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ORIGINAL CONTRIBUTION |
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| Year : 1997 | Volume
: 51
| Issue : 4 | Page : 115-117 |
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Myocarditis and hemiplegia from scorpion bite - A case report
SP Barthwal, R Agarwal, D Khanna, NC Dwivedi, DK Agarwal
M.L.N. Medical College, Allahabad 211001, India
Correspondence Address:
S P Barthwal
M.L.N. Medical College, Allahabad 211001
India
PMID: 9355696
How to cite this article:
Barthwal S P, Agarwal R, Khanna D, Dwivedi N C, Agarwal D K. Myocarditis and hemiplegia from scorpion bite - A case report. Indian J Med Sci 1997;51:115-7 |
How to cite this URL:
Barthwal S P, Agarwal R, Khanna D, Dwivedi N C, Agarwal D K. Myocarditis and hemiplegia from scorpion bite - A case report. Indian J Med Sci [serial online] 1997 [cited 2013 May 25];51:115-7. Available from: http://www.indianjmedsci.org/text.asp?1997/51/4/115/11545 |
Scorpion sting commonly induces local reaction and not infrequently has been reported to produce myocarditis, peripheral circulatory failure, pulmonary odema, [1] non cardiac pulmonary oedema [2] and autonomic disturbances (autonomic storm). [3] Cerebral involvement leading to hemiplegia is a rare manifestation [4],[5] and one such case is being presented.
| ¤ Case Report | |  |
A 16 year old boy was admitted in our institution 4 hours after being stung by a scorpion on the great toe of the left, foot. Apart from local pain and swelling patient developed dyspnoea, restlessness and palpitations two hours prior to admission. At the time of admission patient was in respiratory distress. Pulse was 150/min and regular, Blood pressure was 80/60 mm Hg and respiratory rate was 44/min. Jugular venous pressure was raised. Cardiovascular system examination revealed tachycardia with gallop rhythm. Bilateral basal crepitations were present. Investigatory profile revealed Hb 100 g/L TLC 9.2x10 9 //L DLC P70L28E2, ESR 15 mm in Ist hour, Blood urea 3 mmol/L, Serum creatinine 60 umol/L and random blood sugar 6.2 mmol/L ECG at the time of admission revealed sinus tachycardia and ST - T segment elevation in leads I and aVL suggestive of localized epicardial injury pattern. X-ray revealed a picture suggestive of bilateral pulmonary oedema. Enzyme studies showed SGOT value of 70 U/L and CPK MB reading of 40 U/L. Colour Doppler echocardiography showed generalized hypokinesia of the left ventricle with an ejection of 38%. No clot was detected in the left ventricular cavity and examination of carotid did not reveal any abnormality. Patient was managed on the lines of congestive cardiac failure and showed improvement.
On the 3rd day of admission patient developed sudden onset weakness of the right half of the body. Neurological examination revealed right hemiplegia with grade 0 power. Plantar was extensor on the right side. Pupils and fundi were normal and there were no signs of meningeal irritation. CT scan done 48 hours after development of hemiplegia revealed patchy hypodense areas in the left high frontal and parietal areas which showed enhancement with dye [Figure 1]. Repeat ECG showed disappearance of ST elevation and non specific ST T flattening in anterolateral leads. Colour Doppler showed improvement in left ventricular ejection fraction to 50% No clot was detected. Over a period of one week patient developed grade 5 power in both upper and lower limbs.
| ¤ Discussion | | |
Pulmonary oedema following scorpion bite, (1) cardiac as well as (2) non-cardiac origin has been documented. In our case the pulmonary odema was most likely of cardiac origin secondary to myocarditis. Myocarditis was evident by the typical clinical profile, ST - T segment changes in ECG and global hypokinesia with left ventricular dysfunction of Colour Doppler. Hemiplegia foil lowing scorpion bite is a rare entity. Search of literature revealed only two cases wherein cerebral thrombosis has been attributed to be the basic pathology. [4],[5] In our case, the sudden development of hemiplegia on the third day raised a possibility of cardiac embolus secondary to myocarditis as a possible source of occlusion of the middle cerebral artery. However, colour Doppler examination of the heart and carotid vessels did not reveal any abnormality thereby excluding the possibility of a thromboembolic episode. The findings of distinct patchy hypodense areas with early enhancement it CT scan would rather favour vasculitis with odema surrounding inflammation (cerebritis) as the possible pathogenic process. In addition transient ST - T elevation in leads I and aVL indicative of localized epicardial injury pattern supports the presence of vasculitic patches in the epicardium as well.
Vasculitis of the above mentioned sites could in turn be attributed to the toxin itself which in addition to neurotoxin contains hemolysisin, agglutinins, haemorrhagins, phospholipase A, leucocytolysin, coagulins, ferments, lecithin and cholesterin [6] Hence short of necropsy, vasculitis with cerebritis may be suggested as another pathogenic mechanism leading to hemiplegia following scorpion sting.
| ¤ Summary | | |
A 16 year old boy presenting with features of myocarditis and pulmonary oedema following scorpion sting developed hemiplegia with patchy vasculitic lesions on CT scan. The possible pathogenic mechanism is discussed.
| ¤ References | | |
| 1. | Wynne J, Braunwald E. The cardiomyopathies and myocarditis. Toxic, Chemical & Physical damage to the heart. In : Braunwald Eugene Ed. Heart Disease. A Textbook of Cardiovascular Medicine 4th ed. Philadelphia WB Saunders Company 1992;43:1436.  |
| 2. | Mathur A, Verma G, Gehlot RS, Ojjwal JS. Noncardiac pulmonary oedema in scorpion bite. J Assoc. Phy Ind 1993;41:398-401. |
| 3. | Chaubal CC, Mishra NP. Scorpion sting. Quarterly Medical Review. 1984;35:1-22. |
| 4. | Tiwari SK, Gupta GB, Gupta SR, Mishra SN, Pradhan PK, Fatal stroke following scorpion bite. J Assoc Phys Ind 1988;36:225-226. |
| 5. | Bisarya BN, Vasavada JP, Bhatt A, Nair PNR, Sharma VK. Hemiplegia and Myocarditis following scorpion bite (A case report. Ind Heart J 1977;29:97-100. |
| 6. | Modi JP. Irritant poisons II. Animal Poisons CA Franklin Ed. Modi's Textbook of Medical Jurisprudence and Toxicology 21st Ed. N.M. Tripathi Private Limited 1990, Section II 176. |
[Figure 1]
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Brain infarcts due to scorpion stings in children: MRI |
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| Fernandez-Bouzas A, Morales-Resendiz ML, Llamas-Ibarra F, et al. | | NEURORADIOLOGY. 2000; 42 (2): 118-120 | | [Pubmed] | |
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