Development and clinical application of immunoassays for European adder (Vipera berus berus) venom and antivenom

Suspected envenomation by the common European adder (Vipera berus berus) in 28 horses in Finland

Vipera berus berus is the only venomous snake present in the Nordic countries and cases of envenomation in horses are reported during the warmer months. Little is known about the presentation, treatment and survival of horses with common European adder envenomation. Clinical and laboratory findings, treatment and outcome are reported for 28 horses admitted to Helsinki University Equine Hospital in 2008-2023 due to suspicion of snake bite. Eleven of these horses received antivenom treatment. Other common treatments included non-steroidal anti-inflammatories (22/28), antimicrobials (19/28), intravenous fluid therapy (11/28), corticosteroids (9/28) and local treatment (11/28). All horses survived until discharge. No difference was detected in the length of hospital stay between horses with moderate envenomation that had or had not received antivenom treatment. Horses with moderate envenomation are more likely to receive antivenom treatment and require longer hospital stay than horses with mild envenomation. Antivenom treatment is not associated with shorter hospital stay. Little evidence supports the use of corticosteroids and antibiotics in treatment of envenomation. Studies with larger numbers of animals are warranted to evaluate the effect of treatment, including administration of antivenom, on long-term outcome and survival from envenomation.

Biochemistry and toxicology of proteins and peptides purified from the venom of Vipera berus berus

The isolation and characterization of individual snake venom components is important for a deeper understanding of the pathophysiology of envenomation and for improving the therapeutic procedures of patients. It also opens possibilities for the discovery of novel toxins that might be useful as tools for understanding cellular and molecular processes. The variable venom composition, toxicological and immunological properties of the common vipers (Vipera berus berus) have been reviewed. The combination of venom gland transcriptomics, bottom-up and top-down proteomics enabled comparison of common viper venom proteomes from multiple individuals. V. b. berus venom contains proteins and peptides belonging to 10–15 toxin families: snake venom metalloproteinase, phospholipases A₂ (PLA₂), snake venom serine proteinase, aspartic protease, L-amino acid oxidase (LAAO), hyaluronidase, 5′-nucleotidase, glutaminyl-peptide cyclotransferase, disintegrin, C-type lectin (snaclec), nerve growth factor, Kunitz type serine protease inhibitor, snake venom vascular endothelial growth factor, cysteine-rich secretory protein, bradykinin potentiating peptide, natriuretic peptides. PLA₂ and LAAO from V. b. berus venom produce more pronounced cytotoxic effects in cancer cells than normal cells, via induction of apoptosis, cell cycle arrest and suppression of proliferation. Proteomic data of V. b. berus venoms from different parts of Russia and Slovakian Republic have been compared with analogous data for Vipera nikolskii venom. Proteomic studies demonstrated quantitative differences in the composition of V. b. berus venom from different geographical regions. Differences in the venom composition of V. berus were mainly driven by the age, sex, habitat and diet of the snakes. The venom variability of V. berus results in a loss of antivenom efficacy against snakebites. The effectiveness of antibodies is discussed. This review presents an overview with a special focus on different toxins that have been isolated and characterized from the venoms of V. b. berus. Their main biochemical properties and toxic actions are described.

•

Vipera berus berus venom composition is variable among different populations.

•

Venom contains about 15 protein/peptide families.

•

It disturbs blood coagulation inducing pro- or anticoagulant effects.

•

Venom contains different types of blood factor X activators.

•

PLA₂ and L-amino acid oxidase produce cytotoxic effects in cancer cells.

Snakebite Envenoming Diagnosis and Diagnostics

Snakebite envenoming is predominantly an occupational disease of the rural tropics, causing death or permanent disability to hundreds of thousands of victims annually. The diagnosis of snakebite envenoming is commonly based on a combination of patient history and a syndromic approach. However, the availability of auxiliary diagnostic tests at the disposal of the clinicians vary from country to country, and the level of experience within snakebite diagnosis and intervention may be quite different for clinicians from different hospitals. As such, achieving timely diagnosis, and thus treatment, is a challenge faced by treating personnel around the globe. For years, much effort has gone into developing novel diagnostics to support diagnosis of snakebite victims, especially in rural areas of the tropics. Gaining access to affordable and rapid diagnostics could potentially facilitate more favorable patient outcomes due to early and appropriate treatment. This review aims to highlight regional differences in epidemiology and clinical snakebite management on a global scale, including an overview of the past and ongoing research efforts within snakebite diagnostics. Finally, the review is rounded off with a discussion on design considerations and potential benefits of novel snakebite diagnostics.

Development of sandwich ELISA and lateral flow strip assays for diagnosing clinically significant snakebite in Taiwan

Taiwan is an island located in the south Pacific, a subtropical region that is home to 61 species of snakes. Of these snakes, four species—Trimeresurus stejnegeri, Protobothrops mucrosquamatus, Bungarus multicinctus and Naja atra—account for more than 90% of clinical envenomation cases. Currently, there are two types of bivalent antivenom: hemorrhagic antivenom against the venom of T. stejnegeri and P. mucrosquamatus, and neurotoxic antivenom for treatment of envenomation by B. multicinctus and N. atra. However, no suitable detection kits are available to precisely guide physicians in the use of antivenoms. Here, we sought to develop diagnostic assays for improving the clinical management of snakebite in Taiwan. A two-step affinity purification procedure was used to generate neurotoxic species-specific antibodies (NSS-Abs) and hemorrhagic species-specific antibodies (HSS-Abs) from antivenoms. These two SSAbs were then used to develop a sandwich ELISA (enzyme-linked immunosorbent assay) and a lateral flow assay comprising two test lines. The resulting ELISAs and lateral flow strip assays could successfully discriminate between neurotoxic and hemorrhagic venoms. The limits of quantification (LOQ) of the ELISA for neurotoxic venoms and hemorrhagic venoms were determined to be 0.39 and 0.78 ng/ml, respectively, and the lateral flow strips were capable of detecting neurotoxic and hemorrhagic venoms at concentrations lower than 5 and 50 ng/ml, respectively, in 10–15 min. Tests of lateral flow strips in 21 clinical snakebite cases showed 100% specificity and 100% sensitivity for neurotoxic envenomation, whereas the sensitivity for detecting hemorrhagic envenomation samples was 36.4%. We herein presented a feasible strategy for developing a sensitive sandwich ELISA and lateral flow strip assay for detecting and differentiating venom proteins from hemorrhagic and neurotoxic snakes. A useful snakebite diagnostic guideline according to the lateral flow strip results and clinical symptoms was proposed to help physicians to use antivenoms appropriately. The two-test-line lateral flow strip assay could potentially be applied in an emergency room setting to help physicians diagnose and manage snakebite victims.

Snakebite is a public health issue that causes life-threatening medical emergencies. Rapid diagnosis of snakebite in the clinic is a critical necessity in many tropical and subtropical countries, where various venomous snakes are common. Venoms from different snake species contain distinct protein components that require treatment with different antivenoms. However, given the similarity in clinical symptoms among some snake envenomations, it is often challenging for physicians to precisely define the snake species responsible for envenomation. Thus, a reliable method or assay for rapidly diagnosing envenoming species is urgently needed. Here, we present a two-step affinity purification procedure for generating species-specific antibodies (SSAbs) from antivenom, followed by the development of a sandwich ELISA (enzyme-linked immunosorbent assay) and lateral flow strip assay using these SSAbs. This feasible and cost-effective strategy allowed us to develop workable assays for distinguishing between venom proteins from hemorrhagic and neurotoxic snakes in Taiwan. The usefulness of this strategy was demonstrated in the clinic, where both diagnostic assays were shown capable of detecting venoms in blood samples from snakebite patients. Together with the observation of clinical symptoms, the two-test-line lateral flow strip assay is potentially applicable in an emergency room setting to improve snakebite diagnosis and management.

Pharmacokinetics of Snake Venom

Understanding snake venom pharmacokinetics is essential for developing risk assessment strategies and determining the optimal dose and timing of antivenom required to bind all venom in snakebite patients. This review aims to explore the current knowledge of snake venom pharmacokinetics in animals and humans. Literature searches were conducted using EMBASE (1974–present) and Medline (1946–present). For animals, 12 out of 520 initially identified studies met the inclusion criteria. In general, the disposition of snake venom was described by a two-compartment model consisting of a rapid distribution phase and a slow elimination phase, with half-lives of 5 to 48 min and 0.8 to 28 h, respectively, following rapid intravenous injection of the venoms or toxins. When the venoms or toxins were administered intramuscularly or subcutaneously, an initial absorption phase and slow elimination phase were observed. The bioavailability of venoms or toxins ranged from 4 to 81.5% following intramuscular administration and 60% following subcutaneous administration. The volume of distribution and the clearance varied between snake species. For humans, 24 out of 666 initially identified publications contained sufficient information and timed venom concentrations in the absence of antivenom therapy for data extraction. The data were extracted and modelled in NONMEM. A one-compartment model provided the best fit, with an elimination half-life of 9.71 ± 1.29 h. It is intended that the quantitative information provided in this review will provide a useful basis for future studies that address the pharmacokinetics of snakebite in humans.

Detection and neutralization of cobra venom using rabbit antiserum in experimental envenomated mice

A sandwich enzyme-linked immunosorbent assay (ELISA) was developed to detect the venom of Indian cobra ( Naja naja naja) in various tissues (brain, heart, lungs, liver, spleen, blood, kidneys, and tissue at the site of injection) of mice after cobra venom injected at different time intervals (0, 2, 4, 6, 8, and 12 h intervals up to 24 h). Whole venom antiserum or individual venom protein antiserum (14, 29, 65, 72, and 99 kDa) could recognize N. n. naja venom by Western blotting and ELISA, and antibody titer was also assayed by ELISA. Antiserum raised against cobra venom in rabbit significantly neutralized the toxicity of venom-injected mice at different time intervals after treatment. The assay could detect N. n. naja venom levels up to 2.5 ng/ml of tissue homogenate, and the venom was detected up to 24 h after venom injection. Venom was detected in brain, heart, lungs, liver, spleen, kidneys, tissue at the bite area, and blood. As observed in mice, tissue at the site of bite area showed the highest concentration of venom and the brain showed the least. Moderate amounts of venoms were found in liver, spleen, kidneys, heart, and lungs. Development of a simple, rapid, and species-specific diagnostic kit based on this ELISA technique useful to clinicians is discussed.

Development of a sensitive enzyme immunoassay for measuring taipan venom in serum

The detection and measurement of snake venom in blood is important for confirming snake identification, determining when sufficient antivenom has been given, detecting recurrence of envenoming, and in forensic investigation. Venom enzyme immunoassays (EIA) have had persistent problems with poor sensitivity and high background absorbance leading to false positive results. This is particularly problematic with Australasian snakes where small amounts of highly potent venom are injected, resulting in low concentrations being associated with severe clinical effects. We aimed to develop a venom EIA with a limit of detection (LoD) sufficient to accurately distinguish mild envenoming from background absorbance at picogram concentrations of venom in blood. Serum samples were obtained from patients with taipan bites (Oxyuranus spp.) before and after antivenom, and from rats given known venom doses. A sandwich EIA was developed using biotinylated rabbit anti-snake venom antibodies for detection. For low venom concentrations (i.e. <1 ng/mL) the assay was done before and after addition of antivenom to the sample (antivenom difference method). The LoD was 0.15 ng/mL for the standard assay and 0.1 ng/mL for the antivenom difference method. In 11 pre-antivenom samples the median venom concentration was 10 ng/mL (Range: 0.3-3212 ng/mL). In four patients with incomplete venom-induced consumption coagulopathy the median venom concentration was 2.4 ng/mL compared to 30 ng/mL in seven patients with complete venom-induced consumption coagulopathy. No venom was detected in any post-antivenom sample and the median antivenom dose prior to this first post-antivenom sample was 1.5 vials (1-3 vials), including 7 patients administered only 1 vial. In rats the assay distinguished a 3-fold difference in venom dose administered and there was small inter-individual variability. There was small but measurable cross-reactivity with black snake (Pseudechis), tiger snake (Notechis) and rough-scale snake (Tropidechis carinatus) venoms with the assay for low venom concentrations (<1 ng/mL). The use of biotinylation and the antivenom difference method in venom EIA produces a highly sensitive assay that will be useful for determining antivenom dose, forensic and clinical diagnosis.

[Adder bite. A rare dermatologic emergency]

Bites by poisonous snakes are rare dermatologic emergencies. A 43-year-old woman was bitten on her right forefinger by an adder during a hiking vacation in Austria. Her right arm and chest wall became swollen and then hemorrhagic, but she responded well to analgesics and immobilization. Administration of a specific antiserum was not necessary because of the lack of a systemic reaction.

Effects of bites by the European adder (Vipera berus) in seven Swedish horses

The effects on seven horses of bites by the European adder (Vipera berus) are described and compared with previously available information. The clinical signs varied from local swelling and mild systemic signs to severe systemic signs, including systemic inflammatory response, severe tissue necrosis, ventricular tachycardia and dysphagia. Two of the horses were treated with 'Zagreb' antiserum, and three that were not treated with antiserum were euthanased owing to complications related to the bites.

Enzyme immunoassays in brown snake (Pseudonaja spp.) envenoming: Detecting venom, antivenom and venom–antivenom complexes

Although a commercial snake venom detection kit (SVDK) is available to distinguish between the five major snake groups in Australia, there is no assay for quantifying venom or antivenom concentrations in envenomed patients. Serum samples were obtained from patients with brown snake (Pseudonaja spp.) envenoming before and after the administration of antivenom and patients with suspected brown snake bites but no evidence of envenoming. Enzyme immunoassays (EIAs) were developed for free venom, free antivenom and the venom-antivenom complex. Standard samples measured in duplicate had a coefficient of variation of less than 10%. The EIA for venom was able to detect brown snake venom down to concentrations of 3 ng/mL. A high baseline absorbance was measured in some patients that did not change with the addition of excess antivenom to the samples. In these patients, the baseline absorbance was subtracted from all measurements to calculate the true venom concentration. The EIA for brown snake antivenom had a limit of detection of 20 microg/mL, but 50 microg/mL was used as a cut-off based on assays in patients who had not received antivenom. The EIA for venom-antivenom complexes was unable to detect these at the low venom concentrations that occurred in patients. Quantification of venom and antivenom will help to determine the dose of antivenom required to bind venom and to establish appropriate end points for antivenom treatment.

A nationwide study of Vipera berus bites during one year-epidemiology and morbidity of 231 cases

OBJECTIVES

To describe clinical course, influence of treatment, and epidemiology of Vipera berus envenomation in a defined population, and to compare the results with those of a similar, nationwide study in 1975. Design. Retrospective case review study.

SETTING AND SUBJECTS

Case records regarding all patients treated in Swedish hospitals during 1995 for bites by the common European adder, V. berus, were studied. A severity grading was applied. Possible dropout was fewer than 10 patients.

RESULTS

A total of 231 inpatients were treated for V. berus bites in Sweden in 1995. Children less than 10 years old were overrepresented and there was a slight predominance for males. Maximum severity of envenomation was none in 11%, minor in 47%, moderate in 29%, and severe in 13% of the cases. A few patients with initially minor or moderate symptoms eventually met the criteria of severe envenomation. Less commonly reported features were pulmonary edema, generalized plasma leakage, seizures, deep venous thrombosis, compartment syndrome, numbness and paraesthesia, and myocardial infarction. Treatment included antivenom in 42 patients [ovine Fab in 30 and equine F(ab')2 in 12 cases]. Systemic symptoms resolved during or shortly after the antivenom infusion. Extensive edema involving the trunk occurred in 5% of the cases in 1995, whereas 14% of the patients had extensive swelling in 1975.

CONCLUSIONS

Incidence and other epidemiological data were similar to those 20 years ago, whereas the clinical course was more benign. It seems reasonable to believe that this is due to the introduction of effective antivenoms.

The clinical significance of venom detection in patients of cobra snakebite

Cobra snakebites are one of the most frequent occurrences among the poisonous snakebites. The correlation between the serum concentrations of cobra venom in the victims with the severity of systemic and local symptoms after envenoming is still awaited for investigation. In this paper, we have developed an enzyme-linked immunosorbent assay (ELISA) to detect Taiwan cobra venom existed in the serum of the cobra snakebite victims. This established technique allowed us to detect as low as 1 ng/ml. Totally, 31 serum samples of 27 recognized and suspected cobra snakebite patients were analyzed by the developed ELISA technique. The highest venom level detected was 1270 ng/ml in a case 2 h after being envenomed. We found that the serum concentrations of the venom in the bitten patients were well correlated with the severity of local tissue destruction. Venom levels might remain high 48 h after snakebite. Two or more vials of specific antivenom administered soon after snakebite were effective in neutralizing the circulating venom as revealed by ELISA. Higher doses of antivenom may be indicated in cases of cobra venom-induced local tissue destruction. In conclusion, these results indicate that venom detection in snakebite victims is valuable in diagnosis and severity assessment of Taiwan cobra snakebite.

Enhanced pepsin digestion: a novel process for purifying antibody F(ab')(2) fragments in high yield from serum

Enzyme-cleaved antibodies are used widely for the treatment of envenoming. Such products should comprise only 'highly pure' immunoglobulin fragments since Fc or other contaminating protein fragments or their aggregates may lead to side effects. The digestion of ovine antiserum and its purified IgG were investigated using pepsin and trypsin. Trypsin was effective at digesting purified IgG but unsuitable for the direct digestion of serum. In contrast, pepsin was highly effective at digesting all unwanted serum components to low molecular weight (< or =13 kDa) fragments while leaving the approximately 100-kDa F(ab')(2) intact. The optimum pH for pepsin digestion was between 3.25 and 3.50. The effects of salt concentration and pH on the digestion products were investigated by size exclusion chromatography under various conditions, which revealed a pH-dependent aggregation of some of the low molecular weight Fc and non-IgG fragments. These high molecular weight aggregates were not shown by SDS-PAGE. Unwanted low molecular weight fragments could be removed simply by diafiltration with a 30-kDa nominal molecular weight cutoff membrane and piperazine buffer (containing 150 mM NaCl, pH 6), leaving an F(ab')(2) solution contaminated only with some pepsin and a small amount of the aggregated low molecular weight fragments. These highly acidic contaminants were then removed easily using an anion exchange column and the F(ab')(2) produced following a subsequent concentration step was essentially free from pepsin and aggregates with a purity of over 96% and a yield of 19.3 g F(ab')(2)/l serum. This novel, high yield method for processing serum to highly pure F(ab')(2) avoids salt precipitation and centrifugation and should be suitable for large-scale production.

ELISA for the detection of venoms from four medically important snakes of India

A double antibody sandwich enzyme linked immunosorbent assay (ELISA) was developed to detect Echis carinatus venom in various organs (brain, heart, lungs, liver, spleen and kidneys) as well as tissue at the site of injection of mice, at various time intervals (1, 6, 12, 18, 24 h and 12 h intervals up to 72 h) after death. The assay could detect E. carinatus venom levels up to 2.5 ng/ml of tissue homogenate and the venom was detected up to 72 h after death. A highly sensitive and species-specific avidin-biotin microtitre ELISA was also developed to detect venoms of four medically important Indian snakes (Bungarus caeruleus, Naja naja, E. carinatus and Daboia russelli russelli) in autopsy specimens of human victims of snake bite. The assay could detect venom levels as low as 100 pg/ml of tissue homogenate. Venoms were detected in brain, heart, lungs, liver, spleen, kidneys, tissue at the bite area and postmortem blood. In all 12 human victim cadavers tested the culprit species were identified. As observed in mice, tissue at the site of bite area showed the highest concentration of venom and the brain showed the least. Moderate amounts of venoms were found in liver, spleen, kidneys, heart and lungs. Development of a simple, rapid and species-specific diagnostic kit based on this ELISA technique useful to clinicians is discussed.

Tests for detection of snake venoms, toxins and venom antibodies: review on recent trends (1987-1997)

Various methods developed for the detection of snake venoms, toxins and venom antibodies, during the last decade is reviewed. Radioimmunoassay, agglutination assay, enzyme-linked immunosorbent assay (ELISA), fluorescence immunoassay etc. have been used for detection of venoms and toxins. Important contributions have been made to improve the specificity, sensitivity, rapidity and simplicity of the ELISA method. Monoclonal antibodies and affinity-purified venom-specific antibodies were used to achieve species specificity of ELISA and the latter seems to be the ideal for venom detection. Incorporation of avidin-biotin system as well as the fluorogenic substrate in the enzyme immunoassay sufficiently increased the sensitivity of the assay to detect venom concentrations to picogram levels. The ability to use undiluted blood and other whole biological fluids reduce the assay time considerably. Although there have been several reports were on venom detection, so far only a few field kits have been developed. This implies that the experiments and design were only at the laboratory levels and still more work has to be carried out before it could be used in the field. Concerning the venom antibody detection, ELISA has been used extensively and the humoral response of patients envenomed by snake has been investigated in detail. Non-specific reactivity along with cross-reactivity still limits the use of ELISA for species identification in epidemiological studies. Overall, ELISA remains the suitable method for the detection of snake venoms, toxins and venom antibodies in body fluids. The possible use of a biosensor approach to solve some of the problems associated with the ELISA method are also discussed.

Venoms, antivenoms and immunotherapy

A century after the discovery of antivenom and despite real progress undertaken in its manufacture, its use remains largely empirical. Recent studies of pharmacokinetics of envenoming permitted improved understanding of immunotherapy. Improved purification of the antivenom by using immunoglobulin fragments has lead to increased tolerance and efficiency of antivenom. The respective advantages and disadvantages of F(ab')2 and F(ab) are discussed in relation to neutralising efficacy and clearance from the circulation. Although the time during which the action of antivenom remains beneficial after the bite is unknown, the superiority of intravenous administration has now been proved. Although immunisation procedures and purification and use of IgG fragments can be improved using modern technology, the future of immunotherapy seems promising. It is vital that therapeutic protocols should be rigidly adhered to in order to optimise immunotherapy. The use of vaccination has yet to be explored.