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| Year : 1983 | Volume
: 29
| Issue : 1 | Page : 46-8 |
Myocarditis and pulmonary edema following scorpion bite. (A case report).
Garg AK, Pimparkar AB, Abraham PP, Chikhalikar AA
How to cite this article:
Garg A K, Pimparkar A B, Abraham P P, Chikhalikar A A. Myocarditis and pulmonary edema following scorpion bite. (A case report). J Postgrad Med 1983;29:46 |
How to cite this URL:
Garg A K, Pimparkar A B, Abraham P P, Chikhalikar A A. Myocarditis and pulmonary edema following scorpion bite. (A case report). J Postgrad Med [serial online] 1983 [cited 2023 Mar 21];29:46. Available from: https://www.jpgmonline.com/text.asp?1983/29/1/46/5554 |
Scorpion bites are common in rural India.[1] Most of them are harmless, but some present with neurotoxic or cardiotoxic manifestations. In a city like Bombay, cases of scorpion bite are occasionally reported from the slum areas, and a few cases are referred from nearby towns and villages for management of complication arising from scorpion bite. One such case is reported here, who developed evidence of myocardial injury and pulmonary edema, complications which are being increasingly recognised in Indian reports.[1], [8], [10], [13]
A 15 year old male resident of Ratnagiri suffered a scorpion bite on the lateral aspect of the left foot. The killed scorpion was not available for identification. Three hours later, the patient became unconscious. Blood pressure of 70/? mm of Hg was recorded by the local medical practitioner who diagnosed him as a case of cardiogenic shock with pulmonary edema and treated him with digitalis, diuretics and corticosteroids. A few hours later, he developed haemoptysis and fever. X-ray chest taken at this stage showed bilateral fluffy shadows suggestive of pulmonary edema [Fig. 3]. The patient was then referred to the K.E.M. Hospital, Bombay,
On admission, the patient complained of breathlessness, cough, haemoptysis and palpitation. Findings on clinical examination were as follows: Pulse was 140/min. and regular; B.P. was 130/80 mm Hg. JVP was normal; there was no cyanosis; the respiratory rate was 40/min. Examination of the respiratory system showed bilateral basal rales. Cardiovascular system examination revealed loud S3 gallop at the apex, but no murmurs or pericardial rub, and no cardiomegaly. CNS and PA examination showed nothing abnormal.
Laboratory investigations showed: BUN to be 32 mg%, serum creatinine-2.0 mg%, blood sugar-80 mg% serum bilirubin--2.0 mg%, of which direct was 1.3 mg%, SGOT-34 units and SGPT-30 units.
ECG taken on admission showed sinus tachycardia, q waves, ST segment elevation and flat T waves in leads I, aVL, V4, V5, V6 [Fig. 7] on page 48A.
The patient was diagnosed as a case of myocarditis with left ventricular failure and pulmonary edema, and was treated with digoxin, frusemide, potassium chloride supplements and penicillin.
X-ray chest taken 24 hours later showed clearing up of the lung fields [Fig. 4] or. page 48A. Five ECGs were repeated over the next three weeks. These showed persistence of q wave and T wave inversion in leads I and aVL, while leads V4, V5, V6 returned to normal [Fig. 2] on page 48A. Another ECG taken 6 weeks after the scorpion bite showed the same pattern though clinical examination at this time revealed no abnormality.
Scorpion venom contains a neurotoxin, haemolysins, agglutinins, haemorrhagins, leucocytolysins, coagulins, ferments, lecithin and chlolesterin.[9] The venom produces both local as well as systemic reactions. Local reactions consist of itching, edema and ecchymoses with buring pain.[14] The cardiovascular manifestations comprise successively of giddiness, bradycardia, a fall of body temperature; restlessness and tachycardia; and finally pulmonary edema.[10]
The scorpion venom stimulates the peripheral sympathetic nerve endings and release of catecholamines from the adrenal medula (directly as well as through parasympathetic stimulation).[6], [11] Thus the venom is a powerful arrhythmogenic agent. These actions of the venom are inhibited by atropine, propranolol and phentolamine.[7] Pulmonary edema and cardiac damage are due to several factors.[2], [4],[5],[6] The ECG changes are nonspecific but may sometimes suggest myocardial infarction.[5], [12] Several types of arrhythmias (both tacky and brady types) have been reported.[4], [13]
Successful management of scorpion bite has been reported with local treatment including tourniquette,[14] specific antivenin,[14] lytic cocktail to treat hypotension,[3] atropine[3] and phentolamine.[4] Supportive therapy consists of conventional management of left ventricular failure and pulmonary edema.
The patient reported herein had evidence of acute myocarditis in the form of electrocardiographic changes in leads I, aVL, V4-V6 and clinically in the form of marked sinus tachycardia and a loud S3 gallop. As there was no evidence of coronary vascular, insufficiency, this was most probably due to a direct toxic effect of the scorpion venom on the myocardium or secondary to venom-induced catecholamine release from the adrenals or sympathetic nerve endings. The pulmonary edema which was diagnosed clinically and further documented on X-ray was most likely due to myocardial dysfunction, and this belief was strengthened by the fact that digitalis and diuretics caused disappearance of the pulmonary edema. A neurovegetative effect of the increased circulating pressor amines on the pulmonary capillary permeability[6] could also be at least partly responsible.
We are thankful to the Dean, K.E.M. Hospital and Seth G.S. Medical College, Bombay 400 012, for his kind permission to publish hospital data.
| 1. | Bisarya, B. N., Vasavada, J. P., Bhat,. A., Nair, P. N. R. and Sharma, V. K.: Hemiplegia and myocarditis following scorpion bite. Indian Heart J., 29: 97-100, 1977.  |
| 2. | Fayet, G., Courand, F., Miranda, F. and Lissitsky, S.: Electro-optical system for monitoring activity of heart cells in culture: application to the study of several drugs and scorpion toxins. European J. Pharmacol., 27: 165-174, 1974. |
| 3. | Gajalakshmi, B. S.: Role of lytic cocktail and atropine in neutralising scorpion venom effects. Ind. J. Med. Res., 67: 1038-1044, 1978. |
| 4. | Gueron, M., Adolph, R. J., Grupp, I. L., Gabel, M., Grupp, G. and Fowler, N. O.: Haemodynamic and myocardial consequences of scorpion venom. Amer. J. Cardiol., 45: 979-986, 1980. |
| 5. | Gueron, M., Stern, J. and Cohen, W.: Severe myocardial damage and heart failure in scorpion sting. Report of five cases. Amer. J. Cardio/., 19: 719-726, 1967. |
| 6. | G. Gueron M. and Yaron, R.: Cardiovascular manifestations of severe scorpion sting. Chest, 57: 156-162, 1970. |
| 7. | Ismail, M., El Asmar, M. F. and Osman, O. H.: Pharmacological studies with scorpion venom; evidence for the presence of histamine. Toxicon., 13: 49-56. 1975. |
| 8. | Jain, S. R., Chhabra, M. L., Shah. P. and Sepaha, G. C.: Myocardial injury after scorpion sting. Ind. J. Med. Sci., 24: 645-646, 1970. |
| 9. | Modi, N. J.: "Modi's Textbook of Medical Jurisprudence and Toxicology." 24th Edition, N. M. Tripathi Pvt. Ltd., Princess Street, Bombay, 1977, p. 633. |
| 10. | Mundle, P. M.: Pulmonary edema following scorpion stings. Brit. Med. J., 1: 1042, 1961. |
| 11. | Patterson, R. A.: Physiological action of scorpion venom. Amer. J. Trop. Med. & Hyg., 9: 410-414, 1960. |
| 12. | Poon-King, T.: Myocarditis from scorpion stings. Brit. Med. J., 1: 374-377, 1963. |
| 13. | Shah, S. S., Doshi, H. V. and Kulkarni, P. S.: Myocarditis from scorpion sting. Indian Heart J., 24: 52-55, 1975. |
| 14. | Wallace, J. F.: Disorders caused by venoms, bites and stings. In, "Harrison's Principles of Internal Medicine", Editors:: Isselbacher, K. J., Adams, R. D., Braunwald, E., Petersdorf, R. G. and Wilson, J. D. 9th edition, McGraw Hill International Book Co., Johannesburg, London, Tokyo etc., 1980, pp. 924-925. |
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