Scorpion Sting Myocarditis in Child: A Rare Case & Pediatric Treatment (2025)

A Shocking Twist: When a Scorpion's Sting Targets a Child's Heart

Imagine a seemingly harmless outdoor adventure turning into a life-threatening ordeal for a young child— all because of a tiny scorpion sting. This isn't just a scare story; it's a real medical emergency that showcases how scorpion venom can wreak havoc on the cardiovascular system, leading to toxic myocarditis. But here's where it gets intriguing: while scorpion stings are often dismissed as painful but minor, this case reveals their potential for severe, even fatal complications. Stick around as we dive into the details of this rare pediatric case, exploring the science, treatment, and the debates surrounding it. You might be surprised by what most people overlook about these venomous encounters.

Toxic Myocarditis After a Scorpion Sting in a Young Child: A Detailed Case Study and Pediatric Care Strategy

Case Study
Open Access (accessible via https://www.springernature.com/gp/open-science/about/the-fundamentals-of-open-access-and-open-research)
Published: November 4, 2025

Ali Akbari¹, Fatemeh Niksefat¹, Arvin Mirshahi¹ & Forod Salehi²

BMC Pediatrics (available at https://bmcpediatr.biomedcentral.com/) volume 25, Article number: 900 (2025) Cite this article

Abstract

Abstract Section: Background and Significance

Scorpion stings pose a significant threat in warm, tropical areas, with heart-related issues being uncommon but potentially deadly. This report details the first known case in Iran of toxic myocarditis triggered by a scorpion bite, underscoring the urgent need for greater awareness and thorough recording of such events.

Abstract Section: Patient Details

A healthy 3.5-year-old girl was rushed to the hospital after being stung by a Hemiscorpius lepturus scorpion, showing signs of low blood pressure, allergic shock, and confusion. Her treatment included epinephrine injections, scorpion-specific antivenom, and supportive measures. Heart assessments uncovered toxic myocarditis, confirmed by a weakened pumping ability and elevated heart damage markers. She also had a seizure, managed with phenytoin. After 10 days of care, her heart function and alertness improved, leading to her discharge with partial recovery. Follow-up checks confirmed her heart was back to normal and all symptoms had vanished.

Abstract Section: Analysis

Scorpion bites are a major public health concern in Iran, particularly in countryside areas. This unusual report from Birjand highlights toxic myocarditis from an H. lepturus sting. Scorpion poison can trigger intense cardiovascular problems, such as heart attacks and myocarditis. The venom's quick spread through the bloodstream caused rapid, severe effects here. Although antivenom use is debated due to allergic risks, timely administration alongside supportive care stabilized the patient. This incident stresses the importance of quick diagnosis and vigilant monitoring for dangerous outcomes in scorpion incidents.

Abstract Section: Key Takeaways

This example highlights the critical need for swift, holistic treatment of scorpion stings, especially when complications like toxic myocarditis, severe allergy reactions, or seizures occur. Giving antivenom promptly, providing supportive drugs, and constant observation can greatly enhance recovery. Plus, rising awareness of stings in new regions—thanks to climate shifts—is essential.

Abstract Section: Visual Summary

Peer Review Comments (viewable at https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-025-06266-4/peer-review)

Introduction

Scorpion bites are a frequent toxic issue in subtropical and tropical regions, affecting kids the most. Typically, people experience local discomfort like intense pain and a burning feeling at the bite spot, but sometimes broader problems emerge [1, 2]. Occasionally, individuals might face brain-related complications; however, lethal outcomes are mainly tied to heart issues like irregular rhythms or low blood pressure [3].

Many studies and reports have noted heart muscle problems and circulation disruptions from scorpion bites, especially in affected areas. Yet, no such incidents had been documented in Iran before. This case emphasizes the value of careful examination and logging of toxic myocarditis cases in the context of scorpion envenomation.

This report follows the CARE guidelines for case studies [4].

Patient Story

A previously healthy 3.5-year-old girl arrived at the emergency room in Birjand, Iran, just after 11:50 PM via ambulance, following a sting from a Hemiscorpius lepturus scorpion (known locally as “Gadim”). The bite was on the top side of her right forearm. She displayed reduced consciousness, low blood pressure, and anaphylactic shock. She complained of excruciating pain at the site and had one episode of projectile vomiting mixed with bile but no blood.

The bite area showed a small visible mark near a vein, with redness, swelling, and slight tenderness. Her arm's nerves and blood flow were normal. Mentally, she was unresponsive and disoriented, with closed eyes, no reaction to voices, but some movement in response to pain. The nurse noted an initial Glasgow Coma Scale score of 10. Her breathing was steady and normal, and her pupils were equal and responsive to light.

She was immediately hooked up to heart and lung monitors. On arrival, her stats included: breathing at 30 breaths per minute, pulse at 150 beats per minute, body temperature at 34.7°C, oxygen levels at 89%, and blood pressure at 70/42 mmHg. An emergency doctor assessed her, ordered nothing by mouth (NPO), and inserted an IV line. Right away, she got two intramuscular epinephrine shots (0.1 mg/kg each, in a 1:1000 solution), 5 mg of intravenous chlorpheniramine (about 0.5 cc from the 10 mg/ml vial used in Iran), and three doses of scorpion antivenom, plus a liter of IV saline over an hour to handle the low blood pressure and shock (BP 70/42 mmHg). Initial blood tests covered CBC, differential, BUN, creatinine, blood sugar, sodium, potassium, magnesium, troponin I, creatine phosphokinase (CPK), NT-proBNP, and liver enzymes, all sent for analysis. Based on these and other checks, there were no signs of bleeding issues or muscle breakdown during her stay. A chest X-ray, taken as part of the evaluation, came back clear (Fig. 1)—ruling out lung fluid or other chest problems right at the start.

The chest X-ray showed no abnormalities, eliminating pulmonary edema or other immediate lung issues upon arrival.

Full size image (https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-025-06266-4/figures/1)

After stabilizing, she moved to the Pediatric Intensive Care Unit (PICU) under a pediatrician's care. Due to ongoing low blood pressure, an epinephrine IV drip started at 0.05 µg/kg/min. To ease nausea and vomiting, she received 2 mg/kg of intravenous pantoprazole twice daily. For pain and restlessness, she got 200 mg of intravenous acetaminophen (Apotel) as needed. Antibiotics weren't deemed necessary based on clinical judgment.

As per doctor orders, emergency gear stayed by her bedside. Her vital signs, along with fluid intake and output, were tracked hourly on her chart. Her fluid balance stayed even, with urine output between 1 and 4 cc/kg/hour during admission.

Because of the persistent low blood pressure, a heart specialist was consulted. On exam, her heart and lungs sounded normal. An electrocardiogram (ECG) was done, showing rapid heart rate on the 12-lead ECG and confirming toxic myocarditis (Fig. 2). Dopamine was added at 10–15 µg/kg/min. Close monitoring of fluids and blood pressure continued.

The 12-lead ECG indicated rapid heart rate without changes in ST or T waves. While this alone isn't specific, combined with high heart markers and ultrasound signs of reduced ejection fraction, it pointed to toxic myocarditis.

Full size image (https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-025-06266-4/figures/2)

Her heart ultrasound revealed a weakened ejection fraction (EF) of 45% and fractional shortening (FS) of 22%, plus mild mitral valve leakage, pointing to heart failure from the scorpion envenomation. Extra heart tests were ordered. Results showed high troponin I (2.07 ng/mL; normal < 0.04 ng/mL), CPK (831 U/L; normal 24–170 U/L), D-dimer (2000 ng/mL; normal < 500 ng/mL), and NT-proBNP (8870 pg/mL; normal < 125 pg/mL), solidifying the toxic myocarditis diagnosis from the sting [5].

At admission, she had clouded awareness, shown by confusion, no response to questions, closed eyes, and only slight reactions to pain. Her brain CT scan was normal (Fig. 3), but four hours later, she had a grand mal seizure, stopped with intravenous phenytoin at a loading dose of 15 mg/kg, then 5 mg/kg every 12 hours. Her brain function slowly returned, and by discharge, she was fully alert with no lasting damage.

The brain CT scan was clear, excluding structural brain causes for her seizure and confusion.

Full size image (https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-025-06266-4/figures/3)

After 10 days of supportive care, she was sent home with better EF and FS (55% and 27% respectively). While EF normalized, FS was still on the low side, indicating partial recovery of pumping strength at discharge, but she regained full consciousness and good overall health. At the one-month check-up, EF and FS were normal (70% and 40%), proving complete pumping function recovery, with the mitral valve issue resolved. NT-proBNP dropped to 280 pg/mL, and a two-week follow-up was scheduled. Seizure meds were tapered over four weeks. At six months, heart images and blood tests stayed normal; however, she missed her one-year appointment, so long-term results are unknown.

Discussion

The Poison Control and Drug Monitoring Center (CAPM) records about 30,000 scorpion bites yearly, with 25% affecting kids under 15 [1]. Bites happen across Iran, often with unclear symptoms [6].

Scorpion envenomation is a big deal in Iran, averaging 50,000 cases a year and around 20 deaths, mostly in rural, warm areas. Over 80% occur in southern Iran [7]. This H. lepturus sting (Gadim) in Birjand was odd since that area isn't typical for this species [1]. Possible reasons include changing scorpion ranges due to goods transport or climate shifts [8]. Studies in southern Iran link bite frequency to hotter temps and more sunshine [9], while humidity has an inverse effect [10]. No local data exists for Birjand, but these factors might explain the scorpion's presence outside usual spots. This calls for better ecological tracking and health prep in unexpected areas.

If a scorpion is killed and brought in, an expert can identify it, which helps [11]. Here, the type was confirmed by experts and specialists using symptoms and patterns. The H. lepturus sting was verified.

Scorpion venom can vary from mild pain to deadly systemic issues [12]. Its heart effects include artery spasms, clotting, thrombosis, and low Na-K-ATPase, plus high epinephrine, norepinephrine, and bradykinin, causing allergies [13, 14]. Severity depends on venom amount, influenced by scorpion size, bite force, and site [15]. Common heart problems: high blood pressure (30–77%), heart attacks, myocarditis, heart failure with lung fluid (25%), and shock [16]. In this case, the girl had vomiting, low BP, and shock after the H. lepturus sting. Tests confirmed toxic myocarditis with high troponin I (2.07 ng/mL) and NT-proBNP (8870 pg/mL), and low EF (45%), showing major heart damage.

Venom is a mix of sugars, hyaluronidase, enzymes, serotonin, histamine, blockers, releasers, and nerve toxins [17]. Research by Ismail et al. (1995) [18] on animal venom spread shows a two-phase model: quick tissue absorption (alpha, 4–7 min), then slower removal (beta, 4.2–13.4 hours). Here, the bite near a vein in the arm likely sped up venom entry and spread. This rapid, neurotoxic action explains the quick myocarditis onset. Heart scans and markers highlighted the key role of bite location in severe heart risks.

Venom-caused myocarditis likely involves direct heart harm, nerve imbalance, and immune reactions. Parts like phospholipases A₂, cytotoxins, and cardiotoxins damage heart cell walls and ion flow, leading to cell death [19]. Nerve toxins also spike catecholamines, causing heart stunning, blockage, and swelling [20]. Complement activation and cytokines like TNF-α, IL-1, IL-6 boost inflammation [21], while metalloproteinases harm vessels and cause poor blood flow [22]. Oxidative stress from venom worsens cell death and immune flare-ups [23]. Together, this links envenomation to myocarditis, stressing quick heart care.

Patients with bad symptoms need close heart watching. Venom lowers Na-K-ATPase, causing toxic myocarditis. It releases adrenaline and noradrenaline, leading to adrenergic myocarditis. This includes faster heart rate and stronger beats, raising oxygen needs, especially in weak hearts [24]. Here, venom caused low EF, high troponin, worsening adrenergic myocarditis, straining the heart. Inotropes supported function and BP. Careful monitoring and treatment prevent heart dangers. Recovery was tracked to six months, with normal scans and tests, but possible issues like diastolic problems or rhythms can't be ruled out. Future studies need longer follow-ups for late heart effects.

Neurological issues from scorpion bites vary, with seizures being key. Grand mal seizures and comas occur in severe cases, tied to toxins and heart stress [25, 26, 27]. Brain swelling has been noted [28, 29]. Seizures hit kids more—14.7% in one study, comas 11% [30]. This might be due to higher venom per body weight and stronger responses [31]. Here, confusion and a seizure showed venom's brain impact, likely from metabolic or toxic paths, not structural damage.

Antivenom for scorpion venom is debated. Death risk is low, allergic risk high, so supportive care might be as good or better. But here's where it gets controversial: should antivenom be used at all, given the potential for severe reactions? For effectiveness, it needs IV ASAP. Dose depends on severity, time, progress, and product. It only neutralizes free venom, not bound [32]. In this case, quick antivenom (three vials) and saline aimed to clear venom and stop worsening. Yet, monitoring for reactions and supportive steps were key. This mix might work best with risks, especially in bad cases.

Antivenom debate continues; for H. lepturus in Iran, it's different. This species causes cytotoxicity, bleeding, clotting, kidney failure, and heart risks [33, 34], worse in kids [35]. Local practice favors early IV antivenom in moderate-severe cases, as it's time-sensitive for free venom [36]; once damage happens, like heart harm, antivenom can't fix it, so support takes over [35]. Here, antivenom plus strong care (stabilization, seizure control) likely helped, though not provable from one case. High-quality studies are needed for true efficacy in H. lepturus, but early use in bad pediatric cases seems wise given the venom's dangers. The multivalent antivenom from Iran's Razi Institute (equine-based, stored at 2–8°C) works against key species, including H. lepturus [37].

Key supports here: constant monitoring caught low BP early. Epinephrine and dopamine kept blood flow in myocarditis. Phenytoin controlled seizures, avoiding brain issues. These, with antivenom, were crucial for survival.

While rare in Iran, similar heart issues occur elsewhere. In Brazil, Tityus serrulatus bites cause myocarditis, lung fluid, rhythms [38, 39, 40]. In India, Mesobuthus tamulus leads to heart failure in kids [41, 42, 43]. These show global cardiotoxicity, but species differ. H. lepturus is mainly hemolytic, kidney-toxic, cytotoxic, not cardiotoxic. So, this case, with heart and brain issues, expands its known effects. Documenting this raises awareness for multi-system risks, even in unexpected places.

Scorpion Sting Myocarditis in Child: A Rare Case & Pediatric Treatment (2025)

A Shocking Twist: When a Scorpion's Sting Targets a Child's Heart

References