Severe hemoglobinuria due to Hemiscorpius enischnochela (Scorpiones: Hemiscorpiidae) envenomation from South of Iran

Introduction Scorpion stings and envenomation are common dilemma in the Middle East (1). Scorpion venom contains various substances such as neurotoxins, cardiotoxins, nephrotoxins and hemolytic toxins (2). Clinical complications including cerebral edema, subarachnoid hemorrhage, encephalopathy, hemorrhagic and nonhemorrhagic strokes, and cortical necrosis have been reported following scorpion stings (3). Clinical features of the envenomation de pend on the scorpion species, lethality, and dose of venom received at the time of sting (4). Different species of Hemiscorpius scorpions have been reported from Africa (Eritrea, Somalia and Egypt) and Asia (Iran, Iraq, Oman, Pakistan, Saudi Arabia, Yemen, United Arab Emirates, and Yemen) (5, 6). Hemiscorpius lepturus (Gadim), Hemiscorpius acanthocercus, and Androctonus crassicauda are the most common dangerous scorpions in Iran (7-10). The clinical manifestations of H. lepturus, H. acanthocercus, and A. crassicauda envenomations are shown in Table 1 (4). The highest incidence of scorpion sting is in the southern and western provinces of Iran including Khuzestan, Sistan and Baluchistan, Hormozgan, Bushehr, and Ilam (11). In Iran, most epidemiologic and clinical studies have been conducted on H. lepturus species and other species of this genus are unknown. According to the best of our knowledge, it appears that no report of clinical manifestations of sting by H. enischnochela has been published. This report describes the signs, symptoms and complications of envenomation by this scorpion.

pale, and symptom-free on the first day of admission. He received three vials (IV) of scorpion antivenin (because of the suspicion of Gadim stings) (12). On the second day, he experienced confusion abdominal pain, nausea, headache, fever, and red to brown urine color. Because of the severity of his disease, the patient was hospitalized in ICU ward. The scorpion he had brought with was an adult male H. enischnochela which was preserved in 75% ethanol and deposited in medical entomology museum of Bandar Abbas health school ( Figure 1). Identification of the scorpion species was performed by morphological characteristics according to the latest publication of key diagnostics. Identification was carried out using a Nikon XN model stereomicroscope. Publication of Monod and Lourenco was used as identification key (6). The patient's laboratory data are shown in Tables 2 and 3. During ICU admission the patient received three more intravenous (IV) scorpion antivenin vials, urinary alkalization, IV hydrocortisone, IV clindamycin, packed cell, prazocin (PO), platelet (IV), acetaminophen (PO), and intramuscular tetabulin. He was discharged five days after admission in good general condition.

Discussion
In south-western Iran, most of the mortalities of the scorpion envenomation are associated with H. lepturus stings (13). This scorpion is one of the most dangerous yellow colored scorpions in Iran (8)(9)(10). Not only H. lepturus, but probably other Hemiscorpius species can also cause similar clinical manifestations In Iran (6). The venom of H. lepturus is highly cytotoxic and hemolytic which can cause cutaneous manifestations, laboratory abnormalities, and systemic manifestations including hemolysis, renal failure, and death (Table 1) (4,8). The data of tables 2 and 3 show that the patient's hematologic and biochemical parameters are changed. Other authors and researchers have reported these findings in the patients stung by H. lepturus (13)(14)(15). The results of the laboratory tests in this case showed severe hemoglobinuria (3+). The red blood cell (RBC) count decrease in H. lepturus associated envenomation. This was reported similarly by other authors and researchers following H. lepturus sting. Also, severe hemolysis due to H. lepturus envenomation was reported by Pipelzadeh et al (14). Emam et al showed reduction in the RBC count of the patients stung by H. lepturus in southeast part of Iran (16). They also reported that partial thromboplastin time (PTT), Prothrombin time (PT), hemoglobin (Hb), RBC, and platelet (PLT) counts should be considered as important indicators in H. lepturus envenomation (17). Contrary to the suggestion of these authors, our patient's PT and PTT were not prolonged. It has been shown that the PT is often increased and PTT may be prolonged only in DIC due to H. lepturus and H. acanthocercus envenomations (4,5). However, increased lactate dehydrogenase (LDH), decreased RBC count and   Proteins WBC: white blood cell; RBC: red blood cell. Hb concentration, and increase in indirect bilirubin (IBILI) level are the indicators of hemolysis. Unfortunately, in our case, the LDH and IBILI levels were not checked. We are aware this is a limitation of our case report that should be addressed in the future studies. In accordance with the above-mentioned researchers' reports, in our case some laboratory parameters were abnormal. Biochemical tests showed that serum glutamic-oxaloacetic transaminase (SGOT), alkaline phosphatase (ALP), and total bilirubin (TBIL) increased. In contrast, Radmanesh reported normal levels of SGOT in the patients stung by H. lepturus (18). In our case H. enischnochela envenomation has been resulted in an increase in serum ALP, SGOT, and SGPT levels. It seems that increased SGOT, SGPT and ALP levels in the stung patients are important markers. This data may be used as a factor signifying Hemiscorpius scorpion stings. Radmanesh and Pipelzadeh et al reported hemoglobinuria due to H. lepturus sting (8,14). Fever, confusion, hemoglobinuria and decreased Hb levels were observed in our case. Jalali and Rahim have also recorded these signs and symptoms after H. lepturus envenomation (19). The findings in this report indicate that the clinical manifestations of H. enischnochela envenomation are almost similar to the H. lepturus and H. acanthocercus envenomations. Therefore, the H. enischnochela is one of the most dangerous species in the southern districts of Iran whose envenomation can be life-threatening. It should be emphasized that the diagnosis of Hemiscorpius species envenomation is significant, since unlike other yellow Iranian scorpions, their stings are pain-free and may be considered unimportant. Therefore, the patients may be discharged from the hospital or be referred to emergency department with hemoglobinuria or cutaneous manifestations when it is too late for scorpion antivenin administration (20). The differentiation between Hemiscorpius species and other yellow Iranian scorpions is their wide claws with dark tips and their painless stings (20). In conclusion, pain-free stings of yellow scorpions with wide claws and dark tips should be taken seriously.

Conclusion
Hemiscorpius envenomation is one of the most significant medical problems in southern part of Iran. In the early hours post envenomation, there are no significant clinical manifestations. However, after about 12 hours, symptoms of envenomation include dizziness, nausea, vomiting, abdominal pain, headache, and red to brown urine color may manifest. Hemolysis and hemoglobinuria may occur up to a week after the stings of Hemiscorpius species. It seems that the venom of H. enischnochela has hemolytic and nephrotoxic effects that cause RBC hemolysis, hemoglobinuria, proteinuria, and microscopic hematuria.
Our findings indicate that the clinical manifestations of H. enischnochela envenomation are almost alike to the H. lepturus and H. acanthocercus envenomations. Therefore, the H. enischnochela is one of the most dangerous yellow species in the southern districts of Iran and can be life-threatening. We suggest more studies on this scorpion species for the management of this scorpion envenomation.

Authors' contributions
Each author contributed equally to study design, drafting article, reading critically and accepted finally proof.

Ethical issues
Informed consent was obtained from the parents' patient for publication of this report.