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ORIGINAL CONTRIBUTION
Year : 1997  |  Volume : 51  |  Issue : 4  |  Page : 115-117
 

Myocarditis and hemiplegia from scorpion bite - A case report


M.L.N. Medical College, Allahabad 211001, India

Correspondence Address:
S P Barthwal
M.L.N. Medical College, Allahabad 211001
India
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PMID: 9355696

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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 2014 Nov 26];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 Top


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 Top


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 Top


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 Top

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.  Back to cited text no. 1      
2.Mathur A, Verma G, Gehlot RS, Ojjwal JS. Noncardiac pulmonary oedema in scorpion bite. J Assoc. Phy Ind 1993;41:398-401.  Back to cited text no. 2      
3.Chaubal CC, Mishra NP. Scorpion sting. Quarterly Medical Review. 1984;35:1-22.  Back to cited text no. 3      
4.Tiwari SK, Gupta GB, Gupta SR, Mishra SN, Pradhan PK, Fatal stroke following scorpion bite. J Assoc Phys Ind 1988;36:225-226.  Back to cited text no. 4      
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.  Back to cited text no. 5      
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.  Back to cited text no. 6      


    Figures

  [Figure 1]

This article has been cited by
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