Scorpion sting complications: The uncommon and deadly duo of stroke and myocarditis

Dear Editor, Scorpion sting-induced intracerebral hemorrhage (ICH) is exceptionally uncommon, with only a handful of documented cases, predominantly involving the thalamus, basal ganglia, cerebellum, and subarachnoid spaces.[1] A prominent systemic effect of scorpion venom toxicity is cardiac dysfunction, often manifesting as myocarditis or cardiomyopathy. This cardiac involvement can lead to severe complications such as pulmonary edema and cardiogenic shock, underscoring the complex, multiorgan impact of scorpion envenomation.[2] A 45-year-old male was admitted to the intensive care unit with worsening shortness of breath and a decreased level of consciousness (Glasgow Coma Scale of 6/15) following a scorpion sting while working in the field. Initial assessment revealed tachycardia (heart rate 130/min), hypotension (blood pressure [BP] 73/54), and altered sensorium, prompting immediate intubation and initiation of vasopressor and inotropic support. The cardiac evaluation revealed elevated creatine kinase MB isoenzyme levels, with electrocardiogram showing nonspecific ST change [Figure 1a] and two-dimensional echocardiography showing global hypokinesia and a reduced left ventricular ejection fraction of 40%–45%, consistent with suspected myocarditis. Despite improvement in cardiac function, the patient experienced a sudden neurological decline on day 3, with brain imaging revealing a left gangliocapsular hemorrhage, intraventricular extension, and subarachnoid hemorrhage [Figure 1b]. Neurosurgical consultation advised conservative management. Although his myocarditis improved, the patient’s neurological status did not recover, and he developed sepsis and ventilator-associated pneumonia. On day 10, he succumbed to multiple complications, including brain herniation.Figure 1: (a) Electrocardiogram showing nonspecific ST change, (b) Computed tomography scan brain showing left gangliocapsular hemorrhage, intraventricular extension, and subarachnoid hemorrhageScorpion venom contains potent neurotoxins that disrupt nerve cell depolarization. β-toxins open sodium channels, causing sustained depolarization, whereas α-toxins prolong excitatory states by inhibiting sodium channel deactivation. Kappa-neurotoxins block potassium channels, leading to neuroexcitability and calcines, as ryanodine receptor agonists, increase intracellular calcium, inducing contractile paralysis. These mechanisms collectively lead to severe autonomic disturbances, cardiotoxicity, and neurotoxicity in scorpion envenomation.[3] A key hypothesis suggests that the catecholamine surge from scorpion envenomation can cause severe hypertension and BP fluctuations, increasing the risk of hemorrhage in vulnerable brain regions. The venom may also trigger disseminated intravascular coagulation, vasculitis, or microvascular damage, further elevating the risk of a cerebral hemorrhage. In addition, myocarditis and related cardiac dysfunction may increase the likelihood of thromboembolic events, potentially leading to stroke or hemorrhagic transformation.[4] Recent literature suggests that scorpion venom profoundly disturbs the autonomic nervous system, resulting in severe symptoms. Scorpion stings cause 2% of central nervous system complications and 8% of cerebrovascular disorders. The neurotoxins in the venom can lead to hypertension, tachycardia, and cardiac dysfunction. Early use of antivenom and prazosin has been found to minimize complications and mortality.[5] This case underscores the severe complications that can follow scorpion envenomation, showcasing the unusual presentation of ICH associated with myocarditis. Although scorpion stings are common in tropical regions, cerebrovascular events like ICH remain rare, with most cases involving areas such as the thalamus, basal ganglia, and cerebellum. Here, our patient developed a gangliocapsular hemorrhage with intraventricular extension, mirroring these few reported patterns. This case highlights the importance of vigilant monitoring and early neuroimaging for neurological symptoms poststing, aiming to inform the management of similar cases in the future. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.