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Thakur S, Yasmin R, Malhotra A, Lalremsanga HT, Santra V, Giri S, Doley R. Isolation and Functional Characterization of Erythrofibrase: An Alfa-Fibrinogenase Enzyme from Trimeresurus erythrurus Venom of North-East India. Toxins (Basel) 2024; 16:201. [PMID: 38668626 PMCID: PMC11054993 DOI: 10.3390/toxins16040201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/08/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
Green pit viper bites induce mild toxicity with painful local swelling, blistering, cellulitis, necrosis, ecchymosis and consumptive coagulopathy. Several bite cases of green pit vipers have been reported in several south-east Asian countries including the north-eastern region of India. The present study describes isolation and characterization of a haemostatically active protein from Trimeresurus erythrurus venom responsible for coagulopathy. Using a two-step chromatographic method, a snake venom serine protease erythrofibrase was purified to homogeneity. SDS-PAGE of erythrofibrase showed a single band of ~30 kDa in both reducing and non-reducing conditions. The primary structure of erythrofibrase was determined by ESI LC-MS/MS, and the partial sequence obtained showed 77% sequence similarity with other snake venom thrombin-like enzymes (SVTLEs). The partial sequence obtained had the typical 12 conserved cysteine residues, as well as the active site residues (His57, Asp102 and Ser195). Functionally, erythrofibrase showed direct fibrinogenolytic activity by degrading the Aα chain of bovine fibrinogen at a slow rate, which might be responsible for causing hypofibrinogenemia and incoagulable blood for several days in envenomated patients. Moreover, the inability of Indian polyvalent antivenom (manufactured by Premium Serum Pvt. Ltd., Maharashtra, India) to neutralize the thrombin-like and plasmin-like activity of erythrofibrase can be correlated with the clinical inefficacy of antivenom therapy. This is the first study reporting an α-fibrinogenase enzyme erythrofibrase from T. erythrurus venom, which is crucial for the pathophysiological manifestations observed in envenomated victims.
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Affiliation(s)
- Susmita Thakur
- Molecular Toxinology Laboratory, Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, Assam, India; (S.T.); (R.Y.)
| | - Rafika Yasmin
- Molecular Toxinology Laboratory, Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, Assam, India; (S.T.); (R.Y.)
| | - Anita Malhotra
- Molecular Ecology and Evolution at Bangor, School of Environmental and Natural Sciences, Bangor University, Bangor LL57 2UW, UK;
| | - Hmar Tlawmte Lalremsanga
- Developmental Biology and Herpetology Laboratory, Department of Zoology, Mizoram University, Aizawl 796004, Mizoram, India;
| | - Vishal Santra
- Society for Nature Conservation, Research and Community Engagement (CONCERN), Nalikul 712407, West Bengal, India;
- Captive and Field Herpetology, 13 Hirfron, Anglesey LL65 1YU, UK
- Shree Sainath Surgical and Maternity Hospital, Valsad 396050, Gujrat, India
| | - Surajit Giri
- Demow Government Community Health Centre, Raichai, Konwar Dihingia Gaon, Sivasagar 785662, Assam, India;
| | - Robin Doley
- Molecular Toxinology Laboratory, Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, Assam, India; (S.T.); (R.Y.)
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Alcachupas A, Bellosillo K, Catolico WR, Davis MC, Diaz A, Doyongan YK, Eduarte R, Gersava E, Intrepido MB, Laluma MGK, Lavalle CC, Millan J. Thrombolytic Effects of Philippine Pit Viper (Trimeresurus flavomaculatus) Venom in Human Blood In Vitro and Ferric Chloride-Induced Cardiac Thrombosis on Swiss Webster Mice In Vivo. Cureus 2023; 15:e40856. [PMID: 37489211 PMCID: PMC10363375 DOI: 10.7759/cureus.40856] [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] [Accepted: 06/23/2023] [Indexed: 07/26/2023] Open
Abstract
INTRODUCTION Thrombosis is one of the leading causes of mortality worldwide. Thrombolytic agents are used to reduce this burden. Studies pointed out that certain proteins in the venom of several snake species may have potential thrombolytic properties. Trimeresurus flavomaculatus, known as the Philippine pit viper, is found along damp localities in the Philippines. Venoms of closely related species have been shown to exhibit thrombolytic effects in vitro and in vivo. However, no extensive studies yet have been conducted about the thrombolytic effect of T. flavomaculatus venom. Thus, this two-phased study aimed to determine the thrombolytic effect of T. flavomaculatus venom on human blood and ferric chloride-induced cardiac thrombosis in mice. METHODOLOGY Phase 1 was done using clot lysis method to measure thrombolytic activity in vitro. Venom dilutions of 3:4, 1:2, 2:3, and 1:0, positive control (streptokinase), and negative control (normal saline solution) were inoculated to different samples of human blood. Phase 2 measured the thrombolytic activity in vivo. Ferric chloride-saturated filter paper was applied over the cardiac wall for the induction of thrombus formation. Venom dilutions of 1:64, 1:16, 1:4, and 1:1, positive control (streptokinase), and negative control (normal saline solution) were then injected through the dorsal tail vein of mice. After 1 hour, the cardiac tissues were excised for histologic examination. RESULTS Phase 1 results showed that the venom had significant thrombolytic activity in vitro. Dilutions of 1:0 and 3:4 had no significant differences with streptokinase in vitro. Phase 2 results showed significant lysis in vivo at 1:1, 1:4, and 1:64 venom dilutions. CONCLUSION The results indicated that T. flavomaculatus has a potential thrombolytic activity both in vitro and in vivo.
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Affiliation(s)
| | | | | | - Mark Cullen Davis
- College of Medicine, West Visayas State University, Iloilo City, PHL
| | - Alyssa Diaz
- College of Medicine, West Visayas State University, Iloilo City, PHL
| | | | - Reczy Eduarte
- College of Medicine, West Visayas State University, Iloilo City, PHL
| | - Emerald Gersava
- College of Medicine, West Visayas State University, Iloilo City, PHL
| | | | | | | | - Jeffrey Millan
- College of Medicine, West Visayas State University, Iloilo City, PHL
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Ralph R, Garg D, Balachandran A, Ganesh SR, Lamb T. A case report of Ovophis monitcola (Mountain pit-viper) envenoming in northeastern India resulting in prolonged coagulopathy. Toxicon 2023; 229:107147. [PMID: 37127123 DOI: 10.1016/j.toxicon.2023.107147] [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: 03/14/2023] [Revised: 04/21/2023] [Accepted: 04/29/2023] [Indexed: 05/03/2023]
Abstract
India is home to a diverse spectrum of medically-significant snakes accounting for the world's largest burden of envenoming, morbidity and mortality. Indian polyspecific antivenom is derived from the venom of four snake species (Daboia russelii, Echis carinatus, Naja naja and Bungarus caeruleus), considered to be responsible for the majority of snakebite morbidity and mortality. The treatment of venomous bites from other less-commonly encountered venomous snake species can be challenging. In this report, we describe the case of a 32-year-old male who presented with features of local cytotoxicity and coagulopathy following a bite from Ovophis monitcola (mountain pit-viper) in Nagaland, northeast India. Local and systemic envenoming, confirmed by bedside and laboratory based clotting assays, failed to respond to polyspecific antivenom and venom-induced consumption coagulopathy persisted for 28 days. Remote consultation with a national Poison Control Centre helped establish the responsible snake species and guide appropriate medical management.
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Affiliation(s)
- Ravikar Ralph
- Poison Control Center, Department of Medicine, Christian Medical College (CMC), Vellore, Tamil Nadu, 632004, India.
| | - Deepak Garg
- Medicine, Military Hospital, Dimapur, Nagaland, India; Medicine, Military Hospital, Jodhpur, Rajasthan, India
| | - Amith Balachandran
- Poison Control Center, Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - S R Ganesh
- Chennai Snake Park, Guindy, Chennai, Tamil Nadu, 600022, India
| | - Thomas Lamb
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos; Nuffield Department of Clinical Medicine, University of Oxford, India
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Xie RH, Ye XL, Tang CY, Wang YH, Zhong LX. Associated Clinical Factors for Coagulation Dysfunction due to Trimeresurus stejnegeri: A Retrospective Observational Study. J Toxicol 2023; 2023:8832355. [PMID: 37168533 PMCID: PMC10164868 DOI: 10.1155/2023/8832355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/13/2023] Open
Abstract
Background Trimeresurus stejnegeri (T.s) accounts for most snakebites in southern China, which always leads to coagulation dysfunction. Coagulopathy due to venom is widely considered to be a characteristic phenomenon of the DIC-like syndrome. It is vitally important for first-line clinicians to improve this condition as soon as possible. However, clinical factors associated with coagulation function in Trimeresurus stejnegeri has not been well characterized yet. Materials Patients bitten by vipers were admitted to the Emergency Department of a hospital in Shenzhen, southern China, from 2021 to 2022 and were retrospectively reviewed. Patient clinical characteristics and laboratory data were compared in the eligible patients bitten by T.s by their prothrombin time (PT), fibrinogen level (FIB), and platelet count on 2-3 days after bitten. Results 105 patients were included in this study. The mean values of PT, FIB, and PLT are as follows: 12.8 ± 0.79 s, 2.25 ± 0.47 g/L, and 196.2 ± 57.1 × 109/L. Uric acid (UA) (367.9 ± 103.85), blood glucose (6.53 + 1.64) show negative trend of correlation, while CRP (2.12 + 4.17) shows positive trend of association with coagulation function. The smoke and systolic blood pressure may exert negative effects on PT and PLT, respectively. Logistic regression analysis indicated that uric acid (UA) shows significant connection with PT (OR = 1.15 and P value <0.0001), FIB (OR = 0.89 and P value = 0.026), and PLT (OR = 0.79 and P value = 0.007). CRP is also shown to be associated with FIB (OR = 1.33 and P value = 0.043). Conclusion : Uric acid (UA) shows a significant association with PT, FIB, and PLT. CRP is related to FIB. Blood glucose shows a negative trend of correlation with PT. We do recommend physician should low the level of UA in some degree on the basis of injection of an antivenom serum.
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Affiliation(s)
- Run-Hua Xie
- Shenzhen Hospital, Beijing University of Chinese Medicine, Shenzhen, China
| | - Xiao-Lu Ye
- Shenzhen Hospital, Beijing University of Chinese Medicine, Shenzhen, China
| | - Cong-Yao Tang
- Shenzhen Hospital, Beijing University of Chinese Medicine, Shenzhen, China
| | - Yu-Huai Wang
- Shenzhen Hospital, Beijing University of Chinese Medicine, Shenzhen, China
| | - Long-Xin Zhong
- Shenzhen Hospital, Beijing University of Chinese Medicine, Shenzhen, China
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Othong R, Eurcherdkul T, Chantawatsharakorn P. Green Pit Viper Envenomations in Bangkok: A Comparison of Follow-Up Compliance and Clinical Outcomes in Older and Younger Adults. Toxins (Basel) 2022; 14:toxins14120869. [PMID: 36548767 PMCID: PMC9784995 DOI: 10.3390/toxins14120869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/14/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022] Open
Abstract
We compared older and younger adults envenomated by the green pit viper (GPV) with regard to the following: follow-up compliance, elapsed time between envenomation and emergency department (ED) visit, and clinical/treatment outcomes. This was a two-site retrospective cohort study. We searched hospital electronic medical databases between January 2011 and December 2021. Patients aged 15 and above were eligible if they had a history of snakebite and had at least two VCT and/or platelet count results in their medical records. After the search, 1550 medical records were reviewed and 760 cases were found to be eligible for analysis. In total, 205 cases (27.0%) were ≥60 years old. The median ages in the younger and older groups were 40 (26-51) and 68 (64-75) years, respectively. The median elapsed times from bite to the ED were 47 (30-118) vs. 69 (35-150) min (p-value = 0.001). Overall, 91.3% of all cases were managed as out-patient cases and were eligible for follow-up appointments. The rate of out-patient follow-up at 72 ± 12 h in the older patients was significantly higher (43.2%) than in the younger adult patients (32.4%) (p-value = 0.01). Regarding the clinical/treatment outcomes, the rates of coagulopathy, antivenom administration, and hospital admission were not statistically different between both groups.
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Affiliation(s)
- Rittirak Othong
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok 10300, Thailand
- Correspondence:
| | - Thanaphat Eurcherdkul
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok 10300, Thailand
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Tiyawat G, Lohajaroensub S, Othong R. Diagnostic Tests for Hypofibrinogenemia Resulting from Green Pit Viper (Trimeresurus albolabris) Envenomation: A Simulated In Vitro Study. Wilderness Environ Med 2022; 33:371-378. [PMID: 36216671 DOI: 10.1016/j.wem.2022.07.011] [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: 01/26/2022] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The green pit viper (GPV) Trimeresurus albolabris is found in Southeast Asia. Its venom has a thrombin-like activity that can cause hypofibrinogenemia. Fibrinogen measurement is not always available. We aimed to establish a more available diagnostic tool indicating hypofibrinogenemia caused by GPV envenomation. METHODS This was an in vitro study, in which healthy subjects aged 20 to 45 y were enrolled. There were 2 experiments. In Experiment 1, blood samples from 1 subject had varying amounts of T albolabris venom added to determine its effect on the fibrinogen level (FL). In Experiment 2, 3 sets of blood samples were obtained from another 25 subjects. The 2 venom doses established in Experiment 1 were used on 2 sets of the samples to simulate severe (FL <1.0 g·L-1) and mild hypofibrinogenemia (FL 1.0-1.7 g·L-1). The third set of samples was venom-free. All samples were used for platelet counts, prothrombin time (PT)/international normalized ratio (INR)/activated partial thromboplastin time (aPTT), and 2 bedside clotting tests. Diagnostic parameters were calculated against the target FL of <1.0 g·L-1 and <1.7 g·L-1. RESULTS Twenty-five subjects were enrolled in Experiment 2. On referencing normal cutoff values (platelet count >150,000 cells/mm3, venous clotting time <15 min, normal 20-min whole blood clotting time, INR <1.2, aPTT <30), we found abnormalities of 5, 0, 0, 3, and 22%, respectively. The highest correlation with hypofibrinogenemia was provided by PT/INR. For an FL of <1.0 g·L-1, PT and INR revealed the highest areas under the receiver operating characteristic curve, 0.76 (95% CI, 0.55-0.97) and 0.76 (95% CI, 0.57-0.97), respectively. The highest accuracy and the highest sensitivity were provided by PT/INR. CONCLUSIONS PT/INR could be used as a diagnostic test for severe hypofibrinogenemia in GPV envenomation because of its high accuracy and area under the receiver operating characteristic curve.
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Affiliation(s)
- Gawin Tiyawat
- Department of Disaster and Emergency Medical Operation, Faculty of Sciences and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| | | | - Rittirak Othong
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
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Patikorn C, Blessmann J, Nwe MT, Tiglao PJG, Vasaruchapong T, Maharani T, Doan UV, Zainal Abidin SA, Ismail AK, Othman I, Taychakhoonavudh S, Chaiyakunapruk N. Estimating economic and disease burden of snakebite in ASEAN countries using a decision analytic model. PLoS Negl Trop Dis 2022; 16:e0010775. [PMID: 36170270 PMCID: PMC9518918 DOI: 10.1371/journal.pntd.0010775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 08/30/2022] [Indexed: 12/24/2022] Open
Abstract
Background
Understanding the burden of snakebite is crucial for developing evidence-informed strategies to pursue the goal set by the World Health Organization to halve morbidity and mortality of snakebite by 2030. However, there was no such information in the Association of Southeast Asian Nations (ASEAN) countries.
Methodology
A decision analytic model was developed to estimate annual burden of snakebite in seven countries, including Malaysia, Thailand, Indonesia, Philippines, Vietnam, Lao PDR, and Myanmar. Country-specific input parameters were sought from published literature, country’s Ministry of Health, local data, and expert opinion. Economic burden was estimated from the societal perspective. Costs were expressed in 2019 US Dollars (USD). Disease burden was estimated as disability-adjusted life years (DALYs). Probabilistic sensitivity analysis was performed to estimate a 95% credible interval (CrI).
Principal findings
We estimated that annually there were 242,648 snakebite victims (95%CrI 209,810–291,023) of which 15,909 (95%CrI 7,592–33,949) were dead and 954 (95%CrI 383–1,797) were amputated. We estimated that 161,835 snakebite victims (69% of victims who were indicated for antivenom treatment) were not treated with antivenom. Annual disease burden of snakebite was estimated at 391,979 DALYs (95%CrI 187,261–836,559 DALYs) with total costs of 2.5 billion USD (95%CrI 1.2–5.4 billion USD) that were equivalent to 0.09% (95%CrI 0.04–0.20%) of the region’s gross domestic product. >95% of the estimated burdens were attributed to premature deaths.
Conclusion/Significance
The estimated high burden of snakebite in ASEAN was demonstrated despite the availability of domestically produced antivenoms. Most burdens were attributed to premature deaths from snakebite envenoming which suggested that the remarkably high burden of snakebite could be averted. We emphasized the importance of funding research to perform a comprehensive data collection on epidemiological and economic burden of snakebite to eventually reveal the true burden of snakebite in ASEAN and inform development of strategies to tackle the problem of snakebite.
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Affiliation(s)
- Chanthawat Patikorn
- Department of Social and Administrative Pharmacy, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Jörg Blessmann
- Department of Implementation Research, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | | | - Patrick Joseph G. Tiglao
- Department of Emergency Medicine, Eastern Visayas Regional Medical Center, Tacloban City, Philippines
- Philippine Toxinology Society, Incorporated, Manila, Philippines
- Department of Emergency Medicine, University of the Philippines-Manila, Philippine General Hospital, Manila, Philippines
- Department of Emergency Medicine, Corazon Locsin Montelibano Memorial Regional Hospital, Bacolod City, Negros Occidental, Philippines
| | - Taksa Vasaruchapong
- Snake Farm, Queen Saovabha Memorial Institute, The Thai Red Cross Society, Bangkok, Thailand
| | - Tri Maharani
- National Institute Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Uyen Vy Doan
- Division of Medical Toxicology, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Syafiq Asnawi Zainal Abidin
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Ahmad Khaldun Ismail
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Iekhsan Othman
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Suthira Taychakhoonavudh
- Department of Social and Administrative Pharmacy, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
- * E-mail: (ST); (NC)
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, United States of America
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, United States of America
- School of Pharmacy, Monash University Malaysia, Selangor, Malaysia
- * E-mail: (ST); (NC)
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Uncommon defibrinogenation and coagulopathy caused by Trimeresurus stejnegeri stejnegeri envenomation in a patient with swelling above the ankle. Toxicon 2022; 217:143-147. [PMID: 35987354 DOI: 10.1016/j.toxicon.2022.08.011] [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: 06/08/2022] [Revised: 07/27/2022] [Accepted: 08/11/2022] [Indexed: 11/22/2022]
Abstract
In Taiwan, Trimeresurus stejnegeri stejnegeri (Stejneger's Bamboo pitviper) is responsible for more than half of all venomous snakebites annually. This species often causes local envenoming characterized by tissue swelling and pain, occasional local ecchymosis, bullae and blister formation, and lymphangitis and lymphadenitis. The pathophysiology and treatment of potentially life-threatening coagulopathy and defibrinogenation induced by T. s. stejnegeri systemic envenoming have not been specifically addressed. Here, we describe the case of a man who was bitten by T. s. stejnegeri on his right first toe, which later developed into swelling above the ankle. It was found that there was severe hypofibrinogenemia, prolonged prothrombin time, and reduced activities of factors V and XI, plasminogen, and α2-antiplasmin. Even though a favorable outcome was achieved after repeatedly administering specific antivenom, fresh frozen plasma, and cryoprecipitate, probably low effectiveness of antivenom against the coagulopathy and prodigious amounts of replacement products were observed. To control coagulopathy early and avoid the needless replacement of coagulation factor, which are associated with inherent adverse reactions, more frequent serial blood assessment (e.g., every 6 h) and higher initial antivenom doses may be helpful. Knowledge of the specific coagulation factor deficiencies may improve our understanding of the relationship between hemotoxins and the resulting envenoming syndromes in this snakebite.
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Zeng ZY, Huang PY, Du JY, Liu YX, Guo SG, Zeng LS, Zhang CC, Li Y. Effect of Agkistrodon halys antivenom in patients bit by green pit viper and the prognostic role of the disease - a retrospective cohort study. Clin Toxicol (Phila) 2022; 60:808-817. [PMID: 35225104 DOI: 10.1080/15563650.2022.2041200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND AIMS In Mainland China and Hong Kong, health authorities utilize Agkistrodon halys antivenom in the treatment of patients who sustained bites from green pit vipers. However, the treatment benefit of Agkistrodon halys antivenom among such patients is still controversial. The purpose of this study is to evaluate the coagulation parameters normalization time of Agkistrodon halys antivenom in patients who sustained green pit viper bites and explore independent risk factors of patient prognosis. METHODS Data were extracted from the Donghua Hospital Information System. Comparison of the two groups of patients - who used antivenom (GPUA) and who did not use antivenom (GPNUA) were performed using stratified analysis, univariate and multivariate ordered logistic regression models to evaluate the coagulation parameters normalization time. Univariate and multivariate ordered logistic regression models were used to explore independent risk factors of patient prognosis. RESULTS Between the GPUA and GPNUA groups, there is no significant difference in the coagulation parameters normalization time with the treatment of Agkistrodon halys antivenom. GPNUA consumed more cryoprecipitate and platelets and had a lower cost. The patient's severity of the bite, first coagulation profile, and dosages of fresh frozen plasma, platelet, and red cell suspension was found to be risk factors for the normalization time of coagulation parameters. CONCLUSIONS The therapeutic effect of Agkistrodon halys antivenom in green pit vipers bite patients is not quite satisfying. In addition, more attention should be paid to the first coagulation profile, blood clotting factors indices, platelet count (PLT), and hemoglobin when treating such patients.
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Affiliation(s)
- Zhong-Yi Zeng
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Pei-Ying Huang
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, PR China.,Emergency Department, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, PR China
| | - Jia-Yu Du
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Yu-Xiang Liu
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Shi-Gong Guo
- Department of Rehabilitation Medicine, Southmead Hospital, Bristol, UK
| | - Lin-Sheng Zeng
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Cong-Cong Zhang
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Yi Li
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, PR China
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Zeng L, Liang Q, Liang Z, Han J, Wu M, Liu R, Wang X. Effectiveness of clotting factor replacement therapy after antivenom treatment on coagulopathic envenomation following green pit viper bites: a retrospective observational study. BMC Emerg Med 2022; 22:9. [PMID: 35045831 PMCID: PMC8772100 DOI: 10.1186/s12873-022-00569-w] [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: 03/16/2021] [Accepted: 01/04/2022] [Indexed: 12/17/2022] Open
Abstract
Background Green pit vipers (GPVs), namely Trimeresurus albolabris and Trimeresurus stejnegeri accounts for most snakebites in Southern China. Green pit viper venom contains thrombin-like enzymes, resulting in defibrination syndrome. Using of clotting factor replacement after antivenom administration is controversial. The objective of this study was to investigate the effects of clotting factor replacement in coagulopathic patients with T. albolabris and T. stejnegeri bites after antivenom administration. Methods We retrospectively reviewed 123 patients who were bitten by T. albolabris and T. stejnegeri and were admitted to the Emergency Department of a hospital in Guangzhou, Southern China, from 2013 to 2019. Recovery of prothrombin time (PT) and fibrinogen level were compared among (1) fresh-frozen plasma (FFP) group; (2) cryoprecipitate (cryo) group; (3) FFP and cryo group; and (4) control group after antivenom administration. Results The incidence of coagulopathy was 31%. Persistent and late coagulopathy were the most common patterns among four groups. The median reduction in PT was 20.1 ± 31.2 s for FFP and cryo group. The median increase in fibrinogen level was very small: 0.05 ± 0.20 g/L for FFP group, 0.09 ± 0.37 g/L for cryo group and 0.07 ± 0.31 g/L for FFP and cryo group, respectively. The percentage of unimproved PT was markedly higher in the FFP and cryo group than the control group (P = 0.01 by log-rank test, P = 0.02 by Gehan-Breslow-Wilcoxon test). The percentage of unimproved fibrinogen level tended to be worse in the FFP and cryo group than the control group, but the different was marginal (P = 0.05 by Gehan-Breslow-Wilcoxon test, P = 0.07 by log-rank test). A total of 7.8% (7/90) of the patients in the clotting factor replacement groups developed anaphylaxis and heart failure. Conclusion There is no improvement in coagulopathy profile in patients with T. albolabris and T. stejnegeri bites who received clotting factor replacement after antivenom administration. But the results from GPVs may not be generalized to other species of venomous snakes.
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Thein MM, Rogers CA, White J, Mahmood MA, Weinstein SA, Nwe MT, Thwin KT, Zaw A, Thant M, Oo SSL, Gyi KM, Warrell DA, Alfred S, Peh CA. Characteristics and significance of "green snake" bites in Myanmar, especially by the pit vipers Trimeresurus albolabris and Trimeresurus erythrurus. Toxicon 2021; 203:66-73. [PMID: 34562496 DOI: 10.1016/j.toxicon.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/10/2021] [Accepted: 09/19/2021] [Indexed: 10/20/2022]
Abstract
Snakebite is an important problem in Myanmar. Regionally, bites by Eastern Russell's vipers, Daboia siamensis (Viperidae, Viperinae), and monocled cobras, Naja kaouthia are considered medically important, but those categorised as "green snake" bites are not. However, these may include bites by green pit vipers, Trimeresurus spp. (Viperidae, Crotalinae) for which no antivenom is available in Myanmar. Elsewhere in Southeast Asia, these snakes are reported to cause local and systemic envenoming. As part of the Myanmar Snakebite Project, prospective case data were collected over 3 years from five hospitals in the Mandalay region. These included 3803 snakebite cases reported from Mandalay region. Of these, 355 were listed as bites by a witnessed green-coloured snake. In 22 cases, the snakes responsible were retained and preserved, then expertly identified; 21 were medically important white-lipped pit vipers (Trimeresurus albolabris), and one as an Asian vine snake, Ahaetulla prasina (Colubridae, Ahaetuliinae) which is not of medical importance. Among confirmed Trimeresurus albolabris bites, 15/21 developed swelling of the bitten limb, and 3/21 coagulopathy, defined as a positive 20-min whole blood clotting test (20WBCT). None developed necrosis, blistering, thrombocytopenia or acute kidney injury (AKI). Of the remaining 333 patients bitten by green snakes that were not specifically identified, 241 (72%) developed swelling of the bitten limb, and 62 (19%) coagulopathy. AKI occurred in 21/333 patients, but only one required dialysis. At least 10/21 of the cases with AKI in this study were more likely to represent bites from Trimeresurus spp. than D. siamensis because the snake responsible was brought into the hospital, examined and described by the treating physician as "green-coloured". This study describes a previously unpublished case of AKI from envenoming by T. erythrurus in Yangon, and reviews cases of AKI following bites by this species and T. albolabris in Myanmar. This confirms that, at least on rare occasions, Trimeresurus spp. envenoming can cause AKI. This has important implications for snakebite management in Myanmar as the finding of local swelling, coagulopathy and AKI is generally considered pathognomonic of D. siamensis envenoming. Further collection of confirmed Trimeresurus spp. bites is required in Myanmar in order better to define the syndrome of envenoming and to assess the possible need for antivenom against Trimeresurus spp. in this country.
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Affiliation(s)
- Myat Myat Thein
- Myanmar Snakebite Project, Mandalay Office, Mandalay, Myanmar
| | - Caitlyn A Rogers
- Toxinology Department, Women's and Children's Hospital, North Adelaide, SA, 5006, Australia; University of Adelaide, Adelaide, SA, 5000, Australia.
| | - Julian White
- Toxinology Department, Women's and Children's Hospital, North Adelaide, SA, 5006, Australia; University of Adelaide, Adelaide, SA, 5000, Australia
| | | | - Scott A Weinstein
- Toxinology Department, Women's and Children's Hospital, North Adelaide, SA, 5006, Australia; University of Adelaide, Adelaide, SA, 5000, Australia
| | - Myat Thet Nwe
- Myanmar Snakebite Project, Mandalay Office, Mandalay, Myanmar
| | | | - Aung Zaw
- General Manager, Myanmar Pharmaceutical Industrial Enterprise, Yangon, Myanmar
| | - Myo Thant
- Myanmar Snakebite Project, Mandalay Office, Mandalay, Myanmar
| | - Sai Sein Lin Oo
- Department of Zoology, University of Mandalay, Mandalay, Myanmar
| | - Khin Maung Gyi
- Department of Zoology, University of Mandalay, Mandalay, Myanmar
| | - David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, UK
| | - Sam Alfred
- University of Adelaide, Adelaide, SA, 5000, Australia; Emergency Department, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | - Chen Au Peh
- University of Adelaide, Adelaide, SA, 5000, Australia; Department of Renal Medicine, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
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12
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Bioactive Molecules Derived from Snake Venoms with Therapeutic Potential for the Treatment of Thrombo-Cardiovascular Disorders Associated with COVID-19. Protein J 2021; 40:799-841. [PMID: 34499333 PMCID: PMC8427918 DOI: 10.1007/s10930-021-10019-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 01/08/2023]
Abstract
As expected, several new variants of Severe Acute Respiratory Syndrome-CoronaVirus-2 (SARS-CoV-2) emerged and have been detected around the world throughout this Coronavirus Disease of 2019 (COVID-19) pandemic. Currently, there is no specific developed drug against COVID-19 and the challenge of developing effective antiviral strategies based on natural agents with different mechanisms of action becomes an urgent need and requires identification of genetic differences among variants. Such data is used to improve therapeutics to combat SARS-CoV-2 variants. Nature is known to offer many biotherapeutics from animal venoms, algae and plant that have been historically used in traditional medicine. Among these bioresources, snake venom displays many bioactivities of interest such as antiviral, antiplatelet, antithrombotic, anti-inflammatory, antimicrobial and antitumoral. COVID-19 is a viral respiratory sickness due to SARS-CoV-2 which induces thrombotic disorders due to cytokine storm, platelet hyperactivation and endothelial dysfunction. This review aims to: (1) present an overview on the infection, the developed thrombo-inflammatory responses and mechanisms of induced thrombosis of COVID-19 compared to other similar pathogenesis; (2) underline the role of natural compounds such as anticoagulant, antiplatelet and thrombolytic agents; (3) investigate the management of coagulopathy related to COVID-19 and provide insight on therapeutic such as venom compounds. We also summarize the updated advances on antiviral proteins and peptides derived from snake venoms that could weaken coagulopathy characterizing COVID-19.
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13
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Dang XT, Xuan Nguyen T, Nguyen TTH, Ha HT. Coagulopathy After Viper Snakebite in Vietnam and Relationship with Time of Admission. J Multidiscip Healthc 2021; 14:1259-1265. [PMID: 34103926 PMCID: PMC8180263 DOI: 10.2147/jmdh.s311556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/10/2021] [Indexed: 01/02/2023] Open
Abstract
Background Snakebite envenoming is a potentially life-threatening condition and causes many serious consequences. Subjects and Methods Therefore, this study aimed to throw some light on coagulopathy after Viperidae envenomations at Vietnam Poison Control Center and the relationship between coagulopathy and time of admission. A prospective, descriptive study was conducted from October 2016 to April 2018. The survey questionnaire included socio-economic characteristics, characteristics of snakebite, signs and clinical symptoms and blood test. Disseminated intravascular coagulation (DIC) condition was diagnosed using the International Society on Thrombosis and Haemostasis (ISTH) criteria. Rotational thromboelastometry was evaluated using ROTEM® delta system. Results A total of 41 cases of viper snakebite with the mean age of snakebite victims were 41.27 ± 14.72 years old. Mean hospital stay of the patients was 5.63± 3.29 days. The association between coagulation disorder and clotting time (CT) EXTEM prolonged, CT INTEM prolonged, CT FIBTEM prolonged remained significant (multivariable odds ratio MOR=5.81, 95% CI: 1.20–28.06; MOR= 9.32, 95% CI: 1.001–84.48; MOR=5.55, 95% CI: 1.12–27.50, respectively). Conclusion This study indicates a hypocoagulation status in ROTEM, elevated international normalised ratio (INR), activated partial thromboplastin time (APTT) and D-dimer, decreased fibrinogen concentration and platelet count following envenoming by Viperidae.
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Affiliation(s)
- Xuan Thi Dang
- Vietnam Poison Control Center, Bach Mai Hospital, Hanoi, 100000, Vietnam.,Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, 100000, Vietnam
| | - Thanh Xuan Nguyen
- Geriatrics Department, Hanoi Medical University, Hanoi, 100000, Vietnam.,Scientific Research Department, National Geriatric Hospital, Hanoi, 100000, Vietnam.,Dinh Tien Hoang Institute of Medicine, Hanoi, 100000, Vietnam
| | - Thu Thi Hoai Nguyen
- Geriatrics Department, Hanoi Medical University, Hanoi, 100000, Vietnam.,Scientific Research Department, National Geriatric Hospital, Hanoi, 100000, Vietnam
| | - Hung Tran Ha
- Vietnam Poison Control Center, Bach Mai Hospital, Hanoi, 100000, Vietnam.,Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, 100000, Vietnam
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14
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Bolon I, Durso AM, Botero Mesa S, Ray N, Alcoba G, Chappuis F, Ruiz de Castañeda R. Identifying the snake: First scoping review on practices of communities and healthcare providers confronted with snakebite across the world. PLoS One 2020; 15:e0229989. [PMID: 32134964 PMCID: PMC7058330 DOI: 10.1371/journal.pone.0229989] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/18/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Snakebite envenoming is a major global health problem that kills or disables half a million people in the world's poorest countries. Biting snake identification is key to understanding snakebite eco-epidemiology and optimizing its clinical management. The role of snakebite victims and healthcare providers in biting snake identification has not been studied globally. OBJECTIVE This scoping review aims to identify and characterize the practices in biting snake identification across the globe. METHODS Epidemiological studies of snakebite in humans that provide information on biting snake identification were systematically searched in Web of Science and Pubmed from inception to 2nd February 2019. This search was further extended by snowball search, hand searching literature reviews, and using Google Scholar. Two independent reviewers screened publications and charted the data. RESULTS We analysed 150 publications reporting 33,827 snakebite cases across 35 countries. On average 70% of victims/bystanders spotted the snake responsible for the bite and 38% captured/killed it and brought it to the healthcare facility. This practice occurred in 30 countries with both fast-moving, active-foraging as well as more secretive snake species. Methods for identifying biting snakes included snake body examination, victim/bystander biting snake description, interpretation of clinical features, and laboratory tests. In nine publications, a picture of the biting snake was taken and examined by snake experts. Snakes were identified at the species/genus level in only 18,065/33,827 (53%) snakebite cases. 106 misidentifications led to inadequate victim management. The 8,885 biting snakes captured and identified were from 149 species including 71 (48%) non-venomous species. CONCLUSION Snakebite victims and healthcare providers can play a central role in biting snake identification and novel approaches (e.g. photographing the snake, crowdsourcing) could help increase biting snake taxonomy collection to better understand snake ecology and snakebite epidemiology and ultimately improve snakebite management.
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Affiliation(s)
- Isabelle Bolon
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Andrew M. Durso
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sara Botero Mesa
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicolas Ray
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
| | - Gabriel Alcoba
- Médecins Sans Frontières, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, Geneva, Switzerland
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15
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Othong R, Keeratipornruedee P. A study regarding follow-ups after green pit viper bites treated according to the practice guideline by the Ministry of Public Health of Thailand. Clin Toxicol (Phila) 2020; 58:893-899. [DOI: 10.1080/15563650.2019.1708090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Rittirak Othong
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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16
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Tongpoo A, Niparuck P, Sriapha C, Wananukul W, Trakulsrichai S. Utility of Thrombin Time in Management of Patients with Green Pit Vipers Bite. SAGE Open Med 2020; 8:2050312120966468. [PMID: 35154756 PMCID: PMC8826260 DOI: 10.1177/2050312120966468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/24/2020] [Indexed: 01/12/2023] Open
Abstract
Objectives: GGreen pit vipers (GPV) envenomation causes consumptive coagulopathy mainly by thrombin-like enzymes. Fibrinogen levels are generally investigated to help evaluate systemic envenomation. However, tests of fibrinogen levels may not be available in every hospital. This study aimed to determine the sensitivity, specificity and accuracy for a range of various coagulation tests (20 minute whole blood clotting test (20WBCT), prothrombin time, international normalized ratio and thrombin time (TT)), comparing to the two gold standards performed in patients with GPV bite. Methods: This was the pilot study which we retrospectively reviewed fibrinogen level results including the hospital records of 24 GPV (Trimeresurus albolabris or macrops) bite patients visiting Ramathibodi Hospital, Thailand during 2013–2017 with 65 results of fibrinogen levels. The fibrinogen levels <164 and <100 mg/dL were used as the standard cut-off points or gold standards as the abnormal low and critical levels, respectively. Results: Most were male. All had local effects. For fibrinogen levels <164 and <100 mg/dL, prolonged TT had the highest sensitivity of 57.1% and 82.4%; the negative predictive value of 74.5% and 93.6%; the accuracy of 81.0% and 92.1%; and the area under a receiver operating characteristic curve of 0.762 and 0.873, respectively. For fibrinogen levels <164, unclotted 20WBCT and prolonged TT had the highest specificity and positive predictive value of 100% all. For fibrinogen levels <100, unclotted 20WBCT had the highest specificity and positive predictive value of 100% both, while prolonged TT had the specificity and positive predictive value of 95.7% and 87.5%, respectively. One patient developed isolated thrombocytopenia without hypofibrinogenemia and coagulopathy. Conclusions: Among four coagulation tests, TT was the most sensitive and accurate test to indicate hypofibrinogenemia in GPV bite patients. In case of unavailable fibrinogen levels thrombin time might be investigated to help evaluate patients’ fibrinogen status. Isolated thrombocytopenia could occur in GPV envenomation.
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Affiliation(s)
- Achara Tongpoo
- Ramathibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pimjai Niparuck
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Charuwan Sriapha
- Ramathibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Winai Wananukul
- Ramathibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Satariya Trakulsrichai
- Ramathibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Satariya Trakulsrichai, Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Praram VI Road, Bangkok 10400, Thailand.
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17
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Debono J, Bos MHA, Frank N, Fry B. Clinical implications of differential antivenom efficacy in neutralising coagulotoxicity produced by venoms from species within the arboreal viperid snake genus Trimeresurus. Toxicol Lett 2019; 316:35-48. [PMID: 31509773 DOI: 10.1016/j.toxlet.2019.09.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/04/2019] [Accepted: 09/06/2019] [Indexed: 12/12/2022]
Abstract
Snake envenomation globally is attributed to an ever-increasing human population encroaching into snake territories. Responsible for many bites in Asia is the widespread genus Trimeresurus. While bites lead to haemorrhage, only a few species have had their venoms examined in detail. We found that Trimeresurus venom causes haemorrhaging by cleaving fibrinogen in a pseudo-procoagulation manner to produce weak, unstable, short-lived fibrin clots ultimately resulting in an overall anticoagulant effect due to fibrinogen depletion. The monovalent antivenom 'Thai Red Cross Green Pit Viper antivenin', varied in efficacy ranging from excellent neutralisation of T. albolabris venom through to T. gumprechti and T. mcgregori being poorly neutralised and T. hageni being unrecognised by the antivenom. While the results showing excellent neutralisation of some non-T. albolabris venoms (such as T. flavomaculaturs, T. fucatus, and T. macrops) needs to be confirmed with in vivo tests, conversely the antivenom failure T. hageni, and the very poor results against T. gumprechti and T. mcgregori, despite being conducted in the ideal scenario of preincubation of antivenom:venom, indicates that the likelihood of clinically relevant cross-reactivity for these species is low (T. gumprechti and T. mcgregori) to non-existent (T. hageni). These same latter three species were also not inhibited by the serine protease inhibitor AEBSF, suggesting that the toxins leading to a coagulotoxic effect in these species are non-serine proteases while in contrast T. albolabris coagulotoxicity was completely impeded by AEBSF, and thus driven by kallikrein-type serine proteases. There was a conspicuous lack of phylogenetic pattern in venom variation, with the most potent venoms (T. albolabris and T. hageni) being distant to each other on the organismal tree, and with the three most divergent and poorly neutralised venoms (T. gumprechti, T. hageni, and T. mcgregori) were also not each others closest relatives. This reinforces the paradigm that the fundamental dynamic evolution of venom results in organismal phylogeny being a poor predictor of venom potency or antivenom efficacy. This study provides a robust investigation on the differential venom effects from a wide range of Trimeresurus species on coagulation, highlighting differential fibrinogenolytic effects, while also investigating the relative antivenom neutralisation capabilities of the widely available Thai Red Cross Green Pit Viper antivenom. These results therefore have immediate, real-world implications for patients envenomed by Trimeresurus species.
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Affiliation(s)
- Jordan Debono
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD, 4072, Australia
| | - Mettine H A Bos
- Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | | | - Bryan Fry
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD, 4072, Australia.
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18
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Witharana EWRA, Gnanathasan A, Dissanayake AS, Wijesinghe SKJ, Kadahetti SCL, Rajapaksha RMJK. Sri Lankan green pit viper (Trimeresurus trigonocephalus) bites in Deniyaya: A clinico-epidemiological study. Toxicon 2019; 169:34-37. [PMID: 31348933 DOI: 10.1016/j.toxicon.2019.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 07/11/2019] [Accepted: 07/23/2019] [Indexed: 11/30/2022]
Abstract
Green pit viper (Trimeresurus trigonocephalus) is endemic to Sri Lanka and bites are reported from tropical rain forest and plantation areas. As scant data exists on clinico-epidemiological features of Sri Lankan green pit viper bite, objective of this study was to address this knowledge gap. A prospective observational study was conducted in Base Hospital Deniyaya from October 2013 to September 2015. Green pit viper as the offending snake was identified when the victims brought live or dead specimens. When the specimen was not available, green pit viper was identified by the victim pointing to preserved specimens and photographs of green pit viper and different similar appearing snakes. Clinical details were recorded during the hospital stay. Twenty four green pit viper bite patients (17-68 years) were studied. All cases were daytime bites despite green pit viper being a nocturnally active snake. Sixteen patients (67%) were bitten while they were working in tea plantation. Hands (42%), feet, (33%), forearms (8%), legs (8%), thighs (4%) and shoulders (4%) were the sites of bites. Thirteen (54%) had extensive limb swelling. Nine (38%) had local swelling and two had no swelling. Three (12.5%) developed haemorrhagic blisters. Four (17%) had regional lymphadenopathy. Two (8%) developed non clotting blood by the TWBCT. Green pit viper bites caused substantial morbidity. Risk factors included day time outdoor activities in bordering villages of tropical rain forests and occupation. Pain, extensive limb swelling and bite site swelling were prominent clinical features. However haemorrhagic blisters, regional lymphadenopathy and coagulopathy were reported. Nephrotoxicity and neurotoxicity were notably absent.
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Affiliation(s)
| | - A Gnanathasan
- Department of Clinical Medicine, University of Colombo, Colombo, Sri Lanka
| | - A S Dissanayake
- Department of Clinical Medicine, University of Ruhuna, Galle, Sri Lanka
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19
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Fuchs J, Bessire K, Weiler S. A confirmed bite by a Beautiful Pit Viper (Trimeresurus venustus) resulting in local symptoms. Toxicon 2019; 163:44-47. [PMID: 30902684 DOI: 10.1016/j.toxicon.2019.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/07/2019] [Accepted: 03/17/2019] [Indexed: 11/28/2022]
Abstract
This case report describes the effect of an envenomation by the Beautiful Pit Viper Trimeresurus venustus (or Cryptelytrops venustus), which is a green pit viper native to Thailand and Malaysia. A previously healthy 60-year-old snake breeder with no relevant medical history was bitten by his adult T. venustus in the third finger of his right hand while taking it out of the feeding box. The bite was painful and swelling progressed to include his whole hand within an hour after the bite. He was treated symptomatically with pre-emptive antibiotics and analgesics, never developed any hematological disorders such as coagulopathy and bleeding or disseminated intravascular coagulation and was discharged 26 hours after the bite. The clinical course in our patient matched two other well-documented cases reported to our Poisons Centre, and one further case presented as a conference-poster. All patients recovered with symptomatic therapy and never required antivenom. Therefore, bites by T. venustus seem to present with less severe symptoms compared to other Trimeresurus species.
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Affiliation(s)
- Joan Fuchs
- National Poisons Information Centre, Tox Info Suisse, Associated Institute of the University of Zurich, Zurich, Switzerland.
| | - Karin Bessire
- Centre Hospitalier Universitaire Vaudois, Department of Emergency Medicine, Lausanne, Switzerland
| | - Stefan Weiler
- National Poisons Information Centre, Tox Info Suisse, Associated Institute of the University of Zurich, Zurich, Switzerland
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20
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Retrospective Documentation of a Confirmed White-Lipped Green Pit Viper (Trimeresurus albolabris Gray, 1842) Bite in the South-Central Hills of Nepal. Wilderness Environ Med 2019; 30:79-85. [DOI: 10.1016/j.wem.2018.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 10/29/2018] [Accepted: 11/02/2018] [Indexed: 11/23/2022]
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21
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Zietek BM, Mayar M, Slagboom J, Bruyneel B, Vonk FJ, Somsen GW, Casewell NR, Kool J. Liquid chromatographic nanofractionation with parallel mass spectrometric detection for the screening of plasmin inhibitors and (metallo)proteinases in snake venoms. Anal Bioanal Chem 2018; 410:5751-5763. [PMID: 30090989 PMCID: PMC6096707 DOI: 10.1007/s00216-018-1253-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/22/2018] [Accepted: 07/06/2018] [Indexed: 02/05/2023]
Abstract
To better understand envenoming and to facilitate the development of new therapies for snakebite victims, rapid, sensitive, and robust methods for assessing the toxicity of individual venom proteins are required. Metalloproteinases comprise a major protein family responsible for many aspects of venom-induced haemotoxicity including coagulopathy, one of the most devastating effects of snake envenomation, and is characterized by fibrinogen depletion. Snake venoms are also known to contain anti-fibrinolytic agents with therapeutic potential, which makes them a good source of new plasmin inhibitors. The protease plasmin degrades fibrin clots, and changes in its activity can lead to life-threatening levels of fibrinolysis. Here, we present a methodology for the screening of plasmin inhibitors in snake venoms and the simultaneous assessment of general venom protease activity. Venom is first chromatographically separated followed by column effluent collection onto a 384-well plate using nanofractionation. Via a post-column split, mass spectrometry (MS) analysis of the effluent is performed in parallel. The nanofractionated venoms are exposed to a plasmin bioassay, and the resulting bioassay activity chromatograms are correlated to the MS data. To study observed proteolytic activity of venoms in more detail, venom fractions were exposed to variants of the plasmin bioassay in which the assay mixture was enriched with zinc or calcium ions, or the chelating agents EDTA or 1,10-phenanthroline were added. The plasmin activity screening system was applied to snake venoms and successfully detected compounds exhibiting antiplasmin (anti-fibrinolytic) activities in the venom of Daboia russelii, and metal-dependent proteases in the venom of Crotalus basiliscus. Graphical abstract ᅟ.
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Affiliation(s)
- Barbara M Zietek
- Division of BioAnalytical Chemistry, Amsterdam Institute of Molecules, Medicines and Systems, Vrije Universiteit Amsterdam, de Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Morwarid Mayar
- Division of BioAnalytical Chemistry, Amsterdam Institute of Molecules, Medicines and Systems, Vrije Universiteit Amsterdam, de Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Julien Slagboom
- Division of BioAnalytical Chemistry, Amsterdam Institute of Molecules, Medicines and Systems, Vrije Universiteit Amsterdam, de Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Ben Bruyneel
- Division of BioAnalytical Chemistry, Amsterdam Institute of Molecules, Medicines and Systems, Vrije Universiteit Amsterdam, de Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Freek J Vonk
- Naturalis Biodiversity Center, 2333 CR, Leiden, The Netherlands
| | - Govert W Somsen
- Division of BioAnalytical Chemistry, Amsterdam Institute of Molecules, Medicines and Systems, Vrije Universiteit Amsterdam, de Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Nicholas R Casewell
- Alistair Reid Venom Research Unit, Parasitology Department, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
- Research Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Jeroen Kool
- Division of BioAnalytical Chemistry, Amsterdam Institute of Molecules, Medicines and Systems, Vrije Universiteit Amsterdam, de Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
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22
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Thromboelastographic study of the snakebite-related coagulopathy in Djibouti. Blood Coagul Fibrinolysis 2018; 29:196-204. [PMID: 29369078 DOI: 10.1097/mbc.0000000000000702] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
: Hemostasis disorders are one of the major clinical conditions of snakebites and are because of mechanisms which may disrupt vessels, platelets, clotting factors and fibrinolysis. Thromboelastography (TEG) could help to understand these effects in the clinical practice. A retrospective study reports a series of patients presenting a snakebite-related coagulopathy, treated with antivenom and monitored with conventional tests and TEG in a French military treatment facility (Republic of Djibouti, East Africa) between August 2011 and September 2013. Conventional coagulation assays (platelets, prothrombin time, activated partial thromboplastin time, fibrinogen) and TEG measurements were taken on arrival and at various times during the first 72 h of hospitalization, at the discretion of the physician. The study included 14 patients (median age 28 years). Bleedings were present in five patients. All patients received antivenom. A coagulopathy was present in all patients and was detected by both conventional assays and TEG. None exhibited thrombocytopenia. Prothrombin time and fibrinogen remained abnormal for most of patients during the first 72 h. The TEG profiles of 11 patients (79%) showed incoagulability at admission (R-time > 60 min). TEG distinguished 10 patients with a generalized clotting factor deficiency and 4 patients with an isolated fibrinogen deficiency after an initial profile of incoagulability. Hyperfibrinolysis was evident for 12 patients (86%) after Hour 6. Snake envenomations in Djibouti involve a consumption coagulopathy in conjunction with delayed hyperfibrinolysis. TEG could improve medical management of the condition and assessment of additional therapeutics associated with the antivenom.
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Suen PY. Bamboo snake (Trimeresurus Albolabris) Bite in Hong Kong and its Prognostic Factors for Local Complications with Surgical Intervention, Coagulopathy and Thrombocytopenia. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791702400205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Bamboo snake bite accounts for the majority of venomous snake bites in Hong Kong. The objectives of this study were to evaluate the clinical features and outcomes of Bamboo snake bite in Hong Kong and to identify its prognostic factors for local complications requiring surgical intervention, coagulopathy and thrombocytopenia. Methods It was a retrospective cohort study conducted in a regional hospital of Hong Kong from 1st January 2001 to 31st December 2015. Results Sixty-three subjects were in the final analyses. The mean age was 60 years old. The incidences of swelling, local bruises, blistering, regional lymphadenopathy and local necrosis were 90.5%, 33.3%, 6.3%, 1.6% and 3.2% respectively. The incidences of local complications with surgical intervention, coagulopathy and thrombocytopenia were 6.3%, 13% and 13% respectively. Univariate analysis showed only local necrosis (p=0.003) was significantly associated with local complications with surgical intervention; and only cardiovascular disturbance due to snakebite envenomation (p=0.002) was significantly associated with coagulopathy; and no significantly associated factor was found for thrombocytopenia. There were no case with systemic bleeding and death after Bamboo snake bite. There was no case with allergic reaction after the use of antivenom. Conclusions Local necrosis is significantly associated with surgical intervention. Cardiovascular disturbance is significantly associated with coagulopathy. Allergic reaction after the use of antivenom is rare in Hong Kong.
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Chan KF, Chung CH. A Case of Disseminated Intravascular Coagulopathy Developing Rapidly after a Suspected Bamboo Snakebite. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790601300307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present a case of disseminated intravascular coagulopathy developing rapidly after being bitten by a snake suspected to be Trimeresurus albolabris in a 67-year-old man. The unusually fast onset of coagulation disturbances and the later renal complication should alert emergency physicians that snakebites (including Trimeresurus albolabris) can be devastating if not managed promptly.
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Namal Rathnayaka RMMK, Ranathunga PEAN, Kularatne SAM. Epidemiology and clinical features of Green pit viper (Trimeresurus trigonocephalus) envenoming in Sri Lanka. Toxicon 2017; 137:99-105. [PMID: 28735968 DOI: 10.1016/j.toxicon.2017.07.017] [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] [Received: 04/10/2017] [Revised: 07/13/2017] [Accepted: 07/17/2017] [Indexed: 11/26/2022]
Abstract
Green pit viper is a venomous endemic snake in Sri Lanka. But little is known regarding its envenoming in the country. This study was carried out in order to find out epidemiology and clinical profile of its bites. A series of 17 patients with Sri Lankan Green pit viper (Trimeresurus trigonocephalus) bites was prospectively studied over 4 years. The mean age was 36 ½ years (range 12-61 years) and comprised 14 (82%) males. Except one case, all bites occurred during day time (0600 h-1800 h) due to inadvertent provocation. In 13 cases (76%) bite took place in estates (tea or cinnamon) and 8 patients (47%) were estate workers. The bitten sites were upper limbs in 11 cases (65%) and lower limbs in 6 cases (35%). Ten patients (59%) brought the offending snake to the hospital and one patient was asymptomatic. Sixteen (94%) developed local envenoming features- 16 (94%) local pain and swelling, 6 (35%) local bleeding and lymphadenopathy and blistering in 4 (24%) patients. Systemic envenoming developed in 4 (24%) patients including 3 (18%) with coagulopathy that was treated with fresh frozen plasma. One (6%) patient developed bradycardia. Sri Lankan Green pit viper bites commonly occurs in estates and causes local envenoming frequently and coagulopathy occasionally.
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Affiliation(s)
- R M M K Namal Rathnayaka
- Intensive Care Unit, Provincial General Hospital, Ratnapura, Sri Lanka; Department of Veterinary Pathobiology, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Sri Lanka.
| | | | - S A M Kularatne
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka
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Sontichai W, Reungrongrat S, Narongchai P, Natesirinilkul R. Neurological Involvement and Hepatocellular Injury Caused by a Snake With Hematotoxin Envenomation. Wilderness Environ Med 2015; 26:366-70. [PMID: 25890858 DOI: 10.1016/j.wem.2015.02.006] [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: 07/15/2014] [Revised: 02/11/2015] [Accepted: 02/16/2015] [Indexed: 06/04/2023]
Abstract
Venomous snakes with hematotoxin-Russell's viper (Daboia spp), Malayan pit viper (Calloselasma rhodostoma), and green pit viper (Cryptelytrops albolabris and C macrops, previously named Trimeresurus spp) are commonly found in Thailand. Coagulation factor activation, thrombocytopenia, hyperfibrinolysis, and disseminated intravascular coagulation are the main mechanisms of hemorrhaging from these snake bites. The neurological involvement and hepatocellular injury after Russell's viper bites were reported in Sri Lanka, but there is no report from Southeast Asia. This case was a 12-year-old hill tribe boy who had ptosis and exotropia of the left eye, respiratory distress, and prolonged venous clotting time, prothrombin time, and activated partial thromboplastin time; low fibrinogen and platelet count; and transaminitis after being bitten by a darkish-colored snake. He did not respond to antivenom for cobra, Malayan pit viper, or Russell's viper. However, his neurological abnormalities, respiratory failure, and hepatocellular injury improved, and coagulopathy was finally corrected after receiving antivenom for green pit viper. The unidentified snake with hematotoxin was alleged for all manifestations in this patient.
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Affiliation(s)
| | - Sanit Reungrongrat
- Department of Pediatrics (Drs Sontichai, Reungrongrat, and Natesirinilkul)
| | - Paitoon Narongchai
- Department of Forensic Medicine (Dr Narongchai), Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Aird SD, Aggarwal S, Villar-Briones A, Tin MMY, Terada K, Mikheyev AS. Snake venoms are integrated systems, but abundant venom proteins evolve more rapidly. BMC Genomics 2015; 16:647. [PMID: 26315097 PMCID: PMC4552096 DOI: 10.1186/s12864-015-1832-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 08/07/2015] [Indexed: 12/19/2022] Open
Abstract
Background While many studies have shown that extracellular proteins evolve rapidly, how selection acts on them remains poorly understood. We used snake venoms to understand the interaction between ecology, expression level, and evolutionary rate in secreted protein systems. Venomous snakes employ well-integrated systems of proteins and organic constituents to immobilize prey. Venoms are generally optimized to subdue preferred prey more effectively than non-prey, and many venom protein families manifest positive selection and rapid gene family diversification. Although previous studies have illuminated how individual venom protein families evolve, how selection acts on venoms as integrated systems, is unknown. Results Using next-generation transcriptome sequencing and mass spectrometry, we examined microevolution in two pitvipers, allopatrically separated for at least 1.6 million years, and their hybrids. Transcriptomes of parental species had generally similar compositions in regard to protein families, but for a given protein family, the homologs present and concentrations thereof sometimes differed dramatically. For instance, a phospholipase A2 transcript comprising 73.4 % of the Protobothrops elegans transcriptome, was barely present in the P. flavoviridis transcriptome (<0.05 %). Hybrids produced most proteins found in both parental venoms. Protein evolutionary rates were positively correlated with transcriptomic and proteomic abundances, and the most abundant proteins showed positive selection. This pattern holds with the addition of four other published crotaline transcriptomes, from two more genera, and also for the recently published king cobra genome, suggesting that rapid evolution of abundant proteins may be generally true for snake venoms. Looking more broadly at Protobothrops, we show that rapid evolution of the most abundant components is due to positive selection, suggesting an interplay between abundance and adaptation. Conclusions Given log-scale differences in toxin abundance, which are likely correlated with biosynthetic costs, we hypothesize that as a result of natural selection, snakes optimize return on energetic investment by producing more of venom proteins that increase their fitness. Natural selection then acts on the additive genetic variance of these components, in proportion to their contributions to overall fitness. Adaptive evolution of venoms may occur most rapidly through changes in expression levels that alter fitness contributions, and thus the strength of selection acting on specific secretome components. Electronic supplementary material The online version of this article (doi:10.1186/s12864-015-1832-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Steven D Aird
- Okinawa Institute of Science and Technology Graduate University, Tancha 1919-1, Onna-son, Kunigami-gun, Okinawa-ken, 904-0412, Japan.
| | - Shikha Aggarwal
- Okinawa Institute of Science and Technology Graduate University, Tancha 1919-1, Onna-son, Kunigami-gun, Okinawa-ken, 904-0412, Japan. .,University School of Environment Management, Guru Gobind Singh Indraprastha University, Sector 16C, Dwarka, New Delhi, 110078, India.
| | - Alejandro Villar-Briones
- Okinawa Institute of Science and Technology Graduate University, Tancha 1919-1, Onna-son, Kunigami-gun, Okinawa-ken, 904-0412, Japan.
| | - Mandy Man-Ying Tin
- Okinawa Institute of Science and Technology Graduate University, Tancha 1919-1, Onna-son, Kunigami-gun, Okinawa-ken, 904-0412, Japan.
| | - Kouki Terada
- Okinawa Prefectural Institute of Health and the Environment, Biology and Ecology Group, 2003 Ozato, Ozato, Nanjo-shi, Okinawa, 901-1202, Japan.
| | - Alexander S Mikheyev
- Okinawa Institute of Science and Technology Graduate University, Tancha 1919-1, Onna-son, Kunigami-gun, Okinawa-ken, 904-0412, Japan. .,Research School of Biology, Australian National University, Canberra, ACT 0200, Australia.
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Abstract
Venomous snakebite is considered the single most important cause of human injury from venomous animals worldwide. Coagulopathy is one of the commonest important systemic clinical syndromes and can be complicated by serious and life-threatening haemorrhage. Venom-induced consumption coagulopathy (VICC) is the commonest coagulopathy resulting from snakebite and occurs in envenoming by Viperid snakes, certain elapids, including Australian elapids, and a few Colubrid (rear fang) snakes. Procoagulant toxins activate the clotting pathway, causing a broad range of factor deficiencies depending on the particular procoagulant toxin in the snake venom. Diagnosis and monitoring of coagulopathy is problematic, particularly in resource-poor countries where further research is required to develop more reliable, cheap clotting tests. MEDLINE and EMBASE up to September 2013 were searched to identify clinical studies of snake envenoming with VICC. The UniPort database was searched for coagulant snake toxins. Despite preclinical studies demonstrating antivenom binding toxins (efficacy), there was less evidence to support clinical effectiveness of antivenom for VICC. There were no placebo-controlled trials of antivenom for VICC. There were 25 randomised comparative trials of antivenom for VICC, which compared two different antivenoms (ten studies), three different antivenoms (four), two or three different doses or repeat doses of antivenom (five), heparin treatment and antivenom (five), and intravenous immunoglobulin treatment and antivenom (one). There were 13 studies that compared two groups in which there was no randomisation, including studies with historical controls. There have been numerous observational studies of antivenom in VICC but with no comparison group. Most of the controlled trials were small, did not use the same method for assessing coagulopathy, varied the dose of antivenom, and did not provide complete details of the study design (primary outcomes, randomisation, and allocation concealment). Non-randomised trials including comparison groups without antivenom showed that antivenom was effective for some snakes (e.g., Echis), but not others (e.g., Australasian elapids). Antivenom is the major treatment for VICC, but there is currently little high-quality evidence to support effectiveness. Antivenom is not risk free, and adverse reactions can be quite common and potentially severe. Studies of heparin did not demonstrate it improved outcomes in VICC. Fresh frozen plasma appeared to speed the recovery of coagulopathy and should be considered in bleeding patients.
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Song T, Zhang C, Zhang L, Huang X, Hu C, Xue C, Zhang B. Complete mitochondrial genome of Trimeresurus albolabris (Squamata: Viperidae: Crotalinae). MITOCHONDRIAL DNA 2013; 26:291-2. [PMID: 24047165 DOI: 10.3109/19401736.2013.825780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Trimeresurus albolabris is the most widely distributed species in the genus Trimeresurus and mainly in East and South-East Asia. In this study, we first sequenced and characterized the whole mitochondrial genome of T. albolabris. The total length of the complete mitochondrial genome was 17,220 bp with 13 protein-coding genes, 22 tRNAs, 2 rRNAs and 2 control regions. The overall base composition of T. albolabris was 33.40% A, 27.04% T, 27.28% C, and 12.28% G. Except for ND6 subunit gene and eight tRNA genes which were encoded on the L-stand, all the genes in T. albolabris were distributed on the H-strand.
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Affiliation(s)
- Tao Song
- School of Life Sciences, Anhui University , Hefei, Anhui , P.R. China
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Nuchprayoon I, Pongpan C, Sripaiboonkij N. The role of prednisolone in reducing limb oedema in children bitten by green pit vipers: a randomized, controlled trial. ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 2013; 102:643-9. [DOI: 10.1179/136485908x311786] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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TA-2, a thrombin-like enzyme from the Chinese white-lipped green pitviper (Trimeresurus albolabris): isolation, biochemical and biological characterization. Blood Coagul Fibrinolysis 2013; 23:445-53. [PMID: 22610139 DOI: 10.1097/mbc.0b013e32835496b2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Through three chromatographic steps, a new thrombin-like enzyme (TLE), named TA-2, from the venom of the Chinese white-lipped green pitviper (Trimeresurus albolabris) has been isolated and purified to homogeneity. TA-2 was a single-chain glycoprotein with about 6% sugar, pI 3.9 and a molecular weight of 38.8 kD. Its N-terminal sequence (VVGGDECNIN) showed high sequence conformity with many other TLEs. In vitro, it coagulated bovine fibrinogen (108.6 NIH units/mg) and cleaved the Aα and Bβ chains of bovine fibrinogen-releasing fibrinopeptide A and B, but did not degrade bovine fibrin; displayed high stability at different temperature, pH, and presence of several divalent cations and inhibitors; also exhibited strong activity towards casein (192.3 units/mg) and high esterase activity upon Nα-p-tosyl-L-arginine methyl ester (11 units/mg); and behaved as a promoter to platelet aggregation induced by ADP or collagen. In vivo, TA-2 caused dose-dependent prolongation of bleeding time in mice, but had no hemorrhagic and edema-inducing activities even at high concentrations.
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Pongpit J, Limpawittayakul P, Juntiang J, Akkawat B, Rojnuckarin P. The role of prothrombin time (PT) in evaluating green pit viper (Cryptelytrops sp) bitten patients. Trans R Soc Trop Med Hyg 2012; 106:415-8. [PMID: 22627102 DOI: 10.1016/j.trstmh.2012.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 04/16/2012] [Accepted: 04/16/2012] [Indexed: 12/23/2022] Open
Abstract
Viper bites cause consumptive coagulopathy resulting in hypofibrinogenaemia. Whole-blood clotting time is a standard test used to assess bleeding risk. Prothrombin time (PT) and activated partial thromboplastin time (APTT) are better standardised assays that are widely available, but their diagnostic accuracy in viper bites remains unknown. Adult patients presumed bitten by green pit vipers (Cryptelytops sp.) were enrolled. Conventional venous clotting time (VCT), 20min whole-blood clotting time (20WBCT), PT with international normalized ratio (INR) and APTT were determined. A fibrinogen level below 1.0g/litre was used as the gold standard. There were 97 patients. The average age was 46.1 years and 49.5% were men. VCT >30min, INR >1.2 and fibrinogen level <1.0g/litre were found in 9.3, 10.3 and 7.2%, respectively. The sensitivities of VCT >30min, 20WBCT (N=55), INR and APTT were 57.0%, 85.7%, 85.7% and 57.1%, respectively. The respective specificities were 94.4%, 95.8%, 95.6% and 72.4%. Three hypofibrinogenaemic patients who did not receive antivenom because of VCT <30min had persistently normal VCT and went home without clinical bleeding. In conclusion, PT with INR can be an alternative test for evaluation of coagulopathy in green pit viper bitten patients with potentially improved inter-laboratory standardisation.
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Affiliation(s)
- Jamrus Pongpit
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Rama IV Road, Patumwan, Bangkok 10330, Thailand
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Soogarun S, Sangvanich P, Chowbumroongkait M, Jiemsup S, Wiwanikit V, Pradniwat P, Palasuwan A, Pawinwongchai J, Chanprasert S, Moungkote T. Analysis of green pit viper (Trimeresurus alborabris) venom protein by LC/MS-MS. J Biochem Mol Toxicol 2008; 22:225-9. [DOI: 10.1002/jbt.20232] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Muanpasitporn C, Rojnuckarin P. Expression and characterization of a recombinant fibrinogenolytic serine protease from green pit viper (Trimeresurus albolabris) venom. Toxicon 2007; 49:1083-9. [PMID: 17346761 DOI: 10.1016/j.toxicon.2007.01.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Revised: 01/18/2007] [Accepted: 01/29/2007] [Indexed: 11/26/2022]
Abstract
Viper venom serine proteases (SPs) display several effects on hemostatic system. Molecular cloning showed that Trimeresurus albolabris venom comprised a mixture of five SPs with thrombin-like (2), fibrinogenase (2) and plasminogen-activating (1) activities. Because only few fibrinogenolytic SP sequences were reported, we decided to express albofibrase, a novel fibrinogenase from T. albolabris using Pichia pastoris system. The recombinant active form of enzyme was 30 kDa including 2.2 kDa of glycosylation. Albofibrase showed an alpha fibrinogenase activity. In addition, a plasminogen activating and clotting effect were detectable. Albofibrase prolonged APTT and PT in a time-dependent manner. The effect was neutralized by pre-incubation with equine antivenom to T. albolabris. Therefore, the protein is potentially useful as a new anticoagulant as the antidote is clinically available. Sequence analysis compared with other snake venom fibrinogenases and SPs could not find any unique residues responsible for their various effects. Structure-function relationship should be further studied using mutagenesis in order to explore the mechanisms of venom protease functional diversity.
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Affiliation(s)
- Chuanchom Muanpasitporn
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Patumwan, Bangkok 10330, Thailand
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Rojnuckarin P, Chanthawibun W, Noiphrom J, Pakmanee N, Intragumtornchai T. A randomized, double-blind, placebo-controlled trial of antivenom for local effects of green pit viper bites. Trans R Soc Trop Med Hyg 2006; 100:879-84. [PMID: 16466758 DOI: 10.1016/j.trstmh.2005.10.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2005] [Revised: 10/08/2005] [Accepted: 10/10/2005] [Indexed: 10/25/2022] Open
Abstract
Although systemic administration of antivenom can promptly reverse coagulopathy, efficacy on local effects of viper venom remains to be determined. Currently, there has been no proven specific treatment for snakebite patients with severe local effects. This study is a randomized, double-blind, placebo-controlled trial. Patients bitten by green pit vipers (Trimeresurus albolabris or T. macrops) with marked limb swelling, but no severe coagulopathy requiring antivenom, were randomized to receive either equine F(ab')2 antivenom, or placebo. Twenty-eight cases were included, 14 in each group, and they had their limb circumferences measured on days 1, 2, 4 and 6 after interventions. The percentage reduction in limb circumference was significantly better in the antivenom group compared with the placebo group (ANOVA, P = 0.03), especially in the first 24 h (1.14 vs. 3.62%, in placebo and antivenom group, respectively, P = 0.014). The reduction in pain score was similar. The plasma venom levels were not different at presentation but lower in the antivenom group 24h after intervention (P = 0.033). These data suggest that intravenous antivenom could accelerate local oedema resolution in humans. However, the degree is not clinically significant, and, therefore, general use is not recommended.
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Affiliation(s)
- Ponlapat Rojnuckarin
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Patumwan, Bangkok 10330, Thailand.
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Rojnuckarin P, Muanpasitporn C, Chanhome L, Arpijuntarangkoon J, Intragumtornchai T. Molecular cloning of novel serine proteases and phospholipases A2 from green pit viper (Trimeresurus albolabris) venom gland cDNA library. Toxicon 2005; 47:279-87. [PMID: 16373075 DOI: 10.1016/j.toxicon.2005.11.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2005] [Accepted: 11/01/2005] [Indexed: 11/18/2022]
Abstract
Green pit viper (Trimeresurus albolabris) is the most common venomous snake responsible for bites in Bangkok. It causes local edema and systemic hypofibrinogenemia resulted from the thrombin-like, as well as the fibrinolytic effects of the venom. However, the amino acid sequences of these venom proteins have never been reported. In this study, we have cloned five novel serine proteases from the Thai T. albolabris venom gland cDNA library. They were all closely homologous to the corresponding serine proteases from Chinese green viper (Trimeresurus stejnegeri), suggesting the evolutionary proximity of the two species. In addition, their functional activities could be deduced. There were predicted to be two thrombin-like enzymes (GPV-TL1 and GPV-TL-2), two isoforms of a fibrinogenolytic enzyme (albofibrase) and a plasminogen activator (GPV-PA), suggesting that defibrination syndrome in patients is a combination of these enzymatic effects. By multiple sequence alignment, no conserved residue or motif responsible for distinct functions of snake venom serine proteases could be observed. Moreover, one Lys 49 and one Asn 49 phospholipase A2 (PLA2) genes were cloned. Lys 49 PLA2 was predicted to devoid of catalytic activity, but showed a carboxy terminal cytotoxic region. No Asp 49 PLA2 was found in 150 clones screened. This explains the marked limb edema but no hemolysis in patients. These novel serine proteases have potentials to be therapeutic anti-thrombotic and thrombolytic agents in the future.
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Affiliation(s)
- Ponlapat Rojnuckarin
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Rama IV road, Bangkok 10330, Thailand.
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