Transactions of the Royal Society of Tropical Medicine and Hygiene (2004) 98, 742—750

Scorpion envenoming in two regions of Colombia:

clinical, epidemiological and therapeutic aspects
R. Otero a,b,*, E. Navı́o a , F.A. Céspedes c , M.J. Núñez d , L. Lozano e ,
E.R. Moscoso f , C. Matallana g , N.B. Arsuza h , J. Garcı́a i , D. Fernández j ,
J.H. Rodas k , O.J. Rodrı́guez a , J.E. Zuleta a , J.P. Gómez a ,
M. Saldarriaga a , J.C. Quintana a , V. Núñez a , S. Cárdenas a , J. Barona a ,
R. Valderrama a , N. Paz a , A. Dı́az a , O.L. Rodrı́guez l , M.D. Martı́nez m ,
R. Maturana n , L.E. Beltrán o , M.B. Mesa p , J. Paniagua q , E. Flórez r ,
W.R. Lourenço s

a
Programa de Ofidismo/Escorpionismo, Facultad de Medicina, Universidad de Antioquia, A. A. 1226,
Medellı́n, Colombia
b
Depto. de Pediatrı́a, Facultad de Medicina, Universidad de Antioquia, A.A. 1226, Medellı́n, Colombia
c
Clı́nica del ISS y Hospital Federico Lleras, Ibagué, Colombia
d
Sanidad Militar, Base Aérea, Melgar, Colombia
e
Hospital de Ortega, Colombia
f
Hospital de Melgar, Colombia
g
Hospital de Flandes, Colombia
h
Hospital de El Espinal, Colombia
i
Hospital de Mutatá, Colombia
j
Hospital de Necoclı́, Colombia
k
Hospital de Santa Fé de Antioquia, Colombia
l
Hospital de Caucasia, Colombia
m
Hospital de Zaragoza, Colombia
n
Hospital de Angelópolisy, Colombia
o
Hospital de Puerto Triunfo, Colombia
p
Hospital Universitario San Vicente de Paúl, Medellı́n, Colombia
q
Instituto Bioclón S.A. de C.V., Calzada de Tlalpan 4687, C.P. 14050, México D.F., Mexico
r
Museo de Ciencias Naturales, Universidad Nacional, A. A. 7495, Bogotá, Colombia
s
Muséum National d’Histoire Naturelle, 61 rue de Buffon 75005, Parı́s, France
Received 13 October 2003 ; received in revised form 22 December 2003; accepted 22 December 2003

KEYWORDS Summary To determine clinical and epidemiological features of scorpion stings in

Scorpion; two departments of Colombia, a descriptive study was performed in the hospitals
Envenoming; of 10 towns from Antioquia (2 256 071 inhabitants) and five from Tolima (630 424
inhabitants). One hundred and twenty-nine cases were admitted during one year, 51
Fabotherapy;
in Antioquia, 78 in Tolima and 41 were children less than 15 years old. Most stings

* Correspondingauthor. Tel.: +57 4 263 19 14; fax: +57 4 263 19 14.

E-mail address: rafaotero@epm.net.co (R. Otero).

0035-9203/$ — see front matter © 2004 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.trstmh.2003.12.018
Scorpion envenoming in Colombia 743

(70.5%) occurred inside the house; 27.9% were on the hands and 26.4% on the feet.
Tityus spp.;
Centruroides spp.; The scorpion species involved were Tityus pachyurus (51), Centruroides gracilis (31),
Colombia T. fuehrmanni (29), T. asthenes (7) and Chactas spp. (1). In 10 cases the scorpion
involved was not identified. Systemic envenoming signs (e.g. vomiting, tachypnea)
were significantly more frequent in children than in adults (P < 0.05). Four children
had hypertension, but none developed pulmonary oedema. One 3-year-old girl, stung
by T. asthenes, had acute oedematous pancreatitis. Ninety-eight patients had mild
envenoming. Moderate (27 patients) and severe (four patients) envenoming was sig-
nificantly more frequent in children than in adults (P = 0.003; relative risk = 2.97).
A pepsin-digested anti-Centruroides spp. antivenom was administered to 19 of 31
patients presenting systemic envenoming signs. No adverse reactions to antivenom
were observed.
© 2004 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All
rights reserved.

1. Introduction have been reported in children in the Antioquia

More than 1500 scorpion species belonging to 16
to 20 families, according to different authors (Fet
et al., 2000; Lourenço, 2000a), have been de-
scribed in the world, four of which (Buthidae,
Ischnuridae, Diplocentridae, Chactidae) occur in
Colombia with a total of nine genera and 54 species
(Lourenço, 1997, 1999a, 1999b, 2000b; Lourenço
and Otero-Patiño, 1998; Lucas and Meier, 1995;
Saldarriaga and Otero, 2000). The Buthidae family,
which includes the most lethal scorpions world-
wide, has four genera and 35 species reported in
the country: Tityus (29 spp.), Centruroides (1 sp.),
Ananteris (4 spp.) and Rhopalurus (1 sp.).
Scorpion venoms are apocrine secretions com-
posed of proteins (neurotoxins) and peptides of
low molecular weight which exert their actions on
voltage-dependent ionic channels (Na+ , K+ , Ca++ ,
Cl− ), causing an increase in cellular excitability
and neurotransmitter release (catecholamines and
acetylcholine) at the sympathetic and parasympa-
thetic postganglionic endings. Thus, systemic scor-
pion envenoming, characterized by cardiovascular,
pulmonary, and neurological manifestations, can
be life-threatening, particularly in children less
than 11 years old, due to complications such as my-
ocardial dysfunction, shock, acute respiratory dis-
tress syndrome (ARDS), pulmonary oedema or hy-
pertensive encephalopathy with cerebral oedema
(Becerril et al., 1997; Céard et al., 1992; Couto
et al., 1992; Cupo et al., 1994; Gueron et al., 1993;
Hering et al., 1992; Ismail, 1995; Otero et al.,
1998; Saldarriaga and Otero, 2000).
Neither epidemiological surveillance for ven-
omous animal bites and stings, nor antivenom
production for scorpion stings exists in Colombia.
Nevertheless, severe cases of scorpion envenoming
(e.g. pulmonary oedema, severe cardiomyopathy,
acute haemorrhagic pancreatitis) and fatalities
and Tolima departments, in the northwest of the
country and the high valley of the Magdalena river
respectively (Otero et al., 1998). This study was
designed to describe the clinical and epidemiolog-
ical features of scorpionism in patients admitted
during one year in hospitals from those regions of
Colombia.
2. Materials and methods
2.1. Study area and population
Ten towns representative of different regions
from Antioquia department (Caucasia, Zaragoza,
Segovia, San Roque, Puerto Triunfo, Medellı́n, An-
gelópolis, Santafé de Antioquia, Mutatá, Necoclı́; 2
256 071 inhabitants), and five towns from Tolima
department (Ortega, El Espinal, Flandes, Mel-
gar, Ibagué; 630 424 inhabitants), were selected
(Figure 1). Thus, the total sample (2 886 495 inhab-
itants, 833 139 less than 15 years old) corresponded
to 40% of the expected population in 2000 for the
two departments, and 7.0% for the whole country
(National Administrative Department of Statistics,
DANE).
2.2. Epidemiological and clinical data
Children and adults were enrolled in the study if:
(i) they sought medical attention at the hospitals
of the towns mentioned above between August
2000 and August 2001; (ii) they had suffered a scor-
pion sting, confirmed either by the capture of the
arthropod or when it was seen but not captured,
those collected being then identified at the Uni-
versidad de Antioquia in Medellı́n, using the keys
for Colombian species (González-Sponga, 1996;
Lourenço, 1997, 1999a, 1999b, 2000b; Lourenço
744
Figure 1 Study area in Colombia. Antioquia depart-
ment: (1) Necoclı́, (2) Mutatá, (3) Caucasia, (4) Zaragoza,
(5) Segovia, (6) Santafé de Antioquia, (7) Medellı́n, (8)
Angelópolis, (9) San Roque, and (10) Puerto Triunfo.
Tolima department: (11) Ibagué, (12) Ortega, (13) El Es-
pinal, (14) Flandes, and (15) Melgar.
and Otero-Patiño, 1998). Informed consent was ob-
tained from all patients or their relatives. Clinical
and epidemiological data were recorded, including
age, geographical location where the sting oc-
curred, location of the sting on the patient’s body,
scorpion species, any traditional medical attention,
time elapsed from sting to admission to the hospi-
tal, local and systemic signs of envenoming, results
of haematological and clinical chemistry laboratory
tests, electrocardiogram, diagnostic imaging, dose
of antivenom given and ancillary treatments (e.g.
antihistamines, antihypertensives, steroids, anal-
gesics, crystalloids, oxygen, etc), complications
and outcome.
2.3. Clinical assessment of envenoming and
treatment
Patients were stratified into three arbitrary groups
(mild, moderate, and severe envenoming) using
criteria already described (Cupo et al., 1994;
Dehesa-Dávila and Possani, 1994; Hering et al.,
1992; Krifi et al., 1998; Osnaya-Romero et al., 2001;
Otero et al., 1998). Mild envenoming was charac-
terized by local signs (pain, oedema, paresthesia,
local sweating). Moderate envenoming was charac-
terized by local signs and systemic manifestations
such as sialorrhea, sensation of a foreign body
R. Otero et al.
(hair) in the throat, generalized sweating, nausea,
vomiting, abdominal pain, tachycardia, tachypnea,
mild hypertension, restlessness, drowsiness, ataxia
and priapism. Severe envenoming was character-
ized, besides the moderate signs, by hypertensive
encephalopathy with seizures; stupor or coma;
myocardial failure; electrocardiographic (ECG)
alterations on T wave or ST segment; shock or
arrhythmia; pulmonary oedema or acute respira-
tory insufficiency secondary to ARDS; symptomatic
acute pancreatitis or bleeding gastric ulcer.
Specific treatment was performed with a pepsin-
digested (fabotherapic) antivenom (Alacramyn® ,
Instituto Bioclón, México, batch B-O-D-04, expiry
May 2004), obtained from plasma of horses immu-
nized with a mixture of equal parts of the venoms
of C. limpidus limpidus, C. l. tecomanus, C. nox-
ius noxius and C. suffusus suffusus from Mexico.
This has been used successfully in Mexico since
the 1980s for the treatment of human victims of
scorpion stings (Dehesa-Dávila and Possani, 1994).
This antivenom recognized different antigens of
T. pachyurus and C. gracilis scorpion venoms from
Colombia, as shown by Western blot (unpublished
data). The neutralizing potency indicated by the
manufacturer was at least 150 LD50 (1.8 mg) of
Centruroides spp. scorpion venom per 5 ml vial. For
T. pachyurus scorpion venom from Tolima, the 50%
effective dose (ED50 ) obtained in our laboratory
by the Spearman–Karber method (WHO, 1981), was
0.330 mg venom/ml antivenom, in Webster mice
18—20 g injected by i.p. route (unpublished data).
Symptomatic treatment included analgesics, an-
tihistamines, antihypertensives, antiemetics, and
supportive treatment of vital functions included
oxygen, crystalloids, inotropics, ventilatory sup-
port and monitoring in the Intensive Care Unit
(Freire-Maia et al., 1994; Gueron and Sofer, 1994).
In addition, clinicians in the hospitals were trained
to administer on admission, an i.v. infusion of two
or four vials of the antivenom diluted in saline solu-
tion 0.9% (50—100 ml for children; 100—250 ml for
adults) to patients with moderate or severe enven-
oming respectively. Skin or conjunctival sensitivity
tests were not performed, because they have no
predictive value for the occurrence of early adverse
reactions (EARs) (Malasit et al., 1986), and the an-
tivenom infusion was completed in 30—60 min. All
patients were regarded as potentially reactive to
antivenom therapy and strictly observed for the
development of EARs for 24 h (WHO, 1981). These
should be treated by conventional methods (Fan
and França, 1992; Otero-Patiño et al., 1998). Pa-
tients with mild envenoming (devoid of systemic
signs) should receive only analgesics. The ethical
committee of the Universidad de Antioquia as well
Scorpion envenoming in Colombia 745

as that in every hospital, approved the method- Table 1 Epidemiological aspects of scorpion enven-
ology, the informed consent and the use of the oming in 129 patients in Colombia
antivenom in this study.
No. %
2.4. Analysis of data Age (years)
≤2 5 3.9
A data file was created with the patient information 3—5 14 10.9
and the descriptive analysis was performed using 6—14 22 17.0
15—44 78 60.5
the program STATISTICA 98® . The relative risk (RR)
45—59 4 3.1
and the association test were estimated by EPIINFO
≥60 6 4.6
2000® program. The significance of the differences
in the time of response of some moderate enven- Time elapsed until admission (h)
oming symptoms, according to the treatment ad- <1 50 38.8
ministered, was established by the Mann—Whitney 1—2 23 17.8
2—6 13 10.1
U test. The significance level was P < 0.05.
6—12 5 3.9
12—24 3 2.3
Unknown 35 27.1
3. Results Scorpions implicated

3.1. Epidemiological and clinical data Tolima (n = 78)

Tityus pachyurus 50 64.1
Centruroides gracilis 20 25.6
From August 21 2000 to August 20 2001, 129 pa- Unidentified 8 10.3
tients were admitted to the hospitals with scorpion
stings, 41 (31.8%) were children less than 15 years Antioquia (n = 51)
old, 51 cases (39.5%) occurred in Antioquia depart- Tityus fuehrmanni 29 56.8
ment (Medellı́n 29, Santafé de Antioquia 12, Mutatá Centruroides gracilis 11 21.6
Tityus asthenes 7 13.7
2, Angelópolis 2, Necoclı́ 1, San Roque 1, Puerto Tri-
Tityus pachyurus 1 2.0
unfo 1, Segovia 1, Caucasia 1, Zaragoza 1) and 78 Chactas spp. 1 2.0
in Tolima department (Melgar 42, Ortega 19, Ibagué Unidentified 2 3.9
14, Flandes 2, El Espinal 1) (Table 1). The incidence
of scorpion stings was 4.5/100 000 population/year,
being significantly higher for Tolima (12.4 cases/
100 000 population) than for Antioquia (2.3 cases/
100 000 population) (P < 0.05).
Most of the stings (70.5%) occurred inside human
dwellings, 20.2% at the work place and 73.6% of
them were in urban locations. Interestingly, 32 of 42
cases from Melgar occurred at the Air Force Base,
when soldiers put on their clothes or boots early in
the morning. Hands (27.9%) and feet (26.4%) were
the body sites most affected by the stings, but there
were also cases of stings occurring on other loca-
tions of the body (Figure 2).
Identification of the alive or dead scorpions col-
lected at the site of the accidents showed that T.
pachyurus (Ibagué, Melgar, Flandes), C. gracilis (Or-
tega, El Espinal) in Tolima and T. asthenes (Necoclı́,
Mutatá, Caucasia, Zaragoza, Segovia, San Roque),
T. fuehrmanni (Medellı́n), T. pachyurus (Puerto Tri-
unfo), C. gracilis (Santafé de Antioquia) and Chac-
tas spp. (Angelópolis) in Antioquia, were the species
responsible for the stings (Table 1). The scorpion
was seen but neither captured nor identified in 10
cases. Additionally, people in rural parts of Antio- Figure 2 Distribution of scorpion stings according to the
quia collected other scorpion species not involved anatomical site in 129 patients in Colombia.
746 R. Otero et al.

Table 2 Signs of systemic scorpion envenoming in 129 patients in Colombia

Children (n = 41) Adults (n = 88) Total (n = 129)
No. (%) No. (%) No. (%)

Tachycardia 13 (31.7) 11 (12.5) 24 (18.6)

Vomitinga 18 (43.9) 5 (5.7) 23 (17.8)
Generalized sweating 13 (31.7) 7 (8.0) 20 (15.5)
Drowsiness 12 (29.3) 5 (5.7) 17 (13.2)
Abdominal pain 8 (19.5) 3 (3.4) 11 (8.5)
Tachypnea 10 (24.4) — 10 (7.8)
Sialorrhea/dysphagia 2 (4.9) 8 (9.1) 10 (7.8)
Perioral cyanosis 5 (12.2) 2 (2.3) 7 (5.4)
Dehydration 6 (14.6) — 6 (4.7)
Cold extremities 3 (7.3) 2 (2.3) 5 (3.9)
Hypertension 4 (9.8) — 4 (3.1)
Rales (rhonchus) 4 (9.8) — 4 (3.1)
Bradycardia 2 (4.9) 2 (2.3) 4 (3.1)

Some patients had more than one sign of envenoming.

a
Two children had haematemesis.

in the accidents herein described, such as T. tay- and CK-MB isoenzyme (205 IU/l). Echocardiography
rona, T. nematochirus and Ananteris antioquensis, was not performed.
the latter being a new species (González-Sponga,
personal communication). 3.2. Envenoming grade and treatment
The local signs of envenoming were pain (96.9%),
Ninety-eight (76.0%) patients had mild envenom-
paresthesia (57.4%), negligible perilesional oedema
ing, whereas 27 (20.9%) had moderate and four
(56.6%), sweating (24.0%) and fasciculations (3.1%).
(3.1%) severe envenoming, the latter only in chil-
Tachycardia (18.6%), vomiting (17.8%) with hae-
dren less than six years old (Table 3). Moderate and
matemesis in two children, generalized sweating
severe envenoming was significantly more frequent
(15.5%), drowsiness (13.2%), abdominal pain (8.5%)
in children than in adults (P = 0.003; RR = 2.97).
and tachypnea (7.8%) were the most frequent sys-
Scorpion species involved in moderate and severe
temic signs, all of them of more frequent occur-
envenoming were T. pachyurus (12 cases), C. gra-
rence in children than in adults (P < 0.05) (Table 2).
cilis (9 cases), T. fuehrmanni (4 cases), T. asthenes
One 42-day-old baby, presenting severe tachypnea
(4 cases) and two unidentified scorpions.
(100/min) and tachycardia (200/min), had also gen-
Fifty-four patients (42.0%) received traditional
eralized clonic convulsion and bronchoaspiration
remedies before seeking medical attention. Among
pneumonia. In spite of the presence of tachypnea
them, 14 (10.9%) used poultices or local baths of
in 10 children, four of which also presented with
urine on the wound, 11 (8.6%) used aqueous ex-
hypertension, none had pulmonary oedema. Fever
tracts of medicinal plants administered as drinks
(2.3%), intercostal retractions (2.3%), restlessness
(2.3%) and priapism (0.8%), occurred only in chil-
dren. One adult female presented with ataxia and Table 3 Envenoming grade and age of scorpion sting
one other had mild hypotension. patients in Colombia
Three children (3—7 years old) had hyper- Age Envenoming grade (%)
glycaemia (190—355 mg/dl), one of them with (years)
hypocalcaemia. One 3-year-old girl, stung by T. Mild Moderate Severe Total
asthenes in Segovia, northeast of Antioquia, pre-
≤2 2 2 1 5 (3.9)
sented with persistent vomiting (more than 20
3—5 4 7 3 14 (10.9)
episodes), abdominal pain, tachypnea, hypoxaemia 6—14 17 5 — 22 (17.0)
and hyperamylasaemia (369 IU/l); acute oedema- 15—44 66 12 — 78 (60.5)
tous pancreatitis was documented by computed 45—59 4 — — 4 (3.1)
tomography. Two other patients (three and four ≥60 5 1 — 6 (4.6)
years old), had ECG abnormalities (prolonged QT
Total 98 (76.0) 27 (20.9) 4 (3.1) 129 (100.0)
interval, U wave, or sinus arrhythmia), one of them
with raised serum creatine kinase (CK) (3622 IU/l)
Scorpion envenoming in Colombia
Figure 3 Time (h) for disappearance of signs of systemic
envenoming in patients treated with antivenom (䊏 tri-
partite treatment) or without it ( bipartite treatment).
or poultices; six (4.6%) put an ice bag on the
wound, three (2.3%) drank one cup of a liquor ob-
tained from sugar-cane, and three patients (2.3%)
received poultices of the crushed scorpion.
In addition to symptomatic and supportive treat-
ment, 19 patients (14.7%) received antivenom ther-
apy (tripartite treatment) in the hospital, within
2 to 6 h of the sting; 15 moderate cases received
1—2 vials, and four severe cases 2—4 vials (2.5 ±
1.0; mean ± SD) of Alacramyn® . In spite of the
advice that all patients with systemic envenoming
did require antivenom therapy, clinicians adminis-
tered only symptomatic and supportive treatment
of vital functions (bipartite treatment) to 12 pa-
tients with moderate envenoming. Among symp-
tomatic medication, 74 (57.4%) patients received
oral or parenteral analgesics, 15 (11.6%) corticos-
teroids, 12 (9.3%) H1 and three (2.3%) H2 histamine
receptor blockers, 10 (7.8%) antiemetics (meto-
clopramide), and three (2.3%) antihypertensives
(nifedipine, furosemide). Thirty-four (26.4%) pa-
tients required i.v. crystalloids administration and
10 (7.8%) oxygen. Forty-two other patients (32.6%)
did not receive any kind of treatment.
The mean time of response to therapy, for some
signs of systemic envenoming (sialorrhea/dysphagia,
vomiting, abdominal pain, tachypnea), was signifi-
cantly lower (P < 0.05) in those patients receiving
tripartite treatment than in those receiving bipar-
tite treatment (Figure 3). None of the patients
required ventilatory support. There were neither
deaths nor sequelae.
4. Discussion
Scorpions are poisonous invertebrates found from
deserts to rainforests, including all intermediate
747
vegetation zones, at altitudes as high as 5500 m
in the Andes, and in caves as deep as 800 m
(Lourenço and Cloudsley-Thompson, 1996). They
may live inside or outside the house and lie under
stones, logs or rubbish, in cracks of the ground
or walls, under the wood or palm leaves of the
roofs, and inside dwellings, in shoes and clothes
kept in closets (Gómez et al., 2002; Lourenço and
Cloudsley-Thompson, 1996). Most species can be
defined as equilibrium species, i.e. they produce a
single clutch of eggs after each insemination and
their populations are generally of low density; they
exhibit localized, predictable ecological and bio-
geographic patterns and are usually highly endemic.
These equilibrium species are selected against by
human effects on the environment, causing positive
selection for noxious opportunistic species, which
have short embryonic and postembryonic develop-
ment and produce up to five clutches of eggs after
a single insemination, having, in consequence, high
population densities. Opportunistic species live in
disturbed environments, increasing the risk of ac-
cidents (Lourenço and Cloudsley-Thompson, 1996).
In this study, 70.5% of the stings were inside human
dwellings, most of them (73.6%) in urban situations.
Furthermore, all of the implicated scorpion species
are both of intradomicilary and extradomicilary
habits (unpublished data).
Only about 25 species worldwide are considered
dangerous for humans, e.g. they cause fatal stings,
and live in well-defined geographical regions where
contact with humans is frequent. Almost all of them
belong to five genera from the family Buthidae:
Androctonus and Buthus (North Africa), Leiurus
(North Africa and the Middle East), Centruroides
(North America, Central America, north of South
America) and Tityus (South America, Panamá,
Costa Rica, Trinidad) (Goyffon, 1996; Lourenço and
Flórez, 1989; Lourenço and Cloudsley-Thompson,
1996; Vı́quez, 1999).
The results of this study, the first prospective clin-
ical and epidemiological study on scorpionism per-
formed in Colombia, contributed to knowledge of
distribution ranges for some species as T. asthenes,
T. pachyurus, T. tayrona, T. nematochirus and C.
gracilis. Additionally, a new Ananteris species was
described, raising to five the Colombian species of
the genus (Lourenço and Flórez, 1989; Lourenço,
1990, 1994, 1999a; González-Sponga, personal com-
munication).
The incidence of scorpion stings was significantly
higher in the valley of the Magdalena river in
Tolima department, a region with a predominance
of semidry forest, but also occurred in vegetation
zones of tropical and subtropical rainforest in both
departments. There is no doubt that T. pachyurus
748
and C. gracilis are potentially dangerous species
for the population of Tolima department, as T. as-
thenes, T. fuehrmanni and C. gracilis are also for
the population of Antioquia.
Clinical symptoms and signs observed in the pa-
tients corresponded to cholinergic and/or adren-
ergic manifestations of the envenoming (e.g.
tachycardia, vomiting, generalized sweating,
drowsiness, abdominal pain, tachypnea). Although
the real frequency of mild cases was probably
underestimated because only patients admitted
to hospitals were enrolled in the study (selection
bias), in most cases (76.0%) symptoms and signs
were mild and children were the age group at
highest risk for moderate/severe envenoming (P
= 0.003; RR = 2.97), in agreement with previous
reports (Cupo et al., 1994; Dehesa-Dávila et al.,
1995; Hering et al., 1992).
The clinical picture in children with myocardial
damage secondary to scorpion envenoming resem-
bles myocardial infarction including typical ECG
changes and high CK-MB isoenzyme serum levels
(Cupo et al., 1994; Sofer et al., 1991a). Despite the
presence of cardiovascular signs (two children had
ECG changes, e.g. prolonged Q T interval, U wave,
or sinus arrhythmia, one of them with high CK-MB
levels) and pulmonary alterations in a low number
of patients, there were no deaths. This might be
the result of the absence of pulmonary oedema,
ARDS, and severe cardiomyopathy in this series, as
well as to early antivenom administration (within
2 h in 17 patients). Nevertheless, during a period of
15 months after the end of this study, five children
(two in Tolima and three in Antioquia) died as a
consequence of cardiopulmonary complications of
scorpion envenoming (pulmonary oedema, ARDS,
myocardial dysfunction), only two of them received
antivenom therapy but too late (6 and 14 h after
the sting) (unpublished data).
Experimental and clinical studies strongly indi-
cate that pulmonary oedema may be of cardiac and
non-cardiac origin (e.g. kinins) (Freire-Maia et al.,
1994; Magalhães et al., 1999; Mazzei de Dávila
et al., 2002). Moreover, myocardial dysfunction and
pulmonary oedema may be accompanied by mas-
sive sympathetic activation induced by scorpion
venom action on pre-synaptic sympathetic termi-
nals, creating high concentrations of noradrenaline
in the plasma, as was demonstrated in patients
severely envenomed by T. zulianus from Venezuela.
Thus, very early administration of antivenom may
reduce the risk of cardiopulmonary complications
(Mazzei de Dávila et al., 2002).
Scorpion envenoming may induce excessive gas-
tric, salivary and pancreatic (endocrine and ex-
ocrine) secretion, associated with pancreatitis and
R. Otero et al.
acute gastric mucosal injury (Cunha-Melo et al.,
1991; Freire-Maia et al., 1994; Radha Krishna
Murthy and Hase, 1994). In this study, there were
two children with haematemesis that probably had
gastric mucosal injury, but it was not demonstrated
by endoscopy. Acute pancreatitis (oedematous,
haemorrhagic, pseudocyst formation) complicating
scorpionism was reported in Trinidad in 1938 by
Waterman (cited by Bartholomew, 1970), following
stings by T. trinitatis. Pancreatitis has also been
documented in other countries of America, the Mid-
dle East and Asia in patients stung by other species
(e.g. L. quinquestriatus, T. serrulatus) from Buthi-
dae family (Dehesa-Dávila et al., 1995; Freire-Maia
et al., 1994; Radha Krishna Murthy and Hase, 1994;
Sofer et al., 1991b). Moreover, Otero et al. (1998)
reported the first case described in Colombia of
acute haemorrhagic pancreatitis and pseudocyst
formation in a 10-year-old girl stung by T. asthenes.
In this study, a 3-year-old girl, stung also by T. as-
thenes, presented acute oedematous pancreatitis
that evolved successfully after antivenom ther-
apy. As described by Sofer et al. (1991b) in mild
cases inflicted by L. quinquestriatus, pancreatitis
is usually transient, and subsides within 24—48 h.
Most investigators consider antivenom the only
specific treatment for scorpion stings. Because of
the fast absorption, distribution and action of scor-
pion toxins, the antivenom must be administered
i.v. very soon after the accident. Thus, mortal-
ity decreased considerably to less than 0.1% or
0.3% in many affected countries during the 1990s
due to the use of antivenom (Dehesa-Dávila and
Possani, 1994; El-Amı́n, 1992; Freire-Maia et al.,
1994; Ismail, 1994, 1995; Ismail and Abd-Elsalam,
1998; Krifi et al., 1998, 1999, 2001; Maraboto and
Turrubiarte, 1999; Rezende et al., 1998).
Cross-reactivity has been demonstrated between
monospecific or polyvalent anti-scorpion antiven-
oms and the venoms from different species of
the same genus, or from different genera of the
same family (Estévez et al., 2000; Mancilla et al.,
1999; Nishikawa et al., 1994). Alacramyn® , a prod-
uct used successfully in Mexico since the 1980s
(Dehesa-Dávila and Possani, 1994) and recently ap-
proved by the FDA for clinical trials in USA (IND
10371), recognized different antigens of T. pachyu-
rus and C. gracilis scorpion venoms from Colombia,
as shown by Western blot, and neutralized the
lethal effect of those venoms in mice (unpublished
data). Although conclusions obtained in this study
were limited by the lack of blinding or randomiza-
tion, patients treated with Alacramyn® had signif-
icantly shorter recovery times for systemic enven-
oming signs, when they were compared with pa-
tients receiving only bipartite treatment (P < 0.05).
Scorpion envenoming in Colombia
None of the 19 patients treated with Alacramyn®
reacted adversely to the antivenom. Findings
of absence or low incidence of EARs (1.7—8.0%)
to this and similar anti-scorpion fabotherapics
have been reported (Dehesa-Dávila and Possani,
1994; Freire-Maia et al., 1994; Ismail, 1994;
Osnaya-Romero et al., 2001). This might be related
to the low protein content and absence of the Fc
fragment in these products, as well as to the protec-
tive effect of the massive release of catecholamines
induced by scorpion venom (Dehesa-Dávila and
Possani, 1994; Freire-Maia et al., 1994; Ismail,
1994; Otero, 2002).
Conflicts of interest statement
The authors have no conflicts of interest concerning
the work reported in this paper.
Acknowledgements
We thank the personnel of the hospitals involved
in the study, as well as the financial support of the
Vicerrectorı́a de Investigación, Universidad de An-
tioquia, and Instituto Bioclón S.A. de C.V., México.
We are grateful to Dr. José Marı́a Gutiérrez from
Instituto Clodomiro Picado, Universidad de Costa
Rica, and Dr. David Warrell from Oxford University,
for valuable revision of the manuscript.
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