Immunomodulatory activity of Tityus serrulatus scorpion venom on human T lymphocytes
© Casella-Martins et al. 2015
Received: 19 February 2015
Accepted: 5 November 2015
Published: 11 November 2015
Tityus serrulatus scorpion venom (TsV) contains toxins that act on K+ and Na+ channels and account for the venom’s toxic effects. TsV can activate murine peritoneal macrophages, but its effects on human lymphocytes have been poorly investigated. Considering that lymphocytes may play an important role in envenomation, we assessed whether TsV affects the expression of phenotypic (CD3, CD4, and CD8) and activation (CD69, CD25, and HLA-DR) markers, cell proliferation, and cytokine production in peripheral blood mononuclear cells.
Cytotoxicity of TsV was evaluated via the MTT assay. Cell proliferation, expression of phenotypic and activation markers, and release of cytokines were assessed using flow cytometry, after treatment with non-cytotoxic concentrations of TsV. The combined use of carboxyfluorescein diacetate succinimidyl ester and monoclonal antibodies against phenotypic and activation markers enabled us to simultaneously assess cell proliferation extent and cell activation status, and to discriminate among cell subpopulations.
TsV at concentrations of 25 to 100 μg/mL were not cytotoxic towards peripheral blood mononuclear cells. TsV did not induce significant changes in lymphocyte subpopulations or in the expression of activation markers on CD4+ and CD8+ T cells. TsV inhibited the phytohemagglutinin-stimulated lymphocyte proliferation, particularly in the CD8+ CD25+ T lymphocyte subset. TsV alone, at 50 and 100 μg/mL, did not induce peripheral blood mononuclear cell proliferation, but elicited the production and release of IL-6, a proinflammatory cytokine that plays an important role in innate and adaptive immune responses.
TsV is a potential source of molecules with immunomodulatory action on human T lymphocytes.
Scorpions from the family Buthidae are responsible for the majority of worldwide envenomations, especially in South Asia, the Middle East, Central and South America, and North Africa [1, 2]. Tityus is one genus of this family, of which Tityus serrulatus is the most dangerous species – it causes serious envenomation that may provoke fatalities, the majority of the victims are children [3–7].
Scorpion venom is composed of numerous toxins, mostly of peptides and neurotoxins, which act by deregulating cell membrane ion channels. Such toxins may cause pain, deregulation of cardiovascular and autonomic nervous systems, vomiting, abdominal pain, stimulation of peripheral nervous system, neuromuscular excitation, among other deleterious effects in humans .
Massive activation of the immune system seems also to participate in the pathogenesis of T. serrulatus envenomation. The plasma levels of NO and cytokines – such as interleukin-1 (IL-1), IL-6, IL-8 and interferon-γ (IFN-γ) produced by immune cells – are increased in patients presenting moderate or severe T. serrulatus envenomation, and correlate with the severity of envenomation . The participation of proinflammatory cytokines in the moderate and severe envenomation pathophysiology indicates that these patients may benefit from treatment with glucocorticoids.
Recent studies reported that the venom of T. serrulatus and its toxins activate murine macrophages, which are critical cells for the immune response because they participate in humoral and cellular responses [10–15]. However, the effect of Tityus serrulatus scorpion venom (TsV) on human lymphocytes remains to be investigated. Considering that TsV contains several toxins that act on membrane K+ channels, and that these channels are involved in the regulation of cellular functions, in the present study we examined whether TsV interferes in peripheral blood mononuclear cell (PBMC) cytokine production, as well as in T lymphocyte phenotype, proliferation, and expression of activation markers.
Source and preparation of venom
TsV was obtained from the serpentarium of the Ribeirão Preto Medical School, University of São Paulo, Brazil, by using the electrical stimulation method with the minimal voltage required (− 12 V) .
Peripheral blood mononuclear cell (PBMC) isolation and culture
PBMC were isolated from venous blood of 20 healthy adult volunteers (7 males and 13 females, 20–40 years old) via the Ficoll-Hypaque (Hystopaque®-1077; Sigma-Aldrich, USA) discontinuous density centrifugation method. PBMC were washed twice, suspended in RPMI 1640 medium (GIBCO®, USA) to a concentration of 5 × 106 cells/mL. Cells were cultured in RPMI with phytohemagglutinin (PHA; 2 μg/mL; Sigma-Aldrich, USA) and/or TsV (25, 50, and 100 μg/mL) at 37 °C and under 5 % CO2, during the proliferation assay (96 h) and before the immunophenotyping assay (24 h). The Human Research Ethics Committee at FCFRP-USP approved the research protocol, registered under number CEP/FCFRP 166.
The cytotoxic activity of TsV was evaluated using the MTT method described by Mosmann . PBMC (5 × 105 cells/well) were cultured in 96-well plates in RPMI 1640 complete culture medium containing 10 % fetal calf serum (FCS) in the presence of TsV (12.5; 25.0; 50.0; 62.5; 100.0; 125.0; 250.0; 500.0; 1000.0; 2000.0 μg/mL) or cyclophosphamide (Cyclo; 25 mg/mL; positive control; Sigma-Aldrich, USA) previously diluted in culture medium, for 24 h at 37 °C, and under 5 % CO2. Next, 20 μL of MTT (Sigma-Aldrich, USA) solution at 5 mg/mL was added to each well, and the plates were incubated for 4 h, at 37 °C, and under 5 % CO2. After incubation, the precipitated formazan crystals were dissolved with 200 μL of 20 % SDS (sodium dodecylsulfate), and absorbance was recorded at 570 nm. Absorbance values recorded for untreated cells (negative control) represent 100 % of PBMC viability, and were used as reference to calculate the percentage of cell viability in the presence of each sample concentration.
Immunophenotyping of lymphocyte subsets and activation markers
Flow cytometry analysis was performed to identify and quantify lymphocyte subpopulations (CD3-FITC, CD4-PE, and CD8-PE monoclonal antibodies), and to measure the levels of cellular activation markers expression (CD69, CD25, and HLA-DR monoclonal antibodies conjugated with APC) (Becton-Dickinson, USA).
PBMC (2 × 105 cells per well) were cultured with TsV (25; 50; 100 μg/mL) for 24 h at 37 °C, and under 5 % CO2. Cells were collected, suspended to a concentration of 1 × 106 cells in 100 μL of FACS buffer (phosphate buffered saline – PBS, with 10 % FCS and 1 % sodium azide), and incubated with 1 μL of monoclonal antibodies at the following concentrations (mg/mL): 0.0031(CD4); 0.0125 (CD8); 0.012 (CD25); 0.2 (CD69); 0.05 (HLA-DR); and 0.1 (CD3), for 30 min at 4 °C, in the dark. Then, the cells were washed with PBS and suspended in 100 μL of PBS-FCS.
A total of 30,000 events per tube was acquired on the flow cytometer (FACSCanto, Becton-Dickinson, USA), the lymphocyte gate was selected according to its forward and side scatter distribution, and further analyzed with the aid of the software FACSDiva (Becton-Dickinson, USA). The results were expressed as percentages of stained cells. Additional file 1 depicts representative forward/side scatter dot-plots of human PBMC treated with TsV.
Cell proliferation assay
The use of carboxyfluorescein diacetate succinimidyl ester (CFSE) in combination with monoclonal antibodies against phenotypic and activation markers enabled the concomitant determination of cell proliferation and activation status and discrimination of cell subpopulations.
PBMC were centrifuged, suspended to the concentration of 5 × 106 cells/mL in PBS containing 0.1 % human albumin, and labeled with CFSE (2.5 μM; Molecular Probes, USA) for ten minutes at 37 °C. The labeling process was stopped by addition of five volumes of ice-cold RPMI 1640 containing 10 % FCS (RPMI-FCS) followed by incubation for five minutes in an ice bath, in the dark. The cells were washed three times with 20 mL of RPMI-FCS, and further suspended in the same medium.
PBMC were plated in 96-well plates (5 × 105 cells/well) and cultured with PHA (2 μg/mL) and/or TsV(25, 50, or 100 μg/mL) for 96 h at 37 °C, and under 5 % CO2. The cells (1 × 106) were transferred to flow cytometry tubes and labeled with 2 μL of the following monoclonal antibodies: anti-CD3/PerCP (Peridinin-chlorophyll-protein complex); anti-CD8, or anti-CD4 PE; anti-CD25, anti-HLA-DR, or anti-CD69 APC (Becton-Dickinson, USA). A total of 30,000 events per tube was acquired on the flow cytometer (FACSCanto, Becton-Dickinson, USA) and analyzed with the aid of the software FACSDiva (Becton-Dickinson, USA). The lymphocyte gate was set on light-scatter properties (forward scatter vs. side scatter). The results were expressed as percentages of stained cells.
The levels of tumor necrosis factor-α (TNF-α), IL-2, IL-4, IL-6, IL-10, IL-17, and IFN-γ in culture supernatants of PBMC (1.0 × 105 cells) treated with PHA (2 μg/mL) and/or TsV (25, 50, and 100 μg/mL) for 96 h were quantified by flow cytometry, using the assay kit Cytometric Bead Array (CBA) Human Th1/Th2/Th17 Cytokine (BD Biosciences, USA) according to the manufacturer’s instructions. The samples were analyzed on a FACSCanto cytometer with the aid of the CBA analysis software FCAP Array (version 1.01; Becton-Dickinson, USA). The cytokine concentration was expressed as pg/mL.
The results were expressed as mean ± standard error of the mean (SEM). Statistical analysis was performed by one-way analysis of variance (ANOVA) followed by the Tukey’s test, using the software Graph Pad Prism 5. Significance was defined as p < 0.05.
TsV at lower concentrations is not cytotoxic towards PBMC
TsV does not induce changes in T lymphocyte subpopulations and in the expression of PBMC activation markers
TsV inhibits the proliferation of CD8+CD25+ T lymphocytes
TsV induces IL-6 release by PBMC
In Brazil, the yellow scorpion T. serrulatus is the most dangerous Buthidae species and the main cause of serious accidents . Its venom (TsV) contains toxins that act on K+ and Na+ channels, a property that accounts for great portion of the venom’s toxic effects. Several studies have reported that scorpion venoms and toxins, including TsV, elicit macrophage activation [11–13, 15, 19]. TsV and Ts1 bind Toll-like receptors to mediate cytokine and lipid mediator production . Such reports have helped to elucidate how inflammatory mediators are produced after envenomation.
To date, very little is known about the direct effect of scorpion venoms on human lymphocyte functions. As lymphocytes have membrane K+ channels and TsV contains toxins that interact with these channels, we hypothesized that TsV and its toxins could affect lymphocyte functions mediated by the activity of K+ channels, such as PHA-induced cell proliferation [11, 20–22].
Cell stimulation by pathogens in infectious and inflammatory processes and by mitogens induces the expression of activation markers in T, B, and NK cells. PHA, a commonly used mitogen, is a plant lectin that binds to TCR and activates T lymphocytes . In the present study, we examined the expression of very early (CD69), middle-to-late (CD25), and late (HLA-DR) T cell surface activation markers. CD69 expression can be detected within 1 to 2 h after T cell stimulation . It can initiate tyrosine kinase and calcium flux activity, and transcription of IL-2 and TNF-α . The expression of CD25 (the α-chain of the IL-2 receptor) and HLA-DR (a human class II major histocompatibility complex antigen) increases progressively after 24 h of stimulation with PHA .
After establishing the TsV concentrations and incubation time with PBMC, we examined whether TsV alters the percentage of T lymphocytes, and the extent of CD4+ and CD8+ T cell proliferation. In the presence of TsV, the percentage of T lymphocytes (data not shown), as well as the percentage of CD3+CD4+ and CD3+CD8+ lymphocyte subpopulations expressing CD69, CD25, and HLA-DR were similar to the untreated controls. However, maximum expression of some activation markers, especially CD25 and HLA-DR, may occur later. It suggests that the PBMC culture periods used (24 h and 96 h) were not sufficient to detect significant alterations in the expression level of these markers. To confirm this hypothesis, it is necessary to perform additional experiments using longer culture times. Another possibility is to use higher TsV concentrations to better evaluate its action on the expression of lymphocyte activation markers.
To assess lymphocyte proliferation, we selected CFSE due to its compatibility with several other fluorochromes, which enabled us to simultaneously evaluate several parameters including the percentage of activated cells and proliferation of distinct populations of activated cells, using multi-color flow cytometry . With the aid of this technique, we found that TsV at 50 and 100 μg/mL significantly decreased the percentage of CD8+CD25+ T cells in PHA-stimulated PBMC (Fig. 3). Considering that ion channels participate in an early stage of cell activation by PHA, it is possible that toxins that exist in TsV act on ions channels in CD8+CD25+ T cells and thereby impair the action of PHA on these cells . It is well documented that ion channels play important roles in the activation and proliferation of lymphocytes, as well as in the production of cytokines [20, 28, 29]. Blockage of the K+ channel Kv1.3 inhibits mitogen-induced T cell proliferation, protein synthesis and IL-2 production .
Cytokines are produced during the effector phases of innate and acquired immune responses and regulate immune and inflammatory responses [30, 31]. Besides the knowledge that TsV and its toxins are potent inducers of cytokine and lipid mediator production in vitro and in vivo [11–15, 19], little is known about the effect of TsV on the production of cytokines by human PBMC. We measured the levels of various cytokines – IL-2, IL-4, IL-6, IL-10, IL-17, IFN-γ and TNF-α – in the supernatant of PBMC cultures after 96 h of treatment with PHA and/or different concentrations of crude TsV. Compared with untreated cells, TsV at 50 and 100 μg/mL significantly increased IL-6 release in non-stimulated cells (p < 0.05 and p < 0.01, respectively) (Fig. 4). In contrast, TsV did not alter the PHA-induced IL-6 production by PBMC. Our results partially agree with those reported by several in vitro and in vivo studies [11–15, 19]. TsV fractions stimulate the macrophage production of proinflammatory cytokines such as TNF-α, IL-1, and IL-6 . TsV and the toxins Ts1 and Ts6 stimulate the production of NO, IL-6, and TNF-α in J774.1 cells . When inoculated in mice, Ts2 and Ts6 induce the production of the proinflammatory cytokines IL-6, TNF-α, IL-1β, and IFN-γ, and the lipid mediators prostaglandin E2 and leukotriene B4 . Several authors have reported that IL-6 levels are increased after envenomation in humans [9, 33–35].
To the best of our knowledge, this is the first study that shows immunomodulatory actions of TsV on human T lymphocytes. Taken together, our results suggest that TsV is a potential source of molecules with immunomodulatory effects on these cells, and should stimulate further research to elucidate the action mechanisms involved, including the participation of T lymphocyte ion channels in the phenomena observed.
TsV is a potential immunomodulator of human T lymphocyte functions. The results reported herein stimulate further investigations to identify the venom components responsible for the observed effects and to elucidate the molecular mechanisms involved in TsV immunomodulatory action on lymphocytes. These investigations may facilitate the development of new tools to study the pathophysiological mechanisms of envenomation and to discover new treatment alternatives for diseases mediated by the immune system.
Ethics committee approval
The present study was approved by the Human Research Ethics Committee at FCFRP-USP registered under number CEP/FCFRP 166.
The authors would like to thank the Nucleus for Research on Animal Toxins (NAP-TOXAN-USP, grant n. 12–125432.1.3), the State of São Paulo Research Foundation (FAPESP, grant n. 2011/23236-4), the Coordination for the Improvement of Higher Education Personnel (CAPES, ACM, JCP and SMB grants) and the National Council for Scientific and Technological Development (CNPq, SMB grant) for their funding of this research. We also thanks to T. M. Casare-Ogasawara for the technical support. Thanks are also due to the Center for the Study of Venoms and Venomous Animals (CEVAP) of UNESP for enabling the publication of this special collection (CNPq process 469660/2014-7).
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Chippaux JP, Goyffon M. Epidemiology of scorpionism: a global appraisal. Acta Trop. 2008;107(2):71–9.View ArticlePubMedGoogle Scholar
- Chippaux JP. Epidemiology of envenomations by terrestrial venomous animals in Brazil based on case reporting: from obvious facts to contingencies. J Venom Anim Toxins incl Trop Dis. 2015;21:13. doi:10.1186/s40409-015-0011-1.PubMed CentralView ArticlePubMedGoogle Scholar
- Cupo P, Jurca M, Azevedo-Marques MM, Oliveira JSM, Hering SE. Severe scorpion envenomation in Brazil: clinical, laboratory and anatomopathological aspects. Rev Inst Med Trop São Paulo. 1994;36(1):67–76.View ArticlePubMedGoogle Scholar
- Lourenço WR. What do we know about some of the most conspicuous scorpion species of the genus Tityus? A historical approach. J Venom Anim Toxins incl Trop Dis. 2015;21:20. doi:10.1186/s40409-015-0016-9.PubMed CentralView ArticlePubMedGoogle Scholar
- Ministério da Saúde, Secretaria de Vigilância em Saúde. Manual de Controle de Escorpiões. Brasília: MS; 2009. http://bvsms.saude.gov.br/bvs/publicacoes/manual_controle_escorpioes.pdf. (Accessed 10 Nov 2015).
- Reckziegel GC, Pinto VL. Scorpionism in Brazil in the years 2000 to 2012. J Venom Anim Toxins incl Trop Dis. 2014;20:46. http://www.jvat.org/content/20/1/46. (Accessed 10 Nov 2015).
- Bahloul M, Chabchoub I, Chaari A, Chtara K, Kallel H, Dammak H, et al. Scorpion envenomation among children: clinical manifestations and outcome (analysis of 685 cases). Am J Trop Med Hyg. 2010;83(5):1084–92.PubMed CentralView ArticlePubMedGoogle Scholar
- Isbister KG, Bawaskar HS. Scorpion envenomation. N Engl J Med. 2014;371(5):457–63.View ArticlePubMedGoogle Scholar
- Fukuhara YD, Reis ML, Dellalibera-Joviliano R, Cunha FQ, Donadi EA. Increased plasma levels of IL-1beta, IL-6, IL-8, IL-10 and TNF-alpha in patients moderately or severely envenomed by Tityus serrulatus scorpion sting. Toxicon. 2003;41(1):49–55.View ArticlePubMedGoogle Scholar
- Fialho EM, Maciel MC, Silva AC, Reis AS, Assunção AK, Fortes TS, et al. Immune cells recruitment and activation by Tityus serrulatus scorpion venom. Toxicon. 2011;58(6–7):480–5.View ArticlePubMedGoogle Scholar
- Ortiz E, Gurrola GB, Schwartz EF, Possani LD. Scorpion venom components as potential candidates for drug development. Toxicon. 2015;93:125–35.View ArticlePubMedGoogle Scholar
- Zoccal KF, Bitencourt CS, Secatto A, Sorgi CA, Bordon KC, Sampaio SV, et al. Tityus serrulatus venom and toxins Ts1, Ts2 and Ts6 induce macrophage activation and production of immune mediators. Toxicon. 2011;57(7–8):1101–8.View ArticlePubMedGoogle Scholar
- Zoccal KF, Bitencourt CS, Sorgi CA, Bordon KC, Sampaio SV, Arantes EC, et al. Ts6 and Ts2 from Tityus serrulatus venom induce inflammation by mechanisms dependent on lipid mediators and cytokine production. Toxicon. 2013;61:1–10.View ArticlePubMedGoogle Scholar
- Zoccal KF, Bitencourt CS, Paula-Silva FW, Sorgi CA, Bordon KCF, Arantes EC, et al. TLR2, TLR4 and CD14 recognize venom-associated molecular patterns from Tityus serrulatus to induce macrophage-derived inflammatory mediators. PLoS ONE. 2014;9(2):e88174. doi:10.1371/journal.pone.0088174.PubMed CentralView ArticlePubMedGoogle Scholar
- Zoccal KF, Paula-Silva FW, Bitencourt CS, Sorgi CA, Bordon KC, Arantes EC, et al. PPAR-γ activation by Tityus serrulatus venom regulates lipid body formation and lipid mediator production. Toxicon. 2015;93:90–7.View ArticlePubMedGoogle Scholar
- Lowe RM, Farrell PM. A portable device for the electrical extraction of scorpion venom. Toxicon. 2011;57(2):244–7.View ArticlePubMedGoogle Scholar
- Pucca MB, Amorim FG, Cerni FA, Bordon KC, Cardoso IA, Anjolette FA, et al. Influence of post-starvation extraction time and prey-specific diet in Tityus serrulatus scorpion venom composition and hyaluronidase activity. Toxicon. 2014;90:326–36.View ArticlePubMedGoogle Scholar
- Mosmann T. Rapid colorimetric assay for cellular growth and survival: application to proliferation and cytotoxicity assays. J Immunol Methods. 1983;65(1–2):55–63.View ArticlePubMedGoogle Scholar
- Petricevich VL. Scorpion venom and the inflammatory response. Mediators Inflamm. 2010; Article ID 903295, 16 pages, 2010. doi:10.1155/2010/903295.
- Cahalan MD, Chandy KG. The functional network of ion channels in T lymphocytes. Immunol Rev. 2009;1(1):59–87.View ArticleGoogle Scholar
- Cerni FA, Pucca MB, Peigneur S, Cremonez CM, Bordon KCF, Tytgat J, et al. Electrophysiological characterization of Ts6 and Ts7, K+ channel toxins isolated through an improved Tityus serrulatus venom purification procedure. Toxins. 2014;6(3):892–913.PubMed CentralView ArticlePubMedGoogle Scholar
- DeCoursey TE, Chandy KG, Gupta S, Cahalan MD. Voltage-gated K+ channels in human T lymphocytes: a role in mitogenesis? Nature. 1984;307(5950):465–8.View ArticlePubMedGoogle Scholar
- Licastro F, Davis LJ, Morini MC. Lectins and superantigens: membrane interactions of these compounds with T-lymphocytes affect immune responses. Int J Biochem. 1993;25(6):845–52.View ArticlePubMedGoogle Scholar
- Ziegler SF, Ramsdell F, Alderson MR. The activation antigen CD69. Stem Cells. 1994;12(5):456–65.View ArticlePubMedGoogle Scholar
- Rea IM, McNerlan SE, Alexander HD. CD69, CD25, and HLA-DR activation antigen expression on CD3+ lymphocytes and relationship to serum TNF-alpha, IFN-gamma, and sIL-2R levels in aging. Exp Gerontol. 1999;34(1):79–93.View ArticlePubMedGoogle Scholar
- Reddy M, Eirikis E, Davis C, Davis HM, Prabhakar U. Comparative analysis of lymphocyte activation marker expression and cytokine secretion profile in stimulated human peripheral blood mononuclear cell cultures: an in vitro model to monitor cellular immune function. J Immunol Methods. 2004;293(1–2):127–42.View ArticlePubMedGoogle Scholar
- Quah BJ, Warren HS, Parish CR. Monitoring lymphocyte proliferation in vitro and in vivo with the intracellular fluorescent dye carboxyfluorescein diacetate succinimidyl ester. Nat Protoc. 2007;2(9):2049–56.View ArticlePubMedGoogle Scholar
- Cahalan MD, Wulff H, Chandy KG. Molecular properties and physiological roles of ion channels in the immune system. J Clin Immunol. 2001;21(4):235–52.View ArticlePubMedGoogle Scholar
- Urrego D, Tomczak AP, Zahed F, Stühmer W, Pardo LA. Potassium channels in cell cycle and cell proliferation. Philos Trans R Soc Lond B Biol Sci. 2014;369(1638):20130094. doi:10.1098/rstb.2013.0094.PubMed CentralView ArticlePubMedGoogle Scholar
- Van der Meide PH, Schellekens H. Cytokines and the immune response. Biotherapy. 1996;8(3–4):243–9.View ArticlePubMedGoogle Scholar
- Lacy P, Stow JL. Cytokine release from innate immune cells: association with diverse membrane trafficking pathways. Blood. 2011;118(1):9–18.View ArticlePubMedGoogle Scholar
- Petricevich VL, Lebrun I. Immunomodulatory effects of the Tityus serrulatus venom on murine macrophage functions in vitro. Mediators Inflamm. 2005;2005(1):39–49.PubMed CentralView ArticlePubMedGoogle Scholar
- Sofer S, Gueron M, White RM, Lifshitz M, Apte RN. Interleukin-6 release following scorpion sting in children. Toxicon. 1996;34(3):389–92.View ArticlePubMedGoogle Scholar
- Magalhães MM, Pereira ME, Amaral CF, Rezende NA, Campolina D, Bucaretchi F, et al. Serum levels of cytokines in patients envenomed by Tityus serrulatus scorpion sting. Toxicon. 1999;37(8):1155–64.View ArticlePubMedGoogle Scholar
- Voronov E, Apte RN, Sofer S. The systemic inflammatory response syndrome related to the release of cytokines following severe envenomation. J Venom Anim Toxins. 1999;5(1):5–33. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-79301999000100002. Accessed 10 Nov 2015.