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Clinical and Laboratory Characteristics of Pediatric Scorpion Stings: A

Report From Southern Iran

Article  in  Pediatric emergency care · November 2015

DOI: 10.1097/PEC.0000000000000559

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 ORIGINAL ARTICLE
Clinical and Laboratory Characteristics of Pediatric
Scorpion Stings
A Report From Southern Iran
Maryam Dehghankhalili, MD,* Hossein Mobaraki, PhD,† Armin Akbarzadeh, MD-MPH student,‡§
Reza Yazdani, MD,¶ Abdolmajid Nazemi, MD,# Fariborz Ghaffarpasand, MD,**
Zahra Mohammadi, MD,†† Mohammad Esmaeil Shahrzad, MD,††
Forugh Mohmudi, MD,†† Mohsen Taghavi, MD,†† and Saeed Dehghankhalili, Medical Student§
Objective: Scorpion stings are a major public health problem in many
countries, particularly in pediatrics. Children are more susceptible to severe
clinical manifestations of envenomation. The aim of this study is to
determine the epidemiological and clinical characteristics of pediatric
scorpionism in Hormozgan province of Iran during 2012.
Method: This was a cross-sectional study being conducted during 2010
in Hormozgan, the southern province of Iran. We included 350 patients
admitted to emergency unit of the hospitals of 8 cities of Hormozgan with
impression of scorpion envenomation. The clinical and epidemiological
characteristics as well as the treatment and outcome were recorded.
Results: The prevalence rate of pediatric scorpion stings in the province
was 1.8 in 1000 children. The mean age of the patients was 5.75 ± 4.54
(range, 1–18) years. There were 208 (59.5%) boys and 142 (40.5%) girls
among the patients. The most common site of sting was sole to knee in
94 (26.8%) followed by hand in 61 (17.4%) and fingers in 47 (13.4%).
The most common presenting symptom was vomiting in 236 (67.4%)
followed by localized pain in 131 (37.3%), erythema in 120 (34.2%), and
edema in 119 (33.9%). The highest and lowest frequency occurred in
July (17.7%) and January (3.2%), respectively. Nocturnal envenomations
(53.7%) were more common than diurnal (46.3%). Most of scorpionism
were mild (83.4%) that all evolved to cure, without any deaths.
Conclusions: The results demonstrate the pediatric scorpionism is a
public health problem in Hormozgan province of Iran, and special attention
should be paid to prevention and treatment.
Key Words: scorpionism, epidemiology, Hormozgan, Iran
(Pediatr Emer Care 2015;00: 00–00)
S corpion stings are a major public health problem in many
countries, particularly among children.1,2 Children are more
susceptible to severe clinical manifestations of envenomation.3
Envenomations are usually characterized by some symptoms that
are common among young victims; such as local pain with
variable intensity, restlessness, agitation, and hypertension.4 De-
pending on the scorpion species, envenomation may cause
systemic manifestation, although it is uncommon. Cardiorespira-
tory manifestations may be presented in some victims that
From the *Health Policy Research Center, Shiraz University of Medical Sci-
ences, Shiraz; †Department of Epidemiology, Tehran University of Medical
Sciences, Tehran; ‡Trauma Research Center, §Student Research Committee,
Shiraz University of Medical Sciences, Shiraz; ¶Trauma Research Center, #Pe-
diatric Research Center, Hormozgan University of Medical Sciences, Bandar
Abbas; **Neuroscience Research Center, Shiraz University of Medical Sci-
ences, Shiraz; and ††Student Research Committee, Hormozgan University of
Medical Sciences, Bandar Abbas, Iran.
Disclosure: The authors declare no conflict of interest.
Reprints: Armin Akbarzadeh, MPH, Trauma Research Center, Shiraz
University of Medical Sciences, Shiraz, Iran, Trauma Research Center,
Rajaee Hospotal, Chamran Avenue, Shiraz 71348-43638, Iran
(e‐mail: armin.akbarzadeh@ymail.com).
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0749-5161
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
could lead to death.5,6 Hormozgan is a southern province of
Iran, such as many tropical areas near the Persian Gulf region,
has a high incidence of envenomation by scorpion stings.7
There are more than 23 scorpion species in Iran. Six species
are dangerous, in which 5 species exist in Hormozgan pro-
vince, including Hemiscorpiuslepturus, Androctonuscrassicauda,
Hottentottasaulcyi, Hottentottaschach, and Mesobuthuseupeus.7,8
Serotherapy is a common treatment for victims of scorpion sting
that its proper dose and administration protocol is based on
the National Expert Committee or manufacturer advice. There
are some studies in different parts of the world by that evaluated
the epidemiology and clinical characteristics, and outcomes of
victims, envenomed by scorpion sting.1,3,7,9–11 Considering the
high population of dangerous species in Hormozgan province,
and due to more susceptibility of children to severe complications,
we decided to study epidemiology, clinical manifestation, and out-
come of scorpionism in children in Hormozgan province, Iran.
METHODS
Study Area and Population
This was a cross-sectional study being performed in
Hormozgan, a southern province of Iran which is located nearby
the Persian Gulf and Gulf of Oman during a 1-year period of time
from March 2010 to March 2011. Hormozgan is the youngest
province of the country where 29% of its population is consisted
of children between 0 and 14 years. The data were obtained from
Bandar Abbass Children Hospital that is a tertiary referral center
for pediatric diseases from all hospitals of Hormozgan province.
Also, patients with severe complication of scorpion envenomation
are referred to this center. We included all the pediatric patients
(<14 years) who were admitted to our center during the study
period with a diagnosis of scorpion bite. Scorpionism was docu-
mented in the emergency room according to the patients' history
and the presence of the biting animal. Adult patients, those suspi-
cious to animal bites other than scorpion, and those with suspected
bites were excluded from the study. The study protocol was
approved by the institutional review board of Hormozgan University
of Medical Sciences.
Data Collection and Recording Process
We designed a data gathering form containing information
about envenomation accidents. This questionnaire was completed
by emergency unit in the admission time and by physicians during
hospitalization. The form included the baseline characteristics and
clinical information, such as age, sex, time and date of admission,
date of discharge, site of stung, the time between envenomation
and admission, vital signs. Also, signs and symptoms in addition
to some laboratory tests in the admission and discharge were
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Dehghankhalili et al Pediatric Emergency Care • Volume 00, Number 00, Month 2015

RESULT
TABLE 1. Epidemiological and Clinical Characteristics of
Envenomed Children
Epidemiology
Variable Value Three hundred fifty-one questionnaires were completed for
stung children who were admitted to our referral center in 2011.
Total number 350
Accidents happened year-round, but it was more frequent in warm
Mean age (±SD) 5.75 (±4.546) months. The mean (±SD) age of victims were 5.75 (±4.54). The
Sex rate of envenomation was approximately similar in both sexes
Male 209 (59.5%) (59.5% boys; 40.5% girls). The mean period between sting occur-
Female 142 (40.5%) rence and admission to hospital was 8.86 (±15.2) hours. We
Interval between sting and admission, h 8.86 (±15.2) recorded the site of sting in 11 groups, as illustrated in Table 1.
Site of sting Stings occurred more frequently in lower and upper extremities,
Sole to knee 94 (26.8%) and the least frequencies belong to surface of abdomen (3.1%)
Hand 61 (17.4%) and thorax (4.8%) (Table 1).
Finger 47 (13.4%)
Leg 34 (9.7%) Clinical Findings
Head and neck 25 (7.1%) Systemic symptoms were more frequent compared with the
Forearm 21 (6.0%) local signs. The most frequent systemic symptoms were reported
as: cardiac signs (95.4%), vomiting (67.2%), hematuria (53%),
Back 21 (6.0%)
and urine discoloration (43.9%). Also, the most common local
Thorax 17 (4.8%) signs among the patients were: pain (37.3%), erythema (34.2%),
Abdomen 11 (3.1%) edema (33.9%), and cyanosis (16.8%). Some symptoms such as
Symptoms induration (0.3%), incontinence (0.6%), hypertension, hyperosto-
Cardiac signs 335 (95.4%) sis, tachypenea, and blister (0.9%) were rarely reported (Table 1).
Vomiting 236 (67.2%) Vital signs of the patients were recorded at the time of admis-
Urine coloration 154 (43.9%) sion, including: pulse rate, respiratory rate, temperature, diastolic
Pain 131 (37.3%) blood pressure, and systolic blood pressure. Tachypnea was usual
Nausea 120 (34.2%) among patients with a rate of 87.0%. Although tachycardia was a
Erythema 120 (34.2%) common symptom 58.9%, bradycardia was rare (1.2%). Most of
the victims had normal blood pressure. Hypotension was also
Edema 119 (33.9%)
seen in some of the patients, but hypertension was approximately
Distress 107 (30.5%) rare. Fever was seen in a few patients (3.9%) Temperature was
Headache 69 (19.7%) mostly normal (Table 2).
Cyanosis 59 (16.8%)
Vertigo 50 (14.2%) Laboratory Findings
Sweating 26 (7.4%) Laboratory analysis was conducted for all stung children,
Cachexia 24 (6.8%) which consisted of urinalysis and blood test. Urinalysis records
Cellulitis 24 (6.8%)
Necrosis 11 (3.1%)
Chills 11 (3.1%) TABLE 2. Vital Signs of Stung Children on Admission
Photophobia 10 (2.8%)
Malaise 8 (2.3%) Vital Signs n (%)
Convulse 7 (2.0%) Systolic blood pressure, mm Hg
Blister 3 (0.9%) Hypotension, % 28 (7.9%)
Hyperstasis 3 (0.9%) Normal, % 319 (91.1%)
Incontinence 2 (0.6%) Hypertension, % 13 (1.0%)
Induration 1 (0.3%) Diastolic blood pressure
Hypotension, % 38 (10.9%)
Normal, % 298 (85.1%)
recorded in the questionnaire. Patients were usually discharged Hypertension, % 14 (4.0%)
after 24 hours by physician's permission or patients' consents. Af- Respiratory rate
ter 24 hours from discharge of patients, we asked them about any Tachypnea 294 (87.0%)
probable symptoms, by phone call. Normal 44 (13.0%)
Pulse rate
Statistical Analysis Bradycardia 4 (1.2%)
Normal 142 (40.6%)
Data were prospectively entered into a computer database Tachycardia 204 (58.2%)
and was further analyzed using Statistical Package for Social Temperature
Sciences (SPSS Inc., Chicago, IL) version 16. Descriptive statis- Hypothermia 1 (0.3%)
tics was used for analysis. Data were reported as mean ± SD and Normal 335 (95.8%)
proportions as appropriate. The results were compared to several Fever 14 (3.9%)
national and international studies.

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Pediatric Emergency Care • Volume 00, Number 00, Month 2015 Pediatric Scorpion Stings in Southern Iran

and redness, were much more common among the patients.10,12,13

TABLE 3. Laboratory Tests in the Time of Admission and Discharge In our investigation, a cardiac sign, such as tachycardia, was the
most common symptom among the victims, which is an indica-
Time of Time of
tion for intensive care unit admission. Systematic symptoms are
Parameter Admission Discharge
more dangerous than local ones, so it needs much more care and
Urinalysis attention. Also, most of the victims had tachypnea which was
Pyuria 21 (6.0%) 16 (4.6%) different from the results of other studies where most patients
Hematuria 31 (8.9%) 12 (3.4%) had a normal respiratory rate. Also, the rest equally showed both
Prolonged prothrombin time (n) 19 (5.4%) 4 (1.1%) tachypnea and tachycardia.14 These symptoms could be due
to different species of the scorpion that are populated in this
Prolonged partial thromboplastin 23 (6.5%) 7 (2.0%)
time (n) region.15 Hemiscorpius lepturus, Androctonus crassicauda, and
Mesobuthus eupeus are dangerous species of the scorpions which
Blood tests
are common in Hormozgan province.16 More severe complica-
Na tions among the patients in our study could also be due to late
Hyponatremia 37 (12.5%) — antivenom injection. According to the results, the mean interval
Normal 258 (87.2%) — time between envenomation and admission to hospital and receiv-
Hypernatremia 1 (0.3%) — ing antivenom was long. Although emergency services have
K improved a lot in this region, the long mean interval indicates that
Hypokalemia 33 (11.1%) — the number of the emergency centers with antivenom is not
Normal 260 (87.8%) — enough.17,18 Late antivenom injection may result in more compli-
Hyperkalemia 3 (1.0%) — cation, such as cardiac signs and acute renal failure, in the victims.
WBC Despite more complications in our victims of scorpion envenom-
ation, there was no mortality. The urinalysis test result shows that
Leukopenia 15 (4.4%) —
hematuria was seen in a few number of victims. Thus, it seems that
Normal 264 (78.1%) — hematuria has a week diagnostic value for scorpionism. Prothrom-
Leukocytosis 59 (17.5%) — bin time and partial thromboplastin time were prolonged in a
Anemia 229 (65.4%) 33 (11.1%) few patients at the time of admission. However, its frequency
Platelet was decreased at the time of discharge. The venom of some
Thrombocytopenia 6 (1.8%) — scorpions' species contains anticoagulant components which pro-
Normal 340 (97.0%) — long prothrombin time and partial thromboplastin time.19,20 The
Thrombosis 4 (1.2%) — envenomation did not impair the result of blood test. Unfortunately,
MCV 75.39 (±19.57) — we could not record the species of the scorpion which stung the
MCH 25.17 (±8.57) — victims. However, victims or their parents described the scorpion
to be small and yellow which was probably Hemiscorpius lepturus,
Elevated ESR 52 (14.9%) 47 (13.4%)
a common dangerous species of scorpion in Hormozgan province,
MCV indicates Mean Corpuscular Volume; MCH, Mean Corpuscular and its venom can cause acute renal failure if an antivenom is not
Hemoglobin; ESR, Erythrocyte Sedimentation Rate. injected. It is important to educate the people who lives in high-
risk areas because a Hemiscorpius lepturus bite is not much painful
and could be denied or underestimated. In conclusion, present study
in admission time showed pyuria and hematuria in 6.0% and 8.9% reveals that scorpionism is a serious health problem in Hormozgan
of patients, respectively, and these rates decreased to 4.6% and province of Iran. Also, more facilities and emergency centers
3.4% in discharge time (Table 3). About 5.4% and 6.5% of the vic- with antivenom should be developed to reduce the complications
tims showed prolonged prothrombin time and prolonged partial present in the victims.
thromboplastin time, respectively. However, its frequency had de-
creased at discharge time.
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