Nephrotic syndrome after scorpion sting

Abstract

Scorpion venom is a water soluble, antigenic and heterogeneous mixture. The venom is composed of varying concentration of neurotoxin, cardiotoxin, nephrotoxin, haemolytic toxin, phosphodiesterase, phospholipases, hyaluronidases,
glycosaminoglycans, histamine, serotonins, and tryptophan and cytokine releasers. The reported incidence of scorpion sting in India is 0.6 %. Scorpion sting resulting in acute renal failure has been reported in the past, but not the nephrotic syndrome. We report a patient of nephrotic syndrome after scorpion sting. The lacunae in the present knowledge linking scorpion sting venom with nephrotic syndrome would only be replete with publications of similar reports.

Full text

CASE REPORT
Nephrotic syndrome after scorpion sting
Sangeetha Lakshmi Boju
1
•Hari Krishna Reddy Mogili
1
•R Ram
1
•
Siva Kumar Vishnubotla
1
Received: 6 April 2015 / Accepted: 10 September 2015 / Published online: 29 September 2015
ÓJapanese Society of Nephrology 2015
Abstract Scorpion venom is a water soluble, antigenic
and heterogeneous mixture. The venom is composed of
varying concentration of neurotoxin, cardiotoxin, nephro-
toxin, haemolytic toxin, phosphodiesterase, phospholi-
pases, hyaluronidases, glycosaminoglycans, histamine,
serotonins, and tryptophan and cytokine releasers. The
reported incidence of scorpion sting in India is 0.6 %.
Scorpion sting resulting in acute renal failure has been
reported in the past, but not the nephrotic syndrome. We
report a patient of nephrotic syndrome after scorpion sting.
The lacunae in the present knowledge linking scorpion
sting venom with nephrotic syndrome would only be
replete with publications of similar reports.
Keywords Nephrotic syndrome Scorpion sting 
Minimal change disease
Introduction
Scorpion venom is a water soluble, antigenic and hetero-
geneous mixture. The venom is composed of varying
concentration of neurotoxin, cardiotoxin, nephrotoxin,
haemolytic toxin, phosphodiesterase, phospholipases, hya-
luronidases, glycosaminoglycans, histamine, serotonins,
and tryptophan and cytokine releasers [1,2]. The most
potent toxin, however, is the neurotoxin. In India, 86 spe-
cies of scorpions have been identified. Mesobuthus tamulus
(the Indian red scorpion) and Palmoneus gravimanus are
the common and most lethal species of scorpions in India
with fatalities in adults and children [3]. The reported
incidence of scorpion sting in India is 0.6 % [4]. Scorpion
sting resulting in acute renal failure has been reported in
the past, but not the nephrotic syndrome. We report a
patient of nephrotic syndrome after scorpion sting.
Case report
A 49-year-old gentleman, non-diabetic and not a hyper-
tensive, presented with history of scorpion sting over the
fourth digit of the left hand. Patient had immediate intense
local pain, swelling and redness. Within 1 h he had
hypersalivation, sweating, vomiting and diarrhea. Patient
was managed at a primary health care center for 48 h with
local anesthetic infiltration and anxiolytics. The results of
investigations done were: random blood glucose 117 mg/
dL, serum creatinine 1.2 mg/dL, hemoglobin 14.5 g/dL
and urine for albumin 1?. After 3 days, the patient com-
plained insidious onset of abdominal distension, followed
by pedal edema and facial puffiness. The symptoms
worsened over next 1 week. There was no history of
oliguria, dysuria and haematuria. Patient was managed at a
tertiary care institute. The results of investigations done
were: serum creatinine 2.9 mg/dL, total serum proteins
4.4 g/dL, serum albumin 1.4 g/dL, total cholesterol
347 mg/dL, hemoglobin 13.2 g/dL, urine examination
albumin 4?, red blood cells 10–15/hpf, urine white blood
&R Ram
ram_5_1999@yahoo.com
Sangeetha Lakshmi Boju
Sangee_doctor@gmail.com
Hari Krishna Reddy Mogili
Hkr_mogili@gmail.com
Siva Kumar Vishnubotla
savskumar@yahoo.com
1
Nephrology, Sri Venkateswara Institute of Medical Sciences,
Tirupati, AP, India
123
CEN Case Rep (2016) 5:83–86
DOI 10.1007/s13730-015-0197-7

cells 3–5/hpf, 24 h urine protein was 9.90 g. Ultrasound
abdomen revealed: right kidney 10.7 cm and left kidney
10.2 cm. During the hospital stay the serum creatinine
increased to 3.3 mg/dL. He was subjected to renal biopsy
at that institute. Light microscopy on periodic acid Schiff,
silver and trichrome stains revealed seven glomeruli, one of
which was sclerotic. The glomeruli were normocellular,
capillary loops were patent, and glomerular basement
membrane revealed no spikes or double contours. No
segmental sclerosis was observed. Tubules showed signs of
acute injury. Interstitium and vessels were unremarkable.
Immunofluorescence showed no fluorescence for any
immunoglobulin and complement. The diagnosis was
minimal change disease with acute tubular necrosis. The
serum creatinine remained between 3.5 and 4.0 mg/dL for
the next 2 weeks. Patient had worsening of pedal edema,
facial puffiness and oliguria. He presented to our institute
with breathlessness. Blood pressure was 140/90 mmHg,
pulse was 110 bpm. Respiratory system examination
revealed bilateral diffuse crackles and cardiovascular sys-
tem examination left ventricular third heart sound. Serum
creatinine was 7.0 mg/dL, blood urea was 148 mg/dL, total
serum proteins 5.5 g/dL, serum albumin 2.5 g/dL, total
cholesterol 237 mg/dL, triglycerides 182 mg/dL, hemo-
globin 12.0 g/dL and 24 h protein 2872 mg. He was dia-
lyzed for three sessions and subjected to renal biopsy. The
renal biopsy revealed 14 glomeruli. There was no mesan-
gial hyperplasia, glomerular basement membrane thicken-
ing or crescents. Tubules showed degenerated epithelium
falling towards lumen, regenerating tubular epithelium
with increased mitosis and hyperchromatic nuclei and
periodic acid Schiff stained tubular casts. Interstitium and
vessels were unremarkable. Immunofluorescence was
negative for all immunoglobulins and complement.
Electron microscopy revealed the foot process effacement,
vacuolization, and microvillous transformation of epithelial
cells and increased density of cytoskeleton (Fig. 1). With
the diagnosis of minimal change disease and acute tubular
necrosis, the patient was continued on dialysis. Urine
output improved after three more weeks of dialysis. Serum
creatinine stabilized to 2.0 mg/dL after 8 weeks of scor-
pion sting. Other investigations after 8 weeks were: 24 h
urine protein 1376 mg, total serum protein 5.5 g/dL, serum
albumin 2.4 mg/dL, total cholesterol 225 mg/dL and
triglycerides 185 mg/dL. As the proteinuria persisted even
after 8 weeks, the patient was initiated on tablet pred-
nisolone 2 mg/kg on alternate days. After 12 weeks, the
serum creatinine was 1.8 mg/dL and 24 h urine protein was
900 mg. The prednisolone was tapered and stopped. At last
follow-up, 24 weeks after the scorpion sting the serum
creatinine and 24 h urine protein were 2.0 mg/dL and
1090 mg (Fig. 2).
Discussion
The kidneys and liver are the main routes of excretion from
the human body. The kidneys have the largest concentra-
tion of venom. This appears to be due to two reasons, rapid
redistribution of the venom from the blood to the kidneys
and slow removal from the kidney [5].
Scorpion stings can result in acute renal failure by mul-
titude of factors. Direct venom toxicity to the tissues due to
high molecular weight substances like hyaluronidase and
sphingomyelinase is reported, potassium channel toxins may
mediate vascular contraction by causing smooth muscle
depolarization and hence afferent arteriolar vasoconstriction,
systemic inflammatory response syndrome, complement
activation, myocarditis and adrenergic mediated vasocon-
striction may all reduce renal blood flow [6]. In addition
haemoglobinuria-related pigment nephropathy [7], haemo-
lytic uraemic syndrome [8] and acute interstitial nephritis [9]
are also reported as causes of acute renal failure.
The pathogenesis of nephrotic syndrome following
scorpion sting is not known. Due to the action of an
unrecognized substance similar to the pore forming pep-
tides of Buthus martensii may damage glomerular base-
ment membrane [6].
The diagnosis of nephrotic syndrome is indisputable in
this patient. The renal biopsy, done twice, suggested the
diagnosis of minimal change disease and acute tubular
necrosis. The temporal relation with the scorpion sting and
the nephrotic syndrome is clear cut. The lacunae in the
present knowledge linking scorpion sting venom with
Fig. 1 Complete effacement of foot processes
84 CEN Case Rep (2016) 5:83–86
123

Fig. 2 Panel chart—clinical events
CEN Case Rep (2016) 5:83–86 85
123

nephrotic syndrome would only be replete with publica-
tions of similar reports.
Compliance with ethical standards
Conflict of interest All authors have nothing to disclose and no
conflicts of interest.
Informed consent The consent of the patient is taken.
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