Scorpions are a group of homogeneous arthropods belongs to the class arachnid of the order scorpiones and are about 1500 species. They are found all over the world. In India of the 89 species of scorpions two types are importantly poisonous namely the small red mesobuthus tumulus (Indian red scorpion) and the large black palamneus gravimanus (Indian black scorpion)[4]. Scorpions are nocturnal creatures often hide in crevices and burrows and wait for their prey. Thus accidental stinging occurs when scorpions are touched with most stings on the hands and feet. These are active at night during the summer season [1]. Scorpion venom is a poison. Venom is deposited in the skin deep to the subcutaneous tissue. The half-life of intravenously injected venom is 4 to 7 minutes whereas it takes approximately 4 to 13 hours for its elimination from blood [12]. Venom contains multiple toxins and compounds. The primary target of scorpion venom is voltage gated sodium channel leading to autonomic excitation. The synergistic effects mediated by sodium and potassium channel is responsible for intense and the persistent depolarization of the autonomic nerves leading to massive release of autonomic neuromuscular neurotransmitter producing an “autonomic storm” [11]. High rates of morbidity and lethality in children have been associated with immune system vulnerability and the ratio between dosage of venom and body weight. Most scorpion stings in India cause only minor symptoms and signs, such as pain, which can be intense, numbness and tingling around the sting, slight swelling. More-severe systemic symptoms and signs include cold extremities, sweating, tachycardia, hypotension, hypertension, altered sensorium, pulmonary edema, myocarditis and severe left ventricular dysfunction. [10]. Cardiovascular system is mostly affected by the venomous sting. Tachycardia, hypertension, shock, myocardial dysfunction and pulmonary edema are spectrum of autonomic storm. Pulmonary edema manifests in 27-30% of cases with respiratory failure and is described to be due to myocarditis. Cardiogenic shock occurs due to direct toxicity and indirect mechanism causing myocardial injury. Morbidity and mortality depends on 1. The time lapse between sting and starting prazosin therapy. [8]. (this is the most important factor). 2. Age of patient. (Younger the age more the severity of disease). 3. Order of bite (first or initial sting more severe). To summarise not all scorpion stings are poisonous whereas the fatality rate produced by poisonous scorpion sting is very high. The stings being more prevalent in rural areas with poor facilities for expertise and ECHO to determine the severity besides the time elapsed being the significant prognostic factor. Here comes the need for simple predictive factors of severity that can be used for early referral and reduction in morbidity and mortality. The current study is done to assess whether leukocytosis and/or thrombocytosis can be a predictive factor for assessing the clinical cardiac severity of scorpion sting.

A hospital-based, prospective study was conducted in Paediatrics department, Gmkmch, Salem, Tamil Nadu for over a period of ten months after approval from the institutional ethical committee. One hundred children were enrolled after an Informed and written consent from parents. Children with history or manifestation of scorpion sting were included in the study after applying the inclusion and exclusion criteria. Inclusion criteria: Children in the age group less than 12 years admitted with History of scorpion sting and also history of unknown bite presenting with features of autonomic storm. Exclusion criteria: The following children were excluded from the study those with known cardiac disease, those presenting with features of sepsis, cellulitis also those children whose parents are unwilling for the study. Careful history regarding the time of sting, site of sting and detailed clinical examination was done at the time of admission. Careful examination for local manifestation like pain and swelling, for systemic features like diaphoresis, salivation, cold extremity, and other features of autonomic storm. The children were also assessed as by the paediatric triage for development of complications like peripheral circulatory failure (presenting with tachycardia, cool peripheries, weak peripheral pulses, prolonged capillary refill time and raised or reduced blood pressure). And cardiogenic shock (presenting with cool peripheries with weak peripheral pulses and increased capillary refill time associated with respiratory distress). Complete blood count is sent for all cases at the time of admission. The cases were treated as per the standard treatment protocol. The cases were followed with ECG and ECHO during the hospital stay within 12 hours of admission. The children were monitored closely for complications and outcome. The collected data were analysed with IBM SPSS statistics software 23.0 version. To find the accuracy of the variables the sensitivity, specificity, NPV, PPV & diagnostic accuracy were used. To find the significance in categorical data chi-square test was used similarly, if the expected cell frequency is less than 5 in 2×2 tables then the fisher's exact was used. In both the above statistical tools the probability value 0.05 is considered as significant level.

Total of 100 cases below the age of 12 years were studied, of which 23% were less than 3 years, 48% were between the ages of 4 to 8 years and 29% were 9 to 12 years. Male to female ratio was 1.08, with male 52% and female 48%. Most of the stings were in the upper limb 57%. 82% children got admitted within 4 hours of sting , whereas 18% got admitted after 4 hours. About 92% children had a definite history of scorpion sting of which 32% children did not have any systemic features, whereas 68% children presented with autonomic storm. In 8% of cases, the children were brought with history of unknown bite with features of autonomic storm. 61% of children had a normal hemodynamic status whereas 39% children had shock, of which 16 cases had peripheral circulatory failure and 23 cases children developed cardiogenic shock. Of the 24% (24 cases) of children with a definite history of scorpion sting without autonomic storm all children (100% ) had a normal hemodynamic status. Among the 76% (76 cases) of children who had autonomic storm 30% (23 cases) had cardiogenic shock and 21% (16 cases) had peripheral circulatory failure. Complete blood count was done for all cases at the time of admission. 31% (31 cases) children had leukocytosis and 18% (18 cases) children had thrombocytosis. ECG changes were seen in 40% (40 cases) of children. . ECHO findings of myocardial dysfunction was observed in 20 % of children (20 cases), of which 50% (10 cases) had features like mitral regurgitation and moderate left ventricular dysfunction and remaining 50% (10 cases) had global hypokinesia. The 23% of children who developed cardiogenic shock, 87% (20 cases) had features suggestive of myocardial dysfunction in Echocardiogram. . Among the 31% (31 cases) of children with leukocytosis, 71% (22 cases) developed cardiogenic shock and 29% (9 cases) had peripheral circulatory failure. All the 61% (61 cases) of children who presented with a normal hemodynamic status, all had a normal leukocyte count. 56% of children with peripheral circulatory failure had leukocytosis. 96% of children with cardiogenic shock had leukocytosis. Those with leukocytosis had abnormal ECG finding in 96% children. 95% of children who had ECHO findings of myocardial dysfunction had leukocytosis. The sensitivity of total leucocyte count in predicting children prone for cardiac injury is 91.30% and specificity of 87%. The diagnostic accuracy was 89%. The negative predictive value was high i.e. 97%. 18 % of children had thrombocytosis. 94% children with thrombocytosis had ECG changes and 72% children had ECHO features of myocardial dysfunction. Platelet count had a specificity of 93.5% and sensitivity of 56%. Table1: Descriptive analysis of age in study Population (N=100) Age Frequency Percentages Upto 3 Years 23 23.00% 4 To 8 Years 48 48.00% 9-12 Years 29 29.00% Table 2: Descriptive analysis of time from sting to admission in study Population (N=100) Time From Sting To Admission Frequency Percentage <4 Hours 82 82.00% 4 To 12 Hours 18 18.00% Table 3: Descriptive analysis of distribution of clinical features at time of admission in study Population (N=100) Clinical Feature Frequency Percent Definite Scorpion Sting 92 92.00% H/O Scorpion Sting Alone 32 32.00% H/O Scorpion Sting With Autonomic Storm 68 68.00% Consistent With Scorpion Sting: Unknown Bite With Autonomic Storm 8 8.00% Table 4: Descriptive Analysis Of Cardiopulmonary Assessment In Study Population (N=100) Cardiopulmonary Assessment Frequency Percentage Normal 61 61.00% Shock 39 39.00% Peripheral Circulatory Failure 16 41% Cardiogenic Shock 23 59% Table 5: Descriptive analysis of distribution of ECG changes in study Population (N=100) ECG Changes Frequency Percent Normal 60 60.00% Sinus Tachycardia 17 17.00% T Wave And St Segment Changes 23 23.00% Table 6: Descriptive analysis of distribution of ECHO changes in study Population (N=100) ECHO Changes Frequency Percent Normal 80 80.00% Features Of Myocardial Dysfunction 20 20.00% Table 7: Association of Total leukocyte count in children with cardiogenic shock in the study population (N=100) Total leukocyte count Cardiogenic shock Total Present Absent Abnormal 21 10 31 Normal 2 67 69 Total 23 77 100 Sensitivity 91.30 Specificity 87.01 PPV 67.74 NPV 97.10 Accuracy 89.16 Table 8: Association of Platelet count in children with cardiogenic shock in the study population (N=100) Platelet count Cardiogenic shock Total Present Absent Abnormal 13 5 18 Normal 10 72 82 Total 23 77 100 Sensitivity 56.52 Specificity 93.51 PPV 72.22 NPV 87.80 Accuracy 75.01

In this study majority of children 48% belong to age group of 4-8 years. There was also a male preponderance 52%. Both were as mentioned by various authors. The maximum time elapsed between sting time and admission was 12 hours in my study. The study done by Bawasker [5] in 2003 showed that the maximum time lapse was 36 hours and children who arrived late had a poor prognosis. Most of the stings were in the upper limb 57%. This was in contrast to other study done by Bharath et al. In this study about 92% children had a definite history of scorpion sting and 8% of cases, the children were brought with history of unknown bite with complaints of severe pain, with features of autonomic storm. In these 8% children the history of scorpion sting was not given either due to young children who were not under supervision of parents or elders at that time or due to bites that occurred at night time. 61% of children had a normal hemodynamic status whereas 39% children had shock, of which 16 cases had peripheral circulatory failure and 23 cases children developed cardiogenic shock. Children with a definite history of scorpion sting without autonomic storm all children had a normal hemodynamic status. Among the 76% of children who had autonomic storm 30% had cardiogenic shock and 21% had peripheral circulatory failure. The incidence of cardiogenic shock and peripheral circulatory failure was in agreement with other previous studies. The sensitivity of total leucocyte count in predicting children prone for myocardial dysfunction is 91.30% and specificity of 87%. The diagnostic accuracy was 89%. The negative predictive value was high i.e. 97% which means children with normal leucocyte count usually have a good prognosis and this study suggest that they do not require intensive care management. 18 % of children had thrombocytosis of which 72% developed cardiogenic shock 17% had peripheral circulatory failure and 11% children with normal hemodynamic status. 94% children with thrombocytosis had ECG changes and 72% children had ECHO features of myocardial dysfunction. Platelet count had a specificity of 93.5% and sensitivity of 56%. Thus, total leucocyte count is more sensitive in predicting cardiogenic shock with high negative predictive value with thrombocytosis being more specific. This was in contrast to study done by Aykut caglar et al, who reported that thrombocytosis was more predictive than leukocytosis. Recommendation for further research: Further research with multicentre study and larger sample size will help in better justification of this study. Further studies analysing the serial complete blood count interpretation may give more valuable information for the better monitoring and management of children with severe scorpion sting envenomation.

It was found categorically in this study that leukocytosis and thrombocytosis can predict the cardiac severity with leukocytosis being more sensitive and also specific with high negative predictive value. Hence this study suggests total leukocyte count which is widely available can be used as an easiest and best screening tool for early referral to a tertiary care centre with paediatric intensive care setup enabling these children to be monitored closely. Further this study infers that complete blood count interpretation helps in better monitoring thereby reducing the preventable deaths of scorpion sting envenomation due to the fatal cardiovascular complications. Authors’ contribution: Dr. Sakthi conceptualized study, collected data, drafted manuscript; Dr. Senthil conducted statistical analysis; Dr. DSK supervised and gave guidance.

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