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Kaulgud RS, Hasan T, Vanti GL, Veeresh S, Uppar AP, Kurjogi MM. Snake Venom-specific Phospholipase A2: A Diagnostic Marker for the Management of Snakebite Cases. Indian J Crit Care Med 2022; 26:1259-1266. [PMID: 36755629 PMCID: PMC9886021 DOI: 10.5005/jp-journals-10071-24362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 10/21/2022] [Indexed: 12/02/2022] Open
Abstract
Background Snakebites are a common cause of morbidity and mortality, especially in tropical countries. Snakebites in any community are managed based on the clinical features and intravenous administration of antisnake venom (ASV). The administration of ASV is either deficient or given in excess based on clinical decisions and whole blood clotting test results. The present study is designed to analyze the level of snake venom component in the blood of snakebite in association with the clinical features. Patients and methods Blood samples were collected from the patients admitted to Karnataka Institute of Medical (KIMS) hospital with a history of snakebite considering the inclusion criteria. Serum was collected from the blood of snakebite patients before and after ASV and used to assess the level of venom-specific phospholipase A2 (PLA2) enzyme using the enzyme-linked immunosorbent assay (ELISA) method. Results Quantitative ELISA results revealed that the snake venom-specific PLA2 in the victim's blood was in the range of 0.3-1.27 mg/mL before the administration of ASV. However, the concentration of PLA2 after 24 hours of ASV administration was decreased in most of the patients. Further, it was observed that envenomation complications were directly proportional to the amount of snake venom-specific PLA2 found in the blood of the snakebite patient. Conclusion The study concludes that snake venom-specific PLA2 in the blood of snakebite patients could be used as a reliable venom marker, which helps in determination of appropriate ASV dosage in snakebite patients. How to cite this article Kaulgud RS, Hasan T, Vanti GL, Veeresh S, Uppar AP, Kurjogi MM. Snake Venom-specific Phospholipase A2: A Diagnostic Marker for the Management of Snakebite Cases. Indian J Crit Care Med 2022;26(12):1259-1266.
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Affiliation(s)
- Ram S Kaulgud
- Multi-Disciplinary Research Unit, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India
| | - Tousif Hasan
- Department of General Medicine, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India
| | - Gulamnabi L Vanti
- Multi-Disciplinary Research Unit, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India
| | - S Veeresh
- Multi-Disciplinary Research Unit, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India
| | - Amruta P Uppar
- Multi-Disciplinary Research Unit, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India
| | - Mahantesh M Kurjogi
- Multi-Disciplinary Research Unit, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India,Mahantesh M Kurjogi, Multi-Disciplinary Research Unit, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India, e-mail:
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Grose V, Padula AM, Leister EM. Successful treatment of a potentially fatal eastern brown snake (Pseudonaja textilis) envenomation in a dog with tiger-brown snake antivenom with serial quantification of venom antigen and antivenom concentrations in serum and urine. Aust Vet J 2021; 99:139-145. [PMID: 33442868 DOI: 10.1111/avj.13051] [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: 07/15/2020] [Revised: 11/21/2020] [Accepted: 12/05/2020] [Indexed: 11/28/2022]
Abstract
CASE REPORT A successfully treated case of eastern brown snake (Pseudonaja textilis) envenomation in a Jack Russel Terrier dog is described with measurement of venom and antivenom concentration pre- and post-treatment. Early presentation, prompt administration of tiger-brown snake antivenom, hospitalisation and critical care monitoring lead to low morbidity and rapid recovery from a potentially fatal envenomation. Retrospective measurement of urine and serum venom and antivenom provided insight into the potential severity of the case and rapid efficacy of antivenom. CLINICAL SIGNIFICANCE Potentially fatal brown snakebite cases may initially present with only mild clinical signs despite having high concentrations of venom and potential for fatal outcome. Prompt treatment with antivenom is essential to prevent the development of progressive and fatal coagulopathy and paralysis.
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Affiliation(s)
- V Grose
- Pet Intensive Care Unit (Pet ICU), Underwood, Queensland, 4119, Australia
| | - A M Padula
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, 3010, Australia.,Padula Serums Pty Ltd, Bairnsdale, Victoria, 3875, Australia
| | - E M Leister
- Pet Intensive Care Unit (Pet ICU), Underwood, Queensland, 4119, Australia
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Maduwage KP, Gawarammana IB, Gutiérrez JM, Kottege C, Dayaratne R, Premawardena NP, Jayasingha S. Enzyme immunoassays for detection and quantification of venoms of Sri Lankan snakes: Application in the clinical setting. PLoS Negl Trop Dis 2020; 14:e0008668. [PMID: 33017411 PMCID: PMC7561112 DOI: 10.1371/journal.pntd.0008668] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/15/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022] Open
Abstract
Background Detection and quantification of snake venom in envenomed patients’ blood is important for identifying the species responsible for the bite, determining administration of antivenom, confirming whether sufficient antivenom has been given, detecting recurrence of envenoming, and in forensic investigation. Currently, snake venom detection is not available in clinical practice in Sri Lanka. This study describes the development of enzyme immunoassays (EIA) to differentiate and quantify venoms of Russell’s viper (Daboia russelii), saw-scaled viper (Echis carinatus), common cobra (Naja naja), Indian krait (Bungarus caeruleus), and hump-nosed pit viper (Hypnale hypnale) in the blood of envenomed patients in Sri Lanka. Methodology / Principal findings A double sandwich EIA of high analytical sensitivity was developed using biotin-streptavidin amplification for detection of venom antigens. Detection and quantification of D. russelii, N. naja, B. caeruleus, and H. hypnale venoms in samples from envenomed patients was achieved with the assay. Minimum (less than 5%) cross reactivity was observed between species, except in the case of closely related species of the same genus (i.e., Hypnale). Persistence/ recurrence of venom detection following D. russelii envenoming is also reported, as well as detection of venom in samples collected after antivenom administration. The lack of specific antivenom for Hypnale sp envenoming allowed the detection of venom antigen in circulation up to 24 hours post bite. Conclusion The EIA developed provides a highly sensitive assay to detect and quantify five types of Sri Lankan snake venoms, and should be useful for toxinological research, clinical studies, and forensic diagnosis. Snakebite is a major medical and public health problem in tropical agricultural world. Detection of the type of snake venom and measurement of venom levels in blood are important for snakebite research, selecting the appropriate antivenom, and assessing venom levels in blood at the clinical setting. Currently, a snake venom detection platform is not available in clinical practice in Sri Lanka. This study aimed to develop a double sandwich enzyme immunoassays (EIA) to differentiate and quantify venoms of Russell’s viper (Daboia russelii), saw-scaled viper (Echis carinatus), common cobra (Naja naja), Indian krait (Bungarus caeruleus), and hump-nosed pit viper (Hypnale hypnale) in blood samples of envenomed patients in Sri Lanka. The EIA developed used biotin-streptavidin amplification for detection of venom antigens and showed high analytical sensitivity. The assay allowed the quantification of venoms of the five species in blood samples from envenomed patients. Low level of cross reactivity was noted between species, except in the case of closely related Hypnale species. The presence of D. russelii venom after antivenom treatment is reported, a finding that has implications in the dosing of antivenom in these envenomings. Lack of specific antivenom for H. hypnale envenoming offered an opportunity of study the remaining venom antigen in circulation up to 24 hr post bite. The EIA developed constitutes a useful tool to detect and quantify the five types of Sri Lankan snake venoms, and should be useful for research purposes, as well as for the diagnosis and therapy evaluation of clinical cases of envenomings in this country, and for forensic purposes.
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Affiliation(s)
- Kalana Prasad Maduwage
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- * E-mail:
| | | | - José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
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Isbister GK, Buckley NA. Risks and realities of single vial antivenom recommendations for envenoming by Australian elapid snakes. Med J Aust 2020; 213:45-45.e1. [DOI: 10.5694/mja2.50652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Geoffrey K Isbister
- Clinical Toxicology Research GroupUniversity of Newcastle Newcastle NSW
- Calvary Mater Newcastle Newcastle NSW
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Tibballs J. Australian snake antivenom dosing: What is scientific and safe? Anaesth Intensive Care 2019; 48:129-133. [PMID: 31505950 DOI: 10.1177/0310057x19865268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Because the median dose of one vial 'clears the blood of circulating venom', the authors of the Australian Snakebite Project recommend restriction of antivenom to one vial for all envenomated victims. This is neither scientific nor safe. Methodological flaws in the case series include limited detection of venom toxins and misinterpretation of data. The recommendation fails to consider larger doses of venom than that neutralised by one vial of antivenom. Although one vial may be adequate for minor envenomation, the initial dose should be two vials with more on a clinical basis.
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Weinstein SA, Mirtschin PJ, White J. Risks and realities of single vial antivenom recommendations for envenoming by Australian elapid snakes. Med J Aust 2019; 211:492-493.e1. [PMID: 31441065 DOI: 10.5694/mja2.50314] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Maduwage KP, O'Leary MA, Silva A, Isbister GK. Detection of Snake Venom in Post-Antivenom Samples by Dissociation Treatment Followed by Enzyme Immunoassay. Toxins (Basel) 2016; 8:toxins8050130. [PMID: 27136587 PMCID: PMC4885045 DOI: 10.3390/toxins8050130] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/03/2016] [Accepted: 04/11/2016] [Indexed: 11/16/2022] Open
Abstract
Venom detection is crucial for confirmation of envenomation and snake type in snake-bite patients. Enzyme immunoassay (EIA) is used to detect venom, but antivenom in samples prevents venom detection. We aimed to detect snake venom in post-antivenom samples after dissociating venom-antivenom complexes with glycine-HCl (pH 2.2) and heating for 30 min at 950 °C. Serum samples underwent dissociation treatment and then Russell’s viper venom or Australian elapid venom measured by EIA. In confirmed Russell’s viper bites with venom detected pre-antivenom (positive controls), no venom was detected in untreated post-antivenom samples, but was after dissociation treatment. In 104 non-envenomed patients (negative controls), no venom was detected after dissociation treatment. In suspected Russell’s viper bites, ten patients with no pre-antivenom samples had venom detected in post-antivenom samples after dissociation treatment. In 20 patients with no venom detected pre-antivenom, 13 had venom detected post-antivenom after dissociation treatment. In another 85 suspected Russell’s viper bites with no venom detected pre-antivenom, 50 had venom detected after dissociation treatment. Dissociation treatment was also successful for Australian snake envenomation including taipan, mulga, tiger snake and brown snake. Snake venom can be detected by EIA in post-antivenom samples after dissociation treatment allowing confirmation of diagnosis of envenomation post-antivenom.
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Affiliation(s)
- Kalana P Maduwage
- Clinical Toxicology Research Group, University of Newcastle, Newcastle 2298, Australia.
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka.
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
| | - Margaret A O'Leary
- Clinical Toxicology Research Group, University of Newcastle, Newcastle 2298, Australia.
| | - Anjana Silva
- Monash Venom Group, Monash University, Melbourne 3168, Australia.
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle 2298, Australia.
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka.
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Lim AYL, Singh PN, Isbister GK. Severe rhabdomyolysis from red-bellied black snake (Pseudechis porphyriacus) envenoming despite antivenom. Toxicon 2016; 117:46-8. [PMID: 27039255 DOI: 10.1016/j.toxicon.2016.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/16/2016] [Accepted: 03/23/2016] [Indexed: 11/16/2022]
Abstract
Envenoming by the Australian red-bellied black snake (Pseudechis porphyriacus) causes non-specific systemic symptoms, anticoagulant coagulopathy, myotoxicity and local effects. Current management for systemic envenoming includes administration of one vial of tiger snake antivenom within 6 h of the bite to prevent myotoxicity. We present a case of severe rhabdomyolysis in a 16 year old male which developed despite early administration of one vial of tiger snake antivenom. Free venom was detected after the administration of antivenom concurrent with rapidly decreasing antivenom concentrations. The case suggests that insufficient antivenom was administered and the use of larger doses of antivenom need to be explored for red-bellied black snake envenoming.
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Affiliation(s)
- Adeline Y L Lim
- Children's Critical Care Unit, Gold Coast University Hospital, Queensland, Australia
| | - Puneet N Singh
- Children's Critical Care Unit, Gold Coast University Hospital, Queensland, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia; NSW Poison Information Centre, Children's Hospital Westmead, Sydney, NSW, Australia.
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Miller M, O'Leary MA, Isbister GK. Towards rationalisation of antivenom use in funnel-web spider envenoming: enzyme immunoassays for venom concentrations. Clin Toxicol (Phila) 2015; 54:245-51. [PMID: 26678882 DOI: 10.3109/15563650.2015.1122794] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Funnel-web spider (Atrax and Hadronyche spp.) envenoming is rare but causes severe neuromuscular, autonomic, and cardiac effects. A rabbit-derived IgG antivenom is available, but venom detection in patients has not been reported. OBJECTIVE To use serial venom and antivenom concentrations to better define envenoming and antivenom effectiveness. MATERIALS AND METHODS Serum was collected from nine patients with suspected funnel-web spider bites and clinical effects were recorded. Venom-specific enzyme immunoassays were developed to measure funnel-web spider venom and antivenom concentrations. Goat anti-rabbit whole serum was coupled to UltraLink resin and added to samples to remove bound venom and measure free venom. Antivenom efficacy was defined as antivenom binding all free venom and antivenom effectiveness as resolution of clinical features. RESULTS Venom was detectable in samples from six of nine patients. In three patients without venom detected, there were only moderate effects, which did not completely respond to antivenom in all cases and no spider was identified. In five of six cases, a male Atrax spp. (Sydney funnel-web) spider was identified. Three patients had moderate envenoming which responded to antivenom. Three patients had severe envenoming and developed catecholamine-induced myocarditis and acute pulmonary oedema. Although cholinergic and non-specific clinical features appeared to respond to antivenom, myocarditis and pulmonary oedema lasted 2-4 days. Median venom concentration pre-antivenom in five patients with samples was 5.6 ng/ml (3-35 ng/ml), and immediately post-antivenom decreased to a median of 0 ng/ml (0-1.8 ng/ml). Post-antivenom venom concentrations decreased when bound venom was removed; median, 0 ng/ml (0-0.9 ng/ml), indicating that most venom detected post-antivenom was bound. There was recurrence of venom and clinical features in one patient when a pressure bandage was removed. CONCLUSIONS Detection of venom in suspected funnel-web spider bites identified definite cases with characteristic envenoming and a spider was identified. Measurement of venom concentrations pre- and post-antivenom demonstrated that venom was bound by antivenom, but in severe cases cardiac toxicity was not reversed.
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Affiliation(s)
- Mark Miller
- a Emergency Department , John Hunter Hospital , Newcastle , NSW , Australia
| | - Margaret A O'Leary
- b Clinical Toxicology Research Group , University of Newcastle , Newcastle , NSW , Australia
| | - Geoffrey K Isbister
- b Clinical Toxicology Research Group , University of Newcastle , Newcastle , NSW , Australia ;,c Department of Clinical Toxicology and Pharmacology , Calvary Mater Hospital , Newcastle , NSW , Australia
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Weinstein SA, White J, Ou J, Haiart S, Galluccio S. Reply to Isbister and Page: Further discussion of an illuminated case of presumed brown snake (Pseudonaja spp.) envenoming. Clin Toxicol (Phila) 2015; 53:926-7. [PMID: 26503791 DOI: 10.3109/15563650.2015.1096369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Scott A Weinstein
- a Toxinology Department , Women's and Children's Hospital , North Adelaide , South Australia , Australia
| | - Julian White
- a Toxinology Department , Women's and Children's Hospital , North Adelaide , South Australia , Australia
| | - Judy Ou
- b Departments of Emergency Medicine and Intensive Care , Flinders University Medical Center , Bedford Park , Adelaide , South Australia , Australia
| | - Sebastien Haiart
- b Departments of Emergency Medicine and Intensive Care , Flinders University Medical Center , Bedford Park , Adelaide , South Australia , Australia
| | - Steven Galluccio
- b Departments of Emergency Medicine and Intensive Care , Flinders University Medical Center , Bedford Park , Adelaide , South Australia , Australia
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Affiliation(s)
- Geoffrey K Isbister
- a Clinical Toxicology Research Group, University of Newcastle , Newcastle , Australia.,b Department of Clinical Toxicology and Pharmacology , Calvary Mater Newcastle , New South Wales , Australia.,c New South Wales Poisons information Centre, Sydney Children's Hospital Network , NSW , Australia
| | - Colin B Page
- a Clinical Toxicology Research Group, University of Newcastle , Newcastle , Australia.,b Department of Clinical Toxicology and Pharmacology , Calvary Mater Newcastle , New South Wales , Australia.,c New South Wales Poisons information Centre, Sydney Children's Hospital Network , NSW , Australia
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