Antivenin-related serum sickness

A rare manifestation of serum sickness after common krait envenomation in a patient treated with polyvalent anti-snake venom in India: Presentation and challenges

Envenomation from snakebites is a significant public health concern in the Southeast Asian region resulting in considerable mortality and morbidity. Anti-snake venom (ASV) despite being the only rescue can bring forth several acute and delayed adverse effects. Among them, serum sickness is a late manifestation after treatment with ASV that presents after 5-14 days of treatment. However, there is no specific definition to diagnose serum sickness or proven treatment. Here, we present a case of serum sickness to provide an insight into this unventured zone, briefing the presentation, treatment and probable reason for serum sickness and its prevention after common krait envenomation and treatment with polyvalent ASV in India.

Identification of poorly immunodepleted phospholipase A2 (PLA2) proteins of Bungarus fasciatus venom from Assam, India and evaluation of Indian polyvalent antivenom using third-generation antivenomics

Bungarus fasciatus also referred to as the Banded krait is a snake which possesses venom and belongs to the Elapidae family. It is widely distributed across the Indian subcontinent and South East Asian countries and is responsible for numerous snakebites in the population. B. fasciatus possesses a neurotoxic venom and envenomation by the snake results in significant morbidity and occasional morbidity in the victim if not treated appropriately. In this study, the efficacy of Indian polyvalent antivenom (Premium Serums polyvalent antivenom) was evaluated against the venom of B. fasciatus from Guwahati, Assam (India) employing the Third-generation antivenomics technique followed by identification of venom proteins from three poorly immunodepleted peaks (P5, P6 and P7) using LC-MS/MS analysis. Seven proteins were identified from the three peaks and all these venom proteins belonged to the phospholipase A2 (PLA2) superfamily. The identified PLA2 proteins were corroborated by the in vitro enzymatic activities (PLA2 and Anticoagulant activity) exhibited by the three peaks and previous reports of pathological manifestation in the envenomated victims. Neutralization of enzymatic activities by Premium Serums polyvalent antivenom was also assessed in vitro for crude venom, P5, P6 and P7 which revealed moderate to poor inhibition. Inclusion of venom proteins/peptides, which are non-immunodepleted or poorly immunodepleted, into the immunization mixture of venom used for antivenom production may help in enhancing the efficacy of the polyvalent antivenom.

Application of Sonographic Assessments of the Rate of Proximal Progression to Monitor Protobothrops mucrosquamatus Bite-Related Local Envenomation: A Prospective Observational Study

Patients bitten by Protobothrops mucrosquamatus typically experience significant pain, substantial swelling, and potentially blister formation. The appropriate dosage and efficacy of FHAV for alleviating local tissue injury remain uncertain. Between 2017 and 2022, 29 snakebite patients were identified as being bitten by P. mucrosquamatus. These patients underwent point-of-care ultrasound (POCUS) assessments at hourly intervals to measure the extent of edema and evaluate the rate of proximal progression (RPP, cm/hour). Based on Blaylock's classification, seven patients (24%) were classified as Group I (minimal), while 22 (76%) were classified as Group II (mild to severe). In comparison to Group I patients, Group II patients received more FHAV (median of 9.5 vials vs. two vials, p-value < 0.0001) and experienced longer median complete remission times (10 days vs. 2 days, p-value < 0.001). We divided the Group II patients into two subgroups based on their clinical management. Clinicians opted not to administer antivenom treatment to patients in Group IIA if their RPP decelerated. In contrast, for patients in Group IIB, clinicians increased the volume of antivenom in the hope of reducing the severity of swelling or blister formation. Patients in Group IIB received a significantly higher median volume of antivenom (12 vials vs. six vials; p-value < 0.001) than those in Group IIA. However, there was no significant difference in outcomes (disposition, wound necrosis, and complete remission times) between subgroups IIA and IIB. Our study found that FHAV does not appear to prevent local tissue injuries, such as swelling progression and blister formation, immediately after administration. When administering FHAV to patients bitten by P. mucrosquamatus, the deceleration of RPP may serve as an objective parameter to help clinicians decide whether to withhold FHAV administration.

Venomous Snakebites: Treatment Considerations and the Emergency Department Nurse Practitioners'/Providers' Priorities of Care

In the United States, 7,000-8,000 people are bitten by a venomous snake each year, out of which approximately 5 die. Although common practice is to treat any and all victims of envenomation with repeated doses of antivenom, this approach is not without its risks. The gold standard for treating venomous snakebites with severe symptoms is antivenom. Although a standardized approach to treating envenomation is needed, it cannot be developed without first delineating current practices. This article discusses the ways in which advanced practice emergency nurses should manage bites from a variety of venomous snakes. It is divided into 4 main sections: (1) the types of venomous snakes found in the United States, their habitat, and the effects of their venom; (2) priorities of care in treating venomous snakebites; (3) preparation and administration of antivenom; and (4) other considerations for the advanced practice emergency department nurse.

Label-free SERS characterization of snake venoms by exploring the cysteine environs with bone-shaped gold nanoparticles

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.

[Surgical treatment of bites]

OBJECTIVE

Thorough and profound debridement for acute bite injuries while sparing nerves, vessels and tendons.

INDICATIONS

Acute traumatic and late presented bite injuries.

CONTRAINDICATIONS

General contraindication for anesthesia or surgery.

SURGICAL TECHNIQUE

Extensive flabellate local anesthesia/general anesthesia, wound irrigation using 0.9% NaCl or antiseptic solutions, removal of avital tissues, wound debridement, wound edge excision, anew extensive irrigation, drainage if necessary, wound closure where applicable (except older or punctual deep injuries), bandage, elastic wrapping and immobilization. If necessary, plastic surgery with coverage of remaining defects.

POSTOPERATIVE MANAGEMENT

Immobilization with initially daily wound evaluation, removal of drainage/loop on postoperative day 2; if necessary, antibiotic therapy with amoxicillin and clavulanic acid in high-risk wounds (e.g., puncture wounds, joint or bone involvement, extensive soft tissue squeezing), suture removal on day 10-12 after surgery.

RESULTS

Of 142 bite injuries that were treated and retrospectively evaluated, 46% were caused by dogs and 32% by cats. Patients were on average 44 years old; 55% of all dog bites affected women, but 67% of all cat bites. In 48% of the cases, general anesthesia was necessary. The postoperative infection rate was 6.3%.

The Protocol of Choice for Treatment of Snake Bite

The aim of the current study is to compare three different methods of treatment of snake bite to determine the most efficient one. To unify the protocol of snake bite treatment in our center, we retrospectively reviewed files of the snake-bitten patients who had been referred to us between 2010 and 2014. They were contacted for follow-up using phone calls. Demographic and on-arrival characteristics, protocol used for treatment (WHO/Haddad/GF), and outcome/complications were evaluated. Patients were entered into one of the protocol groups and compared. Of a total of 63 patients, 56 (89%) were males. Five, 19, and 28 patients were managed by Haddad, WHO, or GF protocols, respectively. Eleven patients had fallen into both GF and WHO protocols and were excluded. Serum sickness was significantly more common when WHO protocol was used while 100% of the compartment syndromes and 71% of deformities had been reported after GF protocol. The most important complications were considered to be deformity, compartment syndrome, and amputation and were more frequent after the use of WHO and GF protocols (23.1% versus 76.9%; none in Haddad; P = NS). Haddad protocol seems to be the best for treatment of snake-bitten patients in our region. However, this cannot be strictly concluded because of the limited sample size and nonsignificant P values.

Preclinical safety evaluation of intravenously administered SAL200 containing the recombinant phage endolysin SAL-1 as a pharmaceutical ingredient

Phage endolysins have received increasing attention as potent antibacterial agents. However, although safety evaluation is a prerequisite for the drug development process, a good laboratory practice (GLP)-compliant safety evaluation has not been reported for phage endolysins. A safety evaluation of intravenously administered SAL200 (containing phage endolysin SAL-1) was conducted according to GLP standards. No animals died in any of the safety evaluation studies. In general toxicity studies, intravenously administered SAL200 showed no sign of toxicity in rodent single- and repeated-dose toxicity studies. In the dog repeated-dose toxicity test, there were no abnormal findings, with the exception of transient abnormal clinical signs that were observed in some dogs when daily injection of SAL200 was continued for more than 1 week. In safety pharmacology studies, there were also no signs of toxicity in the central nervous and respiratory system function tests. In the cardiovascular function test, there were no abnormal findings in all tested dogs after the first and second administrations, but transient abnormalities were observed after the third and fourth administrations (2 or 3 weeks after the initial administration). All abnormal findings observed in these safety evaluation studies were slight to mild, were apparent only transiently after injection, and resolved quickly. The safety evaluation results for SAL200 support the implementation of an exploratory phase I clinical trial and underscore the potential of SAL200 as a new drug. We have designed an appropriate phase I clinical trial based on the results of this study.