1994).
    c) PALAMNAEUS SPECIES
    1) Nausea developed in the case of a man stung by Palamnaeus bengalensis (Shah et al, 1989).
    d) TITYUS SPECIES
    1) In 2 large series of patients with Tityus serrulatus envenomation, approximately 85% to 95% developed vomiting (Freire-Maia et al, 1994; De Rezende et al, 1995).
    B) EXCESSIVE SALIVATION
    1) WITH POISONING/EXPOSURE
    a) LEIURUS SPECIES
    1) In a series of 104 children with Leiurus quinquestriatus envenomation, 99 (95%) developed excessive secretions and sweating (Sofer et al, 1994).
    C) PANCREATITIS
    1) WITH POISONING/EXPOSURE
    a) LEIURUS QUINQUESTRIATUS
    1) Signs of acute pancreatitis were seen in 13 of 14 children stung by this scorpion (Sofer et al, 1991).
    b) TITYUS SPECIES
    1) In a series of 18 patients with Tityus serrulatus envenomation, approximately 22% developed hyperamylasemia (De Rezende et al, 1995).

Genitourinary

    3.10.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Priapism has been reported with Leiurus stings.
    3.10.2) CLINICAL EFFECTS
    A) PRIAPISM
    1) WITH POISONING/EXPOSURE
    a) Priapism was reported in 72.2% of the patients (n=951) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australis scorpion or the Buthus occitanus scorpion (Bahloul et al, 2005).
    b) LEIURUS SPECIES
    1) Children stung by Leiurus quinquestriatus have developed priapism (Amitai et al, 1985; Sofer & Gueron, 1988; Bogomolski-Yahalom et al, 1995).
    2) In a series of 59 male children with Leiurus quinquestriatus envenomation, 53 (89%) developed priapism (Sofer et al, 1994).

Acid-Base

    3.11.2) CLINICAL EFFECTS
    A) ACIDOSIS
    1) WITH POISONING/EXPOSURE
    a) LEIURUS SPECIES
    1) Acidosis was common in a series of 104 children with Leiurus quinquestriatus envenomation (Sofer et al, 1994).

Hematologic

    3.13.2) CLINICAL EFFECTS
    A) LEUKOCYTOSIS
    1) WITH POISONING/EXPOSURE
    a) TITYUS SPECIES
    1) In a series of 18 patients with Tityus serrulatus envenomation, approximately 90% developed leukocytosis (De Rezende et al, 1995).

Dermatologic

    3.14.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Diaphoresis develops with most species.
    3.14.2) CLINICAL EFFECTS
    A) EXCESSIVE SWEATING
    1) WITH POISONING/EXPOSURE
    a) Diaphoresis was reported in 80.2% of the patients (n=951) who were admitted to the ICU in Tunisia for scorpion envenomation over a 13-year period. The species of scorpion involved was not identified; however, in Tunisia, severe envenomation is most likely a result of either the Androctonus australus scorpion or the Buthus occitanus scorpion (Bahloul et al, 2005).
    b) GROSPHUS SPECIES
    1) A sting to the finger caused excessive sweating for several hours in an adult woman stung by a Grosphus palpator (Wilson, 1987).
    c) LEIURUS SPECIES
    1) In a series of 104 children with Leiurus quinquestriatus envenomation, 99 (95%) developed excessive secretions and sweating (Sofer et al, 1994).
    2) A 7-year-old boy stung on the left eyelid by a L quinquestriatus was brought to the emergency room after complaining of excessive sweating and severe thirst (Elitsur et al, 1984). Other stings by the yellow scorpion have also caused excessive sweating (Amitai et al, 1985).
    d) TITYUS SPECIES
    1) In 2 large series of patients with Tityus serrulatus envenomation, approximately 45% to 75% developed excessive sweating (Freire-Maia et al, 1994; De Rezende et al, 1995).

Musculoskeletal

    3.15.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Local pain is common with most scorpion stings.
    3.15.2) CLINICAL EFFECTS
    A) PAIN
    1) WITH POISONING/EXPOSURE
    a) Local pain is a common symptom of most scorpion stings. This pain may be severe (Shah et al, 1989; Wilson, 1987; Russell & Madon, 1984).
    b) LEIURUS SPECIES
    1) In a series of 20 patients with Leiurus quinquestriatus envenomation, 14 developed local pain (Bogomolski-Yahalom et al, 1995).
    c) LYCHUS SPECIES
    1) According to a prospective study involving Australian scorpion stings in 95 patients, envenomation by the Lychus species of scorpion resulted in severe pain in the majority of patients (90%; n=72). The median duration of pain was 2 hours (Isbister et al, 2003).
    d) TITYUS SPECIES
    1) In 2 large series of patients with Tityus serrulatus envenomation, approximately 95% to 100% developed local pain (Freire-Maia et al, 1994; De Rezende et al, 1995).
    e) URODACUS SPECIES
    1) According to a prospective study involving Australian scorpion stings in 95 patients, 5 patients received stings from the Urodacus species of scorpion, resulting in mild to moderate pain only. The median duration of pain was 0.5 hours (Isbister et al, 2003).

Endocrine

    3.16.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Hyperglycemia is common with most species.
    3.16.2) CLINICAL EFFECTS
    A) HYPERGLYCEMIA
    1) WITH POISONING/EXPOSURE
    a) LEIURUS SPECIES
    1) Hyperglycemia was a frequent finding in children stung by these species (Amitai et al, 1985; Sofer et al, 1994).
    2) In a series of 15 children with Leiurus quinquestriatus envenomation, 7 developed hyperglycemia (Sofer et al, 1991).
    b) TITYUS SPECIES
    1) In a series of 18 patients with Tityus serrulatus envenomation, approximately 90% developed hyperglycemia (De Rezende et al, 1995).
    3.16.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) HYPERGLYCEMIA
    a) LEIURUS SPECIES
    1) Insulin release was inhibited by this toxin in 1 animal study (Johnson et al, 1976).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor blood pressure, ECG, heart rate, and respiratory status. Monitor electrolytes in patients with clinical evidence of dehydration. If Leiurus quinquestriatus or Tityus serrulatus envenomation is suspected, or there is clinical suspicion of pancreatitis, monitor blood glucose and serum amylase.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Monitor electrolytes in patients with clinical evidence of dehydration.
    2) If Leiurus quinquestriatus or Tityus serrulatus envenomation is suspected, or there is clinical suspicion of pancreatitis, monitor blood glucose and serum amylase.
    3) Monitor CPK in patients with prolonged coma or increased motor activity.
    4.1.4) OTHER
    A) OTHER
    1) MONITORING
    a) Institute continuous cardiac monitoring and obtain an ECG in patients with significant Leiurus quinquestriatus, tityus serrulatus, or mesobuthus tamulus stings.
    b) Echocardiography may be useful in patients with hypotension or pulmonary edema (Kumar et al, 1992).

Radiographic Studies

    A) Obtain a chest x-ray in patients with significant respiratory distress or evidence of pulmonary edema.

Methods

    A) CHROMATOGRAPHY
    1) HPLC may be used to separate and quantify the various components of some of the scorpion venoms (Martin et al, 1987). This is of scientific interest, but is not done in clinical settings.
    B) IMMUNOASSAY
    1) An ELISA for the detection of Tityus serrulatus venom in biological fluids has been developed (Chavez-Olortegui et al, 1994).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.6) DISPOSITION/BITE-STING EXPOSURE
    6.3.6.1) ADMISSION CRITERIA/BITE-STING
    A) Patients with symptoms of systemic envenomation should be admitted and may require intensive supportive care including intubation and ventilation and aggressive management including antivenom if available and other therapies to maintain cardiac output, stabilize hemodynamic function or treat pulmonary edema.
    6.3.6.2) HOME CRITERIA/BITE-STING
    A) SUMMARY
    1) Healthy adults and children older than 5 years with local symptoms of a scorpion sting can usually be managed at home (with telephone follow-up) with ice at the site and other supportive measures for pain relief.
    B) CENTRUROIDES SCULPTURATUS
    1) Normal adults (without hypertension, significant cardiac disease and not elderly or debilitated) and children older than 5 years can usually be handled at home (with telephone follow-up) with ice at the site and other supportive measures for pain relief (Likes et al, 1984). Patients with systemic effects and children younger than 5 years should be referred to a medical facility for evaluation.
    6.3.6.3) CONSULT CRITERIA/BITE-STING
    A) A clinician skilled in the management of scorpion envenomations should be involved in the care of severely envenomated patients. A regional center should also be consulted in such cases.
    6.3.6.5) OBSERVATION CRITERIA/BITE-STING
    A) Any patient with systemic effects and children younger than 5 years should be referred to a medical facility for evaluation. Children are more likely to develop signs and symptoms of severe envenomation following a scorpion sting.

Monitoring

    A) Monitor blood pressure, ECG, heart rate, and respiratory status. Monitor electrolytes in patients with clinical evidence of dehydration. If Leiurus quinquestriatus or Tityus serrulatus envenomation is suspected, or there is clinical suspicion of pancreatitis, monitor blood glucose and serum amylase.

Abstracts

Case Reports

    A) INFANT
    1) A 5-day-old, 3 kg child was stung by a Buthus tamulus scorpion. The child was restless, irritable, refusing to feed, diaphoretic, breathless, crying, and "frothing at the mouth." She had a heart rate of 150 beats/minute, a respiratory rate of 50 per minute, and was considered to be in shock by the examining physician. She was treated with dehydroemetine 3 mg intramuscularly, half strength Ringer's lactate (25 mL/kg) IV, and dexamethasone 0.5 mg/kg IM. Within 5 minutes, the child stopped crying, and in 60 to 90 minutes the other symptoms subsided. She was observed for 24 hours without additional symptoms (Personal Communication, 1990).
    B) ADULT
    1) A personal case of a sting by Grosphus palpator is described by Wilson. It occurred on an expedition to Madagascar. The initial sting was a sharp, searing pain in the right index finger, which rapidly felt "as if it had been hit by a large hammer." It became red and swollen, with painful streaks spreading up the forearm. Within minutes, the pain had spread to the upper arm and axilla, and no position was comfortable. Her left hand and feet began tingling, too, and she developed a backache. Her nose became congested, eyes watered, and she had trouble swallowing. The pain spread to her face, and it became difficult to swallow. The pain began to ease in 2 hours, but painful paresthesias developed in the hands, feet, and tongue, and it was still difficult to swallow. Six hours after the sting, it was still very painful. The pain had eased by the next morning. She was given large doses of oral morphine and hydrocortisone 100 mg by injection. The finger stayed numb for a month and still had a peculiar sensation a year later (Wilson, 1987).

Range Of Toxicity

Summary

    A) A single scorpion sting may be fatal for a child or debilitated or hypertensive adult. Although scorpion stings that produced fatalities were not uncommon years ago, good supportive care has made this a rare outcome.

Minimum Lethal Exposure

    A) SPECIFIC SUBSTANCE
    1) CENTRUROIDES SPECIES: A single sting may be fatal for a child or debilitated or hypertensive adult. Although scorpion stings that produced fatalities were not uncommon years ago, good supportive care has made this a rare outcome (Rachesky et al, 1984; Likes et al, 1984).
    B) ANIMAL DATA
    1) MOUSE: The minimum lethal dose of venom from C exilicauda in mice is 1.12 mg/kg (Stahnke, 1963).

Pharmacology Toxicology

Toxicologic Mechanism

    A) SCORPION VENOM -
    1) GENERAL: Their venom consists of 10 or more basic, neurotoxic proteins and at least 6 nonproteins (Meves et al, 1984). Most scorpion toxins affect the sodium channel of excitable cells by retarding inactivation (alpha toxins) or enhancing activation (beta toxins). A few of these toxins affect the potassium channel (Watt et al, 1990).
    2) ANDROCTONUS AUSTRALIS venom consists of a single chain of 60 to 70 amino acids and 4 disulfide bridges (Rochat et al, 1970; Martin & Rochat, 1986). There are actually 5 distinct toxins in this venom, with a high affinity for specific binding sites on the sodium channel of excitable membranes. A prolongation of the axonal action potential is created by slowing down the inactivation process of the sodium channel (Jover et al, 1978; Rochat et al, 1979). The percent of toxin found in this venom is quite low, being about 3% of the total venom weight (Martin et al, 1987).
    3) BUTHUS MARTENSII (Karsch) is known to contain several insect venoms, 8 mammal neurotoxins, and a crustacean toxin. This scorpion is found in China and East Asia (Hu et al, 1990a; Dong et al, 1990; Ji et al, 1990; Hu et al, 1990).
    4) CENTRUROIDES scorpion venom, the so-called "lethal scorpion," as most scorpion venoms, is poor in enzymes but has at least 5 neurotoxins (Rachesky et al, 1984), all having similar numbers of amino acids, lysine, and tyrosine residues, and 4 disulfide bridges. It has a particular effect on the peripheral nervous system, causing a block in neuromuscular transmission. The clinical effect seen is hypertension. Toxins I alpha, II alpha, III alpha, and III beta act primarily on the activation process of sodium channels. After nerve membranes are depolarized, these toxins reduce the flow of the sodium channel. After membrane repolarization, these toxins (with the exception of I alpha) induce a new inward current, resulting in spontaneous firing and repetitive firing of action potentials even after a single impulse (Rachesky et al, 1984; Wang & Strichartz, 1983). Another group of toxins, which includes IV alpha, affects the sodium channel by slowing and preventing complete inactivation, which results in a prolonged action potential via stabilization of sodium channels in their ion-conducting state (Rachesky et al, 1984; Carbone et al, 1984; Meves et al, 1984). The bradycardia caused by these venoms is thought to be due to the release of acetylcholine by the action on vagal ganglia and postganglionic nerve endings found in the heart (Freire-Maia et al, 1974).
    5) HETEROMETRUS BENGALENSIS: Toxin-Hb from this scorpion has produced neuromuscular blockage in animal studies. The toxin is an antigenic, heat liable basic protein (Dasgupta et al, 1990). It produces smooth muscle contraction even in the presence of acetylcholine, histamine, and prostaglandin (Kar et al, 1983).
    6) LEIURUS QUINQUESTRIATUS venom was investigated in dogs. The venom is a powerful arrhythmogenic agent that stimulates the autonomic sympathetic nervous system and adrenals, inducing dramatic hemodynamic increases in the left ventricular systolic and diastolic pressures, as well as the pulmonary and systemic arterial pressures and left ventricular contractility (Gueron et al, 1980).
    a) LEIURUS QUINQUESTRIATUS hebraeus (Israeli yellow scorpion) venom contains Lqh(alpha)IT, a neurotoxin that exhibits structural and pharmacological characteristics that are similar to those of alpha scorpion neurotoxins. Unique differences of Lqh(alpha)IT, compared with typical alpha toxins, have also been noted. Alpha scorpion toxins affect humans and other mammals.
    1) Lqh(alpha)IT is a nonselective insect toxin, is highly toxic to crustaceans, and is of low toxicity to mice. Alpha toxins bind to mammalian neuronal membranes in a voltage-dependent fashion. These binding sites interact cooperatively with veratridine. Lqh(alpha)IT binds to INSECT but not mouse neuronal membranes in a voltage-INDEPENDENT fashion, and binding sites interact cooperatively with veratridine. Alpha toxins affect sodium channels in mammals. Lqh(alpha)IT similarly prolongs action potentials and slows inactivation of sodium currents, but does so in INSECT models (Zlotkin et al, 1994).
    7) TITYUS SERRULATUS venom contains several components, some of which are phospholipase A (Ibrahim, 1967), neurotoxins (Miranda et al, 1966), and proteases (Mohamed et al, 1969).
    B) Catecholamine Release: Both the venoms of Leiurus quinquestriatus and Tityus serrulatus produce sympathomimetic effects on the heart. Moss et al (1973) demonstrated a massive discharge of catecholamines into the blood from both normal and adrenalectomized rats in which ganglionic transmission had been blocked after injection of the venom from L quinquestriatus (Moss et al, 1973). Gueron & Yarom (1970) demonstrated significant increase in vanillylmandelic acid and catecholamine discharge in patients stung by Leiurus quinquestriatus(Gueron & Yarom, 1970).
    C) Three mechanisms of action have been proposed to explain the development of neurological manifestations (ie, coma, seizures, miosis, mydriasis) following scorpion envenomation (Bahloul et al, 2005):
    1) Neurological signs and symptoms may be due to hypertensive encephalopathy. Severe scorpion envenomation often leads to high arterial blood pressure due to a massive catecholamine discharge.
    2) Secondly, scorpion envenomation may cause a defect in oxygen transport secondary to the development of pulmonary edema and cardiogenic shock, thereby resulting in brain ischemia.
    3) The third proposed mechanism of action is that scorpion venom may have a direct action on the central nervous system.
    D) HUMAN
    1) APOPTOSIS
    a) In a study of 46 children with scorpion envenomation (25 severe and 21 mild; primarily Buthus occitanus and Leiurus quinquestritus), markers of apoptosis (programmed cell death) were significantly higher in serum of envenomated children than in serum of nonenvenomated controls. In addition, markers of oxidative injury were elevated in envenomated children. These findings also correlated with the severity of envenomation (Meki et al, 2003).

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