Echocardiography versus cardiac biomarkers for myocardial dysfunction in children with scorpion envenomation: An observational study from tertiary care center in northern India.

Abstract

Objective This study was done to evaluate myocardial function by 2D Echocardiography and Cardiac biomarkers (cTnI, CK-MB, BNP) changes in patients of scorpion envenomation of grade II-IV and correlate mortality of envenomed children with myocardial dysfunction. Methods A total of 40 patients admitted consecutively with grade II and more scorpion envenomation from October 2015 to July2018 were enrolled in the study. The data included demographics, the time of presentation, clinical features, echocardiographic findings, electrocardiographic findings, cardiac biomarker levels at admission and discharge, use of inotropic medication, oral prazosin, time of discharge, and their outcome. Results The most common ECG abnormality was sinus tachycardia 28 (70%) followed by low voltage complex 13 (32.5%) which got normalized at the time of discharge in majority. Cardiac troponin I (cTnI) levels were more than 0.1 ng/mL, suggesting myocarditis was present in 25 (62.5%) and got normalized at discharge. CK-MB levels were increased in 26 (65%) patients suggesting myocardial involvement. BNP levels were also increased in 24 (60%) patients suggesting heart failure and its value got normalized at discharge. Abnormal 2D Echo findings as reduced left ventricular ejection fraction (LVEF) was present in 18 (45%) cases suggesting myocardial dysfunction and became normal at discharge. The sensitivity, specificity, positive predictive value and negative predictive value of Cardiac troponin I (cTnI) considering ECHO cardiograph as gold standard were 100, 68.1, 72 and 100% respectively. One patient had died whose Ejection fraction was less than 30%. Conclusion Echocardiography and cTnI can identify subgroup of patients, who require early aggressive therapy. Echocardiography, if not available, cardiac troponin I level can guide early therapy and indicates the prognosis.

Scorpion envenomation-associated myocarditis: A systematic review

“…Symptoms and clinical findings associated with myocarditis included respiratory distress (tachypnea and/or dyspnea), mostly associated with pulmonary edema, cold or cyanotic extremities, hypotension or shock, increased heart rate, and gallop rhythm on heart auscultation. Among these, respiratory distress [ 26 , 28 , 34 , 36 – 38 , 40 , 43 – 48 , 51 , 59 , 63 – 71 , 73 – 92 ] and increased heart rate (tachycardia) [ 13 , 27 , 34 , 36 – 39 , 43 , 44 , 47 , 53 , 56 , 58 , 59 , 61 , 64 – 66 , 68 , 69 , 74 , 75 , 77 – 89 ] were the most common manifestations affecting 94.8% (145 from 153) and 82% (137 from 167) of the patients, respectively. In studies where the prevalence of pulmonary edema could be determined unequivocally, it was observed in 60.7% (246 from 405) of patients [ 13 , 27 , 34 , 36 – 39 , 42 – 44 , 47 , 48 , 51 , 56 , 58 , 59 ,…”

“…Among these, respiratory distress [ 26 , 28 , 34 , 36 – 38 , 40 , 43 – 48 , 51 , 59 , 63 – 71 , 73 – 92 ] and increased heart rate (tachycardia) [ 13 , 27 , 34 , 36 – 39 , 43 , 44 , 47 , 53 , 56 , 58 , 59 , 61 , 64 – 66 , 68 , 69 , 74 , 75 , 77 – 89 ] were the most common manifestations affecting 94.8% (145 from 153) and 82% (137 from 167) of the patients, respectively. In studies where the prevalence of pulmonary edema could be determined unequivocally, it was observed in 60.7% (246 from 405) of patients [ 13 , 27 , 34 , 36 – 39 , 42 – 44 , 47 , 48 , 51 , 56 , 58 , 59 , 64 – 66 , 69 , 75 ,…”

“…Hypertension, despite cardiac dysfunction, was another notable presentation reported in some cases [ 34 , 50 , 51 , 57 , 60 , 66 , 74 , 76 , 82 , 84 ]. Sinus tachycardia was the most common ECG reading [ 13 , 27 , 34 – 38 , 43 , 44 , 47 , 53 , 58 – 62 , 64 – 66 , 68 , 69 , 74 , 75 , 77 – 89 ], followed by ST-T changes [ 13 , 27 , 34 , 36 – 38 , 44 , 47 , 58 , 61 , 62 , 64 , 66 , 68 , 69 , 72 , 75 , 77 – 80 , 82 , 83 , 85 , 89 ]. ST-T changes, including ST segment elevation or depression, T inversion, or tall T waves, were present in 64.6% (84 from 130).…”

“…Ventricular tachycardia was another important finding [ 71 , 75 , 76 , 84 ]. Laboratory findings associated with myocarditis were raised levels of cardiac troponin T [ 49 , 57 , 61 , 64 , 70 , 72 , 75 , 87 ], troponin I [ 34 , 41 , 42 , 45 , 46 , 49 , 58 , 60 , 65 , 66 , 74 , 76 , 78 , 79 , 81 , 82 , 84 – 86 , 88 , 91 , 92 ], unspecified-type troponin [ 63 , 67 , 80 , 82 ], CK-MB [ 14 , 18 , 34 , 37 , 40 , 45 , 46 , 49 , 52 , 57 , 59 , 62 , 66 , 68 , 70 , 74 – 76 , <...…”

An update on epidemiology and management practices of Scorpion envenomation in India

“…[ 10 ] At the referral center, early detection of cardiopulmonary complications such as myocarditis, left ventricular failure, and cardiogenic shock based on clinical manifestation, electrocardiographical abnormality, biomarkers, and echocardiography can help in the risk assessment of patients and facilitate decision-making in the management of scorpion envenomation cases. [ 12 ]…”