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Dobaja Borak M, Babić Ž, Caganova B, Grenc D, Karabuva S, Kolpach Z, Krakowiak A, Kolesnikova V, Lukšić B, Pap C, Puljiz I, Piekarska-Wijatkowska A, Radenkova-Saeva J, Vučinić S, Zacharov S, Eddleston M, Brvar M. Viper envenomation in Central and Southeastern Europe: a multicentre study. Clin Toxicol (Phila) 2023; 61:656-664. [PMID: 37988116 DOI: 10.1080/15563650.2023.2273761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Snakebite incidence varies across Europe. However, there is limited research from Central and Southeastern Europe. These regions are notable for the presence of the common European adder (Vipera berus) and the more venomous nose-horned viper (Vipera ammodytes). No standard European antivenom protocol exists. The aim was to assess the epidemiology and treatment of viper bites in this region, focusing on a comparison of bites from Vipera berus and Vipera ammodytes. METHODS We conducted a prospective multicenter study in Central and Southeastern Europe from 2018 to 2020. This study included poison centres and toxicology-associated hospital wards in Poland, the Czech Republic, Slovakia, Hungary, Slovenia, Croatia, Serbia, and Bulgaria. The following data were collected: age, gender, Vipera species, snakebite site, clinical picture, laboratory results, Audebert's clinical severity grading score, and antivenom therapy. RESULTS The annual incidence of viper bites in Central and Southeast Europe was estimated at 2.55 bites per million population. Within their respective geographical distribution areas, the incidence of Vipera ammodytes bites (1.61 bites per million population) was higher than Vipera berus bites (1.00 bites per million population). Patients bitten by Vipera ammodytes more frequently reported local pain and developed thrombocytopenia. Antivenom treatment was more commonly administered in Vipera ammodytes bites (72%) compared to Vipera berus bites (39%). The incidence of Vipera ammodytes bites treated with antivenom within its geographical distribution area was three times higher than Vipera berus bites treated with antivenom (1.16 bites per million population versus 0.39 bites per million population). No deaths were reported. CONCLUSIONS The estimated incidence of viper bites in Central and Southeastern Europe is at least 2.55 per million population. Vipera ammodytes bites are more common and severe, characterized by higher frequencies of pain and thrombocytopenia. Antivenom is needed more often for Vipera ammodytes bites. It is vital that enough European Medicines Agency-approved Vipera ammodytes antivenom is produced and offered affordably.
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Affiliation(s)
- Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Željka Babić
- Poison Centre, Institute for Medical Research and Occupational Health, Zagreb, Croatia
| | - Blažena Caganova
- National Toxicological Information Centre, University Hospital, Bratislava, Slovakia
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital of Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Zuzana Kolpach
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Anna Krakowiak
- Nofer Institute of Occupational Medicine, Łódź, Poland
- Clinic of Anesthesiology and Intensive Care, Toxicology Unit, Central Clinical Hospital of the Medical University of Łódź, Łódź, Poland
| | - Viktoriia Kolesnikova
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital of Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Csaba Pap
- Department of Toxicology, Péterfy Hospital, Budapest, Hungary
| | - Ivan Puljiz
- University hospital for infectious diseases "Dr. Fran Mihaljević", Zagreb, Croatia
| | | | - Julia Radenkova-Saeva
- Clinic of Toxicology, University Hospital for Emergency Medicine "N.I.Pirogov", Sofia, Bulgaria
| | - Slavica Vučinić
- National Poison Centre, Military Medical Academy, Medical Faculty University of Defense, Belgrade, Serbia
| | - Sergej Zacharov
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Michael Eddleston
- Department of Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Osipov A, Utkin Y. What Are the Neurotoxins in Hemotoxic Snake Venoms? Int J Mol Sci 2023; 24:ijms24032919. [PMID: 36769242 PMCID: PMC9917609 DOI: 10.3390/ijms24032919] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/10/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Snake venoms as tools for hunting are primarily aimed at the most vital systems of the prey, especially the nervous and circulatory systems. In general, snakes of the Elapidae family produce neurotoxic venoms comprising of toxins targeting the nervous system, while snakes of the Viperidae family and most rear-fanged snakes produce hemotoxic venoms directed mainly on blood coagulation. However, it is not all so clear. Some bites by viperids results in neurotoxic signs and it is now known that hemotoxic venoms do contain neurotoxic components. For example, viperid phospholipases A2 may manifest pre- or/and postsynaptic activity and be involved in pain and analgesia. There are other neurotoxins belonging to diverse families ranging from large multi-subunit proteins (e.g., C-type lectin-like proteins) to short peptide neurotoxins (e.g., waglerins and azemiopsin), which are found in hemotoxic venoms. Other neurotoxins from hemotoxic venoms include baptides, crotamine, cysteine-rich secretory proteins, Kunitz-type protease inhibitors, sarafotoxins and three-finger toxins. Some of these toxins exhibit postsynaptic activity, while others affect the functioning of voltage-dependent ion channels. This review represents the first attempt to systematize data on the neurotoxins from "non-neurotoxic" snake venom. The structural and functional characteristic of these neurotoxins affecting diverse targets in the nervous system are considered.
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Sharif AF, Kasemy ZA, Alshabibi RA, Almufleh SJ, Abousamak FW, Alfrayan AA, Alshehri M, Alemies RA, Almuhsen AS, AlNasser SN, Al-Mulhim KA. Prognostic factors in acute poisoning with central nervous system xenobiotics: development of a nomogram predicting risk of intensive care unit admission. Toxicol Res (Camb) 2022; 12:62-75. [PMID: 36866212 PMCID: PMC9972822 DOI: 10.1093/toxres/tfac084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 11/01/2022] [Accepted: 12/05/2022] [Indexed: 12/27/2022] Open
Abstract
Background Acute intoxication with central nervous system (CNS) xenobiotics is an increasing global problem. Predicting the prognosis of acute toxic exposure among patients can significantly alter the morbidity and mortality. The present study outlined the early risk predictors among patients diagnosed with acute exposure to CNS xenobiotics and endorsed bedside nomograms for identifying patients requiring intensive care unit (ICU) admission and those at risk of poor prognosis or death. Methods This study is a 6-year retrospective cohort study conducted among patients presented with acute exposure to CNS xenobiotics. Results A total of 143 patients' records were included, where (36.4%) were admitted to the ICU, and a significant proportion of which was due to exposure to alcohols, sedative hypnotics, psychotropic, and antidepressants (P = 0.021). ICU admission was associated with significantly lower blood pressure, pH, and HCO3 levels and higher random blood glucose (RBG), serum urea, and creatinine levels (P < 0.05). The study findings indicate that the decision of ICU admission could be determined using a nomogram combining the initial HCO3 level, blood pH, modified PSS, and GCS. HCO3 level < 17.1 mEq/L, pH < 7.2, moderate-to-severe PSS, and GCS < 11 significantly predicted ICU admission. Moreover, high PSS and low HCO3 levels significantly predicted poor prognosis and mortality. Hyperglycemia was another significant predictor of mortality. Combining initial GCS, RBG level, and HCO3 is substantially helpful in predicting the need for ICU admission in acute alcohol intoxication. Conclusion The proposed nomograms yielded significant straightforward and reliable prognostic outcomes predictors in acute exposure to CNS xenobiotics.
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Affiliation(s)
- Asmaa F Sharif
- Corresponding author: Clinical Medical Sciences Department, College of Medicine, Dar AlUloom University, Riyadh, Al-Falah, 13314, Saudi Arabia.
| | - Zeinab A Kasemy
- Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Shebin ElKom, Egypt
| | | | - Salem J Almufleh
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | | | | | - Muath Alshehri
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - Rakan A Alemies
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - Assim S Almuhsen
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - Shahd N AlNasser
- Poison Control Department, Emergency Medicine Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Khalid A Al-Mulhim
- Emergency Medicine Department, King Fahad Medical City, Riyadh, 1125, Saudi Arabia
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Siigur J, Siigur E. Biochemistry and toxicology of proteins and peptides purified from the venom of Vipera berus berus. Toxicon X 2022; 15:100131. [PMID: 35769869 PMCID: PMC9234072 DOI: 10.1016/j.toxcx.2022.100131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/05/2022] [Accepted: 06/06/2022] [Indexed: 12/19/2022] Open
Abstract
The isolation and characterization of individual snake venom components is important for a deeper understanding of the pathophysiology of envenomation and for improving the therapeutic procedures of patients. It also opens possibilities for the discovery of novel toxins that might be useful as tools for understanding cellular and molecular processes. The variable venom composition, toxicological and immunological properties of the common vipers (Vipera berus berus) have been reviewed. The combination of venom gland transcriptomics, bottom-up and top-down proteomics enabled comparison of common viper venom proteomes from multiple individuals. V. b. berus venom contains proteins and peptides belonging to 10–15 toxin families: snake venom metalloproteinase, phospholipases A2 (PLA2), snake venom serine proteinase, aspartic protease, L-amino acid oxidase (LAAO), hyaluronidase, 5′-nucleotidase, glutaminyl-peptide cyclotransferase, disintegrin, C-type lectin (snaclec), nerve growth factor, Kunitz type serine protease inhibitor, snake venom vascular endothelial growth factor, cysteine-rich secretory protein, bradykinin potentiating peptide, natriuretic peptides. PLA2 and LAAO from V. b. berus venom produce more pronounced cytotoxic effects in cancer cells than normal cells, via induction of apoptosis, cell cycle arrest and suppression of proliferation. Proteomic data of V. b. berus venoms from different parts of Russia and Slovakian Republic have been compared with analogous data for Vipera nikolskii venom. Proteomic studies demonstrated quantitative differences in the composition of V. b. berus venom from different geographical regions. Differences in the venom composition of V. berus were mainly driven by the age, sex, habitat and diet of the snakes. The venom variability of V. berus results in a loss of antivenom efficacy against snakebites. The effectiveness of antibodies is discussed. This review presents an overview with a special focus on different toxins that have been isolated and characterized from the venoms of V. b. berus. Their main biochemical properties and toxic actions are described. Vipera berus berus venom composition is variable among different populations. Venom contains about 15 protein/peptide families. It disturbs blood coagulation inducing pro- or anticoagulant effects. Venom contains different types of blood factor X activators. PLA2 and L-amino acid oxidase produce cytotoxic effects in cancer cells.
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Bhattacharya S, Krishnamurthy A, Gopalakrishnan M, Kalra S, Kantroo V, Aggarwal S, Surana V. Endocrine and Metabolic Manifestations of Snakebite Envenoming. Am J Trop Med Hyg 2020; 103:1388-1396. [PMID: 32602439 DOI: 10.4269/ajtmh.20-0161] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Snakebite envenoming is a neglected, public health problem in tropical and subtropical regions. Local tissue necrosis, neurotoxic, and hemo-vasculotoxic effects are well-recognized features, whereas the endocrine and metabolic derangements are not as well known. In addition to contributing to morbidity, some of these manifestations can be potentially life-threatening if not recognized early. The most prominent endocrine manifestation is hypopituitarism (HP), which can manifest acutely or remain asymptomatic and present years later. Unexplained recurrent hypoglycemia and refractory hypotension are early clinical clues to suspect corticotroph axis involvement in acute settings. Chronic pituitary failure may present, like Sheehan's syndrome, several years after the bite. The occurrence of acute kidney injury, capillary leak syndrome, and disseminated intravascular coagulation are predictors of HP. Adrenal hemorrhages are documented in autopsy series; however, primary adrenal insufficiency is very rare and confounded by the presence of HP. Hyponatremia, hypokalemia or hyperkalemia, and dysglycemia can occur, but the mechanisms involved are only partially understood. Awareness, a high index of suspicion, correct interpretation of hormonal parameters, and timely treatment of these abnormalities can be lifesaving.
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Affiliation(s)
| | | | - Maya Gopalakrishnan
- Department of General Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
| | - Viny Kantroo
- Department of Respiratory Critical Care and Sleep Medicine, Apollo Hospitals, New Delhi, India
| | - Sameer Aggarwal
- Department of Endocrinology, Apex Plus Superspeciality Hospital, Rohtak, India
| | - Vineet Surana
- Department of Endocrinology, Manipal Hospital, New Delhi, India
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Paolino G, Di Nicola MR, Pontara A, Didona D, Moliterni E, Mercuri SR, Grano M, Borgianni N, Kumar R, Pampena R. Vipera snakebite in Europe: a systematic review of a neglected disease. J Eur Acad Dermatol Venereol 2020; 34:2247-2260. [PMID: 32530549 DOI: 10.1111/jdv.16722] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022]
Abstract
In 2009, snakebites were included in the list of the World Health Organization (WHO) neglected diseases. Dermatological literature lacks current and up-to-date articles about snakebites and their management, despite the fact that dermatologists, especially from rural hospitals, can be called into the emergency room to consult the management of suspected snakebites. In this systematic review, we highlighted the main clinical and laboratory aspects of snakebites from Vipera spp. in Europe, by reviewing 3574 studies initially retrieved from PubMed, Embase and Cochrane CENTRAL databases. Of these, 78 were finally included in the systematic review. We found that the most involved taxon was V. berus in 63.3% and the most involved anatomic site of the bite was the upper limbs 53.1% with fang marks reported in 90.5%. The mean age of the patients was 32.9 years, and bites were slightly more common among males (58.2%). A wound washing was performed in 86.9% of cases before the hospitalization. The most frequently reported grade of envenomation was G2 (42.2%). In addition to local dermatological symptoms (extended erythema, oedema, cutaneous necrosis, hives, purpura, petechiae, acute compartment syndrome), numerous systemic symptoms have also been reported, including fatigue (14.4%), pain (75.3%), fever (49.2%), direct anaphylactoid reaction (5.3%), anxiety (60.8%), cranial nerve neurotoxicity (14.8%), dysesthesia/paraesthesia (7.9%), vomiting (33.7%), abdominal pain (23.3%), diarrhoea (15.4%), dyspnoea (6.3%), proteinuria (10.6%) and haematuria (9.3%). Secondary infections were present in 3.5% and disseminated intravascular coagulation in 3.1% of cases, and fasciotomy was performed in 4.2% cases, while an amputation in 6.9%. Only 0.9% of patients died. Antivenom was administered in 3053 cases. In conclusion, there is a pressing need for robust multi-centre randomized control trials, standardized protocol for snakebite management and antivenom administration across Europe and a National snakebite register for each European country.
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Affiliation(s)
- G Paolino
- Clinica Dermatologica, La Sapienza University of Rome, Rome, Italy.,Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - A Pontara
- Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - D Didona
- Department of Dermatology and Allergology, Philipps Medical University of Marburg, Marburg, Germany
| | - E Moliterni
- Clinica Dermatologica, La Sapienza University of Rome, Rome, Italy
| | - S R Mercuri
- Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | - M Grano
- Via Valcenischia, Rome, Italy
| | | | - R Kumar
- Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | - R Pampena
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Giftschlangen in Deutschland und Europa. Hautarzt 2018; 69:681-702. [DOI: 10.1007/s00105-018-4222-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Halassy B, Kurtović T, Lang Balija M. Comment on "Antivenom for European Vipera species envenoming". Clin Toxicol (Phila) 2018. [PMID: 29521124 DOI: 10.1080/15563650.2018.1448402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Beata Halassy
- a Centre for Research and Knowledge Transfer in Biotechnology , University of Zagreb , Zagreb , Croatia
| | - Tihana Kurtović
- a Centre for Research and Knowledge Transfer in Biotechnology , University of Zagreb , Zagreb , Croatia
| | - Maja Lang Balija
- a Centre for Research and Knowledge Transfer in Biotechnology , University of Zagreb , Zagreb , Croatia
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Extending knowledge of the clinical picture of Balkan adder (Vipera berus bosniensis) envenoming: The first photographically-documented neurotoxic case from South-Western Hungary. Toxicon 2018; 143:29-35. [PMID: 29305081 DOI: 10.1016/j.toxicon.2017.12.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/11/2017] [Accepted: 12/30/2017] [Indexed: 02/05/2023]
Abstract
We report a severe envenoming associated with minimal local symptoms following a Balkan adder (Vipera berus bosniensis) bite in South-Western Hungary. A 63-year-old male with a history of hypertension and sinus bradycardia (45/min) was bitten by a sub-adult specimen of V. b. bosniensis in Somogy County on 04 May 2017. The patient was transported to and treated at the Emergency Department of "Moritz Kaposi" General Hospital, Kaposvár. Locally only pain and minimal swelling with a small haematoma developed on the bitten finger. The abdominal muscles were very tender and guarding was detected upon palpation on the way to hospital. The patient, who had taken his telmisartan (80 mg) tablet in that morning, complained of nausea and dizziness during the first medical examination. The systemic signs included fluctuations in blood pressure (115/85-165/105 mmHg), ECG changes (transient horizontal ST depression in V5-6, and sinus tachycardia (90/min)), severe diarrhoea and vomiting (in 7 episodes). Descending neuromuscular paralysis appeared in the next morning, including complete bilateral ptosis with external ophthalmoplegia, and binocular diplopia. Single-fiber electromyography confirmed the neuromuscular block in the frontalis muscle innervated by the facial nerve. Intense dizziness with uncoordinated movement emerged on the 3rd day. The laboratory findings were mild, including anaemia, hypokalaemia, elevated glutamic-pyruvic transaminase and C-reactive protein levels. The absolute neutrophil count remained almost completely normal. Supportive care and monovalent antivenom (Viper Venom Antitoxin®, Biomed, Warsaw) were applied. The patient was discharged from hospital on the 4th day, although recovery was not complete until 9 days after the bite. This is the first photographically-documented case of neurotoxic envenoming from the South-Western Hungarian distribution range of V. b. bosniensis.
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Antivenom for Neuromuscular Paralysis Resulting From Snake Envenoming. Toxins (Basel) 2017; 9:toxins9040143. [PMID: 28422078 PMCID: PMC5408217 DOI: 10.3390/toxins9040143] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/11/2017] [Accepted: 04/13/2017] [Indexed: 02/06/2023] Open
Abstract
Antivenom therapy is currently the standard practice for treating neuromuscular dysfunction in snake envenoming. We reviewed the clinical and experimental evidence-base for the efficacy and effectiveness of antivenom in snakebite neurotoxicity. The main site of snake neurotoxins is the neuromuscular junction, and the majority are either: (1) pre-synaptic neurotoxins irreversibly damaging the presynaptic terminal; or (2) post-synaptic neurotoxins that bind to the nicotinic acetylcholine receptor. Pre-clinical tests of antivenom efficacy for neurotoxicity include rodent lethality tests, which are problematic, and in vitro pharmacological tests such as nerve-muscle preparation studies, that appear to provide more clinically meaningful information. We searched MEDLINE (from 1946) and EMBASE (from 1947) until March 2017 for clinical studies. The search yielded no randomised placebo-controlled trials of antivenom for neuromuscular dysfunction. There were several randomised and non-randomised comparative trials that compared two or more doses of the same or different antivenom, and numerous cohort studies and case reports. The majority of studies available had deficiencies including poor case definition, poor study design, small sample size or no objective measures of paralysis. A number of studies demonstrated the efficacy of antivenom in human envenoming by clearing circulating venom. Studies of snakes with primarily pre-synaptic neurotoxins, such as kraits (Bungarus spp.) and taipans (Oxyuranus spp.) suggest that antivenom does not reverse established neurotoxicity, but early administration may be associated with decreased severity or prevent neurotoxicity. Small studies of snakes with mainly post-synaptic neurotoxins, including some cobra species (Naja spp.), provide preliminary evidence that neurotoxicity may be reversed with antivenom, but placebo controlled studies with objective outcome measures are required to confirm this.
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Lamb T, de Haro L, Lonati D, Brvar M, Eddleston M. Antivenom for European Vipera species envenoming. Clin Toxicol (Phila) 2017; 55:557-568. [PMID: 28349771 DOI: 10.1080/15563650.2017.1300261] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND European viper bite is relatively uncommon but can cause serious envenoming, particularly swelling and hemorrhage spreading from limb to trunk that can cause long term disability. Systemic features are relatively mild compared to many other venomous species. Moderate-to-severe envenoming requires antivenom, which is given many hundreds of times each year across the continent. Several Vipera spp antivenoms are produced in Europe, but there is little comparative information available for the antivenoms and none is licensed with the European Medicines Agency. We aimed to collect descriptive data on European viper antivenoms and assess their relative effectiveness. METHODS A systematic review of articles relating to antivenom in Europe was performed using the Medline medical database. The following keywords "Europ*" or the individual names of each European country and "antiven*" or "immun*" or "envenom*" and "snake" or "viper*" or "adder" were used. Articles published between 1 January 1996 and 11 March 2016 pertaining to clinical outcome, including case reports, were selected. Referenced articles in the indexed articles were explored for suitability and included if they met any of the criteria: specific antivenom used, route of antivenom administration, adverse reactions to antivenom therapy and length of hospital admission. All accepted abstracts from EAPCCT conferences since 2000 were searched and abstracts relating to Vipera spp envenoming were assessed for suitability. We extracted data on study type, safety and effectiveness. We sought information on antivenoms from manufacturers and individual patient data from authors of publications. Since individual patient data were only rarely available, we compared median length of stay between case series reporting each antivenom. We identified 40 papers and six published abstracts, and one unpublished paper that reported clinical cases and case series of envenomed patients treated with antivenom. No publication reported randomized controlled trials comparing any European Vipera antivenom with either placebo or another antivenom. 25 reports were of retrospective hospital- (n = 13) or poison center-based (n = 12) case series including five or more patients; a further 12 reports were either case reports or case series with less than five patients and one paper was a limited literature review. An additional nine papers reported prospective data; seven collected data remotely through poison service telephone communication with the attending physicians. Antivenoms available in Europe: Eight antivenoms are available for European Vipera spp envenoming; a material safety data sheet providing information on manufacture was available for seven. Six are raised against V. berus or V. ammodytes venom; the seventh is raised against a mixture of V. ammodytes, V. aspis and V. berus venom and the eighth is raised against V. ammodytes, Macrovipera lebetina and Montivipera xanthina venom. Six manufacturers recommended intramuscular administration while two recommended intravenous administration. No randomized control trials comparing the effectiveness of antivenoms were identified. Pre-clinical data: We found two papers presenting comparative preclinical data. Clinical data: Clinical studies were predominantly retrospective and contained clinical data on antivenom used in 2602 patients; where the antivenom was identified (n = 2174), 2061 (94.8%) received Zagreb, ViperFAV or ViperaTAb antivenoms. There were few published data on the other antivenoms. Repeated use of antivenom: Repeat doses were reported in 230/1491 of cases (15.4%) where this information was recorded. Outcome and length of hospital stay: Intravenous administration of antivenom was associated with shorter length of hospital stay (median length of hospital stay in studies of intravenous ViperFAV or ViperaTAb ranged from 1 to 4.8 days versus 2 to 18 days for intramuscular Bulbio or Zagreb antivenoms). Antivenom versus no antivenom: Some small studies demonstrated no difference in the length of hospital stay in patients with equivalent envenomation grading who either did or did not receive antivenom. Adverse events: Adverse reactions were reported in 37 of 2408 cases (1.5%) including seven cases of anaphylaxis. CONCLUSIONS There are very limited pre-clinical comparative data and no randomised controlled trials assessing effectiveness of the antivenoms against different Vipera species. Most descriptive data suggest the efficacy of Zagreb, ViperFAV and ViperaTAb antivenoms by the intravenous route but not intramuscular route, although this is level D evidence. Reported adverse reactions were rare, suggesting that the modern intravenous antivenoms are of good quality. Better and more systematic data, including perhaps randomized controlled trials comparing different antivenoms, are required for the many hundreds of antivenom administrations that occur annually across Europe.
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Affiliation(s)
- Thomas Lamb
- a Department of Pharmacology, Toxicology, and Therapeutics , University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
| | - Luc de Haro
- b Centre Antipoison , Hôpital Sainte Marguerite , Marseilles , France
| | - Davide Lonati
- c Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Istituti Clinici Scientifici Maugeri , IRCCS Maugeri Hospital and University of Pavia , Pavia , Italy
| | - Miran Brvar
- d Centre for Clinical Toxicology and Pharmacology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Michael Eddleston
- a Department of Pharmacology, Toxicology, and Therapeutics , University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
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Schwarz ES, Kopec KT, Wiegand TJ, Wax PM, Brent J. Should We Be Using the Poisoning Severity Score? J Med Toxicol 2017; 13:135-145. [PMID: 28283941 DOI: 10.1007/s13181-017-0609-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 02/18/2017] [Accepted: 02/22/2017] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Despite the existence of a number of severity-of-illness classifications for other areas of medicine, toxicology research lacks a well-accepted method for assessing the severity of poisoning. The Poisoning Severity Score (PSS) was developed in the 1990s in Europe as a scoring system for poisonings reported to a poison center in order to describe a patient's most severe symptomatology. We reviewed the literature to describe how the PSS is utilized and describe its limitations. DISCUSSION We searched the medical literature in all languages using PUBMED, EMBASE, and SCOPUS from inception through August 2013 using predefined search terms. Out of 204 eligible publications, 40 met our criteria for inclusion in this review. There has been a paucity of published studies from North America that used the PSS. In some cases, the PSS was misapplied or modified from standard scoring, making a bottom line appraisal of the validity or reliability of the original version of the instrument challenging. The PSS has several subjective criteria, is time consuming to score, and is likely to be of little use with some types of poisonings, limiting its clinical utility. CONCLUSION The PSS was developed as a tool to document encounters with poisoned patients. However, it is used infrequently and, when applied, has been misused or modified from its original form. In its current form, it has limited clinical utility and likely cannot be broadly applied to many exposures due to their unique clinical circumstances. With better global collaboration among medical toxicologists, it is possible that a modified score could be developed for use clinically or as a research instrument.
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Affiliation(s)
- Evan S Schwarz
- Division of Emergency Medicine, Washington University School of Medicine, 660 South Euclid, Campus Box 8072, Saint Louis, MO, 63110, USA.
| | - Kathryn T Kopec
- Department of Emergency Medicine, Carolinas Medical Center, Medical Education Building, Third Floor 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Timothy J Wiegand
- Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Box 655, Rochester, NY, 14642, USA
| | - Paul M Wax
- Department of Emergency Medicine, University of Texas Southwestern School of Medicine, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Jeffrey Brent
- University of Colorado School of Medicine, 12605 E. 16th Ave, Aurora, CO, 80045, USA
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Lewin M, Samuel S, Merkel J, Bickler P. Varespladib (LY315920) Appears to Be a Potent, Broad-Spectrum, Inhibitor of Snake Venom Phospholipase A2 and a Possible Pre-Referral Treatment for Envenomation. Toxins (Basel) 2016; 8:toxins8090248. [PMID: 27571102 PMCID: PMC5037474 DOI: 10.3390/toxins8090248] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/11/2016] [Accepted: 08/15/2016] [Indexed: 01/07/2023] Open
Abstract
Snakebite remains a neglected medical problem of the developing world with up to 125,000 deaths each year despite more than a century of calls to improve snakebite prevention and care. An estimated 75% of fatalities from snakebite occur outside the hospital setting. Because phospholipase A2 (PLA2) activity is an important component of venom toxicity, we sought candidate PLA2 inhibitors by directly testing drugs. Surprisingly, varespladib and its orally bioavailable prodrug, methyl-varespladib showed high-level secretory PLA2 (sPLA2) inhibition at nanomolar and picomolar concentrations against 28 medically important snake venoms from six continents. In vivo proof-of-concept studies with varespladib had striking survival benefit against lethal doses of Micrurus fulvius and Vipera berus venom, and suppressed venom-induced sPLA2 activity in rats challenged with 100% lethal doses of M. fulvius venom. Rapid development and deployment of a broad-spectrum PLA2 inhibitor alone or in combination with other small molecule inhibitors of snake toxins (e.g., metalloproteases) could fill the critical therapeutic gap spanning pre-referral and hospital setting. Lower barriers for clinical testing of safety tested, repurposed small molecule therapeutics are a potentially economical and effective path forward to fill the pre-referral gap in the setting of snakebite.
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Affiliation(s)
- Matthew Lewin
- Research and Development, Ophirex, Inc., Corte Madera, CA 94925, USA.
- Center for Exploration and Travel Health, California Academy of Sciences, San Francisco, CA 94118, USA.
| | - Stephen Samuel
- General Medicine, Queen Elizabeth Hospital, King's Lynn, Norfolk PE30 4ET, UK.
| | - Janie Merkel
- Yale Center for Molecular Discovery, Yale University, West Haven, CT 06516, USA.
| | - Philip Bickler
- Anesthesia and Perioperative Care, University of California, San Francisco, CA 94143, USA.
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Latinović Z, Leonardi A, Šribar J, Sajevic T, Žužek MC, Frangež R, Halassy B, Trampuš-Bakija A, Pungerčar J, Križaj I. Venomics of Vipera berus berus to explain differences in pathology elicited by Vipera ammodytes ammodytes envenomation: Therapeutic implications. J Proteomics 2016; 146:34-47. [PMID: 27327134 DOI: 10.1016/j.jprot.2016.06.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/14/2016] [Accepted: 06/15/2016] [Indexed: 01/12/2023]
Abstract
UNLABELLED Vipera berus berus (Vbb) is the most widely distributed and Vipera ammodytes ammodytes (Vaa) the most venomous viper in Europe. In particular areas of the Old continent their toxic bites constitute a considerable public health problem. To make the current envenomation therapy more effective we have analysed the proteome of Vbb venom and compared it with that of Vaa. We found the proteome of Vbb to be much less complex and to contain smaller levels of particularly snaclecs and sPLA2s. Snaclecs are probably responsible for thrombocytopenia. The neurotoxic sPLA2s, ammodytoxins, are responsible for the most specific feature of the Vaa venom poisoning - induction of signs of neurotoxicity in patients. These molecules were not found in Vbb venom. Both venoms induce haemorrhage and coagulopathy in man. As Vaa and Vbb venoms possess homologous P-III snake venom metalloproteinases, the main haemorrhagic factors, the severity of the haemorrhage is dictated by concentration and specific activity of these molecules. The much greater anticoagulant effect of Vaa venom than that of Vbb venom lies in its higher extrinsic pathway coagulation factor-proteolysing activity and content of ammodytoxins which block the prothrombinase complex formation. BIOLOGICAL SIGNIFICANCE Envenomations by venomous snakes constitute a considerable public health problem worldwide, and also in Europe. In the submitted work we analysed the venom proteome of Vipera berus berus (Vbb), the most widely distributed venomous snake in Europe and compared it with the venom proteome of the most venomous viper in Europe, Vipera ammodytes ammodytes (Vaa). We have offered a possible explanation, at the molecular level, for the differences in clinical pictures inflicted by the Vbb and Vaa venoms. We have provided an explanation for the effectiveness of treatment of Vbb envenomation by Vaa antiserum and explained why full protection of Vaa venom poisoning by Vbb antiserum should not be always expected, especially not in cases of severe poisoning. The latter makes a strong case for Vaa antiserum production as we are faced with its shortage due to ceasing of production of two most frequently used products.
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Affiliation(s)
- Zorica Latinović
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Ljubljana, Slovenia; Jožef Stefan International Postgraduate School, Ljubljana, Slovenia
| | - Adrijana Leonardi
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Ljubljana, Slovenia
| | - Jernej Šribar
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Ljubljana, Slovenia
| | - Tamara Sajevic
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Ljubljana, Slovenia
| | - Monika C Žužek
- Institute of Physiology, Pharmacology and Toxicology, Veterinary Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Robert Frangež
- Institute of Physiology, Pharmacology and Toxicology, Veterinary Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Croatia
| | | | - Jože Pungerčar
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Ljubljana, Slovenia
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Ljubljana, Slovenia; Faculty of Chemistry and Chemical Technology, University of Ljubljana, Ljubljana, Slovenia.
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Martín C, Nogué S. Novedades en el envenenamiento por mordedura de víbora. Med Clin (Barc) 2015; 144:132-6. [DOI: 10.1016/j.medcli.2014.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 06/06/2014] [Accepted: 06/12/2014] [Indexed: 10/24/2022]
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Malina T, Babocsay G, Krecsák L, Erdész C. Further Clinical Evidence for the Existence of Neurotoxicity in a Population of the European Adder (Vipera berus berus) in Eastern Hungary: Second Authenticated Case. Wilderness Environ Med 2013; 24:378-83. [DOI: 10.1016/j.wem.2013.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 06/07/2013] [Accepted: 06/08/2013] [Indexed: 10/26/2022]
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Abstract
PURPOSE Snake bite to the eye is a rare event. Most cases reported in the literature are due to boa constrictor bites. This is a rare case of snake bite from a common adder (Vipera berus) to the ocular adnexa along with a retained intraorbital tooth. METHOD A 57-year-old man presented with a history of being bitten by an adder in the left eye upper lid 12 days previously while bending down to pick up a log at his farm. He developed a firm, tender lump in the medial part of his left upper eyelid. RESULT A CT scan revealed an extraconal curved calcific dense foreign body, about 5 mm in length consistent with adder's tooth in the superomedial part of left orbit. CONCLUSION There are few reports of adder bites on face, ear and neck. We report a rare case of adder bite on eyelid along with retained intraorbital fangs and its clinical outcome.
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Affiliation(s)
- Pallavi Tyagi
- Department of Ophthalmology, Raigmore Hospital , Inverness , United Kingdom
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Abstract
Snakebite is classified by the WHO as a neglected tropical disease. Envenoming is a significant public health problem in tropical and subtropical regions. Neurotoxicity is a key feature of some envenomings, and there are many unanswered questions regarding this manifestation. Acute neuromuscular weakness with respiratory involvement is the most clinically important neurotoxic effect. Data is limited on the many other acute neurotoxic manifestations, and especially delayed neurotoxicity. Symptom evolution and recovery, patterns of weakness, respiratory involvement, and response to antivenom and acetyl cholinesterase inhibitors are variable, and seem to depend on the snake species, type of neurotoxicity, and geographical variations. Recent data have challenged the traditional concepts of neurotoxicity in snake envenoming, and highlight the rich diversity of snake neurotoxins. A uniform system of classification of the pattern of neuromuscular weakness and models for predicting type of toxicity and development of respiratory weakness are still lacking, and would greatly aid clinical decision making and future research. This review attempts to update the reader on the current state of knowledge regarding this important issue.
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Affiliation(s)
- Udaya K. Ranawaka
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
- * E-mail:
| | - David G. Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Current World Literature. Curr Opin Rheumatol 2012; 24:119-22. [DOI: 10.1097/bor.0b013e32834f0d5d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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