Epidemiology of scorpionism in France: nationwide scorpion exposure.

INTRODUCTION: In France, 57 species of scorpions are described with a limited number of clinical studies. In this article, we report the epidemiology of scorpion sting events in mainland France and its overseas territories based on cases reported to the French poison-control centres (FPCC). MATERIAL AND METHOD: This retrospective multicentre study was conducted with data from FPCC's files about scorpion stings between January 1, 2011 and December 31, 2020. RESULT: Among 975 recorded files, 624 patients were included because they were stung by scorpions native to French territories. Most stings occurred along the Mediterranean coast in summer and indoors (in persons' homes) during the daytime. The scorpions were identified in 50% of cases. According to signs of envenoming, patients were divided into class III (2 cases; 1%), class II (51 cases; 8%), class I (444 cases; 71%) and asymptomatic stings (127 cases; 20%). Twelve pregnant women were stung and two of them had contractions, which triggered childbirth in one woman. Ten patients had local infections in the first week after the sting. One patient had venous thrombosis 2 days after the sting. Life-threatening scorpions, i.e., Tityus obscurus, Tityus sylvestris and Centruroides pococki, in French territories are limited to French Guiana and Lesser Antilles. Class II envenoming cases are recorded for Buthus occitanus, Euscorpius spp. in mainland France, and Isometrus maculatus in French Guiana, the Lesser Antilles (Guadeloupe and Martinique) and territories in the Indian Ocean (Mayotte and Réunion Island) and Pacific Ocean (French Polynesia). Only cases of local manifestation was reported for Belisarius xambeui in mainland France. CONCLUSION: Scorpion stings in French territories are frequently on the Mediterranean coast and French Guiana. Life-threatening cases are limited to T. obscurus, T. sylvestris and Centruroides pococki stings in French Guiana and Lesser Antilles.

Involvement of the Endothelin Receptor Type A in the Cardiovascular Inflammatory Response Following Scorpion Envenomation.

Elevated levels of endothelin-1 (ET-1) were recorded in sera of scorpion sting patients. However, no studies focused on the mechanism of ET-1 involvement in the pathogenesis of scorpion envenomation, particularly in the cardiovascular system which is seriously affected in severe cases of scorpion stings. Inflammation induced by Androctonus australis hector (Aah) scorpion venom in the heart together with the aorta was studied in mice pretreated with a specific endothelin A receptor (ETA-R) inhibitor. ETA-R inhibition resulted in the attenuation of the high amounts of cytokine (tumor necrosis factor alpha (TNF-α) and interleukin-17 (IL-17)) recorded in the sera of envenomed mice. The recovery of the oxidative stress marker balance and matrix metalloproteinase (MMP) expression were also observed, concomitantly with the reduction of tissular neutrophil infiltration. Additionally, the cardiac and the aortic tissue alterations, and the metabolic enzymes (creatine kinase (CK) and muscle-brain isoform creatine kinase (CK-MB)) overspread into sera were significantly attenuated. Obtained results suggest the implication of endothelin throughout its ETA receptors in the inflammatory response observed in the cardiovascular components during scorpion envenomation. Further knowledge is needed to better understand the implication of the endothelin axis and to improve the therapeutic management of severe scorpion sting cases.

Interleukin-1 Receptor-Induced Nitric Oxide Production in the Pancreas Controls Hyperglycemia Caused by Scorpion Envenomation.

Tityus serrulatus causes numerous scorpion envenomation accidents and deaths worldwide. The symptoms vary from local to systemic manifestations, culminating in pulmonary edema and cardiogenic shock. Among these events, transitory hyperglycemia is a severe manifestation that influences pulmonary edema, hemodynamic alterations, and cardiac disturbances. However, the molecular mechanism that leads to increased glucose levels after T. serrulatus envenomation remains unknown. This study aimed to investigate our hypothesis that hyperglycemia due to scorpion envenomation involves inflammatory signaling in the pancreas. The present study showed that T. serrulatus venom induces the production of IL-1α and IL-1ß in the pancreas, which signal via IL-1R and provoke nitric oxide (NO) production as well as edema in ß-cells in islets. Il1r1-/- mice were protected from transitory hyperglycemia and did not present disturbances in insulin levels in the serum. These results suggest that the pathway driven by IL-1α/IL-1ß-IL-1R-NO inhibits insulin release by ß-cells, which increases systemic glucose concentration during severe scorpion envenomation. A supportive therapy that inhibits NO production, combined with antiserum, may help to prevent fatal outcomes of scorpion envenomation. Our findings provide novel insights into the design of supportive therapy with NO inhibitors combined with antiscorpion venom serum to overcome fatal outcomes of scorpion envenomation.

Biotechnological Trends in Spider and Scorpion Antivenom Development.

Spiders and scorpions are notorious for their fearful dispositions and their ability to inject venom into prey and predators, causing symptoms such as necrosis, paralysis, and excruciating pain. Information on venom composition and the toxins present in these species is growing due to an interest in using bioactive toxins from spiders and scorpions for drug discovery purposes and for solving crystal structures of membrane-embedded receptors. Additionally, the identification and isolation of a myriad of spider and scorpion toxins has allowed research within next generation antivenoms to progress at an increasingly faster pace. In this review, the current knowledge of spider and scorpion venoms is presented, followed by a discussion of all published biotechnological efforts within development of spider and scorpion antitoxins based on small molecules, antibodies and fragments thereof, and next generation immunization strategies. The increasing number of discovery and development efforts within this field may point towards an upcoming transition from serum-based antivenoms towards therapeutic solutions based on modern biotechnology.

PPAR-γ activation by Tityus serrulatus venom regulates lipid body formation and lipid mediator production.

Tityus serrulatus venom (TsV) consists of numerous peptides with different physiological and pharmacological activities. Studies have shown that scorpion venom increases pro-inflammatory cytokine production, contributing to immunological imbalance, multiple organ dysfunction, and patient death. We have previously demonstrated that TsV is a venom-associated molecular pattern (VAMP) recognized by TLRs inducing intense inflammatory reaction through the production of pro-inflammatory cytokines and arachidonic acid-derived lipid mediators prostaglandin (PG)E2 and leukotriene (LT)B4. Lipid bodies (LBs) are potential sites for eicosanoid production by inflammatory cells. Moreover, recent studies have shown that the peroxisome proliferator-activated receptor gamma (PPAR-γ) is implicated in LB formation and acts as an important modulator of lipid metabolism during inflammation. In this study, we used murine macrophages to evaluate whether the LB formation induced by TsV after TLR recognition correlates with lipid mediator generation by macrophages and if it occurs through PPAR-γ activation. We demonstrate that TsV acts through TLR2 and TLR4 stimulation and PPAR-γ activation to induce LB formation and generation of PGE2 and LTB4. Our data also show that PPAR-γ negatively regulates the pro-inflammatory NF-κB transcription factor. Based on these results, we suggest that during envenomation, LBs constitute functional organelles for lipid mediator production through signaling pathways that depend on cell surface and nuclear receptors. These findings point to the inflammatory mechanisms that might also be triggered during human envenomation by TsV.

Effects of tityustoxin on cerebral inflammatory response in young rats.

Accidents caused by scorpion stings, mainly affecting children, are considered an important cause of morbidity and mortality in tropical countries. Clinical studies demonstrate the relevant role of systemic inflammatory events in scorpion envenoming. However, remains poorly understood whether the major lethal component in Tityus serrulatus venom, tityustoxin (TsTX), is able to induce inflammatory responses in the cerebral microcirculation. In this study, we systematically examined leukocyte recruitment into the CNS in response to TsTX injection. Accordingly, developing rats were subjected to a subcutaneous (s.c.) injection of TsTX (0.75mg/kg), and leukocyte recruitment (i.e., 4, 8 and 12h after injection) and TNF-α levels were evaluated. Rats injected with TsTX presented a significant increase in leukocyte rolling and adhesion and higher levels of TNF-α at all time points studied, compared to the control group. Altogether, this work demonstrates the triggering of neuroimmunological mechanisms induced by TsTX injection in young rats.

Doxazosin in the treatment of scorpion envenomation.

OBJECTIVE: To investigate effectiveness and applicability of Doxazosin in the treatment of scorpion stings in patients who had systemic symptoms. METHODS: The medical records of patients were retrospectively reviewed, and the following data were collected: age, sex, clinical symptoms (localized and systemic), vital signs, information on the date and place of the sting occurrence, the anatomical sting site, time between sting and arrival to the hospital, scorpion identification, severity of the symptoms and treatment. RESULTS: Of the victims, 48.5 % (n = 16) were males, and 51.5 % (n = 17) were females, with a mean age of 6.8 ± 4.2 y. The most common sting site was lower extremity 72.7 % (n = 24). Systemic toxicity (class II) was seen in 93.9 %, and two patients (6.1 %) manifested evidence of severe envenomation (class III). Both local and systemic effects were seen in the patients. Cold extremities persisted for 4.5 ± 1.5 h after administration of Doxazosin. Mean hospitalization time was 2.5 ± 1.5 d (range: 1.5 to 6 d). Thirty-two patients recovered without any sequel, whereas one patient died due to cardio-pulmonary insufficiency. CONCLUSIONS: Doxazosin, especially if Prazosin is not available, can be recommended as an effective drug in the treatment of serious scorpion envenomations with significant sympathetic symptoms.

Immunomodulatory and protective properties of tacrolimus in experimental scorpion envenomation.

Involvement of imbalance between pro- and anti-inflammatory events has been reported in the developed pathogenesis after scorpion envenomation. The immunosuppressive and anti-inflammatory properties of tacrolimus (FK-506) have been investigated: i) to better understand evolution of signaling pathways which are involved in the immune system ii) to reduce observed clinical signs while keeping a balance between pro- and anti-inflammatory cytokines. Naval Medical Research Institute (NMRI) mice received tacrolimus (1 mg/kg every 12 hours per os) for 21 days before envenomation with a sublethal dose (10 microg/20 g body weight) of Androctonus australis hector venom (Aah). Cell migration, pulmonary edema, exudation, Myeloperoxydase (MPO), Eosinophil peroxydase (EPO), C-reactive protein (CRP), C3, Creatine phosphokinase (CPK), aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT), and hyperglycemia were analyzed 30 min, 3 and 24 hours after injection of Aah venom. Histological analysis of lung parenchyma was undertaken 24 hours after envenomation. Aah lethality was evaluated on mice with or without pretreatment with tacrolimus. (Fab’)2 fragments (40 mg/kg) were also used as specific treatment in all protocols. Tacrolimus significantly inhibited cell migration, pulmonary edema, exudation, CRP and hyperglycemia. It also decreased MPO and EPO activities and prevented tissue damage in lung tissue, balancing seric parameter levels (CPK, ASAT and ALAT). The pretreated animals seemed to be protected by this macrolide against the venom lethality. These findings suggest that the overactivation of the immune system is one of the causes involved in the aggravation of the pathophysiological effects induced after envenomation. The obtained results showed that the use of F(ab’)2 fragments as specific treatment cannot reduce the induced inflammatory response.

Identification and phylogenetic analysis of Tityus pachyurus and Tityus obscurus novel putative Na+-channel scorpion toxins.

BACKGROUND: Colombia and Brazil are affected by severe cases of scorpionism. In Colombia the most dangerous accidents are caused by Tityus pachyurus that is widely distributed around this country. In the Brazilian Amazonian region scorpion stings are a common event caused by Tityus obscurus. The main objective of this work was to perform the molecular cloning of the putative Na(+)-channel scorpion toxins (NaScTxs) from T. pachyurus and T. obscurus venom glands and to analyze their phylogenetic relationship with other known NaScTxs from Tityus species. METHODOLOGY/PRINCIPAL FINDINGS: cDNA libraries from venom glands of these two species were constructed and five nucleotide sequences from T. pachyurus were identified as putative modulators of Na(+)-channels, and were named Tpa4, Tpa5, Tpa6, Tpa7 and Tpa8; the latter being the first anti-insect excitatory ß-class NaScTx in Tityus scorpion venom to be described. Fifteen sequences from T. obscurus were identified as putative NaScTxs, among which three had been previously described, and the others were named To4 to To15. The peptides Tpa4, Tpa5, Tpa6, To6, To7, To9, To10 and To14 are closely related to the α-class NaScTxs, whereas Tpa7, Tpa8, To4, To8, To12 and To15 sequences are more related to the ß-class NaScTxs. To5 is possibly an arthropod specific toxin. To11 and To13 share sequence similarities with both α and ß NaScTxs. By means of phylogenetic analysis using the Maximum Parsimony method and the known NaScTxs from Tityus species, these toxins were clustered into 14 distinct groups. CONCLUSIONS/SIGNIFICANCE: This communication describes new putative NaScTxs from T. pachyurus and T. obscurus and their phylogenetic analysis. The results indicate clear geographic separation between scorpions of Tityus genus inhabiting the Amazonian and Mountain Andes regions and those distributed over the Southern of the Amazonian rainforest. Based on the consensus sequences for the different clusters, a new nomenclature for the NaScTxs is proposed.

Balance between pro- and anti-inflammatory cytokines in mice treated with Centruroides noxius scorpion venom.

CSV consists of a very complex of molecules and demonstrates significant cellular activities capable of stimulating immune functions in vivo. The purpose of this study was to analyze the effects of CSV on sex, weight, route of injection and the balance of pro- and anti-inflammatory cytokines in mice. The susceptibility and route of injection were analyzed by lethal (LD(50)) determination. The effects of CSV were also analyzed in blood from immunized mice using detection by means of antibodies and mediators production. Several functional bioassays were employed: TNF activity was assayed by measuring its cytotoxic activity in L929 cells, and other cytokines were assayed by enzyme-linked immunosorbent assay, whereas nitric oxide levels were detected by Griess colorimetric reactions in sera from BALB/c mice. After injecting subcutaneously, the LD(50) presented an increase of the CSV correlation and similar levels of susceptibility were obtained for female and male from BALB/c mice. Significant differences were observed in the time-course of cytokine levels. The balance of pro- and anti-inflammatory cytokines TNF/IL-10 and IL-6/IL-10 ratios were significantly higher in injected mice group when compared with those obtained for non-injected group. The CSV is poor in antigenic composition and it is difficult to get antibodies specific to neutralizing the lethal factor. The effect of immunization with 0.5 LD(50) of CSV on the balance of pro- and anti-inflammatory cytokines was measured. The maximum levels of TNF and IL-6, IFN-gamma and NO were observed on days 7 and 21 after immunization, respectively. IL-10 levels peaked between days 21 and 28 after immunization with CSV. With respect, to balance of pro- and anti-inflammatory cytokines it was possible to observe that negative correlation between serum levels of IL-6/IL-10 and TNF/IL-10 exists. These ratios may possibly reflect the balance of pro- and anti-inflammatory cytokines in serum, which may by manifested in the inflammatory status during the envenoming processes. In conclusion, an increase in the serum levels of TNF and IL-6 may be a useful marker for scorpion envenomation.

Pharmacokinetics of the toxic fraction of Centruroides limpidus limpidus venom in experimentally envenomed rabbits and effects of immunotherapy with specific F(ab')2.

Envenomations after scorpion stings are a major health problem throughout the world. Their specific treatment is immunotherapy which consists of the injection of specific antibody. In this article, we studied the pharmacokinetics of the toxic fraction of Centruroides limpidus limpidus venom (fraction II) in experimentally envenomed rabbits. After an intravenous injection, fraction II (FII) was rapidly distributed and eliminated from the body (terminal half-life of 1.9 h). When injected subcutaneously, high concentrations of FII were measured in the vascular space rapidly after the injection (Tmax = 1 h) and FII was eliminated with a terminal half-life of 1.8 h, close to that determined after intravenous injection. These observations go along with the rapid onset of clinical symptoms observed after accidental envenomations. To investigate the mechanism of action of antivenom, we examined the effects of the intravenous administration of antivenom (horse F(ab')2 directed against Centruroides venoms) on the pharmacokinetics of FII. Immunotherapy performed 2 h after the experimental envenomation largely increased the area under the concentration time curve of FII compared to that calculated in absence of immunotherapy (13,000 versus 170 ng h ml(-1), respectively). These observations agree with previous findings which showed that specific antibody fragments are able to remove drugs from their site of action and sequester them in the vascular space. These studies provide a powerful tool to determine an excellent procedure for further improvement of immunotherapy.

Immunotherapy for scorpion envenoming in Brazil.

Using the ELISA we have shown that in rats subcutaneously injected with Tityus serrulatus scorpion venom there is a fast absorption rate, a fast and high distribution of venom to tissues, a great affinity of the venom for the tissues and a slow elimination half-life. Because of these experimental data, i.v. immunotherapy should be given to patients stung by scorpions as soon as possible after hospital admission. The severity of scorpion envenoming is related to plasma venom concentration (ELISA). The high levels of plasma scorpion venom antigens (ELISA) were cleared 1 h after the infusion of antivenom (5-30 ml of Fab2 fragment) and high concentrations of circulating antivenom persisted for at least 24 h, confirming the efficacy of immunotherapy to neutralise circulating venom. Some symptoms (e.g. local pain and vomiting) decreased 1 h after the starting of immunotherapy, whereas the other symptoms disappeared from 12-48 h later. Using our tripartite approach of treating scorpion envenoming (symptomatic measures, support of vital functions and serotherapy), the mortality rate was very low (0.28%).

Pharmacokinetics of 125I-labelled IgG, F(ab')2 and Fab fractions of scorpion and snake antivenins: merits and potential for therapeutic use.

The immunoglobulin fractions IgG, F(ab')2 and Fab of scorpion and snake antivenoms possess pharmacokinetic characteristics that are significantly different from their respective venoms. The venoms (and their toxins) are several fold faster in their distribution into the tissues than any of the immunoglobulin fraction. In rabbits, F(ab')2 possessed the fastest disposition rate constants and the longest distribution half lives. In the physiologically based pharmacokinetic experiments carried out in mice F(ab')2 possessed the highest Cp(max), smallest AUC and the shortest t1/2beta in the different tissues while Fab had values in between IgG and F(ab')2. Rescue experiments in anaesthetized rats challenged with lethal doses of venoms or toxins and infused with border-line neutralizing doses of antivenoms, showed that rats infused with F(ab')2 completely recovered, those infused with IgG partially rescued and none of the rats infused with Fab survived. It is concluded that F(ab')2 of scorpion and snake antivenoms possess pharmacokinetic characteristics that render it the most suitable for use in serotherapy of scorpion and snake envenoming.

Do changes in body temperature following envenomation by the scorpion Leiurus quinquestriatus influence the course of toxicity?

Four fatal cases following scorpion sting in children are presented. Two victims had rectal temperature above 41 degrees C, the third exhibited a temperature of 40.9 degrees C from the combined effects of scorpion sting and heat stroke, while the fourth was hypothermic. All victims developed hypothermia 48 hr following the sting. The hyperthermia was effectively treated by acetaminophen suppositories, ice packs and water sponges. All victims showed late hypotension that was refractory to dopamine infusion. This was explained by bradykinin released by the venom blocking the dopaminergic receptors. Deterioration of the cortical activity of the victims maintained on mechanical ventilation before the incidence of asystole suggests a central component in the cardiovascular manifestations of envenomation. A. amoreuxi venom was selected as a model for the pharmacokinetic and quantitative toxicological studies since it has no effect on body temperature. In hyperthermic rabbits injected with labelled lethal fraction of A. amoreuxi venom, there was a significant decrease in the elimination half-life, t1/2 beta, the apparent volume of the tissue compartment, Vt, the apparent volume of distribution, Vdss, and the intercompartmental rate constant, kCT. Hypothermic rabbits showed a significant decrease in the apparent first-order elimination rate constant, kd, and a significant increase in the elimination half-life. In both states a higher concentration of the lethal fraction in the blood was calculated. This would explain the rapidity of onset of the electrocardiographic effects and the decreased survival time in both the hyperthermic and hypothermic rabbits injected with venom when compared to normothermic animals. The s.c. LD50 in mice and the i.v. MLD in rats were significantly reduced in the hypothermic mice and hypothermic and hyperthermic rats.