Severe myonecrosis in a fatal case of envenomation by the canebrake rattlesnake (Crotalus horridus atricaudatus)

Timber rattlesnake (Crotalus horridus): Biology, conservation, and envenomation in the Upper Mississippi River Valley (1982-2020)

The Timber Rattlesnake (Crotalus horridus) is the largest pit viper in the Northern United States and is the prominent venomous snake species indigenous to the bluff land habitats of the Upper Mississippi River Valley (UMRV). Conservation of C. horridus in this geographic region not only preserves the ecosystem's biodiversity and ecological balance, but also assures the continued study of their biomedically important venoms/toxins. Field studies of C. horridus biology and natural history performed from 1985 to 2015 in southeastern Minnesota and western Wisconsin along the Mississippi River showed populations have declined. Consequently, the implementation of improved conservation measures afforded the species protective status in both states. Historically, accounts of Timber Rattlesnake bites in the UMRV have been sparse, and medical consequences of envenomation have had limited documentation. However, in recent decades cases of envenomation by C. horridus have continued to occur. Retrospective analysis of clinical toxinology consultations documented from 1982 to 2020 on cases of envenomation by C. horridus in the UMRV revealed a very low incidence of bites annually and revealed that their venom can induce a rapid and precipitous decline in platelets.

Snakebite Envenoming a Challenging Diagnosis for the Forensic Pathologist: A Systematic Review

Snakebite envenoming (SBE) is a public health issue in developing countries. The estimated annual global incidence of snakebites is about 5.4 million snakebites per year, resulting from 1.8 to 2.7 million cases of SBE and from 81,000 to 138,000 deaths with 400,000 survivors suffering permanent physical and psychological disabilities. There are more than 3000 species of snakes around the world: 600 are venomous and over 200 are considered to be medically important because of their clinical effects. The severity of SBE depends on several factors among which bite localization, snake's size, condition of glands and teeth, bite angle and bite duration, the microflora of the snake's mouth and victim's skin, age of the victim, weight, health status, and victim's activity after a bite. Snake venoms are mixtures of protein families, and each of these families contains many different toxins or toxin isoforms. Based on their effects, snake venoms can be classified as hemotoxic, neurotoxic, or cytotoxic and they can all act together involving multiple tissues and organs. When the bite is fatal, the mechanism of death is primarily related to the paralysis of respiratory muscles, which causes asphyxia and hypoxic-ischemic encephalopathy, but also anaphylactic shock, hemorrhagic shock, cardiomyopathy, acute tubular necrosis (ATN). The purpose of this literature review is to evaluate epidemiological and post-mortem examination findings in fatal SBEs in order to better understand the pathophysiological mechanisms, thus helping pathologists in defining the correct diagnosis.

Translational derepression of Elavl4 isoforms at their alternative 5' UTRs determines neuronal development

Neurodevelopment requires precise regulation of gene expression, including post-transcriptional regulatory events such as alternative splicing and mRNA translation. However, translational regulation of specific isoforms during neurodevelopment and the mechanisms behind it remain unknown. Using RNA-seq analysis of mouse neocortical polysomes, here we report translationally repressed and derepressed mRNA isoforms during neocortical neurogenesis whose orthologs include risk genes for neurodevelopmental disorders. We demonstrate that the translation of distinct mRNA isoforms of the RNA binding protein (RBP), Elavl4, in radial glia progenitors and early neurons depends on its alternative 5' UTRs. Furthermore, 5' UTR-driven Elavl4 isoform-specific translation depends on upstream control by another RBP, Celf1. Celf1 regulation of Elavl4 translation dictates development of glutamatergic neurons. Our findings reveal a dynamic interplay between distinct RBPs and alternative 5' UTRs in neuronal development and underscore the risk of post-transcriptional dysregulation in co-occurring neurodevelopmental disorders.

Fatal Envenomations - Snakes and Other Creatures

Envenomations by toxic creatures is a global health problem with an annual mortality from snake envenomation of over 125,000 cases. While various snake species bites are the most commonly encountered fatal envenomation, scorpions, spiders and marine creatures can all cause fatalities. Although venomous creatures have specific geographical habitats, the keeping of exotic pets and modern transportation, along with venomous collections in zoos, means that fatal envenomations may be encountered in non-endemic areas. There are a variety of toxins that may be encountered including neurotoxins, proteases, and myotoxins that will result in a variable amount of tissue damage depending upon the species involved and the toxin they carry. The autopsy findings may be relatively nonspecific and a careful search of the skin may be required to identify the envenomation site, along with a consideration of the history and the scene. External and internal damage will vary with the specific toxin. This paper reviews fatal envenomations, the toxinology and likely autopsy findings.

Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop

BACKGROUND

Envenomation by crotaline snakes (rattlesnake, cottonmouth, copperhead) is a complex, potentially lethal condition affecting thousands of people in the United States each year. Treatment of crotaline envenomation is not standardized, and significant variation in practice exists.

METHODS

A geographically diverse panel of experts was convened for the purpose of deriving an evidence-informed unified treatment algorithm. Research staff analyzed the extant medical literature and performed targeted analyses of existing databases to inform specific clinical decisions. A trained external facilitator used modified Delphi and structured consensus methodology to achieve consensus on the final treatment algorithm.

RESULTS

A unified treatment algorithm was produced and endorsed by all nine expert panel members. This algorithm provides guidance about clinical and laboratory observations, indications for and dosing of antivenom, adjunctive therapies, post-stabilization care, and management of complications from envenomation and therapy.

CONCLUSIONS

Clinical manifestations and ideal treatment of crotaline snakebite differ greatly, and can result in severe complications. Using a modified Delphi method, we provide evidence-informed treatment guidelines in an attempt to reduce variation in care and possibly improve clinical outcomes.

Absence of phospholipase A(2) in most Crotalus horridus venom due to translation blockage: comparison with Crotalus horridus atricaudatus venom

To investigate the peculiar absence of phospholipases A(2) (PLA(2)s) in most Crotalus horridus (CH) venom, we cloned and sequenced the venom PLA(2)s of three CH specimens from different regions. The results revealed that all the venom glands contained mRNAs that encoded an acidic PLA(2) (designated as either CH-E6 or CH-E6'). The predicted CH-E6 from the Iowan CH and CH-E6' from the South Carolinian CH differed by only one amino acid residue, while the PLA(2) cDNA cloned from the Kentuckian CH contained an early stop codon instead of a Tyr(22) codon. Only the individual South Carolinian CH venom was found to contain the CH-E6' protein whose mass was confirmed by MALDI-TOF analysis. Our results suggest that low PLA(2) expression levels in most CH venom can be attributed to translation blockage. We also purified two acidic PLA(2)s and canebrake toxin from the pooled venom of Crotalus horridus atricaudatus (neurotoxic CH subspecies). One of the acidic PLA(2)s was identical to CH-E6 and showed high lipolytic activity and weak anti-platelet activities. The possibility that C. h. atricaudatus could be a hybrid between CH and Crotalus scutulatus is discussed.

Envenomations

Numerous types of envenomations may be encountered by health care workers depending on where in North America they work. Clinicians should be familiar with the animals in their region that may lead to envenomation.A rational approach with use of poison center or medical toxicology consultation services ensures that cases are managed appropriately.

The efficacy of two antivenoms against the in vitro myotoxic effects of black snake (Pseudechis) venoms in the chick biventer cervicis nerve-muscle preparation

Neurotoxicity is rarely seen following human systemic envenoming by Australasian black snakes (genus Pseudechis) with myotoxicity being the most prominent feature following bites by some species. This study investigated the in vitro myotoxicity of venoms from seven species of Australasian Pseudechis and determined the efficacy of CSL black and tiger snake antivenoms. All Pseudechis venoms (10 microg/ml) significantly inhibited direct twitches of the chick biventer cervicis nerve-muscle preparation (p<0.05, one-way ANOVA). Prior addition of black snake antivenom (5 U/ml) prevented the inhibitory effects of all Pseudechis venoms (p<0.05, one-way ANOVA), except Pseudechis butleri. Prior addition of tiger snake antivenom (5 U/ml) prevented the venom-induced reduction in direct twitches to Notechis scutatus venom and all Pseudechis venoms (p<0.05, one-way ANOVA), with the exception of Pseudechis australis and Pseudechis colletti venoms. Black or tiger snake antivenom (5 U/ml) added 1 h after the addition of venom inhibited further reduction of direct twitches by N. scutatus and most Pseudechis venoms, but did not significantly restore twitch height. PLA2 activity was found in all venoms with the following rank order: Pseudechis porphyriacus>P. australis>Pseudechis papuanus>P. butleri>Pseudechis guttatus> or =Pseudechis pailsii>P. colletti>N. scutatus. The results of the present study suggest that Australasian Pseudechis venoms possess variable myotoxic activity. The ability of black or tiger snake antivenom to prevent or inhibit further venom-induced effects varied across the genus.

Absence of myocardial involvement in children victims of Crotalus durissus terrificus envenoming

The myotoxic activity of the venom of Crotalus durissus terrificus is demonstrable by increased serum levels of the enzymes creatine kinase (CK), lactate dehydrogenase (LD), and aspartate aminotransferase. Serial measurements of CK, LD and their isoenzymes in bite victims showed a pattern similar to that observed in acute myocardial infarction, although the clinical course and electro- and echocardiographic data did not suggest cardiac involvement. These data have raised the hypothesis that crotalid venom preferentially causes damage to type I and/or type IIa fibers, which contain quantities of CK-MB and LD1 similar to those found in cardiac fibers. In order to detect a possible concomitant silent cardiac involvement, seven children with severe crotalid envenoming were studied. Serum troponin I, determined more than once in each patient, were found to be normal. These data demonstrate the absence of cardiac involvement in these patients envenomed by C. durissus terrificus and confirmed the skeletal muscle origin of the elevated CK-MB.

Envenomations

Envenomations are uncommon, challenging causes of critical care admissions. This article describes the diagnosis and treatment of envenomations that cause the most critical care admissions in the United States. Most are caused by the following animals: rattlesnakes, copperheads, cottonmouths, coral snakes, brown recluse spiders, and bark scorpions.

Crotalid snake envenomation

Over 5000 Americans suffer from snake bites annually, and of these, nearly one quarter are from poisonous species. Although these cases are undeniably reported, death appears to occur in only a few cases each year, and often reflects delay in obtaining medical care. Two families of venomous snake indigenous to the United States account for most envenomations: Crotalidae (pit vipers or new world vipers) and Elapidae. This article focuses on the snakes of the Crotalidae family.

Canebrake rattlesnake envenomation

STUDY OBJECTIVE

To document the clinical presentation and course of consecutive cases of envenomation by the canebrake rattlesnake (Crotalus horridus atricaudatus).

METHODS

The medical care provided all patients envenomated by canebrake rattlesnakes in two institutions was retrospectively reviewed. Particular attention was paid to coagulation abnormalities, serum enzymes, electrocardiographic findings, and treatment with antivenom.

RESULTS

Of the 15 patients, envenomation was judged to be mild in 3, moderate in 6, and severe in 5. In one case envenomation caused death. The clinical course generally predicted the degree of increase in the serum creatinine kinase (CK) level, as well as the amount of antivenom used for treatment. Despite increases in serum CK concentration and frequent increases in the serum CK-MB fraction, we found no evidence of cardiac damage.

CONCLUSION

In envenomation by North American pit vipers, rhabdomyolysis appears to be characteristic of envenomation by the canebrake rattlesnake. We speculate that toxins in the canebrake venom cause skeletal muscle rhabdomyolysis. Physicians caring for victims of canebrake bite should regard marked increases in CK concentration as coming from skeletal, not cardiac, muscle. Good general medical support and antivenom for victims with moderate to severe envenomation appears effective.

Intraarticular envenomation by Trimeresurus flavomaculatus mcgregori resulting in joint destruction

This article reports a case of digital intraarticular envenomation from a T. flavomaculatus mcgregori pit viper resulting in severe joint damage. Bites by these snakes are rare in the U.S.A. since this species is only found in collections and zoos. Intraarticular envenomations from crotalids are rare and may result in joint destruction.

Protective effects of tannic acid and related natural compounds on Crotalus adamenteus subcutaneous poisoning in mice

The plant natural products namely tannic acid and the flavonoids luteolin, kaempferol and apigenin exerted potent inhibition on the hyaluronidase enzyme. They were able to neutralize the haemorrhage induced by Crotalus adamenteus venom in mice dose-dependently from 0.12-2.4 mg/kg subcutaneously. In addition, they were able to antagonize the lethal activity of the venom when injected subcutaneously into mice and the order of potency was: tannic acid >> luteolin = kaempferol > apigenin. Tannic acid (24 mg/kg, subcutaneously) was able to reduce significantly the venom-induced elevation of blood creatine kinase activity. It could also prolong the survival time(s) of mice, when injected immediately after the administration of venom. Experimental evidence is presented for the first time that malondialdehyde in liver and kidney is significantly elevated as a result of rattlesnake venom poisoning and that this effect can be controlled by tannic acid.

[Crotalid bites in children: clinical, laboratory, epidemiologic aspects and treatment approach]

At the Hospital of Clinics of the Faculty of Medicine of Ribeirão Preto/USP during the years 1980-1989 21 children have been attended after rattlesnake bite: 16 severe and 5 with moderate envenomation. Four (20%) developed acute tubular necrosis 2 necessitating dialysis. One patient died 13 days after the bite and grave complications including digestive hemorrhage and acute respiratory insufficiency. All patients preserved clinical laboratory and epidemiological characteristics of Crotalus durissus terrificus envenomation. We also comment on the correct management of such patients specially related to antivenin dosage and the prevention of acute tubular the most serious complication of such an accident.

Acute myocardial infarction-like enzyme profile in human victims of Crotalus durissus terrificus envenoming

The clinical signs and symptoms of Crotalus durissus terrificus envenoming are due to the neurotoxic, myotoxic systemic and thrombin-like coagulating effects of the venom. The rhabdomyolysis observed after envenoming caused by snakes, the venom of which has a systemic myotoxic activity, has been limited thus far to skeletal muscle, with no reports of myocardial damage. In the present paper we report serial measurements of serum creatine kinase (CK), lactic dehydrogenase (LD) and of CK-MB and LD1 isoenzymes in human victims of Crotalus bites. The results were similar to those reported for acute myocardial infarction even though the clinical evolution, electrocardiogram and echocardiogram findings did not show any involvement of cardiac muscle. The enzymatic profile detected, as well as the pattern of focal involvement observed in muscle biopsies obtained from these patients, suggest that there may be a type of skeletal muscle fibre that is preferentially damaged by C. durissus terrificus venom, i.e., type I and/or IIa fibres, the composition of which is richer in CK-MB and LD1, and is similar to that of cardiac fibres.

Muscle necrosis caused by snake venoms and toxins

Snake bite is often associated with localised soft tissue necrosis. Less frequently victims may suffer extensive muscle damage leading to rhabdomyolysis and the loss of muscle-specific protein. This review describes the organisation and structure of mammalian skeletal muscle, and its response to myotoxic venoms and to isolated pure myotoxic venom fractions. The clinical reports of muscle damage in man following snake bite are discussed, and the various classes of myotoxic toxins are introduced. Muscle damage caused by the toxins is next described, particular emphasis being placed on the correlation between muscle pathology seen at the light level and the morphological changes seen at the level of the electron microscope. Where known, those subcellular components of the muscle fibre that are especially sensitive to assault, and those components that appear to be spared, are identified. The relevance of the selective sparing of some components to the regenerative capacity of the skeletal muscle is considered.

Snake venoms in science and clinical medicine. 3. Neuropharmacological aspects of the activity of snake venoms

Neuromuscular weakness is a common feature of snake bite. The toxins responsible for weakness either block neuromuscular transmission or they are myotoxic and damage skeletal muscle. In this article the major classes of toxins responsible for causing neuromuscular weakness are described. It is shown how a detailed knowledge of the biochemical and pharmacological properties of the toxins is essential if the clinical problems associated with bites by many species are to be properly understood. It is also shown that such an understanding allows apparent discrepancies between 'laboratory' and 'clinical' findings to be resolved.

Snake envenomation. Incidence, clinical presentation and management

Snake envenomation is a major cause of death and disability in the developing countries, particularly India and Southeast Asia. Species variation in venom components, yield, and lethality leads to quite different clinical presentations and mortality. Venomous snakes are divided into 5 families. Bites of the Viperidae, Crotalidae and Colubridae usually cause primarily local effects and bleeding; the Elapidae most commonly cause neurological symptoms, particularly paralysis; while the Hydrophidae cause paralysis and myolysis. Venoms are complex mixtures of enzymes, peptides and metalloproteins. 26 enzymes have been identified, and 10 of those are found in most venoms. Components have been identified that act as procoagulants, anticoagulants, hyaluronidases, RNases, DNases, postsynaptic toxins and presynaptic toxins. Other peptides induce capillary leak syndrome, haemolysis and shock. The clinical results of envenomation vary widely, and there may be no envenomation with a bite. Syndromes reported include oedema, haemolysis, shock, bleeding, pituitary failure, renal failure, myonecrosis, and combinations of the above. First aid measures that have been proposed include tourniquets, constricting bands, tight crepe bandages, incision and suction, cryotherapy, and high voltage electric shock. None of these has been shown to be effective except usage of a crepe bandage for Australian elapid bite. Tourniquets or cryotherapy, if used for extended periods may lead to gangrene. The most important first aid measure is rapid transport to comprehensive medical care. There is some controversy about medical treatment in the United States, but less in other countries. Supportive measures routinely required include intravenous fluids, tetanus prophylaxis and antibiotics. Anticholinergics may be useful in elapid bite. Intubation and ventilation may be necessary. Unproven surgical approaches include excision of envenomated tissues and fasciotomy. The former is disfiguring, the latter should be reserved for those patients with demonstrated increased intracompartmental pressure. More than 100 antivenins are produced by about 36 laboratories worldwide. The products are effective, but carry a high risk of serum sickness and a lesser risk of anaphylaxis. A more effective and less reactive product is under development.

Clinical and laboratory features of South American rattlesnake (Crotalus durissus terrificus) envenomation in children

The venom of the South American rattlesnake Crotalus durissus terrificus was first reported to have mainly haemolytic and neurotoxic physiopathological activities. Later studies demonstrated the systemic myotoxic action of the venom, characterized by the release of myoglobin from damaged skeletal muscle into serum and urine, and a recent report ruled out the presence of intravascular haemolysis in 3 patients, one child and 2 adults. The present paper describes the clinical-laboratory evolution of 10 children bitten by C. durissus terrificus; 2 developed acute renal failure and one died. The myotoxic activity of the venom was evaluated by measuring serum lactic dehydrogenase, creatine kinase and aspartate aminotransferase, by detection of myoglobin in serum and urine, and by muscle biopsy. Haemolytic activity was evaluated by serial measurements of serum haemoglobin and haptoglobin and by detection of urine haemoglobin. We conclude that the signs and symptoms exhibited by patients bitten by C. durissus terrificus are due only to the myotoxic and neurotoxic action of the venom. The only patients with major morbidity were those who initially received subcutaneous antivenin and did not receive definitive antivenin therapy until later.