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Olin S, Schildt J, Lane M, Odunayo A, Springer C, Call D, Jones S, Geiser D, Millis D, Drum M. The effects of hyperbaric oxygen therapy on snake-bite-associated wounds in dogs. J Vet Emerg Crit Care (San Antonio) 2024; 34:211-221. [PMID: 38761038 DOI: 10.1111/vec.13383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/03/2023] [Accepted: 03/08/2023] [Indexed: 05/20/2024]
Abstract
OBJECTIVE To assess the effect of hyperbaric oxygen therapy (HBOT) on Crotalinae envenomation-induced wound swelling and severity and pain in dogs, and to describe the safety and complications of HBOT. DESIGN Prospective, randomized, controlled, blinded study (2017-2021). SETTING University teaching hospital, private veterinary practice. ANIMALS Thirty-six client-owned dogs presenting within 24 hours of a confirmed or suspected naturally occurring Crotalinae snake bite injury were enrolled between 2017 and 2021. INTERVENTIONS In addition to the standard of care treatment, dogs received 2 interventions with either HBOT (n = 19) or control (n = 16) within 24 hours of hospital admission. Dogs receiving HBOT were pressurized over 15 minutes (1 psi/min), maintained at a target pressure of 2 atmosphere absolute (ATA) for 30 minutes, and decompressed over 15 minutes. Control dogs received 1 ATA for 1 hour. Local wound swelling, wound severity score, and pain score were assessed at admission, before and after each intervention, and at hospital discharge. MEASUREMENTS AND MAIN RESULTS There was no significant difference in wound swelling (P = 0.414), severity score (P = 1.000), or pain score (P = 0.689) between HBOT and control groups. Pain decreased significantly over time regardless of the study intervention (P < 0.001). There were no major adverse effects associated with either study intervention. CONCLUSIONS HBOT did not significantly alter the short-term recovery from Crotalinae envenomation in this study population. However, the study might be underpowered to detect a significant treatment effect.
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Affiliation(s)
- Shelly Olin
- Department of Small Animal Clinical Science, University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee, USA
| | - Julie Schildt
- Department of Small Animal Clinical Science, University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee, USA
| | | | - Adesola Odunayo
- Department of Small Animal Clinical Science, University of Florida, Gainesville, Florida, USA
| | - Cary Springer
- Research Computing Support, Office of Information Technology, University of Tennessee, Knoxville, Tennessee, USA
| | - Dana Call
- Neel Veterinary Hospital, Oklahoma City, Oklahoma, USA
| | - Selene Jones
- Allergy Skin and Ear Clinic for Pets, Livonia, Michigan, USA
| | - Dennis Geiser
- Hospital Administration, University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee, USA
| | - Daryl Millis
- Department of Small Animal Clinical Science, University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee, USA
| | - Marti Drum
- Department of Small Animal Clinical Science, University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee, USA
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2
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Marriott AE, Casewell NR, Lilley E, Gutiérrez JM, Ainsworth S. Improving in vivo assays in snake venom and antivenom research: A community discussion. F1000Res 2024; 13:192. [PMID: 38708289 PMCID: PMC11066530 DOI: 10.12688/f1000research.148223.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 05/07/2024] Open
Abstract
On the 26 th January 2023, a free to attend, 'improving in vivo snake venom research: a community discussion' meeting was held virtually. This webinar brought together researchers from around the world to discuss current neutralisation of venom lethality mouse assays that are used globally to assess the efficacy of therapies for snakebite envenoming. The assay's strengths and weaknesses were highlighted, and we discussed what improvements could be made to refine and reduce animal testing, whilst supporting preclinical antivenom and drug discovery for snakebite envenoming. This report summarises the issues highlighted, the discussions held, with additional commentary on key perspectives provided by the authors.
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Affiliation(s)
- Amy E Marriott
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, England, L3 5RF, UK
- Centre for Snakebite Research and Interventions, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Nicholas R Casewell
- Centre for Snakebite Research and Interventions, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Elliot Lilley
- National Centre for the Replacement, Reduction and Refinement of Animals in Research, London, NW1 2BE, UK
| | - José-María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501-2060, Costa Rica
| | - Stuart Ainsworth
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, England, L3 5RF, UK
- Centre for Snakebite Research and Interventions, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
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Werner RM, Soffa AN. Considerations for the development of a field-based medical device for the administration of adjunctive therapies for snakebite envenoming. Toxicon X 2023; 20:100169. [PMID: 37661997 PMCID: PMC10474190 DOI: 10.1016/j.toxcx.2023.100169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/27/2023] [Accepted: 08/12/2023] [Indexed: 09/05/2023] Open
Abstract
The timely administration of antivenom is the most effective method currently available to reduce the burden of snakebite envenoming (SBE), a neglected tropical disease that most often affects rural agricultural global populations. There is increasing interest in the development of adjunctive small molecule and biologic therapeutics that target the most problematic venom components to bridge the time-gap between initial SBE and the administration antivenom. Unique combinations of these therapeutics could provide relief from the toxic effects of regional groupings of medically relevant snake species. The application a PRISMA/PICO literature search methodology demonstrated an increasing interest in the rapid administration of therapies to improve patient symptoms and outcomes after SBE. Advice from expert interviews and considerations regarding the potential routes of therapy administration, anatomical bite location, and species-specific venom delivery have provided a framework to identify ideal metrics and potential hurdles for the development of a field-based medical device that could be used immediately after SBE to deliver adjunctive therapies. The use of subcutaneous (SC) or intramuscular (IM) injection were identified as potential routes of administration of both small molecule and biologic therapies. The development of a field-based medical device for the delivery of adjunctive SBE therapies presents unique challenges that will require a collaborative and transdisciplinary approach to be successful.
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4
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Gamulin E, Mateljak Lukačević S, Halassy B, Kurtović T. Snake Antivenoms-Toward Better Understanding of the Administration Route. Toxins (Basel) 2023; 15:398. [PMID: 37368699 DOI: 10.3390/toxins15060398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Envenomations induced by animal bites and stings constitute a significant public health burden. Even though a standardized protocol does not exist, parenterally administered polyclonal antivenoms remain the mainstay in snakebite therapy. There is a prevailing opinion that their application by the i.m. route has poor efficacy and that i.v. administration should preferentially be chosen in order to achieve better accomplishment of the antivenom therapeutic activity. Recently, it has been demonstrated that neutralization not only in the systemic circulation but also in the lymphatic system might be of great importance for the clinical outcome since it represents another relevant body compartment through which the absorption of the venom components occurs. In this review, the present-day and summarized knowledge of the laboratory and clinical findings on the i.v. and i.m. routes of antivenom administration is provided, with a special emphasis on the contribution of the lymphatic system to the process of venom elimination. Until now, antivenom-mediated neutralization has not yet been discussed in the context of the synergistic action of both blood and lymph. A current viewpoint might help to improve the comprehension of the venom/antivenom pharmacokinetics and the optimal approach for drug application. There is a great need for additional dependable, practical, well-designed studies, as well as more practice-related experience reports. As a result, opportunities for resolving long-standing disputes over choosing one therapeutic principle over another might be created, improving the safety and effectiveness of snakebite management.
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Affiliation(s)
- Erika Gamulin
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Sanja Mateljak Lukačević
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
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5
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Bassett TE, Schaer M. A review of 95 pit viper envenomations in Northcentral Florida (2018-2020). Toxicon 2023; 229:107134. [PMID: 37160192 DOI: 10.1016/j.toxicon.2023.107134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/10/2023] [Accepted: 04/23/2023] [Indexed: 05/11/2023]
Abstract
The medical records of 95 pit viper envenomations in client-owned dogs presented to an academic emergency hospital in the Southeastern United States during the period spanning 2018 and 2020 were retrospectively examined. This study's primary objectives were to record the clinical abnormalities and treatment responses associated with envenomation and their relation to outcome. Approximately 80% of the bites involved the head region associated with varying degrees of hemorrhagic lymphedema. Some of the most common additional symptoms observed were; hypotension (10%), cardiac dysrhythmias (17%), and coagulopathy (21%). Treatment in most cases consisted of intravenous fluids, antivenom, and analgesic drugs. Blood products were used as indicated for anemia and persistent bleeding. The average dose of the F('ab')2 was 1-2 vials. Additional vials (3-22) were administered as needed to counteract persistent or recurrent coagulopathy and hemolysis. Only 3% of the dogs had mild clinical signs of Type 1 hypersensitivity during their treatment period. Antihistamine use at the tertiary hospital was restricted to the three dogs showing signs of a suspected allergic reaction in response to antivenom administration; these patients received diphenhydramine intramuscularly. A glucocorticoid drug was used in only one dog prior to referral but not subsequently. Ninety dogs had a good outcome, while five died. Historically, pit viper envenomation in dogs in the southeastern United States has been a potentially life-threatening problem. Most dogs will survive if treated promptly and appropriately with adequate amounts of intravenous fluids, and antivenom titrated on severity of clinical presentation.
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Affiliation(s)
- Taylor E Bassett
- University of Florida College of Veterinary Medicine, 2015 SW 16th Ave, Gainesville, FL, 32608, USA.
| | - Michael Schaer
- University of Florida College of Veterinary Medicine, 2015 SW 16th Ave, Gainesville, FL, 32608, USA.
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6
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Ralph R, Garg D, Balachandran A, Ganesh SR, Lamb T. A case report of Ovophis monitcola (Mountain pit-viper) envenoming in northeastern India resulting in prolonged coagulopathy. Toxicon 2023; 229:107147. [PMID: 37127123 DOI: 10.1016/j.toxicon.2023.107147] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/21/2023] [Accepted: 04/29/2023] [Indexed: 05/03/2023]
Abstract
India is home to a diverse spectrum of medically-significant snakes accounting for the world's largest burden of envenoming, morbidity and mortality. Indian polyspecific antivenom is derived from the venom of four snake species (Daboia russelii, Echis carinatus, Naja naja and Bungarus caeruleus), considered to be responsible for the majority of snakebite morbidity and mortality. The treatment of venomous bites from other less-commonly encountered venomous snake species can be challenging. In this report, we describe the case of a 32-year-old male who presented with features of local cytotoxicity and coagulopathy following a bite from Ovophis monitcola (mountain pit-viper) in Nagaland, northeast India. Local and systemic envenoming, confirmed by bedside and laboratory based clotting assays, failed to respond to polyspecific antivenom and venom-induced consumption coagulopathy persisted for 28 days. Remote consultation with a national Poison Control Centre helped establish the responsible snake species and guide appropriate medical management.
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Affiliation(s)
- Ravikar Ralph
- Poison Control Center, Department of Medicine, Christian Medical College (CMC), Vellore, Tamil Nadu, 632004, India.
| | - Deepak Garg
- Medicine, Military Hospital, Dimapur, Nagaland, India; Medicine, Military Hospital, Jodhpur, Rajasthan, India
| | - Amith Balachandran
- Poison Control Center, Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - S R Ganesh
- Chennai Snake Park, Guindy, Chennai, Tamil Nadu, 600022, India
| | - Thomas Lamb
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos; Nuffield Department of Clinical Medicine, University of Oxford, India
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Recurrent neurotoxity in Naja kaouthia envenomation: A case report from Assam, India. Toxicon 2023; 222:106990. [PMID: 36470487 DOI: 10.1016/j.toxicon.2022.106990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
A 35 year old, male patient, bitten by Naja kaouthia with mild pain was admitted in Demow Government Community Health Centre. After 90 min post bite he developed neurotoxic symptoms. As per standard protocol, the patient was treated with 25 vials of antivenom and two doses of glycopyrrolate and neostigmine. Subsequently, he was seemingly devoid of any neurotoxic symptoms and showed signs of recovery. However, after 70 h, the neurotoxic symptoms recurred, and the patient was again treated with an additional 10 vials of ASV along with one dose of glycopyrrolate and neostigmine. Subsequently, the patient recovered completely from all the other symptoms of envenomation. This is the first report of recurrence of neurotoxic symptoms in a patient envenomed by Naja kaouthia in Assam, India and supports the need for greater attention and careful documentation of management of snakebite in the region.
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OUTCOMES OF TREATMENT OF SNAKE AND SCORPION ENVENOMATION IN BIRDS OF PREY, WITH AND WITHOUT ANTIVENOM. J Zoo Wildl Med 2023. [DOI: 10.1638/2021-0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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9
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Gonçalves-Machado L, Verçoza BRF, Nogueira FCS, Melani RD, Domont GB, Rodrigues SP, Rodrigues JCF, Zingali RB. Extracellular Vesicles from Bothrops jararaca Venom Are Diverse in Structure and Protein Composition and Interact with Mammalian Cells. Toxins (Basel) 2022; 14:toxins14110806. [PMID: 36422980 PMCID: PMC9698812 DOI: 10.3390/toxins14110806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/14/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
Snake venoms are complex cocktails of non-toxic and toxic molecules that work synergistically for the envenoming outcome. Alongside the immediate consequences, chronic manifestations and long-term sequelae can occur. Recently, extracellular vesicles (EVs) were found in snake venom. EVs mediate cellular communication through long distances, delivering proteins and nucleic acids that modulate the recipient cell's function. However, the biological roles of snake venom EVs, including possible cross-organism communication, are still unknown. This knowledge may expand the understanding of envenoming mechanisms. In the present study, we isolated and characterized the EVs from Bothrops jararaca venom (Bj-EVs), giving insights into their biological roles. Fresh venom was submitted to differential centrifugation, resulting in two EV populations with typical morphology and size range. Several conserved EV markers and a subset of venom related EV markers, represented mainly by processing enzymes, were identified by proteomic analysis. The most abundant protein family observed in Bj-EVs was 5'-nucleotidase, known to be immunosuppressive and a low abundant and ubiquitous toxin in snake venoms. Additionally, we demonstrated that mammalian cells efficiently internalize Bj-EVs. The commercial antibothropic antivenom partially recognizes Bj-EVs and inhibits cellular EV uptake. Based on the proteomic results and the in vitro interaction assays using macrophages and muscle cells, we propose that Bj-EVs may be involved not only in venom production and processing but also in host immune modulation and long-term effects of envenoming.
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Affiliation(s)
- Larissa Gonçalves-Machado
- Laboratório de Hemostase e Venenos, Instituto de Bioquímica Médica Leopoldo de Meis (IBqM), Instituto Nacional de Ciência e Tecnologia de Biologia Estrutural e Bioimagem (Inbeb), Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
- Instituto Vital Brazil, Gerência de Desenvolvimento Tecnológico, Niterói 24230-410, Brazil
| | - Brunno Renato Farias Verçoza
- Núcleo Multidisciplinar de Pesquisa em Biologia (NUMPEX-Bio), Universidade Federal do Rio de Janeiro, Campus UFRJ Duque de Caxias, Duque de Caxias, Rio de Janeiro 25240-005, Brazil
| | - Fábio César Sousa Nogueira
- Laboratório de Química de Proteínas, Unidade Proteômica, Instituto de Química, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-909, Brazil
- Laboratório de Proteômica (LabProt)—LADETEC, Instituto de Química, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-598, Brazil
| | - Rafael Donadélli Melani
- Laboratório de Química de Proteínas, Unidade Proteômica, Instituto de Química, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-909, Brazil
| | - Gilberto Barbosa Domont
- Laboratório de Química de Proteínas, Unidade Proteômica, Instituto de Química, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-909, Brazil
| | - Silas Pessini Rodrigues
- Núcleo Multidisciplinar de Pesquisa em Biologia (NUMPEX-Bio), Universidade Federal do Rio de Janeiro, Campus UFRJ Duque de Caxias, Duque de Caxias, Rio de Janeiro 25240-005, Brazil
| | - Juliany Cola Fernandes Rodrigues
- Núcleo Multidisciplinar de Pesquisa em Biologia (NUMPEX-Bio), Universidade Federal do Rio de Janeiro, Campus UFRJ Duque de Caxias, Duque de Caxias, Rio de Janeiro 25240-005, Brazil
| | - Russolina Benedeta Zingali
- Laboratório de Hemostase e Venenos, Instituto de Bioquímica Médica Leopoldo de Meis (IBqM), Instituto Nacional de Ciência e Tecnologia de Biologia Estrutural e Bioimagem (Inbeb), Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
- Correspondence: ; Tel.: +55-2139386782
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Rafi AM, Innah SJ. Factor assay in victims of snake bite: Experience from a tertiary care institute in South India. Asian J Transfus Sci 2022; 16:175-179. [PMID: 36687535 PMCID: PMC9855208 DOI: 10.4103/ajts.ajts_104_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 03/04/2022] [Accepted: 05/14/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Snake bites tend to cause a high mortality in those who develop coagulopathy. However, there is very limited literature on clotting factor assays in these patients, especially in the presence of clinical bleeding. The aim was to assess the coagulation profile and individual coagulation factors in patients with hematotoxic snake bites. MATERIALS AND METHODS This was a prospective observational study of clotting factor levels in victims of snake bites with hematotoxicity admitted to a single hospital in south India for 12 months. In 43 individuals who fulfilled the criteria, we measured platelet count, prothrombin time (PT), international normalized ratio, activated partial thromboplastin time (aPTT), fibrinogen levels, coagulation factors V, VII, VIII, IX, and X, and the qualitative factor XIII assay. RESULTS Forty-three patients fulfilled the criteria and their samples were studied. There were 36 Russell's viper (Daboia russelli), 4 Hump-nosed pit viper (Hypnale hypnale), and 3 unknown snake bite victims samples, in which factor assays were done. All the Russell viper bite victims without a recordable clotting screen had deficiency of Factor V (0.5%-49.62%, Mean - 20.27%), Factor X (0.08%-92.3%, Mean - 70.73%), and qualitative factor XIII. Pit viper patients showed normal levels of Factor I, V, VII, VIII, IX, X, and XIII despite prolonged PT and aPTT. CONCLUSIONS Early detection and treatment of envenomation remains the cornerstone of managing snake venom-induced consumptive coagulopathy. Anti-snake venom plays a major role in the reversal of coagulopathy. Blood and blood products would be useful when coagulopathy does not revert by ASV alone. Evidence-based transfusion can be implemented and cryoprecipitate may be used as many of the patients had factor XIII and fibrinogen deficiency as part of venom-induced coagulopathy. To improve patient management and thereby the outcome of patients CMEs and training programs for the treating physicians also has to be implemented so that guidelines are formulated and followed.
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Affiliation(s)
- Aboobacker Mohamed Rafi
- Department of IHBT, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | - Susheela Jacob Innah
- Department of IHBT, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
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Cerebral Complications of Snakebite Envenoming: Case Studies. Toxins (Basel) 2022; 14:toxins14070436. [PMID: 35878174 PMCID: PMC9320586 DOI: 10.3390/toxins14070436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 02/01/2023] Open
Abstract
There are an estimated 5.4 million snakebite cases every year. People with snakebite envenoming suffer from severe complications, or even death. Although some review articles cover several topics of snakebite envenoming, a review of the cases regarding cerebral complications, especially rare syndromes, is lacking. Here, we overview 35 cases of snakebite by front-fanged snakes, including Bothrops, Daboia, Cerastes, Deinagkistrodon, Trimeresurus, and Crotalus in the Viperidae family; Bungarus and Naja in the Elapidae family, and Homoroselaps (rare cases) in the Lamprophiidae family. We also review three rare cases of snakebite by rear-fanged snakes, including Oxybelis and Leptodeira in the Colubridae family. In the cases of viper bites, most patients (17/24) were diagnosed with ischemic stroke and intracranial hemorrhage, leading to six deaths. We then discuss the potential underlying molecular mechanisms that cause these complications. In cases of elapid bites, neural, cardiac, and ophthalmic disorders are the main complications. Due to the small amount of venom injection and the inability to deep bite, all the rear-fanged snakebites did not develop any severe complications. To date, antivenom (AV) is the most effective therapy for snakebite envenoming. In the six cases of viper and elapid bites that did not receive AV, three cases (two by viper and one by elapid) resulted in death. This indicates that AV treatment is the key to survival after a venomous snakebite. Lastly, we also discuss several studies of therapeutic agents against snakebite-envenoming-induced complications, which could be potential adjuvants along with AV treatment. This article organizes the diagnosis of hemotoxic and neurotoxic envenoming, which may help ER doctors determine the treatment for unidentified snakebite.
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12
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Morris NM, Blee JA, Hauert S. Developing a computational pharmacokinetic model of systemic snakebite envenomation and antivenom treatment. Toxicon 2022; 215:77-90. [PMID: 35716719 DOI: 10.1016/j.toxicon.2022.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/20/2022] [Accepted: 06/09/2022] [Indexed: 11/19/2022]
Abstract
Snakebite envenomation is responsible for over 100,000 deaths and 400,000 cases of disability annually, most of which are preventable through access to safe and effective antivenoms. Snake venom toxins span a wide molecular weight range, influencing their absorption, distribution, and elimination within the body. In recent years, a range of scaffolds have been applied to antivenom development. These scaffolds similarly span a wide molecular weight range and subsequently display diverse pharmacokinetic behaviours. Computational simulations represent a powerful tool to explore the interplay between these varied antivenom scaffolds and venoms, to assess whether a pharmacokinetically optimal antivenom exists. The purpose of this study was to establish a computational model of systemic snakebite envenomation and treatment, for the quantitative assessment and comparison of conventional and next-generation antivenoms. A two-compartment mathematical model of envenomation and treatment was defined and the system was parameterised using existing data from rabbits. Elimination and biodistribution parameters were regressed against molecular weight to predict the dynamics of IgG, F(ab')2, Fab, scFv, and nanobody antivenoms, spanning a size range of 15-150 kDa. As a case study, intramuscular envenomation by Naja sumatrana (equatorial spitting cobra) and its treatment using Fab, F(ab')2, and IgG antivenoms was simulated. Variable venom dose tests were applied to visualise effective antivenom dose levels. Comparisons to existing antivenoms and experimental rescue studies highlight the large dose reductions that could result from recombinant antivenom use. This study represents the first comparative in silico model of snakebite envenomation and treatment.
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Affiliation(s)
- Natalie M Morris
- Department of Engineering Mathematics, Ada Lovelace Building, University of Bristol, University Walk, Bristol, BS8 1TW, UK.
| | - Johanna A Blee
- Department of Engineering Mathematics, Ada Lovelace Building, University of Bristol, University Walk, Bristol, BS8 1TW, UK.
| | - Sabine Hauert
- Department of Engineering Mathematics, Ada Lovelace Building, University of Bristol, University Walk, Bristol, BS8 1TW, UK.
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Fashionably late: A characterization of late coagulopathies in rattlesnake envenomations between Fab and F(ab’)2 antivenoms. Toxicon 2022; 212:49-54. [DOI: 10.1016/j.toxicon.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/26/2022] [Accepted: 03/29/2022] [Indexed: 11/21/2022]
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14
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Zeng L, Liang Q, Liang Z, Han J, Wu M, Liu R, Wang X. Effectiveness of clotting factor replacement therapy after antivenom treatment on coagulopathic envenomation following green pit viper bites: a retrospective observational study. BMC Emerg Med 2022; 22:9. [PMID: 35045831 PMCID: PMC8772100 DOI: 10.1186/s12873-022-00569-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 01/04/2022] [Indexed: 12/17/2022] Open
Abstract
Background Green pit vipers (GPVs), namely Trimeresurus albolabris and Trimeresurus stejnegeri accounts for most snakebites in Southern China. Green pit viper venom contains thrombin-like enzymes, resulting in defibrination syndrome. Using of clotting factor replacement after antivenom administration is controversial. The objective of this study was to investigate the effects of clotting factor replacement in coagulopathic patients with T. albolabris and T. stejnegeri bites after antivenom administration. Methods We retrospectively reviewed 123 patients who were bitten by T. albolabris and T. stejnegeri and were admitted to the Emergency Department of a hospital in Guangzhou, Southern China, from 2013 to 2019. Recovery of prothrombin time (PT) and fibrinogen level were compared among (1) fresh-frozen plasma (FFP) group; (2) cryoprecipitate (cryo) group; (3) FFP and cryo group; and (4) control group after antivenom administration. Results The incidence of coagulopathy was 31%. Persistent and late coagulopathy were the most common patterns among four groups. The median reduction in PT was 20.1 ± 31.2 s for FFP and cryo group. The median increase in fibrinogen level was very small: 0.05 ± 0.20 g/L for FFP group, 0.09 ± 0.37 g/L for cryo group and 0.07 ± 0.31 g/L for FFP and cryo group, respectively. The percentage of unimproved PT was markedly higher in the FFP and cryo group than the control group (P = 0.01 by log-rank test, P = 0.02 by Gehan-Breslow-Wilcoxon test). The percentage of unimproved fibrinogen level tended to be worse in the FFP and cryo group than the control group, but the different was marginal (P = 0.05 by Gehan-Breslow-Wilcoxon test, P = 0.07 by log-rank test). A total of 7.8% (7/90) of the patients in the clotting factor replacement groups developed anaphylaxis and heart failure. Conclusion There is no improvement in coagulopathy profile in patients with T. albolabris and T. stejnegeri bites who received clotting factor replacement after antivenom administration. But the results from GPVs may not be generalized to other species of venomous snakes.
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Wilson BZ, Bahadir A, Andrews M, Karpen J, Winkler G, Smelski G, Dudley S, Walter FG, Shirazi FM. Initial Experience with F(ab’)2 Antivenom Compared with Fab Antivenom for Rattlesnake Envenomations Reported to a single poison center during 2019. Toxicon 2022; 209:10-17. [DOI: 10.1016/j.toxicon.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/17/2022] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
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16
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Jacobs E, King AM, Vohra V. In cold blood: Observational descriptive review of Eastern Massasauga rattlesnake bites reported to a single poison center over time. Toxicon 2021; 206:14-20. [PMID: 34914939 DOI: 10.1016/j.toxicon.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022]
Abstract
The Eastern Massasauga rattlesnake (Sistrurus catenatus catenatus) is a pit viper indigenous to the Great Lakes region and the only venomous snake native to Michigan. It is small-to-medium, thick-bodied with dark brown, bow-tie shaped blotches. Its behavior is described as reclusive and docile and it prefers damp habitats. The venom of the Eastern Massasauga is primarily cytotoxic and hemotoxic. Previous literature describes severe coagulopathies following Eastern Massasauga envenomings, with some resulting in death. The objective of this study was to characterize Eastern Massasauga envenomings in humans reported to the Michigan Poison & Drug Information Center from 2003 to 2020, including a description of clinical manifestations, incidence and characterization of coagulopathies, and medical outcome severities. This was a retrospective review of Eastern Massasauga snakebites reported to our state poison center over time. Coagulopathies were classified according to previous toxicological snakebite literature. The degree of envenoming was scored using an institutional guideline, representing a modified version of validated snakebite severity score system. Our longitudinal review demonstrated Eastern Massasauga bites led to clinically significant toxicity, including persistent, recurrent, and late coagulopathies, though with low incidence of bleeding events. Cases typically resolved with use of antivenom. This, to our knowledge, is the largest descriptive case series characterizing Eastern Massasauga snakebites.
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Affiliation(s)
- Elizabeth Jacobs
- Detroit Medical Center, Department of Emergency Medicine, 4201, St. Antoine Street, Detroit, MI, USA
| | - Andrew Marshall King
- Detroit Medical Center, Department of Emergency Medicine, 4201, St. Antoine Street, Detroit, MI, USA; Michigan Poison & Drug Information Center, Wayne State University School of Medicine, 550 East Canfield Street, Suite 354, Detroit, MI, USA
| | - Varun Vohra
- Michigan Poison & Drug Information Center, Wayne State University School of Medicine, 550 East Canfield Street, Suite 354, Detroit, MI, USA.
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Willard NK, Salazar E, Oyervides FA, Wiebe CS, Ocheltree JS, Cortez M, Perez RP, Markowitz H, Iliuk A, Sanchez EE, Suntravat M, Galan JA. Proteomic Identification and Quantification of Snake Venom Biomarkers in Venom and Plasma Extracellular Vesicles. Toxins (Basel) 2021; 13:toxins13090654. [PMID: 34564658 PMCID: PMC8473211 DOI: 10.3390/toxins13090654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 12/30/2022] Open
Abstract
The global exploration of snakebites requires the use of quantitative omics approaches to characterize snake venom as it enters into the systemic circulation. These omics approaches give insights into the venom proteome, but a further exploration is warranted to analyze the venom-reactome for the identification of snake venom biomarkers. The recent discovery of extracellular vesicles (EVs), and their critical cellular functions, has presented them as intriguing sources for biomarker discovery and disease diagnosis. Herein, we purified EV’s from the snake venom (svEVs) of Crotalus atrox and C. oreganus helleri, and from plasma of BALB/c mice injected with venom from each snake using EVtrap in conjunction with quantitative mass spectrometry for the proteomic identification and quantification of svEVs and plasma biomarkers. Snake venom EVs from C. atrox and C. o. helleri were highly enriched in 5′ nucleosidase, L-amino acid oxidase, and metalloproteinases. In mouse plasma EVs, a bioinformatic analysis for revealed upregulated responses involved with cytochrome P450, lipid metabolism, acute phase inflammation immune, and heat shock responses, while downregulated proteins were associated with mitochondrial electron transport, NADH, TCA, cortical cytoskeleton, reticulum stress, and oxidative reduction. Altogether, this analysis will provide direct evidence for svEVs composition and observation of the physiological changes of an envenomated organism.
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Affiliation(s)
- Nicholas Kevin Willard
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (N.K.W.); (E.S.); (F.A.O.); (C.S.W.); (J.S.O.); (M.C.); (E.E.S.); (M.S.)
- Department of Chemistry, Texas A&M University-Kingsville, MSC 161, Kingsville, TX 78363, USA
| | - Emelyn Salazar
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (N.K.W.); (E.S.); (F.A.O.); (C.S.W.); (J.S.O.); (M.C.); (E.E.S.); (M.S.)
| | - Fabiola Alejandra Oyervides
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (N.K.W.); (E.S.); (F.A.O.); (C.S.W.); (J.S.O.); (M.C.); (E.E.S.); (M.S.)
- Department of Chemistry, Texas A&M University-Kingsville, MSC 161, Kingsville, TX 78363, USA
| | - Cierra Siobhrie Wiebe
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (N.K.W.); (E.S.); (F.A.O.); (C.S.W.); (J.S.O.); (M.C.); (E.E.S.); (M.S.)
- Department of Chemistry, Texas A&M University-Kingsville, MSC 161, Kingsville, TX 78363, USA
| | - Jack Sutton Ocheltree
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (N.K.W.); (E.S.); (F.A.O.); (C.S.W.); (J.S.O.); (M.C.); (E.E.S.); (M.S.)
- Department of Chemistry, Texas A&M University-Kingsville, MSC 161, Kingsville, TX 78363, USA
| | - Mario Cortez
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (N.K.W.); (E.S.); (F.A.O.); (C.S.W.); (J.S.O.); (M.C.); (E.E.S.); (M.S.)
- Department of Chemistry, Texas A&M University-Kingsville, MSC 161, Kingsville, TX 78363, USA
| | | | - Harry Markowitz
- Tymora Analytical Operations, West Lafayette, IN 47906, USA; (H.M.); (A.I.)
| | - Anton Iliuk
- Tymora Analytical Operations, West Lafayette, IN 47906, USA; (H.M.); (A.I.)
| | - Elda Eliza Sanchez
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (N.K.W.); (E.S.); (F.A.O.); (C.S.W.); (J.S.O.); (M.C.); (E.E.S.); (M.S.)
- Department of Chemistry, Texas A&M University-Kingsville, MSC 161, Kingsville, TX 78363, USA
| | - Montamas Suntravat
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (N.K.W.); (E.S.); (F.A.O.); (C.S.W.); (J.S.O.); (M.C.); (E.E.S.); (M.S.)
- Department of Chemistry, Texas A&M University-Kingsville, MSC 161, Kingsville, TX 78363, USA
| | - Jacob Anthony Galan
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (N.K.W.); (E.S.); (F.A.O.); (C.S.W.); (J.S.O.); (M.C.); (E.E.S.); (M.S.)
- Department of Chemistry, Texas A&M University-Kingsville, MSC 161, Kingsville, TX 78363, USA
- Correspondence:
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Szteiter SS, Diego IN, Ortegon J, Salinas EM, Cirilo A, Reyes A, Sanchez O, Suntravat M, Salazar E, Sánchez EE, Galan JA. Examination of the Efficacy and Cross-Reactivity of a Novel Polyclonal Antibody Targeting the Disintegrin Domain in SVMPs to Neutralize Snake Venom. Toxins (Basel) 2021; 13:254. [PMID: 33807363 PMCID: PMC8066378 DOI: 10.3390/toxins13040254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 11/25/2022] Open
Abstract
Snake envenomation can result in hemorrhage, local necrosis, swelling, and if not treated properly can lead to adverse systemic effects such as coagulopathy, nephrotoxicity, neurotoxicity, and cardiotoxicity, which can result in death. As such, snake venom metalloproteinases (SVMPs) and disintegrins are two toxic components that contribute to hemorrhage and interfere with the hemostatic system. Administration of a commercial antivenom is the common antidote to treat snake envenomation, but the high-cost, lack of efficacy, side effects, and limited availability, necessitates the development of new strategies and approaches for therapeutic treatments. Herein, we describe the neutralization ability of anti-disintegrin polyclonal antibody on the activities of isolated disintegrins, P-II/P-III SVMPs, and crude venoms. Our results show disintegrin activity on platelet aggregation in whole blood and the migration of the SK-Mel-28 cells that can be neutralized with anti-disintegrin polyclonal antibody. We characterized a SVMP and found that anti-disintegrin was also able to inhibit its activity in an in vitro proteolytic assay. Moreover, we found that anti-disintegrin could neutralize the proteolytic and hemorrhagic activities from crude Crotalus atrox venom. Our results suggest that anti-disintegrin polyclonal antibodies have the potential for a targeted approach to neutralize SVMPs in the treatment of snakebite envenomations.
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Affiliation(s)
- Shelby S. Szteiter
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (S.S.S.); (I.N.D.); (J.O.); (E.M.S.); (A.C.); (A.R.); (O.S.); (M.S.); (E.S.)
| | - Ilse N. Diego
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (S.S.S.); (I.N.D.); (J.O.); (E.M.S.); (A.C.); (A.R.); (O.S.); (M.S.); (E.S.)
| | - Jonathan Ortegon
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (S.S.S.); (I.N.D.); (J.O.); (E.M.S.); (A.C.); (A.R.); (O.S.); (M.S.); (E.S.)
| | - Eliana M. Salinas
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (S.S.S.); (I.N.D.); (J.O.); (E.M.S.); (A.C.); (A.R.); (O.S.); (M.S.); (E.S.)
| | - Abcde Cirilo
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (S.S.S.); (I.N.D.); (J.O.); (E.M.S.); (A.C.); (A.R.); (O.S.); (M.S.); (E.S.)
| | - Armando Reyes
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (S.S.S.); (I.N.D.); (J.O.); (E.M.S.); (A.C.); (A.R.); (O.S.); (M.S.); (E.S.)
| | - Oscar Sanchez
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (S.S.S.); (I.N.D.); (J.O.); (E.M.S.); (A.C.); (A.R.); (O.S.); (M.S.); (E.S.)
| | - Montamas Suntravat
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (S.S.S.); (I.N.D.); (J.O.); (E.M.S.); (A.C.); (A.R.); (O.S.); (M.S.); (E.S.)
- Department of Chemistry, Texas A&M University-Kingsville, MSC 161, Kingsville, TX 78363, USA
| | - Emelyn Salazar
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (S.S.S.); (I.N.D.); (J.O.); (E.M.S.); (A.C.); (A.R.); (O.S.); (M.S.); (E.S.)
| | - Elda E. Sánchez
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (S.S.S.); (I.N.D.); (J.O.); (E.M.S.); (A.C.); (A.R.); (O.S.); (M.S.); (E.S.)
- Department of Chemistry, Texas A&M University-Kingsville, MSC 161, Kingsville, TX 78363, USA
| | - Jacob A. Galan
- National Natural Toxins Research Center (NNTRC), Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA; (S.S.S.); (I.N.D.); (J.O.); (E.M.S.); (A.C.); (A.R.); (O.S.); (M.S.); (E.S.)
- Department of Chemistry, Texas A&M University-Kingsville, MSC 161, Kingsville, TX 78363, USA
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Barbosa AN, Ferreira RS, de Carvalho FCT, Schuelter-Trevisol F, Mendes MB, Mendonça BC, Batista JN, Trevisol DJ, Boyer L, Chippaux JP, Medolago NB, Cassaro CV, Carneiro MTR, de Oliveira APP, Pimenta DC, da Cunha LER, Dos Santos LD, Barraviera B. Single-Arm, Multicenter Phase I/II Clinical Trial for the Treatment of Envenomings by Massive Africanized Honey Bee Stings Using the Unique Apilic Antivenom. Front Immunol 2021; 12:653151. [PMID: 33841437 PMCID: PMC8025786 DOI: 10.3389/fimmu.2021.653151] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/05/2021] [Indexed: 12/17/2022] Open
Abstract
We evaluated the safety, optimal dose, and preliminary effectiveness of a new-approach Africanized honeybee (Apis mellifera) Antivenom (AAV) in a phase I/II, multicenter, non-randomized, single-arm clinical trial involving 20 participants with multiple stings. Participants received 2 to 10 vials of AAV depending on the number of stings they suffered, or a predefined adjuvant, symptomatic, and complementary treatment. The primary safety endpoint was the occurrence of early adverse reactions within the first 24 h of treatment. Preliminary efficacy based on clinical evolution, including laboratory findings, was assessed at baseline and at various time points over the four following weeks. ELISA assays and mass spectrometry were used to estimate venom pharmacokinetics before, during, and after treatment. Twenty adult participants, i.e., 13 (65%) men and 7 (35%) women, with a median age of 44 years and a mean body surface area of 1.92 m2 (median = 1.93 m2) were recruited. The number of stings ranged from 7 to > 2,000, with a median of 52.5. Symptoms of envenoming were classified as mild, moderate, or severe in 80% (16), 15% (3), and 5% (1) of patients, respectively; patients with mild, moderate, or severe envenoming received 2, 6, and 10 vials of AAV as per the protocol. None of the patients had late reactions (serum sickness) within 30 d of treatment. There was no discontinuation of the protocol due to adverse events, and there were no serious adverse events. One patient had a moderate adverse event, transient itchy skin, and erythroderma. All participants completed the intravenous antivenom infusion within 2 h, and there was no loss to follow-up after discharge. ELISA assays showed venom (melittin and PLA2) concentrations varying between 0.25 and 1.479 ng/mL prior to treatment. Venom levels decreased in all patients during the hospitalization period. Surprisingly, in nine cases (45%), despite clinical recovery and the absence of symptoms, venom levels increased again during outpatient care 10 d after discharge. Mass spectrometry showed melittin in eight participants, 30 d after treatment. Considering the promising safety results for this investigational product in the treatment of massive Africanized honeybee attack, and its efficacy, reflected in the clinical improvements and corresponding immediate decrease in blood venom levels, the AAV has shown to be safe for human use. Clinical Trial Registration: UTN: U1111-1160-7011, identifier [RBR-3fthf8].
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Affiliation(s)
- Alexandre Naime Barbosa
- Department of Infectology, Dermatology, Imaging Diagnosis and Radiotherapy, Botucatu Medical School (FMB), São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, Brazil
| | - Rui Seabra Ferreira
- Department of Infectology, Dermatology, Imaging Diagnosis and Radiotherapy, Botucatu Medical School (FMB), São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, Brazil.,Graduate Program in Tropical Diseases, Botucatu Medical School (FMB), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil.,Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil.,Graduate Program in Clinical Research, Center for the Study of Venoms and Venomous Animals (CEVAP) and Botucatu Medical School (FMB), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil
| | - Francilene Capel Tavares de Carvalho
- Graduate Program in Tropical Diseases, Botucatu Medical School (FMB), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil.,Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil
| | - Fabiana Schuelter-Trevisol
- Clinical Research Center, Nossa Senhora da Conceição Hospital, Tubarão, Brazil.,Graduate Program in Health Sciences, University of Southern Santa Catarina at Tubarão, Tubarão, Brazil
| | - Mônica Bannwart Mendes
- Department of Infectology, Dermatology, Imaging Diagnosis and Radiotherapy, Botucatu Medical School (FMB), São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, Brazil
| | - Bruna Cavecci Mendonça
- Graduate Program in Tropical Diseases, Botucatu Medical School (FMB), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil.,Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil
| | - José Nixon Batista
- Clinical Research Center, Nossa Senhora da Conceição Hospital, Tubarão, Brazil
| | - Daisson José Trevisol
- Clinical Research Center, Nossa Senhora da Conceição Hospital, Tubarão, Brazil.,Graduate Program in Health Sciences, University of Southern Santa Catarina at Tubarão, Tubarão, Brazil
| | - Leslie Boyer
- VIPER Institute, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Jean-Philippe Chippaux
- MERIT, IRD, Université Paris 5, Sorbonne Paris Cité, Paris, France.,CRT, Institut Pasteur, Paris, France
| | - Natália Bronzatto Medolago
- Clinical Research Unit (UPECLIN), Botucatu Medical School, São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil
| | - Claudia Vilalva Cassaro
- Graduate Program in Tropical Diseases, Botucatu Medical School (FMB), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil.,Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil
| | - Márcia Tonin Rigotto Carneiro
- Clinical Research Unit (UPECLIN), Botucatu Medical School, São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil
| | - Ana Paola Piloto de Oliveira
- Clinical Research Unit (UPECLIN), Botucatu Medical School, São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil
| | - Daniel Carvalho Pimenta
- Graduate Program in Tropical Diseases, Botucatu Medical School (FMB), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil.,Biochemistry and Biophysics Laboratory, Butantan Institute, São Paulo, Brazil
| | | | - Lucilene Delazari Dos Santos
- Department of Infectology, Dermatology, Imaging Diagnosis and Radiotherapy, Botucatu Medical School (FMB), São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, Brazil.,Graduate Program in Tropical Diseases, Botucatu Medical School (FMB), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil.,Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil.,Graduate Program in Clinical Research, Center for the Study of Venoms and Venomous Animals (CEVAP) and Botucatu Medical School (FMB), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil
| | - Benedito Barraviera
- Department of Infectology, Dermatology, Imaging Diagnosis and Radiotherapy, Botucatu Medical School (FMB), São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, Brazil.,Graduate Program in Tropical Diseases, Botucatu Medical School (FMB), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil.,Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil.,Graduate Program in Clinical Research, Center for the Study of Venoms and Venomous Animals (CEVAP) and Botucatu Medical School (FMB), São Paulo State University (UNESP-Univ Estadual Paulista), Botucatu, Brazil
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Greene S, Cheng D, Vilke GM, Winkler G. How Should Native Crotalid Envenomation Be Managed in the Emergency Department? J Emerg Med 2021; 61:41-48. [PMID: 33622584 DOI: 10.1016/j.jemermed.2021.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pit vipers, also known as crotalids, are a group of snakes including rattlesnakes, copperheads, and cottonmouths (water moccasins). Crotalids have a broad geographic distribution across the United States, and bites from these snakes can carry significant morbidity. Their envenomations are characterized by local tissue effects, hematologic effects, and systemic effects. Envenomations are generally treated with 1 of 2 antivenoms available in the United States. OBJECTIVE We developed a series of clinical questions to assist and guide the emergency physician in the acute management of a patient envenomated by a crotalid. METHODS We conducted a PubMed literature review from January 1970 to May 2020 in English for articles with the keywords "bite" and "crotalidae." RESULTS Our literature search resulted in 177 articles. A total of 33 articles met criteria for rigorous review and citation in the development of these consensus guidelines. CONCLUSIONS Patients should be initially evaluated, stabilized, and assessed for local effects, hematologic effects, and systemic toxicity suggestive of envenomation. Antivenom should be given if toxic effects are present. Surgical intervention including debridement and fasciotomy should be avoided. Prophylactic antibiotics are not necessary.
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Affiliation(s)
- Spencer Greene
- Department of Emergency Medicine, HCA Houston Healthcare-Kingwood, University of Houston College of Medicine, Kingwood, Texas
| | - David Cheng
- Department of Emergency Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Gary M Vilke
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Garret Winkler
- Division of Medical Toxicology, Department of Emergency Medicine, University of California San Diego Health, VA San Diego Healthcare System, San Diego, California
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Lazaro RP. Complex Regional Pain Syndrome Following Snakebite: A Putatively Rare Complication of Envenomation and Review of the Literature. Int Med Case Rep J 2020; 13:603-607. [PMID: 33204179 PMCID: PMC7667582 DOI: 10.2147/imcrj.s275591] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/28/2020] [Indexed: 01/15/2023] Open
Abstract
Background Complex regional pain syndrome (CRPS) following snakebite is considered rare. Only four cases have been reported in the world literature. The present case is the first in the United States. We felt the need to report this case to bring attention to health-care providers that CRPS is probably an under-recognized complication of snakebite. Case Presentation A 44-year-old right-handed man developed signs and symptoms of complex regional pain syndrome (CRPS) in the left upper extremity following a bite by a cat-eyed snake (genus Leptodeira), a slightly venomous snake that belongs to the Colubridae (colubrids) family. The man did not develop muscle weakness or hematologic complications at that time. However, in subsequent years, he developed sporadic jerking of the upper extremities without alteration in consciousness or electroencephalographic abnormalities. These movements tended to occur during emotional tension and exacerbation of pain, and decreased in frequency when the subject was distracted. This is the fifth case of snakebite-induced CRPS described in the world literature (Nepal, Turkey, Korea, and Norway), the first reported in the United States, and the first induced by a slightly venomous snake. Conclusion With closer attention to the presence of indicators of sympathetic nerve dysfunction in association with allodynia, it is probable that cases of persistent pain following snakebite might have been instances of CRPS.
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Angioedema and Dual Nurse Flight Crew Cricothyrotomy After Envenomation by a Severed Rattlesnake Head. Air Med J 2020; 39:417-420. [PMID: 33012483 DOI: 10.1016/j.amj.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/05/2020] [Accepted: 06/17/2020] [Indexed: 11/21/2022]
Abstract
Crotalid envenomation may result in airway compromise from angioedema, anaphylaxis, or an anaphylactoid reaction. A 57-year-old man was transported by helicopter to the emergency department (ED) after a bite to his hand from a severed rattlesnake head. He rapidly developed facial and oropharyngeal edema that did not respond to standard treatment. After 2 unsuccessful attempts at intubation, the dual flight nurse team performed a cricothyrotomy. They notified the ED team en route, and antivenom was prepared before arrival. Angioedema was suspected because there was no concomitant urticaria, bronchoconstriction, or persistent hypotension. Edema and ecchymosis of the affected extremity were mild. Severe coagulopathy ensued, which was treated with bolus doses of antivenom and continuous infusion. This case report is significant for several reasons. It is the first detailing a prehospital cricothyrotomy performed by flight crew nurses for life-threatening airway edema caused by snakebite envenomation. In-flight notification enabled the ED staff to prepare and administer antivenom immediately after arrival. Despite the use of antivenom in bolus dosing, crotalid envenomation may be complicated by persistent or recurring coagulopathy, and continuous antivenom infusion may be useful. Finally, it highlights the danger of snakebite envenomation even after the death and decapitation of a snake.
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Thumtecho S, Tangtrongchitr T, Srisuma S, Kaewrueang T, Rittilert P, Pradoo A, Tongpoo A, Wananukul W. Hematotoxic Manifestations and Management of Green Pit Viper Bites in Thailand. Ther Clin Risk Manag 2020; 16:695-704. [PMID: 32801726 PMCID: PMC7398752 DOI: 10.2147/tcrm.s261303] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/28/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction Green pit vipers (GPV) are widely distributed throughout Thailand and are responsible for significant morbidity. The primary objective of this study was to characterize clinical presentations and treatment methods for GPV bites. The secondary objective was to demonstrate the earliest and latest onset of hematotoxicity. Methods GPV bites reported to the Ramathibodi Poison Center between July 1, 2016, and June 30, 2018, were analyzed. Results There were 288 GPV cases within the study period. Patients were predominantly male (62.8%), and the median age was 40 years (interquartile range (IQR) 22.8–58). Median time from envenomation to hospital presentation was 1 hour (IQR 0.5–2). Patients were primarily bitten on the finger (27.4%). Most patients reported swelling (90.3%). Necrosis and compartment syndrome occurred in 13 and 9 cases, respectively. Systemic effects occurred in 190 cases (65.9%), with median onset 15 hours (IQR 6–28.3) post-bite. Venous clotting time (VCT) showed the highest percentage of abnormalities. Systemic bleeding occurred in 13 cases (4.5%). Monitoring patients for 24, 48, and 72 hours after bites detected 62.7%, 85.9%, and 96.5% of cases with systemic effects, respectively. In total, 184 patients (62.5%) were treated, sometimes repeatedly, with antivenoms (285 courses, 949 vials). The most common indication was prolonged VCT (144 courses, 50.5%). Recurrent systemic effects after antivenom occurred in 11 cases (6.1% of patients received antivenom). No recurrence presented as systemic bleeding. Adverse reactions to antivenom were reported in 44 courses (15.4% of 285 courses), being anaphylaxis in 19 courses (6.7%). Other treatments included antibiotics (192 cases, 66.7%), surgical intervention (10, 34.7%), and blood components (4, 1.4%). Conclusion Most GPV bites result in envenomation. The most frequent local effect is mild swelling. Systemic bleeding is uncommon. The current recommendation of a 3-day follow-up can detect up to 96% of patients who may require antivenom. No severe morbidity or mortality is reported. Antivenoms are primarily indicated by prolonged VCT. Side effects of antivenom are minimal.
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Affiliation(s)
- Suthimon Thumtecho
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Ramathibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Sahaphume Srisuma
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Ramathibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanaporn Kaewrueang
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Panee Rittilert
- Ramathibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Aimon Pradoo
- Ramathibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Achara Tongpoo
- Ramathibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Winai Wananukul
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Ramathibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Park EJ, Choi S, Kim HH, Jung YS. Novel Treatment Strategy for Patients with Venom-Induced Consumptive Coagulopathy from a Pit Viper Bite. Toxins (Basel) 2020; 12:toxins12050295. [PMID: 32380672 PMCID: PMC7290867 DOI: 10.3390/toxins12050295] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/01/2020] [Accepted: 05/02/2020] [Indexed: 12/17/2022] Open
Abstract
Pit viper venom commonly causes venom-induced consumptive coagulopathy (VICC), which can be complicated by life-threatening hemorrhage. VICC has a complex pathophysiology affecting multiple steps of the coagulation pathway. Early detection of VICC is challenging because conventional blood tests such as prothrombin time (PT) and activated partial thromboplastin time (aPTT) are unreliable for early-stage monitoring of VICC progress. As the effects on the coagulation cascade may differ, even in the same species, the traditional coagulation pathways cannot fully explain the mechanisms involved in VICC or may be too slow to have any clinical utility. Antivenom should be promptly administered to neutralize the lethal toxins, although its efficacy remains controversial. Transfusion, including fresh frozen plasma, cryoprecipitate, and specific clotting factors, has also been performed in patients with bleeding. The effectiveness of viscoelastic monitoring in the treatment of VICC remains poorly understood. The development of VICC can be clarified using thromboelastography (TEG), which shows the procoagulant and anticoagulant effects of snake venom. Therefore, we believe that TEG may be able to be used to guide hemostatic resuscitation in victims of VICC. Here, we aim to discuss the advantages of TEG by comparing it with traditional coagulation tests and propose potential treatment options for VICC.
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25
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Comparison of thromboelastography versus conventional coagulation tests in simulated Crotalus atrox envenomation using human blood. Toxicon 2019; 175:19-27. [PMID: 31833475 DOI: 10.1016/j.toxicon.2019.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/29/2019] [Accepted: 12/01/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Pit viper bites are a source of significant morbidity and mortality. Pit viper bites can cause venom-induced consumptive coagulopathy (VICC), typically evaluated with laboratory-based conventional coagulation tests (CCTs). However, CCTs require a laboratory and average 1 h to conduct. Thromboelastography (TEG) provides real-time, point-of-care tests of coagulation that are fast and require no separate laboratory facilities, which could be advantageous in both hospital and austere settings. However, the relative efficacy of TEG versus CCTs was unclear, particularly at low venom concentrations. Therefore, the objectives of this study were to test human blood with various concentrations of pit viper venom using CCTs and TEG to determine dose-dependent changes, lowest observed effect concentration (LOEC), and sensitivity to detecting samples out of normal diagnostic range. METHODS Blood samples from 20 volunteers were mixed with varying concentrations of western diamond back rattlesnake (Crotalus atrox) venom based on the mouse LD50IV (none, 0.5%, 1%, 2%, 33%, 66%, and 100% LD50IV). Samples were split and assessed with both CCTs including prothrombin time (PT), international normalized ratio (INR), partial thromboplastin time (PTT), fibrinogen, and D-dimer, along with TEG measures of reaction time (R), kinetic time (K), rate of clot formation (α-angle), and clot strength (MA). Data were analyzed as dose-dependent concentration-based changes in raw values and in percent of samples exceeding diagnostic thresholds using ANOVA and nonparametric statistics at the p < .05 threshold. RESULTS All evaluations showed significant concentration-dependent changes, and 100% of samples exceeded diagnostic thresholds at 33%LD50IV and above, save D-dimer. At 0.5%LD50IV, R, K, α-angle, PT, and INR were significantly different from controls, and at 1%LD50IV, mean values exceeded diagnostic thresholds for R, K, α-angle, MA, PT, and INR, but not for PTT, D-dimer, or fibrinogen. At 2%LD50IV, 100% of samples were out of normal range for K, α-angle, and PT. CONCLUSION: TEG is effective in coagulopathy evaluations of in vitro simulated pit viper envenomation. At low venom concentrations, TEG performed as well or better than the majority of CCTs. These findings provide empirical evidence supporting the use of TEG to rapidly and accurately evaluate VICC.
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Abstract
This article discusses the epidemiology, prevention, clinical features, and treatment of venomous bites by snakes, lizards, and spiders; stings by fish, jellyfish, echinoderms, insects, and scorpions; and poisoning by ingestion of fish, turtles, and shellfish. Invertebrate stings cause fatalities by anaphylaxis, secondary to acquired hypersensitivity (Hymenoptera, such as bees, wasps, and ants; and jellyfish), and by direct envenoming (scorpions, spiders, jellyfish, and echinoderms). Simple preventive techniques, such as wearing protective clothing, using a flashlight at night, and excluding venomous animals from sleeping quarters, are of paramount importance to reduce the risk of venomous bites and stings.
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Affiliation(s)
- David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK.
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27
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Dsilva AA, Basheer A, Thomas K. Snake envenomation: is the 20 min whole blood clotting test (WBCT20) the optimum test for management? QJM 2019; 112:575-579. [PMID: 30918965 DOI: 10.1093/qjmed/hcz077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/14/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The 20 min whole blood clotting test (WBCT20) is a simple bedside test recommended by World Health Organization (WHO) to assess hemotoxic envenomation and guide administration of polyvalent anti-snake venom (ASV). However, reliability and validity of this test has not been well documented in literature. METHODS Sixty consecutive patients with history of snake bite were prospectively evaluated at a teaching hospital in India over 2 years. Envenomation was established by clinical and laboratory criteria. WBCT20 was done at 0, 4 and 12 h using standardized protocol. Prothrombin time (PT) with international normalized ratio (INR) was estimated at similar intervals to detect venom-induced consumption coagulopathy. Sensitivity, specificity and likelihood ratios (LR) were determined for WBCT20 using envenomation criteria as gold standard. WBCT20 was compared with PT/INR at cutoff values of ≥1.4 and ≥1.2. Two observers performed test-retest correlation to determine inter-observer variability of WBCT20. RESULTS . UNLABELLED Seventeen of 60 patients had evidence of hemotoxic envenomation. Four patients had combined neurotoxicity and hemotoxicity. Sensitivity and specificity of WBCT20 were 94 and 76%; positive and negative LR were 3.9 and 0.08, respectively. No inter-observer variability was noted. CONCLUSIONS WBCT20 is a highly sensitive test with excellent reliability for detecting envenomation. However, the false positive rate in this study was 24%. Asymptomatic snake bite patients with a positive WBCT20 but no corresponding clinical signs of envenomation should be tested using PT/INR before receiving ASV to prevent unnecessary waste of anti-venom.
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Affiliation(s)
- A A Dsilva
- From the Department of General Medicine, PIMS Hospital, Pondicherry
| | - A Basheer
- From the Department of General Medicine, PIMS Hospital, Pondicherry
| | - K Thomas
- From the Department of General Medicine, PIMS Hospital, Pondicherry
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Successful Management of Two Patients with Intracranial Hemorrhage due to Carpet Viper (Echis ocellatus) Envenomation in a Limited-Resource Environment. Wilderness Environ Med 2019; 30:295-301. [PMID: 31229367 DOI: 10.1016/j.wem.2019.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 04/08/2019] [Accepted: 04/16/2019] [Indexed: 11/20/2022]
Abstract
The West African carpet viper (Echis ocellatus) causes more deaths than any other snake in sub-Saharan Africa. Carpet viper envenomations are characterized by a venom-induced consumption coagulopathy and systemic bleeding syndrome, in addition to local symptoms of painful progressive swelling and tissue destruction. The highest mortality rate is seen in the final stages of the syndrome, which typically ends with fatal internal bleeding or hemorrhagic shock. We present 2 cases of E ocellatus envenomation with intracranial hemorrhage seen at a rural hospital in Bembèrèkè, Benin, and describe the successful management of these patients in a limited-resource setting. In one case the patient was treated with an ineffective Indian-made antivenom before evaluation by the authors and continued to deteriorate until she was treated with effective antivenom 10 d after the bite. In both cases lumbar puncture was performed for diagnostic or therapeutic purposes with good effect, and both patients made full recoveries without sequelae. These cases demonstrate the remarkable ability of high-quality antivenoms to reverse life-threatening envenomations even in the final stages of the hemorrhagic syndrome and illustrate the dangers posed by low-quality antivenoms that have flooded the market in the developing world.
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29
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Persistent pit viper envenomation in three dogs. Toxicon 2019; 166:83-87. [PMID: 31129161 DOI: 10.1016/j.toxicon.2019.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/15/2019] [Accepted: 05/20/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION North Central Florida is the home to several venomous snakes. The most clinically significant pit vipers include the Eastern Diamondback Rattlesnake, the Water Moccasin, and less commonly the Timber Rattlesnake. Many of the dogs and cats that become envenomated by these particular snakes have moderate to severe clinical signs requiring the use of antivenom in doses that can range from 1 to 20 vials with the average case requiring two vials. Oftentimes, the pet owners' financial limitations restrict the amount of antivenom that can be administered initially to severely envenomed cases. Most of these patients will become clinically stable after the first 48 hours of treatment, but there are rare instances where some patients will follow this same initial course, and then revert back to the initial signs of envenomation associated with delayed absorption of redistributed venom from other tissue sites in addition to the bite site. This report describes three dogs that showed signs of persistent and/or recurrent envenomation requiring additional doses of antivenom. METHODS The medical records of three dogs showing signs of persistent envenomation were reviewed by the author who was available and provided assistance during the course of the dogs' respective hospitalizations. The dog's signalment, time of year of the envenomation, clinical signs, treatment, and outcome are provided in each case. RESULTS Each of these three dogs showed severe signs of envenomation characterized by marked mental depression, prostration, hemorrhagic lymphedema, and evidence of prolonged coagulation times. Initial treatment in each consisted of intravenous crystalloid solution and polyvalent crotalid antivenom that exceeded the usual average dose as reported in the literature. After the coagulation test normalized during the first three days, all of them reverted to abnormal prolonged clotting times with signs of clinical deterioration requiring additional doses of antivenom. Clinical stability was eventually reached and all dogs survived to be discharged. CONCLUSIONS The clinical course of the three dogs described in this study showed that veterinary patients can experience persistent envenomation in a similar manner as described in humans. It behooves the veterinary practitioner to be aware of this complication and to be prepared to extend antivenom treatment as deemed necessary.
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Paniagua D, Vergara I, Román R, Romero C, Benard-Valle M, Calderón A, Jiménez L, Bernas MJ, Witte MH, Boyer LV, Alagón A. Antivenom effect on lymphatic absorption and pharmacokinetics of coral snake venom using a large animal model. Clin Toxicol (Phila) 2019; 57:727-734. [PMID: 30773936 DOI: 10.1080/15563650.2018.1550199] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Context: Historically, administration and dosing of antivenom (AV) have been guided primarily by physician judgment because of incomplete understanding of the envenomation process. As demonstrated previously, lymphatic absorption plays a major role in the availability and pharmacokinetics (PK) of coral snake venom injected subcutaneously, which suggests that absorption from subcutaneous tissue is the limiting step for venom bioavailability, supporting the notion that the bite site is an ongoing venom depot. This feature may underlie the recurrence phenomena reported in viperid envenomation that appear to result from a mismatch between venom and AV PK. The role of lymphatic absorption in neutralization of venom by AV administered intravenously remains unclear. Methods: The effect of AV on systemic bioavailability and neutralization of Micrurus fulvius venom was assessed using a central lymph-cannulated sheep model. Venom was administered by subcutaneous injection in eight sheep, four with and four without thoracic duct cannulation and drainage. Two hours after venom injection, AV was administered intravenously. Venom and AV concentrations in serum and lymph were determined by ELISA assay from samples collected over a 6-h period and in tissues harvested post-mortem. Results: After AV injection, venom levels in serum fell immediately to undetectable with a subsequent increase in concentration attributable to non-toxic venom proteins. In lymph, AV became detectable 6 min after treatment; venom levels dropped concurrently but remained detectable 4 h later. Post-mortem samples from the venom injection site confirmed the presence of venom near the point of injection. Neither venom nor AV was detected at significant concentrations in major organs or contralateral skin. Conclusions: Intravenous AV immediately neutralizes venom in the bloodstream and can extravasate to neutralize venom absorbed by lymph but this neutralization seems to be slow and incomplete. Residual venom in the inoculation site demonstrates that this site functions as a depot where it is not neutralized by AV, which allows the venom to remain active with slow delivery to the bloodstream for ongoing systemic distribution.
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Affiliation(s)
- D Paniagua
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - I Vergara
- b Department of Chemical and Biological Sciences, Sciences School , Universidad de las Américas Puebla , Cholula , México
| | - R Román
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - C Romero
- c Centro Universitario UAEM Amecameca, Universidad Autónoma del Estado de México , Amecameca de Juarez , México
| | - M Benard-Valle
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - A Calderón
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - L Jiménez
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - M J Bernas
- d Department of Medical Education , TCU and UNTHSC School of Medicine , Fort Worth , TX , USA.,e Department of Surgery , University of Arizona , Tucson , AZ , USA
| | - M H Witte
- e Department of Surgery , University of Arizona , Tucson , AZ , USA
| | - L V Boyer
- f Venom Immunochemistry, Pharmacology, and Emergency Response (VIPER) Institute, University of Arizona , Tucson , AZ , USA
| | - A Alagón
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
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31
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Holzman SD, Massey DJ, Clements A, Boesen KJ, Shirazi FM. Arizona Ridge-nosed rattlesnake envenomation: Case report of a personal encounter with the official state reptile of Arizona, Crotalus willardi willardi. Toxicon 2018; 151:84-88. [PMID: 29981814 DOI: 10.1016/j.toxicon.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/05/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Abstract
This case report describes the effects of an envenomation from one of the most infrequently encountered species of rattlesnake in the United States, Crotalus willardi willardi (C. w. willardi), the Arizona Ridge-nosed Rattlesnake. A previously healthy 57-year-old male sustained a bite to his non-dominant hand from a C. w. willardi. The most pronounced effect from the envenomation was edema and progression of edema that extended from his hand to the mid bicep. He also experienced erythema and tenderness to palpation in the affected limb, and some diminished range of motion in the hand. He expressed only minimal pain. Other than a mildly positive D-Dimer and leukocytosis, he had no significant hematologic effects and no systemic effects. He was treated with standard doses of Crotalidae Polyvalent Immune Fab (Ovine). He reported complete recovery from the envenomation within three days of the bite. Although envenomation from rattlesnakes is somewhat common in Arizona, knowing the exact species of snake is not. Confirmed documentation is exceedingly rare as most people do not recognize the different rattlesnake species. In addition, some species of rattlesnake (such as C. w. willardi) are especially reclusive and found only in isolated mountainous regions. Being able to confirm an envenomation by C. w. willardi would require not only someone knowledgeable in herpetology, but also, preferably, photographic evidence. This case has both.
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Affiliation(s)
| | - Daniel J Massey
- Arizona Poison and Drug Information Center, Tucson, AZ, USA; Banner University Medical Center, Tucson, AZ, USA
| | | | - Keith J Boesen
- Arizona Poison and Drug Information Center, Tucson, AZ, USA
| | - Farshad M Shirazi
- Arizona Poison and Drug Information Center, Tucson, AZ, USA; Banner University Medical Center, Tucson, AZ, USA
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32
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Nielsen VG. Effects of purified human fibrinogen modified with carbon monoxide and iron on coagulation in rabbits injected with Crotalus atrox venom. J Thromb Thrombolysis 2018; 44:481-488. [PMID: 28889321 DOI: 10.1007/s11239-017-1549-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
While snake venom derived enzymes, such as the thrombin-like activity possessing ancrod, have been used to treat thrombotic disease by defibrinogenating patients, the therapeutic potential of fibrinogenolytic snake venom enzymes, such as those derived from Crotalus atrox, have not been fully explored. However, one of the potential risks of administering fibrinogenolytic enzymes to effect defibrinogenation is hemorrhage secondary to hypofibrinogenemia. The present investigation sought to determine if human fibrinogen modified with carbon monoxide (CO) and iron (Fe) could resist degradation by C. atrox venom as has been seen in vitro in a recently developed rabbit model of envenomation. Compared with unmodified human fibrinogen, CO/Fe modified fibrinogen administered prior to envenomation had significantly shorter onset of coagulation and greater strength; however, when administered after envenomation, there was no differences between the two types of fibrinogen. Of interest, when administered after envenomation, both types of fibrinogen delayed the onset of coagulation while increasing plasma clot strength, a mixed effect likely secondary to formation of fibrinogen degradation products. Further preclinical investigations are needed to further define the benefits and risks of the use of fibrinogenolytic enzymes as defibrinogenating agents, as well as the risks of the "biochemical brakes" used to modulate the activity or substrate of the fibrinogenolytic enzyme.
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Affiliation(s)
- Vance G Nielsen
- Department of Anesthesiology, The University of Arizona College of Medicine, 1501 North Campbell Avenue, P.O. Box 245114, Tucson, AZ, 85724-5114, USA.
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Wilkins D, Burns DS, Wilson D, Warrell DA, Lamb LEM. Snakebites in Africa and Europe: a military perspective and update for contemporary operations. J ROY ARMY MED CORPS 2018; 164:370-379. [PMID: 29626137 DOI: 10.1136/jramc-2017-000883] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 11/20/2017] [Indexed: 11/04/2022]
Abstract
Snakebite envenoming is rare among military patients, with few cases reported in recent years. Increasingly, however, military operations are taking place in remote parts of Africa, which are inhabited by numerous species of venomous snake, and in Europe, where dangerous species exist but are less common. Bites from a venomous snake may prove fatal, and therefore military medics must be adequately prepared to manage them. This paper reviews the most medically significant species of venomous snake present in Africa and Europe, before suggesting an evidence-based approach to snakebite prevention and management, including possible changes to the UK's Clinical Guidelines for Operations.
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Affiliation(s)
- Daniel Wilkins
- Royal Army Medical Corps, 3 Medical Regiment, Preston, UK
| | - D S Burns
- Department of Infection and Tropical Medicine, Heartlands Hospital, Birmingham, UK.,Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - D Wilson
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK.,Respiratory Medicine, University Hospital Birmingham, Birmingham, UK
| | - D A Warrell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - L E M Lamb
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK.,Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK
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Laureano M, Crowther M. Severe coagulopathy after a massasauga rattlesnake bite. CMAJ 2018; 190:E191-E194. [PMID: 29565019 DOI: 10.1503/cmaj.170783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Marissa Laureano
- Departments of Medicine (Laureano), and Pathology and Molecular Medicine (Laureano, Crowther), Faculty of Health Sciences, McMaster University, Hamilton, Ont.
| | - Mark Crowther
- Departments of Medicine (Laureano), and Pathology and Molecular Medicine (Laureano, Crowther), Faculty of Health Sciences, McMaster University, Hamilton, Ont
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Yankin I, Schaer M, Johnson M, Meland T, Londoño LA. Persistent pit viper envenomation in a cat. JFMS Open Rep 2017; 3:2055116917737463. [PMID: 29123914 PMCID: PMC5661758 DOI: 10.1177/2055116917737463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Case summary A 4-year-old female spayed, indoor/outdoor domestic mediumhair cat presented with multiple bleeding puncture wounds and hemorrhagic shock. The cat was diagnosed with suspected pit viper envenomation based on the location and appearance of the bite wounds, as well as the presence of severe coagulopathy with prolonged activated coagulation time (762 s), which responded to antivenom administration. The clinical course of the cat was unique owing to the prolonged clinical signs of envenomation that appeared as intermittent coagulopathy and hemorrhage over a 2 week period. Five vials of antivenom were administered and three units of packed red blood cells were transfused over a 7 day period. The cat made a complete recovery with cessation of hemorrhage and normalization of clotting times. Relevance and novel information This is the first report of persistent pit viper venom-induced coagulopathy in the feline veterinary literature.
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Affiliation(s)
| | | | | | | | - Leonel A Londoño
- Leonel A Londoño DVM, DACVECC, Department of Small Animal Clinical Sciences, University of Florida, 2015 SW 16th Ave, PO Box 100126, Gainesville, FL 326100126, USA
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Delayed hematologic toxicity following rattlesnake envenomation unresponsive to crotalidae polyvalent antivenom. Am J Emerg Med 2017; 35:1038.e1-1038.e2. [DOI: 10.1016/j.ajem.2017.02.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 02/25/2017] [Indexed: 11/22/2022] Open
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Vestberg AR, Tidholm A, Ljungvall I. Twenty-four-hour ambulatory electrocardiography characterization of heart rhythm in Vipera berus-envenomed dogs. Acta Vet Scand 2017; 59:28. [PMID: 28468664 PMCID: PMC5415709 DOI: 10.1186/s13028-017-0296-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/28/2017] [Indexed: 11/12/2022] Open
Abstract
Background Vipera berus has a worldwide distribution and causes high morbidity in dogs annually. A complication to envenomation may be cardiac arrhythmias. The purpose of this study was to investigate the prevalence, types, and timing of arrhythmias, using 24-h ambulatory electrocardiography (24-AECG), in dogs bitten by V. berus in the first 24–32 h after envenomation. In addition, this study aimed to investigate if there were differences in selected clinical and hematological- and biochemical variables (including cardiac troponin I) at admission between V. berus-envenomed dogs with and without detected pathologic arrhythmias. Seventeen prospectively recruited client-owned dogs acutely envenomed by V. berus, were therefore examined clinically and echocardiographically, sampled for blood, hospitalized, and monitored by 24-AECG. Results Clinically significant pathologic arrhythmias in this study were of ventricular origin, such as frequent single ventricular premature contractions (VPCs) and couplets of VPCs, episodes of ventricular tachycardia and idioventricular rhythm, and “R-on-T phenomenon”. Variations of these arrhythmias were detected by 24-AECG in eight (47%) of included dogs. No arrhythmias were detected by cardiac auscultation. Twenty-four hours following envenomation, four out of eight dogs experienced decreases (all P < 0.039), and three out of eight dogs experienced increases (all P < 0.034), in arrhythmic episodes. All four dogs bitten on a limb developed pathologic arrhythmias. Otherwise, no significant differences in clinical, hematological or biochemical variables were seen between dogs with pathologic arrhythmias and those without. Conclusion Forty-seven percent of dogs bitten by V. berus included in this study experienced pathologic arrhythmias of abnormal ventricular depolarization. During the first 24–32 h from the snakebite, some dogs experienced a decrease in arrhythmic episodes and others an increase in arrhythmic episodes. These findings indicate a potential value of repeated or prolonged electrocardiography monitoring of envenomed dogs for identification of which dogs that might benefit the most from prolonged hospitalization for optimal monitoring and treatment of cardiac abnormalities. In the present study, dogs that developed arrhythmias could not be differentiated from dogs that did not based on clinical findings or hematological or biochemical variables obtained at admission.
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Lasoff DR, Ruha AM, Curry SC, Koh C, Clark RF. A new F(abʹ) 2 antivenom for the treatment of crotaline envenomation in children. Am J Emerg Med 2016; 34:2003-2006. [DOI: 10.1016/j.ajem.2016.07.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/25/2016] [Accepted: 07/29/2016] [Indexed: 12/24/2022] Open
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Kanaan NC, Ray J, Stewart M, Fuller M, Martin Caravati E, Russell KW, Bush SP, Cardwell MD, Norris RL, Weinstein SA. In Reply to Drs Boyer and Ruha. Wilderness Environ Med 2016; 27:342-4. [DOI: 10.1016/j.wem.2015.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/15/2015] [Indexed: 11/26/2022]
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Boyer LV, Ruha AM. Pitviper Envenomation Guidelines Should Address Choice Between FDA-approved Treatments for Cases at Risk of Late Coagulopathy. Wilderness Environ Med 2016; 27:341-2. [PMID: 27079732 DOI: 10.1016/j.wem.2015.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 10/20/2015] [Accepted: 10/29/2015] [Indexed: 11/19/2022]
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Kanaan NC, Ray J, Stewart M, Russell KW, Fuller M, Bush SP, Caravati EM, Cardwell MD, Norris RL, Weinstein SA. Wilderness Medical Society Practice Guidelines for the Treatment of Pitviper Envenomations in the United States and Canada. Wilderness Environ Med 2015; 26:472-87. [DOI: 10.1016/j.wem.2015.05.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 05/12/2015] [Accepted: 05/27/2015] [Indexed: 10/22/2022]
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Recurrent coagulopathy after rattlesnake bite requiring continuous intravenous dosing of antivenom. Case Rep Emerg Med 2015; 2015:719302. [PMID: 25664187 PMCID: PMC4309308 DOI: 10.1155/2015/719302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 12/20/2014] [Indexed: 11/26/2022] Open
Abstract
Context. Snakebite envenomation is common and may result in systemic coagulopathy. Antivenom can correct resulting laboratory abnormalities; however, despite antivenom use, coagulopathy may recur, persist, or result in death after a latency period. Case Details. A 50-year-old previously healthy man presented to the emergency department after a rattlesnake bite to his right upper extremity. His presentation was complicated by significant glossal and oropharyngeal edema requiring emergent cricothyrotomy. His clinical course rapidly improved with the administration of snake antivenom (FabAV); the oropharyngeal and upper extremity edema resolved within several days. However, over the subsequent two weeks, he continued to have refractory coagulopathy requiring multiple units of antivenom. The coagulopathy finally resolved after starting a continuous antivenom infusion. Discussion. Envenomation may result in latent venom release from soft tissue depots that can last for two weeks. This case report illustrates the importance of close hemodynamic and laboratory monitoring after snakebites and describes the administration of continuous antivenom infusion, instead of multidose bolus, to neutralize latent venom release and correct residual coagulopathy.
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Clark RF, O'Connell CW, Villano JH, Kim A, Ly BT, Minns AB. Severe recurrent coagulopathy following crotaline envenomation refractory to maintenance dosing of antivenom. Am J Emerg Med 2014; 33:856.e3-5. [PMID: 25524360 DOI: 10.1016/j.ajem.2014.11.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022] Open
Affiliation(s)
- Richard F Clark
- UCSD Department of Emergency Medicine; UCSD Division of Medical Toxicology.
| | - Charles W O'Connell
- UCSD Department of Emergency Medicine; UCSD Division of Medical Toxicology; Veteran Association San Diego Health System, San Diego, CA
| | - Janna H Villano
- UCSD Department of Emergency Medicine; UCSD Division of Medical Toxicology; Veteran Association San Diego Health System, San Diego, CA
| | - Andrew Kim
- UCSD Department of Pediatric Critical Care
| | - Binh T Ly
- UCSD Department of Emergency Medicine; UCSD Division of Medical Toxicology
| | - Alicia B Minns
- UCSD Department of Emergency Medicine; UCSD Division of Medical Toxicology
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Weinstein SA. The pharmacotherapy for pit viper envenoming in the United States: A brief retrospective on roots, recurrence, and risk. Clin Toxicol (Phila) 2014; 53:1-4. [DOI: 10.3109/15563650.2014.983240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bush SP, Ruha AM, Seifert SA, Morgan DL, Lewis BJ, Arnold TC, Clark RF, Meggs WJ, Toschlog EA, Borron SW, Figge GR, Sollee DR, Shirazi FM, Wolk R, de Chazal I, Quan D, García-Ubbelohde W, Alagón A, Gerkin RD, Boyer LV. Comparison of F(ab')2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial. Clin Toxicol (Phila) 2014; 53:37-45. [PMID: 25361165 PMCID: PMC4364250 DOI: 10.3109/15563650.2014.974263] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background. Crotalidae Polyvalent Immune Fab (Ovine) has been the only antivenom commercially available in the US since 2007 for treatment of Crotalinae envenomation. Late coagulopathy can occur or recur after clearance of Fab antivenom, often after hospital discharge, lasting in some cases more than 2 weeks. There have been serious, even fatal, bleeding complications associated with recurrence phenomena. Frequent follow-up is required, and additional intervention or hospitalization is often necessary. F(ab')2 immunoglobulin derivatives have longer plasma half life than do Fab. We hypothesized that F(ab')2 antivenom would be superior to Fab in the prevention of late coagulopathy following treatment of patients with Crotalinae envenomation. Methods. We conducted a prospective, double-blind, randomized clinical trial, comparing late coagulopathy in snakebitten patients treated with F(ab')2 with maintenance doses [F(ab')2/F(ab')2], or F(ab')2 with placebo maintenance doses [F(ab')2/placebo], versus Fab with maintenance doses [Fab/Fab]. The primary efficacy endpoint was coagulopathy (platelet count < 150 K/mm3, fibrinogen level < 150 mg/dL) between end of maintenance dosing and day 8. Results. 121 patients were randomized at 18 clinical sites and received at least one dose of study drug. 114 completed the study. Of these, 11/37 (29.7%) in the Fab/Fab cohort experienced late coagulopathy versus 4/39 (10.3%, p < 0.05) in the F(ab')2/F(ab')2 cohort and 2/38 (5.3%, p < 0.05) in the F(ab')2/placebo cohort. The lowest heterologous protein exposure was with F(ab')2/placebo. No serious adverse events were related to study drug. In each study arm, one patient experienced an acute serum reaction and one experienced serum sickness. Conclusions. In this study, management of coagulopathic Crotalinae envenomation with longer-half-life F(ab')2 antivenom, with or without maintenance dosing, reduced the risk of subacute coagulopathy and bleeding following treatment of envenomation.
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Affiliation(s)
- Sean P Bush
- East Carolina University Brody School of Medicine/Vidant Medical Center , Greenville, NC , USA
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Hifumi T, Sakai A, Yamamoto A, Murakawa M, Ato M, Shibayama K, Ginnaga A, Kato H, Koido Y, Inoue J, Abe Y, Kawakita K, Hagiike M, Kuroda Y. Clinical characteristics of yamakagashi (Rhabdophis tigrinus) bites: a national survey in Japan, 2000-2013. J Intensive Care 2014; 2:19. [PMID: 25908983 PMCID: PMC4407547 DOI: 10.1186/2052-0492-2-19] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 02/21/2014] [Indexed: 11/24/2022] Open
Abstract
Background Yamakagashi (Rhabdophis tigrinus) is a species of pit viper present throughout Russia and Eastern Asia. Although R. tigrinus venom is known to induce life-threatening hemorrhagic symptoms, the clinical characteristics and effective treatment of R. tigrinus bites remain unknown. The present study aimed to clarify these issues. Methods Records in the Japan Snake Institute between 2000 and 2013 were retrospectively investigated. The following were determined: patient characteristics, coagulation and fibrinolytic system abnormalities, effect of antivenom treatment, and outcomes. Results Nine patients (all males; median age, 38 years) with R. tigrinus bites were identified. On admission, the median levels of fibrinogen and fibrinogen degradation products, and platelet counts were 50 mg/dL, 295 μg/mL, and 107,000/mm3, respectively. The median (minimum–maximum) disseminated intravascular coagulation (DIC) score defined by the Japanese Association of Acute Medicine was 8 (1–8). Antivenom was administered to seven patients, with a median interval of 35 h between bite and antivenom administration. All patients treated with antivenom survived, and the in-hospital mortality rate was 11%. Conclusions Patients with R. tigrinus bites presented with DIC of a fibrinolytic phenotype, which can result in life-threatening injury unless appropriate antivenom and DIC treatment are provided.
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Affiliation(s)
- Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, Toru Hifumi, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793 Japan
| | - Atsushi Sakai
- Japan Snake Institute, 3318 Yabutsuka, Ota, Gunma, 379-2301 Japan
| | - Akihiko Yamamoto
- Department of Bacteriology II, National Institute of Infectious Disease, Gakuen 4-7-1, Musashimurayama-shi, Tokyo, 208-0011 Japan
| | - Masahiro Murakawa
- Department of Internal Medicine, Kaizuka Hospital, Hakosaki 7-7-27, Higashi-kuFukuoka, 812-0053 Japan
| | - Manabu Ato
- Department of Immunology, National Institute of Infectious Disease, Toyama 1-23-1, Shinjuku-ku, Tokyo, 162-8640 Japan
| | - Keigo Shibayama
- Department of Bacteriology II, National Institute of Infectious Disease, Gakuen 4-7-1, Musashimurayama-shi, Tokyo, 208-0011 Japan
| | - Akihiko Ginnaga
- The Chemo-Sero-Therapeutic Research Institute (KAKETSUKEN), 1-6-1 Okubo, Kita-ku, Kumamoto-shi, Kumamoto, 860-8568 Japan
| | - Hiroshi Kato
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014 Japan
| | - Yuichi Koido
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014 Japan
| | - Junichi Inoue
- Division of Critical Care Medicine and Trauma, Yamanashi Prefectural Central Hospital, 1-1-1 Fujimi, Kofu, Yamanashi, 400-8506 Japan
| | - Yuko Abe
- Emergency Medical Center, Kagawa University Hospital, Toru Hifumi, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793 Japan
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Toru Hifumi, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793 Japan
| | - Masanobu Hagiike
- Emergency Medical Center, Kagawa University Hospital, Toru Hifumi, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793 Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, Toru Hifumi, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793 Japan
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Boyer LV, Chase PB, Degan JA, Figge G, Buelna-Romero A, Luchetti C, Alagón A. Subacute coagulopathy in a randomized, comparative trial of Fab and F(ab')2 antivenoms. Toxicon 2013; 74:101-8. [PMID: 23948058 DOI: 10.1016/j.toxicon.2013.07.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 07/18/2013] [Accepted: 07/25/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Envenomation by pit vipers is associated with coagulation disorders including hypofibrinogenemia and thrombocytopenia. These abnormalities correct following antivenom treatment during the acute phase of the disease. Delayed or recurrent coagulation abnormalities have been reported following use of Fab antivenom, resulting in risk of hemorrhage or death. METHODS We hypothesized that the longer plasma persistence of F(ab')2 antivenom, relative to Fab, in patients at risk of coagulopathy would result in decreased venonemia and coagulopathy one week after treatment. We conducted a Phase 2, randomized comparative clinical trial of rattlesnake bitten adults presenting for care in Tucson, Arizona, USA. Patients were randomly assigned to receive either Fab or F(ab')2 antivenom using a predefined treatment schedule. Endpoints included platelet counts, fibrinogen levels, and venom and antivenom ELISAs. Measurements were conducted at baseline and at various times over the following two weeks. RESULTS Twelve patients were studied, with 6 randomly assigned to each treatment group. Early response of platelet counts, fibrinogen, and venom levels to acute treatment was similar in the two groups. One week following treatment, platelet counts and fibrinogen levels were lower in the Fab group than in the F(ab')2 group, following a characteristic pattern that reached its lowest point approximately one week after initial treatment. Venom levels dropped below detection limits in all patients following initial treatment but subsequently rebounded into the measurable range in 4 of 6 Fab cases. F(ab')2 antivenom levels demonstrated a longer plasma persistence than Fab levels, with a less rapid drop during the two days following treatment. Two patients in the Fab group had significant adverse events involving coagulation abnormalities, for which additional antivenom was administered following the initial treatment period. CONCLUSIONS Following the acute phase of presentation and treatment for pit viper envenomation, there appears to be a roughly 2-week subacute phase of the disease during which ongoing presence of venom may result in serious delayed or recurrent coagulation defects. Late hypofibrinogenemia and thrombocytopenia are associated with recurrent venonemia and drop in antivenom levels. This pattern was apparent in patients treated with Fab antivenom but was not seen among F(ab')2 recipients in this Phase 2 study, consistent with pharmacokinetic differences between the two products. Improved understanding of Fab pharmacokinetics is important for the management of coagulopathy-prone pit viper envenomation. Use of F(ab')2 antivenom may prevent recurrent venom effects, but larger studies are necessary for statistical confirmation of this observation.
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Assessing the preclinical efficacy of antivenoms: From the lethality neutralization assay to antivenomics. Toxicon 2013. [DOI: 10.1016/j.toxicon.2012.11.016] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Carstairs SD, Kreshak AA, Tanen DA. Crotaline Fab antivenom reverses platelet dysfunction induced by Crotalus scutulatus venom: an in vitro study. Acad Emerg Med 2013; 20:522-5. [PMID: 23672368 DOI: 10.1111/acem.12135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 10/22/2012] [Accepted: 11/15/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients sustaining rattlesnake envenomation often develop thrombocytopenia, the etiology of which is not clear. Laboratory studies have demonstrated that venom from several species, including the Mojave rattlesnake (Crotalus scutulatus scutulatus), can inhibit platelet aggregation. In humans, administration of crotaline Fab antivenom has been shown to result in transient improvement of platelet levels; however, it is not known whether platelet aggregation also improves after antivenom administration. OBJECTIVES The objective was to determine the effect of C. scutulatus venom on platelet aggregation in vitro in the presence and absence of crotaline Fab antivenom. METHODS Blood was obtained from four healthy male adult volunteers not currently using aspirin, nonsteroidal anti-inflammatory drugs, or other platelet-inhibiting agents. C. scutulatus venom from a single snake with known type B (hemorrhagic) activity was obtained from the National Natural Toxins Research Center. Measurement of platelet aggregation by an aggregometer was performed using five standard concentrations of epinephrine (a known platelet aggregator) on platelet-rich plasma over time, and a mean area under the curve (AUC) was calculated. Five different sample groups were measured: 1) blood alone, 2) blood + C. scutulatus venom (0.3 mg/mL), 3) blood + crotaline Fab antivenom (100 mg/mL), 4) blood + venom + antivenom (100 mg/mL), and 5) blood + venom + antivenom (4 mg/mL). Standard errors of the mean (SEM) were calculated for each group, and paired t-tests were used to measure differences between groups. RESULTS Antivenom administration by itself (group 2) did not significantly affect platelet aggregation compared to baseline (103.8%, SEM ± 3.4%, p = 0.47). Administration of venom (group 3) decreased platelet aggregation (72.0%, SEM ± 8.5%, p < 0.05). Concentrated antivenom administration in the presence of venom (group 4) normalized platelet aggregation (101.4%, SEM ± 6.8%) and in the presence of diluted antivenom (group 5) significantly increased aggregation (133.9%, SEM ± 9.0%; p < 0.05 for both groups when compared to the venom-only group). To further assess the effects of the venom and antivenom, each was run independently in platelet-rich plasma without epinephrine; neither was found to significantly alter platelet aggregation in the absence of epinephrine. CONCLUSIONS Crotaline Fab antivenom improved platelet aggregation in an in vitro model of platelet dysfunction induced by venom from C. scutulatus. It is unclear at this time whether this improvement in platelet dysfunction translates into improved clinical outcomes in envenomated patients.
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Affiliation(s)
| | | | - David A. Tanen
- Department of Emergency Medicine; Naval Medical Center; San Diego; CA
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Lavonas EJ, Khatri V, Daugherty C, Bucher-Bartelson B, King T, Dart RC. Medically significant late bleeding after treated crotaline envenomation: a systematic review. Ann Emerg Med 2013; 63:71-78.e1. [PMID: 23567063 DOI: 10.1016/j.annemergmed.2013.03.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 02/06/2013] [Accepted: 03/04/2013] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE We estimate the proportion of patients with crotaline snake envenomation who are treated with Crotalidae polyvalent immune Fab (ovine) antivenom and who develop medically significant late bleeding. METHODS We performed a systematic review of all published cohort studies of North American crotaline snake envenomation patients treated with Fab antivenom. We searched PubMed, Ovid MEDLINE, and EMBASE from January 1, 1997, to April 30, 2012. Data were extracted by 2 trained researchers. Late bleeding was defined as bleeding that began or recurred after initial control of the envenomation syndrome. Medically significant late bleeding was defined a priori as late bleeding treated with RBC transfusion, vasoactive drug infusion, surgery, or rehospitalization or associated with a hemoglobin decrease of greater than or equal to 3 g/dL, hematocrit decrease of greater than or equal to 8%, disability, or death. Summary incidence and 95% confidence intervals (CIs) were calculated with a random-effects Poisson regression model. RESULTS Nineteen unique cohort studies were identified. Four studies collected data prospectively, and in 9 studies, patients were followed actively after hospital discharge. A total of 1,017 subjects were enrolled in these cohort studies. Late bleeding was reported in 9 subjects (0.9%; 95% CI 0.4% to 2.2%), of whom 5 subjects (0.5%; 95% CI 0.1% to 1.7%) had medically significant late bleeding. Three patients received RBC transfusion; no deaths or permanent sequelae were reported. Estimates of risk may be affected by underreporting. CONCLUSION Medically significant late bleeding appears to be uncommon in snakebite victims treated with Fab antivenom.
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Affiliation(s)
- Eric J Lavonas
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Vaishali Khatri
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO
| | | | | | - Thomas King
- BTG International, Inc., West Conshohocken, PA
| | - Richard C Dart
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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