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Immunoprofiling of Equine Plasma against Deinagkistrodon acutus in Taiwan: Key to Understanding Differential Neutralization Potency in Immunized Horses. Trop Med Infect Dis 2023; 8:tropicalmed8010051. [PMID: 36668958 PMCID: PMC9866385 DOI: 10.3390/tropicalmed8010051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 01/12/2023] Open
Abstract
Snakebite envenoming is a public health issue linked to high mortality and morbidity rates worldwide. Although antivenom has been the mainstay treatment for envenomed victims receiving medical care, the diverse therapeutic efficacy of the produced antivenom is a major limitation. Deinagkistrodon acutus is a venomous snake that poses significant concern of risks to human life in Taiwan, and successful production of antivenom against D. acutus envenoming remains a considerable challenge. Among groups of horses subjected to immunization schedules, few or none subsequently meet the quality required for further scale-up harvesting. The determinants underlying the variable immune responses of horses to D. acutus venom are currently unknown. In this study, we assessed the immunoprofiles of high-potency and low-potency horse plasma against D. acutus venom and explored the conspicuous differences between these two groups. Based on the results of liquid chromatography with tandem mass spectrometry (LC-MS/MS), acutolysin A was identified as the major component of venom proteins that immunoreacted differentially with the two plasma samples. Our findings indicate underlying differences in antivenoms with variable neutralization efficacies, and may provide valuable insights for improvement of antivenom production in the future.
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Lin JH, Sung WC, Mu HW, Hung DZ. Local Cytotoxic Effects in Cobra Envenoming: A Pilot Study. Toxins (Basel) 2022; 14:toxins14020122. [PMID: 35202149 PMCID: PMC8877591 DOI: 10.3390/toxins14020122] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/24/2022] [Accepted: 02/05/2022] [Indexed: 01/31/2023] Open
Abstract
The cobra (genus Naja (N.)) is one of the most common venomous snakes. Due to its frequency and deadly complications of muscle paralysis, local necrosis, and chronic musculoskeletal disability, it should not be ignored. The pathology of devastating tissue destruction, even though specific antivenoms exist, is not fully clear. Here, we attempted to dig in envenomed tissues to study the clinical toxicology of cobra venom. Four cases of N. atra snake envenomation, in which the subjects developed advanced tissue injury, were involved in this study. We used enzyme-ligand sandwich immunoassay (ELISA) to assay the whole venom, cytotoxin A3 and short-chain neurotoxin (sNTX) in blood, bullae, wound discharge, and debrided tissue. We found that persistently high concentrations of venom and toxins, especially cytotoxin A3, were detected in bullae, wound discharge fluid and necrotic tissue of these patients even after large doses of specific antivenom treatment, and wide excision and advanced debridement could largely remove these toxins, lessen the size of necrosis, and promote wound healing. We also found that the point-of-care apparatus, ICT-Cobra kit, might be used to promptly monitor the wound condition and as one of the indicators of surgical intervention in cases of cobra envenomation in Taiwan.
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Affiliation(s)
- Jing-Hua Lin
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan; (J.-H.L.); (H.-W.M.)
| | - Wang-Chou Sung
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli 35053, Taiwan;
| | - Han-Wei Mu
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan; (J.-H.L.); (H.-W.M.)
| | - Dong-Zong Hung
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan; (J.-H.L.); (H.-W.M.)
- Correspondence: ; Tel.: +886-4-2205-2121
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Development of Antibody Detection ELISA Based on Immunoreactive Toxins and Toxin-Derived Peptides to Evaluate the Neutralization Potency of Equine Plasma against Naja atra in Taiwan. Toxins (Basel) 2021; 13:toxins13110818. [PMID: 34822602 PMCID: PMC8622849 DOI: 10.3390/toxins13110818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022] Open
Abstract
Naja atra, also known as Taiwanese cobra, is one of the most prevalent venomous snakes in Taiwan. Clinically, freeze-dried neurotoxic antivenom (FNAV) produced from horses by Taiwan Centers for Disease Control (CDC) has been the only approved treatment for N. atra envenoming for the last few decades. During antivenom production, large numbers of mice are used in the in vivo assay to determine whether the neutralization potency of hyperimmunized equines is satisfactory for large-scale harvesting. However, this in vivo assay is extremely laborious, expensive, and significantly impairs animal welfare. In the present study, we aimed to develop an in vitro ELISA-based system that could serve as an alternative assay to evaluate the neutralization potency of plasma from hyperimmunized equines. We initially obtained 51 plasma samples with known (high or low) neutralization potency assessed in vivo from 9 hyperimmunized equines and subsequently determined their antibody titers against the five major protein components of N. atra venom (neurotoxin (NTX), phospholipase A2 (PLA2), cytotoxin (CTX), cysteine-rich secretory protein (CRISP), and snake venom metalloproteinase (SVMP)) via ELISA. The antibody titer against NTX was the most effective in discriminating between high and low potency plasma samples. To identify the specific epitope(s) of NTX recognized by neutralization potency-related antibodies, 17 consecutive NTX-derived pentadecapeptides were synthesized and used as antigens to probe the 51 equine plasma samples. Among the 17 peptides, immunoreactive signals for three consecutive peptides (NTX1-8, NTX1-9, and NTX1-10) were significantly higher in the high potency relative to low potency equine plasma groups (p < 0.0001). Our ELISA system based on NTX1-10 peptide (RWRDHRGYRTERGCG) encompassing residues 28–42 of NTX displayed optimal sensitivity (96.88%) and specificity (89.47%) for differentiating between high- and low-potency plasma samples (area under the receiver operating characteristic curve (AUC) = 0.95). The collective data clearly indicate that the antibody titer against NTX protein or derived peptides can be used to efficiently discriminate between high and low neutralization potency of plasma samples from venom-immunized horses. This newly developed antibody detection ELISA based on NTX or its peptide derivatives has good potential to complement or replace the in vivo rodent assay for determining whether the neutralization potency of equine plasma is satisfactory for large-scale harvesting in the antivenom production process against N. atra.
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Sadeghi M, Barazandeh M, Zakariaei Z, Davoodi L, Tabaripour R, Fakhar M, Zakariaei A. Massive cutaneous complications due to snakebite: A case report and literature review. Clin Case Rep 2021; 9:e04129. [PMID: 34026167 PMCID: PMC8123543 DOI: 10.1002/ccr3.4129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 12/03/2022] Open
Abstract
Wound infections due to snake bites such as cellulitis and necrotizing fasciitis, although not common, are seen in snake bites and if left untreated can cause serious complications.
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Affiliation(s)
- Mahdieh Sadeghi
- Student Research CommitteeMazandaran University of Medical SciencesSariIran
| | - Maryam Barazandeh
- Student Research CommitteeMazandaran University of Medical SciencesSariIran
| | - Zakaria Zakariaei
- Toxicology and Forensic Medicine DivisionOrthopedic Research CenterImam Khomeini HospitalMazandaran University of Medical SciencesSariIran
- Toxoplasmosis Research CenterCommunicable Diseases InstituteIranian National Registry Center for Lophomoniasis and ToxoplasmosisMazandaran University of Medical SciencesSariIran
| | - Lotfollah Davoodi
- Antimicrobial Resistance Research CenterCommunicable Diseases InstituteMazandaran University of Medical SciencesSariIran
| | - Rabeeh Tabaripour
- Toxoplasmosis Research CenterCommunicable Diseases InstituteIranian National Registry Center for Lophomoniasis and ToxoplasmosisMazandaran University of Medical SciencesSariIran
| | - Mahdi Fakhar
- Toxoplasmosis Research CenterCommunicable Diseases InstituteIranian National Registry Center for Lophomoniasis and ToxoplasmosisMazandaran University of Medical SciencesSariIran
| | - Ashkan Zakariaei
- Student Research CommitteeMazandaran University of Medical SciencesSariIran
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Snakebite envenomings in the Republic of Korea from the 1970s to the 2020s: A review. Toxicon 2021; 196:8-18. [PMID: 33781797 DOI: 10.1016/j.toxicon.2021.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/22/2021] [Accepted: 03/22/2021] [Indexed: 11/23/2022]
Abstract
Snakebite envenomings remain a neglected disease across the globe causing severe injuries and death. An understanding of regional snakebite patterns is a necessary prerequisite for public health programs aimed at reducing snakebite risks. However, such regional knowledge is poorly documented or lacking in many countries where the risk of snakebite envenomings receive little medical attention, and the Republic of Korea is one of these countries. Here, we reviewed the literature on snakebites published between 1970 and 2020 as well as public healthcare data recorded between 2010 and 2019 to determine the patterns of snakebite envenomings in the Republic of Korea. Our results, based on literature data, show Gangwon province as a hotspot of snakebite occurrences and identify middle-aged males living in rural areas as the demographic group at highest risk of venomous snakebites. We also highlight major limitations for further understanding snakebite patterns in the country, most notably the lack of proper species identification for snakes and conflicting patterns of envenomings revealed by different sources of data. Our study provides baseline information on venomous snakebites occurring in the Republic of Korea, thereby filling a gap in the knowledge of snakebite trends in the country.
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Ho CH, Ismail AK, Liu SH, Tzeng YS, Li LY, Pai FC, Hong CW, Mao YC, Chiang LC, Lin CS, Tsai SH. The role of a point-of-care ultrasound protocol in facilitating clinical decisions for snakebite envenomation in Taiwan: a pilot study. Clin Toxicol (Phila) 2021; 59:794-800. [PMID: 33605805 DOI: 10.1080/15563650.2021.1881535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The incidence of acute compartment syndrome (ACS) following snakebite envenomation may be seriously overestimated in Taiwan. Snakebite-induced ACS is difficult to determine solely by clinical examination. Snakebite patients previously underwent surgical intervention based on speculation and general clinical examinations suggesting ACS presentations instead of direct intracompartmental pressure (IP) measurement prior to fasciotomy. Point-of-care ultrasound (POCUS) is a relatively widely available noninvasive tool. This study aimed to evaluate snakebite-envenomated patients for the presence of subcutaneous edema and diastolic retrograde arterial flow (DRAF). MATERIALS AND METHODS Snakebite patients were prospectively recruited between 2017 and 2019. All patients were examined with POCUS to locate edema and directly visualize and measure the arterial flow in the compressed artery. The presence of DRAF in the compressed artery is suggestive of ACS development because when compartment space restriction occurs, increased retrograde arterial flow is observed in the artery. RESULTS Twenty-seven snakebite patients were analyzed. Seventeen patients (63%) were bitten by Crotalinae snakes, seven (26%) by Colubridae, one (4%) by Elapidae, and two (7%) had unidentified snakebites. All Crotalinae bit patients received antivenom, had subcutaneous edema and lacked DRAF in a POCUS examination series. DISCUSSION POCUS facilitates clinical decisions for snakebite envenomation. We also highlighted that the anatomic site of the snakebite is an important factor affecting the prognosis of the wounds. There were limitations of this study, including a small number of patients and no comparison with the generally accepted invasive evaluation for ACS. CONCLUSIONS We are unable to state that POCUS is a valid surrogate measurement of ACS from this study but see this as a starting point to develop further research in this area. Further study will be needed to better define the utility of POCUS in patients envenomated by snakes throughout the world.
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Affiliation(s)
- Cheng-Hsuan Ho
- Department of Emergency Medicine, Tri-Service General Hospital, Taipei, Taiwan.,National Taiwan University College of Medicine, Graduate Institute of Toxicology, Taipei, Taiwan
| | - Ahmad Khaldun Ismail
- Emergency Medicine, Jalan Yaacob Latif, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Shing-Hwa Liu
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yuan-Sheng Tzeng
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ling-Yuan Li
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Feng-Cheng Pai
- Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Wei Hong
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yan-Chiao Mao
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Liao-Chun Chiang
- College of Life Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Chin-Sheng Lin
- Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Division of Cardiology, Department of Internal Medicine, Taipei, Taiwan
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Huang CC, Lai YS, Wang CH, Chau LK, Chen W. Label-free SERS characterization of snake venoms by exploring the cysteine environs with bone-shaped gold nanoparticles. J Mater Chem B 2020; 8:10744-10753. [PMID: 33237068 DOI: 10.1039/d0tb02443k] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Identification of snake venoms is a vital step in the treatment of fatal snakebites. In this study, we use the gold-thiolate interaction between a cysteine residue and gold nanoparticles to establish a SERS method for the differentiation of the venoms of Trimeresurus stejnegeri and Bungarus multicinctus. We confirm the preference of gold nanoparticles over silver for the SERS study of snake venoms by a binding experiment that also functions to differentiate the two venom samples by colorimetry and UV-vis spectroscopy. We report the SERS spectra of Trimeresurus stejnegeri and Bungarus multicinctus venoms for the first time. The spectra display distinct SERS signatures of the snake venoms on bone-shaped gold nanoparticles made with a house recipe. These signatures correlate to selected segments of the venom proteins due to the anchoring effect of the gold-cysteine bond. The method is quick as it accomplishes in situ isolation of the structure of interest to avoid tedious purification of the samples. The location of the interactive cysteine residue makes a novel characteristic of proteins in general.
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Affiliation(s)
- Chia-Chi Huang
- Department of Applied Chemistry, National Chiayi University, 300 Syuefu Road, Chiayi City 60004, Taiwan.
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Huang TI, Hsieh CL. Effect of Traditional Chinese Medicine on Long-Term Outcomes of Snakebite in Taiwan. Toxins (Basel) 2020; 12:E132. [PMID: 32093388 PMCID: PMC7076781 DOI: 10.3390/toxins12020132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 11/16/2022] Open
Abstract
Herein, we review the characteristics of the six predominant venomous snakes in Taiwan and the effects of traditional Chinese medicine on the long-term outcomes of snakebite venom. We electronically searched databases, including PubMed, ClinicalKey, China National Knowledge Infrastructure, National Digital Library of Theses and Dissertations in Taiwan, and Airiti Library, from their inception to November 2019 by using the following Medical Subject Headings' keywords: snakebite, long-term, chronic, Chinese medicine, CAM, herb, and Taiwan. The most common long-term effects of snakebite envenomation include "migraine-like syndrome", brain injuries caused by hypoxia or intracranial hemorrhage, and chronic kidney disease. In addition, hypopituitarism is also worth mentioning. Traditional Chinese medicine can potentially be used in a complementary or alternative treatment for these effects, but additional studies are needed.
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Affiliation(s)
- Teng-I Huang
- Department of Chinese Medicine, China Medical University Hospital, Taichung 40447, Taiwan;
| | - Ching-Liang Hsieh
- Department of Chinese Medicine, China Medical University Hospital, Taichung 40447, Taiwan;
- Chinese Medicine Research Center, China Medical University, Taichung 40402, Taiwan
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, Taichung 40402, Taiwan
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Liu CC, Chou YS, Chen CY, Liu KL, Huang GJ, Yu JS, Wu CJ, Liaw GW, Hsieh CH, Chen CK. Pathogenesis of local necrosis induced by Naja atra venom: Assessment of the neutralization ability of Taiwanese freeze-dried neurotoxic antivenom in animal models. PLoS Negl Trop Dis 2020; 14:e0008054. [PMID: 32032357 PMCID: PMC7032728 DOI: 10.1371/journal.pntd.0008054] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 02/20/2020] [Accepted: 01/14/2020] [Indexed: 02/07/2023] Open
Abstract
Naja atra envenomation is one of the most significant clinical snakebite concerns in Taiwan. Taiwanese freeze-dried neurotoxic antivenom (FNAV) is currently used clinically for the treatment of cobra snakebite, and has been shown to limit the mortality of cobra envenomation to less than 1%. However, more than half of victims (60%) require surgery because of local tissue necrosis, a major problem in patients with cobra envenomation. Although the importance of evaluating the neutralizing effect of FNAV on this pathology is recognized, whether FNAV is able to prevent the local necrosis extension induced by N. atra venom has not been investigated in detail. Cytotoxins (CTXs) are considered as the major components of N. atra venom that cause necrosis. In the current study, we isolated CTXs from whole cobra venom and used both whole venom and purified CTXs to develop animal models for assessing the neutralization potential of FNAV against venom necrotizing activity. Local necrotic lesions were successfully produced in mice using CTXs in place of whole N. atra venom. FNAV was able to rescue mice from a subcutaneously injected lethal dose of cobra venom; however, it was unable to prevent CTX-induced dermo-necrosis. Furthermore, using the minimal necrosis dose (MND) of CTXs and venom proteome data, we found a dose of whole N. atra venom suitable for FNAV and developed a workable protocol for inducing local necrosis in rodent models that successfully imitated the clinical circumstance of cobra envenoming. This information provides a more comprehensive understanding of the pathophysiology of N. atra envenomation, and serves as a guide for improving current antivenom strategies and advancing clinical snakebite management in Taiwan. Naja atra envenomation is an important public health issue in Taiwan. Although the mortality rate of cobra snakebite is controlled using antivenom, more than half of victims develop symptoms of local necrosis and require surgical intervention. Whether the Taiwanese freeze-dried neurotoxic antivenom (FNAV) currently in clinical use is able to prevent the local necrosis extension induced by N. atra venom is still unclear. In this study, we developed a dermo-necrosis animal model using purified cytotoxins (CTXs), the major necrosis-related proteins from N. atra venom. We found that FNAV was able to neutralize the lethality of whole cobra venom, but was unable to neutralize the necrosis induced by CTXs in vivo. This finding introduced an example that supplementary quality control assays may be necessary to determine the effectiveness of antivenoms in neutralizing specific pathology induced by the venom; only evaluating the rodent lethality prevention is insufficient. Our results provide insights that should help improve current antivenoms and advance cobra snakebite management in Taiwan.
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Affiliation(s)
- Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Shao Chou
- Department of Emergency Medicine, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Chun-Yu Chen
- Department of Emergency Medicine, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Kuei-Lin Liu
- Faculty of Biotechnology and Laboratory Science in Medicine, School of Medical Technology and Engineering, National Yang-Ming University, Taipei, Taiwan
| | - Guo-Jen Huang
- Department and Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
- Department of Cell and Molecular Biology, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Liver Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- Research Center for Food and Cosmetic Safety, Research Center for Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Cho-Ju Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Geng-Wang Liaw
- Department of Emergency Medicine, Yeezen General Hospital, Taoyuan, Taiwan
| | - Cheng-Hsien Hsieh
- Department of Emergency Medicine, En Chu Kong Hospital, New Taipei City, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- * E-mail: (CHH); (CKC)
| | - Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
- * E-mail: (CHH); (CKC)
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Tsai TH, Lin CC, Mao YC, Hung CL, Yang YC, Yang CC, Jeng MJ. Naja atra venom-spit ophthalmia in Taiwan: An epidemiological survey from 1990 to 2016. J Chin Med Assoc 2020; 83:77-83. [PMID: 31714443 DOI: 10.1097/jcma.0000000000000223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Venomous snakebites are common during hot seasons in Taiwan. However, rarely is venom spat directly into the subject's eyes, causing eye injury. Despite being uncommon, analytical data regarding venom-spit ophthalmia in Taiwan have been lacking. This study thus aimed to conduct an epidemiological survey on Naja atra venom-spit ophthalmia in Taiwan during the past decades to improve future care of such patients. METHODS Registered records of cases with snake venom injuries at the Taiwan National Poison Control Center from 1990 to 2016 were retrospectively reviewed, enrolling those with records of cobra venom-spit eye injuries and excluding exotic species. Demographic data, clinical symptoms, snake species, ocular conditions, management, and outcomes were recorded and analyzed. RESULTS A total of 39 cases suffering from Naja atra venom-spit ophthalmia were enrolled. The overall incidence rate was 1.6 cases per million people from 1990 to 2016. Among the included cases, most were unilaterally injured (82%), male (95%), aged 18 to 59 years (90%), injured during catching (51%), and injured in spring and summer (92%). Ocular symptoms occurred in 90% of the cases, majority of which included ocular pain (90%) and redness (85%). Conjunctivitis (67%) and corneal injury (59%) of involved eyes were common. Immediate water irrigations were done in all cases, most of whom received further topical eye drops, including antibiotics, corticosteroids, and vasoconstrictors. Although topical or intravenous antivenoms were administered in 11 cases, no obviously superior outcome was observed. Most cases (77%) were symptom free after the acute stage. CONCLUSION Although Naja atra venom-spit ophthalmia in Taiwan is uncommon, the risk for transient ocular symptoms and corneal/conjunctival injury does exists. Prompt ocular irrigation and professional ophthalmic care after envenomation help prevent serious ocular sequelae. Moreover, superior outcomes were not achieved with the use of antivenom. Nonetheless, further studies are required to clarify the role antivenoms play in venom-spit ophthalmia.
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Affiliation(s)
- Tsung-Han Tsai
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Department of Emergency, Taichung Armed Forces General Hospital, Taichung, Taiwan, ROC
- Department of Emergency, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chun-Chi Lin
- Division of Occupational Medicine, Department of Family Medicine, National Yang-Ming University Hospital, I-Lan, Taiwan, ROC
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yan-Chiao Mao
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Chia-Lien Hung
- Department of Medical Education and Research, Taichung Armed Forces General Hospital, Taichung, Taiwan, ROC
| | - Yi-Chiang Yang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chen-Chang Yang
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Mei-Jy Jeng
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Liu CC, Lin CC, Hsiao YC, Wang PJ, Yu JS. Proteomic characterization of six Taiwanese snake venoms: Identification of species-specific proteins and development of a SISCAPA-MRM assay for cobra venom factors. J Proteomics 2018; 187:59-68. [DOI: 10.1016/j.jprot.2018.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/28/2018] [Accepted: 06/13/2018] [Indexed: 01/07/2023]
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12
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Su H, Li Y, Tang C, Su C, Tsai M. Can Surgery in Patient with Protobothrops Mucrosquamatus Envenomation be Predicted in Emergency Department? HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791602300402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Protobothrops mucrosquamatus, a Crotalinae snake with haemorrhagic venom, is responsible for the most common poisoning snakebites in Taiwan. Although a specific antivenin has been developed to treat this snakebite, surgical intervention is still needed in some patients because of the progression of tissue injury. Early risk stratification is important to identify the early signs of need for surgery. The purpose of this study was to investigate the early predictors for surgery in patients with P. mucrosquamatus envenomation. Methods The medical records of inpatients with P. mucrosquamatus envenomation between 2008 and 2013 were retrospectively reviewed. Clinical information was collected and analysed between surgical and nonsurgical patients. Results A total of 60 patients with P. mucrosquamatus envenomation, including 8 surgical patients (13.3%) and 52 non-surgical patients (86.7%), presented to the emergency department during the study period. Compartment syndrome (62.5%) and tissue necrosis (37.5%) were the main reasons for surgery. Comparison between surgical and non-surgical patients showed significantly higher white blood cell count (17.1 × 103/μL vs. 8.5 × 103/μL; p=0.002) and peak D-dimer level (1924.8 ng/mL vs. 730.0 ng/mL; p=0.006) in the surgical group. Ecchymosis (p=0.009), haemorrhagic bulla formation (p=0.002), leukocytosis (p=0.002), elevated peak D-dimer level (>1000 ng/mL) (p=0.005), and rhabdomyolysis (creatine kinase level >1000 IU/L) (p=0.007) were the significant signs relevant to surgery. On multivariate analysis, leukocytosis and ecchymosis were the most significant predictors of surgery in patients with P. mucrosquamatus envenomation. Conclusions Patients with P. mucrosquamatus envenomation presenting with leukocytosis and wound ecchymosis will have a high probability of requiring surgical therapy. (Hong Kong j.emerg.med. 2016;23:210-219)
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Affiliation(s)
- Hy Su
- E-Da Hospital and I-Shou University, Department of Emergency Medicine, Kaohsiung; and Buddhist Tzu Chi General Hospital, Department of Emergency Medicine, Hualien, Taiwan
| | - Yh Li
- Tzu Chi University, Department of Public Health, Hualien, Taiwan
| | - Cn Tang
- Buddhist Tzu Chi General Hospital, Department of Family Medicine, Hualien, Taiwan
| | - Ci Su
- National Cheng-Kung University, Department of Microbiology and Immunology, Tainan, Taiwan
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Contributing Factors for Complications and Outcomes in Patients With Snakebite: Experience in a Medical Center in Southern Taiwan. Ann Plast Surg 2017; 78:S32-S36. [PMID: 28195896 DOI: 10.1097/sap.0000000000001002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Snakebite usually results in various complications, such as significant soft tissue damage, infection, hematological, and neurological deficit. Surgical intervention, usually, is indicated in patients with tissue necrosis, infection, and compartment syndrome. To identify the contributing factors for complications and outcomes in different patients with snakebite so that outcomes can be evaluated and treatment of such patients can be initiated at the earliest. METHODS Information was collected regarding age, sex, underlying disease, species of snake, and the course of treatment of the victims of snakebite who visited the emergency department of a medical center in southern Taiwan between 2004 and 2014. The data obtained were analyzed using SPSS 20.0. RESULTS The bites from Taiwan cobra (Naja naja atra) significantly resulted in more complications than those from other snakes and required surgical intervention. The use of antivenin and antibiotics, immediate presentation to the hospital, and the location of the bite also were significant contributing factors. CONCLUSIONS Taiwan cobra significantly results in higher possibility of prolonged hospitalization, operation, tissue necrosis, infection, and necrotizing fasciitis. Location of the bite, immediate presentation to the hospital, and use of antivenin and antibiotics affect the outcome of snakebite. Knowledge of these factors will help in a better management of patients with snakebite.
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Tsai YH, Hsu WH, Huang KC, Yu PA, Chen CL, Kuo LT. Necrotizing fasciitis following venomous snakebites in a tertiary hospital of southwest Taiwan. Int J Infect Dis 2017; 63:30-36. [PMID: 28811229 DOI: 10.1016/j.ijid.2017.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 08/04/2017] [Accepted: 08/08/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Necrotizing fasciitis following venomous snakebites is uncommon. The purpose of this study was to describe the initial clinical features of necrotizing fasciitis after snakebites, and to identify the risk factors for patients with cellulitis who later developed necrotizing fasciitis. METHODS Sixteen patients with surgically confirmed necrotizing fasciitis and 25 patients diagnosed with cellulitis following snakebites were retrospectively reviewed over a 6-year period. Differences in patient characteristics, clinical presentations, snake species and laboratory data were compared between the necrotizing fasciitis and the cellulitis groups. RESULTS None of the 41 patients died after being bitten by a snake. Twenty-nine patients (70.7%) were bitten by a cobra. Enterococcus species and Morganella morganii were the most common pathogens identified in wound cultures. Relative to the cellulitis group, the necrotizing fasciitis group had significantly higher rates of hemorrhagic bullae (p=0.000), patients with underlying chronic disease (p=0.019), white blood cell counts (p=0.035), segmented white cell counts (p=0.02), and days of hospitalization (p=0.001). CONCLUSIONS Victims of venomous snakebites should be admitted for close monitoring of secondary wound infections. The risk factors of developing necrotizing fasciitis from cellulitis following snakebites were associated with chronic underlying diseases and leukocytosis (total white blood-cell counts ≥10000cells/mm3 and ≥80% of segmented leukocyte forms). Physicians should be alert to a worsening wound condition after a snakebite, and surgical interventions should be performed for established necrotizing fasciitis with the empirical use of third-generation cephalosporins plus other regimens.
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Affiliation(s)
- Yao-Hung Tsai
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospita, Taiwan, Republic of China; College of Medicine, Chang Gung University at Taoyuan, Taiwan, Republic of China.
| | - Wei-Hsiu Hsu
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospita, Taiwan, Republic of China; College of Medicine, Chang Gung University at Taoyuan, Taiwan, Republic of China
| | - Kuo-Chin Huang
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospita, Taiwan, Republic of China; College of Medicine, Chang Gung University at Taoyuan, Taiwan, Republic of China
| | - Pei-An Yu
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospita, Taiwan, Republic of China
| | - Chi-Lung Chen
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospita, Taiwan, Republic of China; College of Medicine, Chang Gung University at Taoyuan, Taiwan, Republic of China
| | - Liang Tseng Kuo
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospita, Taiwan, Republic of China; College of Medicine, Chang Gung University at Taoyuan, Taiwan, Republic of China
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Tianyi FL, Dimala CA, Feteh VF. Shortcomings in snake bite management in rural Cameroon: a case report. BMC Res Notes 2017; 10:196. [PMID: 28595590 PMCID: PMC5465594 DOI: 10.1186/s13104-017-2518-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Snake bites are an important public health problem in developing countries with most bites occurring in rural areas. Severe envenomation often occurs in children and following bites to the face. Prompt administration of potent anti-venom remains the mainstay of management. However in Cameroon, the use of anti-venoms is limited by non-availability, high cost (where available) and poor mastery of treatment guidelines. CASE PRESENTATION We present a 10-year-old muslim Cameroonian child from an enclaved rural area, brought to the hospital 12 h after a snake bite to the face, with signs of severe envenomation. Despite the suboptimal anti-venom dose administered to this patient due to a stock out of this medication, supportive therapy was beneficial in ensuring a positive outcome and satisfactory recovery. CONCLUSION This highlights snake bites as a public health problem due to the lack of snake anti-venoms in peripheral health facilities, rendering them unable to appropriately manage these cases. National health policies should encourage constant peripheral availability of anti-venoms and the institution of an intervention package for snake bite management, comprising: treatment protocol, staff training, monitoring of compliance and community education to help reduce the mortality and morbidity from snake bites.
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Affiliation(s)
- Frank-Leonel Tianyi
- Mayo Darle sub-Divisional Hospital, Mayo Banyo, Adamaoua Region Cameroon
- Mayo Darle sub-Divivsional Hospital, Mayo Banyo, Adamawa region Cameroon
| | - Christian Akem Dimala
- Orthopaedics Department, Southend University Hospital, Essex, UK
- Health and Human Development (2HD) Research Network, Douala, Cameroon
| | - Vitalis Fambombi Feteh
- Health and Human Development (2HD) Research Network, Douala, Cameroon
- Njikwa District Hospital, Momo, North West Region Cameroon
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Lee YC, Chen WC, Liang MH, Lee CH, Tsai KC, Chiang JR, Chiang LC, Chen CC, Chang CY, Lee CH, Leu SJ, Yang YY. Single chain antibody fragment with serine protease inhibitory property capable of neutralizing toxicity of Trimeresurus mucrosquamatus venom. Biochem Biophys Res Commun 2015; 460:170-6. [PMID: 25769957 DOI: 10.1016/j.bbrc.2015.02.169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 02/28/2015] [Indexed: 11/19/2022]
Abstract
Trimeresurus mucrosquamatus (TM) is one of majorities of snake envenomation with necrotic and hemorrhagic toxin in Taiwan. In this study, chickens were used as an alternative animal model for immunization with TM venom. Using phage display technology to process four rounds of panning, selected single chain variable fragments (scFv) could specifically recognize TM venom proteins, which were later identified as a group of homogeneous venom serine protease. The specific scFv antibodies showed various inhibitory effects on sheep RBC lysis induced by TM venom using an indirect hemolytic assay in vitro. In addition, the survival times of mice were extended to certain degrees when treated with these scFv antibodies individually or in a combination. To elucidate the inhibitory mechanism, we used molecular modeling to build up the serine protease structure to simulate the possible interactions with scFv antibodies. The results suggested that the CDR-loop of the scFv antibodies (3S10 or 4S1) might bind at the 99-loop of venom serine protease so as to affect substrate access due to the partial collapse of the subsite S2 and the partial movement of the subsite S4. It is hoped these chicken-derived antibodies could be applied to develop diagnostic and therapeutic agents against snakebites.
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Affiliation(s)
- Yu-Ching Lee
- The Center of Translational Medicine, Taipei Medical University, Taipei, Taiwan; Antibody and Hybridoma Core Facility, Taipei Medical University, Taipei, Taiwan
| | - Wang-Chuan Chen
- The School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan; Department of Chinese Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Meng-Huei Liang
- Antibody and Hybridoma Core Facility, Taipei Medical University, Taipei, Taiwan
| | - Chi-Hsin Lee
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Keng-Chang Tsai
- National Research Institute of Chinese Medicine, Ministry of Health and Welfare, Taipei, Taiwan
| | - Jen-Ron Chiang
- Center for Research, Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan
| | - Liao-Chun Chiang
- Center for Research, Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan
| | - Chi-Ching Chen
- Department of Pathology and Laboratory Medicine, Landseed Hospital, Taoyuan, Taiwan
| | - Chang-Yu Chang
- Department of Medical Technology, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Ching-Hsiao Lee
- Department of Medical Technology, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Sy-Jye Leu
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Yuan Yang
- Antibody and Hybridoma Core Facility, Taipei Medical University, Taipei, Taiwan; School of Medical Laboratory Sciences and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan; Department of Laboratory Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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Hsiao MH, Yang MC, Yan SH, Yang CH, Chou CC, Chang CF, Hsu HY, Lin YR. Environmental factors associated with the prevalence of animal bites or stings in patients admitted to an emergency department. J Acute Med 2012. [DOI: 10.1016/j.jacme.2012.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tan HH. Epidemiology of Snakebites from A General Hospital in Singapore: A 5-year Retrospective Review (2004-2008). ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2010. [DOI: 10.47102/annals-acadmedsg.v39n8p640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: This is a retrospective study on the epidemiology of snakebites that were presented to an emergency department (ED) between 2004 and 2008. Materials and Methods: Snakebite cases were identified from International Classification of Diseases (ICD) code E905 and E906, as well as cases referred for eye injury from snake spit and records of antivenom use. Results: Fifty-two cases were identified: 13 patients witnessed the snake biting or spitting at them, 22 patients had fang marks and/or clinical features of envenomations and a snake was seen and the remaining 17 patients did not see any snake but had fang marks suggestive of snakebite. Most of the patients were young (mean age 33) and male (83%). The three most commonly identified snakes were cobras (7), pythons (4) and vipers (3). One third of cases occurred during work. Half of the bites were on the upper limbs and about half were on the lower limbs. One patient was spat in the eye by a cobra. Most of the patients (83%) arrived at the ED within 4 hours of the bite. Pain and swelling were the most common presentations. There were no significant systemic effects reported. Two patients had infection and 5 patients had elevated creatine kinase (>600U/L). Two thirds of the patients were admitted. One patient received antivenom therapy and 5 patients had some form of surgical intervention, of which 2 had residual disability. One patient had heparin instilled in the eye for eye injury from cobra spit. Conclusions: Snakebite infrequently presents to the ED. Most of the patients developed local effects that do well with supportive treatment.
Key words: Antivenom, Cobra, Envenomomation, Spit, Viper
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