Takotsubo cardiomyopathy following envenomation:An updated review

BACKGROUND Takotsubo cardiomyopathy(TTC)can be diagnosed in patients presenting with clinical features of acute coronary syndrome(ACS)by using Mayo clinic criteria.Multiple precipitators have been attributed to causing TTC.Rarely it has been reported to occur following an acute envenomation.AIM This review describes the various patterns,mechanisms,and outcomes of envenomation induced TTC.METHODS In this review,we included all studies on“TTC”and“envenomation”published in the various databases before June 2022.To be included in the review articles had to have a distinct diagnosis of TTC and an envenomation RESULTS A total of 20 patients with envenomation induced TTC were identified.Most episodes of envenomation induced TTC were reported following a bee sting,scorpion sting,and snake envenomation.Fear and anxiety related to the sting,direct catecholamine toxicity and administration of exogenous beta-adrenergic agents have been commonly postulated to precipitate TTC in these patients.95%of these patients presented with a clinical picture of ACS.Most of these patients also fulfill at least 3 out of 4 criteria of Mayo clinic criteria for TTC.Echocardiographic evidence of Apical TTC was noted in 72%of patients.94%of these patients had clinical improvement following optimal management and 35%of these patients were treated with guideline directed medications for heart failure.CONCLUSION Envenomation following multiple insect stings and reptile bites can precipitate TTC.Most reported envenomation related TTC has been due to bee stings and scorpion bites.Common mechanisms causing TTC were fear,anxiety,and stress of envenomation.Most of these patients present with clinical presentation of ACS,ST elevation,and elevated troponin.The most common type of TTC in these patients is Apical,which improved following medical management.

Confirmed Envenomation by Androctonus amoreuxi (Egyptian Yellow Fat Tail Scorpion)

In the United States, envenomations by native scorpion species such as Centruroides are common and generally well-tolerated. On the contrary, Androctonus species envenomations are exceedingly rare outside the Middle East and North Africa but are particularly deadly. We report a case of envenomation by an Egyptian Yellow Fat Tail (Androctonus amoreuxi) scorpion and the subsequent clinical course. A hobbyist and dangerous scorpion collector was stung by his pet Androctonus amoreuxi, purchased online. Our patient rapidly developed severe localized pain followed by systemic effects, including tachycardia, hypertension, tachypnea, anxiety, GI symptoms, diplopia, dyspnea, profound myalgias, and intense paresthesias. Ultimately, he was diagnosed with a grade 2-to-3 scorpion envenomation based upon evidence of autonomic hyperactivity and cranial nerve dysfunction. He never progressed to cardiopulmonary compromise;neither dobutamine nor antivenom was administered, and he improved with supportive care alone. Case details were verified in person and via electronic medical record review.

Early severity predictors of snakebite envenomation in the southern region of Tunisia: a multivariate analysis

Objective:To identify the early predictors of severe envenomation in the southern region of Tunisia.Methods:It was a retrospective monocentric study including consecutive patients admitted to the emergency department for snakebite envenomation.Snakebite envenomation was defined by a history of snakebite.Predictors of severe envenomation were determined by univariate and multivariate analyses.Results:Our sample consisted of 109 patients aged 30(20-44)years with a 1.1:1 sex-ratio(56 males and 53 females).During the 24-hour surveillance period,25 patients developed severe envenomation(22.9%).The in-hospital mortality rate was 4.6%(n=5).The independent predictors of severe snakebite envenomation were leucocyte count over 11550/mm3(OR:18.7,95%CI:3.3-107.8),creatine kinase over 155 IU/L(OR:6.16,95%CI:1.1-35.6),and/or tourniquet before arrival to the ED(OR:32.14,95%CI:3.5-295.9).Conclusions:This study emphasizes the importance of early evaluation of snakebite envenomation.Further studies are required to approve a severity scale proper to snakebite envenomation in Tunisia.

Massive Envenomation by Bees Sting in a Child in Togo

Attacks by swarm of bees realize arrays of mass poisoning. We report the case of a 9 years old boy whoes severity was related to the large number of bees which was about 400 and their locations spread throughout the skin surface with a preponderance to the cephalic end. Complications were hemolytic anemia, kidney failure and convulsions. The outcome was favorable with symptomatic care and hemodialysis.

Faunal data and envenomation emergency first aid of cone snails (Conus spp.) in Qeshm Island, the Persian Gulf

Objective: To investigate the fauna of a highly venomous marine species group, the cone snails(Family Conidae), in the shores of Qeshm Island, of evaluating the possibility of envenomation in the area and summarize recommendations for emergency first aid.Methods: Shores surrounding Qeshm Island were surveyed to collect cone snails during cold(February and March) and warm(May and June) seasons of 2017. Collected snails were identified to the species level. Abundance and species richness were estimated in shores of different structures, including muddy and sandy-rocky shores. Also, the most updated medical literature was reviewed to summarize related emergency first aid.Results: Three cone snail species were recorded from southern sandy-rocky shores of the Island, in decreasing order of abundance, included crowned cone(Conus coronatus)(65%), feathered cone(Conus pennaceus)(28%), and frigid cone(Conus frigidus)(7%).Abundance of these species were significantly higher in cold season compared to the warm season(P < 0.05). No cone snails were recorded along the northern muddy shores of the Island.Conclusions: Envenomation can cause various symptoms ranging from minor local pain to systemic paralysis and death due to respiratory failure. We recommend an awareness programme for the seashore visiting public.

A Study of Cardiac Profile in Patients with Snake Envenomation and Its Complications

Background: Snake bite is a common and frequently devastating environmental and occupational disease, especially in rural areas of tropical developing countries. The present study was undertaken to evaluate the effect on cardiac profile in patients with snake envenomation and its complications. Methods: A total of 200 patients with snake envenomation were enrolled in this study excluding patients having history of any cardiovascular disease, renal disease, coagulopathy, liver disease, neuromuscular disease and those cases who bitten by non-poisonous snakes. All patients underwent physical examination, laboratory, Electrocardiogram (ECG), X-ray of chest and echocardiogram investigations. Results: A total of 200 cases had envenomation having 116 (58%) of male subjects. Most common local signs were edema 187 (93.5%), tenderness 141 (70.5%), skin necrosis 81 (40.5%) and blistering 12 (6%). Severity of local envenomation was graded into mild 66 (33%), moderate 120 (60%) and severe 14 (7%) cases. Systemic manifestations were present in 83 patients of venomous bites. It includes that majorly 53 (26.5%) cases had vomiting, 44 (22%) cases had abdominal pain and 9 (4.5%) cases of hypotension. ECG manifestation showed 27 (13.5%), 6 (3%) and 1 (0.5%) patients had sinus tachycardia, sinus bradycardia and ventricular tachycardia respectively. While, 9 (4.5%) cases had T inversion alone in precordial leads. Mortality (3%) was observed in intracranial bleed, neurotoxicity and capillary leak syndrome. However, cardiovascular involvement was not responsible for mortality in any cases. Conclusion: In conclusion, ventricular tachycardia is one of the manifestations of snake envenomation. Moreover, sinus tachycardia is common cardiovascular sign which may not be due to cardiac causes. Mortality results conclude that, cardiovascular involvement could not be responsible for mortality in snake envenomation.

Deadly Envenomation by Massive Bee Stings in a 7-Year Old Child in Ouagadougou

Introduction: We are reporting a deadly case of massive bee stings observed in a 7-year-old child in Ouagadougou. Observation: The first symptoms, which appeared two hours after the stings of about 200 bees, motivated a consultation in a nearby dispensary in which the child received intravenous betamethasone before being referred to the University Hospital Center Yalgado Ouédraogo (CHUYO). Seven hours after the accident, a rapid deterioration in the general condition was noted with hemorrhage, respiratory distress, coma, and shock. A grade 3 anaphylaxis was diagnosed. The patient didn’t survive despite of the cardiopulmonary resuscitation using adrenaline in intensive care. Conclusion: The massive bee stings have caused a severe biphasic anaphylactic reaction which could not be reversed by the adrenaline administered in the second phase. The development of a protocol would contribute to a better management of the cases.

An epidemiological study on scorpion envenomation in the Zagora oases(Morocco)

Objective:To determine epidemiological features of scorpion stings in the oases of Southern Morocco:Zagora Province.Methods:A three-year prospective descriptive survey was performed to obtain epidemiological data on scorpion stings,including information on epidemiological characteristics of patients stung,and gathered information on scorpion species distribution.The following information was recorded for each scorpion sting:demographics of stung patients(age,gender,geographical location),circumstances of the sting(location,time,date,activity at the time),and many traditional medical attention.A questionnaire was completed for every stung patient.Concomitantly with the epidemiological survey,a systematic sampling of scorpions based on observations and direct captures in situ was applied.Results:There were 50 cases of death among 1053 cases studied.Most cases of death were recorded among children(under 15 years)(64%).The average age of victims was(23.00±15.36)years.The scorpion sting occurred in 34.37%of cases between 18:00 and 24:00,and it coincided with the warm period and particularly between June and September(70%).The stings were principally in hands and feet(897 cases,85.71%).The majority of victims had chosen traditional remedies(69.61%),and only 22.79%had received modern treatment while 1.33%of cases did not receive any treatment.The scorpion species involved were yellow in 179 cases and black in 815 cases.In 59 cases the scorpion involved was not identified.Conclusions:Our data constitute a preliminary descriptive study and suggest that scorpion envenomation is an important problem in the studied area.

A clinical and epidemiological study on spider bites in Turkey

Objective:To classify and characterize spider bites among inquiries to the National Poison Information Center(NPIC) between 1995 and 2004,in terms of the epidemiology and clinical symptomatology.Methods:Clinical and epidemiological data were obtained from the NPIC’s patient records.The following information was recorded for each spider bite:demographics, circumstances of the bite,and local and systemic effects.Results:A total of 82 cases were reported.The accidents were mostly seen during August.The gender distribution was 59.76% male,37.20%female,and 2.44%unknown and the 20-29 age group presented more spider bites. Most of the cases were in the Central Anatolia,Marmara,Mediterranean,and Black Sea regions. Local symptoms were observed in 60.87%of the cases,including local pain,edema,redness, itching,debris,burning,and numbness.Systemic symptoms were observed such as nausea, vomiting,abdominal pain,lethargy,anxiety,weakness,somnolence,dyspnea,hypertension, hypotension,and hyperthermia.Conclusions:In conclusion,these findings emphasize the presence of medically important spider species in Turkey.All patients and especially pediatric patients should be admitted to the hospital.Identification of spider species may be considered a useful clinical and epidemiological tool in determining the incidence and risk of spider bites.

Wilderness medicine

BACKGROUND: Human activity in wilderness areas has increased globally in recent decades, leading to increased risk of injury and illness. Wilderness medicine has developed in response to both need and interest.METHODS: The field of wilderness medicine encompasses many areas of interest. Some focus on special circumstances(such as avalanches) while others have a broader scope(such as trauma care). Several core areas of key interest within wilderness medicine are discussed in this study.RESULTS: Wilderness medicine is characterized by remote and improvised care of patients with routine or exotic illnesses or trauma, limited resources and manpower, and delayed evacuation to definitive care. Wilderness medicine is developing rapidly and draws from the breadth of medical and surgical subspecialties as well as the technical fields of mountaineering, climbing, and diving. Research, epidemiology, and evidence-based guidelines are evolving. A hallmark of this field is injury prevention and risk mitigation. The range of topics encompasses high-altitude cerebral edema, decompression sickness, snake envenomation, lightning injury, extremity trauma, and gastroenteritis. Several professional societies, academic fellowships, and training organizations offer education and resources for laypeople and health care professionals.CONCLUSIONS: The future of wilderness medicine is unfolding on multiple fronts: education, research, training, technology, communications, and environment. Although wilderness medicine research is technically difficult to perform, it is essential to deepening our understanding of the contribution of specific techniques in achieving improvements in clinical outcomes.

A life threatening scratch on little toe-at most clinical suspicion the essential key in management of snake bite

Snake bites are one among the under reported clinical emergencies from tropical countries.There are variations in clinical presentation of snake bites and its toxic features differ with the species and type of bite.There are lots of controversies in the treatment guidelines which often makes it difficult to manage.We report the case of a severe hemotoxic snake bite who presented to the outpatient service of our hospital with a trivial fool injury.Even though snakebites are familiar clinical situations for an emergency physician from tropics,we report this case as mast are under reported.We also intend to emphasize the excellent outcome of appropriately diagnosed and treated cases of snake bite.

Clinical consequences of centipede bite:Is it neurotoxic?

The primary purpose of this article was to review the current literature regarding the clinical consequences of centipede envenomation in humans,in order to determine whether the bite of these arthropods is neurotoxic to humans or not. A thorough search of the literature regarding the clinical consequences of centipede bites in humans was applied,with great respect to neurological symptoms potentially caused by such bites. Centipede bite commonly causes only local reactions,which usually resolve within a few days without sequelae. The patients in the majority of centipede envenomations describe a painful but benign syndrome. However,mild constitutional symptoms are relatively frequent. Remarkably,centipedes can rarely cause severe systematic reactions such as anaphylaxis or even hypotension and myocardial ischemia. Factors such as patient age,comorbidity,anatomic site of envenomation,and size/species of centipede should be considered when evaluating a centipede envenomation victim. According to the current literature,the centipede bite does not seem to be neurotoxic to humans. However,it commonly causes symptoms mediated by the nervous system. These include local and generalized symptoms,with the first dominated by sensory disturbances and the second by non-specific symptoms such as headache,anxiety and presyncope. Based on our results,the answer to our study's question is negative. The centipede bite is not neurotoxic to humans. However,it commonly causes symptoms mediated by the nervous system,which include primarily local pain and sensory disturbances,as well as generalized non-specific symptoms such as headache,anxiety and vagotonia.

Cardiac Sarcolemmal Defects in Acute Myocarditis Due to Scorpion Envenoming Syndrome

Death due to scorpion envenoming syndrome is a common event in tropical and subtropical countries. Severe scorpion envenoming causes autonomic storm, massive release of catecholamines, counter-regulatory hormones, suppressed insulin/hyperinsulinemia, acute myocarditis, hyperglycemia, increased free fatty Acid levels, acute pancreatitis, disseminated intra-vascular coagulation, acute pulmonary oedema and death. Severe scorpion envenoming causes cardiac sarcolemmal defects displayed by alterations in Na+ - K+ ATPase, Mg++ ATPase and Ca2+ ATPase activities, inhibition of erythrocyte Na+ - K+ ATPase activities, hyperkalemia and may result in death. Based on our animal experiments in which insulin administration reversed the metabolic and ECG changes induced by scorpion envenoming and treating the poisonous scorpion sting victims with insulin, we consider that insulin has a primary metabolic role in preventing and reversing acute myocarditis, the cardiovascular, haemodynamic, and neurological manifestations and pulmonary oedema induced by scorpion envenoming. Administration of insulin-glucose infusion to scorpion sting victims appears to be the physiological basis for the control of the metabolic response when that has become a determinant to survival. Continuous infusion of regular crystalline insulin should be given at the rate of 0.3 U/g glucose and glucose at the rate of 0.1 g/kg body weight/hour, for 48 - 72 hours, with supplementation of potassium as needed and maintenance of fluid, electrolytes and acid-base balance. The observation of cardiac sarcolemmal defects and physiological basis of various patho-physiological mechanisms involved in the genesis of scorpion envenoming syndrome and its reversal (in the experimental animals and scorpion sting victims) by administration of insulin are reviewed.

The Chinese guideline for management of snakebites

In 2009,the World Health Organization included snakebite on the list of neglected tropical diseases,acknowledging it as a common occupational hazard for farmers,plantation workers,and others,causing tens of thousands of deaths and chronic physical disabilities every year.This guideline aims to provide practical information to help clinical professionals evaluate and treat snakebite victims.These recommendations are based on clinical experience and clinical research evidence.This guideline focuses on the following topics:snake venom,clinical manifestations,auxiliary examination,diagnosis,treatments,and prevention.

An updated checklist of poisonous ifshes of Turkish Aegean Sea

The current status of marine poisonous fish species ranging in the Aegean Sea coastline in Turkey were introduced.Turkey is a peninsula surrounded by seas with different ecological features on three sides.The total length of shoreline is 8333 km including the islands.The total number of fish species in Turkish seas is 512,of which 449 live in the Aegean Sea followed by the Mediterranean Sea(441 species),the Marmara Sea(257 species)and the Black Sea(154species).On the Aegean Sea coasts,the richest sea regarding fish diversity,the number of poisonous fish species is also high.This mini-review revealed 51 poisonous fish species belonging to 14 families in the Turkish Aegean Sea.On the Aegean Sea coasts poisonous fish species can be categorized into three groups:(i)Fish that contain venomous spines on the tail or on the operculum(ii)Fish that carry poisonous bite and(iii)Fish having poisonous flesh or liver.Poisoning fish that contain venomous spines on the tail or on the operculum mostly are dangerous because of their poisonous thorns whereas the passive poisonous fish species poison when they are eaten.These toxins can cause morbidity and rarely,mortality in humans.Apart from these,swallowing the blood of species such as European eel Anguilla anguilla and European conger Conger conger might also cause poisoning.Besides,as there has been an invasion of puffer fish especially on the Turkish Mediterranean and Aegean coasts in recent years,there is a danger in question.Thus,it is very important to particularly draw attention to these fish on the Turkish coasts.

A ten-year retrospective review of 1 107 snakebite patients in Sanya,China

Sanya is the one of most southern cities and tropical cities in China,situated on Hainan Island.It located between 18°09′ and 18°37′ latitude almost the same geographic position as Hawaii.Because of Sanya＇s location,it is a suitable habitat for snake to reproduce as other tropical areas.