Evaluation of Scorpion Stings in Children

Abstract

Introduction

Scorpion stings are a significant public health problem in many parts of the world. Children are at a higher risk of developing severe complications from scorpion envenoming, including cardiac, respiratory, and neurologic complications. In Turkey, members of the Buthidae family are the most common culprits in severe envenoming events.

Methods

This retrospective-descriptive study was conducted in Turkey. Children aged 0 to 18 y admitted to the emergency department of Kahta State Hospital between December 2017 and December 2020 were included in the study. Patient information was reviewed, and 78 patients with complete demographic, laboratory, and clinical data were included in the study.

Results

Out of the 78 patients, 24.4% were six years old or younger while the 75.6% were older than six years. Alpha blocker was given to 12.8% of the patients, and antivenom was given to 43.6% of the patients. Of the 78 patients, 71.8% were followed up in the emergency department, 21.8% were followed up in the inpatient unit, and 6.4% were followed up in the intensive care unit. Two patients (2.6%) died within 1 month. There was a significant difference regarding lactate dehydrogenase value according to the sting site (P=0.014). Lactate dehydrogenase values of patients stung on the head and neck and upper extremity were higher than those of patients bitten on lower extremities.

Conclusions

Elevated levels of specific laboratory parameters, such as leukocytes, aspartate transaminase, and lactate dehydrogenase, are linked to worse outcomes. Additionally, stings on the head, neck, and upper extremities are more strongly associated with severity. These findings guide tailored treatment strategies for scorpion stings, with the potential for further refinement through broader studies across diverse regions and populations.

Keywords

poisoning LDH concentration sting site pediatric emergencies

Introduction

Scorpion stings are a significant public health problem in many parts of the world, especially in tropical and subtropical regions. Scorpionism is a major public health problem in numerous tropical countries because of its frequent incidence and potential severity. Scorpion stings are important not only because of their incidence but also because of their potential ability to induce severe, and often fatal, clinical situations, especially among children.¹ The species of scorpions that are present in Turkey and pose a threat to public health include Androctonus crassicauda, Leiurus quinquestriatus, Mesobuthus gibbosus, and Mesobuthus eupeus, all of which belong to the Buthidae family. The venom of the Buthidae family has neurotoxic effects.² Scorpion envenoming cases are common in Turkey due to its geographical location, climate, and socioeconomic structure.³ Among the scorpions found in Turkey, A crassicauda and Leiurus abdullahbayramii from the family Buthidae are highly toxic and potentially fatal.⁴ There is limited epidemiological and clinical research on scorpion stings in Turkey.

Scorpion venom contains neurotoxins that can cause a range of symptoms, including pain, swelling, and numbness at the site of the sting. In severe cases, scorpion venom can cause respiratory distress, cardiac arrhythmias, and convulsions.⁵ Scorpion stings pose a significant health concern across various geographical regions in Turkey. This study delved into an extensive dataset of patient information to understand the distribution, frequency, and seasonal variations of scorpion sting cases.

Children are particularly sensitive to scorpion envenoming, and scorpion sting in children is a hazardous and potentially lethal condition.^6,7 The primary objective of this research was to comprehensively investigate the epidemiological, clinical, and laboratory parameters of scorpion stings in Turkey while also exploring data that might be associated with prognosis.

Methods

Ethics committee approval for the study was received by the Fırat University Non-Interventional Research Ethics Committee, with the decision dated January 12, 2022 and coded 14-29. Written permission was obtained from the institution whose records were examined. Since the structure of the study was planned retrospectively, written or verbal consent was not obtained from the patients. The study process complied with the Declaration of Helsinki rules.

The retrospective-descriptive study was conducted in the Kahta district of Adıyaman, a southeastern province of Turkey. Children aged 0 to 18 y admitted to the emergency department (ED) of Kahta State Hospital between December 2017 and December 2020 following a scorpion envenomation were included. Patients were found by searching with the diagnosis code T63.2 (Scorpion envenomation) from the Hospital Information System. Patient information was retrospectively reviewed, and 78 patients with complete demographic, laboratory, and clinical data were included in the study. Patients with chronic diseases (celiac disease, anemia, diabetes mellitus, epilepsy, hyperthyroidism, mental retardation, and autism spectrum disorder) or whose treatment process continued in other hospitals were not included in the study. A flowchart illustration of the study is shown in Figure 1.

Figure 1.

Patient selection diagram.

The clinical severity of each case was assessed according to the Abroug classification, which is a validated classification. According to the Abroug classification, scorpion stings can be classified into 3 categories: mild, moderate, and severe.⁸ Mild scorpion stings are characterized by local pain and swelling at the site of the sting, while moderate stings are characterized by systemic symptoms such as sweating, nausea, vomiting, and tachycardia. Severe scorpion stings are characterized by severe systemic symptoms, such as respiratory distress, cardiac arrhythmias, and convulsions.⁸

Complete blood count, serum biochemistry, and venous blood gas tests were performed in all patients admitted to the hospital, and electrocardiograms were analyzed. Those with pulmonary edema, myocarditis, arrhythmia, high troponin-I levels, or suspected heart failure were evaluated by a physician. “Autonomic storm” was considered in patients with cold and pale hands and feet, tachycardia, hypertension, sweating, and hypersalivation. These patients were given prazosin (0.03 mg/kg) via a nasogastric tube or orally. Scorpion antivenom was administered intravenously in patients with systemic symptoms.

Another significant aspect of the study was identifying prognostic factors that influence the course of scorpion stings. In this context, data on patients’ clinical progress, response to treatment, and rates of complications were scrutinized, and the impact of these factors on the severity and outcomes of scorpion envenomation was analyzed. This information could be utilized to develop more effective treatment strategies for medical professionals and aid in achieving better outcomes for patients.

STATISTICAL ANALYSIS

Analyses were evaluated in the package program of SPSS 22.0 (Statistical Package for Social Sciences; SPSS Inc, Chicago, IL). In this study, categorical data are presented as number counts and percentages, while continuous data are expressed as mean ± standard deviation, median, and interquartile range (25th–75th percentile). χ² analysis (Pearson χ²) was used to compare categorical variables between groups. Conformity of continuous variables to normal distribution was evaluated by the Kolmogorov-Smirnov test. In the comparison of more than 2 variables, One-Way analysis was performed for those with normal distribution, and the Kruskal-Wallis test was performed for those without normal distribution. The statistical significance level in the analyses was accepted as P<0.05.

The incidence was calculated by dividing the annual number of scorpion stings in children by the 0- to 18-y age group child population. The mortality rate was calculated by dividing the number of deaths in children due to scorpion stings by the population of children aged 0 to 18 y. The fatality rate was found by dividing the number of children who died from scorpion stings by the number of cases.

Results

78 patients with a median age of 13 were included in the study. Of these patients, 24.4% were aged ≤6 y and 75.6% were aged >6 y. Moreover, 51.3% of the patients were female, and 48.7% were male. For the Kahta district, the incidence of scorpion stings in children was calculated as 49.43/100,000, and the mortality rate was 1.27/100,000. The fatality rate after scorpion sting is 2.56%. Two patients (2.6%) died within 1 month (Table 1).

Table 1.

All characteristics of the cases.

		n	%
Age category	≤6 y	19	24.4
Age category	>6 y	59	75.6
Sex	Female	40	51.3
Sex	Male	38	48.7
Complaint^a	Agitation/sweating	15	19.2
	Nausea-vomiting	10	12.8
	Chest pain	4	5.1
	Dyspnea	3	3.8
	Priapism	3	3.8
Use of alpha blocker	Yes	10	12.8
Use of alpha blocker	No	68	87.2
Use of antivenom	Yes	34	43.6
Use of antivenom	No	44	56.4
Unit followed	ED	56	71.8
	IU	17	21.8
	ICU	5	6.4
Mortality	Yes	2	2.6
Mortality	No	76	97.4

ED, emergency department; IU, inpatient unit; ICU, intensive care unit.

^aThere is a case with more than 1 complaint.

When the patients were evaluated according to their stages, 51 (65.4%) were Stage 1, 22 (28.2%) were Stage 2, and 5 (6.4%) were Stage 3 (Figure 2).

Figure 2.

a. Distribution of cases according to stage, b. Distribution of cases according to bite sites.

There was no significant difference between age categories and sex regarding sting sites (P>0.05). There was no significant difference between the sting sites in terms of stage, admission complaints, unit followed, and mortality (P>0.05) (Table 2).

Table 2.

Comparison of various parameters according to sting site.

		Head-neck-trunk	Upper extremity	Lower extremity	P value^a
		n (%)	n (%)	n (%)	P value^a
Age category^b	≤6 y	2 (10.5)	10 (52.6)	7 (36.8)	0.579
Age category^b	>6 y	11 (18.6)	24 (40.7)	24 (40.7)	0.579
Sex^b	Female	10 (25.0)	16 (40.0)	14 (35.0)	0.127
Sex^b	Male	3 (7.9)	18 (47.4)	17 (44.7)	0.127
Stage^c	Stage 1	9 (69.2)	20 (58.8)	22 (71.0)	0.056
	Stage 2	3 (23.1)	14 (41.2)	5 (16.1)
	Stage 3	1 (7.7)	0 (0)	4 (12.9)
Chest pain^c		0 (0)	0 (0)	3 (9.7)	0.384
Nausea-vomiting^c		1 (8.3)	2 (15.4)	4 (12.9)	0.946
Dyspnea^c		0 (0)	1 (7.7)	2 (6.5)	0.288
Priapism^c		0 (0)	0 (0)	1 (3.2)	0.627
Agitation/sweating^c		2 (16.7)	3 (23.1)	6 (19.4)	0.914
Unit followed^c	ED	10 (76.9)	23 (67.6)	23 (74.2)	0.088
	IU	2 (15.4)	11 (32.4)	4 (12.9)
	ICU	1 (7.7)	0 (0)	4 (12.9)
Mortality^c	Yes	1 (7.7)	0 (0)	1 (3.2)	0.160
Mortality^c	No	12 (92.3)	34 (100.0)	30 (96.8)	0.160

ED, emergency department; IU, inpatient unit; ICU, intensive care unit.

P<0.05 was accepted as statistically significant.

^aχ² analysis was applied.

^bRow percent is used.

^cColumn percent is used.

Of the Stage 1 and Stage 2 patients, 92.2% and 40.9%, respectively, were followed up in the ED. All of the Stage 3 patients were followed up in the intensive care unit (ICU). There was no significant difference between the stages in terms of the unit followed (P<0.001) (Table 3, Figure 3).

Figure 3.

Comparison of the unit followed according to the stage.

Table 3.

Comparison of the unit followed according to the stage.

	ED		IU		ICU		P value^b
	n	%^a	n	%^a	n	%^a	P value^b
Stage 1	47	92.2	4	7.8	0	0	<0.001
Stage 2	9	40.9	13	59.1	0	0
Stage 3	0	0	0	0	5	100

ED, emergency department; IU, inpatient unit; ICU, intensive care unit.

P<0.05 was accepted as statistically significant.

^aRow percentage is used.

^bχ² analysis was applied.

There was a statistically significant difference in the increase in lactate dehydrogenase (LDH) value according to the sting site (P=0.014) (Table 4).

Table 4.

Comparison of laboratory parameters according to sting site.

	Head-neck-trunk	Upper extremity	Lower extremity	P value
	Median (min to max) or mean±SD	Median (min to max) or mean±SD	Median (min to max) or mean±SD	P value
SBP (mm Hg)	115.0 (96.0–120.0)	110.0 (93.0–125.0)	120.0 (100.0–132.0)	0.377^a
DBP (mm Hg)	62.8±11.5	60.8±15.5	65.5±15.6	0.454^b
Heart rate (beats/min)	89.0 (87.0–98.0)	96.5 (78.0–110.0)	88.0 (78.0–99.0)	0.776^a
SO₂ (%)	98.0 (98.0–98.0)	98.0 (97.0–99.0)	98.0 (97.0–99.0)	0.695^a
Glucose (mg/dL)	94.0 (86.0–122.0)	98.5 (90.0–116.0)	104.0 (90.0–111.0)	0.822^a
AST (U/L)	21.3±10.4	23.5±8.0	25.3±8.4	0.369^b
ALT (U/L)	13.0 (12.0–16.0)	17.5 (14.0–21.0)	15.0 (12.0–21.0)	0.131^a
LDH (U/L)	284.9±92.2^c	264.9±81.0^c	204.9±41.1^c	0.014^b
CK-MB microgram/dL)	2.0 (2.0–2.5)	2.8 (2.0–4.5)	2.4 (2.0–4.0)	0.271^a
Creatinine (mg/dL)	0.66±0.15	0.61±0.16	0.65±0.15	0.354^b
PLT (10³/μL)	260.0 (231.0–265.0)	261.0 (228.0–298.0)	266.0 (219.0–310.0)	0.516^a
WBC (10³/μL)	10.3 (8.3–10.7)	10.0 (8.2–12.7)	11.0 (7.5–13.9)	0.987^a
Hgb (g/dL)	13.5±1.6	13.2±1.4	13.7±1.7	0.414^b
INR	1.1 (1.0–1.2)	1.1 (1.0–1.2)	1.1 (1.0–1.2)	0.742^a

min, minimum; max, maximum; SBP, systolic blood pressure; DBP, diastolic blood pressure; SO₂, oxygen saturation; AST, aspartate transaminase; ALT, alanine transaminase; LDH, lactate dehydrogenase; CK-MB, creatine kinase muscle-brain; PLT, platelet count; WBC, white blood cell; Hgb, hemoglobin; INR, international normalized ratio.

P<0.05 was accepted as statistically significant.

^aKruskal-Wallis test was applied.

^bOne-way analysis of variance was applied.

^cGroup from which the difference originates.

There was a significant difference between the stages in terms of heart rate (P=0.002), oxygen saturation (P=0.038), and aspartate transaminase (AST) (P=0.023). This difference was only due to the difference between Stage 1 and Stage 3. Those with Stage 1 had lower heart rates, and AST and oxygen saturation values were higher. There was a significant difference between the stages regarding creatine kinase muscle-brain (CK-MB) (P=0.012). This difference was due to the difference between Stage 1 and the other 2 stages, and the CK-MB values of those with Stage 1 were found to be lower (Table 5).

Table 5.

Comparison of laboratory parameters by stage.

	Stage 1	Stage 2	Stage 3	P value
	Median (min to max) or mean±SD	Median (min to max) or mean±SD	Median (min to max) or mean±SD	P value
SBP (mm Hg)	120.0 (100.0–127.0)	103.0 (90.0–124.0)	80.0 (75.0–80.0)	0.056^a
DBP (mm Hg)	65.4±11.8	60.0±18.4	51.8±22.4	0.079^b
Heart rate (beats/min)	87.0 (78.0–98.0)^c	100.0 (85.0–118.0)^c	130.0 (125.0–138.0)^c	0.002^a
SO₂ (%)	98.0 (98.0–99.0)^c	97.5 (97.0–98.0)^c	96.0 (88.0–97.0)^c	0.038^a
Glucose (mg/dL)	99.0 (89.0–107.0)	110.5 (95.0–123.0)	105.0 (86.0–160.0)	0.101^a
AST (U/L)	22.6±8.9^c	24.5±5.3^c	33.4±12.0^c	0.023^b
ALT (U/L)	15.0 (12.0–21.0)	16.5 (13.0–19.0)	21.0 (18.0–22.0)	0.231^a
LDH (U/L)	256.3±89.8	268.3±69.9	305.4±90.0	0.442^b
CK-MB (microgram/dL)	2.0 (2.0–3.5)^c	3.2 (2.5–4.8)^c	4.0 (2.3–4.0)^c	0.012^a
Creatinine (mg/dL)	0.64±0.15	0.60±0.15	0.68±0.19	0.352^b
PLT (10³/μL)	265.0 (228.0–295.0)	246.0 (198.0–291.0)	223.0 (180.0–350.0)	0.614^a
WBC (10³/μL)	10.1 (7.6–11.8)	10.3 (7.8–12.7)	14.0 (13.9–14.5)	0.051^a
Hgb (g/dL)	13.4±1.5	13.7±1.7	12.7±0.9	0.472^b
INR	1.1 (1.0–1.2)	1.1 (1.0–1.2)	1.6 (1.0–1.6)	0.402^a

^aKruskal-Wallis was applied.

^bOne-way analysis of variance was applied.

^cGroup from which the difference originates.

Discussion

The incidence of scorpion stings in Turkey is approximately 36 per 100,000 people, and the estimated mortality rate due to scorpion stings is 0.01.^7,8 In our study, the incidence of scorpion stings in children in Adıyaman province was calculated as 49.43/100,000, with a mortality rate of 1.27/100,000 and a fatality rate of 2.56% per year.

According to a study conducted in the Sanliurfa region of Turkey, scorpion stings were most commonly found in the extremities, such as the hand, arm, leg, thigh, and foot.⁹ Another study conducted in Morocco found that the most common sites of scorpion stings were the upper limbs, lower limbs, and trunk.⁵ Therefore, the distribution of scorpion stings in different body parts can vary depending on the geographical location and the type of scorpion involved. In our study, 39.7% of scorpion stings were in the lower extremity, 43.6% were in the upper extremity, 15.4% were in the trunk, and 1.3% were in the head and neck region.

According to the research results, there is a difference in sex distribution in scorpion stings. In Tunisia, Egypt, Saudi Arabia, Argentina, and Brazil, most scorpion stings were seen in males.^9,10 However, in a study conducted in the Sanliurfa region of Turkey, scorpion stings were primarily seen in females.³ It is important to note that scorpion envenomations are more severe in children, and epidemiological studies have shown that most scorpion stings were seen in boys.¹¹ Therefore, sex differences in scorpion stings can vary depending on the population’s geographical location and age group. In our study, scorpion stings were seen in 51.3% of women and 48.7% of men.

According to the Abroug classification, in our study, 65.4% of the cases were Stage 1, 28.2% were Stage 2, and 6.4% were Stage 3. These data are similar to the study conducted by Kurt and Ak¹² in Turkey in 2020 (Stage 1, 64.6%; Stage 2, 30.8%; Stage 3, 4.6%). However, the rates in the study conducted by Ismail et al¹³ in Egypt in 2022 are very different from those in Turkey, with 12.2% (Stage 1), 55.6% (Stage 2), and 32.3% (Stage 3).

Another study conducted in Saudi Arabia found that the majority of scorpion stings were classified as mild (class I) or moderate (class II) according to the Abroug classification.¹ The study also found that severe scorpion stings (class III) were rare, but they were associated with a high mortality rate when they did occur. This may be due to the different scorpion species in the countries and may also be related to the time elapsed between the scorpion sting and admission to the hospital.^14,15

Of the patients in our study, 56 (71.8%) were followed up in the ED, 17 (21.8%) were followed up in the inpatient unit (IU), and 5 (6.4%) were followed up in the ICU. In the study by Ismail et al,¹³ 14.5% of the patients were followed up in the ICU. In our study, an alpha blocker (prazosin) was used at a rate of 12.8%, and in a study conducted by Kurt and Ak,¹² the rate of prazosin use was 14.4%.

Although the fatality rate in children aged <15 y is 23% in Niger, Abroug et al,⁸ in their study in 2020, stated that the fatality rate from scorpion stings was 1% in the world.¹⁶ In studies on scorpion stings in children in Turkey, the fatality rate ranges from 0 to 12.5%.¹⁷ In our study, 2 of 78 patients died, and the fatality rate was 2.56%. One of the children who died was aged 1 y, and the other was aged 5 y. A 1-y-old boy was stung on the neck, and a 5-y-old boy was stung on the torso. The death of a single patient stung on the head and neck region is consistent with the knowledge that the sting site is close to the head, aggravating the clinical course.^14,18

Serum blood glucose, leukocyte, platelet, LDH, creatinine, hemoglobin, AST, alanine transaminase, creatine phosphokinase, and troponin levels and international normalized ratio may increase in scorpion stings.^13,19 The findings in our study were compared between children aged ≤6 y and those aged >6 y. Heart rate, LDH, CK-MB, platelets, and leukocytes were higher in children aged ≤6 y. Systolic blood pressure, diastolic blood pressure, creatinine, and hemoglobin concentrations were higher in those aged >6 y. These findings in our study are similar to those in the study by Kurt and Ak.¹² Therefore, 6 y of age can be used as a cutoff value for clinical evaluation in children.¹²

Elevated AST, alanine transaminase, and creatinine phosphokinase may indicate cardiac and/or skeletal muscle damage. With these 2 values, hemoglobin, white blood cell count, and activated prothrombin time are higher in severe poisoning than in mild-moderate concentration poisoning.¹⁹ In our study, CK-MB concentrations were significantly higher in Stage 1 patients compared to Stage 2 patients and those who were followed up in the IU compared to patients in the ED. Although this may seem contradictory, blood tests, working from the blood sample taken when the patient first applied to the ED, and the late rise of CK-MB compared to other parameters, may explain the initial low concentrations. However, AST values were significantly higher in our patients who were followed up in the IU or the ICU than in those who were followed up in the ED. Our study also supports the study by Bosnak et al.¹⁹ It shows that CK-MB and AST can be evaluated as indicators of the severity of poisoning in scorpion stings.²⁰

In our study, the leukocyte concentration was found to be significantly higher in the patients followed up in the ICU compared to the patients followed up in the ED. This finding is consistent with other studies stating that leukocyte elevation correlates with the severity of poisoning.^11,13,20

In the literature, we could only find 1 study examining the difference between the sting site and LDH values in scorpion stings. In their study, Kurt and Ak¹² found that LDH concentration was lower in head and neck or trunk stings than in lower extremity stings. On the contrary, in our study, the LDH value was significantly higher in upper extremity stings compared to trunk stings and in trunk stings compared to lower extremity stings. Lactate dehydrogenase concentration rises in pulmonary and cardiac tissue damage.²¹ The closer the scorpion sting is to the head, the greater the severity of the poisoning.^14,18

A study conducted in Iran found that the LDH concentration was significantly higher in patients with severe scorpion stings compared to those with mild or moderate stings.²² Another study conducted in Tunisia found that the LDH concentration was significantly higher in children with severe scorpion stings than in those with mild or moderate stings.²³ Therefore, measuring LDH concentrations in patients with scorpion stings can be a valuable tool in assessing the severity of the sting and monitoring the patient’s response to treatment. However, it is essential to note that LDH concentrations can also be elevated in other conditions, such as heart attack, liver disease, and muscle injury. Hence, a comprehensive evaluation of the patient’s clinical status is necessary to make an accurate diagnosis.

In our study, LDH was higher in patients who were stung, especially in the head and neck region, and this is because the presentation is worse in patients who are stung in the head and neck region. In our study, similar to the literature, it was shown that the symptoms worsened as the LDH concentration increased.

Conclusion

In conclusion, this research conducted in the Southeastern Anatolia Region of Turkey demonstrated the significant determinants in the clinical course and prognosis prediction of scorpion envenomations. Elevated laboratory parameters such as increased leukocyte count and CK-MB, AST, and LDH concentrations are emphasized to be associated with unfavorable prognosis among the patients. Furthermore, the study underscores the impact of different sting locations, revealing that stings to the head, neck, and upper extremities correlate with more severe outcomes compared to stings on the trunk or lower extremities. These findings provide crucial guidance for healthcare professionals to better assess scorpion envenomation cases and intervene according to patients’ specific needs. Future investigations may aim to validate these findings in a broader patient population and across diverse geographical regions, thus facilitating the development of effective treatment and management strategies for scorpion envenomations.

Footnotes

Author Contribution(s)

Study concept and design (OK, MEP, EÖ); acquisition of the data (OK, MEP); analysis of the data (OK, MEP); drafting of the manuscript (MEP, EÖ); critical revision and approval of the final manuscript (MEP, EÖ, OK).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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