A 40-year-old farmer from the Indian state of Uttar Pradesh presented in the emergency room in an unconscious state with a history of a scorpion sting (Mesobuthus tamulus or the Indian red scorpion) in his right foot. As per the attendants, the patient returned from work with headache, vomiting, and pain at the site of the sting. Eventually, he developed weakness of the right side of the body and lost his consciousness within 4 h. The patient had no history of hypertension or any drug intake or any significant illness in the family. He had no other addiction apart from smoking 10 cigarettes per day for the last 20 years. On initial evaluation in the ER, the patient was altered with Glasgow Coma Scale score of 6 (E2V2M2), pupils were mid-dilated and reactive, blood pressure was elevated (178/100 mmHg), and pulse rate was 110 per minute and oxygen saturation of 84% on room air. Cellulitis of the right foot was obvious on general examination (Fig. 1). Auscultation of the chest revealed bilateral coarse crepitations. An urgent non-contrast CT scan of the head showed intracerebral hemorrhage (left basal ganglia involving left temporoparietal lobe with intraventricular extension) (Fig. 2). Hematoma volume was 140 cc as measured by ABC/2 score [5].
The patient was shifted to the intensive care unit; his airway was first secured with intubation and mechanical ventilation. He was put on intravenous fluids, mannitol, dexamethasone, and prazosin. Arterial blood gas analysis, complete hemogram (hemoglobin 120 g/L; total leucocyte count, 14 × 109/L; platelets, 160 × 109/L), liver and kidney functional tests, serum electrolytes, coagulation profile (prothrombin time, 14 s; international normalized ratio, 1.8; activated partial thromboplastin time, 34 s), FDP (7 mg/L), and D-dimer (< 0.50) were within normal limits. Chest radiograph showed bilateral basal infiltrates due to aspiration, sinus tachycardia on electrocardiogram, and elevated troponin T (0.8 ng/ml) suggested possible myocarditis. Transthoracic echocardiogram showed mild diastolic dysfunction without valvular and pericardial involvement, and left ventricular ejection fraction was 56%. A neurosurgical consultation was taken and an external ventricular drain was planned. But surgery was deferred as the patient developed hypotension on day 3 (blood pressure—systolic 60 mmHg) probably due to sepsis secondary to aspiration pneumonitis or toxin-induced myocarditis. The patient was given intravenous vasopressor support, and blood pressure was intensively monitored. He had a cardiac arrest and eventually succumbed to his illness on day 4 despite the best possible efforts.