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Scorpion Envenomation: Differential Diagnoses & Workup

Author: David Cheng, MD, Assistant Professor of Emergency Medicine, Associate Emergency Medicine Residency Director, Associate Medical Director of Emergency Services, University of Arkansas Medical Sciences
Coauthor(s): Judith A Dattaro, MD, FACEP, Assistant Professor of Emergency Medicine in Surgery, Cornell University Medical College; Consulting Staff, Department of Emergency Medicine, Weill-Cornell University Medical Center, New York Presbyterian Hospital; Ramy Yakobi, MD, MBA, Medical Director of Emergency Department, Beth Israel/Kings Highway Division; Lecturer, Physician Assistant School, Cornell School of Medicine; Lecturer, Pre-hospital Management of Patient, Cornell/New York Presbyterian Hospital; Director of Emergency Department, New York Community Hospital
Contributor Information and Disclosures

Updated: Aug 6, 2009

Differential Diagnoses

Bites, Insects
Spider Envenomations, Funnel Web
Botulism
Spider Envenomations, Redback
Caterpillar Envenomations
Spider Envenomations, Tarantula
CBRNE - Botulism
Spider Envenomations, Widow
Centipede Envenomations
Tetanus
Diphtheria
Tetanus
Disseminated Intravascular Coagulation
Toxicity, Medication-Induced Dystonic Reactions
Myasthenia Gravis
Toxicity, Organophosphate
Pancreatitis
Snake Envenomations, Coral
Snake Envenomations, Rattle

Other Problems to Be Considered

Myasthenia gravis
Diphtheria
Guillain-Barré syndrome
Neuroleptic overdose
Sympathomimetic overdose
Venomous jellyfish, snake, and lizard envenomation
Seizures
Dystonia

Workup

Laboratory Studies

Scorpion envenomation cases vary from those requiring no laboratory tests to scenarios requiring extensive hematologic, electrolyte, and respiratory analysis.

  • Obtain a CBC count for leukocytosis and hemolysis in patients with stings from the Hemiscorpius species. Hemiscorpius lepturus has been shown to cause severe hemolysis.
  • Electrolyte evaluation is warranted in patients with venom-induced salivation, vomiting, and diarrhea.
  • Coagulation parameters should be measured for venom-induced defibrination because, at high concentrations, the venom is an anticoagulant. Defibrination syndrome has been reported following Mesobuthus tamulus stings.
  • Glucose levels should be measured to evaluate for hyperglycemia from liver and pancreas dysfunction.
  • Creatine kinase and urinalysis help evaluate for venom-induced excessive motor rhabdomyolysis. Renal failure may occur secondary to hemoglobinuria from hemolysis (after H lepturus sting) or myoglobinuria from rhabdomyolysis
  • Obtain amylase/lipase values to assess for pancreatitis, which is common, from Tityus trinitatis stings.
  • Patients may have increased aspartate aminotransferase and alanine aminotransferase levels from venom-induced liver cell destruction.
  • Increased catecholamine, aldosterone, renin angiotensin, and antidiuretic hormone levels are detected a few hours after the sting. The increased levels persist for 6 hours, after which a gradual decline occurs.
  • Interleukin (IL)–1 levels are elevated in all envenomations.
  • High levels of IL-6, interferon-gamma, and granulocyte-macrophage colony-stimulating factor are present in severe envenomations.
  • Radiolabeled antibodies or immunoenzymatic assays help quantify the serum venom level because an association exists between the clinical signs of envenomation and this level.
  • Obtain arterial blood gas (ABG) measurements as indicated for respiratory distress or to determine acid/base status.

Imaging Studies

  • Obtain a chest radiograph in cases of respiratory difficulty. Unilateral pulmonary edema may be seen on chest x-ray films because of the venom effect on pulmonary vascular permeability.
  • Echocardiography findings are discussed as follows:
    • Echocardiography is more sensitive than electrocardiography and creatine kinase assays for assessing myocardial compromise after a scorpion sting.
    • Findings show a diffuse global biventricular hypokinesis with a decreased left and right ventricular ejection fraction of approximately 0.14-0.38. This dysfunction can appear just a few hours after the sting and usually normalizes within 4-8 days.
    • Serial echocardiography findings show that the return of left ventricular function to a normal state correlates to clinical cardiorespiratory improvement.
  • Color-flow Doppler study findings show mitral incompetence, probably secondary to venom-induced dilated cardiomyopathy.

Other Tests

  • Arterial blood gas determinations show a decrease in arterial oxygenation tension and an increase in PCO2 within 15 minutes of the envenomation, findings consistent with mild metabolic acidosis.
  • Pulmonary artery catheterization findings may include the following:
    • Elevated systemic vascular resistance occurs up to 4 times the normal level, with elevated mean arterial pressure (MAP) of 203 mm Hg.
    • Left ventricular failure produces a MAP of 57-69 mm Hg.
    • Biventricular failure produces a MAP of 47 mm Hg.
    • Low cardiac index occurs with elevated filling pressures.
  • Perform serial spirometry measurements to help detect impending venom-induced diaphragmatic failure.
  • Electrocardiography, if indicated
    • ECG changes persist for 10-12 days before normalizing.
    • ECG changes are observed in 63% of children who have been envenomated.
    • Rhythm disturbances are not dose-dependent but are related to the venom composition.
      • Sinus tachycardia - Most common rhythm
      • QTc prolongation - 53%
      • ST changes - 39%
      • T-wave inversion - 39%
      • Ventricular repolarization abnormalities - 15%
      • Bundle-branch block - 12.8%
      • First-degree block - 10.2%
    • A possible sequence of ECG changes has been noted. This sequence starts with bizarre, broad-notched, biphasic, peaked T waves with a beat-to-beat variation. This bizarre T wave is followed by the appearance of tiny Q waves and then atrioventricular dissociation with an accelerated junctional rhythm.

Procedures

  • Cerebrospinal fluid pleocytosis is evident on spinal tap studies.

Histologic Findings

The local sting site shows mixed inflammatory cell infiltrates with eosinophils scattered among collagen bundles in an edematous dermis. Myocardial changes, which are most prominent at the papillary muscle and subendocardial region, include focal myocardial necrosis; myofibril destruction, especially at the I band; fine fatty deposits in the cardiac muscle fibers; interstitial edema; and increased cellularity, mainly lymphocytes and monocytes. Changes resemble interstitial hypoxia-induced myocarditis caused by large doses of catecholamines.

More on Scorpion Envenomation

Overview: Scorpion Envenomation
Differential Diagnoses & Workup: Scorpion Envenomation
Treatment & Medication: Scorpion Envenomation
Follow-up: Scorpion Envenomation
Multimedia: Scorpion Envenomation
References
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Further Reading

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Keywords

scorpion sting, scorpion envenomation, scorpion venom, arthropod sting, insect sting, arachnid sting, venom, antivenom, antivenin, Buthidae, Scorpionidae, Ischnuridae, Buthus, Parabuthus, Mesobuthus, Tityus, Leiurus, Androctonus, Centruroides, Centruroides exilicauda, Centruroides sculpturatus, C sculpturatus, neurotoxin, cardiotoxin, nephrotoxin, toxin, wildlife emergency, envenomation, severe local skin reaction, neurologic collapse, respiratory collapse, cardiovascular collapse, respiratory failure, cardiovascular failure, Buthus, Mesobuthus, Buthotus, Buthus tamulus, Hottentotta, Leiurus, Leiurus quinquestriatus, Leiurus quinquestriatus, Androctonus, Androctonus australis, Hemiscorpius, Hemiscorpius lepturus

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Contributor Information and Disclosures

Author

David Cheng, MD, Assistant Professor of Emergency Medicine, Associate Emergency Medicine Residency Director, Associate Medical Director of Emergency Services, University of Arkansas Medical Sciences
David Cheng, MD is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, Council of Emergency Medicine Residency Directors, International Society for Mountain Medicine, National Association of EMS Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Judith A Dattaro, MD, FACEP, Assistant Professor of Emergency Medicine in Surgery, Cornell University Medical College; Consulting Staff, Department of Emergency Medicine, Weill-Cornell University Medical Center, New York Presbyterian Hospital
Judith A Dattaro, MD, FACEP is a member of the following medical societies: American Association of Women Emergency Physicians, American College of Emergency Physicians, American Medical Association, Chicago Medical Society, Illinois State Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Ramy Yakobi, MD, MBA, Medical Director of Emergency Department, Beth Israel/Kings Highway Division; Lecturer, Physician Assistant School, Cornell School of Medicine; Lecturer, Pre-hospital Management of Patient, Cornell/New York Presbyterian Hospital; Director of Emergency Department, New York Community Hospital
Ramy Yakobi, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Lisa Kirkland, MD, FACP, CNSP, MSHA, Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital
Lisa Kirkland, MD, FACP, CNSP, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, and Society of Hospital Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H, Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine
Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine
Disclosure: Keck School of Medicine, USC None None

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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