ASSESSMENT OF SCORPION STING

BURDEN IN YANBU

STUDENT NAME: RAIF HAMED SIBAIH

STUDENT NUMBER: 44287123
COURSE NAME: Master’s in clinical Toxicology
DEPARTMENT: Department of Pharmacology and Toxicology
COURSE CODE: CLTOX1
SUPERVISOR: Dr. Ibrahim Abdulaziz
DATE OF SUBMISSION: 08 10 2021

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Table of Contents
ABSTRACT:..............................................................................................................................................3
INTRODUCTION:....................................................................................................................................4
LITERATURE REVIEW:........................................................................................................................5
AIMS AND OBJECTIVES:......................................................................................................................7
RESEARCH DESIGN AND METHODS:...............................................................................................7
Population and study sample................................................................................................................7
Data Analysis Strategies........................................................................................................................7
Ethics and human subject issues..........................................................................................................7
Timeframes............................................................................................................................................7
STRENGTHS AND WEAKNESSES OF THE STUDY.........................................................................7
CLINICAL TOXICOLOGY SIGNIFICANCE......................................................................................7
REFERENCES:.........................................................................................................................................8
Appendix 1: consent form:......................................................................................................................10
Appendix 2...............................................................................................................................................11
Patient’s demographics and relevant information:...............................................................................11

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ABSTRACT:
Scorpion envenomation is a worldwide problem especially in tropical and subtropical regions.(1)
Scorpion stings can be as mild as local pain and inflammation in the site of sting. It can also be
as severe as cardiomyopathy and pulmonary edema. The latter is mainly the cause of death in
lethal cases of envenomation.(2) This can be a serious problem in some areas inhabited by
poisonous scorpion species. In Saudi Arabia there are about 26 scorpion species with an average
of 14500 stings per year.(3,4) This can be a considerable health problem that needs to be dealt
with to reduce its impact on health care system and on the society. Systemic manifestations
mainly occur due to neurotoxins present in the venom.(5) Children below the age of 10 are the
main population at risk of systematic affection that leads to the need for hospitalization and
serious consequences.(6) This study aims to assess the burden of scorpion stings and their
severity. Also, it aims to evaluate the treatment plan and see if there are other measures needed
to be added to it.

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INTRODUCTION:
Scorpions are members of Arachnida class and order Scorpiones. They are venomous arthropods
who inhabit nearly all continents of the world except Antarctica. Order Scorpiones has 16
families and 1500 different species and subspecies. Scorpions have conserved their morphology
almost unaltered.(7) Scorpions that are considered of medical importance are mainly those who
belong to the family Buthidae. Those are represented by the genera Androctonus, Buthus,
Mesobuthus, Buthotus, Parabuthus,  and Leirus who are generally found in North Africa, Asia,
the Middle East, and India. While Centruroides spp are found in Southwest of United States,
Mexico, and Central America. Also Tityus spp is located mainly in South and Central America
and Caribbean.(8) There are approximately 117 scorpion species within six families found in the
Arab countries of the middle east. 25 species of which are medically important and recognized as
dangerously venomous, that can cause potentially life-threatening stings. The scorpion species
that is considered medically dangerous belongs to the family of Buthidae, which is the largest
group in scorpion families (more than 800 scorpion species), and is mainly found in North
Africa, Asia, Middle East, and India, and represented by the genera Androctonus, Buthus,
Mesobuthus, Buthotus, Parabuthus, and Leirus.(2,9) 
Scorpionism, a term used for scorpion stings, is a phenomenon that is spread all over the world.
However, it is a public health problem of a considerable impact on society in the tropical and
subtropical regions.(10) Scorpion stings can cause trauma, tissue damage, infection, allergies,
disability, psychological effects, and rarely death.(11) Scorpion sting can be presented as
localized reactions in most of the injuries. However in some cases it can be presented as severe
cardiorespiratory manifestations, mainly cardiogenic shock and pulmonary edema. (12) The
management of scorpion stings is difficult due to the complexity of its pathophysiology. Body
systems are almost entirely affected. However, circulatory shock and pulmonary edema are the
main cause of death. In emergency department, scorpion antivenom and symptomatic treatment
are generally the main aspects of management of scorpion envenoming. (6)
The signs and severity of the scorpion envenomation are variant and depend on several criteria.
First of which is the scorpion species which affects the venom composition and quantity injected.
Also, the victim’s physiological condition and his body’s reaction to the venom plays an
important role.(7) That is why children and elderly people are most susceptible to sever
systematic manifestations.(1,6)
This study aims to collect data on the initial presentation of victims of scorpion stings and
evaluate the treatment protocol that is followed with such cases. This will help to identify the
burden that scorpion stings exert on the emergency department in a general hospital in Yanbu.

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LITERATURE REVIEW:
Scorpions are highly diverse arachnids that have been present on earth for over 400 million
years.(9,13) Androctonus crassicauda Family: Buthidae; is the most common species present in
many areas of Saudi Arabia.(13) In Saudi Arabia, there is an average of 14500 scorpion stings
per year.(4) Mortality rate due to scorpion stings in Saudi Arabia was found to be 3% between
1985 and 1993.(14) Incidence of scorpion stings were found to be higher in the months of May–
October.(15) Spicies Parabuthus liosoma, Leiurus quinquestriatus, Nebo hierichonticus,
Androctonus crassicauda and A. amoureuxi were related to sever cases of envenomation in Saudi
Arabia.(16)
A study that was performed in Riadh province aimed to specify scorpion species that are present
in that region. They detected two species which belonged to the family Scorpionidae. They are
Scorpio maurus kruglovi and Hemiscorpius arabicus. Hemiscorpius arabicus is now part of the
Hemiscorpiidae family which is recently upgraded from a subfamily. They also found eight
species that belong to the Buthidae family. These species are Leiurus quinquestriatus,
Androctonus crassicauda, Androctonus bicolor, Compsobuthus arabicus, Compsobuthus werneri,
Buthacusyotvatensis nigroaculeatus, Buthacusleptochelys and Orthochirus innesi.(3) Another
study that covered the entire Kingdom of Saudi Arabia. They found 26 species that belong to
four families, 4 of them are endemic to Saudi Arabia. Species that were found in the region of Al
Madina: Androctonus crassicauda, Leiurus arabicus, Leiurus haenggii, Orthochirus Karsch,
Trypanothacus buettikeri, Nebo hierichonticus and Scorpio kruglovi.(13)
Usually the volume of venom ejected is 0.1-0.6 mg.(17) The scorpion species highly determines
the potency of the venom while the age and physical condition of the victim may affect the
severity of the symptoms.(18) Scorpionism symptoms may vary from only a mild flu like
syndrome to sever neurological and cardiovascular symptoms that may lead to death within few
hours if not treated properly.(2) Electrophoresis studies showed that scorpion venom is a
heterogenous mixture that is water-soluble. It was also found to be antigenic. This wide variety
of composition leads to a wide variety in effects exerted on the victims.(19)
Usually, scorpion venom contains various types of toxins beside other compounds. Those toxins
are present in various concentrations. For example, a scorpion venom may contain neurotoxin,
cardiotoxin, nephrotoxin, hemolytic toxin, phosphodiesterases, phospholipases, hyaluronidases,
glycosaminoglycans, histamine, serotonin, tryptophan, and cytokine releasers. The neurotoxin is
considered the most medically important toxin. It is the most potent one too.(5) There are two
types of neuro toxins both of which are of low molecular weight and are heat stable. They act by
altering ion channel permeability in nerve cells, muscles, and the heart. This causes the
neuromuscular and neuroautonomic known symptoms of envenomation.(20)
Scorpion venom toxins mainly target voltage-dependent ion channels. Sodium channels are the
best studied voltage-dependent ion channels affected by scorpion venom. Venom toxins
generally cause excessive neuronal excitation. This happens due to alteration of ion channels by

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neurotoxins leading to persistent neuronal activity.(5) Toxins target sodium channels that are
present in excitable membranes at the neuromuscular junction. They cause repetitive
depolarization of nerves which affects sympathetic and parasympathetic nervous systems. This
will result in excessive release of catecholamine and acetylcholine.(21) This excessive
excitation is the reason behind many end organ manifestations. For example, cardiopulmonary
manifestations observed after some scorpion envenomation is due to excessive autonomic
excitation.(22) Additionally neurotoxins cause neuromuscular overstimulation which results in
cranial and somatic nerve hyperactivity.(23)
Scorpion envenomation is sorted to grades according to the severity of manifestations
accompanying the sting. Grade one is the least severe grade and is defined as the presence of
local pain and paresthesia at the site of sting. Grade two is featured with the presence of pain
and/or proximal to the site of the sting together with the local manifestations. Grade three is
featured by the presence of either somatic neuromuscular or autonomic excessive excitation.
Somatic neuromuscular excessive excitation manifestations are involuntary tremors and jerking
of the arms and legs that are miss diagnosed as seizures. However, autonomic excitation is
manifested as blurred vision, drifting eye movements, dysphagia, tongue muscle twitching,
problems with the upper air way and dysphonia. Finally, grade four envenomation is featured by
the presence of both autonomic and somatic neuromuscular excessive excitation. This can lead to
more sever symptoms as hyperthermia, rhabdomyolysis, pulmonary edema and multiple organ
failure.(21,24) Usually, treatment of grades one and two will be limited to analgesics,
antihistamines and local compress. However, grades three and four will need antivenom together
with other drugs needed to stabilize the case according to the systematic symptoms present.
Anxiolytics can be helpful in those cases as well.(25)

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AIMS AND OBJECTIVES:
The study aims to survey scorpion stings in Yanbu. Our aim is to evaluate the existing practice
for dealing with scorpion stings. Also, to evaluate the severity of scorpion stings and the need for
hospitalization which may exert a burden on health care system.

RESEARCH DESIGN AND METHODS:

A Prospective descriptive cross-sectional study of all patients presenting to emergency
department of hospital Yanbu after scorpion sting over 3 months period.
Patient demographics will be recorded along with their presenting symptoms, type of scorpion,
treatment plan, need for hospitalization and need for intensive care unit admission.
Population and study sample
Inclusion criteria will be all patients presenting to the emergency department with scorpion sting
and who are willing to participate in the study.
Data Analysis Strategies
Data will be analysed using SPSS 26 by descriptive analysis.
Ethics and human subject issues
The study must be approved first from the ethical committee of the hospital Yanbu . Subjects
will be informed about the purpose of the study and confidentiality of their information.
Informed consent will be given to each patient to read carefully and sign it. (Appendix 1) the
survey will be carried out in a separate isolated room. Respondents will be participating
anonymously and voluntarily.
Timeframes
Data will be collected for three months from01-12-2021 to 01-02-2022

STRENGTHS AND WEAKNESSES OF THE STUDY

This study design is relatively easy, quick and inexpensive. However, it is susceptible to
sampling bias, interviewer bias and recall bias. The interview will be time consuming, but it will
improve the response rate relative to letting the patients answer the questionnaire on their own.
This study will not generate causal inference but is a good way to generate hypothesis for further
investigation.

CLINICAL TOXICOLOGY SIGNIFICANCE

Scorpion stings are very common in Saudi Arabia and can affect the healthcare system and the
community. Symptoms vary from local pain and reaction in the sting site to more severe
systemic manifestations especially in children. This may increase the need for hospitalization

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and may lead to death in some cases. We need to be aware of the burden that scorpion stings
exert on the community and see if there are any measures that need to be done to limit their
harm.

REFERENCES:
1. Al-Asmari AK, Al-Saif AA. Scorpion sting syndrome in a general hospital in Saudi Arabia.
Saudi Med J. 2004 Jan;25(1):64–70.

2. Amr ZS, Abu Baker MA, Al-Saraireh M, Warrell DA. Scorpions and scorpion sting
envenoming (scorpionism) in the Arab Countries of the Middle East. Toxicon. 2021
Feb;191:83–103.

3. Al-Asmari AK, Al-Saief AA, Abdo NM, Al-Moutaery KR. New additions to the scorpion
fauna of Riyadh region, Saudi Arabia. J Venom Anim Toxins incl Trop Dis. 2009;15:612–
32.

4. Jarrar BM, Al-Rowaily MA. Epidemiological aspects of scorpion stings in Al-Jouf Province,
Saudi Arabia. Ann Saudi Med. 2008;28(3):183–7.

5. Zahid MT, Tahir M. Nature and applications of scorpion venom: an overview. Toxin
Reviews. 2018 Dec 20;39.

6. el Aminn EO, Berair R. [Scorpion stings in children. Saudi Arabian experience]. Arch
Pediatr. 1995 Aug;2(8):766–73.

7. Petricevich VL. Scorpion Venom and the Inflammatory Response. Mediators of

Inflammation. 2010 Mar 14;2010:e903295.

8. Ismail M. The scorpion envenoming syndrome. Toxicon. 1995 Jul 1;33(7):825–58.

9. Alkahlout BH, Abid MM, Kasim MM, Haneef SM. Epidemiological review of scorpion
stings in Qatar: The need for regional management guidelines in emergency departments.
Saudi Medical Journal. 2015 Jul 1;36(7):851–5.

10. Dehghani R, Vazirianzadeh B, Nasrabadi MR, Moravvej SA. Study of scorpionism in

Kashan in central Iran. :4.

11. Khan A, Al-Kathiri WH, Balkhi B, Samrkandi O, Al-Khalifa MS, Asiri Y. The burden of
bites and stings management: Experience of an academic hospital in the Kingdom of Saudi
Arabia. Saudi Pharmaceutical Journal. 2020 Aug;28(8):1049–54.

12. Mourad. Assessment of patients with snake bite and scorpion sting attending Poison Control
Unit of Tanta University Hospital [Internet]. [cited 2021 Sep 21]. Available from:
https://www.tdj.eg.net/article.asp?issn=1110-
1415;year=2020;volume=48;issue=2;spage=46;epage=52;aulast=Mourad#ref4

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13. Alqahtani A, Badry A. A contribution to the scorpion fauna of Saudi Arabia, with an
identification key (Arachnida: Scorpiones). Journal of King Saud University - Science. 2021
Jun 1;33:101396.

14. Dittrich K, Power AP, Smith NA. Scorpion Sting Syndrome — A Ten Year Experience.
Annals of Saudi Medicine. 1995 Mar 1;15(2):148–55.

15. Jahan S, Mohammed Al Saigul A, Abdul Rahim Hamed S. Scorpion stings in Qassim, Saudi
Arabia--a 5-year surveillance report. Toxicon. 2007 Aug;50(2):302–5.

16. D. A. W. Venomous bites and stings in Saudi Arabia. 1993;196–202.

17. van der Meijden A, Coelho P, Rasko M. Variability in venom volume, flow rate and duration
in defensive stings of five scorpion species. Toxicon. 2015 Jun 15;100:60–6.

18. Tiwari AK, Deshpande SB. Toxicity of scorpion (Buthus tamulus) venom in mammals is
influenced by the age and species. Toxicon. 1993 Dec 1;31(12):1619–22.

19. Scorpion Envenomation: Background, Pathophysiology, Etiology. 2021 Apr 3 [cited 2021
Sep 21]; Available from: https://emedicine.medscape.com/article/168230-overview#a4

20. Zlotkin E, Fraenkel G, Miranda F, Lissitzky S. The effect of scorpion venom on blowfly
larvae—A new method for the evaluation of scorpion venoms potency. Toxicon. 1971 Jan
1;9(1):1–2.

21. Scorpion envenomation - WikEM [Internet]. [cited 2021 Oct 7]. Available from:
https://wikem.org/wiki/Scorpion_envenomation

22. Scorpion-related cardiomyopathy: Clinical characteristics, pathophysiology, and treatment.

[Internet]. [cited 2021 Oct 7]. Available from:
https://reference.medscape.com/medline/abstract/25851549

23. Sanaei-Zadeh H, Marashi SM, Dehghani R. Epidemiological and clinical characteristics of

scorpionism in Shiraz (2012-2016); development of a clinical severity grading for Iranian
scorpion envenomation. Med J Islam Repub Iran. 2017;31:27.

24. Shamoon Z, Peterfy RJ, Hammoud S, Khazaeni B. Scorpion Toxicity. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2021 [cited 2021 Oct 8]. Available
from: http://www.ncbi.nlm.nih.gov/books/NBK430928/

25. Ismail M. Treatment of the scorpion envenoming syndrome: 12-years experience with
serotherapy. Int J Antimicrob Agents. 2003 Feb;21(2):170–4.

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Appendix 1: consent form:

Research Study Title

ASSESSMENT OF SCORPION STING BURDEN IN YANBU

Ethical committee
Approval Number
Researcher’s Name

Participant Consent
I __________________________, agree to participate in this research. I have been informed about the
details of the research and its purpose and had any question I have about the research answered for me by
the researcher. _____________________________________________________________________

Name of Research Participant (First name and Surname)

Are you 18 years of age or older? ¨ Yes ¨ No –( If yes, a parental consent form is required to be
completed.)______________________________________________________________________

Research Participant Signature Date

____________________________________________ ______________________

Name of Witness __________________________________________________________________

Relationship of Witness to Research Participant (e.g., friend, sibling, parent,..etc)

__________________________________________________________________

Witness Signature Date

________________________________ _________________________

Researcher’s Signature Date

________________________________ _________________________

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Appendix 2

Patient’s demographics and relevant information:

Age: ………………………………………………………………………………………………
Sex: …………………………………………………………………………………………………………

Are you a smoker? □ Yes □ No

If yes, what do you smoke?
………………………………………………………………………………………………………………

Morbidities:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

Mention your medications (please mention doses):

………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

Describe the scorpion that stung you

………………………………………………………………………………………………………………
………………………………………………………………………………………………………………..

State the time of the sting (time between the incidence and arrival to the emergency department)
………………………………………………………………………………………………………………

Please mention all the symptoms you have been experiencing since you were stung
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

Need for hospitalization □ Yes □ No

Need for ICU admission □ Yes □ No
Treatment plan:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

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………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

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