The case history of a toxic sting of a Leiurus abdullahbayrami scorpion in Turkey

Scorpion stings are very common in Turkey. Nevertheless, they are not well documented in the literature and were never reported for the recently described scorpion species Leiurus abdullahbayrami Yağmur, Koç & Kunt, 2009. Here, we report a case in which a 30-year-old male was stung by a L. abdullahbayrami scorpion in the field. He was directly brought to the emergency department of the local hospital. The symptomatic process was observed and documented. In this case, no antivenom was necessary; we hypothesize that the scorpion has used most of its venom in a previous incident (explained in further detail below) and was therefore not able to inject a

Scorpions (Scorpiones) belong to the class Arachnida and have a near worldwide distribution.They can be easily distinguished from other arthropods by their morphological structures (Polis 1990).All scorpion species bear a venom gland and are able to sting, but only a handful of them are potentially lethal to humans.As their venom can have lifelong consequences for humans (i.e.respiratory and/or cardiovascular diseases) they are considered as medically important arthropods (e.g.Dittrich et al. 1995, Hisham 1997).Species of medical importance are all found within two families, Buthidae and Hemiscorpiidae, but are spread over several genera: Androctonus, Buthus, Centruroides, Leiurus, Mesobuthus, Parabuthus, Tityus and Hemiscorpius.Their distribution covers Central and South America (incl.Mexico), the Middle East, northern Africa and southern Africa (e.g.Adıguzel 2010, Adolfo et al. 2003, Borges et al. 2012, Pardal et al. 2014, Pipelzadeha et al. 2007, Reckziegel & Pinto 2014).
Scorpion stings are a common occurrence in Turkey.The majority of them are known from the Antalya, Kahramanmaraş, Mersin and Hatay Provinces in the Mediterranean region.However, deaths have been rarely documented and, when occurring, were due to cardiovascular and respiratory failure within the first 24 hours of hospitalization (Ozkan et al. 2007).In south-eastern Anatolia, seven scorpion species from the family Buthidae are known: Androctonus crassicauda, Buthacus macrocentrus, Compsobuthus matthiesseni, Hottentotta saulcyi, Leiurus abdullahbayrami (L.abdullahbayrami was previously identified as L. quinquestriatus in Turkey and was classified as a new species by Yağmur et al. 2009), Mesobuthus phillipsii and Mesobuthus nigrocinctus.Of these seven, three have been considered dangerous to humans: A. crassicauda, L. abdullahbayrami and H. saulcyi (Ozkan & Kat 2005, Ozkan et al. 2006, 2011).
The species in our case report is L. abdullahbayrami, which is only distributed in Turkey and Syria (Yağmur et al. 2009, Khalil & Yağmur 2010).In a recent study, Ozkan et al. (2011) documented the lethality and biological effects of L. abdullahbayrami scorpion venom in mice.They reported the median lethal dose of the venom to be 0.19 mg/kg (LD 50 ) by subcutaneous injection in mice (Ozkan et al. 2011).By comparison, the median lethal dose of L. quinquestriatus -previously considered the most lethal species for mice -is 0.25 mg/kg (Watt & Simard 1984).
Here we present a detailed progression of symptoms in a 30 year-old man from Central Europe after envenomation by an adult L. abdullahbayrami female.This report is the first documented envenomation from the most toxic scorpion species known to science.

Case report
A 30-year-old male was stung by a scorpion in south-eastern Anatolia (c/o Küplüce in Kilis Province, close to the Syrian border) on 06.September 2014 at 9:30 p.m. in the tip of the right thumb.Afterwards, the scorpion was caught and was brought to the laboratory for identification, where it was confirmed to be an adult L. abdullahbayrami female, which is now deposited in the collection of the Natural History Museum Vienna (Fig. 1).The event took place at night, approximately 12 kilometres away from the nearest hospital.The habitat was typical for this scorpion species (Fig. 2) and has been documented before (Yağmur et al. 2009).Within 20 minutes, the person was brought to the emergency department in Kilis.
Upon arrival, the patient complained of severe local pain spreading from his right thumb (Fig. 3).He was very calm and showed no sign of abnormal blood pressure and pulse.The patient was a smoker and there is no history of hypertension or cardiac diseases in the recent family tree.It is worth mentioning that this scorpion specimen was previously inadvertently damaged by turning a stone.
Michael SEITEr, Group of Arthropod Ecology and Behavior, Division of Plant Protection, Department of Crop Sciences, University of Natural resources and Life Sciences, Vienna, Austria; E-mail: michael.seiter@boku.ac.atHalil Koç, Sinop University, Science and Art Faculty, Biology Department, Sinop, Turkey; E-mail: halilkoc@sinop.edu.trAlexander ULLrICH, Gartenstraße 22, 59514 Welver, Germany.E-mail: alex@hottentotta.comErsen Aydın YAğMUr, Alaşehir Vocational School, Celal Bayar University, Manisa, Turkey; E-mail: ersen.yagmur@gmail.comsubmitted 6.11.2015, accepted 1.2.2016, online 4.3.2016Below are the observations made by the patient himself and two eyewitnesses.After arrival of the ambulance at 9:55 p.m., the medical team decided to monitor the patient and not immediately administer antivenom.However, one litre of sodium chloride was intravenously applied as an infusion and antihistamine was administered.Additionally, in order to reduce the pain, an initial mild painkiller was dispensed in the envenomation area.A full blood count, liver function, electrolyte blood levels and other routine laboratory tests were conducted and all showed normal values after 25 minutes of envenomation.
After approximately one hour, the acute pain (see Tab. 1 for the progress) radiated from the fingertip to the wrist.The area where the aculeus penetrated the skin started to redden.Up to this point, severe pain would sporadically set in and last for approximately four minutes at a time.The patient tried to stay as calm as possible and hold his thumb straight using his muscular strength to avoid additional pain caused by bending the finger or moving it quickly around.Additionally, every few minutes, seizures went down to the feet.After one hour, considering the more or less good condition of the patient, the medical team maintained their decision not to inject antivenom.Nevertheless, the pain was incredibly powerful.The patient held the railings of the bed tightly and his body was shaking because of the relapsing seizures.After two hours, the critical climax had been reached.The patient described this moment as the most painful minutes in his life.The skin of his arm began to contract and the first growth of pimples and small blisters became visible.Any contact of the skin initiated nearly unbearable pain and any active muscle movement in the thumb itself and the hand was impossible.After three hours, the medical team decided to administer new painkillers.They decided to evaluate the patient's condition every ten minutes to decide if antivenom would be used or not.After reaching this peak, the pain declined.At the end of the six hour observation and treatment period the patient was discharged with no further therapy or medication.The pain was still present, and vertical movement of the arm was not possible.During the following night, the patient was not able to sleep, any slow movement of the arm caused pain.In the morning of the next day (around 14 hours after the sting), a pharmacy was visited and some Ibuprofen Atid 800 mg was bought.After two tablets, the pain reached a bearable level, however numbness in the thumb remained and moving the arm caused pain.The stung area remained hypersensitive and touching the thumb resulted in paresthesia, which gradually resolved over two days.After ten days, another blood test was conducted and it showed more or less normal values.

Discussion
The genus Leiurus is one of the most dangerous in the world and is responsible for many scorpion envenomation cases in different countries in North Africa, the Middle East and the Arabian Peninsula.Therefore, the species L. abdullahbayrami is considered to be the most significant to humans in Turkey (Dittrich et al. 1995, Ozkan et al. 2011).This species is reported from Adıyaman, Gaziantep, Hatay, Kilis, Mardin and Şanlıurfa Provinces in south-eastern Turkey and also from northern Syria (Yağmur et al. 2009, Khalil & Yağmur 2010).In these regions, scorpionism is de facto a known medical problem and many scorpion stings have been reported in re-   cent history (for a review see Ozkan et al. 2007).Generally, the only specific treatment against scorpion poisoning is species-specific antivenom.It is often used, but its effectiveness is unclear and often disputed (Ozkan et al. 2011).
In Turkey the Refik Saydam Public Health Agency is the producer of the antivenom, compounded from the species Androctonus crassicauda.This antivenom has been used for all scorpion stings in Turkey (Adıguzel et al. 2007).Cesaretli & Ozkan (2010) presented a review of epidemiological and clinical aspects of scorpion stings in Turkey and revealed that most patients (more than 50%) were only treated symptomatically and only around one third of all cases were treated with antivenom.Therefore, the treatment at the Kilis hospital was a normal and proven protocol.
In conclusion, the initial sting caused mild pain and progressed to a hardly bearable one within three hours.The pain originated in the thumb of the right hand and progressed to the shoulder of the patient.Almost all systemic scorpion envenomation produce pain at the site of the sting and several other symptoms can follow.After the alpha and other toxins, the excess can cause adrenergic, cholinergic effects, sympathetic and parasympathetic effects respectively, and neuromuscular excitation (Isbister & Bawaskar 2014).In this case, only sympathetic effects occurred and only some of the classic effects were seen, i.e. irritability, agitation and seizures.The patient suffered pain, but no cardiovascular effects, arrhythmias, hypotension, multi-organ failure or respiratory failure (Yağmur et al. 2015).
Since the sting was by the most venomous species known to science, the patient was very lucky that a stone, and not his thumb, was the first encounter with the culprit.Some plausible explanations might be that (i) the specimen previously lost some of its venom during the first encounter with a stone, (ii) the scorpion had recently used its venom stinging some other animals and was therefore exhausted, (ii) the species' venom is more toxic to mice than humans, or (iii) some combination of these.Another possible explanation for this is that the toxic sting contained only a so-called prevenom, highly painful and toxic but with a different mixture of ingredients than a normal sting (Inceoglu et al. 2003).This study did not scrutinize to what extent the venom of L. abdullahbayrami is deadly or not and, therefore, does not portray the real potential power of the venom.However, it constitutes an important starting point and stimulus for exciting future reports.Further research should quantify the true effects and the whole clinical spectrum of the scorpion sting.

Fig. 3 :
Fig. 3: Sting site at the time the patient was monitored in hospital after one hour of envenomation.White rectangle shows the area where the aculeus penetrated the skin.

Fig. 2 :
Fig. 2: Envenomation locality in Kilis Province close to the Syrian border