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Lin WH, Tsai TS, Chuang PC. The Presence of Four Pathogenic Oral Bacterial Species in Six Wild Snake Species from Southern Taiwan: Associated Factors. Microorganisms 2024; 12:263. [PMID: 38399667 PMCID: PMC10891919 DOI: 10.3390/microorganisms12020263] [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: 12/29/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
The oral cavity of snakes serves as a habitat for various microorganisms, some of which may include potential zoonotic pathogens posing risks to hosts and causing wound infections in snakebite victims. Clinical studies on snakebite cases in Taiwan have identified specific pathogens, such as Enterococcus faecalis (Gram-positive), Morganella morganii, Aeromonas hydrophila, and Pseudomonas aeruginosa (Gram-negative). However, the prevalence of these bacteria in the oral cavity of wild snakes remains largely unknown. This study investigated the occurrence of these bacteria in six wild snake species (Naja atra, Bungarus multicinctus, Trimeresurus stejnegeri, Protobothrops mucrosquamatus, Boiga kraepelini, and Elaphe taeniura friesi) from southern Taiwan, along with factors influencing their presence. Oropharyngeal swab samples were collected from a substantial number of wild-caught snakes (n = 1104), followed by DNA extraction, polymerase chain reaction, and gel electrophoresis. The band positions of samples were compared with positive and negative controls to determine the presence of target bacteria in each sample. The overall occurrence rates were 67.4% for E. faecalis, 31.5% for M. morganii, 8.2% for A. hydrophila, and 7.7% for P. aeruginosa. Among snake species, B. kraepelini exhibited dominance in E. faecalis (93.4%), A. hydrophila (17.1%), and P. aeruginosa (14.5%), while male N. atra showed dominance in M. morganii (51.3%). The occurrence of E. faecalis was lowest in winter. The results of multiple logistic regression analyses suggest that factors such as species, sex, temperature, season, and coexisting pathogens may have a significant impact on the occurrence of target bacteria. These findings have implications for wildlife medicine and snakebite management.
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Affiliation(s)
- Wen-Hao Lin
- Institute of Wildlife Conservation, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan;
| | - Tein-Shun Tsai
- Institute of Wildlife Conservation, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan;
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan
| | - Po-Chun Chuang
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung 804201, Taiwan;
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan
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2
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Yeh H, Gao SY, Lin CC. Wound Infection of Snakebite from Venomous Protobothrops mucrosquamatus, Viridovipera stejnegeri and Naja atra in Taiwan: Validation of BITE and Cobra BITE Scoring Systems and their Bacteriological Differences in Wound Cultures. Toxins (Basel) 2023; 15:78. [PMID: 36668897 PMCID: PMC9861491 DOI: 10.3390/toxins15010078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/08/2023] [Accepted: 01/10/2023] [Indexed: 01/17/2023] Open
Abstract
Patients bitten by Protobothrops mucrosquamatus, Viridovipera stejnegeri, and Naja atra develop different degrees of wound infection. This study validated BITE and Cobra BITE scoring systems that we established previously. Bacteriological studies of patients with wound infection were conducted. The operating characteristic curves and area under the curve (AUC) and wound infection rates were compared between the derivation set (our previous study patient population) and the validation set (new patient cohorts enrolled between June 2017 and May 2021). No significant differences in the AUC for both the BITE (0.84 vs. 0.78, p = 0.27) and Cobra BITE (0.88 vs. 0.75, p = 0.21) scoring systems were observed between the derivation and validation sets. Morganella morganii and Enterococcus faecalis were the two most commonly detected bacteria in the microbiological study. More bacterial species were cultured from N. atra-infected wounds. Antibiotics such as amoxicillin with clavulanic acid, oxacillin, and ampicillin may not be suitable for treating patients with P. mucrosquamatus, V. stejnegeri, and N. atra bites in Taiwan. Carbapenem, third-generation cephalosporins, and fluoroquinolone may be superior alternatives.
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Affiliation(s)
- Heng Yeh
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shi-Ying Gao
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Chih-Chuan Lin
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
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3
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Wang CC, Yang CHO, Hsu CP, Liu CC, Yu JS, Lo CH, Fann WC, Chen YC, Lin CC. Taiwan cobra envenoming: serum venom concentration before and after specific treatment and relationship with debridement of necrotic wound tissue. J Venom Anim Toxins Incl Trop Dis 2023; 29:e20220027. [PMID: 36721427 PMCID: PMC9851669 DOI: 10.1590/1678-9199-jvatitd-2022-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/01/2022] [Indexed: 01/15/2023] Open
Abstract
Background Bivalent freeze-dried neurotoxic (FN) antivenom has been the primary treatment since the 1980s for Taiwan cobra (Naja atra) envenomation in Taiwan. However, envenomation-related wound necrosis is a significant problem after cobra snakebites. In the present study, we analyzed the changes in serum venom concentration before and after antivenom administration to discover their clinical implications and the surgical treatment options for wound necrosis. Methods The patients were divided into limb swelling and wound necrosis groups. The clinical outcome was that swelling started to subside 12 hours after antivenom treatment in the first group. Serum venom concentrations before and after using antivenoms were measured to assess the antivenom's ability to neutralize the circulating cobra venom. The venom levels in wound wet dressing gauzes, blister fluids, and debrided tissues were also investigated to determine their clinical significance. We also observed the evolutional changes of wound necrosis and chose a better wound debridement timing. Results We prospectively enrolled 15 Taiwan cobra snakebite patients. Males accounted for most of this study population (n = 11, 73%). The wound necrosis group received more antivenom doses than the limb swelling group (4; IQR:2-6 vs 1; IQR:1-2, p = 0.05), and less records of serum venom concentrations changed before/after antivenom use (p = 0.0079). The necrotic wound site may release venom into circulation and cause more severe envenomation symptoms. Antivenom can efficiently diminish limb swelling in cobra bite patients. However, antivenom cannot reduce wound necrosis. Patients with early debridement of wound necrosis had a better limb outcome, while late or without debridement may have long-term hospital stay and distal limb morbidity. Conclusions Antivenom can efficiently eliminate the circulating cobra venom in limb swelling patients without wound necrosis. Early debridement of the bite site wound and wet dressing management are suggestions for preventing extended tissue necrosis and hospital stay.
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Affiliation(s)
- Chia-Cheng Wang
- Department of Traumatology and Emergency Surgery, Chang Gung
Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Hsiang Ou Yang
- Department of Traumatology and Emergency Surgery, Chang Gung
Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Po Hsu
- Department of Traumatology and Emergency Surgery, Chang Gung
Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan,
Taiwan
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan,
Taiwan.,Department of Cell and Molecular Biology, College of Medicine, Chang
Gung University, Taoyuan, Taiwan.,Liver Research Center, Chang Gung Memorial Hospital, Linkou,
Taiwan.,Research Center for Food and Cosmetic Safety, Research Center for
Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science
and Technology, Taoyuan, Taiwan
| | - Chih-Hong Lo
- Department of General Surgery, Chang Gung Memorial Hospital,
Taoyuan, Taiwan
| | - Wen-Chih Fann
- Department of Emergency Medicine, Chiayi Chang Gung Memorial
Hospital, Chiayi, Taiwan
| | - Yen-Chia Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital,
Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, National
Yang-Ming University, Taipei, Taiwan
| | - Chih Chuan Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Emergency Medicine, Linkou Chang Gung Memorial
Hospital, Taoyuan, Taiwan.,Correspondence:
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Kalita B, Utkin YN, Mukherjee AK. Current Insights in the Mechanisms of Cobra Venom Cytotoxins and Their Complexes in Inducing Toxicity: Implications in Antivenom Therapy. Toxins (Basel) 2022; 14:toxins14120839. [PMID: 36548736 PMCID: PMC9780984 DOI: 10.3390/toxins14120839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022] Open
Abstract
Cytotoxins (CTXs), an essential class of the non-enzymatic three-finger toxin family, are ubiquitously present in cobra venoms. These low-molecular-mass toxins, contributing to about 40 to 60% of the cobra venom proteome, play a significant role in cobra venom-induced toxicity, more prominently in dermonecrosis. Structurally, CTXs contain the conserved three-finger hydrophobic loops; however, they also exhibit a certain degree of structural diversity that dictates their biological activities. In their mechanism, CTXs mediate toxicity by affecting cell membrane structures and membrane-bound proteins and activating apoptotic and necrotic cell death pathways. Notably, some CTXs are also responsible for depolarizing neurons and heart muscle membranes, thereby contributing to the cardiac failure frequently observed in cobra-envenomed victims. Consequently, they are also known as cardiotoxins (CdTx). Studies have shown that cobra venom CTXs form cognate complexes with other components that potentiate the toxic effects of the venom's individual component. This review focuses on the pharmacological mechanism of cobra venom CTXs and their complexes, highlighting their significance in cobra venom-induced pathophysiology and toxicity. Furthermore, the potency of commercial antivenoms in reversing the adverse effects of cobra venom CTXs and their complexes in envenomed victims has also been discussed.
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Affiliation(s)
- Bhargab Kalita
- Amrita School of Nanosciences and Molecular Medicine, Amrita Vishwa Vidyapeetham, Kochi 682041, India
| | - Yuri N. Utkin
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Moscow 117997, Russia
| | - Ashis K. Mukherjee
- Institute of Advanced Study in Science and Technology, Guwahati 781035, India
- Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, India
- Correspondence:
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Lin CC, Shih CP, Wang CC, Ouyang CH, Liu CC, Yu JS, Lo CH. The Clinical Usefulness of Taiwan Bivalent Freeze-Dried Hemorrhagic Antivenom in Protobothrops mucrosquamatus- and Viridovipera stejnegeri-Envenomed Patients. Toxins (Basel) 2022; 14:toxins14110794. [PMID: 36422968 PMCID: PMC9699225 DOI: 10.3390/toxins14110794] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/18/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022] Open
Abstract
Snakebites from Protobothrops mucrosquamatus (Taiwan habus) and Viridovipera stejnegeri (green bamboo vipers) account for the most venomous snakebites in Taiwan. The bivalent freeze-dried hemorrhagic (FH) antivenom is employed to treat these two snakebite patients without a strict clinical trial. We evaluated the clinical usefulness of Taiwan bivalent freeze-dried hemorrhagic (FH) antivenom in Taiwan habu- and green bamboo viper-envenomed patients. We checked ELISA- based serum venom antigen levels before and after FH antivenom to evaluate FH's ability to neutralize patients' serum snake venom and its usefulness in reducing limb swelling after snakebites. Patients who had higher serum venom antigen levels had more severe limb swelling. Of the 33 enrolled patients, most of their snake venom antigen levels were undetected after the appliance of antivenom. Most enrolled patients (25/33) had their limb swelling subside within 12 h after antivenom treatment. The failure to reduce limb swelling was probably due to an inadequate antivenom dose applied in more severely envenomated patients. Our data indicate the feasibility of the FH antivenom in effectively eliminating venom and resolving the affected limb swelling caused by Taiwan habu and green bamboo viper bites.
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Affiliation(s)
- Chih-Chuan Lin
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Correspondence:
| | - Chia-Pang Shih
- Department of Nursing, Yuanpei University of Medical Technology, Hsinchu 300, Taiwan
| | - Chia-Cheng Wang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chun-Hsiang Ouyang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Cell and Molecular Biology, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Liver Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan
| | - Chih-Hong Lo
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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6
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Hung WH, Sung J, Chen WY, Chiu LT, Yip HT, Wei JCC, Hung YM, Chang R. Risk of stroke with antivenom usage after venomous snakebite in Taiwan: a population-based cohort study. QJM 2022; 115:587-595. [PMID: 34613415 DOI: 10.1093/qjmed/hcab259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 09/03/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND AND PURPOSE Stroke is a rare complication of snakebites, but may lead to serious sequelae. We aimed to explore the relationship between venomous snakebite and the risk for acute stroke, in a nationwide population-based cohort study. METHODS This retrospective cohort study used claims data between 1 January 2000 and 31 December 2012, from the Taiwan National Health Insurance Research Database. The study included data of patients aged 18 years or older with venomous snakebite (n = 535), matched for propensity score with controls without venomous snakebite (n = 2140). The follow-up period was the duration from the initial diagnosis of venomous snakebite and administration of antivenom to the date of an acute stroke, or until 31 December 2013. The competing risk model was used to estimate the hazard ratio (HR) and 95% confidence intervals (CIs) of stroke, ischemic stroke and hemorrhagic stroke, after adjusting for demographic and other possible stroke risk factors. RESULTS The adjusted HR for the venomous snakebite group compared with the control group was 2.68 for hemorrhagic stroke (95% CI = 1.35-5.33). Stratified analysis showed that the older age group (>65 years old) had a higher risk of hemorrhagic stroke. A 2.72-fold significant increase in the risk for hemorrhagic stroke was observed following venomous snakebite with antivenom usage (95% CI = 1.41-5.26). CONCLUSION Venomous snakebite is associated with an increased risk of hemorrhagic stroke after the use of antivenom. Further study of the underlying mechanism is warranted.
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Affiliation(s)
- W-H Hung
- Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - J Sung
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospitals, Kaohsiung, Taiwan
| | - W-Y Chen
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - L-T Chiu
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - H-T Yip
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - J C-C Wei
- Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Y-M Hung
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospitals, Kaohsiung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - R Chang
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Recreation and Sports Management, Tajen University, Pingtung, Taiwan
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Prediction of Compartment Syndrome after Protobothrops mucrosquamatus Snakebite by Diastolic Retrograde Arterial Flow: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58080996. [PMID: 35893111 PMCID: PMC9330921 DOI: 10.3390/medicina58080996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/19/2022] [Accepted: 07/23/2022] [Indexed: 11/16/2022]
Abstract
Post-snakebite compartment syndrome (PSCS) is an uncommon but dangerous condition. Compartment syndrome-like symptoms after snakebite by Protobothrops mucrosquamatus (P. mucrosquamatus) are not effective in guiding fasciotomy. Objective evaluation of intracompartmental pressure measurements in patients with suspected PSCS is recommended. However, there is a lack of consensus regarding PSCS and indications for surgical intervention, including the threshold value of chamber pressure. In addition, intracompartmental pressure measurements may not be readily available in all emergency service settings. Measuring intracompartmental pressure in all snakebite patients for early diagnosis of PSCS is impractical. Therefore, identifying risk factors, continuous real-time monitoring tools, and predictive factors for PSCS are important. Sonography has proved useful in identifying the location and extension of edema after a snakebite. In this study, we attempted to use point-of-care ultrasound to manage PSCS in real-time. Here, we describe a rare case of snakebite from P. mucrosquamatus. PSCS was considered as diastolic retrograde arterial flow (DRAF) was noted in the affected limb with a cobblestone-like appearance in the subcutaneous area, indicating that the target artery was compressed. The DRAF sign requires physicians to aggressively administer antivenom to salvage the limb. The patient was administered 31 vials of P. mucrosquamatus antivenom, and fasciotomy was not performed. DRAF is an early sign of the prediction of PSCS.
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Liu CC, Wu CJ, Chou TY, Liaw GW, Hsiao YC, Chu LJ, Lee CH, Wang PJ, Hsieh CH, Chen CK, Yu JS. Development of a Monoclonal scFv against Cytotoxin to Neutralize Cytolytic Activity Induced by Naja atra Venom on Myoblast C2C12 Cells. Toxins (Basel) 2022; 14:toxins14070459. [PMID: 35878197 PMCID: PMC9320128 DOI: 10.3390/toxins14070459] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022] Open
Abstract
The Taiwanese cobra, Naja atra, is a clinically significant species of snake observed in the wild in Taiwan. Victims bitten by N. atra usually experience severe pain and local tissue necrosis. Although antivenom is available for treatment of cobra envenomation, its neutralization potency against cobra-induced necrosis is weak, with more than 60% of cobra envenoming patients developing tissue necrosis after antivenom administration. The present study found that cytotoxin (CTX) is a key component of N. atra venom responsible for cytotoxicity against myoblast cells. Anti-CTX IgY was generated in hens, and the spleens of these hens were used to construct libraries for the development of single chain variable fragments (scFv). Two anti-CTX scFv, S1 and 2S7, were selected using phage display technology and biopanning. Both polyclonal IgY and monoclonal scFv S1 reacted specifically with CTX in cobra venom. In a cell model assay, the CTX-induced cytolytic effect was inhibited only by monoclonal scFv S1, not by polyclonal IgY. Moreover, the neutralization potency of scFv S1 was about 3.8 mg/mg, approximately three times higher than that of conventional freeze-dried neurotoxic antivenom (FNAV). Collectively, these results suggest that scFv S1 can effectively neutralize CTX-induced cytotoxicity and, when combined with currently available antivenom, can improve the potency of the latter, thereby preventing tissue damage induced by cobra envenoming.
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Affiliation(s)
- Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
| | - Cho-Ju Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan;
| | - Tsai-Ying Chou
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
| | - Geng-Wang Liaw
- Department of Emergency Medicine, Yeezen General Hospital, Taoyuan 32645, Taiwan;
| | - Yung-Chin Hsiao
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
- Liver Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
| | - Lichieh-Julie Chu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
- Liver Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
| | - Chi-Hsin Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 11042, Taiwan;
- Ph.D. Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 11042, Taiwan
| | - Po-Jung Wang
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
| | - Cheng-Hsien Hsieh
- Department of Emergency Medicine, En Chu Kong Hospital, New Taipei City 23741, Taiwan;
| | - Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan;
- Correspondence: (C.-K.C.); (J.-S.Y.); Tel.: +88-63-2118800 (ext. 5171) (J.-S.Y.); Fax: +88-63-2118891 (J.-S.Y.)
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
- Liver Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
- Research Center for Food and Cosmetic Safety, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan 33302, Taiwan
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- Correspondence: (C.-K.C.); (J.-S.Y.); Tel.: +88-63-2118800 (ext. 5171) (J.-S.Y.); Fax: +88-63-2118891 (J.-S.Y.)
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Chuang PC, Lin WH, Chen YC, Chien CC, Chiu IM, Tsai TS. Oral Bacteria and Their Antibiotic Susceptibilities in Taiwanese Venomous Snakes. Microorganisms 2022; 10:microorganisms10050951. [PMID: 35630396 PMCID: PMC9147925 DOI: 10.3390/microorganisms10050951] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/15/2022] [Accepted: 04/28/2022] [Indexed: 12/07/2022] Open
Abstract
Wound infections after venomous snakebites are clinically important. Information regarding the nature and antibiotic susceptibilities of snake oral bacterial flora could support empiric antibiotic therapy. Wild venomous snakes were collected from southern Taiwan: a total of 30 each of Bungarus multicinctus, Naja atra, Protobothrops mucrosquamatus, and Trimeresurus stejnegeri; 3 Deinagkistrodon acutus; and 4 Daboia siamensis. The species and antibiotic susceptibilities of their oral bacteria were determined. Aerobic gram-negative bacteria, especially Pseudomonas aeruginosa and Proteus vulgaris, were the most abundant. Proteus vulgaris were more abundant in B. multicinctus, N. atra, and P. mucrosquamatus than in T. stejnegeri (40%, 43.3%, and 40% vs. 13.3%, respectively). The gram-negative species were less susceptible to first- and second-generation cephalosporins and ampicillin-sulbactam than to third-generation cephalosporins, fluoroquinolones, carbapenems, or piperacillin-tazobactam. The most abundant aerobic gram-positive species cultured was Enterococcus faecalis, which was more abundant in N. atra than in other snakes (p < 0.001) and was highly susceptible to ampicillin, high-level gentamicin, penicillin, teicoplanin, and vancomycin. Bacteroides fragilis and Clostridium species were the most common anaerobic bacteria. The anaerobic organisms were highly susceptible to metronidazole and piperacillin. As a reference for empiric antimicrobial therapy, third-generation cephalosporins, fluoroquinolones, carbapenems, or piperacillin-tazobactam can be initiated in venomous snakebites wound infections.
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Affiliation(s)
- Po-Chun Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan; (P.-C.C.); (I.-M.C.)
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
| | - Wen-Hao Lin
- Institute of Wildlife Conservation, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan;
| | - Yi-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan;
| | - Chun-Chih Chien
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan;
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan; (P.-C.C.); (I.-M.C.)
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
| | - Tein-Shun Tsai
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan
- Correspondence: or
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Chiang LC, Chaou CH, Li YY, Seak CJ, Yu SR, Lin CC. Management and Prognosis of Snake Envenomation Among Pediatric Patients: A National Database Study. J Acute Med 2022; 12:13-22. [PMID: 35619724 PMCID: PMC9096508 DOI: 10.6705/j.jacme.202203_12(1).0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 02/22/2021] [Accepted: 05/21/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Snakebites constitute a common medical emergency in tropical and subtropical regions. Pediatric snake envenomation is a special category that has not been well studied. This study investigated the management and prognostic factors of snake envenomation in children using a Taiwanese national database. METHODS This observational study used the National Health Insurance database of all pediatric snake envenomation patients treated from 2005 to 2009. Patients' demographic data, antivenom types and doses, medical and surgical interventions, and prognostic variables were collected. Comparisons were made according to the envenomation types, age groups, and whether the patients were hospitalized using univariate and multivariate methods. RESULTS A total of 106 patients' data were collected. Of the patients, 73 (68.9%) were male, 62 (58.5%) were under the age of 12, 69 (65.1%) received intravenous (IV) antibiotic treatment, 38 (35.9%) were hospitalized, 5 (4.72%) required surgical intervention, and none died. Compared with non-hospitalized patients, the patients who required hospitalization were more likely to have suffered hemorrhagic envenomation ( p = 0.035), receive IV antibiotic treatment ( p = 0.0078), and require surgical intervention ( p = 0.005). In the multivariate analysis, hemorrhagic envenomation was an independent predictor for hospitalization (odds ratio: 3.47, 95% confidence interval: 1.18-10.21) after adjusting for other covariates. No significant differences were observed between age groups in total antivenom usage ( p = 0.2880), IV antibiotic usage ( p = 0.3190), hospitalization ( p = 0.3988), and surgical intervention ( p = 0.1874). CONCLUSIONS In this Taiwanese population-based national database study, antivenom treatment of pediatric snakebite patients resulted in zero mortality and a low surgical intervention rate. Patients with hemorrhagic envenomation were associated with a higher probability of hospitalization.
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Affiliation(s)
- Lin-Chi Chiang
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
| | - Chung-Hsien Chaou
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
- Chang Gung Memorial Hospital Chang Gung Medical Education Research Centre Taoyuan Taiwan
| | - Yi-Yun Li
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
| | - Chen-June Seak
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
- New Taipei Municipal Tucheng Hospital Department of Emergency Medicine New Taipei City Taiwan
| | - Shiuan-Ruey Yu
- Chang Gung Memorial Hospital Chang Gung Medical Education Research Centre Taoyuan Taiwan
| | - Chih-Chuan Lin
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
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11
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Lin JH, Sung WC, Mu HW, Hung DZ. Local Cytotoxic Effects in Cobra Envenoming: A Pilot Study. Toxins (Basel) 2022; 14:toxins14020122. [PMID: 35202149 PMCID: PMC8877591 DOI: 10.3390/toxins14020122] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/24/2022] [Accepted: 02/05/2022] [Indexed: 01/31/2023] Open
Abstract
The cobra (genus Naja (N.)) is one of the most common venomous snakes. Due to its frequency and deadly complications of muscle paralysis, local necrosis, and chronic musculoskeletal disability, it should not be ignored. The pathology of devastating tissue destruction, even though specific antivenoms exist, is not fully clear. Here, we attempted to dig in envenomed tissues to study the clinical toxicology of cobra venom. Four cases of N. atra snake envenomation, in which the subjects developed advanced tissue injury, were involved in this study. We used enzyme-ligand sandwich immunoassay (ELISA) to assay the whole venom, cytotoxin A3 and short-chain neurotoxin (sNTX) in blood, bullae, wound discharge, and debrided tissue. We found that persistently high concentrations of venom and toxins, especially cytotoxin A3, were detected in bullae, wound discharge fluid and necrotic tissue of these patients even after large doses of specific antivenom treatment, and wide excision and advanced debridement could largely remove these toxins, lessen the size of necrosis, and promote wound healing. We also found that the point-of-care apparatus, ICT-Cobra kit, might be used to promptly monitor the wound condition and as one of the indicators of surgical intervention in cases of cobra envenomation in Taiwan.
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Affiliation(s)
- Jing-Hua Lin
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan; (J.-H.L.); (H.-W.M.)
| | - Wang-Chou Sung
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli 35053, Taiwan;
| | - Han-Wei Mu
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan; (J.-H.L.); (H.-W.M.)
| | - Dong-Zong Hung
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan; (J.-H.L.); (H.-W.M.)
- Correspondence: ; Tel.: +886-4-2205-2121
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12
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Personal Experience of Daboia siamensis Envenomation. Case Rep Med 2022; 2021:3396373. [PMID: 34976069 PMCID: PMC8719983 DOI: 10.1155/2021/3396373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/08/2021] [Indexed: 11/24/2022] Open
Abstract
Reports of envenomation induced by Daboia siamensis, a medically important venomous snake in Taiwan, are rare, and species identification might not be definitive. This article reports the complete course of a definite D. siamensis bite. The patient in this report was one of the authors who was bitten on the right palm near the base of the index finger by D. siamensis. The patient experienced local effects, neurological manifestations, and acute kidney injury. The laboratory analysis revealed elevated D-dimer and coagulopathy. The patient was administered 8 vials of antivenom and did not undergo surgical intervention or endotracheal tube intubation, but serum sickness occurred 8 days after antivenom administration. The horse immunoglobulin produced by the Centers for Disease Control, R. O. C. (Taiwan), against D. siamensis was effective and safe in the treatment of the patient. However, the best antivenom administration strategy remains unclear and requires further study.
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13
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Puzari U, Fernandes PA, Mukherjee AK. Advances in the Therapeutic Application of Small-Molecule Inhibitors and Repurposed Drugs against Snakebite. J Med Chem 2021; 64:13938-13979. [PMID: 34565143 DOI: 10.1021/acs.jmedchem.1c00266] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The World Health Organization has declared snakebite as a neglected tropical disease. Antivenom administration is the sole therapy against venomous snakebite; however, several limitations of this therapy reinforce the dire need for an alternative and/or additional treatment against envenomation. Inhibitors against snake venoms have been explored from natural resources and are synthesized in the laboratory; however, repurposing of small-molecule therapeutics (SMTs) against the principal toxins of snake venoms to inhibit their lethality and/or obnoxious effect of envenomation has been garnering greater attention owing to their established pharmacokinetic properties, low-risk attributes, cost-effectiveness, ease of administration, and storage stability. Nevertheless, SMTs are yet to be approved and commercialized for snakebite treatment. Therefore, we have systematically reviewed and critically analyzed the scenario of small synthetic inhibitors and repurposed drugs against snake envenomation from 2005 to date and proposed novel approaches and commercialization strategies for the development of efficacious therapies against snake envenomation.
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Affiliation(s)
- Upasana Puzari
- Department of Molecular Biology and Biotechnology, School of Sciences, Tezpur University, Tezpur-784028, Assam, India
| | - Pedro Alexandrino Fernandes
- LAQV@REQUIMTE, Departamento de Química e Bioquímica, Faculdade de Ciências, Universidade do Porto, Rua Do Campo Alegre S/N, 4169-007 Porto, Portugal
| | - Ashis K Mukherjee
- Department of Molecular Biology and Biotechnology, School of Sciences, Tezpur University, Tezpur-784028, Assam, India.,Institute of Advanced Study in Science and Technology, Vigyan Path Garchuk, Paschim Boragaon, Guwahati-781035, Assam, India
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14
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Influential Factors of Local Tissue Necrosis after Taiwan Cobra Bites: A Secondary Analysis of the Clinical Significance of Venom Detection in Patients of Cobra Snakebites. Toxins (Basel) 2021; 13:toxins13050338. [PMID: 34067062 PMCID: PMC8151269 DOI: 10.3390/toxins13050338] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/30/2021] [Accepted: 05/05/2021] [Indexed: 12/04/2022] Open
Abstract
Local tissue swelling, inflammation, and wound necrosis are observed in Taiwan cobra bites. Knowledge of the factors influencing local tissue necrosis after cobra bites might improve the cobra bite treatment strategy. Therefore, we aimed to explore the factors influencing local tissue necrosis after cobra bites. This was a retrospective observational cohort study. All patients clinical presentations including serum venom levels for determining the influential factors in this study were obtained from Hung et al.’s previous study. Clinical features, such as bite information, initial swelling, patient presentation time, serum venom levels, and antivenom, use were extracted. The measurement outcome was the development of wound necrosis. The factors influencing wound necrosis were investigated using univariate and logistic regression analyses. The influential factors of local tissue necrosis and their areas under the curve were: initial limb swelling, 0.88; presentation time × serum level, 0.80; initial necrosis, 0.75; patient presentation time, 0.70. Serum venom level alone cannot be used as a predictive factor. The development of tissue necrosis might be associated with the venom factor, time factor, and their interaction. These influential factors can be used in future studies to evaluate antivenom efficacy.
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15
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Yeh H, Gao SY, Lin CC. Wound Infections from Taiwan Cobra ( Naja atra) Bites: Determining Bacteriology, Antibiotic Susceptibility, and the Use of Antibiotics-A Cobra BITE Study. Toxins (Basel) 2021; 13:toxins13030183. [PMID: 33801318 PMCID: PMC7999477 DOI: 10.3390/toxins13030183] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/17/2021] [Accepted: 02/25/2021] [Indexed: 02/04/2023] Open
Abstract
Wound necrosis and secondary infection are common complications after Naja atra bites. Clinical tools to evaluate the infection risk after Taiwan cobra bites are lacking. In this Cobra BITE study, we investigated the prevalence of wound infection, bacteriology, and corresponding antibiotic usage in patients presenting with Taiwan cobra snakebites. Patients with wound infection lacking tissue necrosis were included in developing Cobra BITE score utilizing univariate and multiple logistic regression, as patients with wound necrosis require antibiotics for infection treatment. 8,295,497 emergency department visits occurred in the span of this study, with 195 of those patients being diagnosed as having cobra bites. Of these patients, 23 had wound necrosis, and 30 had wound infection, resulting in a wound infection rate of 27.2% (53/195). Enterococcus faecalis and Morganella morganii were the main bacteria identified in the culture report regardless of whether patients’ wounds had necrosis. As per our Cobra BITE score, the three factors predicting secondary wound infection after cobra bites are hospital admission, a white blood cell count (in 103/µL) × by neu-trophil-lymphocyte ratio value of ≥114.23, and the use of antivenin medication. The area under the receiver operating characteristic curve for the Cobra BITE score system was 0.88; ideal sensitivity and specificity were 0.89 and 0.76. This scoring system enables the assessment of wound infections after N. atra bites, and it could be modified and improved in the future for other Naja spp. bites.
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Affiliation(s)
- Heng Yeh
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.Y.); (S.-Y.G.)
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shi-Ying Gao
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.Y.); (S.-Y.G.)
| | - Chih-Chuan Lin
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.Y.); (S.-Y.G.)
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence:
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16
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Ho CH, Ismail AK, Liu SH, Tzeng YS, Li LY, Pai FC, Hong CW, Mao YC, Chiang LC, Lin CS, Tsai SH. The role of a point-of-care ultrasound protocol in facilitating clinical decisions for snakebite envenomation in Taiwan: a pilot study. Clin Toxicol (Phila) 2021; 59:794-800. [PMID: 33605805 DOI: 10.1080/15563650.2021.1881535] [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] [Indexed: 10/22/2022]
Abstract
BACKGROUND The incidence of acute compartment syndrome (ACS) following snakebite envenomation may be seriously overestimated in Taiwan. Snakebite-induced ACS is difficult to determine solely by clinical examination. Snakebite patients previously underwent surgical intervention based on speculation and general clinical examinations suggesting ACS presentations instead of direct intracompartmental pressure (IP) measurement prior to fasciotomy. Point-of-care ultrasound (POCUS) is a relatively widely available noninvasive tool. This study aimed to evaluate snakebite-envenomated patients for the presence of subcutaneous edema and diastolic retrograde arterial flow (DRAF). MATERIALS AND METHODS Snakebite patients were prospectively recruited between 2017 and 2019. All patients were examined with POCUS to locate edema and directly visualize and measure the arterial flow in the compressed artery. The presence of DRAF in the compressed artery is suggestive of ACS development because when compartment space restriction occurs, increased retrograde arterial flow is observed in the artery. RESULTS Twenty-seven snakebite patients were analyzed. Seventeen patients (63%) were bitten by Crotalinae snakes, seven (26%) by Colubridae, one (4%) by Elapidae, and two (7%) had unidentified snakebites. All Crotalinae bit patients received antivenom, had subcutaneous edema and lacked DRAF in a POCUS examination series. DISCUSSION POCUS facilitates clinical decisions for snakebite envenomation. We also highlighted that the anatomic site of the snakebite is an important factor affecting the prognosis of the wounds. There were limitations of this study, including a small number of patients and no comparison with the generally accepted invasive evaluation for ACS. CONCLUSIONS We are unable to state that POCUS is a valid surrogate measurement of ACS from this study but see this as a starting point to develop further research in this area. Further study will be needed to better define the utility of POCUS in patients envenomated by snakes throughout the world.
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Affiliation(s)
- Cheng-Hsuan Ho
- Department of Emergency Medicine, Tri-Service General Hospital, Taipei, Taiwan.,National Taiwan University College of Medicine, Graduate Institute of Toxicology, Taipei, Taiwan
| | - Ahmad Khaldun Ismail
- Emergency Medicine, Jalan Yaacob Latif, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Shing-Hwa Liu
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yuan-Sheng Tzeng
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ling-Yuan Li
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Feng-Cheng Pai
- Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Wei Hong
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yan-Chiao Mao
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Liao-Chun Chiang
- College of Life Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Chin-Sheng Lin
- Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Division of Cardiology, Department of Internal Medicine, Taipei, Taiwan
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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17
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Tan CH, Liew JL, Chong HP, Tan NH. Protein decomplexation and proteomics: A complementary assessment method of the physicochemical purity of antivenom. Biologicals 2021; 69:22-29. [PMID: 33431232 DOI: 10.1016/j.biologicals.2020.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/28/2020] [Accepted: 12/22/2020] [Indexed: 01/21/2023] Open
Abstract
The quality of antivenom is governed by its safety and efficacy profiles. These quality characteristics are much influenced by the purity of antivenom content. Rigorous assessment and meticulous monitoring of antivenom purity at the preclinical setting is hence crucial. This study aimed to explore an integrative proteomic method to assess the physicochemical purity of four commercially available antivenoms in the region. The antivenoms were subjected to Superdex 200 HR 10/30 size-exclusion fast-protein liquid chromatography (SE-FPLC). The proteins in each fraction were trypsin-digested and analyzed by nano-ESI-liquid chromatography-tandem mass spectrometry (LC-MS/MS). SE-FPLC resolved the antivenom proteins into three major protein components of very high (>200 kDa), high (100-120 kDa) and medium (<60 kDa) molecular weights. The major components (80-95% of total proteins) in the antivenoms were proteins of 100-120 kDa consisting of mainly the light and partially digested heavy immunoglobulin chains, consistent with F(ab')2 as the active principle of the antivenoms. However, LC-MS/MS also detected substantial quantity of large proteins (e.g. alpha-2-macroglobulins), immunoglobulin aggregates and impurities e.g. albumins in some products. The method is practical and able to unveil the quantitative and qualitative aspects of antivenom protein compositions. It is therefore a potentially useful preclinical assessment tool of antivenom purity.
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Affiliation(s)
- Choo Hock Tan
- Venom Research and Toxicology Laboratory, Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Jia Lee Liew
- Venom Research and Toxicology Laboratory, Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ho Phin Chong
- Venom Research and Toxicology Laboratory, Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nget Hong Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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18
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Chuang PC, Chang KW, Cheng SY, Pan HY, Huang KC, Huang YT, Li CJ. Benefits of Early In-Hospital Antivenom Administration to Patients with Protobothrops mucrosquamatus Envenomation. Am J Trop Med Hyg 2020; 104:323-328. [PMID: 33146122 DOI: 10.4269/ajtmh.20-0659] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Protobothrops mucrosquamatus is one of the common venomous snakes in Southeast Asia. This retrospective cohort study conducted in six medical institutions in Taiwan aimed to obtain information on the optimal management strategies for P. mucrosquamatus snakebite envenomation. Data were extracted from the Chang Gung Research Database from January 2006 to December 2016. The association between early antivenom administration and patient demographics, pain requiring treatment with analgesic injections, and hospital length of stay was analyzed. A total of 195 patients were enrolled; 130 were administered antivenom within 1 hour after emergency department arrival (early group), whereas 65 were treated later than 1 hour after arrival (late group). No in-hospital mortality was identified. The difference in surgical intervention rates between the early and late groups was statistically insignificant (P = 0.417). Compared with the early group, the late group showed a higher rate of antivenom skin test performance (46.9% versus 63.1%, respectively, P = 0.033), longer hospital stay (42 ± 62 hours versus 99 ± 70 hours, respectively, P = 0.016), and higher rate of incidences of pain requiring treatment with analgesic injections (29.2% versus 46.2%, respectively, P = 0.019). After adjusting for confounding factors, early antivenom administration was associated with decreased pain requiring treatment with analgesic injections (adjusted odds ratio: 0.51, 95% CI: 0.260-0.985). Antivenom administration within 1 hour of arrival was associated with a decreased likelihood of experiencing pain and hospital length of stay in patients with P. mucrosquamatus snakebites. Antivenom skin testing was associated with delays in antivenom administration.
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Affiliation(s)
- Po-Chun Chuang
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Kang-Wei Chang
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Shih-Yu Cheng
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Hsiu-Yung Pan
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan.,2Chang Gung University College of Medicine, Taoyuan City, Taiwan
| | - Kuo-Chen Huang
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Yii-Ting Huang
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Chao-Jui Li
- 1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
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19
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Lin CC, Chen YC, Goh ZNL, Seak CK, Seak JCY, Shi-Ying G, Seak CJ. Wound Infections of Snakebites from the Venomous Protobothrops mucrosquamatus and Viridovipera stejnegeri in Taiwan: Bacteriology, Antibiotic Susceptibility, and Predicting the Need for Antibiotics-A BITE Study. Toxins (Basel) 2020; 12:toxins12090575. [PMID: 32906845 PMCID: PMC7551380 DOI: 10.3390/toxins12090575] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 12/18/2022] Open
Abstract
Snakebites from Taiwan habus (Protobothrops mucrosquamatus) and green bamboo vipers (Viridovipera stejnegeri) account for two-thirds of all venomous snakebites in Taiwan. While there has been ongoing optimization of antivenin therapy, the proper management of superimposed bacterial wound infections is not well studied. In this Bacteriology of Infections in Taiwanese snake Envenomation (BITE) study, we investigated the prevalence of wound infection, bacteriology, and corresponding antibiotic usage in patients presenting with snakebites from these two snakes. We further developed a BITE score to evaluate the probability of wound infections and guide antibiotic usage in this patient population. All snakebite victims who presented to the emergency departments of seven training and research hospitals and received at least one vial of freeze-dried hemorrhagic antivenin between January 2001 and January 2017 were identified. Patient biodata, laboratory investigation results, and treatment modalities were retrieved. We developed our BITE score via univariate and multiple logistic regression analyses. The receiver operating characteristic (ROC) curve was plotted to evaluate the predictive performance of the BITE score. Out of 8,295,497 emergency department visits, 726 patients presented with snakebites from a Taiwan habu or a green bamboo viper. The wound infection rate was 22.45%, with seven positive wound cultures, including six polymicrobial infections. Morganella morganii, Enterococcus spp., Bacteroides fragilis, and Aeromonas hydrophila were most frequently cultured. There were no positive blood cultures. A total of 33.0% (n = 106) of snakebite patients who received prophylactic antibiotics nevertheless developed wound infections, while 44.8% (n = 73) of wound infection patients were satisfactorily treated with one of the following antibiotics: amoxicillin/clavulanic acid, oxacillin, cefazolin, and ampicillin/sulbactam. With the addition of gentamicin, the success of antibiotic therapy increased by up to 66.54%. The prognostic factors for the secondary bacterial infection of snakebites were white blood cell counts, the neutrophil lymphocyte ratio, and the need for hospital admission. The area under the ROC curve for the BITE score was 0.839. At the optimal cut-off point of 5, the BITE score had a 79.58% accuracy, 82.31% sensitivity, and 79.71% specificity when predicting infection in snakebite patients. Our BITE score may help with antibiotic stewardship by guiding appropriate antibiotic use in patients presenting with snakebites. It may also be employed in further studies into antibiotic prophylaxis in snakebite patients for the prevention of superimposed bacterial wound infections.
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Affiliation(s)
- Chih-Chuan Lin
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (C.-C.L.); (G.S.-Y.); (S.I.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Yen-Chia Chen
- Department of Emergency medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
- Department of Emergency Medicine, School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
| | - Zhong Ning Leonard Goh
- Sarawak General Hospital, Kuching, Sarawak 93586, Malaysia; (Z.N.L.G.); (C.-K.S.); (J.C.-Y.S.)
| | - Chen-Ken Seak
- Sarawak General Hospital, Kuching, Sarawak 93586, Malaysia; (Z.N.L.G.); (C.-K.S.); (J.C.-Y.S.)
| | - Joanna Chen-Yeen Seak
- Sarawak General Hospital, Kuching, Sarawak 93586, Malaysia; (Z.N.L.G.); (C.-K.S.); (J.C.-Y.S.)
| | - Gao Shi-Ying
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (C.-C.L.); (G.S.-Y.); (S.I.)
| | - Chen-June Seak
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (C.-C.L.); (G.S.-Y.); (S.I.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Emergency Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City 23652, Taiwan
- Correspondence:
| | - SPOT Investigators
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (C.-C.L.); (G.S.-Y.); (S.I.)
- Sarawak General Hospital, Kuching, Sarawak 93586, Malaysia; (Z.N.L.G.); (C.-K.S.); (J.C.-Y.S.)
- Department of Emergency Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City 23652, Taiwan
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20
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Risk factors associated with snake antivenom reaction and the role of skin test. Acta Trop 2020; 203:105293. [PMID: 31821788 DOI: 10.1016/j.actatropica.2019.105293] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/22/2019] [Accepted: 12/06/2019] [Indexed: 11/21/2022]
Abstract
Antivenom reactions are a common complication of snake antivenom. This study aimed to identify predicators of antivenom reaction and the involvement of antivenom skin test in antivenom reaction development. This retrospective cohort study was conducted in six medical institutions in Taiwan. Data were extracted from the Chang Gung Research Database (CGRD) from January 2006 to December 2016. The association between antivenom reaction and patient demographics, type and dose of antivenom, and skin test results was analyzed. The study enrolled 799 patients, including 219 who developed antivenom reactions. Compared to patients receiving both freeze-dried hemorrhagic (FH) and freeze-dried neurotoxic (FN) antivenom, those administered a single type had a lower antivenom reaction risk (adjusted odds ratios [aORs]: 0.5 and 0.4, 95% confidence interval [CI]: 0.35-0.74 and 0.24-0.69, FH and FN respectively). Patients administered a higher antivenom dose (≥ 5 vials) had higher antivenom reaction risk (aOR: 1.8, 95% CI: 1.23-2.76). A positive skin test result was also associated with antivenom reaction (aOR: 16.7, 95% CI: 5.42-51.22). The skin test showed high specificity (98.5%, 95% CI: 97.49%-99.83%) but low sensitivity (17.5%, 95% CI: 10.74%-24.18%). The antivenom skin test should be abolished because of the extremely low sensitivity and possible misinterpretation of results because of the limitation of this examination.
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Huang TI, Hsieh CL. Effect of Traditional Chinese Medicine on Long-Term Outcomes of Snakebite in Taiwan. Toxins (Basel) 2020; 12:E132. [PMID: 32093388 PMCID: PMC7076781 DOI: 10.3390/toxins12020132] [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: 01/15/2020] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 11/16/2022] Open
Abstract
Herein, we review the characteristics of the six predominant venomous snakes in Taiwan and the effects of traditional Chinese medicine on the long-term outcomes of snakebite venom. We electronically searched databases, including PubMed, ClinicalKey, China National Knowledge Infrastructure, National Digital Library of Theses and Dissertations in Taiwan, and Airiti Library, from their inception to November 2019 by using the following Medical Subject Headings' keywords: snakebite, long-term, chronic, Chinese medicine, CAM, herb, and Taiwan. The most common long-term effects of snakebite envenomation include "migraine-like syndrome", brain injuries caused by hypoxia or intracranial hemorrhage, and chronic kidney disease. In addition, hypopituitarism is also worth mentioning. Traditional Chinese medicine can potentially be used in a complementary or alternative treatment for these effects, but additional studies are needed.
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Affiliation(s)
- Teng-I Huang
- Department of Chinese Medicine, China Medical University Hospital, Taichung 40447, Taiwan;
| | - Ching-Liang Hsieh
- Department of Chinese Medicine, China Medical University Hospital, Taichung 40447, Taiwan;
- Chinese Medicine Research Center, China Medical University, Taichung 40402, Taiwan
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, Taichung 40402, Taiwan
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Liu CC, Chou YS, Chen CY, Liu KL, Huang GJ, Yu JS, Wu CJ, Liaw GW, Hsieh CH, Chen CK. Pathogenesis of local necrosis induced by Naja atra venom: Assessment of the neutralization ability of Taiwanese freeze-dried neurotoxic antivenom in animal models. PLoS Negl Trop Dis 2020; 14:e0008054. [PMID: 32032357 PMCID: PMC7032728 DOI: 10.1371/journal.pntd.0008054] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 02/20/2020] [Accepted: 01/14/2020] [Indexed: 02/07/2023] Open
Abstract
Naja atra envenomation is one of the most significant clinical snakebite concerns in Taiwan. Taiwanese freeze-dried neurotoxic antivenom (FNAV) is currently used clinically for the treatment of cobra snakebite, and has been shown to limit the mortality of cobra envenomation to less than 1%. However, more than half of victims (60%) require surgery because of local tissue necrosis, a major problem in patients with cobra envenomation. Although the importance of evaluating the neutralizing effect of FNAV on this pathology is recognized, whether FNAV is able to prevent the local necrosis extension induced by N. atra venom has not been investigated in detail. Cytotoxins (CTXs) are considered as the major components of N. atra venom that cause necrosis. In the current study, we isolated CTXs from whole cobra venom and used both whole venom and purified CTXs to develop animal models for assessing the neutralization potential of FNAV against venom necrotizing activity. Local necrotic lesions were successfully produced in mice using CTXs in place of whole N. atra venom. FNAV was able to rescue mice from a subcutaneously injected lethal dose of cobra venom; however, it was unable to prevent CTX-induced dermo-necrosis. Furthermore, using the minimal necrosis dose (MND) of CTXs and venom proteome data, we found a dose of whole N. atra venom suitable for FNAV and developed a workable protocol for inducing local necrosis in rodent models that successfully imitated the clinical circumstance of cobra envenoming. This information provides a more comprehensive understanding of the pathophysiology of N. atra envenomation, and serves as a guide for improving current antivenom strategies and advancing clinical snakebite management in Taiwan. Naja atra envenomation is an important public health issue in Taiwan. Although the mortality rate of cobra snakebite is controlled using antivenom, more than half of victims develop symptoms of local necrosis and require surgical intervention. Whether the Taiwanese freeze-dried neurotoxic antivenom (FNAV) currently in clinical use is able to prevent the local necrosis extension induced by N. atra venom is still unclear. In this study, we developed a dermo-necrosis animal model using purified cytotoxins (CTXs), the major necrosis-related proteins from N. atra venom. We found that FNAV was able to neutralize the lethality of whole cobra venom, but was unable to neutralize the necrosis induced by CTXs in vivo. This finding introduced an example that supplementary quality control assays may be necessary to determine the effectiveness of antivenoms in neutralizing specific pathology induced by the venom; only evaluating the rodent lethality prevention is insufficient. Our results provide insights that should help improve current antivenoms and advance cobra snakebite management in Taiwan.
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Affiliation(s)
- Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Shao Chou
- Department of Emergency Medicine, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Chun-Yu Chen
- Department of Emergency Medicine, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Kuei-Lin Liu
- Faculty of Biotechnology and Laboratory Science in Medicine, School of Medical Technology and Engineering, National Yang-Ming University, Taipei, Taiwan
| | - Guo-Jen Huang
- Department and Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
- Department of Cell and Molecular Biology, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Liver Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- Research Center for Food and Cosmetic Safety, Research Center for Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Cho-Ju Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Geng-Wang Liaw
- Department of Emergency Medicine, Yeezen General Hospital, Taoyuan, Taiwan
| | - Cheng-Hsien Hsieh
- Department of Emergency Medicine, En Chu Kong Hospital, New Taipei City, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- * E-mail: (CHH); (CKC)
| | - Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
- * E-mail: (CHH); (CKC)
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Tsai TH, Lin CC, Mao YC, Hung CL, Yang YC, Yang CC, Jeng MJ. Naja atra venom-spit ophthalmia in Taiwan: An epidemiological survey from 1990 to 2016. J Chin Med Assoc 2020; 83:77-83. [PMID: 31714443 DOI: 10.1097/jcma.0000000000000223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Venomous snakebites are common during hot seasons in Taiwan. However, rarely is venom spat directly into the subject's eyes, causing eye injury. Despite being uncommon, analytical data regarding venom-spit ophthalmia in Taiwan have been lacking. This study thus aimed to conduct an epidemiological survey on Naja atra venom-spit ophthalmia in Taiwan during the past decades to improve future care of such patients. METHODS Registered records of cases with snake venom injuries at the Taiwan National Poison Control Center from 1990 to 2016 were retrospectively reviewed, enrolling those with records of cobra venom-spit eye injuries and excluding exotic species. Demographic data, clinical symptoms, snake species, ocular conditions, management, and outcomes were recorded and analyzed. RESULTS A total of 39 cases suffering from Naja atra venom-spit ophthalmia were enrolled. The overall incidence rate was 1.6 cases per million people from 1990 to 2016. Among the included cases, most were unilaterally injured (82%), male (95%), aged 18 to 59 years (90%), injured during catching (51%), and injured in spring and summer (92%). Ocular symptoms occurred in 90% of the cases, majority of which included ocular pain (90%) and redness (85%). Conjunctivitis (67%) and corneal injury (59%) of involved eyes were common. Immediate water irrigations were done in all cases, most of whom received further topical eye drops, including antibiotics, corticosteroids, and vasoconstrictors. Although topical or intravenous antivenoms were administered in 11 cases, no obviously superior outcome was observed. Most cases (77%) were symptom free after the acute stage. CONCLUSION Although Naja atra venom-spit ophthalmia in Taiwan is uncommon, the risk for transient ocular symptoms and corneal/conjunctival injury does exists. Prompt ocular irrigation and professional ophthalmic care after envenomation help prevent serious ocular sequelae. Moreover, superior outcomes were not achieved with the use of antivenom. Nonetheless, further studies are required to clarify the role antivenoms play in venom-spit ophthalmia.
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Affiliation(s)
- Tsung-Han Tsai
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Department of Emergency, Taichung Armed Forces General Hospital, Taichung, Taiwan, ROC
- Department of Emergency, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chun-Chi Lin
- Division of Occupational Medicine, Department of Family Medicine, National Yang-Ming University Hospital, I-Lan, Taiwan, ROC
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yan-Chiao Mao
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Chia-Lien Hung
- Department of Medical Education and Research, Taichung Armed Forces General Hospital, Taichung, Taiwan, ROC
| | - Yi-Chiang Yang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chen-Chang Yang
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Mei-Jy Jeng
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Chen PC, Huang MN, Chang JF, Liu CC, Chen CK, Hsieh CH. Snake venom proteome and immuno-profiling of the hundred-pace viper, Deinagkistrodon acutus, in Taiwan. Acta Trop 2019; 189:137-144. [PMID: 30268686 DOI: 10.1016/j.actatropica.2018.09.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/31/2018] [Accepted: 09/20/2018] [Indexed: 01/17/2023]
Abstract
Deinagkistrodon acutus, also known as the hundred-pace viper or Chinese moccasin, is a clinically significant venomous snake in Taiwan. To address the lack of knowledge on the venom proteome of D. acutus, the venom composition was studied by a bottom-up proteomic approach combining reverse phase high-performance liquid chromatography, SDS-PAGE, and LC-MS/MS analysis. The immunoreactivity and cross-reactivity of Taiwanese freeze-dried D. acutus antivenom (DA-AV) and hemorrhagic antivenom (FH-AV) were investigated, as well. The proteomic analysis revealed the presence of 29 distinct proteins from D. acutus venom belonging to 8 snake venom protein families. Snake venom metalloproteinase (SVMP, 46.86%), C-type lectin (CLEC, 37.59%), phospholipase A2 (PLA2, 7.33%) and snake venom serine protease (SVSP, 6.62%) were the most abundant proteins. In addition to DA-AV, FH-AV also showed a profile of broad immunorecognition toward the venom of D. acutus. Remarkably, both antivenoms specifically reacted with the HPLC fractions containing SVMPs, and the titer was 5-10 times higher than fractions of other components. This information helps us to deeply understand the pathophysiology of D. acutus envenomation and guide us to development of more effective antivenom for clinical treatment.
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Affiliation(s)
- Po-Chuan Chen
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ming-Nan Huang
- Department of Emergency Medicine, En Chu Kong Hospital, New Taipei City, Taiwan; Department of Medical Laboratory Science and Biotechnology, Yuanpei University, Hsinchu, Taiwan
| | - Jia-Feng Chang
- Department of Medical Laboratory Science and Biotechnology, Yuanpei University, Hsinchu, Taiwan; Divison of Nephrology, Department of Internal Medicine, En-Chu-Kong Hospital, New Taipei City, Taiwan; Renal Care Joint Foundation, Taipei, Taiwan
| | - Chien-Chun Liu
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Cheng-Hsien Hsieh
- Department of Emergency Medicine, En Chu Kong Hospital, New Taipei City, Taiwan; Department of Medical Laboratory Science and Biotechnology, Yuanpei University, Hsinchu, Taiwan.
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Liu CC, Yu JS, Wang PJ, Hsiao YC, Liu CH, Chen YC, Lai PF, Hsu CP, Fann WC, Lin CC. Development of sandwich ELISA and lateral flow strip assays for diagnosing clinically significant snakebite in Taiwan. PLoS Negl Trop Dis 2018; 12:e0007014. [PMID: 30507945 PMCID: PMC6292642 DOI: 10.1371/journal.pntd.0007014] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 12/13/2018] [Accepted: 11/21/2018] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Tao-Yuan, Taiwan
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Tao-Yuan, Taiwan
- Department of Cell and Molecular Biology, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
- Liver Research Center, Chang Gung Memorial Hospital, Linkou, Tao-Yuan, Taiwan
- Research Center for Food and Cosmetic Safety, Research Center for Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan
| | - Po-Jung Wang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
| | - Yung-Chin Hsiao
- Molecular Medicine Research Center, Chang Gung University, Tao-Yuan, Taiwan
- Liver Research Center, Chang Gung Memorial Hospital, Linkou, Tao-Yuan, Taiwan
| | - Chien-Hsin Liu
- Center for Research, Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
| | - Yen-Chia Chen
- Department of Emergency medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Pei-Fang Lai
- Department of Emergency, Buddihist Tzu Chi Hospital, Hualien, Taiwan
| | - Chih-Po Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan, Taiwan
| | - Wen-Chih Fann
- Department of Emergency Medicine, Chia-Yi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chih-Chuan Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
- * E-mail:
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Translational Venomics: Third-Generation Antivenomics of Anti-Siamese Russell's Viper, Daboia siamensis, Antivenom Manufactured in Taiwan CDC's Vaccine Center. Trop Med Infect Dis 2018; 3:tropicalmed3020066. [PMID: 30274462 PMCID: PMC6073718 DOI: 10.3390/tropicalmed3020066] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 06/07/2018] [Accepted: 06/11/2018] [Indexed: 12/20/2022] Open
Abstract
The venom proteome of Siamese Russell’s viper from Taiwan, alongside complementary in vivo lethality neutralization assay and in vitro third-generation antivenomics assessment of the preclinical efficacy of the homologous antivenom manufactured in Taiwan CDC’s Vaccine Center, are here reported. Taiwanese Russell’s viper venom proteome comprised 25 distinct gene products, with the heterodimeric PLA2 viperotoxin-F representing the most abundant toxin (47.5% of total venom proteome). Coagulation FV-activating serine proteinase (RVV-V, 14%), the PIV-SVMP activator of FX (RVV-FX, 8.5%), and less abundant toxins from nine protein families, make up its venom proteome. Venom composition-pathology correlations of D. siamensis envenomings in Taiwan are discussed. The lethal effect of Taiwanese D. siamensis venom was 0.47 mg/g mouse. Antivenomics-guided assessment of the toxin recognition landscape of the Taiwanese Russell’s viper antivenom, in conjunction with complementary in vivo neutralization analysis, informed the antivenom’s maximal toxin immunorecognition ability (14 mg total venom proteins/vial), neutralization capacity (6.5 mg venom/vial), and relative content of lethality neutralizing antibodies (46.5% of the toxin-binding F(ab’)2 antibodies). The antivenomics analysis also revealed suboptimal aspects of the CDC-Taiwan antivenom. Strategies to improve them are suggested.
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Identification of Immunoreactive Peptides of Toxins to Simultaneously Assess the Neutralization Potency of Antivenoms against Neurotoxicity and Cytotoxicity of Naja atra Venom. Toxins (Basel) 2017; 10:toxins10010010. [PMID: 29295601 PMCID: PMC5793097 DOI: 10.3390/toxins10010010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 11/17/2022] Open
Abstract
Assessing the neutralization capability of nonlethal but medically relevant toxins in venom has been a challenging task. Nowadays, neutralization efficacy is evaluated based simply on the survival rates of animals injected with antivenom together with a predefined dose of venom, which can determine potency against neurotoxicity but not validate the capability to neutralize cytotoxin-induced complications. In this study, a high correlation with in-vivo and in-vitro neutralization assays was established using the immunoreactive peptides identified from short-chain neurotoxin and cytotoxin A3. These peptides contain conserved residues associated with toxin activities and a competition assay indicated that these peptides could specifically block the antibody binding to toxin and affect the neutralization potency of antivenom. Moreover, the titers of peptide-specific antibody in antivenoms or mouse antisera were determined by enzyme-linked immunosorbent assay (ELISA) simultaneously, and the results indicated that Taiwanese bivalent antivenom (BAV) and Vietnamese snake antivenom-Naja (SAV-Naja) exhibited superior neutralization potency against the lethal effect of short-chain neurotoxin (sNTX) and cytotoxicity of cardiotoxin/cytotoxin (CTX), respectively. Thus, the reported peptide ELISA shows not only its potential for antivenom prequalification use, but also its capability of justifying the cross-neutralization potency of antivenoms against Naja atra venom toxicity.
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Liu CC, You CH, Wang PJ, Yu JS, Huang GJ, Liu CH, Hsieh WC, Lin CC. Analysis of the efficacy of Taiwanese freeze-dried neurotoxic antivenom against Naja kaouthia, Naja siamensis and Ophiophagus hannah through proteomics and animal model approaches. PLoS Negl Trop Dis 2017; 11:e0006138. [PMID: 29244815 PMCID: PMC5747474 DOI: 10.1371/journal.pntd.0006138] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 12/29/2017] [Accepted: 11/28/2017] [Indexed: 11/18/2022] Open
Abstract
In Southeast Asia, envenoming resulting from cobra snakebites is an important public health issue in many regions, and antivenom therapy is the standard treatment for the snakebite. Because these cobras share a close evolutionary history, the amino acid sequences of major venom components in different snakes are very similar. Therefore, either monovalent or polyvalent antivenoms may offer paraspecific protection against envenomation of humans by several different snakes. In Taiwan, a bivalent antivenom—freeze-dried neurotoxic antivenom (FNAV)—against Bungarus multicinctus and Naja atra is available. However, whether this antivenom is also capable of neutralizing the venom of other species of snakes is not known. Here, to expand the clinical application of Taiwanese FNAV, we used an animal model to evaluate the neutralizing ability of FNAV against the venoms of three common snakes in Southeast Asia, including two ‘true’ cobras Naja kaouthia (Thailand) and Naja siamensis (Thailand), and the king cobra Ophiophagus hannah (Indonesia). We further applied mass spectrometry (MS)-based proteomic techniques to characterize venom proteomes and identify FNAV-recognizable antigens in the venoms of these Asian snakes. Neutralization assays in a mouse model showed that FNAV effectively neutralized the lethality of N. kaouthia and N. siamensis venoms, but not O. hannah venom. MS-based venom protein identification results further revealed that FNAV strongly recognized three-finger toxin and phospholipase A2, the major protein components of N. kaouthia and N. siamensis venoms. The characterization of venom proteomes and identification of FNAV-recognizable venom antigens may help researchers to further develop more effective antivenom designed to block the toxicity of dominant toxic proteins, with the ultimate goal of achieving broadly therapeutic effects against these cobra snakebites. Cobra envenomation is a public health issue in Southeast Asia. Currently, antivenom therapy is the standard treatment for snakebite. However, antivenoms are not available in many rural countries and communities or have only limited effectiveness. Taiwan has wealth of experience in producing antivenoms, including the bivalent freeze-dried neurotoxic antivenom (FNAV), which is raised against venom proteins from Bungarus multicinctus and Naja atra. Our results showed that FNAV effectively neutralized the lethality of Naja kaouthia(Thailand) and Naja siamensis (Thailand) venoms, but not Ophiophagus hannah (Indonesia) venom, in an animal model. We further characterized the venom proteome profiles of the four cobras and identified three abundant proteins—neurotoxin, cytotoxin and phospholipase A2—in the venom of N. atra, N. kaouthia and N. siamensisas the major antigens recognized by FNAV. In contrast, we found that β-cardiotoxin and phospholipase A2, common toxin proteins in all king cobra venom samples, are weakly or not recognized by FNAV. Our data provide evidence suggesting the potential use of Taiwan’s FNAV to treat envenomation by other cobra species (N. kaouthia and N. siamensis) in Southeast Asia. Moreover, our findings support the previous recommendation and current experimental approach that major cobra toxins are used as antigens to generate more efficient antivenoms than those currently available.
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Affiliation(s)
- Chien-Chun Liu
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chen-Hsien You
- Department of Medicine, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Po-Jung Wang
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Jau-Song Yu
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
- Department of Cell and Molecular Biology, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
- Molecular Medicine Research Center, Chang Gung University, Tao-Yuan, Taiwan
- Liver Research Center, Chang Gung Memorial Hospital, Linkou, Tao-Yuan, Taiwan
- * E-mail: (JSY); (CCL)
| | - Guo-Jen Huang
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chien-Hsin Liu
- Center for Research, Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
| | - Wen-Chin Hsieh
- Center for Research, Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
| | - Chih-Chuan Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Tao-Yuan, Taiwan
- * E-mail: (JSY); (CCL)
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Contributing Factors for Complications and Outcomes in Patients With Snakebite: Experience in a Medical Center in Southern Taiwan. Ann Plast Surg 2017; 78:S32-S36. [PMID: 28195896 DOI: 10.1097/sap.0000000000001002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Snakebite usually results in various complications, such as significant soft tissue damage, infection, hematological, and neurological deficit. Surgical intervention, usually, is indicated in patients with tissue necrosis, infection, and compartment syndrome. To identify the contributing factors for complications and outcomes in different patients with snakebite so that outcomes can be evaluated and treatment of such patients can be initiated at the earliest. METHODS Information was collected regarding age, sex, underlying disease, species of snake, and the course of treatment of the victims of snakebite who visited the emergency department of a medical center in southern Taiwan between 2004 and 2014. The data obtained were analyzed using SPSS 20.0. RESULTS The bites from Taiwan cobra (Naja naja atra) significantly resulted in more complications than those from other snakes and required surgical intervention. The use of antivenin and antibiotics, immediate presentation to the hospital, and the location of the bite also were significant contributing factors. CONCLUSIONS Taiwan cobra significantly results in higher possibility of prolonged hospitalization, operation, tissue necrosis, infection, and necrotizing fasciitis. Location of the bite, immediate presentation to the hospital, and use of antivenin and antibiotics affect the outcome of snakebite. Knowledge of these factors will help in a better management of patients with snakebite.
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Mao YC, Liu PY, Chiang LC, Liao SC, Su HY, Hsieh SY, Yang CC. Bungarus multicinctus multicinctus Snakebite in Taiwan. Am J Trop Med Hyg 2017; 96:1497-1504. [PMID: 28719273 DOI: 10.4269/ajtmh.17-0005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractAlthough specific antivenom is available in Taiwan, respiratory failure and general pain frequently accompany Bungarus multicinctus envenomation and there have been few reports on the management of B. multicinctus envenomation. We retrospectively analyzed 44 cases of B. multicinctus bite admitted to Taichung Veterans General Hospital (VGH) or to Taipei VGH. Demographic data, treatment, and outcome of patients with and without respiratory failure were compared. In this study, 20.5% patients had bites without noticeable signs or symptoms of significant envenoming, 27.3% developed respiratory failure, and 27.3% experienced general pain. Bivalent specific antivenom for B. multicinctus and N. atra was administered in all envenomed cases. Respiratory failure occurred 1.5-6.5 hours post-bite and general pain occurred 1-12 hours post-bite. Specific antivenom for B. multicinctus and N. atra at the recommended dose (i.e., 2-4 vials) might not effectively prevent respiratory failure and pain. Respiratory failure, general pain, and autonomic effects after B. multicinctus bite were probably caused, at least partly, by β-bungarotoxin. Although general weakness, ptosis, dysarthria, and dilated pupils were significantly associated with respiratory failure, their predictive value could not be accurately determined in such a retrospective study. Due to the rapid onset of respiratory failure, every suspected envenomed case thus should be closely monitored in the first few hours. We recommend the initial administration of four vials of antivenom in all envenomation cases, and a subsequent four vials be considered if the patient's condition is deteriorating. Prospective evaluation of the antivenom dosing regimen is urgently needed to improve B. multicinctus envenomation treatment.
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Affiliation(s)
- Yan-Chiao Mao
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Po-Yu Liu
- Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Liao-Chun Chiang
- National Health Research Institutes, National Institute of Infectious Diseases and Vaccinology, Miaoli, Taiwan.,National Tsing Hua University, College of Life Sciences, Hsinchu, Taiwan
| | - Shu-Chen Liao
- Department of Emergency Medicine, Chang Guang Memorial Hospital, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Yuan Su
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Szu-Yin Hsieh
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chen-Chang Yang
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Mao YC, Liu PY, Chiang LC, Lai CS, Lai KL, Ho CH, Wang TH, Yang CC. Naja atra snakebite in Taiwan. Clin Toxicol (Phila) 2017; 56:273-280. [PMID: 28830248 DOI: 10.1080/15563650.2017.1366502] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Naja atra snakebite is uncommon in Taiwan and causes distinct effects on its victims. Although the Taiwan government produces its own specific antivenom, little information on the management of N. atra snakebite is available. MATERIALS AND METHODS We retrospectively evaluated 183 patients admitted to two medical centers. Of these, 45 were identified as definite cases of N. atra snakebite, 86 as suspected cases, and 52 as clinical cases. Demographic data, symptomatology, and management were compared between these case groups. RESULTS Symptomatology and management were similar in the three groups. Among the 183 patients, 10 (5.5%) were asymptomatic and nine (4.9%) had transient and partial ptosis or body weakness. The principal effects were local tissue swelling and pain in 173 patients (94.5%), followed by clinically suspected wound infection in 148 (80.9%), skin necrosis in 120 (65.6%), necrotizing soft tissue infection in 77 (42.1%), fever in 59 (32.2%), and gastrointestinal effects in 53 (29%). The median total dose of specific antivenom needed to treat N. atra envenoming was 10 vials. In the envenomed patients, debridement was required in 74 patients (42.8%), fasciotomy/fasciectomy in 46 (26.6%), and finger or toe amputation in seven (4%). The first operation was performed at a median of 3.5 days after the bite. DISCUSSION AND CONCLUSIONS Based on these typical manifestations, clinical diagnosis of N. atra snakebites may be feasible and practical. In contrast to other snakes of Elapidae family, N. atra bite did not cause serious neurological effects. Early surgical consultation should be obtained because half of the patients underwent surgery due to infectious complications. Acute compartment syndrome was the surgical indication in rare cases; however, overestimation of the incidence may have occurred. This syndrome should be confirmed by serial intracompartmental pressure monitoring instead of only physical examination, and a sufficient dose of antivenom should be given prior to surgical decompression.
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Affiliation(s)
- Yan-Chiao Mao
- a Division of Clinical Toxicology, Department of Emergency Medicine , Taichung Veterans General Hospital , Taichung , Taiwan.,b Division of Clinical Toxicology and Occupational Medicine, Department of Medicine , Taipei Veterans General Hospital , Taipei , Taiwan.,c Institute of Environmental and Occupational Health Sciences , School of Medicine, National Yang-Ming University , Taipei , Taiwan.,d School of Medicine , National Defense Medical Center , Taipei , Taiwan
| | - Po-Yu Liu
- e Division of Infection, Department of Medicine , Taichung Veterans General Hospital , Taichung , Taiwan.,f Rong Hsing Research Center for Translational Medicine , National Chung Hsing University , Taichung , Taiwan
| | - Liao-Chun Chiang
- g College of Life Sciences , National Tsing Hua University , Hsinchu , Taiwan
| | - Chih-Sheng Lai
- h Division of Plastic and Reconstructive Surgery, Department of Surgery , Taichung Veterans General Hospital , Taichung , Taiwan
| | - Kuo-Lung Lai
- i Division of Allergy, Immunology and Rheumatology, Department of Medicine , Taichung Veterans General Hospital , Taichung , Taiwan
| | - Cheng-Hsuan Ho
- d School of Medicine , National Defense Medical Center , Taipei , Taiwan.,j Department of Emergency Medicine , Tri-Service General Hospital , Taipei , Taiwan
| | - Te-Huo Wang
- b Division of Clinical Toxicology and Occupational Medicine, Department of Medicine , Taipei Veterans General Hospital , Taipei , Taiwan.,k Department of Emergency Medicine , National Yang-Ming University Hospital , Yilan , Taiwan
| | - Chen-Chang Yang
- b Division of Clinical Toxicology and Occupational Medicine, Department of Medicine , Taipei Veterans General Hospital , Taipei , Taiwan.,c Institute of Environmental and Occupational Health Sciences , School of Medicine, National Yang-Ming University , Taipei , Taiwan
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A Survey of Snakebite Knowledge among Field Forces in China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 14:ijerph14010015. [PMID: 28035960 PMCID: PMC5295266 DOI: 10.3390/ijerph14010015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/22/2016] [Accepted: 12/20/2016] [Indexed: 01/09/2023]
Abstract
Background: A snakebite is a neglected extrinsic injury associated with high morbidity and global mortality. Members of Chinese field forces are at high risk of snakebites, and their perception and knowledge of snakebites are unknown. The aim of this study is to assess perception and knowledge of snakebites in field forces in southeast China; Methods: A cross-sectional questionnaire-based survey was conducted in July 2016. A total of 216 field force members participated in this study; Results: A total of 10.3% had experienced snakebites and 86.4% rated their demands for knowledge about snakebite as “high”. No significant correlation between the actual and perceived snakebite knowledge status was detected (κ = 0.0237, p = 0.3852). Ineffective and harmful traditional first-aid methods, such as the application of tourniquets, sucking the venom out of the wound, and making local incisions, were used by more than three quarters of the respondents. However, pressure immobilization bandages were applied by only 17.3% of members. The proportion of responses for each question was not significantly different among the respondents when considering separate demographic groups; Conclusions: Snakebite knowledge among Chinese field force members is inadequate and in some cases misleading, when focusing on manifestation, prevention, and first-aid. A pragmatic, intensive educational scheme should be undertaken in at-risk populations.
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