A Cause of Hematuria Following Hemiscorpius acanthocercus (Scorpiones: Hemiscorpiidae) Sting in South of Iran

AUTHORS

Mehran Shahi 1 , Parivash Davoodian ORCID 2 , Nasrin Davaridolatabadi 3 , Mehraban Shahi 3 , *

1 Department of Medical Entomology and Vector Control, School of Public Health and Infectious and Tropical Diseases Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

2 Infectious and Tropical Diseases Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

3 Department of Health Information Technology, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

How to Cite: Shahi M, Davoodian P , Davaridolatabadi N , Shahi M. A Cause of Hematuria Following Hemiscorpius acanthocercus (Scorpiones: Hemiscorpiidae) Sting in South of Iran, Hormozgan Med J. Online ahead of Print ; 24(1):e95481. doi: 10.5812/hmj.95481.

ARTICLE INFORMATION

Hormozgan Medical Journal: 24 (1); e95481
Published Online: March 9, 2020
Article Type: Case Report
Received: June 18, 2019
Revised: January 6, 2020
Accepted: February 15, 2020
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Abstract

Introduction: A scorpion sting is one of the major medical problems in southern Iran. Hemiscorpius scorpions are the most dangerous species in this area and Hemiscorpius acanthocercus belonging to this genus is distributed in the southern part of Iran. The venom of this scorpion causes pathological changes in the blood and kidney of the victims, which eventually lead to hemolysis and renal failure.

Case Presentation: This report describes the occurrence of severe hematuria in a patient within a few hours after the scorpion sting.

Conclusions: The present report suggests that more studies are needed to set out a protocol for the management of scorpion stings in high risk areas.

Copyright © 2020, Hormozgan Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Introduction

Scorpion stings are of clinical importance worldwide, which is associated with cardiovascular toxic effects or neuromuscular toxic effects that leads to illness and in children the cause of death (1). Various complications due to scorpion sting have been described in literature, such as cerebral edema, subarachnoid hemorrhage, encephalopathy, hemorrhagic, and cortical necrosis (2). Hemiscorpius species are the most venomous scorpions in the south and southwest of Iran. Their sting is associated with serious clinical symptoms. Most of the deaths due to scorpion stings in Iran are caused by Hemiscorpius lepturus (3). This case represents the first report of clinical complication of H. acanthocercus envenomation exhibited in the form of extensive hematuria in a young child from the South of Iran.

2. Case Presentation

A 12-year-old female resident of Bashagard, which is in the South of Iran was stung 24 hours before admission by H. acanthocercus on her face and flank (Figure 1). Based on her mother’s description, five hours after envenomation and hematuria, she was referred to the hospital. She received two vials of scorpion antivenom and hydrocortisone in the hospital. Due to the severe envenomation, she was transferred to the central hospital in Bandar Abbas District. Primary symptoms included vomiting, lethargy, abdominal pain, headache, fever, and hematuria. Vital signs were fever = 39.6°, BP = 100/60, PR = 110, and RR = 30. Tow cyanotic spots, erythema without pain was observed at the sting site. On the second day, her temperature was lower = 38°, WBC = 18 - 20, RBC = 25 - 30, blood = 3+, PH = 5, and the color of urine bloody. The patient was hospitalized for nine days due to the severity of the disease. Due to severe hematuria and ill condition, she was transferred to the intensive care unit (ICU). Laboratory findings on the first day are shown in Tables 1 and 2. The results of hematology and biochemistry test were as follows: Hemoglobin = 12.4 g/dL, white blood cell = 15.4 × 103/µL, red blood cell = 15.4 × 103/µL, MCV = 75.6 × 103/µL, platelet = 508 × 103/µL, SGOT = 1000 U/L, SGPT = 408 U/L, PTT = 60 S, PT = 17 S, serum creatinine = 0.5 mg/dL, sodium = 140 mEq/L, potassium = 5.6 mEq/L, BUN = 20.6 mg/dL, blood urea = 44 mg/dL, total bilirubin = 10.3 mg/dL, and urine microscopy showed hematuria. The patient was discharged with good condition on the ninth day.

H. acanthocercus (pedipalps stout and bulky, pedipalp chela manus color predominantly orange to redbrown, metasoma very elongated and slender) male from Hormozgan province, south of Iran, (Scale, 10 mm).
Figure 1. H. acanthocercus (pedipalps stout and bulky, pedipalp chela manus color predominantly orange to redbrown, metasoma very elongated and slender) male from Hormozgan province, south of Iran, (Scale, 10 mm).
Table 1. Urine Analysis Laboratory Test Results
TestResults Day 1
Hemoglobin2+
ColorBloody
AppearanceTurbid
PH6.5
Proteins3+
BloodTrace
WBC1 - 2
RBC3 - 4
Epithelia cells1 - 2
Table 2. Hematology Test Results
TestResults Day 1Normal Range
WBC× 103 µL9.84 - 10
RBC, miciu/mL4.294.6 - 6.2
HGB, g/dL1010 - 12
HCT, %31.931 - 52 hk
MCV, f lit74.480 - 96
MCH, pg23.326 - 32
MCHC, g/dL31.326 - 36
PLT × 103 µL56150 - 400

3. Discussion

The presented data in Tables 1 and 2 showed that patients who were stung by H. acanthocercus developed renal changes, the hematology and biochemistry parametric were significant. This data is consistent with the results of the Rahmani and Jalali (3), and Pourkhalili et al. 2014, finding in Iran. The results of the hemoglobinuria test in a study by Mohseni (4) showed that the most severe hemoglobinuria (+4) occurred in the victims stung by H. lepturus.

The symptoms observed in our patient was similar to some of the symptoms listed above.

Biochemistry result showed that urea, BUN, and total bilirubin increased to 44 mg/dL, 20.6 mg/dL and 10.3, respectively. Increasing BUN and Urea levels in victims were good markers of renal failure, following a H. lepturus sting (4). Therefore, based on this result and finding of this report, the levels of BUN of the blood may be used as factors signifying in Hemiscorpus sting.

In this case, calcium decreased to 8.3 mg/dL and potassium increased to 5.6 mEq/L. The neurotoxic fraction of H. lepturus venom contains a peptide active on Ca2+ channels called hemicalcin (5). Fever, confusion, hematuria, hemoglobinuria, and decrease in hemoglobin level were observed in this case. The histology results in Tables 1 and 2 showed that H. acanthocercus venom caused pathological changes in the blood and kidney. Based on this patient, the sting of H. acanthocercus does not cause severe pain. Isbester reported that the patient likened it to pain of an ant sting (1). The results of this report and other studies showed that laboratory tests including hematology, biochemistry, and urine analysis can be of great help in early detection and treatment of scorpion victims. Anemia, due to reduced RBC and hemoglobinuria, should also be seriously considered. Increasing knowledge about the mechanism of action venom, especially of medically important scorpions, can help patients. Scorpion sting is a medical problem for residents in south regions of country. In this region the most venomous scorpion is Hemiscorpius, which belong to the family Hemiscorpiidae. The venom of H. acnthocercus has cytotoxic effects. This venom result in the manifestation of a number of clinical symptom such as hemoglobinuria, proteinuria, hematuria, necrosis, hemolysis of blood cells, and lower creatinine excretion. These toxic effects are more severe and fatal in children. Urine analysis, hematology, and biochemistry data should be considered to be the most important factors in the follow-up of scorpion victims.

3.1. Conclusions

This report showed that the venom of H. acanthocercus such as H. lepturus had an effect on erythrocyte hemolysis. Therefore, H. acanthocercus envenoming must be considered as a serious medical emergency that requires immediate attention. Based on the available evidence, it appears that H. acanthocercus is one of the most dangerous scorpions found in Hormozgan, the south Province of Iran. Due to lack of physicians’ knowledge about scorpion species, treatment is difficult, therefore, patients, especially children, are at risk. This report suggests that more studies are needed to set out a protocol for the management of scorpion sting in high risk area.

Acknowledgements

Footnotes

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