Scorpion sting is a major health problem in many countries with several clinical manifestations varying from isolated local pain to major symptoms including respiratory, hemodynamic or neurologic failure.

Digestive manifestations after scorpion sting were widely described. They usually include gastric distension, abdominal pain, nausea, and vomiting [1-3]. Pancreatitis was also reported after Tityus serrulatus, Tityus trinitatis, and Leiurus quinquestriatus envenomation in children [4-8]. However and in our knowledge, acute pancreatitis after Tityus obscurus envenomation has not been previously reported.

A seven years old boy was admitted to our ICU after severe scorpion envenomation. The animal was captured by the parents and was recognized by experts as a Tytius obscurus.

The accident occurred at 7:00 am, the boy was putting on his shoes, and the scorpion stung him on the third toe of his right foot.

The first symptoms occurred 30 min later they included hyper salivation, agitation, twitching and hyperventilation. He was transported to our ICU with the diagnosis of severe scorpion sting.

On admission to ICU, the clinical exam found somnolence, twitches, hyper salivation, Dysarthria, abdominal pain with a maximum in the epigastric region, severe pain of the third right toe and urine retention. The pupilles were symmetric and reactive to light. Arterial blood pressure was 116/48 mmHg, cardiac rhythm was 128/ min, respiratory rhythm was 38/min, temperature was 36.9°C, and SpO₂ was 100% under 6 l oxygen. Cardiac sounds were normal. Pulmonary auscultation showed no crackles or abnormal sounds.

Biological exams showed blood sugar at 10.9 mmol/l, leucocytosis at 14400/mm³, troponine level <0.003 μg/l, metabolic acidosis with alkaline reserves at 16 mmol/l and lactates at 7.3 mmol/l. C-reactive protein (CRP) was non-detectable. Renal and liver functions were normal.

Chest X-ray showed no pulmonary abnormalities but a gastric distension. The patient was putted on oxygen, gastric aspiration and Paracetamol. At day 2, we noted a worsening of abdominal pain with maximum at the epigastric region, vomiting and fever. Biological exams showed leucocytosis at 20700/mm³, raised CRP level at 48.5 mg/l, elevated amylase level at 1921 UI/l, elevated lipase level at 960 UI/l, alkaline reserves decreased to 14 mmol/l and CK were at 3935 UI/l. Microbiological exams were negative.

The abdominal CT scan showed large region of necrosis involving most of body and tail of pancreas with a minimal amount of ascites, (Figure 1). The chest CT scan showed a left-sided abundant pleural effusion (Figure 1).

Figure 1: Abdominal and thoracic CT scan showing (A) necrosis involving most of body and tail of the pancreas with a minimal amount of ascites, (B) a left-sided abundant pleural effusion.

Thoracocentesis and pleural fluid analysis performed at day 5, showed an exudate pleural fluid with protein dosage at 29 g/l and amylase dosage at 3643 UI/l (The ratio amylase in the pleural liquid/ blood amylase level was 13.8).

The patient was given more pain relievers, metoclopramide, glucose serum infusion and he was kept fasting.

Evolution was marked by an improvement of the patient’s condition within 6 days with return of pancreatic enzymes to normal, return of the temperature to normal, disappearance of abdominal pain, and well tolerated refeeding (Figure 2).

Figure 2: Evolution of amylase and lipase levels during hospitalization.

The patient was transferred to the paediatric department at day 8 of hospitalization and he leaved the hospital at day 10.

We report a case of necrotizing pancreatitis after Tytius obscurus sting in 7 years old boy. This complication is very rare and was poorly reported in the literature. Digestive complications after scorpion sting were well described with all types of scorpions. They include gastric distension, abdominal pain, nausea, and vomiting [1-3]. More rarely, acute pancreatitis was reported after Tityus serrulatus, Tityus trinitatis, and Leiurus quinquestriatus envenomation in children [4-8]. In all cases, pancreatitis was diagnosed biologically. However and in our knowledge, acute pancreatitis after Tityus obscurus envenomation has not been previously reported.

In 1970, Bartholomew et al. [4] reported 24 cases of acute pancreatitis which appeared soon after Tityus trinitatis sting. The diagnosis of pancreatitis was based only on the dosage of serum amylase. This complication was explained by the capacity of venom to induce exocrine secretion in both isolated and intact pancreas and to cause contraction of sphincter of oddi [9]. Novaes et al. [6], in an experimental study found the same results with cellular damage to the pancreas when they inject Tityus toxin (from Tityus serrulatus ) to dogs and rats. They suggest a direct action of the venom to pancreas. In another experimental study, Novaes et al. [10], found that the toxin of Tityus serrulatus scorpion is an agent of considerable efficacy in the induction of acute and pancreatitis in rats.

Overall, four mechanisms were advanced to explain acute pancreatitis after scorpion sting. The first is a local and direct effect of the venom on the pancreas as demonstrated by Bartholomew et al. [9] and Novaes et al. [6]. The second mechanism is ischemic secondary to a massive outpouring of catecholamines immediately after the sting leading to gastrointestinal ischemia and lactic acidosis [3]. The third mechanism is that scorpion venom inhibits angiotensine converting enzyme resulting in accumulation of bradykinine which is implicated in the development of acute reversible pancreatitis [11]. And the fourth mechanism is an over-stimulation of parasympathic system with a cholinergic effect on the pancreas [2,12].

In our case, patient developed acute necrotizing pancreatitis soon after the envenomation. The gastric distension and the elevated level of lactic acid found on admission lead us to think that ischemia is one of the principal factors explaining the occurrence of pancreatitis. In addition, in our case, pancreatitis was severe because of necrosis observed on the abdominal CT-scan and because of pleural reaction effusion with respiratory difficulties and need to thoracosenthesis. However, pancreatitis was reversible with return to normal of clinical and biological disturbances within 6 days.

Tytius obscurus is the most encountered scorpion in French Guyana [13]. It can be described as a great scorpion measuring 8 to 10 cm, it is dark in color with thin pincers [14,15]. In our case, the scorpion was captured and brought by the parents to the hospital. It was identified by experienced professionals as a Tytius obscurus. Even if it is known as a non-dangerous scorpion, it can cause severe envenomation in children [14] because of the ratio body weight/volume of venom injected. So, in French Guyana, physicians have to be aware from scorpion envenomation especially in children and in low body weight persons.

In our case, the patient recovered and no further investigation was performed. So we cannot exclude pancreas malformation. However patient was examined later in the outpatient department and he was going very well.