Microsoft Word - 8-Dehghani.doc Iranian J Arthropod-Borne Dis, (2008), 2(1): 49-52 R Dehghani and T Khamehchian: Scrotum Injury… 49 Case Report Scrotum Injury by Scorpion Sting *R Dehghani1, T Khamehchian2 1Department of Medical Entomology, School of Medicine, Kashan University Medical Sciences, Kashan,Iran 2 Department of Pathology, School of Medicine, Kashan University Medical Sciences, Kashan, Iran (Received 17 Feb 2007; accepted 1 Jan 2008) Abstract Androctonus crassicauda is the second most frequent causes of scorpion sting in south-west Iran. Its venom can cause sever pain, autonomic, central nervous system (CNS), muscle function disturbances, and death. Appropriate medical and nursing cares can lead to complete recovery with no sequel .The majority of scorpion stings are oligosymptomatic, occurring mainly on the hands and feet (about 90%). Here one rare case of a scorpion sting on the scrotum is reported from Kashan, central Iran. Keywords: Scorpion sting, Androctonus crassicauda, Scrotum, Iran Introduction In Iran 45000-50000 scorpion stings are reported every year (Deghani 2003). Accord- ing to the reports a total of 32 species of scorpions are found in Iran (Kovarik 1997). Three species of Hemiscorpius lepturus, An- droctonus crassicauda and Mesobuthus eu- peus play an important role in almost all cases of scorpion stings in Iran. The black scorpion A. crassicauda (Fig.1) and the Gadim (the local name of H. lepturus) are consid- ered as the most dangerous scorpions exist in sub-tropical areas of Iran. Scorpion stings re- corded in Khuzestan and Hormozgan Prov- inces have significant social hazard. About 5 species of scorpions were found in the Ka- shan (Dehghani et al. 1999). The city of Kashan (33°58’28” N; 51°26’07” E, altitude ca. 850 m asl) in Esfa- han Province (central Iran), is one of the oldest cities of Iran. This city is situated in a peculiar natural area. Its west borders Kavir salt desert (Dasht-e Kavīr), which is one of the seven desert plains of Iran and one of the driest and the hottest parts of Iran. On the east, the Karkas Mountains are located, while further to the west, there also is a large mountainous area, the north-eastern portion of the Zagros Mountains (Dehghani 2003). A. crassicauda with sting being common and fatalities on record is of medical impor- tance in the Middle East. A. crassicauda is the first and most dangerous cause of scor- pion sting in Kashan. At serum therapy cen- ter of Kashan, two-hundred cases were ob- served per year. Thirty percent of the cases of scorpion sting in Kashan and the total of mortality are caused by A. crassicauda. The rate of mortality was 1.5% (Dehghani et al. 1999). Androctonus genus is very toxic, with symptoms of envenomation including malignant hyperthermia, myocarditis and pulmonary edema and with many lethal stings on record (Nouira et al. 1995). Typical effects of the sting are pain and tenderness at the injection site, with severe neurological effects and hy- pertension (Nouira et al. 1995). A. crassi- *Corresponding author: Dr R Dehghani, Tel: +98 0913 3610919, Fax: +98 0361 5550111, E-mail: dehghani37@yahoo.com Iranian J Arthropod-Borne Dis, (2008), 2(1): 49-52 R Dehghani and T Khamehchian: Scrotum Injury… 50 cauda is the second frequent of scorpion sting in south-west Iran. Its venom can cause severe pain, autonomic CNS, muscle function disturbances and death. Appropriate medical and nursing cares can lead to complete re- covery with no sequel (Radmanesh 1990). The majority of scorpion stings occurring mainly on the hands and feet (about 90%) are oligosymptomatic and fatality is rare. Here we report a rare case of a scorpion sting on scrotum from Kashan, central Iran. Case report A 38-yr old man with 88 kg weight, when had been wearing his work trousers was stung on his scrotum by A. crassicauda. It was associated with burning pain at the site of sting. Administration of alcohol and pressuring on the sting site were used by victim without success to relieve pain. He received medical assistance one hour after the event when he suffered from diffuse ery- thema, edema and severe local pain on the scrotum and inguinal lymph node and when severe systemic manifestation including: sweat- ing, thirsty, dry mouth, agitation and restless- ness and local muscle spasm were observed. He did not complain of visual disturbances, sensory disturbances or weakness of his limbs. Lidocaine was administered subcuta- neously for the immediate relief of the pain. Antivenin to scorpion sting was not adminis- trated because it was not available at that time in the center, but he was managed with atropine in order to antagonize the muscarinic effect of Ach and chlorpromazine as a tran- quilizing of the agitation and restlessness. Discussion Envenomation by scorpion stings is a ma- jor public health problem especially in chil- dren in Iran (Radamnesh 1990). Scorpions are held responsible for a lot of injured an- nually, especially in the rural areas and dur- ing the hot seasons (Dehghani 2003). En- venoming by the Iranian scorpion A. crassi- cauda can cause massive discharge of cate- cholamine. The relationship between these effects and the clinical situation is unclear (Vatanpor 2003). A. crassicauda venom can specifically stimulate the acetylcholine recep- tors through the body, so it can be considered as neurotoxic venom (Radmanesh 1990). The classical clinical picture of scorpion stings is characterized by local pain, which may ex- tend to regional lymph nodes, hyperemia and edema (Garcia et al. 1999). Systemic mani- festations are meiosis, lacrimation, strabismus, increased salivation, dry mouth, thirst, increase bronchial secretion, sweating, nausea, vomit- ing, priapism, urinary incontinence, confusion, coma, local muscle spasm, general muscle paralysis, convulsion, more commonly in chil- dren and old people (Radmanesh 1990). Hy- pertension, hypothermia, cardiac arrhythmia and pulmonary edema may also occur. There are only three reported cases of stings on unusual areas of the body: one on the face (Nishioka et al. 1992) by T. serrula- tus and two on the penis (Nishioka et al. 1993), both by T. serrulatus and T. trivitatus (Garcia et al. 1999). In addition to unusual site of the sting, our patient showed a clini- cal picture of mild intensity. Self-administra- tion of alcohol may have contributed to aug- menting the pain. A sting on the scrotum should be treated like stings on any other part of the body. Local analgesic block with 1% lidocaine for pain relief is usually re- sorted to. For those cases of systemic mani- festation, a specific antivenin is indicated. Us- ing prazosin for treatment of hypertension and acute pulmonary edema has been re- ported to be successful. In our case report the scorpion was the A. crassicauda species, and mild systemic manifestations were ob- served. A. crasicuda venom can increases the release of acetylcholine at the neuromus- cular junction by both increasing quantal con- tent as well as the release after single shock Iranian J Arthropod-Borne Dis, (2008), 2(1): 49-52 R Dehghani and T Khamehchian: Scrotum Injury… 51 stimulation (Vatanpor 2003). In addition in- jection of A. crassicauda venom in animal laboratory such as rat, clinical manifestations were occurred include: paralysis, irregular pulse, twitching, rhinorrhea, salivation, hem- orrhage from eyes, nosebleeds and death (Dehghani et al. 2006). The venom of A. crasicuda predominantly parasympathetic ef- fects but it is possible that under special circumstances it may also cause sympathetic activities (Radmanesh 1990). The venom of A. crasicuda is a potent autonomic stimulator. Severity of symptoms depends on the size of the victim, season, and duration lapse be- tween sting and hospitalization. So therapy should disappear such effects. First aid meas- ures should include putting ice on the sting site and elevation of the affected part. General supportive measures include the use of anti- histamines, corticosteroids, and analgesics. Bar- biturate therapy is recommended to control seizures and excessive neuromuscular activity (Carbonaro et al. 1996). We recommend that the treatment for scorpion stinging in Kashan should be based on the neurotoxic effect of their venom produced in victims (Dehghani et al. 1998). 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