Neurotoxic envenoming by South American coral snake (Micrurus lemniscatus helleri): case report from eastern Ecuador and review

Neurotoxic snakebites in Africa: Clinical implications, therapeutic strategies, and antivenom efficacy

Snakebite is a significant health concern in Africa, particularly due to neurotoxic envenomation which can lead to neuromuscular paralysis and respiratory failure. In Nigeria, snakes from the Elapidae family are a notable cause of envenomation cases, though these incidents are underreported. This review examined case reports of neurotoxic envenomation in Africa, highlighting the clinical impacts and the efficacy of available antivenoms. Preclinical studies showed that the polyvalent antivenom from the South African Institute for Medical Research (SAIMR) was highly effective against neurotoxicity with a protective efficacy (R) of 1346.80 mg/mL, while clinical assessment emphasized the need for high-dose antivenom therapy along with supportive measures like mechanical ventilation. Unlike hemorrhagic envenomation, where antivenom promptly resolves bleeding, neurotoxic cases often require additional interventions. The review underscores the necessity for tailored approaches in antivenom therapy to address the complexities of neurotoxic snakebites and reduce their public health burden in Africa.

Unveiling the Venom Composition of the Colombian Coral Snakes Micrurus helleri, M. medemi, and M. sangilensis

Little is known of the biochemical composition and functional features of the venoms of poorly known Colombian coral snakes. Here, we provide a preliminary characterization of the venom of two Colombian endemic coral snake species, Micrurus medemi and M. sangilensis, as well as Colombian populations of M. helleri. Electrophoresis and RP-HPLC techniques were used to identify venom components, and assays were conducted to detect enzyme activities, including phospholipase A2, hyaluronidase, and protease activities. The median lethal dose was determined using murine models. Cytotoxic activities in primary cultures from hippocampal neurons and cancer cell lines were evaluated. The venom profiles revealed similarities in electrophoretic separation among proteins under 20 kDa. The differences in chromatographic profiles were significant, mainly between the fractions containing medium-/large-sized and hydrophobic proteins; this was corroborated by a proteomic analysis which showed the expected composition of neurotoxins from the PLA2 (~38%) and 3FTx (~17%) families; however, a considerable quantity of metalloproteinases (~12%) was detected. PLA2 activity and protease activity were higher in M. helleri venom according to qualitative and quantitative assays. M. medemi venom had the highest lethality. All venoms decreased cell viability when tested on tumoral cell cultures, and M. helleri venom had the highest activity in neuronal primary culture. These preliminary studies shed light on the venoms of understudied coral snakes and broaden the range of sources that could be used for subsequent investigations of components with applications to specific diseases. Our findings also have implications for the clinical manifestations of snake envenoming and improvements in its medical management.

Epidemiology and clinical features of venomous snake bites in the Northern Amazon of Ecuador (2017-2021)

Introduction: In Ecuador, poisonous snakebites are a public health problem. However, there is no recent hospital information from the Amazon. Objective: To retrospectively analyse the clinical-epidemiological characteristics of snakebites in patients admitted to a hospital in the Ecuadorian Amazon. Materials and methods: This is a cross-sectional study conducted at the Nueva Loja-Sucumbíos Provincial Hospital, bordering Colombia (2017-2021). Demographic, epidemiological and clinical variables, and condition at hospital discharge, were obtained from the epidemiological file of the Ministerio de Salud Pública. Results: In 5 years, 147 patients (29.4 per year) were hospitalized with no mortality. They corresponded to 26, 34, 32, 29 and 26 cases, in 2017, 2018, 2019, 2020 and 2021, respectively. Men with 99 (67.3%), aged 21-30 years with 28, mixed race with 94 cases, students, and farmers, were the most affected. The most affected (99; 67.3%) were men, people 21 to 30 years-old (28; 19.0%), mestizos (94; 63.9%), students, and farmers. The median age was 28 (range: 4-81) years. Prevalence was higher in April, June, and September. All accidents were caused by Viperidae snakes. Twenty (13.6%) cases were mild, (61.2%) were moderate and 37 (25.2%) were severe. The feet with 45 were the most bitten. Pre-hospitalization anti-venom serum was received by 53.1% and tourniquet by 19.8% patients. Median hospital arrival time was 5 (range 1-192) hours, mostly between 2-3 hours with 41 cases. No statistically significant differences were found considering the severity. Conclusions: A high prevalence of snakebites was evidenced in the north of the Amazon in Ecuador, with a higher incidence in the rainy season and all by Viperidae species. It is important to highlight the null mortality. Information campaigns on prevention and first aid, such as discouraging the use of tourniquets, especially among vulnerable groups.

Envenomation by Micrurus hemprichii in Brazilian Amazonia: A report of three cases

Herein, we report three new separate cases of human envenomations by Micrurus hemprichii for the Amazon, which is a biome where envenomations by Micrurus are seldom reported. Two women were bitten after stepping on the snakes and one man was bitten while handling the animal. All cases occurred in the peridomicile, in rural areas. The first case evolved mainly to local symptoms, but the patient was discharged before the identification of the snake and had to be called back for observation before being eventually discharged. In the second case, the patient presented transitory dyspnea and she was discharged after four days in hospital. In the third case, the patient showed only local symptoms, but he was about to receive unnecessary antivenom against coral snakes. Cases like these show the importance of educational problems regarding local venomous snakes in order to avoid bites and to provide the correct hospital treatment. For this, trained professionals in cases involving venomous animals are needed.

First Insights into the Venom Composition of Two Ecuadorian Coral Snakes

Micrurus is a medically relevant genus of venomous snakes composed of 85 species. Bites caused by coral snakes are rare, but they are usually associated with very severe and life-threatening clinical manifestations. Ecuador is a highly biodiverse country with a complex natural environment, which is home to approximately 20% of identified Micrurus species. Additionally, it is on the list of Latin American countries with the highest number of snakebites. However, there is no local antivenom available against the Ecuadorian snake venoms, and the biochemistry of these venoms has been poorly explored. Only a limited number of samples collected in the country from the Viperidae family were recently characterised. Therefore, this study addressed the compositional patterns of two coral snake venoms from Ecuador, M. helleri and M. mipartitus, using venomics strategies, integrating sample fractionation, gel electrophoresis, and mass spectrometry. Chromatographic and electrophoretic profiles of these snake venoms revealed interspecific variability, which was ascertained by mass spectrometry. The two venoms followed the recently recognised dichotomic toxin expression trends displayed by Micrurus species: M. helleri venom contains a high proportion (72%) of phospholipase A₂, whereas M. mipartitus venom is dominated by three-finger toxins (63%). A few additional protein families were also detected in these venoms. Overall, these results provide the first comprehensive views on the composition of two Ecuadorian coral snake venoms and expand the knowledge of Micrurus venom phenotypes. These findings open novel perspectives to further research the functional aspects of these biological cocktails of PLA₂s and 3FTxs and stress the need for the preclinical evaluation of the currently used antivenoms for therapeutic purposes in Ecuador.

South American snake venoms with abundant neurotoxic components. Composition and toxicological properties. A literature review

In South America there are three snake genera with predominantly neurotoxic venoms: Crotalus, Micrurus and Hydrophis, which include nine species/subspecies, 97 species and a single marine species, respectively. Although accidents with neurotoxic venoms are less frequent than those with anticoagulant, cytotoxic or necrotic venoms (e.g. from Bothrops), they are of major public health importance. Venoms from genus Crotalus have been extensively studied, while data on the venoms from the other two genera are very limited, especially for Hydrophis. The venoms of North and South American Crotalus species show biochemical and physiopathological differences. The former species cause bothrops-like envenomation symptoms, while the latter mainly have neurotoxic and myotoxic effects, leading to respiratory paralysis and, occasionally, renal failure by myoglobinuria and death, often with no local lesions. Micrurus and Hydrophis also cause neurotoxic envenomations. Many studies have isolated, identified and characterized new enzymes and toxins, thus expanding the knowledge of snake venom composition. The present review summarizes the currently available information on neurotoxic venoms from South American snakes, with a focus on protein composition and toxicological properties. It also includes some comments concerning potential medical applications of elapid and crotalic toxins.

Snake antivenom production in Ecuador: Poor implementation, and an unplanned cessation leads to a call for a renaissance

Snakebite envenomation is a global health problem. This health problem asymmetrically affects rural populations in developing countries to such an extent that it recently has been listed as a priority neglected tropical disease (NTD). It is estimated that 5.4 million individuals are bitten by snakes each year, causing at least 2.7 million envenomations and more than 100,000 deaths each year. Ecuador has one of the highest snakebite envenomation incidence rates in Latin America, mostly in the coastal and Amazonian provinces. Envenomations in these regions are the result of bites primarily by species of snakes belonging to the Viperidae family. Ecuador was able to locally produce antivenoms, however serious flaws were revealed in the antivenom production process, leading to the decommissioning of the existing facility. In the interest of public health, we have summarized the political and social setbacks experienced by the antivenom serum production plant in Ecuador, while encouraging resuming local production of snake antivenom to improve the responsiveness of the already overburdened health system.

Cross-reactivity of some Micrurus venoms against experimental and therapeutic anti-Micrurus antivenoms

We developed experimental equine polyvalent and monovalent antivenoms against the venoms of Micrurus (M.) fulvius, M. nigrocinctus and M. surinamensis and studied their immunochemical reactivity on the venoms used as immunogens and on M. pyrrhocryptus, M altirostris and M. balyocoriphus venoms. Assessment of the neutralizing capacity of the polyvalent experimental antivenom was based on inhibition of lethality (preincubation and rescue assay experiments in mice) and indirect hemolytic and phospholipase activities. The immunochemical reactivity and neutralizing capacity were compared with those of two therapeutic antivenoms used for the treatment of coral snake envenomation in North America and in Argentina. In general, the experimental antivenom conferred a comparable level of neutralization against the venoms used as immunogens when compared to the therapeutic antivenoms and a certain level of cross-neutralization against the other venoms. The results suggest the need for additional venoms in the immunogenic mixture used, in order to obtain a broad spectrum anti-Micrurus antivenom with a good neutralizing potency. Paraspecific neutralization of South American coral snake venoms, although present at a higher level than the neutralization conferred by available nonspecific Micrurus therapeutic antivenoms, was rather low in relation to the specific neutralizing capacity.

Cardiotoxic Effects of Micrurus surinamensis (Cuvier, 1817) Snake Venom

Micrurus surinamensis is a coral snake from the Elapidae family of wide distribution in Amazonia Forest. Its venom contains neurotoxins that induce muscular and respiratory paralysis; however, its cardiovascular action is not yet characterized. The aim of this study was to investigate the cardiotoxic effects caused by M. surinamensis poisoning in rodents. Twelve guinea pigs (Cavia porcellus) were distributed in two groups (n = 6) named as control and envenomed. The control group received 0.2 ml of PBS/BSA via intramuscular injection (IM), while envenomed animals received 0.75 µg of venom per g of body weight, also via IM. Electrocardiographic examination (ECG) and biochemical serum tests were conducted before and 2 h after inoculation. ECG of the envenomed animals revealed severe progressive arrhythmias including atrioventricular block, supraventricular, and ventricular extrasystoles. Serum biochemistry showed significant increase in CK, CK-MB, and LDH enzymes corroborating the skeletal and cardiac muscle damage. Myonecrosis and degeneration were observed in both skeletal and heart muscle; nevertheless, transmission electron microscopy revealed cardiac muscle fibers fragmentation. In conclusion, M. surinamensis venom has a potent cardiotoxic activity eliciting arrhythmogenic effects and heart damage after only 2 h of envenomation.

Myalgia as a Symptom of Envenomation by the Eastern Coral Snake, Micrurus Fulvius: A Case Report

We present the case of a patient who developed myalgia as the primary symptom of envenomation by the eastern coral snake, Micrurus fulvius. The patient was evaluated and treated in the emergency department. Physical examination did not demonstrate any neuromuscular abnormalities. On consultation with the poison control center, the patient's myalgia was determined to be an effect of envenomation, and 5 vials of North American coral snake antivenin were administered. The patient was admitted to the intensive care unit where his symptoms resolved. He was discharged the following day after remaining asymptomatic for 24 h.

Anticoagulant Micrurus venoms: Targets and neutralization

Snakebite is a neglected tropical disease with a massive global burden of injury and death. The best current treatments, antivenoms, are plagued by a number of logistical issues that limit supply and access in remote or poor regions. We explore the anticoagulant properties of venoms from the genus Micrurus (coral snakes), which have been largely unstudied, as well as the effectiveness of antivenom and a small-molecule phospholipase inhibitor-varespladib-at counteracting these effects. Our in vitro results suggest that these venoms likely interfere with the formation or function of the prothrombinase complex. We find that the anticoagulant potency varies widely across the genus and is especially pronounced in M. laticollaris. This variation does not appear to correspond to previously described patterns regarding the relative expression of the three-finger toxin and phospholipase A₂ (PLA₂) toxin families within the venoms of this genus. The coral snake antivenom Coralmyn, is largely unable to ameliorate these effects except for M. ibiboboca. Varespladib on the other hand completely abolished the anticoagulant activity of every venom. This is consistent with the growing body of results showing that varespladib may be an effective treatment for a wide range of toxicity caused by PLA₂ toxins from many different snake species. Varespladib is a particularly attractive candidate to help alleviate the burden of snakebite because it is an approved drug that possesses several logistical advantages over antivenom including temperature stability and oral availability.

Envenomations by coral snakes in an Amazonian metropolis: Ecological, epidemiological and clinical aspects

Envenomation by coral snakes represents a little known burden in Brazilian Amazonia. So far, details on clinical and epidemiological aspects remain obscure in the region. We gathered data from medical charts and from the scientific collection of snakes from Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, finding 26 cases of envenomation by five species of Micrurus in Manaus region, between 1987 and 2018. They represent 0.7% of the snakebites treated in the hospital since the records began, in 1979. Micrurus lemniscatus was responsible for most of the bites (10), followed by M. hemprichii (five), M. spixii (three), M. surinamensis (three) and M. averyi (one). There was no difference between the sexes of the snakes that caused bites. Patients were mostly males, and most of the cases were reported in urban areas. Bites predominated in dry season, and there was a clear geographical segregation among species. We describe seven cases of envenomation, three mild and four severe, all of which evolved to cure. Paresthesia (six), pain (five) and edema (four) were the most common local symptoms. Systemic features such as dyspnea/shallow breath (four), palpebral ptosis (four), blurred vision (three), dysarthria (three) and difficulty to walk (three) were also detected. Two patients bitten by Micrurus sp. and M. hemprichii, showed slight increased serum levels of creatine kinase (reference level <190 U/L), 1184 U/L and 1229 U/L, respectively, indicative of mild systemic myotoxicity. This is the first report of myotoxic manifestation in the envenomation by M. hemprichii. No patient developed respiratory failure, though one bitten by an adult M. spixii required intubation and mechanical ventilation due to decreased level of consciousness during evolution, probably related to induced sedation caused by concurrent alcohol intoxication. All patients were treated with Brazilian Micrurus antivenom (soro antielapídico, median = 10 vials). Six patients were pretreated intravenously with H1 and H2 antagonists and steroids, with two patients developing early adverse reactions. The median length of hospital stay was four days. Envenomations by coral snakes in Manaus region are clinically severe, but rare and sparsely distributed over time, making the detection of epidemiological and clinical patterns a challenge for public health.

Evaluation of systemic inflammatory response and lung injury induced by Crotalus durissus cascavella venom

This study investigated the systemic inflammatory response and mechanism of pulmonary lesions induced by Crotalus durissus cascavella venom in murine in the state of Bahia. In order to investigate T helper Th1, Th2 and Th17 lymphocyte profiles, we measured interleukin (IL) -2, IL-4, IL-6, IL-10, IL-17, tumor necrosis factor (TNF) and interferon gamma (IFN-γ) levels in the peritoneal fluid and macerated lungs of mice and histopathological alterations at the specific time windows of 1h, 3h, 6h, 12h, 24h and 48h after inoculation with Crotalus durissus cascavella venom. The data demonstrated an increase of acute-phase cytokines (IL-6 and TNF) in the first hours after inoculation, with a subsequent increase in IL-10 and IL-4, suggesting immune response modulation for the Th2 profile. The histopathological analysis showed significant morphological alterations, compatible with acute pulmonary lesions, with polymorphonuclear leukocyte (PMN) infiltration, intra-alveolar edema, congestion, hemorrhage and atelectasis. These findings advance our understanding of the dynamics of envenomation and contribute to improve clinical management and antiophidic therapy for individuals exposed to venom.

Neurotoxicity of Micrurus lemniscatus lemniscatus (South American coralsnake) venom in vertebrate neuromuscular preparations in vitro and neutralization by antivenom

We investigated the effect of South American coralsnake (Micrurus lemniscatus lemniscatus) venom on neurotransmission in vertebrate nerve-muscle preparations in vitro. The venom (0.1-30 µg/ml) showed calcium-dependent PLA₂ activity and caused irreversible neuromuscular blockade in chick biventer cervicis (BC) and mouse phrenic nerve-diaphragm (PND) preparations. In BC preparations, contractures to exogenous acetylcholine and carbachol (CCh), but not KCl, were abolished by venom concentrations ≥ 0.3 µg/ml; in PND preparations, the amplitude of the tetanic response was progressively attenuated, but with little tetanic fade. In low Ca²⁺ physiological solution, venom (10 µg/ml) caused neuromuscular blockade in PND preparations within ~ 10 min that was reversible by washing; the addition of Ca²⁺ immediately after the blockade temporarily restored the twitch responses, but did not prevent the progression to irreversible blockade. Venom (10 µg/ml) did not depolarize diaphragm muscle, prevent depolarization by CCh, or cause muscle contracture or histological damage. Venom (3 µg/ml) had a biphasic effect on the frequency of miniature end-plate potentials, but did not affect their amplitude; there was a progressive decrease in the amplitude of evoked end-plate potentials. The amplitude of compound action potentials in mouse sciatic nerve was unaffected by venom (10 µg/ml). Pre-incubation of venom with coralsnake antivenom (Instituto Butantan) at the recommended antivenom:venom ratio did not neutralize the neuromuscular blockade in PND preparations, but total neutralization was achieved with a tenfold greater volume of antivenom. The addition of antivenom after 50% and 80% blockade restored the twitch responses. These results show that M. lemniscatus lemniscatus venom causes potent, irreversible neuromuscular blockade, without myonecrosis. This blockade is apparently mediated by pre- and postsynaptic neurotoxins and can be reversed by coralsnake antivenom.

Use of infrared thermography in a case of systemic envenomation by the coral snake Micrurus frontalis (Duméril et al., 1854) in Sao Paulo, Brazil

Infrared thermography is a technique that quantifies the thermal (infrared) radiation emitted by an object and produces a high-resolution, digital thermal image of it. Medically, this technique is used to visualize the body's surface temperature distribution in a non-invasive, safe, and convenient fashion. However, to the best of our knowledge, the use of infrared thermography for assessing the systemic effects of envenomation by coral snakes has not been reported. In this case report, we describe the use of this technique in the management of a case of snakebite in Sao Paulo, Brazil. A 51-year-old woman was bitten on the back of the right hand by Micrurus frontalis, a species of coral snake, 10 min prior to her arrival at the hospital. Infrared imaging performed at admission revealed elevated temperatures at the bite site and in the elbow, as well as the preservation of a normal distal thermal gradient in both hands. A few minutes later, the patient developed muscle weakness in the upper limbs and in the eyelids, and infrared imaging showed an alteration of the thermal gradient in both hands, reflecting the systemic action of the venom. Following these observations, the patient was treated with the specific antivenom and was discharged 48 h post admission. At the two-week follow-up, the thermal image obtained showed no anomalies, indicating the recovery of the patient. Hence, infrared thermography can be very useful in the early identification of systemic neurotoxicity in cases of Micrurus snake bites, facilitating the decision to prescribe the antivenom.

Pro-inflammatory response and hemostatic disorder induced by venom of the coral snake Micrurus tener tener IN C57BL/6 mice

Micrurus venoms are known to induce mainly neurotoxicity in victims. However, other manifestations, including hemorrhage, edema, myotoxicity, complement activation, and hemostatic activity have been reported. In order to develop a more complete pharmacological profile of these venoms, inflammatory responses and hemostasis were evaluated in C57BL/6 mice treated with a sub-lethal dose of M. t. tener (Mtt) venom (8 μg/mouse), inoculated intraperitoneally. The venom induced moderate bleeding into the abdominal cavity and lungs, as well as infiltration of leukocytes into the liver. After 30 min, the release of pro-inflammatory mediators (TNF-α, IL-6, and NO) were observed, being most evident at 4 h. There was a decrease in hemoglobin and hematocrit levels at 72 h, a prolongation in coagulation times (PT and aPTT), a decrease in the fibrinogen concentration and an increase in fibrinolytic activity. In this animal model, it was proposed that Mtt venom induces inflammation with the release of mediators such as TNF-α, in response to the toxins. These mediators may activate hemostatic mechanisms, producing systemic fibrinolysis and hemorrhage. These findings suggest alternative treatments in Micrurus envenomations in which neurotoxic manifestations do not predominate.

Ancient Diversification of Three-Finger Toxins in Micrurus Coral Snakes

Coral snakes, most notably the genus Micrurus, are the only terrestrial elapid snakes in the Americas. Elapid venoms are generally known for their potent neurotoxicity which is usually caused by Three-Finger Toxin (3FTx) proteins. These toxins can have a wide array of functions that have been characterized from the venom of other elapids. We examined publicly available sequences from Micrurus 3FTx to show that they belong to 8 monophyletic clades that diverged as deep in the 3FTx phylogenetic tree as the other clades with characterized functions. Functional residues from previously characterized clades of 3FTx are not well conserved in most of the Micrurus toxin clades. We also analyzed the patterns of selection on these toxins and find that they have been diversifying at different rates, with some having undergone extreme diversifying selection. This suggests that Micrurus 3FTx may contain a previously underappreciated functional diversity that has implications for the clinical outcomes of bite victims, the evolution and ecology of the genus, as well as the potential for biodiscovery efforts focusing on these toxins.

Envenomation by Micrurus psyches in French Guiana

We report here the first known envenomation by Micrurus psyches, the so-called Carib coral snake, which occurred on April 2016 in the surroundings of Saint-Laurent-du-Maroni, Western French Guiana. Besides local neurological symptoms, it featured unexpected electrocardiogram changes, which were emergence of a first-degree atrioventricular block and biphasic T waves, both transient. NewWorld elapid venoms were not known for being cardiotoxic so far. The possible reasons of this cardiac injury are discussed.

Antivenom for Neuromuscular Paralysis Resulting From Snake Envenoming

Antivenom therapy is currently the standard practice for treating neuromuscular dysfunction in snake envenoming. We reviewed the clinical and experimental evidence-base for the efficacy and effectiveness of antivenom in snakebite neurotoxicity. The main site of snake neurotoxins is the neuromuscular junction, and the majority are either: (1) pre-synaptic neurotoxins irreversibly damaging the presynaptic terminal; or (2) post-synaptic neurotoxins that bind to the nicotinic acetylcholine receptor. Pre-clinical tests of antivenom efficacy for neurotoxicity include rodent lethality tests, which are problematic, and in vitro pharmacological tests such as nerve-muscle preparation studies, that appear to provide more clinically meaningful information. We searched MEDLINE (from 1946) and EMBASE (from 1947) until March 2017 for clinical studies. The search yielded no randomised placebo-controlled trials of antivenom for neuromuscular dysfunction. There were several randomised and non-randomised comparative trials that compared two or more doses of the same or different antivenom, and numerous cohort studies and case reports. The majority of studies available had deficiencies including poor case definition, poor study design, small sample size or no objective measures of paralysis. A number of studies demonstrated the efficacy of antivenom in human envenoming by clearing circulating venom. Studies of snakes with primarily pre-synaptic neurotoxins, such as kraits (Bungarus spp.) and taipans (Oxyuranus spp.) suggest that antivenom does not reverse established neurotoxicity, but early administration may be associated with decreased severity or prevent neurotoxicity. Small studies of snakes with mainly post-synaptic neurotoxins, including some cobra species (Naja spp.), provide preliminary evidence that neurotoxicity may be reversed with antivenom, but placebo controlled studies with objective outcome measures are required to confirm this.

Lemnitoxin, the major component of Micrurus lemniscatus coral snake venom, is a myotoxic and pro-inflammatory phospholipase A2

The venom of Micrurus lemniscatus, a coral snake of wide geographical distribution in South America, was fractionated by reverse-phase HPLC and the fractions screened for phospholipase A2 (PLA2) activity. The major component of the venom, a PLA2, here referred to as 'Lemnitoxin', was isolated and characterized biochemically and toxicologically. It induces myotoxicity upon intramuscular or intravenous injection into mice. The amino acid residues Arg15, Ala100, Asn108, and a hydrophobic residue at position 109, which are characteristic of myotoxic class I phospholipases A2, are present in Lemnitoxin. This PLA2 is antigenically related to M. nigrocinctus nigroxin, Notechis scutatus notexin, Pseudechis australis mulgotoxin, and Pseudonaja textilis textilotoxin, as demonstrated with monoclonal and polyclonal antibodies. Lemnitoxin is highly selective in its targeting of cells, being cytotoxic for differentiated myotubes in vitro and muscle fibers in vivo, but not for undifferentiated myoblasts or endothelial cells. Lemnitoxin is not lethal after intravenous injection at doses up to 2μg/g in mice, evidencing its lack of significant neurotoxicity. Lemnitoxin displays anticoagulant effect on human plasma and proinflammatory activity also, as it induces paw edema and mast cell degranulation. Thus, the results of this work demonstrate that Lemnitoxin is a potent myotoxic and proinflammatory class I PLA2.

Pulmonary effects and complications of snakebites

This review is on the pulmonary complications of snakebites, which can have fatal consequences. We identified three common themes as reported in the literature regarding envenomation: generalized neuromuscular paralysis affecting airway and respiratory muscles, pulmonary edema, and pulmonary hemorrhages or thrombosis due to coagulopathy. Respiratory paralysis and pulmonary edema can be due to either elapid or viper bites, whereas pulmonary complications of coagulopathy are exclusively reported with viper bites. The evidence for each complication, timeline of appearance, response to treatment, and details of pathophysiology are discussed.

Reducing the impact of snakebite envenoming in Latin America and the Caribbean: achievements and challenges ahead

Snakebite envenoming constitutes an important public health problem in Latin America and some countries of the Caribbean. The advances and pending tasks in the study and control of this neglected tropical disease in this region are reviewed in the light of a roadmap proposed in 2006. Significant progress has been achieved in the study of snake venoms, particularly regarding venom proteomics, i.e.'venomics', and the analysis of the mechanism of action of toxins. Likewise, a deeper understanding has been gained in the preclinical efficacy of antivenoms produced in the region. In contrast, despite advances made in the study of clinical manifestations of envenomings and safety and efficacy of antivenoms at the clinical level, much remains to be done in this subject. Improvements have occurred in antivenom manufacturing technologies and availability, although there are still countries where there is insufficient supply of antivenoms, or where manufacture has to be improved. In spite of considerable efforts in some countries in prevention, accessibility to treatment, and training of health staff in the management of envenomings, important challenges remain for the region as a whole, with the long term goal of reducing the impact of this disease in terms of personal and social suffering.

Eastern coral snake Micrurus fulvius venom toxicity in mice is mainly determined by neurotoxic phospholipases A2

Here we show for the first time that the venom from an elapid (Micrurus fulvius) contains three finger toxin (3FTxs) peptides with low toxicity but high content of lethal phospholipases A2 (PLA2). The intravenous venom LD50 in mice was 0.3μg/g. Fractionation on a C18 column yielded 22 fractions; in terms of abundance, 58.3% of them were components of 13-14kDa and 24.9% were molecules of 6-7kDa. Two fractions with PLA2 activity represented 33.4% of the whole venom and were the most lethal fractions. Fractions with low molecular mass (<7000Da) partially and reversibly blocked the nicotinic acetylcholine receptor (nAChR), with the exception of one that blocked it completely. The fraction that blocked 100% contained two protein species whose dose-response was determined; the IC50s were 13±1 and 9.5±0.3nM. Despite the apparent effect on nAChR none of the low molecular mass fractions were lethal in mice, at concentrations of 1μg/g. From 2D-PAGE and LC-MS/MS, we identified fourteen species of PLA2, four protein species of C-type lectin, three zinc metalloproteinases, one phosphodiesterase and one 3FTx. The N-terminal amino acid sequence of fractions with biological interest was obtained.

BIOLOGICAL SIGNIFICANCE

In contrast with coral snake venoms from South America, M. fulvius has minor amounts of low molecular mass components, but high content of PLA2, which is responsible for the venom lethality of this species. The results reported here contribute to better understanding of envenomation development and to improve antivenom design and production. These findings break from the paradigm that neurotoxicity caused by Micrurus venoms is mainly attributable to 3FTx neurotoxins and encourage future studies on Micrurus evolution and venom specialization. This article is part of a Special Issue entitled Non-model organisms.

Neurotoxicity in snakebite--the limits of our knowledge

Snakebite is classified by the WHO as a neglected tropical disease. Envenoming is a significant public health problem in tropical and subtropical regions. Neurotoxicity is a key feature of some envenomings, and there are many unanswered questions regarding this manifestation. Acute neuromuscular weakness with respiratory involvement is the most clinically important neurotoxic effect. Data is limited on the many other acute neurotoxic manifestations, and especially delayed neurotoxicity. Symptom evolution and recovery, patterns of weakness, respiratory involvement, and response to antivenom and acetyl cholinesterase inhibitors are variable, and seem to depend on the snake species, type of neurotoxicity, and geographical variations. Recent data have challenged the traditional concepts of neurotoxicity in snake envenoming, and highlight the rich diversity of snake neurotoxins. A uniform system of classification of the pattern of neuromuscular weakness and models for predicting type of toxicity and development of respiratory weakness are still lacking, and would greatly aid clinical decision making and future research. This review attempts to update the reader on the current state of knowledge regarding this important issue.

Isolation, characterization, cloning and expression of an alpha-neurotoxin from the venom of the Mexican coral snake Micrurus laticollaris (Squamata: Elapidae)

A new member of short chain α-neurotoxic protein family from venom of the Mexican coral snake, Micrurus laticollaris, was characterized. This protein, named MlatA1, possesses 61 amino acids with 8 conserved cysteine residues, sharing 30-91% sequence identity with other fully sequenced Micrurus toxins. MlatA1 (LD50i.v. = 0.064 mg/kg) antagonizes with both fetal and adult nicotinic acetylcholine receptor (nAChR) as well as α-7 neuronal nAChR in a dose-dependent way. Specific rabbit anti-Mlat serum (titer higher than 18,000) does not show any protective ability against this toxin, nevertheless it was able to recognize protein bands in six out of twelve Micrurus venoms showing the existence of two distinct antigenic groups for α-neurotoxins in North American coral snakes species. The MlatA1 gene was cloned and used to produce recombinant toxin (rMlatA1) that was recognized by rabbit anti-native toxin but was depleted of toxic activity.

Envenoming by coral snakes (Micrurus) in Argentina, during the period between 1979-2003

Envenomation by coral snakes (Micrurus sp.) is one of the most dangerous injuries in America and it is considered as a serious medical emergency, however bites by these snakes appear to be rare. We analyzed epidemiological data, clinical signs and antivenom use in Argentina during the period between 1979-2003. During this period of study 46 non-fatal Micrurus bites were reported. The majority of cases were men from 31 to 40 years old. Bites occurred primarily in spring and summer. Most cases were reported from the northeast and northwest provinces of the country. The bites were mostly located on hands or feet and occurred mostly during agricultural activities and so mainly involved farmers. Only four cases occurred as a result of handling snakes. The median time it took for antivenom to be administrated was 60 minutes after the bite, and the median number of vials applied was 2. Local pain was mentioned and edema was reported in 41% of patients. All patients recovered without sequelae. This study showed a low incidence of Micrurus bites and low severity of envenomation. However, although no deaths have been reported during the last 30 years, given the toxicity of the venom of Micrurus snakes, the risk of severe envenomation should be considered.

Redi award lecture: clinical studies of snake-bite in four tropical continents

Research is discussed in the areas of venomous snake taxonomy, epidemiology, species diagnosis, defining the clinical phenotype of human envenoming, pathophysiological mechanisms of envenoming, clinical testing of antivenoms and prevention of snake-bite through community education. This work was carried out over the past 40 years in many countries in four tropical continents. The help and friendship of a large number of collaborators is gratefully acknowledged.

Venomous snakebites in the Croatian North Dalmatia region

AIM

The aim of this research project is to analyze the epidemiological, clinical and laboratory attributes of venomous snakebites and to ascertain the timely and efficient treatment at the location where the incident took place or in varying clinical conditions.

METHODS

Epidemiological, clinical and laboratory data were collected from people who were bitten by venomous snakes as well as treatments at Zadar General Hospital during a span of eleven years (1999-2009) which were analyzed retrospectively.

RESULTS

During that period, 93 people were bitten by venomous snakes of which 57 patients (62%) were male and 36 (38%) were female. In 82 cases (90%), the bite area was localized on the limbs while in the remaining 11 cases the bite area was located elsewhere. At the time of the venomous snakebite, 31 (33%) patients were performing leisure activities and 44 (47.31%) of them were at work. The most common local snakebite signs are swelling and pain at the bite site (93 patients; 100%), hematomas and ecchymoses (87 patients; 89%). Of the affected patients, 8 suffered from compartment syndrome and one person (0.97%) expired.

CONCLUSION

Antivenom treatment for preventing possible allergic reactions should take place at the medical institution where the victim was transported. However, when transport is not immediately available or in cases where the victim shows clear signs of envenomation, antivenom treatment should be used immediately because its effect is weaker if the venom is allowed to run its course.

Neuromuscular activity of the venoms of the Colombian coral snakes Micrurus dissoleucus and Micrurus mipartitus: an evolutionary perspective

The venoms of coral snakes (genus Micrurus) are known to induce a broad spectrum of pharmacological activities. While some studies have investigated their potential human effects, little is known about their mechanism of action in terms of the ecological diversity and evolutionary relationships among the group. In the current study we investigated the neuromuscular blockade of the venom of two sister species Micrurus mipartitus and Micrurus dissoleucus, which exhibit divergent ecological characteristics in Colombia, by using the chick biventer cervicis nerve-muscle preparation. We also undertook a phylogenetic analysis of these species and their congeners, in order to provide an evolutionary framework for the American coral snakes. The venom of M. mipartitus caused a concentration-dependant inhibition (3-10 μg/ml) of nerve-mediated twitches and significantly inhibited contractile responses to exogenous ACh (1 mM), but not KCl (40 mM), indicating a postsynaptic mechanism of action. The inhibition of indirect twitches at the lower venom dose (3 μg/ml) showed to be triphasic and the effect was further attenuated when PLA2 was inhibited. M. dissoleucus venom (10-50 μg/ml) failed to produce a complete blockade of nerve-mediated twitches within a 3 h time period and significantly inhibited contractile responses to exogenous ACh (1 mM) and KCl (40 mM), indicating both postsynaptic and myotoxic mechanisms of action. Myotoxic activity was confirmed by morphological studies of the envenomed tissues. Our results demonstrate a hitherto unsuspected diversity of pharmacological actions in closely related species which exhibit divergent ecological characteristics; these results have important implications for both the clinical management of Coral snake envenomings and the design of Micrurus antivenom.

Envenomation by Micrurus coral snakes in the Brazilian Amazon region: report of two cases

Two cases of proven coral snake bites were reported in Belém, Pará State, Brazil. The first case was a severe one caused by Micrurus surinamensis. The patient required mechanical ventilation due to acute respiratory failure. The second case showed just mild signs of envenomation caused by Micrurus filiformis. Both patients received specific Micrurus antivenom and were discharged without further complications. Coral snake bites are scarcely reported in the Amazon region and there is a broad spectrum of clinical manifestations, varying from extremely mild to those which may rapidly lead to death if the patient is not treated as soon as possible.

Diversity of Micrurus snake species related to their venom toxic effects and the prospective of antivenom neutralization

BACKGROUND

Micrurus snake bites can cause death by muscle paralysis and respiratory arrest, few hours after envenomation. The specific treatment for coral snake envenomation is the intravenous application of heterologous antivenom and, in Brazil, it is produced by horse immunization with a mixture of M. corallinus and M. frontalis venoms, snakes that inhabit the South and Southeastern regions of the country. However, this antivenom might be inefficient, considering the existence of intra- and inter-specific variations in the composition of the venoms. Therefore, the aim of the present study was to investigate the toxic properties of venoms from nine species of Micrurus: eight present in different geographic regions of Brazil (M. frontalis, M. corallinus, M. hemprichii, M. spixii, M. altirostris, M. surinamensis, M. ibiboboca, M. lemniscatus) and one (M. fulvius) with large distribution in Southeastern United States and Mexico. This study also analyzed the antigenic cross-reactivity and the neutralizing potential of the Brazilian coral snake antivenom against these Micrurus venoms.

METHODOLOGY/PRINCIPAL FINDINGS

Analysis of protein composition and toxicity revealed a large diversity of venoms from the nine Micrurus species. ELISA and Western blot assays showed a varied capability of the therapeutic antivenom to recognize the diverse species venom components. In vivo and in vitro neutralization assays indicated that the antivenom is not able to fully neutralize the toxic activities of all venoms.

CONCLUSION

These results indicate the existence of a large range of both qualitative and quantitative variations in Micrurus venoms, probably reflecting the adaptation of the snakes from this genus to vastly dissimilar habitats. The data also show that the antivenom used for human therapy in Brazil is not fully able to neutralize the main toxic activities present in the venoms from all Micrurus species occurring in the country. It suggests that modifications in the immunization scheme, with the inclusion of other venoms in the antigenic mixture, should occur in order to generate effective therapeutic coral snake antivenom.