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Maciulewicz TS, Axon DR, Shirazi FM. Characterization of hypofibrinogenemia following rattlesnake envenomation treated with crotalidae immune F(ab') 2 (equine) antivenom. Clin Toxicol (Phila) 2024:1-5. [PMID: 39318272 DOI: 10.1080/15563650.2024.2406427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 09/12/2024] [Accepted: 09/13/2024] [Indexed: 09/26/2024]
Abstract
INTRODUCTION Hemotoxicity is common following rattlesnake envenomation. Published experiences with equine-derived crotalidae immune F(ab')2 antivenom have characterized hemotoxicity as delayed, recurrent, or persistent. This study investigated recovery of hypofibrinogenemia following rattlesnake envenomation treated with equine-derived crotalidae immune F(ab')2 antivenom. METHODS This is a retrospective analysis of human rattlesnake envenomations reported to the Arizona Poison and Drug Information Center over four years. We included rattlesnake-envenomated patients who developed hypofibrinogenemia (<1,500 mg/L) and were treated with equine-derived crotalidae immune F(ab')2 antivenom. The primary outcomes were recovery period (h) and recovery rate (mg/L/h) of hypofibrinogenemia following equine-derived crotalidae immune F(ab')2 antivenom administration. Collected data included demographics, laboratory values, and antivenom administered. Statistics used were percentages, medians, and Kruskall-Wallis test. RESULTS There were 527 rattlesnake envenomations treated with antivenom, of which 80 met the inclusion criteria. Patients receiving treatment with F(ab')2 antivenom and had a median fibrinogen concentration recovery rate of 62.3 mg/L/h (IQR: 42.0-74.3 mg/L/h) and median recovery period of 19.2 h (IQR: 13.8-26.2 h). There were statistically significant differences between categories for time to antivenom for the median recovery period (P = 0.0154). DISCUSSION Hypofibrinogenemia is a common laboratory finding following rattlesnake envenomation in Arizona. This study investigated rattlesnake envenomated patients treated with F(ab')2 antivenom and monitored fibrinogen concentrations as a surrogate marker of venom toxicity. Additionally, time to administration of F(ab')2 antivenom was a statistical significant marker of the recovery period from hypofibrinogenemia. Limitations of this study included the geographic coverage of the poison center and exclusion of patients with insufficient laboratory monitoring or those who received another antivenom. CONCLUSIONS Following rattlesnake envenomation in Arizona, recovery from hypofibrinogenemia was able characterized in a rate (mg/L/h) and period (h) with the quantity and time to administration of antivenom. More studies are needed to assess this finding with other antivenoms and its clinical significance.
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Affiliation(s)
- Thom S Maciulewicz
- Arizona Poison and Drug Information Center, R. Ken Coit College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - David R Axon
- Department of Pharmacy Practice and Science, R. Ken Coit College of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Farshad Mazda Shirazi
- Arizona Poison and Drug Information Center, R. Ken Coit College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
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Gamulin E, Mateljak Lukačević S, Halassy B, Kurtović T. Snake Antivenoms-Toward Better Understanding of the Administration Route. Toxins (Basel) 2023; 15:398. [PMID: 37368699 DOI: 10.3390/toxins15060398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Envenomations induced by animal bites and stings constitute a significant public health burden. Even though a standardized protocol does not exist, parenterally administered polyclonal antivenoms remain the mainstay in snakebite therapy. There is a prevailing opinion that their application by the i.m. route has poor efficacy and that i.v. administration should preferentially be chosen in order to achieve better accomplishment of the antivenom therapeutic activity. Recently, it has been demonstrated that neutralization not only in the systemic circulation but also in the lymphatic system might be of great importance for the clinical outcome since it represents another relevant body compartment through which the absorption of the venom components occurs. In this review, the present-day and summarized knowledge of the laboratory and clinical findings on the i.v. and i.m. routes of antivenom administration is provided, with a special emphasis on the contribution of the lymphatic system to the process of venom elimination. Until now, antivenom-mediated neutralization has not yet been discussed in the context of the synergistic action of both blood and lymph. A current viewpoint might help to improve the comprehension of the venom/antivenom pharmacokinetics and the optimal approach for drug application. There is a great need for additional dependable, practical, well-designed studies, as well as more practice-related experience reports. As a result, opportunities for resolving long-standing disputes over choosing one therapeutic principle over another might be created, improving the safety and effectiveness of snakebite management.
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Affiliation(s)
- Erika Gamulin
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Sanja Mateljak Lukačević
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
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Nong JF, Huang Z, Huang ZZ, Yang J, Li JC, Yang F, Huang DL, Wang F, Wang W. Development of sandwich ELISA and lateral flow assay for the detection of Bungarus multicinctus venom. PLoS Negl Trop Dis 2023; 17:e0011165. [PMID: 36996245 PMCID: PMC10089342 DOI: 10.1371/journal.pntd.0011165] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 04/11/2023] [Accepted: 02/13/2023] [Indexed: 04/01/2023] Open
Abstract
Snakebite envenoming adversely affects human health and life worldwide. Presently, no suitable diagnostic tools for snakebite envenoming are available in China. Therefore, we sought to develop reliable diagnostic tests for snakebite management. We conducted affinity purification experiments to prepare species-specific antivenom antibody (SSAb). In brief, affinity chromatography with an antibody purification column (Protein A) was conducted to purify immunoglobulin G from Bungarus multicinctus (BM) venom hyperimmunized rabbit serum. The cross-reactive antibodies were removed from commercial BM antivenin by immune adsorption on the affinity chromatography columns of the other three venoms, Bungarus Fasciatus (FS), Naja atra (NA), and O. hannah (OH), generating SSAb. The results of western blot analysis and enzyme-linked immunosorbent assay (ELISA) showed the high specificity of the prepared SSAb. The obtained antibodies were then applied to ELISA and lateral flow assay (LFA) to detect BM venom. The resulting ELISA and LFA could specifically and rapidly detect BM venom in various samples with the limits of quantification as 0.1 and 1 ng/ml, respectively. This method could effectively detect snake venom in experimentally envenomed rats (simulating human envenomation), which could distinguish positive and negative samples within 10-15 min. This method also showed promise in serving as a highly useful tool for a rapid clinical distinguishing of BM bites and rational use of antivenom in emergency centers. The study also revealed cross-reactivity between BM and heterogenous venoms, suggesting that they shared common epitopes, which is of great significance for developing detection methods for venoms of the snakes belonging to the same family.
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Affiliation(s)
- Ji-Fei Nong
- Department of Emergency, the First Affiliated Hospital, Guangxi Medical University, Nanning, China
| | - Zhou Huang
- Department of Emergency, the First Affiliated Hospital, Guangxi Medical University, Nanning, China
| | - Zheng-Zhuang Huang
- Department of Emergency, the First Affiliated Hospital, Guangxi Medical University, Nanning, China
| | - Jie Yang
- Department of Emergency, the First Affiliated Hospital, Guangxi Medical University, Nanning, China
| | - Jin-Cheng Li
- Department of Emergency, the First Affiliated Hospital, Guangxi Medical University, Nanning, China
| | - Feng Yang
- Department of Emergency, the First Affiliated Hospital, Guangxi Medical University, Nanning, China
| | - Dong-Ling Huang
- Department of Emergency, the First Affiliated Hospital, Guangxi Medical University, Nanning, China
| | - Fan Wang
- Department of Emergency, the First Affiliated Hospital, Guangxi Medical University, Nanning, China
| | - Wei Wang
- Department of Emergency, the First Affiliated Hospital, Guangxi Medical University, Nanning, China
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Keyler DE, Armitage J, Bush S. Professor Steven Alan Seifert (1950-2022). Toxicon 2022; 217:S0041-0101(22)00228-8. [PMID: 35987660 DOI: 10.1016/j.toxicon.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Affiliation(s)
- Daniel E Keyler
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA.
| | - James Armitage
- Center for Hematological Malignancies Research, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sean Bush
- North American Society of Toxinology, Duke University Health, Durham, NC, USA
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5
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Boyer L. In memoriam: Steven Alan Seifert (1950-2022). Clin Toxicol (Phila) 2022. [PMID: 35796188 DOI: 10.1080/15563650.2022.2088379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Morris NM, Blee JA, Hauert S. Developing a computational pharmacokinetic model of systemic snakebite envenomation and antivenom treatment. Toxicon 2022; 215:77-90. [PMID: 35716719 DOI: 10.1016/j.toxicon.2022.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/20/2022] [Accepted: 06/09/2022] [Indexed: 11/19/2022]
Abstract
Snakebite envenomation is responsible for over 100,000 deaths and 400,000 cases of disability annually, most of which are preventable through access to safe and effective antivenoms. Snake venom toxins span a wide molecular weight range, influencing their absorption, distribution, and elimination within the body. In recent years, a range of scaffolds have been applied to antivenom development. These scaffolds similarly span a wide molecular weight range and subsequently display diverse pharmacokinetic behaviours. Computational simulations represent a powerful tool to explore the interplay between these varied antivenom scaffolds and venoms, to assess whether a pharmacokinetically optimal antivenom exists. The purpose of this study was to establish a computational model of systemic snakebite envenomation and treatment, for the quantitative assessment and comparison of conventional and next-generation antivenoms. A two-compartment mathematical model of envenomation and treatment was defined and the system was parameterised using existing data from rabbits. Elimination and biodistribution parameters were regressed against molecular weight to predict the dynamics of IgG, F(ab')2, Fab, scFv, and nanobody antivenoms, spanning a size range of 15-150 kDa. As a case study, intramuscular envenomation by Naja sumatrana (equatorial spitting cobra) and its treatment using Fab, F(ab')2, and IgG antivenoms was simulated. Variable venom dose tests were applied to visualise effective antivenom dose levels. Comparisons to existing antivenoms and experimental rescue studies highlight the large dose reductions that could result from recombinant antivenom use. This study represents the first comparative in silico model of snakebite envenomation and treatment.
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Affiliation(s)
- Natalie M Morris
- Department of Engineering Mathematics, Ada Lovelace Building, University of Bristol, University Walk, Bristol, BS8 1TW, UK.
| | - Johanna A Blee
- Department of Engineering Mathematics, Ada Lovelace Building, University of Bristol, University Walk, Bristol, BS8 1TW, UK.
| | - Sabine Hauert
- Department of Engineering Mathematics, Ada Lovelace Building, University of Bristol, University Walk, Bristol, BS8 1TW, UK.
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Fashionably late: A characterization of late coagulopathies in rattlesnake envenomations between Fab and F(ab’)2 antivenoms. Toxicon 2022; 212:49-54. [DOI: 10.1016/j.toxicon.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/26/2022] [Accepted: 03/29/2022] [Indexed: 11/21/2022]
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Abstract
SNAKE ENVENOMATION REPRESENTS AN IMPORTANT HEALTH PROBLEM IN much of the world. In 2009, it was recognized by the World Health Organization (WHO) as a neglected tropical disease, and in 2017, it was elevated into Category A of the Neglected Tropical Diseases list, further expanding access to funding for research and antivenoms. However, snake envenomation occurs in both tropical and temperate climates and on all continents except Antarctica. Worldwide, the estimated number of annual deaths due to snake envenomation (80,000 to 130,000) is similar to the estimate for drug-resistant tuberculosis and for multiple myeloma., In countries with adequate resources, deaths are infrequent (e.g., <6 deaths per year in the United States, despite the occurrence of 7000 to 8000 bites), but in countries without adequate resources, deaths may number in the tens of thousands. Venomous snakes kept as pets are not rare, and physicians anywhere might be called on to manage envenomation by a nonnative snake. Important advances have occurred in our understanding of the biology of venom and the management of snake envenomation since this topic was last addressed in the Journal two decades ago. For the general provider, it is important to understand the spectrum of snake envenomation effects and approaches to management and to obtain specific guidance, when needed.
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Affiliation(s)
- Steven A Seifert
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - James O Armitage
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - Elda E Sanchez
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
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Mender MM, Bolton F, Berry C, Young M. Antivenom: An immunotherapy for the treatment of snakebite envenoming in sub-Saharan Africa. ADVANCES IN PROTEIN CHEMISTRY AND STRUCTURAL BIOLOGY 2021; 129:435-477. [PMID: 35305724 DOI: 10.1016/bs.apcsb.2021.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Snakebite envenoming (SBE) leads to significant morbidity and mortality, resulting in over 90,000 deaths and approximately 400,000 amputations annually. In sub-Saharan Africa (SSA) alone, SBE accounts for over 30,000 deaths per annum. Since 2017, SBE has been classified as a priority Neglected Tropical Disease (NTD) by the World Health Organisation (WHO). The major species responsible for mortality from SBE within SSA are from the Bitis, Dendroaspis, Echis and Naja genera. Pharmacologically active toxins such as metalloproteinases, serine proteinases, 3-finger toxins, kunitz-type toxins, and phospholipase A2s are the primary snake venom components. These toxins induce cytotoxicity, coagulopathy, hemorrhage, and neurotoxicity in envenomed victims. Antivenom is currently the only available venom-specific treatment for SBE and contains purified equine or ovine polyclonal antibodies, collected from donor animals repeatedly immunized with low doses of adjuvanted venom. The resulting plasma or serum contains a high titre of specific antibodies, which can then be collected and stored until required. The purified antibodies are either whole IgG, monovalent fragment antibody (Fab) or divalent fragment antibody F(ab')2. Despite pharmacokinetic and pharmacodynamic differences, all three are effective in the treatment of SBE. No antivenom is without adverse reactions but, the level of their impact and severity varies from benign early adverse reactions to the rarely occurring fatal anaphylactic shock. However, the major side effects are largely reversible with immediate administration of adrenaline and corticosteroids. There are 16 different antivenoms marketed within SSA, but the efficacy and safety profiles are only published for less than 50% of these products.
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Affiliation(s)
- Mender M Mender
- School of Bioscience, Cardiff University, Cardiff, United Kingdom; Department of Research and Development, MicroPharm Ltd, Newcastle Emlyn, United Kingdom.
| | - Fiona Bolton
- Department of Research and Development, MicroPharm Ltd, Newcastle Emlyn, United Kingdom
| | - Colin Berry
- School of Bioscience, Cardiff University, Cardiff, United Kingdom
| | - Mark Young
- School of Bioscience, Cardiff University, Cardiff, United Kingdom
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10
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Choraria A, Somasundaram R, Janani S, Rajendran S, Oukkache N, Michael A. Chicken egg yolk antibodies (IgY)-based antivenom for neutralization of snake venoms: a review. TOXIN REV 2021. [DOI: 10.1080/15569543.2021.1942063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Ankit Choraria
- Department of Microbiology, PSG College of Arts and Science, Coimbatore, India
| | | | - S. Janani
- Nanobiotechnology Laboratory, PSG Institute of Advanced Studies, Coimbatore, India
| | - Selvakumar Rajendran
- Nanobiotechnology Laboratory, PSG Institute of Advanced Studies, Coimbatore, India
| | - Naoual Oukkache
- Venoms and Toxins Laboratory, Institute Pasteur of Morocco, Casablanca, Morocco
| | - A. Michael
- Department of Microbiology, PSG College of Arts and Science, Coimbatore, India
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Slade J, Baja A, Al Zaki A, Auerbach P, Rodriguez F. Wilderness Cardiology: A Case of Envenomation-Associated Cardiotoxicity Following a Rattlesnake Bite. Cardiol Ther 2021; 10:271-276. [PMID: 33620669 PMCID: PMC8126537 DOI: 10.1007/s40119-021-00215-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/10/2021] [Indexed: 11/27/2022] Open
Abstract
Cardiac injury is infrequently described as a complication of snake bite envenomation. We present the case of a 62-year-old male with shortness of breath, right lower extremity edema, and elevated cardiac troponin 6 days after a Northern Pacific rattlesnake bite.
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Affiliation(s)
- Justin Slade
- Department of Medicine, Stanford University, Stanford, CA, USA.
- Medical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA.
| | | | - Ajlan Al Zaki
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Paul Auerbach
- Department of Emergency Medicine, Stanford University, Stanford, CA, USA
| | - Fatima Rodriguez
- Department of Medicine, Stanford University, Stanford, CA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
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12
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Knudsen C, Jürgensen JA, Føns S, Haack AM, Friis RUW, Dam SH, Bush SP, White J, Laustsen AH. Snakebite Envenoming Diagnosis and Diagnostics. Front Immunol 2021; 12:661457. [PMID: 33995385 PMCID: PMC8113877 DOI: 10.3389/fimmu.2021.661457] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Snakebite envenoming is predominantly an occupational disease of the rural tropics, causing death or permanent disability to hundreds of thousands of victims annually. The diagnosis of snakebite envenoming is commonly based on a combination of patient history and a syndromic approach. However, the availability of auxiliary diagnostic tests at the disposal of the clinicians vary from country to country, and the level of experience within snakebite diagnosis and intervention may be quite different for clinicians from different hospitals. As such, achieving timely diagnosis, and thus treatment, is a challenge faced by treating personnel around the globe. For years, much effort has gone into developing novel diagnostics to support diagnosis of snakebite victims, especially in rural areas of the tropics. Gaining access to affordable and rapid diagnostics could potentially facilitate more favorable patient outcomes due to early and appropriate treatment. This review aims to highlight regional differences in epidemiology and clinical snakebite management on a global scale, including an overview of the past and ongoing research efforts within snakebite diagnostics. Finally, the review is rounded off with a discussion on design considerations and potential benefits of novel snakebite diagnostics.
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Affiliation(s)
- Cecilie Knudsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
- BioPorto Diagnostics A/S, Hellerup, Denmark
| | - Jonas A. Jürgensen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Sofie Føns
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Aleksander M. Haack
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Rasmus U. W. Friis
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Søren H. Dam
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Sean P. Bush
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Julian White
- Toxinology Department, Women’s and Children’s Hospital, North Adelaide, SA, Australia
| | - Andreas H. Laustsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
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Kurtović T, Karabuva S, Grenc D, Dobaja Borak M, Križaj I, Lukšić B, Halassy B, Brvar M. Intravenous Vipera berus Venom-Specific Fab Fragments and Intramuscular Vipera ammodytes Venom-Specific F(ab') 2 Fragments in Vipera ammodytes-Envenomed Patients. Toxins (Basel) 2021; 13:toxins13040279. [PMID: 33919927 PMCID: PMC8070888 DOI: 10.3390/toxins13040279] [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: 03/01/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 11/25/2022] Open
Abstract
Vipera ammodytes (V. ammodytes) is the most venomous European viper. The aim of this study was to compare the clinical efficacy and pharmacokinetic values of intravenous Vipera berus venom-specific (paraspecific) Fab fragments (ViperaTAb) and intramuscular V. ammodytes venom-specific F(ab’)2 fragments (European viper venom antiserum, also called “Zagreb” antivenom) in V.ammodytes-envenomed patients. This was a prospective study of V.ammodytes-envenomed patients that were treated intravenously with ViperaTAb or intramuscularly with European viper venom antiserum that was feasible only due to the unique situation of an antivenom shortage. The highest venom concentration, survival, length of hospital stay and adverse reactions did not differ between the groups. Patients treated with intravenous Fab fragments were sicker, with significantly more rhabdomyolysis and neurotoxicity. The kinetics of Fab fragments after one or more intravenous applications matched better with the venom concentration in the early phase of envenomation compared to F(ab’)2 fragments that were given intramuscularly only on admission. F(ab’)2 fragments given intramuscularly had 25-fold longer apparent total body clearance and 14-fold longer elimination half-time compared to Fab fragments given intravenously (2 weeks vs. 24 h, respectively). In V.ammodytes-envenomed patients, the intramuscular use of specific F(ab’)2 fragments resulted in a slow rise of antivenom serum concentration that demanded their early administration but without the need for additional doses for complete resolution of all clinical signs of envenomation. Intravenous use of paraspecific Fab fragments resulted in the immediate rise of antivenom serum concentration that enabled their use according to the clinical progress, but multiple doses might be needed for efficient therapy of thrombocytopenia due to venom recurrence, while the progression of rhabdomyolysis and neurotoxic effects of the venom could not be prevented.
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Affiliation(s)
- Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia;
- Center of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital of Split, Šoltanska 1, 21000 Split, Croatia; (S.K.); (B.L.)
- School of Medicine, University of Split, Šoltanska 2, 21000 Split, Croatia
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (D.G.); (M.D.B.)
| | - Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (D.G.); (M.D.B.)
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova 39, 1000 Ljubljana, Slovenia;
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital of Split, Šoltanska 1, 21000 Split, Croatia; (S.K.); (B.L.)
- School of Medicine, University of Split, Šoltanska 2, 21000 Split, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia;
- Center of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
- Correspondence: (B.H.); (M.B.)
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (D.G.); (M.D.B.)
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, 1000 Ljubljana, Slovenia
- Correspondence: (B.H.); (M.B.)
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Greene S, Cheng D, Vilke GM, Winkler G. How Should Native Crotalid Envenomation Be Managed in the Emergency Department? J Emerg Med 2021; 61:41-48. [PMID: 33622584 DOI: 10.1016/j.jemermed.2021.01.020] [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: 12/21/2020] [Accepted: 01/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pit vipers, also known as crotalids, are a group of snakes including rattlesnakes, copperheads, and cottonmouths (water moccasins). Crotalids have a broad geographic distribution across the United States, and bites from these snakes can carry significant morbidity. Their envenomations are characterized by local tissue effects, hematologic effects, and systemic effects. Envenomations are generally treated with 1 of 2 antivenoms available in the United States. OBJECTIVE We developed a series of clinical questions to assist and guide the emergency physician in the acute management of a patient envenomated by a crotalid. METHODS We conducted a PubMed literature review from January 1970 to May 2020 in English for articles with the keywords "bite" and "crotalidae." RESULTS Our literature search resulted in 177 articles. A total of 33 articles met criteria for rigorous review and citation in the development of these consensus guidelines. CONCLUSIONS Patients should be initially evaluated, stabilized, and assessed for local effects, hematologic effects, and systemic toxicity suggestive of envenomation. Antivenom should be given if toxic effects are present. Surgical intervention including debridement and fasciotomy should be avoided. Prophylactic antibiotics are not necessary.
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Affiliation(s)
- Spencer Greene
- Department of Emergency Medicine, HCA Houston Healthcare-Kingwood, University of Houston College of Medicine, Kingwood, Texas
| | - David Cheng
- Department of Emergency Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Gary M Vilke
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Garret Winkler
- Division of Medical Toxicology, Department of Emergency Medicine, University of California San Diego Health, VA San Diego Healthcare System, San Diego, California
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Current research into snake antivenoms, their mechanisms of action and applications. Biochem Soc Trans 2021; 48:537-546. [PMID: 32196542 DOI: 10.1042/bst20190739] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 01/11/2023]
Abstract
Snakebite is a major public health issue in the rural tropics. Antivenom is the only specific treatment currently available. We review the history, mechanism of action and current developments in snake antivenoms. In the late nineteenth century, snake antivenoms were first developed by raising hyperimmune serum in animals, such as horses, against snake venoms. Hyperimmune serum was then purified to produce whole immunoglobulin G (IgG) antivenoms. IgG was then fractionated to produce F(ab) and F(ab')2 antivenoms to reduce adverse reactions and increase efficacy. Current commercial antivenoms are polyclonal mixtures of antibodies or their fractions raised against all toxin antigens in a venom(s), irrespective of clinical importance. Over the last few decades there have been small incremental improvements in antivenoms, to make them safer and more effective. A number of recent developments in biotechnology and toxinology have contributed to this. Proteomics and transcriptomics have been applied to venom toxin composition (venomics), improving our understanding of medically important toxins. In addition, it has become possible to identify toxins that contain epitopes recognized by antivenom molecules (antivenomics). Integration of the toxinological profile of a venom and its composition to identify medically relevant toxins improved this. Furthermore, camelid, humanized and fully human monoclonal antibodies and their fractions, as well as enzyme inhibitors have been experimentally developed against venom toxins. Translation of such technology into commercial antivenoms requires overcoming the high costs, limited knowledge of venom and antivenom pharmacology, and lack of reliable animal models. Addressing such should be the focus of antivenom research.
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Sarmiento K, Rodríguez A, Quevedo-Buitrago W, Torres I, Ríos C, Ruíz L, Salazar J, Hidalgo-Martínez P, Diez H. Comparación de la eficacia, la seguridad y la farmacocinética de los antivenenos antiofídicos: revisión de literatura. UNIVERSITAS MÉDICA 2019. [DOI: 10.11144/javeriana.umed61-1.anti] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
En Colombia se presentan anualmente alrededor de 5000 casos de mordedura de serpiente y su tratamiento se basa en la neutralización con inmunoglobulinas completas purificadas, sin embargo, globalmente se utilizan antivenenos faboterápicos. Objetivo: Dar a conocer diferencias entre las generaciones de antivenenos, la importancia del veneno en la producción de anticuerpos, comparar aspectos farmacocinéticos y los efectos adversos en pacientes. Materiales Métodos: Se realizó una búsqueda de literatura en bases de datos utilizando combinaciones de los descriptores y términos Mesh, en inglés y español. Se cotejaron parámetros farmacocinéticos en estudios preclínicos y los efectos adversos en estudios clínicos. Resultados: Se encontraron diferencias debidas al tamaño de la fracción de la inmunoglobulina que la compone, así entre más pequeña es ésta, se observa mayor distribución a los tejidos y una vida media más corta, comparada con las moléculas más pesadas. Se encontraron estudios con disminución de efectos adversos con antivenenos faboterápicos
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Knudsen C, Ledsgaard L, Dehli RI, Ahmadi S, Sørensen CV, Laustsen AH. Engineering and design considerations for next-generation snakebite antivenoms. Toxicon 2019; 167:67-75. [DOI: 10.1016/j.toxicon.2019.06.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/22/2019] [Accepted: 06/03/2019] [Indexed: 11/27/2022]
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18
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Persistent pit viper envenomation in three dogs. Toxicon 2019; 166:83-87. [PMID: 31129161 DOI: 10.1016/j.toxicon.2019.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/15/2019] [Accepted: 05/20/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION North Central Florida is the home to several venomous snakes. The most clinically significant pit vipers include the Eastern Diamondback Rattlesnake, the Water Moccasin, and less commonly the Timber Rattlesnake. Many of the dogs and cats that become envenomated by these particular snakes have moderate to severe clinical signs requiring the use of antivenom in doses that can range from 1 to 20 vials with the average case requiring two vials. Oftentimes, the pet owners' financial limitations restrict the amount of antivenom that can be administered initially to severely envenomed cases. Most of these patients will become clinically stable after the first 48 hours of treatment, but there are rare instances where some patients will follow this same initial course, and then revert back to the initial signs of envenomation associated with delayed absorption of redistributed venom from other tissue sites in addition to the bite site. This report describes three dogs that showed signs of persistent and/or recurrent envenomation requiring additional doses of antivenom. METHODS The medical records of three dogs showing signs of persistent envenomation were reviewed by the author who was available and provided assistance during the course of the dogs' respective hospitalizations. The dog's signalment, time of year of the envenomation, clinical signs, treatment, and outcome are provided in each case. RESULTS Each of these three dogs showed severe signs of envenomation characterized by marked mental depression, prostration, hemorrhagic lymphedema, and evidence of prolonged coagulation times. Initial treatment in each consisted of intravenous crystalloid solution and polyvalent crotalid antivenom that exceeded the usual average dose as reported in the literature. After the coagulation test normalized during the first three days, all of them reverted to abnormal prolonged clotting times with signs of clinical deterioration requiring additional doses of antivenom. Clinical stability was eventually reached and all dogs survived to be discharged. CONCLUSIONS The clinical course of the three dogs described in this study showed that veterinary patients can experience persistent envenomation in a similar manner as described in humans. It behooves the veterinary practitioner to be aware of this complication and to be prepared to extend antivenom treatment as deemed necessary.
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Rattlesnake venom-induced recurrent coagulopathy in first trimester pregnant women – Two Cases. Toxicon 2019; 163:8-11. [DOI: 10.1016/j.toxicon.2019.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/23/2019] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
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Paniagua D, Vergara I, Román R, Romero C, Benard-Valle M, Calderón A, Jiménez L, Bernas MJ, Witte MH, Boyer LV, Alagón A. Antivenom effect on lymphatic absorption and pharmacokinetics of coral snake venom using a large animal model. Clin Toxicol (Phila) 2019; 57:727-734. [PMID: 30773936 DOI: 10.1080/15563650.2018.1550199] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Context: Historically, administration and dosing of antivenom (AV) have been guided primarily by physician judgment because of incomplete understanding of the envenomation process. As demonstrated previously, lymphatic absorption plays a major role in the availability and pharmacokinetics (PK) of coral snake venom injected subcutaneously, which suggests that absorption from subcutaneous tissue is the limiting step for venom bioavailability, supporting the notion that the bite site is an ongoing venom depot. This feature may underlie the recurrence phenomena reported in viperid envenomation that appear to result from a mismatch between venom and AV PK. The role of lymphatic absorption in neutralization of venom by AV administered intravenously remains unclear. Methods: The effect of AV on systemic bioavailability and neutralization of Micrurus fulvius venom was assessed using a central lymph-cannulated sheep model. Venom was administered by subcutaneous injection in eight sheep, four with and four without thoracic duct cannulation and drainage. Two hours after venom injection, AV was administered intravenously. Venom and AV concentrations in serum and lymph were determined by ELISA assay from samples collected over a 6-h period and in tissues harvested post-mortem. Results: After AV injection, venom levels in serum fell immediately to undetectable with a subsequent increase in concentration attributable to non-toxic venom proteins. In lymph, AV became detectable 6 min after treatment; venom levels dropped concurrently but remained detectable 4 h later. Post-mortem samples from the venom injection site confirmed the presence of venom near the point of injection. Neither venom nor AV was detected at significant concentrations in major organs or contralateral skin. Conclusions: Intravenous AV immediately neutralizes venom in the bloodstream and can extravasate to neutralize venom absorbed by lymph but this neutralization seems to be slow and incomplete. Residual venom in the inoculation site demonstrates that this site functions as a depot where it is not neutralized by AV, which allows the venom to remain active with slow delivery to the bloodstream for ongoing systemic distribution.
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Affiliation(s)
- D Paniagua
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - I Vergara
- b Department of Chemical and Biological Sciences, Sciences School , Universidad de las Américas Puebla , Cholula , México
| | - R Román
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - C Romero
- c Centro Universitario UAEM Amecameca, Universidad Autónoma del Estado de México , Amecameca de Juarez , México
| | - M Benard-Valle
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - A Calderón
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - L Jiménez
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - M J Bernas
- d Department of Medical Education , TCU and UNTHSC School of Medicine , Fort Worth , TX , USA.,e Department of Surgery , University of Arizona , Tucson , AZ , USA
| | - M H Witte
- e Department of Surgery , University of Arizona , Tucson , AZ , USA
| | - L V Boyer
- f Venom Immunochemistry, Pharmacology, and Emergency Response (VIPER) Institute, University of Arizona , Tucson , AZ , USA
| | - A Alagón
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
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Venomics of Trimeresurus (Popeia) nebularis, the Cameron Highlands Pit Viper from Malaysia: Insights into Venom Proteome, Toxicity and Neutralization of Antivenom. Toxins (Basel) 2019; 11:toxins11020095. [PMID: 30736335 PMCID: PMC6410072 DOI: 10.3390/toxins11020095] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/23/2019] [Accepted: 01/30/2019] [Indexed: 12/18/2022] Open
Abstract
Trimeresurus nebularis is a montane pit viper that causes bites and envenomation to various communities in the central highland region of Malaysia, in particular Cameron’s Highlands. To unravel the venom composition of this species, the venom proteins were digested by trypsin and subjected to nano-liquid chromatography-tandem mass spectrometry (LC-MS/MS) for proteomic profiling. Snake venom metalloproteinases (SVMP) dominated the venom proteome by 48.42% of total venom proteins, with a characteristic distribution of P-III: P-II classes in a ratio of 2:1, while P-I class was undetected. Snaclecs constituted the second most venomous protein family (19.43%), followed by snake venom serine proteases (SVSP, 14.27%), phospholipases A2 (5.40%), disintegrins (5.26%) and minor proteins including cysteine-rich secretory proteins, L-amino acid oxidases, phosphodiesterases, 5′-nucleotidases. The venomic profile correlates with local (painful progressive edema) and systemic (hemorrhage, coagulopathy, thrombocytopenia) manifestation of T. nebularis envenoming. As specific antivenom is unavailable for T. nebularis, the hetero-specific Thai Green Pit viper Monovalent Antivenom (GPVAV) was examined for immunological cross-reactivity. GPVAV exhibited good immunoreactivity to T. nebularis venom and the antivenom effectively cross-neutralized the hemotoxic and lethal effects of T. nebularis (lethality neutralizing potency = 1.6 mg venom per mL antivenom). The findings supported GPVAV use in treating T. nebularis envenoming.
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Effects of Two Fractions of Swietenia macrophylla and Catechin on Muscle Damage Induced by BothropsVenom and PLA₂. Toxins (Basel) 2019; 11:toxins11010040. [PMID: 30646591 PMCID: PMC6356255 DOI: 10.3390/toxins11010040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/04/2019] [Accepted: 01/07/2019] [Indexed: 01/09/2023] Open
Abstract
Plant natural products can attenuate the myonecrosis caused by Bothrops snake venom and their phospholipases A₂ (PLA₂). In this study, we evaluated the effects of two fractions (F4 and F6) from Swietenia macrophylla and purified catechin on the muscle damage caused by a myotoxic PLA₂ from Colombian Bothrops asper venom (BaColPLA₂) in mice and by Bothrops marmoratus venom from Brazil in mouse phrenic nerve-diaphragm muscle (PND) preparations in vitro. Male mice were injected with PLA₂ (50 µg) in the absence or presence of F4, F6, and catechin, in the gastrocnemius muscle and then killed 3, 7, 14, and 28 h later for histopathological analysis of myonecrosis, leukocyte infiltration, and the presence of collagen. Fractions F4 and F6 (500 µg) and catechin (90 µg) significantly reduced the extent of necrosis at all-time intervals. These two fractions and catechin also attenuated the leukocyte infiltration on day 3, as did catechin on day 14. There was medium-to-moderate collagen deposition in all groups up to day 7, but greater deposition on days 14 and 28 in the presence of F6 and catechin. Bothrops marmoratus venom (100 µg/mL) caused slight (~25%) muscle facilitation after 10 minutes and weak neuromuscular blockade (~64% decrease in contractile activity after a 120-minute incubation). Pre-incubation of venom with F4 or F6 abolished the facilitation, whereas catechin, which was itself facilitatory, did not. All three fractions attenuated the venom-induced decrease in muscle contractions. These findings indicate that fractions and catechin from S. macrophylla can reduce the muscle damage caused by Bothrops venom and PLA₂. These fractions or their components could be useful for treating venom-induced local damage.
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León G, Vargas M, Segura Á, Herrera M, Villalta M, Sánchez A, Solano G, Gómez A, Sánchez M, Estrada R, Gutiérrez JM. Current technology for the industrial manufacture of snake antivenoms. Toxicon 2018; 151:63-73. [DOI: 10.1016/j.toxicon.2018.06.084] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/28/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
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Fry BG. Snakebite: When the Human Touch Becomes a Bad Touch. Toxins (Basel) 2018; 10:E170. [PMID: 29690533 PMCID: PMC5923336 DOI: 10.3390/toxins10040170] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 01/08/2023] Open
Abstract
Many issues and complications in treating snakebite are a result of poor human social, economic and clinical intervention and management. As such, there is scope for significant improvements for reducing incidence and increasing patient outcomes. Snakes do not target humans as prey, but as our dwellings and farms expand ever farther and climate change increases snake activity periods, accidental encounters with snakes seeking water and prey increase drastically. Despite its long history, the snakebite crisis is neglected, ignored, underestimated and fundamentally misunderstood. Tens of thousands of lives are lost to snakebites each year and hundreds of thousands of people will survive with some form of permanent damage and reduced work capacity. These numbers are well recognized as being gross underestimations due to poor to non-existent record keeping in some of the most affected areas. These underestimations complicate achieving the proper recognition of snakebite’s socioeconomic impact and thus securing foreign aid to help alleviate this global crisis. Antivenoms are expensive and hospitals are few and far between, leaving people to seek help from traditional healers or use other forms of ineffective treatment. In some cases, cheaper, inappropriately manufactured antivenom from other regions is used despite no evidence for their efficacy, with often robust data demonstrating they are woefully ineffective in neutralizing many venoms for which they are marketed for. Inappropriate first-aid and treatments include cutting the wound, tourniquets, electrical shock, immersion in ice water, and use of ineffective herbal remedies by traditional healers. Even in the developed world, there are fundamental controversies including fasciotomy, pressure bandages, antivenom dosage, premedication such as adrenalin, and lack of antivenom for exotic snakebites in the pet trade. This review explores the myriad of human-origin factors that influence the trajectory of global snakebite causes and treatment failures and illustrate that snakebite is as much a sociological and economic problem as it is a medical one. Reducing the incidence and frequency of such controllable factors are therefore realistic targets to help alleviate the global snakebite burden as incremental improvements across several areas will have a strong cumulative effect.
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Affiliation(s)
- Bryan G Fry
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St. Lucia, QLD 4072, Australia.
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Laureano M, Crowther M. Severe coagulopathy after a massasauga rattlesnake bite. CMAJ 2018; 190:E191-E194. [PMID: 29565019 DOI: 10.1503/cmaj.170783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Marissa Laureano
- Departments of Medicine (Laureano), and Pathology and Molecular Medicine (Laureano, Crowther), Faculty of Health Sciences, McMaster University, Hamilton, Ont.
| | - Mark Crowther
- Departments of Medicine (Laureano), and Pathology and Molecular Medicine (Laureano, Crowther), Faculty of Health Sciences, McMaster University, Hamilton, Ont
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Berry CM. Antibody immunoprophylaxis and immunotherapy for influenza virus infection: Utilization of monoclonal or polyclonal antibodies? Hum Vaccin Immunother 2017; 14:796-799. [PMID: 28854120 DOI: 10.1080/21645515.2017.1363135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Control programs for emerging influenza are in urgent need of novel therapeutic strategies to mitigate potentially devastating threats from pathogenic strains with pandemic potential. Current vaccines and antivirals have inherent limitations in efficacy, especially with rapid evolutionary changes of influenza viruses. Antibody-based antiviral protection harnesses the natural power of the immune system. Antibodies present prophylactic and therapeutic intervention options for prevention and control of influenza, especially for at-risk populations. Specific monoclonal antibodies are well defined in purity and initial efficacy but polyclonal antibodies are easier to scale-up and cost-effective with long-term efficacy, using batches with broadly neutralizing properties against influenza variants. This review presents the pros and cons of monoclonal versus polyclonal antibody therapy for influenza.
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Affiliation(s)
- Cassandra M Berry
- a Department of Medical and Molecular Sciences , School of Veterinary and Life Sciences, Murdoch University , Perth , Western Australia , Australia
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Yankin I, Schaer M, Johnson M, Meland T, Londoño LA. Persistent pit viper envenomation in a cat. JFMS Open Rep 2017; 3:2055116917737463. [PMID: 29123914 PMCID: PMC5661758 DOI: 10.1177/2055116917737463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Case summary A 4-year-old female spayed, indoor/outdoor domestic mediumhair cat presented with multiple bleeding puncture wounds and hemorrhagic shock. The cat was diagnosed with suspected pit viper envenomation based on the location and appearance of the bite wounds, as well as the presence of severe coagulopathy with prolonged activated coagulation time (762 s), which responded to antivenom administration. The clinical course of the cat was unique owing to the prolonged clinical signs of envenomation that appeared as intermittent coagulopathy and hemorrhage over a 2 week period. Five vials of antivenom were administered and three units of packed red blood cells were transfused over a 7 day period. The cat made a complete recovery with cessation of hemorrhage and normalization of clotting times. Relevance and novel information This is the first report of persistent pit viper venom-induced coagulopathy in the feline veterinary literature.
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Affiliation(s)
| | | | | | | | - Leonel A Londoño
- Leonel A Londoño DVM, DACVECC, Department of Small Animal Clinical Sciences, University of Florida, 2015 SW 16th Ave, PO Box 100126, Gainesville, FL 326100126, USA
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Melatonin inhibits snake venom and antivenom induced oxidative stress and augments treatment efficacy. Acta Trop 2017; 169:14-25. [PMID: 28089603 DOI: 10.1016/j.actatropica.2017.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/10/2016] [Accepted: 01/07/2017] [Indexed: 12/25/2022]
Abstract
Snakebite is a neglected health hazard. Its patho-physiology has largely been focused on systemic and local toxicities; whereas, venom and antivenom induced oxidative stress has long been ignored. Antivenom therapy although neutralizes venom lethality and saves many lives, remains ineffective against oxidative stress. This prompted us to complement antivenom with an antioxidant molecule melatonin that would protect against oxidative stress and increase the efficacy of the existing snakebite therapy. Here we show that D. russelli and E. carinatus venoms induce strong oxidative stress that persists even after antivenom administration in mice model. Additionally, antivenoms also induce oxidative stress. Polyvalent antivenom induce more oxidative stress than monovalent antivenom. Strikingly, antivenom and melatonin together not only inhibit venom and antivenom induced oxidative stress but also significantly reduce the neutralizing antivenom dose. This study provides a therapeutic potential for enhancing the existing snakebite therapy. The combined treatment of antivenom+melatonin would prevent the upsurge of oxidative stress as well as minimize the antivenom load. Thus the investigation offers immense scope for physicians and toxinologists to reinvestigate, design new strategies and think beyond the conventional mode of antivenom therapy.
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Pyankov OV, Setoh YX, Bodnev SA, Edmonds JH, Pyankova OG, Pyankov SA, Pali G, Belford S, Lu L, La M, Lovrecz G, Volchkova VA, Chappell KJ, Watterson D, Marsh G, Young PR, Agafonov AA, Farmer JF, Volchkov VE, Suhrbier A, Khromykh AA. Successful post-exposure prophylaxis of Ebola infected non-human primates using Ebola glycoprotein-specific equine IgG. Sci Rep 2017; 7:41537. [PMID: 28155869 PMCID: PMC5290740 DOI: 10.1038/srep41537] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 12/19/2016] [Indexed: 12/31/2022] Open
Abstract
Herein we describe production of purified equine IgG obtained from horses immunized with plasmid DNA followed by boosting with Kunjin replicon virus-like particles both encoding a modified Ebola glycoprotein. Administration of the equine IgG over 5 days to cynomolgus macaques infected 24 hours previously with a lethal dose of Ebola virus suppressed viral loads by more than 5 logs and protected animals from mortality. Animals generated their own Ebola glycoprotein-specific IgG responses 9-15 days after infection, with circulating virus undetectable by day 15-17. Such equine IgG may find utility as a post-exposure prophylactic for Ebola infection and provides a low cost, scalable alternative to monoclonal antibodies, with extensive human safety data and WHO-standardized international manufacturing capability available in both high and low income countries.
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Affiliation(s)
- Oleg V. Pyankov
- State Center for Virology and Biotechnology Vector, Koltsovo, Russian Federation
| | - Yin Xiang Setoh
- Australian Infectious Diseases Research Centre, School of Chemistry and Molecular Biosciences, University of Queensland, St Lucia, Brisbane, QLD, Australia
| | - Sergey A. Bodnev
- State Center for Virology and Biotechnology Vector, Koltsovo, Russian Federation
| | - Judith H. Edmonds
- Australian Infectious Diseases Research Centre, School of Chemistry and Molecular Biosciences, University of Queensland, St Lucia, Brisbane, QLD, Australia
| | - Olga G. Pyankova
- State Center for Virology and Biotechnology Vector, Koltsovo, Russian Federation
| | - Stepan A. Pyankov
- State Center for Virology and Biotechnology Vector, Koltsovo, Russian Federation
| | - Gabor Pali
- Australian Infectious Diseases Research Centre, School of Chemistry and Molecular Biosciences, University of Queensland, St Lucia, Brisbane, QLD, Australia
| | | | - Louis Lu
- Bio Medical Manufacturing, Fermentation and Protein Production Facility, CSIRO, Clayton, VIC, Australia
| | - Mylinh La
- Bio Medical Manufacturing, Fermentation and Protein Production Facility, CSIRO, Clayton, VIC, Australia
| | - George Lovrecz
- Bio Medical Manufacturing, Fermentation and Protein Production Facility, CSIRO, Clayton, VIC, Australia
| | - Valentina A. Volchkova
- Molecular Basis of Viral Pathogenicity, CIRI, INSERM, U1111-CNRS UMR5308, Université de Lyon, Université Claude Bernard Lyon 1, Ecole Normale Supérieure de Lyon, France
| | - Keith J. Chappell
- Australian Infectious Diseases Research Centre, School of Chemistry and Molecular Biosciences, University of Queensland, St Lucia, Brisbane, QLD, Australia
| | - Daniel Watterson
- Australian Infectious Diseases Research Centre, School of Chemistry and Molecular Biosciences, University of Queensland, St Lucia, Brisbane, QLD, Australia
| | - Glenn Marsh
- Australian Animal Health Laboratory, CSIRO Health and Biosecurity, Geelong, VIC, Australia
| | - Paul R. Young
- Australian Infectious Diseases Research Centre, School of Chemistry and Molecular Biosciences, University of Queensland, St Lucia, Brisbane, QLD, Australia
| | | | | | - Victor E. Volchkov
- Molecular Basis of Viral Pathogenicity, CIRI, INSERM, U1111-CNRS UMR5308, Université de Lyon, Université Claude Bernard Lyon 1, Ecole Normale Supérieure de Lyon, France
| | - Andreas Suhrbier
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Alexander A. Khromykh
- Australian Infectious Diseases Research Centre, School of Chemistry and Molecular Biosciences, University of Queensland, St Lucia, Brisbane, QLD, Australia
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Brvar M, Kurtović T, Grenc D, Lang Balija M, Križaj I, Halassy B. Vipera ammodytes bites treated with antivenom ViperaTAb: a case series with pharmacokinetic evaluation. Clin Toxicol (Phila) 2017; 55:241-248. [PMID: 28092984 DOI: 10.1080/15563650.2016.1277235] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONTEXT In clinical practice it is difficult to differentiate between V. berus and V. ammodytes venomous bites. In the past this was not a concern, but due to the current shortage in Viperfav™ and European viper venom antiserum availability, V. a. ammodytes venomous bites have recently been treated with ViperaTAb®, which is a pharmaceutical formulation containing a monospecific ovine Fab fragments against the venom of V. berus. OBJECTIVE To evaluate ViperaTAb® in V. a. ammodytes envenomations. MATERIALS AND METHODS This is a prospective case series of three consecutive patients envenomed by V. a. ammodytes snakebite treated with ViperaTAb®. V. ammodytes venom, neurotoxic ammodytoxins, and Fab fragment levels were determined in serum samples and a pharmacokinetic analysis of the antivenom Fab fragments was carried out. RESULTS Three patients bitten by V. a. ammodytes with extensive local swelling, neurological symptoms and recurrent thrombocytopenia were treated with ViperaTAb®. V. ammodytes venom was detected in serum of all three patients. Ammodytoxins were detected in the serum of only the most severely envenomed patient who developed neurological symptoms. In the presented moderate cases, a dose of 8 mL of ViperaTAb® reduced swelling and improved systemic effects, such as thrombocytopenia. However, this dose of ViperaTAb® was not effective in the most severely envenomed patient with the highest serum values of V. ammodytes venom. In this case ViperaTAb® did not stop local swelling and it had no effect on neurological signs. ViperaTAb®'s systemic clearance, distribution and elimination half-lives were 4.3-13.4 mL/h/kg, 1.2-3.2 h and 14.1-55.4 h, respectively. CONCLUSIONS In patients envenomed by V. a. ammodytes venom, ViperaTAb® reduces moderate swelling and temporarily improves systemic effects, except neurological symptoms. ViperaTAb® application induces a decrement of V. ammodytes venom level in the blood, but did not affect serum concentration of neurotoxic ammodytoxins in the one patient with measurable concentrations.
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Affiliation(s)
- Miran Brvar
- a Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Faculty of Medicine , Institute of Pathophysiology, University of Ljubljana , Ljubljana , Slovenia
| | - Tihana Kurtović
- c Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb , Zagreb , Croatia
| | - Damjan Grenc
- a Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Maja Lang Balija
- c Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb , Zagreb , Croatia
| | - Igor Križaj
- d Department of Molecular and Biomedical Sciences , Jožef Stefan Institute , Ljubljana , Slovenia.,e Faculty of Chemistry and Chemical Technology , University of Ljubljana , Ljubljana , Slovenia
| | - Beata Halassy
- c Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb , Zagreb , Croatia
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Tan CH, Liew JL, Tan KY, Tan NH. Assessing SABU (Serum Anti Bisa Ular), the sole Indonesian antivenom: A proteomic analysis and neutralization efficacy study. Sci Rep 2016; 6:37299. [PMID: 27869134 PMCID: PMC5116744 DOI: 10.1038/srep37299] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 10/27/2016] [Indexed: 02/08/2023] Open
Abstract
Serum Anti Ular Bisa (SABU) is the only snake antivenom produced locally in Indonesia; however, its effectiveness has not been rigorously evaluated. This study aimed to assess the protein composition and neutralization efficacy of SABU. SDS polyacrylamide gel electrophoresis, size-exclusion liquid chromatography and shotgun proteomics revealed that SABU consists of F(ab’)2 but a significant amount of dimers, protein aggregates and contaminant albumins. SABU moderately neutralized Calloselasma rhodostoma venom (potency of 12.7 mg venom neutralized per ml antivenom, or 121.8 mg venom per g antivenom protein) and Bungarus fasciatus venom (0.9 mg/ml; 8.5 mg/g) but it was weak against the venoms of Naja sputatrix (0.3 mg/ml; 2.9 mg/g), Naja sumatrana (0.2 mg/ml; 1.8 mg/g) and Bungarus candidus (0.1 mg/ml; 1.0 mg/g). In comparison, NPAV, the Thai Neuro Polyvalent Antivenom, outperformed SABU with greater potencies against the venoms of N. sputatrix (0.6 mg/ml; 8.3 mg/g), N. sumatrana (0.5 mg/ml; 7.1 mg/g) and B. candidus (1.7 mg/ml; 23.2 mg/g). The inferior efficacy of SABU implies that a large antivenom dose is required clinically for effective treatment. Besides, the antivenom contains numerous impurities e.g., albumins that greatly increase the risk of hypersensitivity. Together, the findings indicate that the production of SABU warrants further improvement.
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Affiliation(s)
- Choo Hock Tan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Jia Lee Liew
- Department of Pharmacology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Kae Yi Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Nget Hong Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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Steuerwald MT, Gabbard SRK, Beauchamp GA, Riddle MK, Otten EJ. Administration of CroFab Antivenom by a Helicopter Emergency Medical Service Team. Air Med J 2016; 35:371-373. [PMID: 27894563 DOI: 10.1016/j.amj.2016.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/09/2016] [Accepted: 08/20/2016] [Indexed: 10/20/2022]
Abstract
The case presented here highlights an unconventional use of a helicopter emergency medical service (HEMS) to provide a specialized medication to a critically ill patient when definitive transport was delayed. A 39-year-old man presented to a rural hospital 1 hour after sustaining a copperhead envenomation. He developed severe symptoms and was intubated. Arrangements were made for transfer to a tertiary referral center by HEMS, but because of incoming weather conditions, the team would not be able to make the return flight safely. The decision was made for the HEMS team to fly antivenom to the patient, administer the medication, and then transport the patient by ground to the tertiary medical center. This plan was executed, and the patient was safely transported to the accepting facility. Antivenom is most effective when administered early because this will halt the progression of edema and may reverse the systemic effects of envenomation. In this case, HEMS transport of antivenom to the patient with severe toxicity prevented a delay to administration and likely improved the patient's outcome. Although the traditional role of HEMS is to provide rapid transport to critically ill patients, HEMS teams can also function to deliver specialized medications to remote settings.
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Affiliation(s)
- Michael T Steuerwald
- Assistant Professor, Department of Emergency Medicine, University of Wisconsin, Madison and Flight Physician, UW Med Flight, UW Hospital and Clinics, Madison.
| | - Season R K Gabbard
- Flight Nurse, AirCare and Mobile Care, University of Cincinnati Medical Center, Cincinnati, OH
| | - Gillian A Beauchamp
- Fellow, Toxicology, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Matthew K Riddle
- Flight Physician, AirCare and Mobile Care, University of Cincinnati Medical Center and Resident Physician, Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | - Edward J Otten
- Professor, Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH
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Lasoff DR, Ruha AM, Curry SC, Koh C, Clark RF. A new F(abʹ) 2 antivenom for the treatment of crotaline envenomation in children. Am J Emerg Med 2016; 34:2003-2006. [DOI: 10.1016/j.ajem.2016.07.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/25/2016] [Accepted: 07/29/2016] [Indexed: 12/24/2022] Open
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Kurtović T, Brvar M, Grenc D, Lang Balija M, Križaj I, Halassy B. A Single Dose of Viperfav(TM) May Be Inadequate for Vipera ammodytes Snake Bite: A Case Report and Pharmacokinetic Evaluation. Toxins (Basel) 2016; 8:toxins8080244. [PMID: 27548220 PMCID: PMC4999860 DOI: 10.3390/toxins8080244] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/11/2016] [Indexed: 11/26/2022] Open
Abstract
ViperfavTM is a commercial F(ab’)2 antivenom prepared against European vipers venom. It is safe and effective for treating envenomation caused by Vipera aspis and Vipera berus. Therapeutic efficacy for treating Vipera ammodytes ammodytes (V. a. ammodytes) envenoming has not been yet described, although protective efficacy has been demonstrated in preclinical studies. We report on a 32-year-old man bitten by V. a. ammodytes who was treated with Viperfav™. Viperfav™ promptly reduced local extension and improved systemic pathological signs, but 24 h after the incident a recurrence of thrombocytopenia occurred despite a favorable pharmacokinetic profile with systemic clearance (1.64 (mL·h−1)·kg−1) and elimination half-life (97 h) among the highest ever reported. The recommended dose of Viperfav™ for V. aspis and V. berus bites may be inadequate for serious V. a. ammodytes envenomations. Following V. a. ammodytes bite, serial blood counts and coagulation profiles should be performed to help guide Viperfav™ treatment, along with supplemental administration as indicated.
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Affiliation(s)
- Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, HR-10000 Zagreb, Croatia.
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia.
- Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, 1000 Ljubljana, Slovenia.
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia.
| | - Maja Lang Balija
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, HR-10000 Zagreb, Croatia.
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova 39, 1000 Ljubljana, Slovenia.
- Faculty of Chemistry and Chemical Technology, University of Ljubljana, Večna pot 113, 1000 Ljubljana, Slovenia.
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, HR-10000 Zagreb, Croatia.
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Tan KY, Tan CH, Sim SM, Fung SY, Tan NH. Geographical venom variations of the Southeast Asian monocled cobra (Naja kaouthia): venom-induced neuromuscular depression and antivenom neutralization. Comp Biochem Physiol C Toxicol Pharmacol 2016; 185-186:77-86. [PMID: 26972756 DOI: 10.1016/j.cbpc.2016.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 03/06/2016] [Accepted: 03/09/2016] [Indexed: 11/30/2022]
Abstract
The Southeast Asian monocled cobras (Naja kaouthia) exhibit geographical variations in their venom proteomes, especially on the composition of neurotoxins. This study compared the neuromuscular depressant activity of the venoms of N. kaouthia from Malaysia (NK-M), Thailand (NK-T) and Vietnam (NK-V), and the neutralization of neurotoxicity by a monospecific antivenom. On chick biventer cervicis nerve-muscle preparation, all venoms abolished the indirect twitches, with NK-T venom being the most potent (shortest t90, time to 90% twitch inhibition), followed by NK-V and NK-M. Acetylcholine and carbachol failed to reverse the blockade, indicating irreversible/pseudo-irreversible post-synaptic neuromuscular blockade. KCl restored the twitches variably (NK-M preparation being the least responsive), consistent with different degree of muscle damage. The findings support that NK-T venom has the most abundant curarimimetic alpha-neurotoxins, while NK-M venom contains more tissue-damaging cytotoxins. Pre-incubation of tissue with N. kaouthia monovalent antivenom (NKMAV) prevented venom-induced twitch depression, with the NK-T preparation needing the largest antivenom dose. NKMAV added after the onset of neuromuscular depression could only halt the inhibitory progression but failed to restore full contraction. The findings highlight the urgency of early antivenom administration to sequester as much circulating neurotoxins as possible, thereby hastening toxin elimination from the circulation. In envenomed mice, NKMAV administered upon the first neurological sign neutralized the neurotoxic effect, with the slowest full recovery noticed in the NK-T group. This is consistent with the high abundance of neurotoxins in the NK-T venom, implying that a larger amount or repeated dosing of NKMAV may be required in NK-T envenomation.
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Affiliation(s)
- Kae Yi Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Choo Hock Tan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Si Mui Sim
- Department of Pharmacology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Shin Yee Fung
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Nget Hong Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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Biodistribution and Lymphatic Tracking of the Main Neurotoxin of Micrurus fulvius Venom by Molecular Imaging. Toxins (Basel) 2016; 8:85. [PMID: 27023607 PMCID: PMC4848612 DOI: 10.3390/toxins8040085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/16/2016] [Accepted: 03/16/2016] [Indexed: 11/19/2022] Open
Abstract
The venom of the Eastern coral snake Micrurus fulvius can cause respiratory paralysis in the bitten patient, which is attributable to β-neurotoxins (β-NTx). The aim of this work was to study the biodistribution and lymphatic tracking by molecular imaging of the main β-NTx of M. fulvius venom. β-NTx was bioconjugated with the chelator diethylenetriaminepenta-acetic acid (DTPA) and radiolabeled with the radionuclide Gallium-67. Radiolabeling efficiency was 60%–78%; radiochemical purity ≥92%; and stability at 48 h ≥ 85%. The median lethal dose (LD50) and PLA2 activity of bioconjugated β-NTx decreased 3 and 2.5 times, respectively, in comparison with native β-NTx. The immune recognition by polyclonal antibodies decreased 10 times. Biodistribution of β-NTx-DTPA-67Ga in rats showed increased uptake in popliteal, lumbar nodes and kidneys that was not observed with 67Ga-free. Accumulation in organs at 24 h was less than 1%, except for kidneys, where the average was 3.7%. The inoculation site works as a depot, since 10% of the initial dose of β-NTx-DTPA-67Ga remains there for up to 48 h. This work clearly demonstrates the lymphatic system participation in the biodistribution of β-NTx-DTPA-67Ga. Our approach could be applied to analyze the role of the lymphatic system in snakebite for a better understanding of envenoming.
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Witsil AJ, Wells RJ, Woods C, Rao S. 272 cases of rattlesnake envenomation in dogs: Demographics and treatment including safety of F(ab')2 antivenom use in 236 patients. Toxicon 2015; 105:19-26. [PMID: 26341419 DOI: 10.1016/j.toxicon.2015.08.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 08/25/2015] [Accepted: 08/27/2015] [Indexed: 10/23/2022]
Abstract
Medical records of 272 rattlesnake envenomations of canines from 5 veterinary emergency centers in Maricopa County, Arizona between 2010 and 2012 were investigated. The objectives were to examine the patient demographics, severity of clinical signs, and treatment modalities employed, in order to discuss the outcomes of certain therapies including glucocorticoid use, antibiotic use, rattlesnake vaccination, and safety of antivenom administration in dogs. Evaluation was performed to model each response (survival, proposed canine snakebite severity score (cSSS), and length of stay) as a function of multiple variables. Of the 272 bite incidences, 8 dogs had a fatal outcome. In dogs older than 10 years, there was a greater likelihood of fatal outcome associated with a longer delay between the bite and presentation. 236 of the envenomated patients were treated with a F(ab')2 antivenom, 24 with a whole immunoglobulin antivenom, and 12 with both products. Overall incidence of acute hypersensitivity reaction was 0.7% with one incident observed in each antivenom group and F(ab')2 antivenom administration having the lowest rate of acute hypersensitivity reactions; no reactions were life-threatening. Antivenom administration was found to be generally safe in treatment of canine rattlesnake envenomation. In view of the results of this study, in dogs with rattlesnake envenomation, there is no evidence that use of glucocorticoids, diphenhydramine, prophylactic antibiotics, or vaccination lessen morbidity or mortality.
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Affiliation(s)
- Amanda J Witsil
- Colorado State University Veterinary Teaching Hospital, 300 W. Drake Road, Fort Collins, CO 80523, USA.
| | - Raegan J Wells
- Colorado State University Veterinary Teaching Hospital, 300 W. Drake Road, Fort Collins, CO 80523, USA.
| | - Craig Woods
- Colorado State University Veterinary Teaching Hospital, 300 W. Drake Road, Fort Collins, CO 80523, USA.
| | - Sangeeta Rao
- Colorado State University Veterinary Teaching Hospital, 300 W. Drake Road, Fort Collins, CO 80523, USA.
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Isbister GK, Maduwage K, Saiao A, Buckley NA, Jayamanne SF, Seyed S, Mohamed F, Chathuranga U, Mendes A, Abeysinghe C, Karunathilake H, Gawarammana I, Lalloo DG, de Silva HJ. Population Pharmacokinetics of an Indian F(ab')2 Snake Antivenom in Patients with Russell's Viper (Daboia russelii) Bites. PLoS Negl Trop Dis 2015; 9:e0003873. [PMID: 26135318 PMCID: PMC4489840 DOI: 10.1371/journal.pntd.0003873] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 06/02/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is limited information on antivenom pharmacokinetics. This study aimed to investigate the pharmacokinetics of an Indian snake antivenom in humans with Russell's viper bites. METHODS/PRINCIPAL FINDINGS Patient data and serial blood samples were collected from patients with Russell's viper (Daboia russelii) envenoming in Sri Lanka. All patients received Indian F(ab')2 snake antivenom manufactured by VINS Bioproducts Ltd. Antivenom concentrations were measured with sandwich enzyme immunoassays. Timed antivenom concentrations were analysed using MONOLIXvs4.2. One, two and three compartment models with zero order input and first order elimination kinetics were assessed. Models were parameterized with clearance (CL), intercompartmental clearance (Q), central compartment volume (V) and peripheral compartment volume (VP). Between-subject-variability (BSV) on relative bioavailability (F) was included to account for dose variations. Covariates effects (age, sex, weight, antivenom batch, pre-antivenom concentrations) were explored by visual inspection and in model building. There were 75 patients, median age 57 years (40-70 y) and 64 (85%) were male. 411 antivenom concentration data points were analysed. A two compartment model with zero order input, linear elimination kinetics and a combined error model best described the data. Inclusion of BSV on F and weight as a covariate on V improved the model. Inclusion of pre-antivenom concentrations or different batches on BSV of F did not. Final model parameter estimates were CL,0.078 L h(-1), V,2.2L, Q,0.178 L h(-1) and VP,8.33L. The median half-life of distribution was 4.6 h (10-90%iles:2.6-7.1 h) and half-life of elimination, 140 h (10th-90th percentilesx:95-223h). CONCLUSION Indian F(ab')2 snake antivenom displayed biexponential disposition pharmacokinetics, with a rapid distribution half-life and more prolonged elimination half-life.
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Affiliation(s)
- Geoffrey K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Kalana Maduwage
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Ana Saiao
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
| | - Nicholas A. Buckley
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Shaluka F. Jayamanne
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Shahmy Seyed
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Umesh Chathuranga
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Alexandre Mendes
- School of Electrical Engineering and Computer Science, University of Newcastle, Newcastle, New South Wales, Australia
| | | | | | - Indika Gawarammana
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - David G. Lalloo
- Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - H. Janaka de Silva
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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Maduwage K, O'Leary MA, Scorgie FE, Shahmy S, Mohamed F, Abeysinghe C, Karunathilake H, Lincz LF, Gnanathasan CA, Isbister GK. Detection of venom after antivenom is not associated with persistent coagulopathy in a prospective cohort of Russell's viper (Daboia russelii) envenomings. PLoS Negl Trop Dis 2014; 8:e3304. [PMID: 25521820 PMCID: PMC4270487 DOI: 10.1371/journal.pntd.0003304] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 09/30/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Venom recurrence or persistence in the circulation after antivenom treatment has been documented many times in viper envenoming. However, it has not been associated with clinical recurrence for many snakes, including Russell's viper (Daboia spp.). We compare the recovery of coagulopathy to the recurrence or persistence of venom in patients with Russell's viper envenoming. METHODOLOGY/PRINCIPAL FINDINGS The study included patients with Russell's viper (D. russelii) envenoming presenting over a 30 month period who had Russell's viper venom detected by enzyme immunoassay. Demographics, information on the snake bite, and clinical effects were collected for all patients. All patients had serum collected for venom specific enzyme immunoassay and citrate plasma to measure fibrinogen levels and prothrombin time (international normalised ratio; INR). Patients with venom recurrence/persistence were compared to those with no detectable recurrence of venom. There were 55 patients with confirmed Russell's viper envenoming and coagulopathy with low fibrinogen concentrations: 31 with venom recurrence/persistence, and 24 with no venom detected post-antivenom. Fibrinogen concentrations increased and INR decreased after antivenom in both the recurrence and non-recurrence patients. Clinical features, laboratory parameters, antivenom dose and length of hospital were similar for both groups. Pre-antivenom venom concentrations were higher in patients with venom recurrence/persistence with a median venom concentration of 385 ng/mL (16-1521 ng/mL) compared to 128 ng/mL (14-1492 ng/mL; p = 0.008). CONCLUSION Recurrence of Russell's viper venom was not associated with a recurrence of coagulopathy and length of hospital stay. Further work is required to determine if the detection of venom recurrence is due to the venom specific enzyme immunoassay detecting both venom-antivenom complexes as well as free venom.
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Affiliation(s)
- Kalana Maduwage
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Margaret A. O'Leary
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Fiona E. Scorgie
- Hunter Haematology Research Group, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Seyed Shahmy
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Pharmacology and Toxicology Group, Professorial Medicine Unit, The Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | | | | | - Lisa F. Lincz
- Hunter Haematology Research Group, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | | | - Geoffrey K. Isbister
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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Weinstein SA. The pharmacotherapy for pit viper envenoming in the United States: A brief retrospective on roots, recurrence, and risk. Clin Toxicol (Phila) 2014; 53:1-4. [DOI: 10.3109/15563650.2014.983240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Antivenom cross neutralisation in a suspected Asian pit viper envenoming causing severe coagulopathy. Toxicon 2014; 90:286-90. [DOI: 10.1016/j.toxicon.2014.08.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/20/2014] [Accepted: 08/21/2014] [Indexed: 11/19/2022]
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Bush SP, Ruha AM, Seifert SA, Morgan DL, Lewis BJ, Arnold TC, Clark RF, Meggs WJ, Toschlog EA, Borron SW, Figge GR, Sollee DR, Shirazi FM, Wolk R, de Chazal I, Quan D, García-Ubbelohde W, Alagón A, Gerkin RD, Boyer LV. Comparison of F(ab')2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial. Clin Toxicol (Phila) 2014; 53:37-45. [PMID: 25361165 PMCID: PMC4364250 DOI: 10.3109/15563650.2014.974263] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background. Crotalidae Polyvalent Immune Fab (Ovine) has been the only antivenom commercially available in the US since 2007 for treatment of Crotalinae envenomation. Late coagulopathy can occur or recur after clearance of Fab antivenom, often after hospital discharge, lasting in some cases more than 2 weeks. There have been serious, even fatal, bleeding complications associated with recurrence phenomena. Frequent follow-up is required, and additional intervention or hospitalization is often necessary. F(ab')2 immunoglobulin derivatives have longer plasma half life than do Fab. We hypothesized that F(ab')2 antivenom would be superior to Fab in the prevention of late coagulopathy following treatment of patients with Crotalinae envenomation. Methods. We conducted a prospective, double-blind, randomized clinical trial, comparing late coagulopathy in snakebitten patients treated with F(ab')2 with maintenance doses [F(ab')2/F(ab')2], or F(ab')2 with placebo maintenance doses [F(ab')2/placebo], versus Fab with maintenance doses [Fab/Fab]. The primary efficacy endpoint was coagulopathy (platelet count < 150 K/mm3, fibrinogen level < 150 mg/dL) between end of maintenance dosing and day 8. Results. 121 patients were randomized at 18 clinical sites and received at least one dose of study drug. 114 completed the study. Of these, 11/37 (29.7%) in the Fab/Fab cohort experienced late coagulopathy versus 4/39 (10.3%, p < 0.05) in the F(ab')2/F(ab')2 cohort and 2/38 (5.3%, p < 0.05) in the F(ab')2/placebo cohort. The lowest heterologous protein exposure was with F(ab')2/placebo. No serious adverse events were related to study drug. In each study arm, one patient experienced an acute serum reaction and one experienced serum sickness. Conclusions. In this study, management of coagulopathic Crotalinae envenomation with longer-half-life F(ab')2 antivenom, with or without maintenance dosing, reduced the risk of subacute coagulopathy and bleeding following treatment of envenomation.
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Affiliation(s)
- Sean P Bush
- East Carolina University Brody School of Medicine/Vidant Medical Center , Greenville, NC , USA
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Díaz P, Malavé C, Zerpa N, Vázquez H, D'Suze G, Montero Y, Castillo C, Alagón A, Sevcik C. IgY pharmacokinetics in rabbits: implications for IgY use as antivenoms. Toxicon 2014; 90:124-33. [PMID: 25111201 DOI: 10.1016/j.toxicon.2014.07.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/23/2014] [Accepted: 07/30/2014] [Indexed: 12/18/2022]
Abstract
This paper presents the first study of chicken IgY pharmacokinetics (PK) in rabbits. We measured IgY blood serum concentrations using a specific high sensitivity ELISA method. The fast initial component observed when studying horse Fab, F(ab')2 or IgG was absent from IgY PK. During the first 80 min of observation there was only a single slow exponential decay, which sped up afterward to the point that IgY became undetectable after 216 h of observation; due to this time course, PK parameters were determined with trapezoidal integration. The most significant IgY pharmacokinetic parameters determined were (all presented as medians and their 95% confidence interval): Area Under the Curve = 183.8 (135.2, 221.5) mg·h·L(-1); Distribution volume of the central compartment·[Body Weight (BW)](-1) = 46.0 (21.7, 70.3) mL·kg(-1); Distribution volume in steady state·BW(-1) = 56.8 (44.4, 68.5) mLkg(-1); Mean Residence Time = 40.1 (33.6, 48.5) h; Total plasma clearance·BW(-1) = 1.44 (1.15, 1.66) mL·h(-1)·kg(-1). Anti IgY IgG titers determined by ELISA increased steadily after 72 h, and reached 2560 (1920, 5760) dilution(-1) at 264 h; anti-chicken IgG concentrations rose up to 3.19 (2.31, 6.17) μg/mL in 264 h. Our results show that IgY PK lacks the fast initial decay observed in other PK studies using horse IgG, F(ab')2 or Fab, remains in the body 39.0 (28.7, 47.2) % much as IgG and is ≈3 times more immunogenic that horse IgG in rabbits.
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Affiliation(s)
- Patricia Díaz
- Laboratory on Cellular Neuropharmacology, Centro de Biofísica y Bioquímica, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela
| | - Caridad Malavé
- Unidad de Neurociencias, Instituto de Estudios Avanzados (IDEA), Caracas, Venezuela
| | - Noraida Zerpa
- Unidad de Neurociencias, Instituto de Estudios Avanzados (IDEA), Caracas, Venezuela
| | - Hilda Vázquez
- Instituto de Biotecnología (IBt), Universidad Nacional Autónoma de México, Cuernavaca, Mexico
| | - Gina D'Suze
- Laboratory on Cellular Neuropharmacology, Centro de Biofísica y Bioquímica, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela
| | - Yuyibeth Montero
- Unidad de Neurociencias, Instituto de Estudios Avanzados (IDEA), Caracas, Venezuela
| | - Cecilia Castillo
- Unidad de Neurociencias, Instituto de Estudios Avanzados (IDEA), Caracas, Venezuela
| | - Alejandro Alagón
- Instituto de Biotecnología (IBt), Universidad Nacional Autónoma de México, Cuernavaca, Mexico
| | - Carlos Sevcik
- Laboratory on Cellular Neuropharmacology, Centro de Biofísica y Bioquímica, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela.
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PK/TD modeling for prediction of the effects of 8C2, an anti-topotecan mAb, on topotecan-induced toxicity in mice. Int J Pharm 2014; 465:228-38. [PMID: 24508555 DOI: 10.1016/j.ijpharm.2014.01.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 12/30/2013] [Accepted: 01/29/2014] [Indexed: 12/31/2022]
Abstract
To facilitate the development of an inverse targeting strategy, where anti-topotecan antibodies are administered to prevent systemic toxicity following intraperitoneal topotecan, a pharmacokinetic/toxicodynamic (PK/TD) model was developed and evaluated. The pharmacokinetics of 8C2, a monoclonal anti-topotecan antibody, were assessed following IV and SC administration, and the data were characterized using a two compartmental model with nonlinear absorption and elimination. A hybrid PK model was constructed by combining a PBPK model for topotecan with the two-compartment model for 8C2, and the model was employed to predict the disposition of topotecan, 8C2, and the topotecan-8C2 complex. The model was linked to a toxicodynamic model for topotecan-induced weight-loss, and simulations were conducted to predict the effects of 8C2 on the toxicity of topotecan in mice. Increasing the molar dose ratio of 8C2 to topotecan resulted in a dose-dependent decrease in the unbound (i.e., not bound to 8C2) topotecan exposure in plasma (AUCf) and a decrease in the extent of topotecan-induced weight-loss. Consistent with model predictions, toxicodynamic experiments showed substantial reduction in the percent nadir weight loss observed with 30 mg/kg IP topotecan after co-administration of 8C2 (20 ± 8% vs. 10 ± 8%). The investigation supports the use of anti-topotecan mAb to reduce the systemic toxicity of IP topotecan chemotherapy.
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Predicting the effects of 8C2, a monoclonal anti-topotecan antibody, on plasma and tissue disposition of topotecan. J Pharmacokinet Pharmacodyn 2013; 41:55-69. [PMID: 24368689 DOI: 10.1007/s10928-013-9346-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 12/14/2013] [Indexed: 10/25/2022]
Abstract
We are investigating an inverse targeting strategy to reduce the dose limiting systemic toxicities resultant from intraperitoneal administration of topotecan, a model chemotherapeutic drug. This approach utilizes systemic co-administration of anti-topotecan antibodies to alter the plasma and tissue disposition kinetics of topotecan. To better predict the effects of 8C2, a high affinity anti-topotecan monoclonal antibody, on the pharmacokinetics of topotecan, two mathematical models have been developed and evaluated. Model 1 is a hybrid physiologically based pharmacokinetic (PBPK) model that was created by merging a PBPK model for topotecan with a simple two compartment model of 8C2 pharmacokinetics. Model 2 is a comprehensive PBPK model developed by merging a PBPK model for IgG with a PBPK model for topotecan. To help validate the simulation results from both the models, a tissue distribution experiment was conducted, in which topotecan and 8C2 were co-administered in mice. Experimental and simulated data were compared by calculating the median percent prediction error (%PE) for all tissues. For both models, the median %PE values for all the tissues were less than 100 %, indicating that the predicted values were, on average, less than twofold the observed plasma and tissue topotecan concentrations values. In general model 2 was found to be more predictive of the data set than model 1, as the overall median %PE value for model 2 (%PE = 63) was less than model 1 (%PE = 73).
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Barash JR, Arnon SS. A Novel Strain of Clostridium botulinum That Produces Type B and Type H Botulinum Toxins. J Infect Dis 2013; 209:183-91. [DOI: 10.1093/infdis/jit449] [Citation(s) in RCA: 241] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Boyer LV, Chase PB, Degan JA, Figge G, Buelna-Romero A, Luchetti C, Alagón A. Subacute coagulopathy in a randomized, comparative trial of Fab and F(ab')2 antivenoms. Toxicon 2013; 74:101-8. [PMID: 23948058 DOI: 10.1016/j.toxicon.2013.07.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 07/18/2013] [Accepted: 07/25/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Envenomation by pit vipers is associated with coagulation disorders including hypofibrinogenemia and thrombocytopenia. These abnormalities correct following antivenom treatment during the acute phase of the disease. Delayed or recurrent coagulation abnormalities have been reported following use of Fab antivenom, resulting in risk of hemorrhage or death. METHODS We hypothesized that the longer plasma persistence of F(ab')2 antivenom, relative to Fab, in patients at risk of coagulopathy would result in decreased venonemia and coagulopathy one week after treatment. We conducted a Phase 2, randomized comparative clinical trial of rattlesnake bitten adults presenting for care in Tucson, Arizona, USA. Patients were randomly assigned to receive either Fab or F(ab')2 antivenom using a predefined treatment schedule. Endpoints included platelet counts, fibrinogen levels, and venom and antivenom ELISAs. Measurements were conducted at baseline and at various times over the following two weeks. RESULTS Twelve patients were studied, with 6 randomly assigned to each treatment group. Early response of platelet counts, fibrinogen, and venom levels to acute treatment was similar in the two groups. One week following treatment, platelet counts and fibrinogen levels were lower in the Fab group than in the F(ab')2 group, following a characteristic pattern that reached its lowest point approximately one week after initial treatment. Venom levels dropped below detection limits in all patients following initial treatment but subsequently rebounded into the measurable range in 4 of 6 Fab cases. F(ab')2 antivenom levels demonstrated a longer plasma persistence than Fab levels, with a less rapid drop during the two days following treatment. Two patients in the Fab group had significant adverse events involving coagulation abnormalities, for which additional antivenom was administered following the initial treatment period. CONCLUSIONS Following the acute phase of presentation and treatment for pit viper envenomation, there appears to be a roughly 2-week subacute phase of the disease during which ongoing presence of venom may result in serious delayed or recurrent coagulation defects. Late hypofibrinogenemia and thrombocytopenia are associated with recurrent venonemia and drop in antivenom levels. This pattern was apparent in patients treated with Fab antivenom but was not seen among F(ab')2 recipients in this Phase 2 study, consistent with pharmacokinetic differences between the two products. Improved understanding of Fab pharmacokinetics is important for the management of coagulopathy-prone pit viper envenomation. Use of F(ab')2 antivenom may prevent recurrent venom effects, but larger studies are necessary for statistical confirmation of this observation.
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Gilliam LL, Ownby CL, McFarlane D, Canida A, Holbrook TC, Payton ME, Krehbiel CR. Development of a double sandwich fluorescent ELISA to detect rattlesnake venom in biological samples from horses with a clinical diagnosis of rattlesnake bite. Toxicon 2013; 73:63-8. [PMID: 23834918 DOI: 10.1016/j.toxicon.2013.06.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 06/17/2013] [Accepted: 06/27/2013] [Indexed: 11/26/2022]
Abstract
Rattlesnake bites in horses are not uncommon and the clinical outcomes are widely variable. Treatment of horses with anti-venom is often cost prohibitive and could have negative consequences; therefore, the development of a quantitative test to determine if anti-venom therapy is indicated would be valuable. The objective of this study was to develop an ELISA to detect rattlesnake venom in biological samples from clinically bitten horses. Nineteen horses were enrolled in the study. Urine was available from 19 horses and bite site samples were available from 9 horses. A double sandwich fluorescent ELISA was developed and venom was detected in 5 of 9 bite site samples and 12 of 19 urine samples. In order to determine if this assay is useful as a guide for treatment, a correlation between venom concentration and clinical outcome needs to be established. For this, first peak venom concentration needs to be determined. More frequent, consistent sample collection will be required to define a venom elimination pattern in horses and determine the ideal sample collection time to best estimate the maximum venom dose. This report describes development of an assay with the ability to detect rattlesnake venom in the urine and at the bite site of horses with a clinical diagnosis of rattlesnake bite.
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Affiliation(s)
- Lyndi L Gilliam
- 1 Farm Rd-OSU BVMTH, Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK 74078, USA.
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Validating a faster method for reconstitution of Crotalidae Polyvalent Immune Fab (ovine). Toxicon 2013; 69:42-9. [DOI: 10.1016/j.toxicon.2012.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 12/12/2012] [Indexed: 11/20/2022]
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