Patient had immediate intense local pain, swelling and redness. sting. Case report A 49-year-old gentleman, non-diabetic and not a hypertensive, 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 complained 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 C 87 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 C 87 cholesterol 347?mg/dL, hemoglobin 13.2?g/dL, urine examination albumin 4+, red blood cells 10C15/hpf, urine white blood cells 3C5/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 system 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, hemoglobin 12.0?g/dL and 24?h protein 2872?mg. He was dialyzed for three sessions and subjected to C 87 renal biopsy. The renal biopsy revealed 14 glomeruli. There was no mesangial hyperplasia, glomerular basement membrane thickening 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 unfavorable for all those 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 CACNLG 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 scorpion 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 prednisolone 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). Open in a separate window Fig.?1 Complete effacement of foot processes Open in a separate window Fig.?2 Panel chartclinical events Discussion The kidneys and liver are the main routes of excretion from the human body. The kidneys have the largest concentration 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 . Scorpion stings can result in acute renal failure by multitude of factors. Direct venom toxicity to the tissues due to high molecular weight substances.