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Moutaouakkil Y, el Jaoudi R, Tadlaoui Y, Adouani B, el cadi MA, Serragui S, Cherrah Y, Lamsaouri J, Bousliman Y. Envenimations ophidiennes au Maroc : revue de la littérature. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2018. [DOI: 10.1016/j.toxac.2018.07.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lamb T, de Haro L, Lonati D, Brvar M, Eddleston M. Antivenom for European Vipera species envenoming. Clin Toxicol (Phila) 2017; 55:557-568. [PMID: 28349771 DOI: 10.1080/15563650.2017.1300261] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND European viper bite is relatively uncommon but can cause serious envenoming, particularly swelling and hemorrhage spreading from limb to trunk that can cause long term disability. Systemic features are relatively mild compared to many other venomous species. Moderate-to-severe envenoming requires antivenom, which is given many hundreds of times each year across the continent. Several Vipera spp antivenoms are produced in Europe, but there is little comparative information available for the antivenoms and none is licensed with the European Medicines Agency. We aimed to collect descriptive data on European viper antivenoms and assess their relative effectiveness. METHODS A systematic review of articles relating to antivenom in Europe was performed using the Medline medical database. The following keywords "Europ*" or the individual names of each European country and "antiven*" or "immun*" or "envenom*" and "snake" or "viper*" or "adder" were used. Articles published between 1 January 1996 and 11 March 2016 pertaining to clinical outcome, including case reports, were selected. Referenced articles in the indexed articles were explored for suitability and included if they met any of the criteria: specific antivenom used, route of antivenom administration, adverse reactions to antivenom therapy and length of hospital admission. All accepted abstracts from EAPCCT conferences since 2000 were searched and abstracts relating to Vipera spp envenoming were assessed for suitability. We extracted data on study type, safety and effectiveness. We sought information on antivenoms from manufacturers and individual patient data from authors of publications. Since individual patient data were only rarely available, we compared median length of stay between case series reporting each antivenom. We identified 40 papers and six published abstracts, and one unpublished paper that reported clinical cases and case series of envenomed patients treated with antivenom. No publication reported randomized controlled trials comparing any European Vipera antivenom with either placebo or another antivenom. 25 reports were of retrospective hospital- (n = 13) or poison center-based (n = 12) case series including five or more patients; a further 12 reports were either case reports or case series with less than five patients and one paper was a limited literature review. An additional nine papers reported prospective data; seven collected data remotely through poison service telephone communication with the attending physicians. Antivenoms available in Europe: Eight antivenoms are available for European Vipera spp envenoming; a material safety data sheet providing information on manufacture was available for seven. Six are raised against V. berus or V. ammodytes venom; the seventh is raised against a mixture of V. ammodytes, V. aspis and V. berus venom and the eighth is raised against V. ammodytes, Macrovipera lebetina and Montivipera xanthina venom. Six manufacturers recommended intramuscular administration while two recommended intravenous administration. No randomized control trials comparing the effectiveness of antivenoms were identified. Pre-clinical data: We found two papers presenting comparative preclinical data. Clinical data: Clinical studies were predominantly retrospective and contained clinical data on antivenom used in 2602 patients; where the antivenom was identified (n = 2174), 2061 (94.8%) received Zagreb, ViperFAV or ViperaTAb antivenoms. There were few published data on the other antivenoms. Repeated use of antivenom: Repeat doses were reported in 230/1491 of cases (15.4%) where this information was recorded. Outcome and length of hospital stay: Intravenous administration of antivenom was associated with shorter length of hospital stay (median length of hospital stay in studies of intravenous ViperFAV or ViperaTAb ranged from 1 to 4.8 days versus 2 to 18 days for intramuscular Bulbio or Zagreb antivenoms). Antivenom versus no antivenom: Some small studies demonstrated no difference in the length of hospital stay in patients with equivalent envenomation grading who either did or did not receive antivenom. Adverse events: Adverse reactions were reported in 37 of 2408 cases (1.5%) including seven cases of anaphylaxis. CONCLUSIONS There are very limited pre-clinical comparative data and no randomised controlled trials assessing effectiveness of the antivenoms against different Vipera species. Most descriptive data suggest the efficacy of Zagreb, ViperFAV and ViperaTAb antivenoms by the intravenous route but not intramuscular route, although this is level D evidence. Reported adverse reactions were rare, suggesting that the modern intravenous antivenoms are of good quality. Better and more systematic data, including perhaps randomized controlled trials comparing different antivenoms, are required for the many hundreds of antivenom administrations that occur annually across Europe.
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Affiliation(s)
- Thomas Lamb
- a Department of Pharmacology, Toxicology, and Therapeutics , University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
| | - Luc de Haro
- b Centre Antipoison , Hôpital Sainte Marguerite , Marseilles , France
| | - Davide Lonati
- c Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Istituti Clinici Scientifici Maugeri , IRCCS Maugeri Hospital and University of Pavia , Pavia , Italy
| | - Miran Brvar
- d Centre for Clinical Toxicology and Pharmacology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Michael Eddleston
- a Department of Pharmacology, Toxicology, and Therapeutics , University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
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Reveneau E, Cottin P, Rasuli A. Two decades of pharmacovigilance and clinical experience with highly purified rabies immunoglobulin F(ab') 2 fragments. Expert Rev Vaccines 2016; 16:273-287. [PMID: 27809689 DOI: 10.1080/14760584.2017.1244009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Rabies is a worldwide zoonotic viral disease with no specific treatment once symptoms occur; manifest disease is almost always fatal. WHO recommendations for exposed individuals include immediate attention to the wound and use of rabies immunoglobulin and/or vaccine for post-exposure prophylaxis (PEP). Here, we provide an overview of the clinical experience with a highly purified preparation of F(ab')2 fragments from equine rabies immunoglobulin (F(ab')2 pERIG; FavirabTM) in rabies PEP. Areas covered: Our review comprises a retrospective analysis of adverse event reports in the Sanofi Pasteur global pharmacovigilance database for F(ab')2 pERIG, including adverse event reports from eight Sanofi Pasteur-sponsored clinical trials and post-market surveillance data collected between 1995 and 2014. The general safety profile of F(ab')2 pERIG is discussed, as are the occurrence of rare anaphylactic reactions, and suspected intervention failure. Expert commentary: Over 20 years of clinical development and post-licensure experience has established the safety and effectiveness of F(ab')2 pERIG (FavirabTM) in rabies PEP.
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Estefanía Díez M, Alonso Peña D, García Cano P, López Gamo A. Tratamiento de la mordedura por víbora en España. Semergen 2016; 42:320-6. [DOI: 10.1016/j.semerg.2014.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 07/28/2014] [Accepted: 08/02/2014] [Indexed: 10/24/2022]
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Claudet I, Grouteau E, Cordier L, Franchitto N, Bréhin C. Hyperglycemia is a risk factor for high-grade envenomations after European viper bites (Vipera spp.) in children. Clin Toxicol (Phila) 2015; 54:34-9. [PMID: 26582080 DOI: 10.3109/15563650.2015.1113542] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Hyperglycemia has been described in severe scorpion envenomation, we wanted to analyze if it was applicable to viper bites in children. AIM To describe clinical, biological, and therapeutic characteristics of 83 children bitten by European viper (Vipera spp.) and to confirm that hyperglycemia is a risk factor for high-grade envenomation. MATERIAL AND METHODS A retrospective study was conducted between 2001 and 2014 in the pediatric emergency department of a tertiary level children's hospital. Collected data were: age and sex of children; day and time of admission; day, time and circumstances of the accident; snake identification; bite location; envenomation severity; presence of fang marks; prehospital care; laboratory abnormalities, use of specific immunotherapy, associated treatments; length of stay; hospital course. RESULTS Eighty-three children were included (62 boys, 21 girls). The mean age was 7.4 ± 3.9 years. Bites were most often located on the lower extremities (66%). The classification of envenomation was: 83% low grade (absent or minor envenomation) and 17% high grade (moderate to severe envenomation). All high-grade envenomations received specific immunotherapy (Viperfav(TM), (Aventis Pasteur, MSD, Lyon, France). Being bitten on an upper extremity (odds ratio [OR] 51.1 95% class interval [CI] [6.1-424], p < 0.0001), during the afternoon (OR 13.4 95% CI [1.7-107.9], p = 0.015), feeling violent pain (OR 4.2 95% CI [1.1-16.5], p = 0.023), and high initial plasma glucose level (6.5 ± 1.7 mmol/L versus 5.0 ± 0.9 mmol/L, p = 0.027) were associated with a significant risk of high-grade envenomation. CONCLUSION We have confirmed a potential link between initial hyperglycemia and the risk of progression to high-grade envenomation as well as its association with other published predictive factors.
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Affiliation(s)
- I Claudet
- a Pediatric Emergency Department , Children Hospital , Toulouse , France
| | - E Grouteau
- a Pediatric Emergency Department , Children Hospital , Toulouse , France
| | - L Cordier
- b Regional Poison Centre, CHU Purpan , Toulouse , France
| | - N Franchitto
- b Regional Poison Centre, CHU Purpan , Toulouse , France
| | - C Bréhin
- a Pediatric Emergency Department , Children Hospital , Toulouse , France
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Jollivet V, Hamel JF, de Haro L, Labadie M, Sapori JM, Cordier L, Villa A, Nisse P, Puskarczyk E, Berthelon L, Harry P, Boels D. European viper envenomation recorded by French poison control centers: A clinical assessment and management study. Toxicon 2015; 108:97-103. [PMID: 26454165 DOI: 10.1016/j.toxicon.2015.09.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 08/20/2015] [Accepted: 09/29/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Immunotherapy is the gold standard treatment for patients bitten by European vipers in France; it significantly decreases morbidity, frequency and severity of complications and length of stay. A national prospective study was performed by all Poison Control Centers (PCC) to validate the emergency protocol for viper envenomations. METHODS This prospective study included all cases of viper bites in France, treated or not with Viperfav(®) in 2013. RESULTS In 2013, 277 cases of viper bites were collected: ratio M/F 2.1; mean aged 43 years (<15 years 25% 15-65 63% > 65 12%). The final severity was divided into 68 grades 0, 58 grades I, 62 grades IIA, 71 grades IIB and 18 grades III. One death was reported. Five patients had neurological signs. For the 114 patients who received Viperfav(®), all systemic signs disappeared in 5 h and in 24 h for biological and neurological signs. No severe anaphylactic reaction with Viperfav(®) was reported. Late Viperfav(®) administration increased the risk of functional impairment 15 days after the bite (OR = 3.21 p = 0.043). The administration of Low Molecular Weight Heparin (LMWH) increased the frequency of functional impairment to 15 days after the bite (OR = 6.38 p = 0.064), although Viperfav(®) was given in the first 18 h. DISCUSSION This study confirms the efficiency, safety and recommendation of an early administration of a single dose of Viperfav(®), LMWH should not be used. It also shows the extension of neurotoxic venom of vipers in France.
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Affiliation(s)
- V Jollivet
- Poison Control Center, Angers University Hospital, France
| | - J F Hamel
- Clinical Research Center, Angers University Hospital, France
| | - L de Haro
- Poison Control Center, Marseille University Hospital, France
| | - M Labadie
- Poison Control Center, Bordeaux University Hospital, France
| | - J M Sapori
- Poison Control Center, Lyon University Hospital, France
| | - L Cordier
- Poison Control Center, Toulouse University Hospital, France
| | - A Villa
- Poison Control Center, Paris University Hospital, France
| | - P Nisse
- Poison Control Center, Lille University Hospital, France
| | - E Puskarczyk
- Poison Control Center, Nancy University Hospital, France
| | - L Berthelon
- Poison Control Center, Strasbourg University Hospital, France
| | - P Harry
- Poison Control Center, Angers University Hospital, France
| | - D Boels
- Poison Control Center, Angers University Hospital, France.
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Safety, potential efficacy, and pharmacokinetics of specific polyclonal immunoglobulin F(ab')₂ fragments against avian influenza A (H5N1) in healthy volunteers: a single-centre, randomised, double-blind, placebo-controlled, phase 1 study. THE LANCET. INFECTIOUS DISEASES 2015; 15:285-92. [PMID: 25662592 DOI: 10.1016/s1473-3099(14)71072-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Human infection with the avian influenza A H5N1 virus results in disease with a high fatality rate, against which antiviral treatments have limited efficacy. We aimed to investigate the safety, pharmacokinetics, and therapeutic potential of specific polyclonal immunoglobulin equine F(ab')₂ fragments raised against influenza A/Vietnam/1194/2004 virus (H5N1 subtype) in healthy volunteers. METHODS We did a randomised, double-blind, placebo-controlled, single-centre phase 1 study. In stage 1 (one infusion) and stage 2 (five infusions) of the trial, we randomly assigned healthy male volunteers to receive once-daily intravenous infusions of 0·85 U/kg body weight of F(ab')₂ or once-daily saline placebo. Randomisation was done centrally, with one block of four patients and one block for substitutes (three actives, one placebo) in stage 1, and two blocks of six patients (five actives and one placebo) and the same block for substitutes in stage 2. The primary objective was assessment of the clinical and laboratory safety of F(ab')₂, which was monitored for 22 days in the group that received one dose (assessments on days 0-2, 4, 8, 15, and 22) and 33 days in the group that received five doses (days 0-6, 8, 10, 12, 19, 26, and 33). A final post-study safety assessment was done at 120 days. We also assessed pharmacokinetic outcomes, and assayed haemagglutination and seroneutralisation activity. Analysis was done according to intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT02295813. FINDINGS We enrolled 16 healthy Asian men between Sept 28 and Dec 28, 2012, and randomly assigned 13 to one or five doses of F(ab')₂ and three to placebo. F(ab')₂ was well tolerated, and no deaths or serious adverse events occurred. Three patients had mild adverse events (one each of blepharospasm, sinusitis, and pyrexia). The pyrexia (38°C) was regarded as probably related to the infusion, and resolved after 37 min. Our laboratory assessments of blood and urine samples and physical examinations of heart rate, electrocardiogram readings, and weight showed no clinically significant safety issues. Mean peak plasma concentrations were 19·3 μg/mL (SD 3·5) with the one dose schedule and 23·0 μg/mL (4·5) with the five-dose schedule. F(ab')₂ were still detectable in plasma on average up to 5 days after five doses. Haemagglutination inhibition was only increased after the third dose, but in-vitro seroneutralisation activity was transiently increased after each of the five doses to concentrations regarded as clinically beneficial in infected patients. INTERPRETATION F(ab')₂ showed good safety, tolerability, and therapeutic potential for managing of H5N1 exposed patients. FUNDING Fab'entech.
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Martín C, Nogué S. Novedades en el envenenamiento por mordedura de víbora. Med Clin (Barc) 2015; 144:132-6. [DOI: 10.1016/j.medcli.2014.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 06/06/2014] [Accepted: 06/12/2014] [Indexed: 10/24/2022]
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Chabli H, Arib S, Mouafak Y, Younous S. [Epidemiological profile of snake bites in a pediatric intensive care unit at the Children's Hospital of Marrakech, Morocco]. Arch Pediatr 2014; 21:1293-8. [PMID: 25449443 DOI: 10.1016/j.arcped.2014.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 07/31/2014] [Accepted: 09/22/2014] [Indexed: 10/24/2022]
Abstract
Snake bites are a serious medical emergency. They are most commonly associated with substantial morbidity and mortality in many parts of the world. This study aimed to determine the epidemiological profile of snake bites, as well as their severity and treatment in children in the Marrakech pediatric intensive care unit. The clinicobiological picture, physiopathology, the toxicokinetics of the venom, and the risk factors are discussed. Treatment of confirmed envenomation is based on antivenom administration via the venous route as soon as possible after the bite. Its efficacy and tolerance have been established by several studies. In our context, no specific immunotherapy is available, and the management of snake bites is based on symptomatic measures. Hence, the local health institutions must ensure the availability of antivenom specific to the Moroccan snake species, the only proven specific therapy against snake bite envenomation. The administration of highly purified immunoglobulin appears to improve the prognosis of envenomation, reduce morbidity and mortality, and reduce the length of the hospital stay.
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Affiliation(s)
- H Chabli
- Service de réanimation pédiatrique, hôpital Mère-enfant, CHU Mohammed VI, Marrakech 40000, Maroc.
| | - S Arib
- Service de réanimation pédiatrique, hôpital Mère-enfant, CHU Mohammed VI, Marrakech 40000, Maroc
| | - Y Mouafak
- Service de réanimation pédiatrique, hôpital Mère-enfant, CHU Mohammed VI, Marrakech 40000, Maroc
| | - S Younous
- Service de réanimation pédiatrique, hôpital Mère-enfant, CHU Mohammed VI, Marrakech 40000, Maroc
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Envenimation par morsure de vipère en Provence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0464-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Herbreteau CH, Jacquot F, Rith S, Vacher L, Nguyen L, Carbonnelle C, Lotteau V, Jolivet M, Raoul H, Buchy P, Saluzzo JF. Specific polyclonal F(ab')2 neutralize a large panel of highly pathogenic avian influenza A viruses (H5N1) and control infection in mice. Immunotherapy 2014; 6:699-708. [PMID: 24673720 DOI: 10.2217/imt.14.40] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
AIM There is still no specific therapy for infection with the highly pathogenic avian influenza A virus (HPAI) H5N1, which caused 39 human cases with a 64% fatality rate in 2013. MATERIALS & METHODS We prepared highly purified specific equine polyclonal immunoglobulin fragments (F(ab')2) against H5N1 and tested them for efficacy in vitro and with different administration schedules in H5N1-challenged BALB/c mice. RESULTS in vitro, F(ab')2 neutralized 21 different H5N1 strains from different areas, representative of 11 different clades and sub-clades and 9 years of evolution of the virus. In vivo mouse experiments identified that the most efficient administration protocol consists of five consecutive daily injections after infection; 10 mg/kg giving a 60% increase in survival. CONCLUSION These data demonstrate the ability of anti-H5N1 F(ab')2 to markedly reduce the mortality and morbidity associated with infection of mice with HPAI H5N1 virus, and their potential for human therapy.
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León G, Herrera M, Segura Á, Villalta M, Vargas M, Gutiérrez JM. Pathogenic mechanisms underlying adverse reactions induced by intravenous administration of snake antivenoms. Toxicon 2013; 76:63-76. [PMID: 24055551 DOI: 10.1016/j.toxicon.2013.09.010] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 09/01/2013] [Accepted: 09/11/2013] [Indexed: 11/28/2022]
Abstract
Snake antivenoms are formulations of immunoglobulins, or immunoglobulin fragments, purified from the plasma of animals immunized with snake venoms. Their therapeutic success lies in their ability to mitigate the progress of toxic effects induced by snake venom components, when administered intravenously. However, due to diverse factors, such as deficient manufacturing practices, physicochemical characteristics of formulations, or inherent properties of heterologous immunoglobulins, antivenoms can induce undesirable adverse reactions. Based on the time lapse between antivenom administration and the onset of clinical manifestations, the World Health Organization has classified these adverse reactions as: 1 - Early reactions, if they occur within the first hours after antivenom infusion, or 2 - late reactions, when occurring between 5 and 20 days after treatment. While all late reactions are mediated by IgM or IgG antibodies raised in the patient against antivenom proteins, and the consequent formation of immune complexes, several mechanisms may be responsible for the early reactions, such as pyrogenic reactions, IgE-mediated reactions, or non IgE-mediated reactions. This work reviews the hypotheses that have been proposed to explain the mechanisms involved in these adverse reactions to antivenoms. The understanding of these pathogenic mechanisms is necessary for the development of safer products and for the improvement of snakebite envenomation treatment.
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Affiliation(s)
- Guillermo León
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica.
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Guillot P, Bedock B, Poyet F, Szymezak P, Jinkine O, Alassan E. Morsures, griffures et envenimations. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/s1959-5182(12)58701-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Viper bites and subsequent evolution to severe envenomations are more frequent in children. AIM The aims of this study were to describe the clinical, biological, and therapeutic characteristics of children bitten by vipers in France and to identify risk factors associated with severe envenomations. METHODS A retrospective study was conducted between 2001 and 2009 in the pediatric emergency department of a tertiary-level children hospital. Collected data were age and sex of children; day and time of admission; day, time, and circumstances of the accident; snake identification; bite location; envenomation severity; presence of fang marks; prehospital care; use of specific immunotherapy and associated treatments; length of stay; and hospital course. RESULTS Fifty-eight children were included (43 boys, 15 girls). The mean age was 7.8 ± 4.1 years. Bites were most often located on the lower extremities (77%). The classification of envenomation was: 83% low grade (absence or minor envenomation) and 17% high-grade (moderate to severe envenomations). All high-grade envenomations received specific immunotherapy (Viperfav). Being bitten on an upper extremity (P < 0.001), during the afternoon (P = 0.025), feeling violent pain (P = 0.037), and high initial glucose level (P = 0.016) were associated with a significant risk of high-grade envenomation. In the multivariate analysis, 3 factors remained significant: upper-extremity location (relative risk [RR], 60.5 [3.5-1040]; P = 0.005), immediate violent pain (RR, 21.5 [1.3-364.5]; P = 0.03), and female sex (RR, 17.5 [0.9-320.3]; P = 0.053). CONCLUSIONS A certain number of criteria seem related to more significant risk of progression to high-grade envenomation. Bites to the upper extremities should be carefully observed because of the risk of evolution to a high-grade envenomation.
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Kurtović T, Leonardi A, Lang Balija M, Brgles M, Habjanec L, Križaj I, Halassy B. The standard mouse assay of anti-venom quality does not measure antibodies neutralising the haemorrhagic activity of Vipera ammodytes venom. Toxicon 2012; 59:709-17. [DOI: 10.1016/j.toxicon.2012.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 02/21/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
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Larréché S, Mion G, Mornand P, Imbert P. [Adder bites in France]. Arch Pediatr 2012; 19:660-2. [PMID: 22555073 DOI: 10.1016/j.arcped.2012.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 03/06/2012] [Accepted: 03/26/2012] [Indexed: 11/25/2022]
Abstract
Snake bites are a major public health problem in the tropics but they have a low incidence in Europe and are responsible for few deaths each year. The incidence is higher in children than in adults but no difference in severity seems to be observed between children and adults. In France, snake envenomations are due mainly to Vipera aspis and Vipera berus. The clinical presentation is usually limited to a local syndrome with pain and local inflammatory edema, but systemic signs occur in 17% of cases. Clinical grading published by the Institut Pasteur in Paris helps to assess the severity of envenomation and to decide the use of antivenom. Every bitten patient must be transferred in a hospital for medical assessment. Specific treatment is based on antivenom immunotherapy. However, other medical and surgical treatments have limited value.
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Affiliation(s)
- S Larréché
- Service de biologie médicale, HIA Bégin, 69, avenue de Paris, 94163 Saint-Mandé, France
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Boels D, Hamel JF, Bretaudeau Deguigne M, Harry P. European viper envenomings: Assessment of Viperfav™ and other symptomatic treatments. Clin Toxicol (Phila) 2012; 50:189-96. [PMID: 22372786 DOI: 10.3109/15563650.2012.660695] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED The treatment of European viper envenomings is based on IV antivenom infusions. Viperfav™ contains purified F(ab')(2) fragments of equine antibodies, and a 4 ml vial can neutralize 500-1000 mouse LD50 of Vipera aspis, V. ammodytes and V. berus venoms and is known to be safe and efficient. Assessments of Viperfav™ (dosage and timing of infusions) and of symptomatic treatments such as low-molecular-weight heparin (LWHM), corticosteroids and the routine use of antibiotic therapy have not as yet been reported. OBJECTIVES The objective was to compare the efficacy and safety of Viperfav™ as a function of the time to infusion and to assess other symptomatic treatments given for European viper bites such as antibiotics, corticosteroids and LWMH. METHODS A prospective case review study of viper envenomings treated with Viperfav™ was compiled by the Angers Poisons Centre. The endpoints chosen were as follows: duration of hospital stay, complications (haematoma, infection) and persistent functional discomfort on day 15. Statistical studies were based on multivariate data analysis (MVA). RESULTS 268 moderate or severe envenomings (Grades II and III) recorded in adults and children between 1999 and 2009 were included in the study. A time to the Viperfav™ infusion < 10 h after the bite (179 patients vs. 72) significantly reduced the incidence of haematomas (OR 2.3; p < 0.006), functional discomfort (OR 3.7; p < 10 - 4) and length of hospital stay (OR 2.1; p < 0.03). Multiple doses of Viperfav™ (2 or 3 vials in 22 patients vs. 246 treated with 1 vial) did not improve the selected endpoints. Routine antibiotic therapy was prescribed in 102 patients (vs. 166 patients without) and no significant difference was seen with respect to the endpoints. Moreover, no local or systemic infections were recorded in the non-antibiotic group. Corticosteroids were prescribed in 36 patients (vs. 232 without) but they did not significantly improve the endpoints or oedema. LMWH in 32 patients (vs. 236 without) increased the length of hospital stay (OR 3.2; p < 0.009 and the level of significantly persistent functional discomfort at day 15 (OR 3.7; p < 0.003). CONCLUSIONS A single infusion of Viperfav™ (one vial) was effective whatever the grade of envenomation, and multiple doses did not improve the outcome. Viperfav™ was most effective when given soon (< 10 h) after envenoming. The routine use of antibiotic therapy was not necessary. Corticosteroids did not improve the endpoints selected, and we do not recommend the use of LMWH as this increased persistent functional discomfort and the length of hospital stay.
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Affiliation(s)
- David Boels
- University Hospital, Poisons and Toxicovigilance Centre, Angers, France.
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Management of snakebites in France. Toxicon 2012; 60:712-8. [PMID: 22465493 DOI: 10.1016/j.toxicon.2012.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 02/29/2012] [Accepted: 03/13/2012] [Indexed: 11/20/2022]
Abstract
Although not a major health problem in Europe, snakebite in the old continent was the focus of recent studies to evaluate their overall incidence and define management techniques. The purpose of this three-part report is to present the experience of the Marseille Poison Centre with snakebite in France. The first section deals with viper envenomation that now benefits from a validated therapeutic protocol using of purified antivenom of proven efficacy and tolerance in patients showing grade 2 and 3 symptoms. The second section describes the highly variable snakebite situation in French overseas territories that include areas where local species require specialized management, e.g. Martinique and French Guiana. The third section involves the emerging problems associated with the keeping of exotic snakes as pets with problems related to the use of antivenoms from foreign countries. The exotic-snake pets fashion was at the origin of the creation of a national antivenom bank by two French poison centers (Angers and Marseille) to ensure prompt delivery of antivenoms for exotic snake envenomation anywhere in mainland France.
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Morsures de vipères chez l’enfant. Arch Pediatr 2011; 18:1278-83. [DOI: 10.1016/j.arcped.2011.08.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/23/2011] [Accepted: 08/26/2011] [Indexed: 11/18/2022]
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Chippaux JP. Epidemiology of snakebites in Europe: a systematic review of the literature. Toxicon 2011; 59:86-99. [PMID: 22056768 DOI: 10.1016/j.toxicon.2011.10.008] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 10/07/2011] [Accepted: 10/11/2011] [Indexed: 11/19/2022]
Abstract
Snakebites are rare medical emergency cases in Europe but may sometimes be severe and lead to complications. A better knowledge of snakebite epidemiology may help health authorities to better understand therapeutic requirements, especially concerning antivenoms, and thus improve treatment of snakebite. An extensive literature search for studies and articles published between 1970 and 2010 was performed. Both indexed and non-indexed articles were examined, the analysis of which took into account the heterogeneity between the studies and weighted the studies according to size of the study population covered. Most of the articles involved hospitalized patients who represented more than 90% of snakebites. Incidence, mortality and population at risk were estimated after stratification into three regions (northern, central and southern Europe) based both on viper species distribution and climatic characteristics. There was no significant variation in incidence from the north to the south of Europe. In the whole of Europe, including European Russia and Turkey, the annual number of snakebite cases was estimated at 7992 [CI 95% = 6860-9178] bites, out of which approximately 15% were considered severe (grade 3). These bites usually occurred between May and September, with a more dispersed distribution in southern Europe. The average number of deaths per annum was 4 [0.7-7.7]. Children and male victims are more affected, contrary to what one would expect given their respective proportion in the entire population. Both upper and lower limb bites were recorded at an equal frequency while the bites in other parts of the body were very rare. Immunotherapy was prescribed in one out of three snakebites in Europe, with a very high geographical variability, in spite of excellent tolerance, at least considering highly-purified immunoglobulin fragments. Snakebites are uncommon in Europe but can cause life-threatening envenomation. Fragments of highly-purified immunoglobulins are now very well tolerated and dramatically reduce both severity and mortality of snakebites when used in treatment.
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Affiliation(s)
- Jean-Philippe Chippaux
- Institut de Recherche pour le Développement, UMR 216, Mother and Child Facing Tropical Diseases, 08 BP 841 Cotonou, Bénin.
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Guiavarch M, Médus M, Tichadou L, Glaizal M, de Haro L. [Uneven efficacy of Viperfav® antivenom for the treatment of neurotoxic viper envenomations]. Presse Med 2011; 40:654-6. [PMID: 21397446 DOI: 10.1016/j.lpm.2011.01.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 01/18/2011] [Accepted: 01/23/2011] [Indexed: 11/19/2022] Open
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Methodology of clinical studies dealing with the treatment of envenomation. Toxicon 2010; 55:1195-212. [DOI: 10.1016/j.toxicon.2010.02.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Revised: 02/05/2010] [Accepted: 02/18/2010] [Indexed: 01/22/2023]
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Vipera berus bites in the Region of Southwest Poland--a clinical analysis of 26 cases. Wilderness Environ Med 2010; 21:114-9. [PMID: 20591372 DOI: 10.1016/j.wem.2010.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Vipera berus is the only naturally occurring venomous snake in Poland. Its venom is primarily vasculotoxic and evokes both local and systemic findings. The aim of the study was to review a series of clinical cases of V berus bites occurring in southwest Poland. METHODS The charts of 26 patients (age range, 16-66 years; mean, 42 years) hospitalized with V berus bites were retrospectively analyzed using a data collection tool. Demographic and clinical data were extracted. RESULTS The most common local findings of envenomation were edema of the bitten limb with associated extravasations observed in 24 (92.3%) patients, but in only 1 (3.8%) case did the edema spread to the trunk. In 22 (84.6%) cases edema disappeared within 2 weeks after the bite. Systemic disturbances observed in the patients were: shock (1 case), mild transient hypotension (1 case), prolonged hypotension (3 cases), bronchospasm and laryngeal edema (1 case), diarrhea (1 case), transient supraventricular arrhythmias (2 cases), neutrophilic hyperleukocytosis (2 cases), and thrombocytopenia below 50000 cells/microL (5 cases). In 16 patients (61.5%) the envenomation was classified as moderate and this type was predominant. Six cases were classified as severe. No fatal case was reported. Treatment included the administration of specific antivenom in 14 cases (in all severe and half of moderate cases) and symptomatic treatment applied in all cases. CONCLUSIONS Moderate envenomation prevailed among the patients analyzed in the study. Antivenom treatment is primarily necessary in cases of severe (grade 3) and in some cases of moderate (grade 2) envenomation, especially in patients with persistent or recurring hypotension.
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Asp Viper (Vipera aspis) envenomation: experience of the Marseille Poison Centre from 1996 to 2008. Toxins (Basel) 2009; 1:100-12. [PMID: 22069534 PMCID: PMC3202779 DOI: 10.3390/toxins1020100] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Revised: 11/18/2009] [Accepted: 11/23/2009] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED A retrospective case review study of viper envenomations collected by the Marseille's Poison Centre between 1996 and 2008 was performed. RESULTS 174 cases were studied (52 grade 1 = G1, 90 G2 and 32 G3). G1 patients received symptomatic treatments (average hospital stay 0.96 day). One hundred and six (106) of the G2/G3 patients were treated with the antivenom Viperfav* (2.1+/-0.9 days in hospital), while 15 of them received symptomatic treatments only (plus one immediate death) (8.1+/-4 days in hospital, 2 of them died). The hospital stay was significantly reduced in the antivenom treated group (p < 0.001), and none of the 106 antivenom treated patients had immediate (anaphylaxis) or delayed (serum sickness) allergic reactions. CONCLUSION Viperfav* antivenom was safe and effective for treating asp viper venom-induced toxicity.
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Mahjoub Y, Hijazi M, Airapetian N, Tinturier F, Dupont H. [Shock after native snakebite in France]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:811-2. [PMID: 19647978 DOI: 10.1016/j.annfar.2009.07.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Envenimation cobraïque en France métropolitaine : repenser la prise en charge des envenimations exotiques. ACTA ACUST UNITED AC 2008; 27:323-5. [DOI: 10.1016/j.annfar.2007.10.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Accepted: 10/23/2007] [Indexed: 11/18/2022]
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Affiliation(s)
- G Re
- Department of Emergency Medicine, Policlinico S Orsola, Bologna, Italy
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Rivière G, Bon C. Immunothérapie antivenimeuse des envenimations ophidiennes: vers une approche rationnelle d'un traitement empirique. ACTA ACUST UNITED AC 1999. [DOI: 10.1016/s0924-4204(99)80032-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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