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Centruroides Exillcauda Envenomation in Arizona

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Centruroides Exillcauda Envenomation in Arizona Cli'nical edcn Centruroides exillcauda Envenomation in Arizona KEITH LIKES, MS, DPh; WILLIAM BANNER, Jr, MD, PhD, and MARY CHAVEZ, RPh, Tucson A retrospective surveyof 1, 135 telephone calls during 1980 and 1981, reporting scorpion envenom- ation to the Arizona Poison and Drug Information Center, was reviewed. Of these, 438 calls identified Centruroides exilicauda as the offending scorpion on the basis of description of the arthropod and consistency ofphysical findings and clinical course. Envenomation by C exilicauda occurred primarily in adults during the summer and early fall months of the year. Although most patients (92%) were treated at home with conservative therapy, 8% ofpatients either came to or were referred to a medical faculty. Children younger than 5 years were frequently brought or were referred to either emergency care orinpatient hospital care. We conclude on the basis of this series that despite the historical reputation of lethality associated with envenomation by C exilicauda, most envenomations by this scorpion are relatively minor. The otherimportantobservation was that children younger than 5 years appear to beparticularlyprone to severe toxicity. (Likes K, Banner W Jr, Chavez M: Centruroides exilicauda envenomation in Arizona. West J Med 1984 Nov; 141:634-637) Scorpion envenomation is a major reason for telephone physician treatment. Patients were called at 1, 5 to 8, and calls to the Arizona Poison and Drug Information 24 hours, with additional calls at 24-hour intervals if symp- Center. Centruroides exilicauda, the only truly dangerous toms persisted. Those patients with signs of local ecchy- species of scorpion in Arizona, is distinguished from other mosis, erythema and swelling were eliminated from the genera by its slender body (Figure 1) and a small tubercle at series as not having symptoms consistent with a diagnosis the base of the stinger.' Patients envenomated by this scor- of C exilicauda envenomation. Envenomated patients with pion have a distinct and typical clinical course including the typical syndrome of C exilicauda sting were included local pain, numbness or hypoesthesia, increased salivation, even if a detailed description of the scorpion was not avail- agitation, wheezing, tachycardia, hypertension and muscle able. spasm. Previous reports of cases have been based on physi- cian contacts, clinical experiences and hospital popula- tions.24 A retrospective review of two years of telephone calls from patients envenomated by this scorpion was under- taken to evaluate the clinical course of these patients and to establish a basis for improved management. Methods .: ..:- eSX~~~~~~~~~~~~~~~~~~~~~~~~~'j .' A total of 1,135 cases of scorpion envenomation reported during the years 1980 and 1981 to the Arizona Poison and Drug Information Center in Tucson were reviewed. The fol- lowing information was extracted from the poison control form: age, sex, preexisting medical conditions, current medications, time of exposure, description of scorpion, Figure 1.-Centruroides exilicauda showing the typical slender pin- home management (analgesics, cold pack, antihistamine), cers and tail segments. (Photograph courtesy of Findlay Russell, description and duration of pain and emergency room or MD, PhD.) From the Arizona Poison and Drug Information Center and the Departments ofPediatrics and Pharmacology, University ofArizona, Tucson. Submitted, revised, December 12, 1983. Reprint requests to William Banner, Jr, MD, Department ofPediatrics, University ofArizona, Tucson, AZ 85724. 634 THE WESTERN JOURNAL OF MEDICINE CENTRUROIDES EXILICAUDA ENVENOMATION IN ARIZONA V) Lii (A300 *) 100 z 0 0 Lai 50 z U 9t~~~~~ri z 100 0 MONTHS OF THE YEAR AGE IN YEARS Figure 2.-The incidence of C exilicauda envenomation is plotted Figure 3.-The age distribution of patient contacts is shown for en- as a function of reporting month from a series of 438 cases reported venomation by C exilicauda in Arizona. to the Arizona Poison and Drug Information Center. s0 80 z.0 0 V)40 0 AGE IN YEARS 0 fop ekn z Figure 5.-The reageditr of patientsfromneachtsiage < 0 Lii Lii 30 z 20 veoasadsrbtion eicaudayariznain LiJ 0 byf Lii zLi20 0-10 U CLi 0~ 8 %0iniecHfhprxitblt.TefnigofShperex- TIME IN HOURS AGE IN YEARS Figure 4.-The number of patients describing local pain due to C Figure 5.-The percentage of patients from each age group seeking exilicauda envenomation is shown versus the maximal duration of or requiring either emergency room or inpatient hospital care is shown this symptom in hours. as a distribution of age in years. Results patients described it as moderate and the remaining 300 pa- The 1,135 calls reviewed were widely distributed tients as mild. throughout the state. Of these, 438 were identified as being Agitation or hyperexcitability was described for 5% of the caused by C exilicauda envenomation. Monthly distribution patients. The group younger than 2 years, however, had an of stings showed a high prevalence in the summer and early 80% incidence of hyperexcitability. The finding of hyperex- fall months (Figure 2). The age range of patients was from citability was described in all children younger than 1 year. 6 months to 81 years with a distribution favoring the adult The envenomation was located on the foot in 52 % of cases age group from 16 to 60 years (Figure 3). There was a and on the hand in 40m%. The remaining 8t% had various slight predominance of male patients, 245 compared to 193 contact points. Eight of the 438 patients had been stung more females. than one time. The most common symptom was local pain (70%) with In all, 92% of the patients were treated conservatively in sensory abnormalities in the extremities reported in 234 pa- the home. The remaining 8 % either were referred for medical tients. The majority ofpatients had a relatively short duration care or came themselves to a medical facility. As can be seen of pain (less than 4 hours) (see Figure 4). In a subjective in Figure 5, there was an age-related variability in the number description one patient described the pain as severe, seven ofpatients receiving medical care. All patients younger than 1 NOVEMBER 1984 * 141 * 5 635 CENTRUROIDES EXILICAUDA ENVENOMATION IN ARIZONA year were either admitted to hospital or seen in an emergency near the stinger,9 and secretion of the venom is of apocrine facility. In the 1- to 2-year and the 2- to 5-year age groups a type. C e-xilicauda can be differentiated from other species by similarly high rate of either emergency room or inpatient the presence of a small subaculear tooth (tubercle or hair) at hospital care was evident. the base ofthe stinger.3 Those patients who stayed at home used mild analgesics The size of C exilicauda ranges from about 1.3 cm when and local cold compresses for discomfort. Among the group the young leave the mother's back to about 7.6 cm when they seen either by private physicians, at emergency facilities or in are fully grown. C exilicauda are sometimes called "bark" a hospital, various regimens were prescribed. In patients ad- scorpions because oftheir favored habitat under the loose bark mitted to hospital, phenobarbital was given for agitation or of trees and in crevices of dead trees and logs. The bark hyperactivity, and one patient, 2 and a half years ofage, also scorpions characteristically rest their tails on the substrate received calcium gluconate, which was reportedly effective in while ground scorpions arch the tail over their back. C e-xili- relieving muscle spasms. One man admitted to hospital (age cauda have a negative geotaxis which enables them to cling to 39 years) was given scorpion antivenin prepared from goats ceilings and the underside of objects.'0 Therefore, many for bradycardia, hypertension and laryngeal spasm. In this people are stung as they pick up objects they have failed to single case the symptoms reportedly abated within one hour. look under, or when they attempt to pick scorpions offofwalls Emergency room treatment included observation, cold com- and ceilings. The species is nocturnal and the greatest activity presses and nonnarcotic analgesics; however, one patient was is at night. During the day they seek out moist, cool micro- given phenobarbital and two patients received diphenhydra- habitats under lumber piles, bricks, stones and debris. They mine. may crawl into houses and hide under clothing, in shoes or in other objects. Discussion Scorpions are predacious, feeding for the most part on in- There are 650 known living representatives of scorpions, sects and other arthropods; prey is usually grasped with the divided into six families. In North America all of the dan- pincers and stung by means of the scorpion arching its post- gerous species are in the family Buthidae. C exilicauda is one abdomen over its own head. The prey is then torn and crushed of the neurotoxic species of this family and inhabits Arizona, with the mouth parts; only the liquified tissue is ingested. western New Mexico, California, parts ofTexas and northern Solid material is ejected as small pellets. Mexico.5 C e-xilicauda shows much interpopulation vari- Scorpion envenomation from C exilicauda is a very ability and is now believed to be synonymous with Csculptur- common occurrence in the southwestern United States from atus. 6 April to November. Although there are more than 20 species The original description of C sculpturatus by Ewing was of scorpions recorded in Arizona, C e-xilicauda is quite distin- based on two adults and two immature specimens collected in guishable from the nonlethal species. The base color of the 1927 at Tempe, Arizona.7 Ewing described the general color body is pale to golden yellow (straw colored). The entire body of this species as yellowish brown with no dorsal stripes, (especially the joints of the legs, pincers and tail) is Ilong and spots or other markings. Stahnke8 described a new species slender.
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