1
|
Warrell DA, Williams DJ. Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet 2023; 401:1382-1398. [PMID: 36931290 DOI: 10.1016/s0140-6736(23)00002-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/26/2022] [Accepted: 12/18/2022] [Indexed: 03/16/2023]
Abstract
There is increasing recognition of the public health importance of snakebite envenoming. Worldwide annual incidence is likely to be 5 million bites, with mortality exceeding 150 000 deaths, and the resulting physical and psychological morbidity leads to substantial social and economic repercussions. Prevention through community education by trained health workers is the most effective and economically viable strategy for reducing risk of bites and envenoming. Clinical challenges to effective treatment are most substantial in rural areas of low-resource settings, where snakebites are most common. Classic skills of history taking, physical examination, and use of affordable point-of-care tests should be followed by monitoring of evolving local and systemic envenoming. Despite the profusion of new ideas for interventions, hyperimmune equine or ovine plasma-derived antivenoms remain the only specific treatment for snakebite envenoming. The enormous interspecies and intraspecies complexity and diversity of snake venoms, revealed by modern venomics, demands a radical redesign of many current antivenoms.
Collapse
Affiliation(s)
- David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Experimental Medicine Division, John Radcliffe Hospital, Headington, UK.
| | - David J Williams
- Regulation and Prequalification Department, World Health Organization, Geneva, Switzerland
| |
Collapse
|
2
|
Chowdhury A, Youngman NJ, Liu J, Lewin MR, Carter RW, Fry BG. The relative efficacy of chemically diverse small-molecule enzyme-inhibitors against anticoagulant activities of Black Snake (Pseudechis spp.) venoms. Toxicol Lett 2022; 366:26-32. [PMID: 35788045 DOI: 10.1016/j.toxlet.2022.06.009] [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: 01/12/2022] [Revised: 05/31/2022] [Accepted: 06/28/2022] [Indexed: 11/28/2022]
Abstract
Snakebite remains a worldwide public health burden and a severely neglected tropical disease. Recent research has begun to focus on the potential use of repurposed small-molecule enzyme-inhibitors as early treatments to neutralise the effects of snake venoms. Black snakes (Pseudechis spp.) are a widespread and dangerously venomous group found throughout Australia and New Guinea. Utilising validated coagulation assays, our study assessed the efficacy of two chemically different small molecule inhibitors, a phospholipase A2 inhibitor (varespladib) and a metalloproteinase inhibitor (prinomastat), in vitro neutralisation of the anticoagulant prothrombinase-inhibiting activity of venom from seven species within the Pseudechis genus (P. australis, P. butleri, P. coletti, P. guttatus, P. papuanus, P.rossignolii, P. sp (NT).). Varespladib was shown to be highly effective at neutralising this anticoagulant activity for all seven species, but with P. coletti notably less so than the others. In contrast, prinomastat showed strong neutralisation for five out of the seven species, but was ineffective at neutralising the activity of P. coletti or P. rossignolii venoms. This suggests that varespladib binds to a highly conserved site but that prinomastat binds to a more variable site. These results build upon recent literature indicating that metalloproteinase inhibitors have cross-neutralising potential towards snake venom phospholipase A2 toxins, but with higher degrees of variability that PLA2-specific inhibitors. An important caveat is that these are in vitro tests and while suggestive of potential clinical utility, in vivo animal testing and clinical trials are required as future work.
Collapse
Affiliation(s)
- Abhinandan Chowdhury
- Venom Evolution Lab, School of Biological Science, University of Queensland, St. Lucia QLD, 4072 Australia; Department of Biochemistry & Microbiology, North South University, Dhaka 1229, Bangladesh.
| | - Nicholas J Youngman
- Venom Evolution Lab, School of Biological Science, University of Queensland, St. Lucia QLD, 4072 Australia
| | - Jiaojiao Liu
- Venom Evolution Lab, School of Biological Science, University of Queensland, St. Lucia QLD, 4072 Australia
| | - Matthew R Lewin
- California Academy of Sciences, San Francisco, CA, 94118, USA; Ophirex, Inc., Corte Madera, CA, 94925, USA
| | | | - Bryan G Fry
- Venom Evolution Lab, School of Biological Science, University of Queensland, St. Lucia QLD, 4072 Australia.
| |
Collapse
|
3
|
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.
Collapse
|
4
|
The Snake Study: Survey of National Attitudes and Knowledge in Envenomation. Toxins (Basel) 2021; 13:toxins13070482. [PMID: 34357954 PMCID: PMC8310140 DOI: 10.3390/toxins13070482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 11/27/2022] Open
Abstract
Despite recent reviews of best practice for the treatment of Australian venomous bites and stings, there is controversy about some aspects of care, particularly the use of antivenom. Our aim was to understand current attitudes and practice in the management of suspected snake envenoming. A single-stage, cross-sectional survey of Australian emergency care physicians who had treated snake envenomation in the previous 36 months was conducted. Hospital pharmacists were also invited to complete a survey about antivenom availability, usage, and wastage in Australian hospitals. The survey was available between 5 March and 16 June 2019. A total of 121 snake envenoming cases were reported, and more than a third (44.6%) of patients were not treated with antivenom. For those treated with antivenom (n = 67), 29 patients (43%) received more than one ampoule. Nearly a quarter of respondents (21%) identified that antivenom availability was, or could be, a barrier to manage snake envenoming, while cost was identified as the least important factor. Adverse reactions following antivenom use were described in 11.9% of cases (n = 8). The majority of patients with suspected envenoming did not receive antivenom. We noted variation in dosage, sources of information, beliefs, and approaches to the care of the envenomed patient.
Collapse
|
5
|
Zdenek CN, Youngman NJ, Hay C, Dobson J, Dunstan N, Allen L, Milanovic L, Fry BG. Anticoagulant activity of black snake (Elapidae: Pseudechis) venoms: Mechanisms, potency, and antivenom efficacy. Toxicol Lett 2020; 330:176-184. [PMID: 32442717 DOI: 10.1016/j.toxlet.2020.05.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 12/21/2022]
Abstract
Venoms from Pseudechis species (Australian black snakes) within the Elapidae family are rich in anticoagulant PLA2 toxins, with the exception of one species (P. porphyriacus) that possesses procoagulant mutated forms of the clotting enzyme Factor Xa. Previously the mechanism of action of the PLA2 toxins' anticoagulant toxicity was said to be due to inhibition of Factor Xa, but this statement was evidence free. We conducted a series of anticoagulation assays to elucidate the mechanism of anticoagulant action produced by P. australis venom. Our results revealed that, rather than targeting FXa, the PLA2 toxins inhibited the prothrombinase complex, with FVa-alone or as part of the prothrombinase complex-as the primary target; but with significant thrombin inhibition also noted. In contrast, FXa, and other factors inhibited only to a lesser degree were minor targets. We quantified coagulotoxic effects upon human plasma caused by all nine anticoagulant Pseudechis species, including nine localities of P. australis across Australia, and found similar anticoagulant potency across all Pseudechis species, with greater potency in P. australis and the undescribed Pseudechis species in the NT. In addition, the northern localities and eastern of P. australis were significantly more potent than the central, western, and southern localities. All anticoagulant venoms responded well to Black Snake Antivenom, except P. colletti which was poorly neutralised by Black Snake Antivenom and also Tiger Snake Antivenom (the prescribed antivenom for this species). However, we found LY315920 (trade name: Varespladib), a small molecule inhibitor of PLA2 proteins, exhibited strong potency against P. colletti venom. Thus, Varespladib may be a clinically viable treatment for anticoagulant toxicity exerted by this species that is not neutralised by available antivenoms. Our results provide insights into coagulotoxic venom function, and suggest future in vivo work be conducted to progress the development of a cheaper, first-line treatment option to treat PLA2-rich snake venoms globally.
Collapse
Affiliation(s)
- Christina N Zdenek
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD, 4072, Australia
| | - Nicholas J Youngman
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD, 4072, Australia
| | - Chris Hay
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD, 4072, Australia; Australian School of Herpetology, Southport, QLD, Australia
| | - James Dobson
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD, 4072, Australia
| | - Nathan Dunstan
- Venom Supplies Pty Ltd, Stonewell Rd, Tanunda, SA, 5352, Australia
| | - Luke Allen
- Venom Supplies Pty Ltd, Stonewell Rd, Tanunda, SA, 5352, Australia
| | - Leontina Milanovic
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD, 4072, Australia
| | - Bryan G Fry
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD, 4072, Australia.
| |
Collapse
|
6
|
Bolon I, Durso AM, Botero Mesa S, Ray N, Alcoba G, Chappuis F, Ruiz de Castañeda R. Identifying the snake: First scoping review on practices of communities and healthcare providers confronted with snakebite across the world. PLoS One 2020; 15:e0229989. [PMID: 32134964 PMCID: PMC7058330 DOI: 10.1371/journal.pone.0229989] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/18/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Snakebite envenoming is a major global health problem that kills or disables half a million people in the world's poorest countries. Biting snake identification is key to understanding snakebite eco-epidemiology and optimizing its clinical management. The role of snakebite victims and healthcare providers in biting snake identification has not been studied globally. OBJECTIVE This scoping review aims to identify and characterize the practices in biting snake identification across the globe. METHODS Epidemiological studies of snakebite in humans that provide information on biting snake identification were systematically searched in Web of Science and Pubmed from inception to 2nd February 2019. This search was further extended by snowball search, hand searching literature reviews, and using Google Scholar. Two independent reviewers screened publications and charted the data. RESULTS We analysed 150 publications reporting 33,827 snakebite cases across 35 countries. On average 70% of victims/bystanders spotted the snake responsible for the bite and 38% captured/killed it and brought it to the healthcare facility. This practice occurred in 30 countries with both fast-moving, active-foraging as well as more secretive snake species. Methods for identifying biting snakes included snake body examination, victim/bystander biting snake description, interpretation of clinical features, and laboratory tests. In nine publications, a picture of the biting snake was taken and examined by snake experts. Snakes were identified at the species/genus level in only 18,065/33,827 (53%) snakebite cases. 106 misidentifications led to inadequate victim management. The 8,885 biting snakes captured and identified were from 149 species including 71 (48%) non-venomous species. CONCLUSION Snakebite victims and healthcare providers can play a central role in biting snake identification and novel approaches (e.g. photographing the snake, crowdsourcing) could help increase biting snake taxonomy collection to better understand snake ecology and snakebite epidemiology and ultimately improve snakebite management.
Collapse
Affiliation(s)
- Isabelle Bolon
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Andrew M. Durso
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sara Botero Mesa
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicolas Ray
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
| | - Gabriel Alcoba
- Médecins Sans Frontières, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | | |
Collapse
|
7
|
Pla D, Bande BW, Welton RE, Paiva OK, Sanz L, Segura Á, Wright CE, Calvete JJ, Gutiérrez JM, Williams DJ. Proteomics and antivenomics of Papuan black snake (Pseudechis papuanus) venom with analysis of its toxicological profile and the preclinical efficacy of Australian antivenoms. J Proteomics 2016; 150:201-215. [PMID: 27650695 DOI: 10.1016/j.jprot.2016.09.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 09/15/2016] [Accepted: 09/16/2016] [Indexed: 11/28/2022]
Abstract
The Papuan black snake (Pseudechis papuanus Serpentes: Elapidae) is endemic to Papua New Guinea, Indonesian Papua and Australia's Torres Strait Islands. We have investigated the biological activity and proteomic composition of its venom. The P. papuanus venom proteome is dominated by a variety (n≥18) of PLA2s, which together account for ~90% of the venom proteins, and a set of low relative abundance proteins, including a short-neurotoxic 3FTx (3.1%), 3-4 PIII-SVMPs (2.8%), 3 cysteine-rich secretory proteins (CRISP; 2.3%) 1-3 l-amino acid oxidase (LAAO) molecules (1.6%). Probing of a P. papuanus cDNA library with specific primers resulted in the elucidation of the full-length nucleotide sequences of six new toxins, including vespryn and NGF not found in the venom proteome, and a calglandulin protein involved in toxin expression with the venom glands. Intravenous injection of P. papuanus venom in mice induced lethality, intravascular haemolysis, pulmonary congestion and oedema, and anticoagulation after intravenous injection, and these effects are mainly due to the action of PLA2s. This study also evaluated the in vivo preclinical efficacy of Australian black snake and polyvalent Seqirus antivenoms. These antivenoms were effective in neutralising the lethal, PLA2 and anticoagulant activities of P. papuanus venom in mice. On the other hand, all of the Seqirus antivenoms tested using an antivenomic approach exhibited strong immunorecognition of all the venom components. These preclinical results suggest that Australian Seqirus1 antivenoms may provide paraspecific protection against P. papuanus venom in humans. SIGNIFICANCE PARAGRAPH The toxicological profile and proteomic composition of the venom of the Papuan black snake, Pseudechis papuanus, a large diurnal snake endemic to the southern coast of New Guinea and a handful of close offshore islands, were investigated. Intravenous injection of P. papuanus venom in mice induced intravascular hemolysis, pulmonary congestion and edema, anticoagulation, and death. These activities could be assigned to the set of PLA2 molecules, which dominate the P. papuanus venom proteome. This study also showed that Australian Seqirus black snake or polyvalent antivenoms were effective in neutralising the lethal, PLA2 and anticoagulant activities of the venom. These preclinical results support the continued recommendation of these Seqirus antivenoms in the clinical management of P. papuanus envenoming in Australia, Papua New Guinea or Indonesian Papua Province.
Collapse
Affiliation(s)
- Davinia Pla
- Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain
| | - Benjamin W Bande
- Charles Campbell Toxinology Centre, School of Medicine & Health Sciences, University of Papua New Guinea, Boroko, NCD, Papua New Guinea
| | - Ronelle E Welton
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Owen K Paiva
- Charles Campbell Toxinology Centre, School of Medicine & Health Sciences, University of Papua New Guinea, Boroko, NCD, Papua New Guinea
| | - Libia Sanz
- Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain
| | - Álvaro Segura
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Christine E Wright
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, Victoria 3010, Australia; Cardiovascular Therapeutics Unit, Department of Pharmacology and Therapeutics, University of Melbourne, Victoria 3010, Australia
| | - Juan J Calvete
- Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain.
| | - José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica.
| | - David J Williams
- Charles Campbell Toxinology Centre, School of Medicine & Health Sciences, University of Papua New Guinea, Boroko, NCD, Papua New Guinea; Australian Venom Research Unit, Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, Victoria 3010, Australia.
| |
Collapse
|
8
|
Padula AM, Winkel KD. Antivenom production in the alpaca (Vicugna pacos): physiological and antibody responses to monovalent and polyvalent immunisation with Australian elapid venoms. Small Rumin Res 2016. [DOI: 10.1016/j.smallrumres.2016.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|