|
Myocardial
Injury in Scorpion Envenomed Children:
Significance of Assessment of Serum Troponin I and Interleukin-8
Abstract
| Introduction
| Materials
and Methods:
Biochemical
analysis; Statistical analysis |
Results
|
Discussion
In
conclusion |
References
Abdel-Raheim
A. M. Meki,1
Zeinab M. Mohey El-Deen, 2
Hassan M. Mohey El-Deen, 3
1.
Biochemistry Department, Faculty of Medicine, Assuit University,
Assiut, Egypt.
2. Pediatric Department, Faculty of Medicine, Assuit University,
Assiut, Egypt.
3. Internal Medicine Department, Faculty of Medicine, Minia
University, Minia, EGYPT.
Submitted:
February 4, 2002
Accepted: February 13, 2002
Key words:
scorpion, children, cardiac injury, troponin I, interleukin-8.
Abstract
OBJECTIVES:
(1) To investigate the significance of assessment of serum
levels of cardiac troponin I (cTnI) and interleukin-8 (IL-8)
beside other biomarkers of myocardial injury in scorpion envenomed
children. (2) To find the correlation between these biochemical
indices with clinical status, prognosis and outcome of these
cases.
METHODS:
Forty-one children in Upper Egypt were admitted to Pediatric
Intensive Care Unit, Assiut University Hospital, for scorpion
envenomation. They were compared with fifteen apparently healthy
children of matching age as controls. The victims and controls
were subjected to complete clinical examination, full blood
count and arterial blood gases analysis. According to severity
of scorpion envenomation, 17 children had manifestations of
severe envenomation and clinical signs of toxic myocarditis
(severe cases), 14 children had moderate manifestations of
envenomation without clinical evidence of carditis (moderate
cases) and 10 cases showing only mild symptoms of envenomation
(mild cases). The serum levels of cTnI and IL-8 beside the
enzymatic activities of creatine phosphokinase (CPK), CPK-MB
isoenzyme (CPK-MB) and lactate dehydrogenase (LDH) were determined
once for mild cases and controls on admission and twice for
severe and moderate cases on admission and after 24 hrs. The
measurements of electrocardiography (ECG), echocardiographic
measurement of % fractional shortening of left ventricule
(%SF), left ventricular ejection fraction (LVEF) and cardiac
chambers dilatation were done for severe and moderate cases.
RESULTS:
All the envenomed victims showed significantly higher mean
values of CPK, CPK-MB, LDH, and IL-8 on admission in comparison
to control group. cTnI was not detectable in the sera of control
group as well as patients with mild envenomation. The mean
values of CPK, CPK-MB, LDH, and IL-8 were significantly higher
in severe cases while only IL-8 and CPK-MB were significantly
higher in moderate cases in comparison with mild cases. The
mean values of IL-8, cTnI, CPK, CPK-MB and LDH were significantly
higher in severe cases both on admission and on follow-up
comparing with moderate cases. The case fatality rate was
12.5% and all were from severe cases with toxic myocarditis
(5/41=12.5%). The non-survivors victims showed significant
higher mean values of only cTnI on admission and both cTnI
and IL-8 on follow up in comparison to the survivors. Significant
reduction of % SF and LVEF were noticed among the non-survivors
in comparison to survivors. The cTnI showed 100% specificity
and sensitivity for diagnosis of myocardial injury in relation
to Echo finding in the envenomed victims. In severe cases,
cTnI was positively correlated with IL-8 while negatively
correlated with %SF and LVEF.
CONCLUSION: it may be suggested that cTnI is the most specific
marker for diagnosis of myocardial injury in scorpion envenomation,
which is almost associated with skeletal muscle injury. Other
biochemical markers did not show such specificity. Also, IL-8
may be involved in the pathogenesis of myocardial injury of
scorpion envenomation. Both cTnI and IL-8 may be useful to
forecast the fatal outcome in scorpion envenomation.
Introduction
Scorpion
envenomation is a common medical problem and life- threatening
hazard in many countries. Scorpion envenomation in children
can be a potentially fatal condition. Neurotoxins and cardiotoxins
are present in the majority of scorpion venoms [1]. The signs
and symptoms of envenomation are usually more severe in children
especially younger ones [2-3]. Scorpion envenoming results in
multi-organ system failure and death. It is brought about by
a massive release of catecholamines, glucagon and angiotensin
II and a simultaneous reduction in insulin levels [4-5]. The
severity of envenomation is related to neurological and cardio-respiratory
dysfunction. The mechanism of scorpion envenomation induced
cardiac dysfunction is still unclear [6]. Gueron et al., [7]
hypothesized that catecholamine storm post envenomation may
cause cardiac dysfunction by catecholamine -induced hypoxia
and that death might result from myocarditis and congestive
heart failure [8]. Some authors suggested that cardiac dysfunction
in scorpion envenomation may be due to a direct effect of scorpion
venom evoking the so-called scorpionic myocarditis characterized
by non-specific ultra-structural changes [9]. Nouira et al.
[10] showed the presence of right and left ventricular dysfunction
after scorpion envenomation providing further augmentation to
the hypothesis of scorpionic myocarditis.
Myocardial damage in children may be clinically occult in a
variety of stressful conditions. However, biochemical markers
have not been routinely used in children at risk of myocardial
damage due to lack of sufficient specificity. As the criterion
for myocyte injury is not well established, so the need for
a specific serum marker for myocardial injury might be useful
to augment the clinical and echocardiographic (Echo) diagnosis
of myocarditis [11]. Troponin I, C and T form a complex that
regulates the Ca2+ mediated interaction of actin and myosin
in striated muscles. Troponin I from the cardiac muscle and
slow and fast twitch skeletal muscles are products of different
genes with unique amino acid sequence. The developed monoclonal
antibodies to cardiac troponin I (cTnI) have non cross reactivity
with the skeletal muscle form were reported [12]. Briassoulis
et al., [13] proved that cTnI is an early markers of viral myocarditis.
Adams et al., [14] stated that the increases in cTnI don’t
occur despite severe acute or chronic muscle injury even when
level of creatine phosphokinase (CPK) and CPK-MB isoenzyme (CPK-MB)
are increased unless cardiac injury is present.
Scorpion venoms can stimulate the neuroendocrinal-immunological
axis by its ability to release catecholamines, corticosteroids,
bradykinin and prostaglandins and all these agents proved to
induce the release of immunological mediators as cytokines [15].
Cytokines regulate and amplify the immune response, induce tissue
injury and mediate complications of the inflammatory response
[16]. There is now accumulating evidence to suggest a causal
relationship between overproduction of certain cytokines such
as interleukin-1b (IL-1b)
and interleukin-6 (IL-6) and both morbidity and mortality associated
with critically ill patients [17]. Studies from Egypt indicated
that levels of cytokines in scorpion envenomed children correlated
with the clinical severity of envenomation [3].
Interleukin-8 (IL-8) is a potent chemoattractant factor for
neutrophils, basophils and T lymphocytes and to control their
trafficking [18]. Endothelial cells have been shown to produce
IL-8 on stimulation with a variety of inflammatory mediators.
Moreover, cultured endothelial cells release IL-8 under hypoxic
conditions (Karakurum et al., 1994). According to the current
knowledge, cytotoxic lymphocytes rather than monocytes are found
at sites of myocardial inflammation. The inflammatory cytokines
are target to myocardiac cells as the immune cells adhere to
myocytes (Lang and Schreiner, 1994).
The aim of the present study was to assess the frequency of
myocardial injury in scorpion envenomed children using the different
biochemical markers (cTnI, IL-8, CPK, CPK-MB and LDH) hoping
to identify the most specific marker for early detection of
myocardial damage and forecasting the prognosis of these cases.
In addition, to clarify the role of IL-8 in the pathogenesis
of myocardial injury in scorpion envenomation and also to find
the correlation between these biochemical indices with clinical
status.
Materials
and Methods
Biochemical
analysis ... ....
Statistical analysis ... ....
Results
... ....
Discussion
... ....
In
conclusion, the present study is considered the first study
which provided evidence that: ... ....
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