Neurologic Complications in Children With Scorpionism: A Retrospective Study in Upper Egypt

The aetiologies, mortality, and disability of non-traumatic coma in African children: a systematic review and meta-analysis

BACKGROUND

Non-traumatic coma in African children is a common life-threatening presentation often leading to hospital attendance. We aimed to estimate the distribution of non-traumatic coma causes and outcomes, including disease-specific outcomes, for which evidence is scarce.

METHODS

We systematically reviewed MEDLINE, Embase, and Scopus databases from inception to Feb 6, 2024. We included studies recruiting children (aged 1 month to 16 years) with non-traumatic coma (Blantyre Coma Scale score ≤2, ie deep coma or comparable alternative) from any African country. Disease-specific studies were included if outcomes were reported. Primary data were requested where required. We used a DerSimonian-Laird random effects model to calculate pooled estimates for prevalence of causes, mortality, and morbidity (in-hospital and post-discharge), including analysis of mortality by temporality. This study was registered with PROSPERO (CRD4202014193).

FINDINGS

We screened 16 666 articles. 138 studies were eligible for analysis, reporting causes, outcome data, or both from 35 027 children with non-traumatic coma in 30 African countries. 114 (89%) of 128 studies were determined to be high quality. Among the causes, cerebral malaria had highest pooled prevalence at 58% (95% CI 48-69), encephalopathy of unknown cause was associated with 23% (9-36) of cases, and acute bacterial meningitis was the cause of 10% (8-12) of cases, with all other causes representing lower proportions of cases. Pooled overall case-fatality rates were 17% (16-19) for cerebral malaria, 37% (20-55) for unknown encephalopathy, and 45% (34-55) for acute bacterial meningitis. By meta-regression, there was no significant difference in cerebral malaria (p=0·98), acute bacterial meningitis (p=0·99), or all-cause coma (p=0·081) mortality by year of study. There was no substantial difference in deaths associated with cerebral malaria in-hospital compared with post-discharge (17% [16-19] vs (18% [16-20]). Mortality was higher post-discharge than in-hospital in most non-malarial comas, including acute bacterial meningitis (39% [26-52]) vs 53% [38-69]). Disability associated with cerebral malaria was 11% (9-12). Pooled disability outcomes associated with other non-malarial diseases were largely absent.

INTERPRETATION

The prevalence and outcomes of cerebral malaria and meningitis associated with non-traumatic coma were strikingly static across five decades. Enhanced molecular and radiological diagnostics, investment, policy making, community awareness, and health service provision are all required to facilitate earlier referral to specialist centres, to drive a step-change in diagnostic yield and treatment options to improve these outcomes.

FUNDING

Wellcome Trust.

TRANSLATIONS

For the Chichewa, French and Portuguese translations of the abstract see Supplementary Materials section.

EFFECT OF SCORPION VENOM TOXINS ON STRUCTURAL AND FUNCTIONAL PARAMETERS OF INTERNAL ORGANS, INCLUDING KIDNEYS (REVIEW)

OBJECTIVE

The aim: To establish patterns of structural and functional changes in internal organs, including kidneys, under the conditions of exposure to scorpion venom toxins.

PATIENTS AND METHODS

Materials and methods: A thorough literature analysis was conducted on the basis of PubMed, Google Scholar, Web of Science, and Scopus databases. When processing the search results, we chose the newest publications up to 5 years old or the most thorough publications that vividly described the essence of our topic.

CONCLUSION

Conclusions: The venom of various species of scorpions exhibits a wide range of biological activity. Acting on the structures of the central and peripheral nervous system, the toxins of scorpion venom cause the development of paralysis, convulsions, brain inflammation, hemorrhagic and ischemic strokes. Under conditions of influence on the cardiovascular system, damage to the endothelial lining of the vascular wall, disturbances in heart rhythm, conduction, and the development of destructive changes in the myocardium are characteristic. Data on kidney damage due to scorpion bites require a more detailed study, as information on microscopic and submicroscopic changes in the structure of the organ is too limited. However, cases of the development of tubular necrosis, interstitial nephritis, and kidney infarction are currently known.

DNA Barcoding for Scorpion Species from New Valley Governorate in Egypt Reveals Different Degrees of Cryptic Speciation and Species Misnaming

(1) Background: Scorpions (Arthropoda: Arachnida) represent a diverse group of invertebrates, accounting for a significant proportion of earth’s predators and ecosystems’ modulators. Surviving mostly in hardly reachable nests, and representing key hazards to human health, they attracted major interest for characterizing their eco-, morpho-, and genotypes. (2) Methods: Four scorpion species were collected from the New Valley governorate in Upper Egypt, where a high level of scorpionism and related neurological symptoms are found, that were Leiurus quinquestriatus, Androctonus amoreuxi, Orthochirus innesi, Buthacus leptochelys. They were DNA barcoded, genetically and phylogenetically analyzed through PCR amplification and sequencing of the mitochondrial cytochrome oxidase subunit 1 (COI) gene hypervariable 5′ region. (3) Results: New, morphologically authenticated scorpion barcodes could be added to the barcoding databases. However, several discrepancies and barcode database inadequacies could be revealed. Moreover, taxon-specific patterns for nitrogenous bases’ distribution could be identified, resulting in a significantly high percentage of COI barcode guanine in scorpionids, in comparison to araneids and opilions. (4) Conclusions: For a group of animals where both cryptic speciation and a high risk of human envenomation are evident, the findings of the current study strongly recommend continuous and comprehensive research efforts dealing with morphogenetic authentication for different species of scorpions.

Neurological and Systemic Manifestations of Severe Scorpion Envenomation

Scorpion envenomation is a life-threatening toxicological emergency and considered as a major public health problem, especially in endemic regions (India, Africa, Latin America); it is generally characterized by low resources and tropical or subtropical weather. Scorpion envenomation is especially fatal in the first hours, usually due to respiratory and/or cardiovascular collapse. The neurologic manifestations, triggered by multiple neurotoxic mechanisms, are varied and complex and mostly reported in children. The aim of this review is to clarify the epidemiologic characteristics and clinical manifestations as well as diagnosis and management of neurologic complications following scorpion envenomation. The management of patients with severe clinical forms is based on early recognition of the sting, antivenom serum administration, and cardiorespiratory and systemic support.

Pediatric scorpionism in northern Amazonia: a 16-year study on epidemiological, environmental and clinical aspects

Background:

The Amazon basin is one of the seven major geographical areas where scorpionism is recorded. In French Guiana, 90 stings per 100,000 inhabitants are registered per year. As the severity of cases is higher in children, descriptive studies are needed to have a better understanding of this pathology. The aim of the present study is to describe pediatric scorpionism in French Guiana.

Methods:

We conducted a monocentric descriptive retrospective study on scorpion stings in all pediatric patients admitted to Cayenne General Hospital from January 1, 2002 to December 31, 2018.

Results:

In this survey, 132 patients were included. Of them, 63% were male. Patients with general signs of envenomation were younger and lighter (p = 0.04). The picture was “one sting” (95.3%) by a “big” (47.6%), “black” (60%) and “small pincer” (58%) scorpion on the extremity of the body (84%). Stings occurred mainly during the day, while patients changed clothes. There was no envenomation during night. The monthly evaluation highlights that the number of stings and percentage of general signs of envenomation were closely connected to a composite variable including the variation of the level of rivers (p = 0.005). Cardiac symptoms were recorded in 82% of cases with general signs of envenomation. The presence of pulmonary; ear, nose, and throat (ENT); or gastrointestinal symptoms are related to major envenomation (p = 0.001, p = 0.01, and p = 0.02 respectively). Leukocytosis and glycemia increased according to the envenomation grade whereas serum potassium and alkaline reserve decreased. Forty-six patients needed hospitalization and seven of them required intensive care. No patient died nor presented sequelae at discharge from the hospital.

Conclusion:

Pediatric scorpionism in French Guiana is closely associated with child activities and climatic conditions. Severe envenomation presented most of the time with cardiac, pulmonary, and gastrointestinal symptoms.

Avaliação do uso de soros antivenenos na emergência de um hospital público regional de Vitória da Conquista (BA), Brasil

Resumo O presente estudo tem como objetivo caracterizar o perfil epidemiológico de vítimas de acidentes escorpiônicos e ofídicos e avaliar a adequação das prescrições de soros antivenenos. Estudo transversal cujas fontes de dados foram as fichas de notificação de acidentes por animais peçonhentos do Sistema de Informação de Agravos de Notificação no município de Vitória da Conquista (BA), Brasil. Foram incluídas as informações de acidentes escorpiônicos ou ofídicos no período entre julho de 2016 e junho de 2017 atendidos no município. Os dados obtidos e as variáveis de interesse foram analisadas de acordo com as perguntas deste estudo. No período observado foram atendidas 293 vítimas de acidentes por animais peçonhentos. Destas, 149 (50,9%) foram homens e 114 (38,9%) possuíam entre 20 a 59 anos. Foram 235 (80,9%) casos de escorpionismo e 58 (19,1%) de ofidismo. Destes, 203 (69,3%) foram classificados como leves e em 200 (68,5%) casos foi prescrita soroterapia para estes pacientes. Quanto à adequação das prescrições, 172 (59,7%) foram julgadas inadequadas e destas, o uso de número de ampolas acima do indicado foi a mais frequente. A prescrição inapropriada de soros antivenenos ocorreu em aproximadamente em 60% dos casos avaliados. Apesar disso, a maioria dos acidentes foi classificada como leve, em homens jovens.

A randomized comparative study between intravenous and intramuscular scorpion antivenom regimens in children

BACKGROUND

Scorpion envenomation and its consequences represented a serious healthcare problem in Upper Egypt and considered to be an important cause of life-threatening emergency particularly in children.

METHODS

One hundred patients presented to the emergency department of Assiut University Children Hospital with a history of scorpion sting aged less than 18 years were included in our randomized comparative trial during 2016. Two groups of patients were randomly categorized according to the route of administration of scorpion antivenom; intramuscular and intravenous with 50 patients in each group. Full history, clinical examination, and routine baseline investigations were performed.

RESULTS

Myocarditis, encephalopathy, cardiogenic shock, ICU admission, need for mechanical ventilation, mean hospital stay and mortality were significantly lower in those received intravenous antivenom compared with those received intramuscular one.

CONCLUSION

The results of the present study and other experimental and clinical trials confirmed that the administration of the scorpion antivenom by intravenous route has a lower incidence of systemic toxicity, a better outcome of fatal complication resulted from envenomation especially cardiogenic shock, decreased need for ICU facilities and mechanical ventilation, shorter hospital stay, and better overall outcome than the intramuscular route.

TRIAL REGISTRATION NUMBER

UMIN-CTR Study Design: trial number: UMIN000022032.

Evidence of Direct Toxicological Effects of Scorpion Venom on Central Nervous System in Tunisian Children

Background

Severe scorpion envenomation can lead to severe neurological manifestations, which are an indicator of the severity of the scorpion sting. The direct action of scorpion venom on the central nervous system can explain partly these neurological disorders.

Methods and Findings

We report a case of severe scorpion envenomation in 16-month-old boy with no pathological history admitted in ICU for severe scorpion envenomation. The result of cerebral MRI agrees with the hypothesis of direct action of scorpion venom on the central nervous system. Patient had improved; however, he has kept as neurological sequelae language disorders and blindness. The boy was discharged 21 days after ICU admission.

Conclusion

Our observation confirms that severe scorpion envenomation can be complicated by severe neurological manifestations. Although one case report is not enough to conclude such important hypothesis regarding the direct effect of scorpion venom on central nervous system (especially that the age of patient is more than one year), our case agrees with this hypothesis.