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Sassoè-Pognetto M, Cavalcante R, Paonessa M. Acute compartment syndrome and fasciotomy after a viper bite in Italy: a case report. Ital J Pediatr 2024; 50:70. [PMID: 38627836 PMCID: PMC11020867 DOI: 10.1186/s13052-024-01638-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/28/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Bites caused by European vipers are rare medical emergencies but can occasionally cause life-threatening complications. Viper venom causes local symptoms, which can be accompanied by systemic manifestations in severe cases. The local effects of snakebites include edema and, more rarely, necrosis and compartment syndrome. The consequences of envenomation are often more pronounced in children due to their smaller body size. CASE PRESENTATION We present the case of a 6-year-old girl who experienced multiple viper bites in the lower limb in northwest Italy. The girl received supportive care but progressed to develop compartment syndrome that required emergency fasciotomy. The patient's condition improved promptly after surgical decompression and administration of antivenom, but full recovery required prolonged hospitalization and rehabilitation. CONCLUSIONS This case highlights the importance of obtaining a timely assessment of the severity of viper envenomation without delaying the administration of antivenom in most serious cases. The presence of multiple bite marks on the patient is one factor that may help to predict the clinical severity of snakebites and anticipate symptom progression.
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Affiliation(s)
- Marco Sassoè-Pognetto
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, C.so Massimo d'Azeglio, 52, 10126, Torino, Italy.
| | - Riccardo Cavalcante
- Centro Emys Piemonte, ELEADE Società Cooperativa a.r.l, Chiaverano, TO, Italy
| | - Matteo Paonessa
- Pediatric Orthopedic Surgery Department, "Regina Margherita" Children's Hospital, Torino, Italy
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Li Q, Huang Y, Zhang Y, Zeng L, Liang Q, Luo J. Venomous snakebites in children: a 10 year experience in South China. Clin Toxicol (Phila) 2024; 62:229-236. [PMID: 38668745 DOI: 10.1080/15563650.2024.2341124] [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: 04/29/2023] [Accepted: 03/20/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Many studies have focused on snakebites in adults, but very few have described snakebites in children. METHODS We reviewed the clinical characteristics and outcomes of children with venomous snakebites aged less than 15 years who presented to a regional medical centre in South China from January 2013 to December 2022. RESULTS A total of 69 envenomed patients were analyzed in our study; 42 (60.9 per cent) patients were male, and 59 (85.5 per cent) reported lower limb bites. Most bites (89.8 per cent) occurred between April and October. Twenty-seven patients received first aid management, and 47 required admission to the general ward. Antivenom was administered to 58 patients, glucocorticoids to 43 patients, antibiotics to 48 patients, and tetanus antitoxin to 40 patients. No fatalities were reported. The most common snake identified was Trimeresurus albolabris. Four were classified as dry bites, 15 as mild, 43 as moderate, and seven as severe. The most common local signs were pain and swelling, while the most common systemic effects were haematological complications. Patients with high severity scores had significantly higher lactate dehydrogenase activities, creatine kinase isoenzyme activities, aspartate aminotransferase activities, D-dimer concentrations, prothrombin times and lower fibrinogen concentrations. In a receiver operating characteristic curve analysis of the values with the highest Youden index, the following cut-offs proved significant: lactate dehydrogenase activity > 248.1 U/L, creatine kinase isoenzyme activities > 17.5 U/L, fibrinogen concentration < 1,455 mg/L, D-dimer concentration > 437.0 µg/L, aspartate aminotransferase activity > 26.1 U/L, and prothrombin time > 15.2 seconds. DISCUSSION This study provides insight into the epidemiology, clinical profile, and management of snakebites in children. Data from the present study were compared with those from our previous adult study. Limitations include that 50.7 per cent of our snakebites were attributed to Trimeresurus albolabris. Therefore, the results of our study may not be generalizable to all snakebites. CONCLUSION The clinical symptoms were more severe in children than in adults in our previous study. Even though there were no fatalities, close monitoring should be performed to detect haematological and other potentially fatal complications promptly.
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Affiliation(s)
- Qianqin Li
- Department of Emergency Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yan Huang
- Department of Emergency Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Youhong Zhang
- Department of Internal Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Liangbo Zeng
- Department of Emergency Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qing Liang
- Department of Emergency Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jiangfu Luo
- Department of Emergency Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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3
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Pandit K, Rawal A, Maskey HMS, Nepal G. Neurological and neuro-ophthalmological manifestations of snake bite: a systematic review. Ann Med Surg (Lond) 2024; 86:392-400. [PMID: 38222724 PMCID: PMC10783398 DOI: 10.1097/ms9.0000000000001523] [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: 08/01/2023] [Accepted: 11/09/2023] [Indexed: 01/16/2024] Open
Abstract
Objective Snakebites, a major health concern in developing countries, affect rural farming communities. Venom, primarily neurotoxin, injected during a snake bite disrupts the nervous system, causing symptoms like muscle weakness, paralysis, altered sensation, and coordination issues. This review focuses on evaluating neurological and neuro-ophthalmological manifestations associated with snakebites. Methods A database search was conducted in EMBASE and PubMed for studies published from 2000 to 2023. The investigation centered on examining neurological and neuro-ophthalmological symptoms and signs, treatment approaches, treatment outcomes, and long-term complications of snake bites. Results Neurological and neuro-ophthalmological symptoms were common in both neurotoxic and hemotoxic snake bites, especially in neurotoxic cases. Ptosis was a prevalent manifestation across various snake bites, along with respiratory paralysis, limb weakness, dysphasia, and visual disturbances in some instances. However, most patients improved without residual neurological symptoms after treatment. Conclusions Understanding patterns of neurological manifestations contributes valuable insights for the comprehensive management of snakebite.
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Affiliation(s)
- Kamal Pandit
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Aastha Rawal
- Department of Pharmacy, Manmohan Memorial Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Himang Man Singh Maskey
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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Iliyasu G, Gutiérrez JM, Habib AG. Snakebites in children: Also a European occurrence. Toxicon 2023; 236:107346. [PMID: 37951247 DOI: 10.1016/j.toxicon.2023.107346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/09/2023] [Indexed: 11/13/2023]
Affiliation(s)
- Garba Iliyasu
- Department of Medicine, Bayero University Kano, Nigeria.
| | - José M Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501, Costa Rica
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Gamulin E, Mateljak Lukačević S, Halassy B, Kurtović T. Snake Antivenoms-Toward Better Understanding of the Administration Route. Toxins (Basel) 2023; 15:398. [PMID: 37368699 DOI: 10.3390/toxins15060398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Envenomations induced by animal bites and stings constitute a significant public health burden. Even though a standardized protocol does not exist, parenterally administered polyclonal antivenoms remain the mainstay in snakebite therapy. There is a prevailing opinion that their application by the i.m. route has poor efficacy and that i.v. administration should preferentially be chosen in order to achieve better accomplishment of the antivenom therapeutic activity. Recently, it has been demonstrated that neutralization not only in the systemic circulation but also in the lymphatic system might be of great importance for the clinical outcome since it represents another relevant body compartment through which the absorption of the venom components occurs. In this review, the present-day and summarized knowledge of the laboratory and clinical findings on the i.v. and i.m. routes of antivenom administration is provided, with a special emphasis on the contribution of the lymphatic system to the process of venom elimination. Until now, antivenom-mediated neutralization has not yet been discussed in the context of the synergistic action of both blood and lymph. A current viewpoint might help to improve the comprehension of the venom/antivenom pharmacokinetics and the optimal approach for drug application. There is a great need for additional dependable, practical, well-designed studies, as well as more practice-related experience reports. As a result, opportunities for resolving long-standing disputes over choosing one therapeutic principle over another might be created, improving the safety and effectiveness of snakebite management.
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Affiliation(s)
- Erika Gamulin
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Sanja Mateljak Lukačević
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
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Dehghani R, Monzavi SM, Mehrpour O, Shirazi FM, Hassanian-Moghaddam H, Keyler DE, Wüster W, Westerström A, Warrell DA. Medically important snakes and snakebite envenoming in Iran. Toxicon 2023; 230:107149. [PMID: 37187227 DOI: 10.1016/j.toxicon.2023.107149] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/17/2023]
Abstract
Snakebite is a common health condition in Iran with a diverse snake fauna, especially in tropical southern and mountainous western areas of the country with plethora of snake species. The list of medically important snakes, circumstances and effects of their bite, and necessary medical care require critical appraisal and should be updated regularly. This study aims to review and map the distributions of medically important snake species of Iran, re-evaluate their taxonomy, review their venomics, describe the clinical effects of envenoming, and discuss medical management and treatment, including the use of antivenom. Nearly 350 published articles and 26 textbooks with information on venomous and mildly venomous snake species and snakebites of Iran, were reviewed, many in Persian (Farsi) language, making them relatively inaccessible to an international readership. This has resulted in a revised updated list of Iran's medically important snake species, with taxonomic revisions of some, compilation of their morphological features, remapping of their geographical distributions, and description of species-specific clinical effects of envenoming. Moreover, the antivenom manufactured in Iran is discussed, together with treatment protocols that have been developed for the hospital management of envenomed patients.
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Affiliation(s)
- Ruhollah Dehghani
- Department of Environmental Health, Kashan University of Medical Sciences, Kashan, Iran; Social Determinants of Health Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Seyed Mostafa Monzavi
- Medical Toxicology Center, Mashhad University of Medical Sciences, Mashhad, Iran; Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center, Birjand University of Medical Sciences, Birjand, Iran; Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA.
| | - Farshad M Shirazi
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - Hossein Hassanian-Moghaddam
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Daniel E Keyler
- Department of Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Wolfgang Wüster
- Molecular Ecology and Evolution at Bangor, School of Natural Sciences, Bangor University, Bangor, UK
| | | | - David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Sassoè M. Envenomation by Vipera aspis in Piedmont (Italy): A report of three cases, including one case with neurological symptoms. Toxicon 2023; 230:107154. [PMID: 37169267 DOI: 10.1016/j.toxicon.2023.107154] [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: 03/30/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 05/13/2023]
Abstract
This report describes three cases of human envenomation by the asp viper (Vipera aspis) in Piedmont, north-west Italy. A woman was bitten on the ankle while she was hiking and two herpetologists received bites on the hand while they were manipulating the animals. In the first case, the victim presented severe systemic symptoms (abdominal pain, vomiting, diarrhea) that required treatment with two vials of antivenom and hospitalization for one week. In the second case, the patient manifested neurological symptoms (blepharoptosis, ophtalmoplegia); he was treated with antivenom and discharged after five days. In the third case, the patient was bitten by a juvenile viper and showed only local symptoms (edema and bruising). All patients reported prolonged functional impairment after discharge from hospital. Although uncommon, envenomation by Vipera aspis can cause severe consequences that require immediate management and antivenom administration. These cases highlight the importance of obtaining better knowledge of the intraspecific variability of venoms and its clinical significance, as well as of the factors that determine the severity of snakebite injuries.
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Affiliation(s)
- Marco Sassoè
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, C.so Massimo d'Azeglio, 52, 10126, Torino, Italy.
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Genomic Confirmation of the P-IIIe Subclass of Snake Venom Metalloproteinases and Characterisation of Its First Member, a Disintegrin-Like/Cysteine-Rich Protein. Toxins (Basel) 2022; 14:toxins14040232. [PMID: 35448841 PMCID: PMC9028321 DOI: 10.3390/toxins14040232] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 12/15/2022] Open
Abstract
Disintegrin-like/cysteine-rich (DC) proteins have long been regarded just as products of proteolysis of P-III snake venom metalloproteinases (SVMPs). However, here we demonstrate that a DC protein from the venom of Vipera ammodytes (Vaa; nose-horned viper), VaaMPIII-3, is encoded per se by a P-III SVMP-like gene that has a deletion in the region of the catalytic metalloproteinase domain and in part of the non-catalytic disintegrin-like domain. In this way, we justify the proposal of the introduction of a new subclass P-IIIe of SVMP-derived DC proteins. We purified VaaMPIII-3 from the venom of Vaa in a series of chromatographic steps. A covalent chromatography step based on thiol-disulphide exchange revealed that VaaMPIII-3 contains an unpaired Cys residue. This was demonstrated to be Cys6 in about 90% and Cys19 in about 10% of the VaaMPIII-3 molecules. We further constructed a three-dimensional homology model of VaaMPIII-3. From this model, it is evident that both Cys6 and Cys19 can pair with Cys26, which suggests that the intramolecular thiol-disulphide exchange has a regulatory function. VaaMPIII-3 is an acidic 21-kDa monomeric glycoprotein that exists in at least six N-glycoforms, with isoelectric points ranging from pH 4.5 to 5.1. Consistent with the presence of an integrin-binding motif in its sequence, SECD, VaaMPIII-3 inhibited collagen-induced platelet aggregation. It also inhibited ADP- and arachidonic-acid-induced platelet aggregation, but not ristocetin-induced platelet agglutination and the blood coagulation cascade.
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Chiang LC, Chaou CH, Li YY, Seak CJ, Yu SR, Lin CC. Management and Prognosis of Snake Envenomation Among Pediatric Patients: A National Database Study. J Acute Med 2022; 12:13-22. [PMID: 35619724 PMCID: PMC9096508 DOI: 10.6705/j.jacme.202203_12(1).0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 02/22/2021] [Accepted: 05/21/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Snakebites constitute a common medical emergency in tropical and subtropical regions. Pediatric snake envenomation is a special category that has not been well studied. This study investigated the management and prognostic factors of snake envenomation in children using a Taiwanese national database. METHODS This observational study used the National Health Insurance database of all pediatric snake envenomation patients treated from 2005 to 2009. Patients' demographic data, antivenom types and doses, medical and surgical interventions, and prognostic variables were collected. Comparisons were made according to the envenomation types, age groups, and whether the patients were hospitalized using univariate and multivariate methods. RESULTS A total of 106 patients' data were collected. Of the patients, 73 (68.9%) were male, 62 (58.5%) were under the age of 12, 69 (65.1%) received intravenous (IV) antibiotic treatment, 38 (35.9%) were hospitalized, 5 (4.72%) required surgical intervention, and none died. Compared with non-hospitalized patients, the patients who required hospitalization were more likely to have suffered hemorrhagic envenomation ( p = 0.035), receive IV antibiotic treatment ( p = 0.0078), and require surgical intervention ( p = 0.005). In the multivariate analysis, hemorrhagic envenomation was an independent predictor for hospitalization (odds ratio: 3.47, 95% confidence interval: 1.18-10.21) after adjusting for other covariates. No significant differences were observed between age groups in total antivenom usage ( p = 0.2880), IV antibiotic usage ( p = 0.3190), hospitalization ( p = 0.3988), and surgical intervention ( p = 0.1874). CONCLUSIONS In this Taiwanese population-based national database study, antivenom treatment of pediatric snakebite patients resulted in zero mortality and a low surgical intervention rate. Patients with hemorrhagic envenomation were associated with a higher probability of hospitalization.
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Affiliation(s)
- Lin-Chi Chiang
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
| | - Chung-Hsien Chaou
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
- Chang Gung Memorial Hospital Chang Gung Medical Education Research Centre Taoyuan Taiwan
| | - Yi-Yun Li
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
| | - Chen-June Seak
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
- New Taipei Municipal Tucheng Hospital Department of Emergency Medicine New Taipei City Taiwan
| | - Shiuan-Ruey Yu
- Chang Gung Memorial Hospital Chang Gung Medical Education Research Centre Taoyuan Taiwan
| | - Chih-Chuan Lin
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
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İpek S, Gungor S, Güllü UU, Dalkıran T, Mercan M, Demiray Ş, Gürbüz Y. Snakebites in Pediatric Patients in Kahramanmaraş: Is Pro-brain Natriuretic Peptide a Prognostic Biomarker for Snakebites? Cureus 2022; 14:e21570. [PMID: 35228929 PMCID: PMC8866160 DOI: 10.7759/cureus.21570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 11/19/2022] Open
Abstract
Background: Snake envenomations are a serious cause of mortality and morbidity in the world. Aims: This study was conducted to investigate snake bites in pediatric patients in Kahramanmaraş and to determine whether pro-brain natriuretic peptide (proBNP) has a prognostic value in these patients. Methods: Pediatric patients aged <18 years who presented to the pediatric emergency department with snakebites were reviewed retrospectively. The demographical, clinical, laboratory, treatments, and outcomes data were collected from their medical records. Stage 0 and 1 envenomation was considered as a non-serious complication and stage 2 and 3 envenomation was considered as a serious complication. Results: A total of 32 pediatric patients, six females and 26 males, between 2016 and 2021, were included in the study. The mean age was 12.52±3.28 years. There were seven patients without serious complications and 25 patients with serious complications. The best cutoff point for proBNP to predict serious complications was found to be ≥272.5 ng∙L-1 (sensitivity, 83.3%; specificity, 100%, p=0.011). We also detected complex regional pain syndrome in one of our patients. Conclusions: In this study, proBNP was shown to be predictive of a poor outcome of snakebites. Moreover, complex regional pain syndrome, which is rarely reported in the literature, should be kept in mind during the long-term follow-up of snakebites.
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Affiliation(s)
- Sevcan İpek
- Pediatric Critical Care, Kahramanmaraş Sütçü İmam University Faculty of Medicine, Kahramanmaraş, TUR
| | - Sukru Gungor
- Pediatric Gastroenterology, Kahramanmaraş Sütçü İmam University Faculty of Medicine, Kahramanmaraş, TUR
| | - Ufuk U Güllü
- Pediatric Cardiology, Kahramanmaraş Sütçü İmam University Faculty of Medicine, Kahramanmaraş, TUR
| | - Tahir Dalkıran
- Department of Pediatric Intensive Care Unit, Kahramanmaraş Necip Fazıl City Hospital, Kahramanmaraş, TUR
| | - Mehmet Mercan
- Department of Pediatrics, Kahramanmaraş Necip Fazıl City Hospital, Kahramanmaraş, TUR
| | - Şeyma Demiray
- Pediatrics, Kahramanmaraş Sütçü İmam University Faculty of Medicine, Kahramanmaraş, TUR
| | - Yunus Gürbüz
- Pediatric Intensive Care Unit, Kahramanmaraş Sütçü İmam University Health Practice and Research Hospital, Kahramanmaraş, TUR
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Savu AN, Schoenbrunner AR, Politi R, Janis JE. Practical Review of the Management of Animal Bites. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3778. [PMID: 34522565 PMCID: PMC8432645 DOI: 10.1097/gox.0000000000003778] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/01/2021] [Indexed: 11/26/2022]
Abstract
Animal bites are common worldwide. Due to the plethora of animals, there are diverse pathogens with specific associated risks and treatment algorithms. It is crucial to understand these to develop and execute appropriate management plans. This practical review was designed to amalgamate the most common bites worldwide and synthesize data to help guide treatment plans. METHODS A PubMed literature search was performed focusing on the major animal bites. High-level studies were preferred and analyzed but lower-level studies were also used if high-level studies did not exist. RESULTS The tables presented in this article cover the pertinent information regarding the incidence, common presentation, initial treatment, and potential complications associated with bites from dogs, cats, horses, rodents, snakes, marine life, and spiders. Many of the pathogens associated with the bites are treatable with various and somewhat common antimicrobials, though some are less easy to access. Basic irrigation, debridement, and wound culture are common to almost every animal and should be the first step in treatment. CONCLUSIONS Based on the current studies, the most important factor in treating animal bites is timely presentation to a medical facility and/or physician. It is critical that the offending animal be accurately identified to help guide medical and surgical algorithms, including specific antimicrobial treatment guided by the most commonly presenting pathogens specific to certain animals.
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Affiliation(s)
- Andrei N. Savu
- From the Ohio State College of Medicine, The Ohio State University, Columbus, Ohio
| | - Anna R. Schoenbrunner
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- The University of Virginia School of Medicine, The University of Virginia, Charlottesville, Va
| | - Rachel Politi
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- The University of Virginia School of Medicine, The University of Virginia, Charlottesville, Va
| | - Jeffrey E. Janis
- The University of Virginia School of Medicine, The University of Virginia, Charlottesville, Va
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Pintor AF, Ray N, Longbottom J, Bravo-Vega CA, Yousefi M, Murray KA, Ediriweera DS, Diggle PJ. Addressing the global snakebite crisis with geo-spatial analyses - Recent advances and future direction. Toxicon X 2021; 11:100076. [PMID: 34401744 PMCID: PMC8350508 DOI: 10.1016/j.toxcx.2021.100076] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 02/08/2023] Open
Abstract
Venomous snakebite is a neglected tropical disease that annually leads to hundreds of thousands of deaths or long-term physical and mental ailments across the developing world. Insufficient data on spatial variation in snakebite risk, incidence, human vulnerability, and accessibility of medical treatment contribute substantially to ineffective on-ground management. There is an urgent need to collect data, fill knowledge gaps and address on-ground management problems. The use of novel, and transdisciplinary approaches that take advantage of recent advances in spatio-temporal models, 'big data', high performance computing, and fine-scale spatial information can add value to snakebite management by strategically improving our understanding and mitigation capacity of snakebite. We review the background and recent advances on the topic of snakebite related geospatial analyses and suggest avenues for priority research that will have practical on-ground applications for snakebite management and mitigation. These include streamlined, targeted data collection on snake distributions, snakebites, envenomings, venom composition, health infrastructure, and antivenom accessibility along with fine-scale models of spatio-temporal variation in snakebite risk and incidence, intraspecific venom variation, and environmental change modifying human exposure. These measures could improve and 'future-proof' antivenom production methods, antivenom distribution and stockpiling systems, and human-wildlife conflict management practices, while simultaneously feeding into research on venom evolution, snake taxonomy, ecology, biogeography, and conservation.
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Affiliation(s)
- Anna F.V. Pintor
- Division of Data, Analytics and Delivery for Impact (DDI), World Health Organization, Geneva, Switzerland
- Australian Institute of Tropical Health and Medicine, Division of Tropical Health and Medicine, James Cook University, Cairns, Australia
| | - Nicolas Ray
- GeoHealth Group, Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
| | - Joshua Longbottom
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Centre for Health Informatics, Computing and Statistics, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
| | - Carlos A. Bravo-Vega
- Research Group in Mathematical and Computational Biology (BIOMAC), Department of Biomedical Engineering, University of Los Andes, Bogotá, Colombia
| | - Masoud Yousefi
- School of Biology, College of Science, University of Tehran, Iran
| | - Kris A. Murray
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, UK
- MRC Unit the Gambia at London School of Hygiene and Tropical Medicine, Atlantic Blvd, Fajara, Gambia
| | - Dileepa S. Ediriweera
- Health Data Science Unit, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Peter J. Diggle
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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13
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Ediriweera DS, Kasthuriratne A, Pathmeswaran A, Gunawardene NK, Jayamanne SF, Murray K, Iwamura T, Isbister G, Dawson A, Lalloo DG, de Silva HJ, Diggle PJ. Evaluating spatiotemporal dynamics of snakebite in Sri Lanka: Monthly incidence mapping from a national representative survey sample. PLoS Negl Trop Dis 2021; 15:e0009447. [PMID: 34061839 PMCID: PMC8195360 DOI: 10.1371/journal.pntd.0009447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 06/11/2021] [Accepted: 05/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Snakebite incidence shows both spatial and temporal variation. However, no study has evaluated spatiotemporal patterns of snakebites across a country or region in detail. We used a nationally representative population sample to evaluate spatiotemporal patterns of snakebite in Sri Lanka. METHODOLOGY We conducted a community-based cross-sectional survey representing all nine provinces of Sri Lanka. We interviewed 165 665 people (0.8% of the national population), and snakebite events reported by the respondents were recorded. Sri Lanka is an agricultural country; its central, southern and western parts receive rain mainly from Southwest monsoon (May to September) and northern and eastern parts receive rain mainly from Northeast monsoon (November to February). We developed spatiotemporal models using multivariate Poisson process modelling to explain monthly snakebite and envenoming incidences in the country. These models were developed at the provincial level to explain local spatiotemporal patterns. PRINCIPAL FINDINGS Snakebites and envenomings showed clear spatiotemporal patterns. Snakebite hotspots were found in North-Central, North-West, South-West and Eastern Sri Lanka. They exhibited biannual seasonal patterns except in South-Western inlands, which showed triannual seasonality. Envenoming hotspots were confined to North-Central, East and South-West parts of the country. Hotspots in North-Central regions showed triannual seasonal patterns and South-West regions had annual patterns. Hotspots remained persistent throughout the year in Eastern regions. The overall monthly snakebite and envenoming incidences in Sri Lanka were 39 (95%CI: 38-40) and 19 (95%CI: 13-30) per 100 000, respectively, translating into 110 000 (95%CI: 107 500-112 500) snakebites and 45 000 (95%CI: 32 000-73 000) envenomings in a calendar year. CONCLUSIONS/SIGNIFICANCE This study provides information on community-based monthly incidence of snakebites and envenomings over the whole country. Thus, it provides useful insights into healthcare decision-making, such as, prioritizing locations to establish specialized centres for snakebite management and allocating resources based on risk assessments which take into account both location and season.
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Affiliation(s)
| | | | | | | | | | - Kris Murray
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
| | - Takuya Iwamura
- Department of Forest Ecosystems and Society, College of Forestry, Oregon State University, Corvallis, Oregon, United States of America
| | - Geoffrey Isbister
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, University of Newcastle, Waratah, Australia
| | - Andrew Dawson
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Addiction Medicine, Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | | | | | - Peter John Diggle
- CHICAS, Lancaster University Medical School, Lancaster, United Kingdom
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14
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Kurtović T, Karabuva S, Grenc D, Dobaja Borak M, Križaj I, Lukšić B, Halassy B, Brvar M. Intravenous Vipera berus Venom-Specific Fab Fragments and Intramuscular Vipera ammodytes Venom-Specific F(ab') 2 Fragments in Vipera ammodytes-Envenomed Patients. Toxins (Basel) 2021; 13:toxins13040279. [PMID: 33919927 PMCID: PMC8070888 DOI: 10.3390/toxins13040279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 11/25/2022] Open
Abstract
Vipera ammodytes (V. ammodytes) is the most venomous European viper. The aim of this study was to compare the clinical efficacy and pharmacokinetic values of intravenous Vipera berus venom-specific (paraspecific) Fab fragments (ViperaTAb) and intramuscular V. ammodytes venom-specific F(ab’)2 fragments (European viper venom antiserum, also called “Zagreb” antivenom) in V.ammodytes-envenomed patients. This was a prospective study of V.ammodytes-envenomed patients that were treated intravenously with ViperaTAb or intramuscularly with European viper venom antiserum that was feasible only due to the unique situation of an antivenom shortage. The highest venom concentration, survival, length of hospital stay and adverse reactions did not differ between the groups. Patients treated with intravenous Fab fragments were sicker, with significantly more rhabdomyolysis and neurotoxicity. The kinetics of Fab fragments after one or more intravenous applications matched better with the venom concentration in the early phase of envenomation compared to F(ab’)2 fragments that were given intramuscularly only on admission. F(ab’)2 fragments given intramuscularly had 25-fold longer apparent total body clearance and 14-fold longer elimination half-time compared to Fab fragments given intravenously (2 weeks vs. 24 h, respectively). In V.ammodytes-envenomed patients, the intramuscular use of specific F(ab’)2 fragments resulted in a slow rise of antivenom serum concentration that demanded their early administration but without the need for additional doses for complete resolution of all clinical signs of envenomation. Intravenous use of paraspecific Fab fragments resulted in the immediate rise of antivenom serum concentration that enabled their use according to the clinical progress, but multiple doses might be needed for efficient therapy of thrombocytopenia due to venom recurrence, while the progression of rhabdomyolysis and neurotoxic effects of the venom could not be prevented.
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Affiliation(s)
- Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia;
- Center of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital of Split, Šoltanska 1, 21000 Split, Croatia; (S.K.); (B.L.)
- School of Medicine, University of Split, Šoltanska 2, 21000 Split, Croatia
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (D.G.); (M.D.B.)
| | - Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (D.G.); (M.D.B.)
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova 39, 1000 Ljubljana, Slovenia;
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital of Split, Šoltanska 1, 21000 Split, Croatia; (S.K.); (B.L.)
- School of Medicine, University of Split, Šoltanska 2, 21000 Split, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia;
- Center of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
- Correspondence: (B.H.); (M.B.)
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (D.G.); (M.D.B.)
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, 1000 Ljubljana, Slovenia
- Correspondence: (B.H.); (M.B.)
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15
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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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16
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Leonardi A, Sajevic T, Pungerčar J, Križaj I. Comprehensive Study of the Proteome and Transcriptome of the Venom of the Most Venomous European Viper: Discovery of a New Subclass of Ancestral Snake Venom Metalloproteinase Precursor-Derived Proteins. J Proteome Res 2019; 18:2287-2309. [PMID: 31017792 PMCID: PMC6727599 DOI: 10.1021/acs.jproteome.9b00120] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
![]()
The
nose-horned viper, its nominotypical subspecies Vipera
ammodytes ammodytes (Vaa), in particular,
is, medically, one of the most relevant snakes in Europe. The local
and systemic clinical manifestations of poisoning by the venom of
this snake are the result of the pathophysiological effects inflicted
by enzymatic and nonenzymatic venom components acting, most prominently,
on the blood, cardiovascular, and nerve systems. This venom is a very
complex mixture of pharmacologically active proteins and peptides.
To help improve the current antivenom therapy toward higher specificity
and efficiency and to assist drug discovery, we have constructed,
by combining transcriptomic and proteomic analyses, the most comprehensive
library yet of the Vaa venom proteins and peptides.
Sequence analysis of the venom gland cDNA library has revealed the
presence of messages encoding 12 types of polypeptide precursors.
The most abundant are those for metalloproteinase inhibitors (MPis),
bradykinin-potentiating peptides (BPPs), and natriuretic peptides
(NPs) (all three on a single precursor), snake C-type lectin-like
proteins (snaclecs), serine proteases (SVSPs), P-II and P-III metalloproteinases
(SVMPs), secreted phospholipases A2 (sPLA2s),
and disintegrins (Dis). These constitute >88% of the venom transcriptome.
At the protein level, 57 venom proteins belonging to 16 different
protein families have been identified and, with SVSPs, sPLA2s, snaclecs, and SVMPs, comprise ∼80% of all venom proteins.
Peptides detected in the venom include NPs, BPPs, and inhibitors of
SVSPs and SVMPs. Of particular interest, a transcript coding for a
protein similar to P-III SVMPs but lacking the MP domain was also
found at the protein level in the venom. The existence of such proteins,
also supported by finding similar venom gland transcripts in related
snake species, has been demonstrated for the first time, justifying
the proposal of a new P-IIIe subclass of ancestral SVMP precursor-derived
proteins.
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Affiliation(s)
- Adrijana Leonardi
- Department of Molecular and Biomedical Sciences , Jožef Stefan Institute , Jamova cesta 39 , SI-1000 Ljubljana , Slovenia
| | - Tamara Sajevic
- Department of Molecular and Biomedical Sciences , Jožef Stefan Institute , Jamova cesta 39 , SI-1000 Ljubljana , Slovenia
| | - Jože Pungerčar
- Department of Molecular and Biomedical Sciences , Jožef Stefan Institute , Jamova cesta 39 , SI-1000 Ljubljana , Slovenia
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences , Jožef Stefan Institute , Jamova cesta 39 , SI-1000 Ljubljana , Slovenia
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17
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García-Arredondo A, Martínez M, Calderón A, Saldívar A, Soria R. Preclinical Assessment of a New Polyvalent Antivenom (Inoserp Europe) against Several Species of the Subfamily Viperinae. Toxins (Basel) 2019; 11:E149. [PMID: 30841582 PMCID: PMC6468668 DOI: 10.3390/toxins11030149] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 11/17/2022] Open
Abstract
The European continent is inhabited by medically important venomous Viperinae snakes. Vipera ammodytes, Vipera berus, and Vipera aspis cause the greatest public health problems in Europe, but there are other equally significant snakes in specific regions of the continent. Immunotherapy is indicated for patients with systemic envenoming, of which there are approximately 4000 annual cases in Europe, and was suggested as an indication for young children and pregnant women, even if they do not have systemic symptoms. In the present study, the safety and venom-neutralizing efficacy of Inoserp Europe-a new F(ab')₂ polyvalent antivenom, designed to treat envenoming by snakes in the Eurasian region-were evaluated. In accordance with World Health Organization recommendations, several quality control parameters were applied to evaluate the safety of this antivenom. The venom-neutralizing efficacy of the antivenom was evaluated in mice and the results showed it had appropriate neutralizing potency against the venoms of several species of Vipera, Montivipera, and Macrovipera. Paraspecificity of the antivenom was demonstrated as well, since it neutralized venoms of species not included in the immunization schemes and contains satisfactory levels of total proteins and F(ab')₂ fragment concentration. Therefore, this new polyvalent antivenom could be effective in the treatment of snake envenoming in Europe, including Western Russia and Turkey.
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Affiliation(s)
- Alejandro García-Arredondo
- Laboratorio de Investigación Química y Farmacológica de Productos Naturales, Facultad de Química, Universidad Autónoma de Querétaro, Querétaro 76010, Mexico.
| | - Michel Martínez
- Veteria Labs, S.A. de C.V. Lucerna 7, Col. Juárez, Del. Cuauhtémoc, Ciudad de México 06600, Mexico.
| | - Arlene Calderón
- Inosan Biopharma, S.A. Arbea Campus Empresarial, Edificio 2, Planta 2, Carretera Fuencarral a Alcobendas, Km 3.8, 28108 Madrid, Spain.
| | - Asunción Saldívar
- Veteria Labs, S.A. de C.V. Lucerna 7, Col. Juárez, Del. Cuauhtémoc, Ciudad de México 06600, Mexico.
| | - Raúl Soria
- Inosan Biopharma, S.A. Arbea Campus Empresarial, Edificio 2, Planta 2, Carretera Fuencarral a Alcobendas, Km 3.8, 28108 Madrid, Spain.
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18
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Lukšić B, Karabuva S, Markić J, Polić B, Kovačević T, Meštrović J, Križaj I. Thrombocytopenic purpura following envenomation by the nose-horned viper (Vipera ammodytes ammodytes): Two case reports. Medicine (Baltimore) 2018; 97:e13737. [PMID: 30593149 PMCID: PMC6314653 DOI: 10.1097/md.0000000000013737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Two clinical cases are reported of envenomation by the nose-horned viper (Vipera ammodytes ammodytes) venom of a 9-year-old boy and of an 84-year-old woman. PATIENT CONCERNS Both patients had been bitten on their extremities by such a snake in August near Split, a town in southern Croatia. DIAGNOSES Clinical manifestation of envenomation was severe in the case of the boy, being characterized by a severe coagulopathy. This was only just apparent in the case of the elderly woman, who suffered extensive local edema and hematoma at the site of the bite, together with a neurotoxic effect-bilateral ptosis. This was the first occasion of thrombocytopenic purpura being observed in patients envenomed by nose-horned viper venom. This unexpected clinical finding was characterized by an unusually profound thrombocytopenia of 5 and 10 × 10/L platelets of the respective patients on their admission to the hospital, together with purpura, observed on the face and thorax of both individuals. In the most serious cases, such pathology can be life threatening if not promptly recognized and treated. INTERVENTIONS The patients recovered quickly on receiving the specific antivenom along with all the usual supportive treatments. OUTCOMES No serious sequels were noticed at the moment of discharge. LESSONS Our finding constitutes an important message to clinicians to consider the possibility of such complications in the case of nose-horned viper envenomation.
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Affiliation(s)
- Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital of Split
- University of Split, School of Medicine
| | - Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital of Split
| | - Joško Markić
- University of Split, School of Medicine
- Department of Pediatrics, University Hospital of Split, Split
| | - Branka Polić
- Department of Pediatrics, University Hospital of Split, Split
| | - Tanja Kovačević
- Department of Pediatrics, University Hospital of Split, Split
| | - Julije Meštrović
- University of Split, School of Medicine
- Department of Pediatrics, University Hospital of Split, Split
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Ljubljana, Slovenia
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19
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Ediriweera DS, Diggle PJ, Kasturiratne A, Pathmeswaran A, Gunawardena NK, Jayamanne SF, Isbister GK, Dawson A, Lalloo DG, de Silva HJ. Evaluating temporal patterns of snakebite in Sri Lanka: the potential for higher snakebite burdens with climate change. Int J Epidemiol 2018; 47:2049-2058. [PMID: 30215727 PMCID: PMC6280932 DOI: 10.1093/ije/dyy188] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 11/14/2022] Open
Abstract
Background Snakebite is a neglected tropical disease that has been overlooked by healthcare decision makers in many countries. Previous studies have reported seasonal variation in hospital admission rates due to snakebites in endemic countries including Sri Lanka, but seasonal patterns have not been investigated in detail. Methods A national community-based survey was conducted during the period of August 2012 to June 2013. The survey used a multistage cluster design, sampled 165 665 individuals living in 44 136 households and recorded all recalled snakebite events that had occurred during the preceding year. Log-linear models were fitted to describe the expected number of snakebites occurring in each month, taking into account seasonal trends and weather conditions, and addressing the effects of variation in survey effort during the study and of recall bias amongst survey respondents. Results Snakebite events showed a clear seasonal variation. Typically, snakebite incidence is highest during November-December followed by March-May and August, but this can vary between years due to variations in relative humidity, which is also a risk factor. Low relative-humidity levels are associated with high snakebite incidence. If current climate-change projections are correct, this could lead to an increase in the annual snakebite burden of 31.3% (95% confidence interval: 10.7-55.7) during the next 25-50 years. Conclusions Snakebite in Sri Lanka shows seasonal variation. Additionally, more snakebites can be expected during periods of lower-than-expected humidity. Global climate change is likely to increase the incidence of snakebite in Sri Lanka.
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Affiliation(s)
- Dileepa Senajith Ediriweera
- Centre for Health Informatics, Biostatistics and Epidemiology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
- Centre for Health Informatics, Computing and Statistics, Lancaster University Medical School, Lancaster, UK
| | - Peter John Diggle
- Centre for Health Informatics, Computing and Statistics, Lancaster University Medical School, Lancaster, UK
| | | | | | | | | | - Geoffrey Kennedy Isbister
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, University of Newcastle, Waratah, Australia
| | - Andrew Dawson
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Addiction Medicine, Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - David Griffith Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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20
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Zanetti G, Duregotti E, Locatelli CA, Giampreti A, Lonati D, Rossetto O, Pirazzini M. Variability in venom composition of European viper subspecies limits the cross-effectiveness of antivenoms. Sci Rep 2018; 8:9818. [PMID: 29959358 PMCID: PMC6026201 DOI: 10.1038/s41598-018-28135-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/14/2018] [Indexed: 12/17/2022] Open
Abstract
Medically relevant cases of snakebite in Europe are predominately caused by European vipers of the genus Vipera. Systemic envenoming by European vipers can cause severe pathology in humans and different clinical manifestations are associated with different members of this genus. The most representative vipers in Europe are V. aspis and V. berus and neurological symptoms have been reported in humans envenomed by the former but not by the latter species. In this study we determined the toxicological profile of V. aspis and V. berus venoms in vivo in mice and we tested the effectiveness of two antivenoms, commonly used as antidotes, in counteracting the specific activities of the two venoms. We found that V. aspis, but not V. berus, is neurotoxic and that this effect is due to the degeneration of peripheral nerve terminals at the NMJ and is not neutralized by the two tested antisera. Differently, V. berus causes a haemorrhagic effect, which is efficiently contrasted by the same antivenoms. These results indicate that the effectiveness of different antisera is strongly influenced by the variable composition of the venoms and reinforce the arguments supporting the use polyvalent antivenoms.
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Affiliation(s)
- Giulia Zanetti
- University of Padova, Department of Biomedical Sciences, Padova, 35131, Italy
| | - Elisa Duregotti
- University of Padova, Department of Biomedical Sciences, Padova, 35131, Italy
- King's College London, Department of Cardiology, James Black Centre, London, SE5 9NU, United Kingdom
| | - Carlo Alessandro Locatelli
- Istituti Clinici Scientifici Maugeri, IRCCS Maugeri Hospital and University of Pavia, Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Pavia, 27100, Italy
| | - Andrea Giampreti
- Istituti Clinici Scientifici Maugeri, IRCCS Maugeri Hospital and University of Pavia, Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Pavia, 27100, Italy
| | - Davide Lonati
- Istituti Clinici Scientifici Maugeri, IRCCS Maugeri Hospital and University of Pavia, Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Pavia, 27100, Italy
| | - Ornella Rossetto
- University of Padova, Department of Biomedical Sciences, Padova, 35131, Italy
| | - Marco Pirazzini
- University of Padova, Department of Biomedical Sciences, Padova, 35131, Italy.
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21
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Soares KSR, Gláucia-Silva F, Daniele-Silva A, Torres-Rêgo M, Araújo NKD, Menezes YASD, Damasceno IZ, Tambourgi DV, da Silva-Júnior AA, Fernandes-Pedrosa MDF. Antivenom Production against Bothrops jararaca and Bothrops erythromelas Snake Venoms Using Cross-Linked Chitosan Nanoparticles as an Immunoadjuvant. Toxins (Basel) 2018; 10:toxins10040158. [PMID: 29659491 PMCID: PMC5923324 DOI: 10.3390/toxins10040158] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/03/2018] [Accepted: 04/05/2018] [Indexed: 12/17/2022] Open
Abstract
In Brazil, envenomation by snakes of the genus Bothrops is clinically relevant, particularly for the species Bothrops jararaca and B. erythromelas. The most effective treatment for envenomation by snakes is the administration of antivenoms associated with adjuvants. Novel adjuvants are required to reduce side effects and maximize the efficiency of conventional serum and vaccine formulations. The polymer chitosan has been shown to have immunoadjuvant properties, and it has been used as a platform for delivery systems. In this context, we evaluated the potential immunoadjuvant properties of chitosan nanoparticles (CNPs) loaded with B. jararaca and B. erythromelas venoms in the production of sera against these venoms. Stable CNPs were obtained by ionic gelation, and mice were immunized subcutaneously for 6 weeks with 100 µL of each snake venom at concentrations of 5.0 or 10.0% (w/w), encapsulated in CNPs or associated with aluminium hydroxide (AH). The evaluation of protein interactions with the CNPs revealed their ability to induce antibody levels equivalent to those of AH, even with smaller doses of antigen. In addition, the CNPs were less inflammatory due to their modified release of proteins. CNPs provide a promising approach for peptide/protein delivery from snake venom and will be useful for new vaccines.
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Affiliation(s)
- Karla Samara Rocha Soares
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Federal University of Rio Grande do Norte, Natal 59012-570, Brazil.
| | - Fiamma Gláucia-Silva
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Federal University of Rio Grande do Norte, Natal 59012-570, Brazil.
| | - Alessandra Daniele-Silva
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Federal University of Rio Grande do Norte, Natal 59012-570, Brazil.
| | - Manoela Torres-Rêgo
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Federal University of Rio Grande do Norte, Natal 59012-570, Brazil.
| | - Nathália Kelly de Araújo
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Federal University of Rio Grande do Norte, Natal 59012-570, Brazil.
| | - Yamara Arruda Silva de Menezes
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Federal University of Rio Grande do Norte, Natal 59012-570, Brazil.
| | - Igor Zumba Damasceno
- Department of Materials Engineering, Technology Center, University Campus, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil.
| | | | - Arnóbio Antônio da Silva-Júnior
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Federal University of Rio Grande do Norte, Natal 59012-570, Brazil.
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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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Karabuva S, Lukšić B, Brizić I, Latinović Z, Leonardi A, Križaj I. Ammodytin L is the main cardiotoxic component of the Vipera ammodytes ammodytes venom. Toxicon 2017; 139:94-100. [PMID: 29030107 DOI: 10.1016/j.toxicon.2017.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/08/2017] [Accepted: 10/08/2017] [Indexed: 11/15/2022]
Abstract
Venom of the nose-horned viper (V. a. ammodytes) as also venoms of some related European viperids can induce also cardiotoxic effects in mammals. In this work we demonstrated that the protein in the V. a. ammodytes venom acting on heart is a myotoxic secreted phospholipase A2 analogue ammodytin L (AtnL). In the isolated perfused rat heart AtnL induced significant and irreversible cardiotoxicity characterized by atrioventricular (AV) blockade. This venom protein induced appearance of high levels of creatine kinase, lactate dehydrogenase, aspartate aminotransferase and troponin I in the sinus effluent of the isolated heart, indicative for myocardial damage, which is obviously the primary cause of its cardiotoxic action. Gel filtration chromatography subfractions C1 and C2 of the V. a. ammodytes venom harboured most of the venom cardiotoxicity. As we showed, just these two subfractions contained also AtnL. Subfraction C1 in the final CF concentration 11.3 μg/mL (containing 3.1 μg/mL AtnL) induced a complete cardiac arrest while subfraction C2 in the final CF concentration 6.0 μg/mL (containing 0.8 μg/mL AtnL) and the pure AtnL (1.0 μg/mL) did not. Contrary to AtnL, subfraction C1 at 11.3 μg/mL was not able to induce the AV blockade. This exposed the only other cardiotoxic subfractions-specific venom protein, a cysteine-rich secretory protein (CRISP), as an additional venom component potentially involved in modulation of the heart activity. Cardiotoxicity reported in some cases of the adder (V. berus) venom and the asp viper (V. aspis) venom poisonings may be assigned to AtnL in these venoms.
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Affiliation(s)
- Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital of Split, Šoltanska 1, Split, Croatia.
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital of Split, Šoltanska 1, Split, Croatia; University of Split School of Medicine, Šoltanska 2, Split, Croatia.
| | - Ivica Brizić
- Department of Pharmacology, Mostar University School of Medicine, Bijeli brijeg bb, Mostar, Bosnia and Herzegovina.
| | - Zorica Latinović
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia; Jožef Stefan International Postgraduate School, Jamova cesta 39, Ljubljana, Slovenia.
| | - Adrijana Leonardi
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia.
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia.
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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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Brvar M, Kurtović T, Grenc D, Lang Balija M, Križaj I, Halassy B. Vipera ammodytes bites treated with antivenom ViperaTAb: a case series with pharmacokinetic evaluation. Clin Toxicol (Phila) 2017; 55:241-248. [PMID: 28092984 DOI: 10.1080/15563650.2016.1277235] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONTEXT In clinical practice it is difficult to differentiate between V. berus and V. ammodytes venomous bites. In the past this was not a concern, but due to the current shortage in Viperfav™ and European viper venom antiserum availability, V. a. ammodytes venomous bites have recently been treated with ViperaTAb®, which is a pharmaceutical formulation containing a monospecific ovine Fab fragments against the venom of V. berus. OBJECTIVE To evaluate ViperaTAb® in V. a. ammodytes envenomations. MATERIALS AND METHODS This is a prospective case series of three consecutive patients envenomed by V. a. ammodytes snakebite treated with ViperaTAb®. V. ammodytes venom, neurotoxic ammodytoxins, and Fab fragment levels were determined in serum samples and a pharmacokinetic analysis of the antivenom Fab fragments was carried out. RESULTS Three patients bitten by V. a. ammodytes with extensive local swelling, neurological symptoms and recurrent thrombocytopenia were treated with ViperaTAb®. V. ammodytes venom was detected in serum of all three patients. Ammodytoxins were detected in the serum of only the most severely envenomed patient who developed neurological symptoms. In the presented moderate cases, a dose of 8 mL of ViperaTAb® reduced swelling and improved systemic effects, such as thrombocytopenia. However, this dose of ViperaTAb® was not effective in the most severely envenomed patient with the highest serum values of V. ammodytes venom. In this case ViperaTAb® did not stop local swelling and it had no effect on neurological signs. ViperaTAb®'s systemic clearance, distribution and elimination half-lives were 4.3-13.4 mL/h/kg, 1.2-3.2 h and 14.1-55.4 h, respectively. CONCLUSIONS In patients envenomed by V. a. ammodytes venom, ViperaTAb® reduces moderate swelling and temporarily improves systemic effects, except neurological symptoms. ViperaTAb® application induces a decrement of V. ammodytes venom level in the blood, but did not affect serum concentration of neurotoxic ammodytoxins in the one patient with measurable concentrations.
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Affiliation(s)
- Miran Brvar
- a Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Faculty of Medicine , Institute of Pathophysiology, University of Ljubljana , Ljubljana , Slovenia
| | - Tihana Kurtović
- c Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb , Zagreb , Croatia
| | - Damjan Grenc
- a Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Maja Lang Balija
- c Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb , Zagreb , Croatia
| | - Igor Križaj
- d Department of Molecular and Biomedical Sciences , Jožef Stefan Institute , Ljubljana , Slovenia.,e Faculty of Chemistry and Chemical Technology , University of Ljubljana , Ljubljana , Slovenia
| | - Beata Halassy
- c Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb , Zagreb , Croatia
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Karabuva S, Brizić I, Latinović Z, Leonardi A, Križaj I, Lukšić B. Cardiotoxic effects of the Vipera ammodytes ammodytes venom fractions in the isolated perfused rat heart. Toxicon 2016; 121:98-104. [PMID: 27623431 DOI: 10.1016/j.toxicon.2016.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/31/2016] [Accepted: 09/01/2016] [Indexed: 01/16/2023]
Abstract
The nose-horned viper (Vipera ammodytes ammodytes) is the most venomous European snake. Its venom is known as haematotoxic, myotoxic and neurotoxic but it exerts also cardiotoxic effects. To further explore the cardiotoxicity of the venom we separated it into four fractions by gel filtration chromatography. Three fractions that contain polypeptides (A, B, and C) were tested for their effects on isolated rat heart. Heart rate (HR), incidence of arrhythmias (atrioventricular (AV) blocks, ventricular tachycardia, ventricular fibrillation, and asystolia), coronary flow (CF), systolic, developed and diastolic left ventricular pressure (LVP) were measured before, during, and after the application of venom fractions in three different concentrations. Fraction A, containing proteins of 60-100 kDa, displayed no effect on the rat heart. Fractions B and C disturbed heart functioning in similar way, but with different potency that was higher by the latter. This was manifested by significant decrease of HR and CF, the increase of diastolic, and the decrease of systolic and developed LVPs. All hearts treated with fraction C in the final CF concentrations 22.5 and 37.5 μg/mL suffered rapid and irreversible asystolia without AV blockade. They underwent also ventricular fibrillation and ventricular tachycardia. Fraction B affected hearts only at the highest dose inducing asystolia in all hearts, ventricular fibrillation in 80% and ventricular tachycardia in 70% of the hearts. Venom fraction C induced 71% of all recorded heart rhythm disturbances, significantly more than fraction B, which induced 29%. Most abundant proteins in fraction C were secreted phospholipases A2 among which the venom component acting on the heart is most probably to be looked for.
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Affiliation(s)
- Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia.
| | - Ivica Brizić
- Department of Pharmacology, Mostar University School of Medicine, Bijeli brijeg bb, Mostar, Bosnia and Herzegovina.
| | - Zorica Latinović
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia; Jožef Stefan International Postgraduate School, Jamova cesta 39, Ljubljana, Slovenia.
| | - Adrijana Leonardi
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia.
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia; Department of Chemistry and Biochemistry, Faculty of Chemistry and Chemical Technology, University of Ljubljana, Aškerčeva cesta 5, Ljubljana, Slovenia.
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia; University of Split School of Medicine, Šoltanska 2, Split, Croatia.
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27
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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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