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Tippett Barr BA, Brown G, Perry M, Ridzon R, Warrell DA. Sudden death after a bite by a lowland swamp viper (Proatheris superciliaris) in Malawi: Dying of fright? Toxicon 2023; 235:107324. [PMID: 37838003 DOI: 10.1016/j.toxicon.2023.107324] [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] [Revised: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 10/16/2023]
Abstract
Proatheris superciliaris, the lowland swamp viper, has a limited distribution along lakeshores and rivers in Malawi, Southern Tanzania, and central Mozambique. Its venom is known to be procoagulant. Only five P. superciliaris bites have been reported, all inflicted by captive snakes, and none was fatal. Here we present a case of sudden death following a bite by Proatheris superciliaris in rural Malawi that cannot be attributed to envenoming. A healthy 32-year-old woman was planting rice in a flooded rice paddy field when she suddenly told her sister in a quiet voice that she had been bitten by a snake. She then collapsed face-upwards into the ankle-deep water. She remained motionless while her sister and uncle carried her out of the rice paddy onto dry land a few meters away. The victim did not regain consciousness. Her uncle heard one exhalation but no further breathing. The snake responsible was killed by a friend. Although the venom of this species can cause life-threatening coagulopathy, this woman's death occurred too rapidly to be attributable to envenoming. Only two explanations seem plausible: anaphylaxis, or vasovagal shock triggered by fear. In the present case, the victim died within minutes of the bite, closely observed by her anxious relatives, but showed no features of anaphylaxis. In Malawi, as in much of sub-Saharan Africa, many people are reportedly terrified of snakes, believing that bites by almost any species can cause rapid death. In this case, death occurred less than 2 min after a bite from Proatheris superciliaris. We believe that the cause of death was most likely a severe vasovagal attack, in response to the fear and pain of the snakebite that triggered vasodilatation, bradycardia, and hypotension leading to cardiac arrest.
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Affiliation(s)
| | | | - Mike Perry
- African Reptiles & Venom, Johannesburg, South Africa
| | - Renee Ridzon
- Nyanja Health Research Institute, PO Box 579, Salima, Malawi
| | - David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, UK
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2
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Extreme Procoagulant Potency in Human Plasma of Venoms from the African Viperid Genera Atheris, Cerastes, and Proatheris and the Relative Efficacy of Antivenoms and Synthetic Enzyme-Inhibitors. Toxins (Basel) 2022; 14:toxins14120836. [PMID: 36548733 PMCID: PMC9788330 DOI: 10.3390/toxins14120836] [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: 11/01/2022] [Revised: 11/16/2022] [Accepted: 11/25/2022] [Indexed: 12/02/2022] Open
Abstract
The African viperid snake genera Atheris, Cerastes, and Proatheris are closely related, similar in size, but occupy extremely divergent ecological niches (arboreal in tropical rainforests, fossorial in deserts, and swamp-dwelling, respectively). Their venoms have not previously been subjected to comparative analyses for their action upon the coagulation of blood, most notably with significant data deficiencies from Atheris and Proatheris. In contrast, the closely related genus Echis is well-documented as capable of producing potent procoagulant effects. In light of this, we set out to compare the coagulotoxic actions of Atheris ceratophora, A. chlorechis, A. desaixi, A. nitschei, A. squamigera, C. cerastes, C. cerastes gasperettii, C. vipera, and Proatheris superciliaris and explore potential pharmacological interventions to reestablish normal blood coagulation. All venoms displayed extremely potent procoagulant effects, over twice as fast as the most potent Echis reported to date. Although Cerastes is used in the immunising mixture of two different regionally available antivenoms (Inoserp-MENA with C. cerastes, C. cerastes gasperettii, C. vipera and Saudi Arabian polyvalent with C. cerastes), none of the other species in this study are included in the immunising mixture of any antivenom. Notably, all the Cerastes species were only neutralised by the Inoserp-MENA antivenom. C. cerastes venom was not neutralised well by the Saudi Arabian antivenom, with the low levels of recognition for any of the Cerastes venoms suggesting a strong regional variation in the venom of this species, as the C. cerastes venom tested was of African (Tunisian) origin versus Saudi locality used in that antivenom's production. The other antivenoms (Micropharm EchiTAbG, ICP EchiTAb-Plus-ICP, Inosan Inoserp Pan-Africa, Premium Serums PANAF Sub-Sahara Africa, South African Vaccine Producers Echis, South African Vaccine Producers Polyvalent) all displayed trivial-to-no ability to neutralise the procoagulant toxicity of any of the Atheris, Cerastes, or Proatheris venoms. Comparative testing of the enzyme inhibitors DMPS, marimastat, and prinomastat, revealed a very potent neutralising capacity of marimastat, with prinomastat showing lower but still significant potency at the same molar concentration, while a 5× molar concentration of DMPS had no apparent effect on procoagulant venom effects normalized by the other inhibitors. These results and methods contribute to the body of knowledge of potential clinical effects and data necessary for evidence-based advancement of clinical management strategies.
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Review of the Mechanisms of Snake Venom Induced Pain: It's All about Location, Location, Location. Int J Mol Sci 2022; 23:ijms23042128. [PMID: 35216244 PMCID: PMC8879488 DOI: 10.3390/ijms23042128] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/12/2022] [Accepted: 02/14/2022] [Indexed: 02/06/2023] Open
Abstract
Pain—acute, chronic and debilitating—is the most feared neurotoxicity resulting from a survivable venomous snake bite. The purpose of this review is to present in a novel paradigm what we know about the molecular mechanisms responsible for pain after envenomation. Progressing from known pain modulating peptides and enzymes, to tissue level interactions with venom resulting in pain, to organ system level pain syndromes, to geographical level distribution of pain syndromes, the present work demonstrates that understanding the mechanisms responsible for pain is dependent on “location, location, location”. It is our hope that this work can serve to inspire the molecular and epidemiologic investigations needed to better understand the neurotoxic mechanisms responsible for these snake venom mediated diverse pain syndromes and ultimately lead to agent specific treatments beyond anti-venom alone.
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Chérifi F, Laraba-Djebari F. Bioactive Molecules Derived from Snake Venoms with Therapeutic Potential for the Treatment of Thrombo-Cardiovascular Disorders Associated with COVID-19. Protein J 2021; 40:799-841. [PMID: 34499333 PMCID: PMC8427918 DOI: 10.1007/s10930-021-10019-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 01/08/2023]
Abstract
As expected, several new variants of Severe Acute Respiratory Syndrome-CoronaVirus-2 (SARS-CoV-2) emerged and have been detected around the world throughout this Coronavirus Disease of 2019 (COVID-19) pandemic. Currently, there is no specific developed drug against COVID-19 and the challenge of developing effective antiviral strategies based on natural agents with different mechanisms of action becomes an urgent need and requires identification of genetic differences among variants. Such data is used to improve therapeutics to combat SARS-CoV-2 variants. Nature is known to offer many biotherapeutics from animal venoms, algae and plant that have been historically used in traditional medicine. Among these bioresources, snake venom displays many bioactivities of interest such as antiviral, antiplatelet, antithrombotic, anti-inflammatory, antimicrobial and antitumoral. COVID-19 is a viral respiratory sickness due to SARS-CoV-2 which induces thrombotic disorders due to cytokine storm, platelet hyperactivation and endothelial dysfunction. This review aims to: (1) present an overview on the infection, the developed thrombo-inflammatory responses and mechanisms of induced thrombosis of COVID-19 compared to other similar pathogenesis; (2) underline the role of natural compounds such as anticoagulant, antiplatelet and thrombolytic agents; (3) investigate the management of coagulopathy related to COVID-19 and provide insight on therapeutic such as venom compounds. We also summarize the updated advances on antiviral proteins and peptides derived from snake venoms that could weaken coagulopathy characterizing COVID-19.
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Affiliation(s)
- Fatah Chérifi
- USTHB, Faculty of Biological Sciences, Laboratory of Cellular and Molecular Biology, USTHB, BP 32, El-Alia, Bab Ezzouar, Algiers, Algeria
| | - Fatima Laraba-Djebari
- USTHB, Faculty of Biological Sciences, Laboratory of Cellular and Molecular Biology, USTHB, BP 32, El-Alia, Bab Ezzouar, Algiers, Algeria.
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5
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Youngman NJ, Chowdhury A, Zdenek CN, Coster K, Sundman E, Braun R, Fry BG. Utilising venom activity to infer dietary composition of the Kenyan horned viper (Bitis worthingtoni). Comp Biochem Physiol C Toxicol Pharmacol 2021; 240:108921. [PMID: 33122136 DOI: 10.1016/j.cbpc.2020.108921] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 09/29/2020] [Accepted: 10/18/2020] [Indexed: 02/07/2023]
Abstract
Bitis are well known for being some of the most commonly encountered and medically important snake species in all of Africa. While the majority of species possess potently anticoagulant venom, only B. worthingtoni is known to possess procoagulant venom. Although known to be the basal species within the genus, B. worthingtoni is an almost completely unstudied species with even basic dietary information lacking. This study investigated various aspects of the unique procoagulant effects of B. worthingtoni venom. Coagulation assays determined the primary procoagulant effect to be driven by Factor X activating snake venom metalloprotease toxins. In addition to acting upon the mammalian blood clotting cascade, B. worthingtoni venom was also shown to clot amphibian plasma. As previous studies have shown differences in clotting factors between amphibian and mammalian plasmas, individual enzymes in snake venoms acting on plasma clotting factors can be taxon-selective. As venoms evolve under purifying selection pressures, this suggests that the procoagulant snake venom metalloprotease toxins present in B. worthingtoni have likely been retained from a recent common ancestor shared with the related amphibian-feeding Proatheris superciliaris, and that both amphibians and mammals represent a substantial proportion of B. worthingtoni current diet. Thus, taxon-specific actions of venoms may have utility in inferring dietary composition for rare or difficult to study species. An important caveat is that to validate this hypothesis field studies investigating the dietary ecology of B. worthingtoni must be conducted, as well as further investigations of its venom composition to reconstruct the molecular evolutionary history of the toxins present.
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Affiliation(s)
- Nicholas J Youngman
- Toxin Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD 4072, Australia
| | - Abhinandan Chowdhury
- Toxin Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD 4072, Australia
| | - Christina N Zdenek
- Toxin Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD 4072, Australia
| | | | - Eric Sundman
- Universeum, Södra Vägen 50, 412 54 Gothenburg, Sweden
| | - Ralph Braun
- Serpentarium Calden, Birkenweg 11, 34379 Calden, Germany
| | - Bryan G Fry
- Toxin Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD 4072, Australia.
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Venomous Landmines: Clinical Implications of Extreme Coagulotoxic Diversification and Differential Neutralization by Antivenom of Venoms within the Viperid Snake Genus Bitis. Toxins (Basel) 2019; 11:toxins11070422. [PMID: 31331004 PMCID: PMC6669450 DOI: 10.3390/toxins11070422] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/29/2022] Open
Abstract
The genus Bitis comprises 17 snake species that inhabit Africa and the Arabian Peninsula. They are responsible for a significant proportion of snakebites in the region. The venoms of the two independent lineages of giant Bitis (B. arietans and again in the common ancestor of the clade consisting of B. gabonica, B. nasicornis, B. parviocula and B. rhinoceros) induce an array of debilitating effects including anticoagulation, hemorrhagic shock and cytotoxicity, whilst the dwarf species B. atropos is known to have strong neurotoxic effects. However, the venom effects of the other species within the genus have not been explored in detail. A series of coagulation assays were implemented to assess the coagulotoxic venom effects of fourteen species within the genus. This study identified procoagulant venom as the ancestral condition, retained only by the basal dwarf species B. worthingtoni, suggesting anticoagulant venom is a derived trait within the Bitis genus and has been secondarily amplified on at least four occasions. A wide range of anticoagulant mechanisms were identified, such as coagulant and destructive activities upon fibrinogen in both giant and dwarf Bitis and the action of inhibiting the prothrombinase complex, which is present in a clade of dwarf Bitis. Antivenom studies revealed that while the procoagulant effects of B. worthingtoni were poorly neutralized, and thus a cause for concern, the differential mechanisms of anticoagulation in other species were all well neutralized. Thus, this study concludes there is a wide range of coagulotoxic mechanisms which have evolved within the Bitis genus and that clinical management strategies are limited for the procoagulant effects of B. worthingtoni, but that anticoagulant effects of other species are readily treated by the South African polyvalent antivenom. These results therefore have direct, real-work implications for the treatment of envenomed patients.
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Wang H, Chen X, König E, Zhou M, Wang L, Chen T, Shaw C. Comparative Profiling of Three Atheris Snake Venoms: A. squamigera, A. nitschei and A. chlorechis. Protein J 2018; 37:353-360. [PMID: 30014259 DOI: 10.1007/s10930-018-9781-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A proteomic and transcriptomic comparative analysis of the venoms of three Atheris species (A. squamigera, A. nitschei and A. chlorechis) was carried out by size exclusion liquid chromatography, gel electrophoresis, mass spectrometry, and mRNA sequencing. The improved proteomic profiling utilised in this work was combined with transcript studies, advancing our insights into venom composition, protein distribution and inter-species variation among the three bush vipers. Crude venoms of all three samples contained at least 10-20 protein components, ranging in size from ≤ 3 to > 98 kDa. Both approaches yielded converging overall information, pointing to phospholipases, disintegrins, serine proteases and metalloproteases as the major toxin classes, which are likely to explain the local and systemic symptoms observed in envenomation by Atheris genus. Being considered as the main factors involved in the distinct venom-induced pathologies, these identified snake venom proteins are of particular interest in terms of understanding their physiological and biological function as well as for their contribution in potential medical treatments.
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Affiliation(s)
- He Wang
- School of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China.
| | - Xiaole Chen
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China.
| | - Enrico König
- Laboratory of Synthetic and Structural Vaccinology, University of Trento, Trento, Trentino, Italy
| | - Mei Zhou
- Natural Drug Discovery Group, School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Lei Wang
- Natural Drug Discovery Group, School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Tianbao Chen
- Natural Drug Discovery Group, School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Chris Shaw
- Natural Drug Discovery Group, School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
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Wilkinson MC, Nightingale DJH, Harrison RA, Wagstaff SC. Isolation and characterization of renin-like aspartic-proteases from Echis ocellatus venom. Toxicon 2017; 137:92-94. [PMID: 28734982 DOI: 10.1016/j.toxicon.2017.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 07/06/2017] [Indexed: 10/19/2022]
Abstract
Three aspartic proteases (SVAPs) have been isolated from venom of the saw-scaled viper, Echis ocellatus. In confirmation of prior transcriptomic predictions, all three forms match to sequences of either of the two SVAP transcripts (EOC00051 and EOC00123), have a molecular weight of 42 kDa and possess a single N-glycan. The SVAPs act in a renin-like manner, specifically cleaving human and porcine angiotensinogen into angiotensin-1 and possess no general protease activity. Their activity is completely inhibited by the aspartyl protease inhibitor Pepstatin A.
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Affiliation(s)
- M C Wilkinson
- Institute of Integrative Biology, University of Liverpool, Liverpool, L69 7ZB 4, UK.
| | - D J H Nightingale
- Institute of Integrative Biology, University of Liverpool, Liverpool, L69 7ZB 4, UK
| | - R A Harrison
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - S C Wagstaff
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
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9
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Abstract
Snakebites by exotic venomous snakes can cause serious or even life-threatening envenoming. In Europe and North America most victims are breeders, with a few snakebites from wild native American rattlesnakes. The envenomed victims may present in organ and/or system failure with muscle paralysis, respiratory failure, circulatory instability, acute kidney injury, severe coagulation disorder, and local disability - compartment syndrome and necrosis. Best managed by close collaboration between clinical toxicology and intensive care, most severe envenomings are managed primarily by intensive care physicians. Due to the low incidence of severe envenoming, the clinical course and correct management of these cases are not intrinsically familiar to most physicians. This review article summarizes the clinical syndromes caused by severe envenoming and the therapeutic options available in the intensive care setting.
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Affiliation(s)
- Jiří Valenta
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
| | - Zdeněk Stach
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Pavel Michálek
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Molecular Characterization of Three Novel Phospholipase A₂ Proteins from the Venom of Atheris chlorechis, Atheris nitschei and Atheris squamigera. Toxins (Basel) 2016; 8:toxins8060168. [PMID: 27258312 PMCID: PMC4926135 DOI: 10.3390/toxins8060168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/12/2016] [Accepted: 05/20/2016] [Indexed: 01/17/2023] Open
Abstract
Secretory phospholipase A2 (sPLA2) is known as a major component of snake venoms and displays higher-order catalytic hydrolysis functions as well as a wide range of pathological effects. Atheris is not a notoriously dangerous genus of snakes although there are some reports of fatal cases after envenomation due to the effects of coagulation disturbances and hemorrhaging. Molecular characterization of Atheris venom enzymes is incomplete and there are only a few reports in the literature. Here, we report, for the first time, the cloning and characterization of three novel cDNAs encoding phospholipase A2 precursors (one each) from the venoms of the Western bush viper (Atheris chlorechis), the Great Lakes bush viper (Atheris nitschei) and the Variable bush viper (Atheris squamigera), using a “shotgun cloning” strategy. Open-reading frames of respective cloned cDNAs contained putative 16 residue signal peptides and mature proteins composed of 121 to 123 amino acid residues. Alignment of mature protein sequences revealed high degrees of structural conservation and identity with Group II venom PLA2 proteins from other taxa within the Viperidae. Reverse-phase High Performance Liquid Chromatography (HPLC) profiles of these three snake venoms were obtained separately and chromatographic fractions were assessed for phospholipase activity using an egg yolk suspension assay. The molecular masses of mature proteins were all identified as approximately 14 kDa. Mass spectrometric analyses of the fractionated oligopeptides arising from tryptic digestion of intact venom proteins, was performed for further structural characterization.
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Abstract
Venomous snakebite is considered the single most important cause of human injury from venomous animals worldwide. Coagulopathy is one of the commonest important systemic clinical syndromes and can be complicated by serious and life-threatening haemorrhage. Venom-induced consumption coagulopathy (VICC) is the commonest coagulopathy resulting from snakebite and occurs in envenoming by Viperid snakes, certain elapids, including Australian elapids, and a few Colubrid (rear fang) snakes. Procoagulant toxins activate the clotting pathway, causing a broad range of factor deficiencies depending on the particular procoagulant toxin in the snake venom. Diagnosis and monitoring of coagulopathy is problematic, particularly in resource-poor countries where further research is required to develop more reliable, cheap clotting tests. MEDLINE and EMBASE up to September 2013 were searched to identify clinical studies of snake envenoming with VICC. The UniPort database was searched for coagulant snake toxins. Despite preclinical studies demonstrating antivenom binding toxins (efficacy), there was less evidence to support clinical effectiveness of antivenom for VICC. There were no placebo-controlled trials of antivenom for VICC. There were 25 randomised comparative trials of antivenom for VICC, which compared two different antivenoms (ten studies), three different antivenoms (four), two or three different doses or repeat doses of antivenom (five), heparin treatment and antivenom (five), and intravenous immunoglobulin treatment and antivenom (one). There were 13 studies that compared two groups in which there was no randomisation, including studies with historical controls. There have been numerous observational studies of antivenom in VICC but with no comparison group. Most of the controlled trials were small, did not use the same method for assessing coagulopathy, varied the dose of antivenom, and did not provide complete details of the study design (primary outcomes, randomisation, and allocation concealment). Non-randomised trials including comparison groups without antivenom showed that antivenom was effective for some snakes (e.g., Echis), but not others (e.g., Australasian elapids). Antivenom is the major treatment for VICC, but there is currently little high-quality evidence to support effectiveness. Antivenom is not risk free, and adverse reactions can be quite common and potentially severe. Studies of heparin did not demonstrate it improved outcomes in VICC. Fresh frozen plasma appeared to speed the recovery of coagulopathy and should be considered in bleeding patients.
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12
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Pengas IP, Assiotis A, Kokkinakis M, Khan WS, Meyers P, Arbuthnot J, Mcnicholas MJ. Knee Osteochondritis Dissecans Treated by the AO Hook Fixation System: A Four Year Follow-Up of an Alternative Technique. Open Orthop J 2014; 8:209-14. [PMID: 25067976 PMCID: PMC4110397 DOI: 10.2174/1874325001408010209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 03/09/2014] [Accepted: 03/11/2014] [Indexed: 11/22/2022] Open
Abstract
Surgical fixation is recommended for stable osteochondritis dissecans (OCD) lesions that have failed nonoperative management and for all unstable lesions. In this study we set out to describe and evaluate an alternative method of surgical fixation for such lesions. Five knees with unstable OCD lesions in four male adolescent patients with open physes were treated with the AO Hook Fixation System. The outcome was evaluated both clinically and with three separate outcome systems (IKDC 2000, KOOS, Lysholm) at one and a mean four year follow-up. We demonstrated excellent clinical results in all patients. At four years, all scoring systems demonstrated statistically significant improvement when compared to the preoperative status. Our study suggests that the AO Hook Fixation System is an alternative method of surgical intervention with comparable medium term results with other existing modes of fixation and the added biomechanical advantage of the absence of distracting forces during hardware removal.
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Affiliation(s)
- Ioannis P Pengas
- Joint Reconstruction Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, UK ; Department of Orthopaedics and Trauma Surgery, Warrington Hospital, Lovely Lane, Cheshire, WA5 1QG, UK
| | - Angelos Assiotis
- Department of Orthopaedics and Trauma Surgery, Central Middlesex Hospital, Acton Lane, London, NW10 7NS, UK
| | - Michail Kokkinakis
- Department of Orthopaedics and Trauma Surgery, Evelina Childrens Hospital, Guy's & St Thomas Hospital NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Wasim S Khan
- Joint Reconstruction Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, UK
| | - Paul Meyers
- Department of Orthopaedics and Trauma Surgery, Warrington Hospital, Lovely Lane, Cheshire, WA5 1QG, UK
| | - James Arbuthnot
- Department of Orthopaedics and Trauma Surgery, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham, B9 5SS, UK
| | - Michael J Mcnicholas
- Department of Orthopaedics and Trauma Surgery, Aintree University Hospital, Liverpool, Merseyside L9 7AL, UK
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Raval P, Khan W, Haddad B, Mahapatra AN. Bite injuries to the hand - review of the literature. Open Orthop J 2014; 8:204-8. [PMID: 25097675 PMCID: PMC4112338 DOI: 10.2174/1874325001408010204] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 04/05/2014] [Accepted: 04/10/2014] [Indexed: 11/22/2022] Open
Abstract
Patients presenting to the emergency department with bite injuries to the hand sustain them through a number of causes including domesticated as well as stray animal bites, and human bites commonly sustained as a result of violence. The nature of the injuries sustained can be very deceptive. A small tooth mark on the exterior can be a fulminant infection in the tissues deeper down. Tendon injuries, fractures of the metacarpals and phalanges and management of the wound are critical issues faced by a surgeon in dealing with such patients. Similarly the less common bite injuries to the hand, often with disastrous and sometimes fatal complications, do also present to the emergency department. A high incidence of suspicion is needed in dealing with these injuries effectively. In our article we discuss the common as well as uncommon causes of bite injuries to the hand and their management. In addition to reviewing the literature to ascertain the management of such injuries, we also discuss interesting and rare case reports.
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Affiliation(s)
- Pradyumna Raval
- Department of Orthopaedic Surgery, Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - Wasim Khan
- University College London Institute of Orthopaedics & Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Behrooz Haddad
- University College London Institute of Orthopaedics & Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, UK
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14
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Pourreau F, Pinsard M, Goyffon M, Plasse F, Desport E, Thierry A, Touchard G, Bridoux F. Bilateral renal cortical necrosis with end-stage renal failure following envenoming by Proatheris superciliaris: a case report. Toxicon 2014; 84:36-40. [PMID: 24709757 DOI: 10.1016/j.toxicon.2014.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 03/10/2014] [Accepted: 03/25/2014] [Indexed: 10/25/2022]
Abstract
Acute bilateral renal cortical necrosis (BRCN) has been reported following envenoming by exotic venomous snakes. Proatheris superciliaris is a rare viper with restricted distribution in east Africa. Very little information is available on envenoming by this species. We herein describe the case of a 60-year-old professional wildlife photographer who was bitten on his thumb while photographing an adult specimen of P. superciliaris that he held at home in France. On admission, physical examination revealed severe hypertension and bruising with edema at the bite site. Within the following 24 h, he developed vomiting, diarrhea, acute lumbar pain and anuria. Laboratory tests showed acute kidney injury (serum creatinine 4.6 mg/dL), with thrombocytopenia, anemia and severe coagulopathy. Contrast-enhanced computed tomography scan revealed hypodense areas in the cortex of both kidneys consistent with diffuse BRCN. As no appropriate antivenom existed, only symptomatic care was given to the patient. Coagulation tests returned to normal within 48 h. The patient was placed on chronic hemodialysis, until he underwent successful kidney transplantation 18 months later. In developed countries, severe complications provoked by snake bites tend to be more frequent with the number of trendy exotic pets. Acute kidney injury, including BRCN, is a classic complication of viper bites. The present case of end-stage renal failure related to diffuse BRCN illustrates the potentially devastating effects of envenoming by P. superciliaris. Clinicians in developed countries should be informed about renal disorders and other potentially fatal complications of venomous snake bites and seek urgent expert advice for optimizing clinical management. Education and coaching of envenomed patients and exotic snake owners is mandatory to prevent dramatic accidents.
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Affiliation(s)
- François Pourreau
- Department of Nephrology and Renal Transplantation, University Hospital and University of Poitiers, France
| | - Michel Pinsard
- Department of Intensive Care Unit, University Hospital and University of Poitiers, France
| | - Max Goyffon
- Museum National d'Histoire Naturelle, Paris, France
| | - Florent Plasse
- Department of Nephrology and Renal Transplantation, University Hospital and University of Poitiers, France
| | - Estelle Desport
- Department of Nephrology and Renal Transplantation, University Hospital and University of Poitiers, France
| | - Antoine Thierry
- Department of Nephrology and Renal Transplantation, University Hospital and University of Poitiers, France
| | - Guy Touchard
- Department of Nephrology and Renal Transplantation, University Hospital and University of Poitiers, France
| | - Frank Bridoux
- Department of Nephrology and Renal Transplantation, University Hospital and University of Poitiers, France.
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Valenta J, Stach Z, Michalek P. Exotic snake bites in the Czech Republic--Epidemiological and clinical aspects during 15-year period (1999-2013). Clin Toxicol (Phila) 2014; 52:258-64. [PMID: 24666339 DOI: 10.3109/15563650.2014.902066] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED Only one natural venomous snake-the adder viper-lives in the central European region and its bite is usually associated only with mild course of envenoming. Cases of envenoming caused by exotic snakes among their breeders are clinically more important. OBJECTIVE The aim of this study was to analyze the epidemiological and clinical aspects of registered venomous bites caused by exotic snakes in the Czech Republic over a period of 15 years (1999-2013). MATERIALS AND METHODS This is an observational case series. Data have been collected retrospectively from a database and medical charts of the Toxinology Center belonging to the General University Hospital in Prague. RESULTS In total, 87 cases of exotic snakebites caused by 34 venomous snake species were registered during the study period, coming from 18 genera of Elapinae, Viperinae, and Crotalinae subfamilies. In the cohort, 29 patients (33.3%) developed systemic envenoming and 17 (19.5%) were treated with antivenom. Ten cases of envenoming (11.5%) were considered as potentially life threatening. No patient died due to envenoming caused by exotic snake bites during the study period. Four illustrative cases of envenoming (Echis pyramidum, Dendroaspis polylepis, Protobothrops mangshanensis, and Proatheris superciliaris) are described in detail. CONCLUSION Bites caused by exotic snakes resulted in serious and life-threatening envenomings in some patients. Early transfer to the Center, antivenom administration, and support of failing organ functions contributed to favorable outcome of victims.
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Affiliation(s)
- Jiri Valenta
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital , Prague , Czech Republic
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Hatten BW, Bueso A, French LK, Hendrickson RG, Horowitz BZ. Envenomation by the Great Lakes Bush Viper (Atheris nitschei). Clin Toxicol (Phila) 2013; 51:114-6. [PMID: 23327286 DOI: 10.3109/15563650.2012.763134] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION We present a case of envenomation by a Great Lakes Bush Viper, Atheris nitschei. Atheris species are a group of snakes that are indigenous to the forested areas of Central Africa. Prior reports of envenomation by Great Lakes Bush Vipers were not found in a Medline search. However, reports of other Atheris species envenomations describe coagulopathy and acute renal failure. CASE DETAILS A 30-year-old male was bitten by a Great Lakes Bush Viper on his left hand. His left upper extremity was edematous with ecchymoses in the left axilla. There was bleeding from the bite site and from the patient's oral mucosa. Initial laboratory studies demonstrated significant derangement of hematologic parameters including anemia, thrombocytopenia, coagulopathy, and hypofibrinoginemia. There is no antivenom for this species. The patient was treated with blood products. Mucosal bleeding ceased within 12 h of admission. DISCUSSION Atheris nitschei is an African snake with no available antivenom. In this case, the patient developed coagulopathy with hemolytic anemia, thrombocytopenia, and low fibrinogen. Renal function remained unaffected. Despite the lack of specific antivenom or the use of plasmapheresis, our patient was successfully treated with transfusion of multiple blood products.
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Affiliation(s)
- Benjamin W Hatten
- Oregon Poison Center, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States.
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Venomous snakebites in the Croatian North Dalmatia region. Wien Klin Wochenschr 2011; 123:732-7. [PMID: 22124839 DOI: 10.1007/s00508-011-0085-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 09/23/2011] [Indexed: 12/19/2022]
Abstract
AIM The aim of this research project is to analyze the epidemiological, clinical and laboratory attributes of venomous snakebites and to ascertain the timely and efficient treatment at the location where the incident took place or in varying clinical conditions. METHODS Epidemiological, clinical and laboratory data were collected from people who were bitten by venomous snakes as well as treatments at Zadar General Hospital during a span of eleven years (1999-2009) which were analyzed retrospectively. RESULTS During that period, 93 people were bitten by venomous snakes of which 57 patients (62%) were male and 36 (38%) were female. In 82 cases (90%), the bite area was localized on the limbs while in the remaining 11 cases the bite area was located elsewhere. At the time of the venomous snakebite, 31 (33%) patients were performing leisure activities and 44 (47.31%) of them were at work. The most common local snakebite signs are swelling and pain at the bite site (93 patients; 100%), hematomas and ecchymoses (87 patients; 89%). Of the affected patients, 8 suffered from compartment syndrome and one person (0.97%) expired. CONCLUSION Antivenom treatment for preventing possible allergic reactions should take place at the medical institution where the victim was transported. However, when transport is not immediately available or in cases where the victim shows clear signs of envenomation, antivenom treatment should be used immediately because its effect is weaker if the venom is allowed to run its course.
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Keyler DE. Envenomation by the lowland viper (Proatheris superciliaris): Severe case profile documentation. Toxicon 2008; 52:836-41. [DOI: 10.1016/j.toxicon.2008.10.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 10/08/2008] [Accepted: 10/10/2008] [Indexed: 10/21/2022]
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