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Nascimento TP, Gomes TA, Costa BJC, Carvalho E, Cunha AB, Pereira BL, Sartim MA, Murta FLG, Monteiro W, Sachett JDAG. Long-term hospital care needs after Bothrops atrox envenomation with hemorrhagic stroke in the Brazilian Amazon: 'From social to physical death' - A case report. Toxicon 2024; 241:107682. [PMID: 38460605 DOI: 10.1016/j.toxicon.2024.107682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/19/2024] [Accepted: 03/05/2024] [Indexed: 03/11/2024]
Abstract
Hemorrhagic stroke is a severe complication reported in cases of Bothrops atrox snakebite envenomation. We report an unusual case of a patient who evolved with an intracranial hemorrhagic stroke and was in a coma for more than five years in a tertiary hospital located in Manaus, Amazonas. 52-year-old man, carpenter, resident in the rural area of the municipality of Tabatinga, located 1106 km from Manaus, capital of Amazonas, Brazil, victim of an accident involving Bothrops atrox evolution with cardiorespiratory arrest, acute kidney injury and hemorrhagic stroke. After 43 days of hospitalization in the ICU, he was transferred to the ward, without contact with the environment and family, sent for home treatment, however, without acceptance by family members. During a long hospital stay for a period of 6 years, totally dependent on special care, in a flexed position, using a tracheostomy and mechanical ventilation, diagnosed and treated for hospital infections throughout his hospitalization, he died due to bacterial pneumonia. Losses of autonomy can result in an individual being completely disconnected from social life - a "social death before physical death".
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Affiliation(s)
- Thaís Pinto Nascimento
- School of Health Sciences, Amazonas State University, Manaus, Amazonas, Brazil; Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Talyson Aparicio Gomes
- School of Health Sciences, Amazonas State University, Manaus, Amazonas, Brazil; Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Bárbara Juliana Carvalho Costa
- School of Health Sciences, Amazonas State University, Manaus, Amazonas, Brazil; Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Erica Carvalho
- School of Health Sciences, Amazonas State University, Manaus, Amazonas, Brazil; Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Amanda Braga Cunha
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Bianca Leite Pereira
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Marco Aurélio Sartim
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil; Research and Development Department, University Nilton Lins, Manaus, Amazonas, Brazil
| | - Felipe Leão Gomes Murta
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Wuelton Monteiro
- School of Health Sciences, Amazonas State University, Manaus, Amazonas, Brazil; Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Jacqueline de Almeida Gonçalves Sachett
- School of Health Sciences, Amazonas State University, Manaus, Amazonas, Brazil; Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil.
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Larréché S, Chippaux JP, Chevillard L, Mathé S, Résière D, Siguret V, Mégarbane B. Bleeding and Thrombosis: Insights into Pathophysiology of Bothrops Venom-Related Hemostasis Disorders. Int J Mol Sci 2021; 22:ijms22179643. [PMID: 34502548 PMCID: PMC8431793 DOI: 10.3390/ijms22179643] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/29/2021] [Accepted: 09/03/2021] [Indexed: 12/13/2022] Open
Abstract
Toxins from Bothrops venoms targeting hemostasis are responsible for a broad range of clinical and biological syndromes including local and systemic bleeding, incoagulability, thrombotic microangiopathy and macrothrombosis. Beyond hemostais disorders, toxins are also involved in the pathogenesis of edema and in most complications such as hypovolemia, cardiovascular collapse, acute kidney injury, myonecrosis, compartmental syndrome and superinfection. These toxins can be classified as enzymatic proteins (snake venom metalloproteinases, snake venom serine proteases, phospholipases A2 and L-amino acid oxidases) and non-enzymatic proteins (desintegrins and C-type lectin proteins). Bleeding is due to a multifocal toxicity targeting vessels, platelets and coagulation factors. Vessel damage due to the degradation of basement membrane and the subsequent disruption of endothelial cell integrity under hydrostatic pressure and tangential shear stress is primarily responsible for bleeding. Hemorrhage is promoted by thrombocytopenia, platelet hypoaggregation, consumption coagulopathy and fibrin(ogen)olysis. Onset of thrombotic microangiopathy is probably due to the switch of endothelium to a prothrombotic phenotype with overexpression of tissue factor and other pro-aggregating biomarkers in association with activation of platelets and coagulation. Thrombosis involving large-caliber vessels in B. lanceolatus envenomation remains a unique entity, which exact pathophysiology remains poorly understood.
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Affiliation(s)
- Sébastien Larréché
- INSERM, UMRS-1144, Paris University, 75006 Paris, France; (S.L.); (L.C.); (S.M.)
- Department of Medical Biology, Bégin Military Teaching Hospital, 94160 Saint-Mandé, France
| | - Jean-Philippe Chippaux
- MERIT, IRD, Paris University, 75006 Paris, France;
- CRT, Pasteur Institute, 75015 Paris, France
| | - Lucie Chevillard
- INSERM, UMRS-1144, Paris University, 75006 Paris, France; (S.L.); (L.C.); (S.M.)
| | - Simon Mathé
- INSERM, UMRS-1144, Paris University, 75006 Paris, France; (S.L.); (L.C.); (S.M.)
| | - Dabor Résière
- Clinical Toxicology Unit, Critical Care Department, University Hospital of Martinique, Fort de France, 97200 Martinique, France;
| | - Virginie Siguret
- INSERM, UMRS-1140, Paris University, 75006 Paris, France;
- Laboratory of Hematology, Lariboisière Hospital, 75010 Paris, France
| | - Bruno Mégarbane
- INSERM, UMRS-1144, Paris University, 75006 Paris, France; (S.L.); (L.C.); (S.M.)
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, 75010 Paris, France
- Correspondence: ; Tel.: +33-(0)-143-985-299
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Kasturiratne A, Lalloo DG, Janaka de Silva H. Chronic health effects and cost of snakebite. Toxicon X 2021; 9-10:100074. [PMID: 34355162 PMCID: PMC8321925 DOI: 10.1016/j.toxcx.2021.100074] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/29/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022] Open
Abstract
The burden of disability among survivors and the socio-economic impact of snakebite have not been adequately researched. We reviewed original research articles, case reports and small case series relating to chronic physical, mental and psycho-social disability and economic burden of snakebite. Both physical and psychological health problems seem common in snakebite survivors and can lead to disability and loss of productivity. Chronic physical health effects, musculoskeletal disability being the commonest, can be largely attributed to limited and delayed access to optimal treatment of acute envenoming. The economic burden is considerable, and includes health system costs, out-of-pocket expenditure and opportunity costs, with regional variations. Health systems should be more responsive to needs and circumstances of bite victims, and a more holistic approach should be developed in the treatment of snakebite which incorporates the management of chronic health effects. Limited attention has been paid to chronic disability and the socio-economic impact of snakebite. Physical and psychological health problems occur in snakebite survivors leading to disability and loss of productivity. Chronic health effects can be largely attributed to limited and delayed access to optimal treatment of acute envenoming. Economic burden includes health system costs, out-of-pocket expenditure and opportunity costs. Health systems should be responsive to needs and circumstances of bite victims including care of chronic health effects.
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Nascimento LS, Nogueira-Souza PD, Rocha-Junior JRS, Monteiro-Machado M, Strauch MA, Prado SAL, Melo PA, Veiga-Junior VF. Phytochemical composition, antisnake venom and antibacterial activities of ethanolic extract of Aegiphila integrifolia (Jacq) Moldenke leaves. Toxicon 2021; 198:121-131. [PMID: 33984369 DOI: 10.1016/j.toxicon.2021.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/30/2021] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Abstract
Snakebites are considered a major neglected tropical disease, resulting in around 100,000 deaths per year. The recommended treatment by the WHO is serotherapy, which has limited effectiveness against the toxins involved in local tissue damage. In some countries, patients use plants from folk medicines as antivenoms. Aegiphila species are common plants from the Brazilian Amazon and are used to treat snakebites. In this study, leaves from Aegiphila integrifolia (Jacq) Moldenke were collected from Roraima state, Brazil and its ethanolic extract was evaluated through in vitro and in vivo experiments to verify their antiophidic activity against Bothrops atrox crude venom. The isolated compounds from A. integrifolia were analyzed and the chemical structures were elucidated on the basis of infrared, ultraviolet, mass, 1H and 1³C NMR spectrometry data. Among the described compounds, lupeol (7), betulinic acid (1), β-sitosterol (6), stigmasterol (5), mannitol (4), and the flavonoids, pectolinarigenin (2) and hispidulin (3), were identified. The ethanolic extract and flavonoids (2 and 3) partially inhibited the proteolytic, phospholipase A2 and hyaluronidase activities of B. atrox venom, and the skin hemorrhage induced by this venom in mice. Antimicrobial activity against different bacteria was evaluated and the extract partially inhibited bacterial growth. Thus, taken together, A. integrifolia ethanolic extract has promising use as an antiophidic and antimicrobial.
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Affiliation(s)
- Leandro S Nascimento
- Chemical Engineering Section, Military Institute of Engineering, Rio de Janeiro, RJ, Brazil
| | - Pâmella D Nogueira-Souza
- Federal University of Rio de Janeiro, Pharmacology and Medicinal Chemistry Program, Rio de Janeiro, RJ, Brazil
| | - José R S Rocha-Junior
- Federal University of Rio de Janeiro, Pharmacology and Medicinal Chemistry Program, Rio de Janeiro, RJ, Brazil
| | - Marcos Monteiro-Machado
- Federal University of Rio de Janeiro, Pharmacology and Medicinal Chemistry Program, Rio de Janeiro, RJ, Brazil
| | | | - Simone A L Prado
- Federal University of Roraima, Department of Chemistry, Boa Vista, RR, Brazil
| | - Paulo A Melo
- Federal University of Rio de Janeiro, Pharmacology and Medicinal Chemistry Program, Rio de Janeiro, RJ, Brazil
| | - Valdir F Veiga-Junior
- Chemical Engineering Section, Military Institute of Engineering, Rio de Janeiro, RJ, Brazil.
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Seneci L, Zdenek CN, Chowdhury A, Rodrigues CFB, Neri-Castro E, Bénard-Valle M, Alagón A, Fry BG. A Clot Twist: Extreme Variation in Coagulotoxicity Mechanisms in Mexican Neotropical Rattlesnake Venoms. Front Immunol 2021; 12:612846. [PMID: 33815366 PMCID: PMC8011430 DOI: 10.3389/fimmu.2021.612846] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/11/2021] [Indexed: 12/11/2022] Open
Abstract
Rattlesnakes are a diverse clade of pit vipers (snake family Viperidae, subfamily Crotalinae) that consists of numerous medically significant species. We used validated in vitro assays measuring venom-induced clotting time and strength of any clots formed in human plasma and fibrinogen to assess the coagulotoxic activity of the four medically relevant Mexican rattlesnake species Crotalus culminatus, C. mictlantecuhtli, C. molossus, and C. tzabcan. We report the first evidence of true procoagulant activity by Neotropical rattlesnake venom in Crotalus culminatus. This species presented a strong ontogenetic coagulotoxicity dichotomy: neonates were strongly procoagulant via Factor X activation, whereas adults were pseudo-procoagulant in that they converted fibrinogen into weak, unstable fibrin clots that rapidly broke down, thereby likely contributing to net anticoagulation through fibrinogen depletion. The other species did not activate clotting factors or display an ontogenetic dichotomy, but depleted fibrinogen levels by cleaving fibrinogen either in a destructive (non-clotting) manner or via a pseudo-procoagulant mechanism. We also assessed the neutralization of these venoms by available antivenom and enzyme-inhibitors to provide knowledge for the design of evidence-based treatment strategies for envenomated patients. One of the most frequently used Mexican antivenoms (Bioclon Antivipmyn®) failed to neutralize the potent procoagulant toxic action of neonate C. culminatus venom, highlighting limitations in snakebite treatment for this species. However, the metalloprotease inhibitor Prinomastat substantially thwarted the procoagulant venom activity, while 2,3-dimercapto-1-propanesulfonic acid (DMPS) was much less effective. These results confirm that venom-induced Factor X activation (a procoagulant action) is driven by metalloproteases, while also suggesting Prinomastat as a more promising potential adjunct treatment than DMPS for this species (with the caveat that in vivo studies are necessary to confirm this potential clinical use). Conversely, the serine protease inhibitor 4-(2-aminoethyl)benzenesulfonyl fluoride hydrochloride (AEBSF) inhibited the direct fibrinogen cleaving actions of C. mictlantecuhtli venom, thereby revealing that the pseudo-procoagulant action is driven by kallikrein-type serine proteases. Thus, this differential ontogenetic variation in coagulotoxicity patterns poses intriguing questions. Our results underscore the need for further research into Mexican rattlesnake venom activity, and also highlights potential limitations of current antivenom treatments.
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Affiliation(s)
- Lorenzo Seneci
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD, Australia.,Institute of Biology Leiden (IBL), Leiden University, Leiden, Netherlands
| | - Christina N Zdenek
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD, Australia
| | - Abhinandan Chowdhury
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD, Australia.,Department of Biochemistry and Microbiology, North South University, Dhaka, Bangladesh
| | - Caroline F B Rodrigues
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD, Australia.,Laboratório de Herpetologia, Instituto Butantan, São Paulo, Brazil
| | - Edgar Neri-Castro
- Instituto de Biotecnología, Universidad Autónoma de México, Cuernavaca, Mexico
| | - Melisa Bénard-Valle
- Instituto de Biotecnología, Universidad Autónoma de México, Cuernavaca, Mexico
| | - Alejandro Alagón
- Instituto de Biotecnología, Universidad Autónoma de México, Cuernavaca, Mexico
| | - Bryan G Fry
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD, Australia
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