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Iliyasu G, Gutiérrez JM, Habib AG. Snakebites in children: Also a European occurrence. Toxicon 2023; 236:107346. [PMID: 37951247 DOI: 10.1016/j.toxicon.2023.107346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/09/2023] [Indexed: 11/13/2023]
Affiliation(s)
- Garba Iliyasu
- Department of Medicine, Bayero University Kano, Nigeria.
| | - José M Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501, Costa Rica
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Paolino G, Pampena R, Di Nicola MR. Snakebites in children: Also a European occurrence. Toxicon 2023; 236:107344. [PMID: 37949245 DOI: 10.1016/j.toxicon.2023.107344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/05/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Giovanni Paolino
- Unità di Dermatologia e Cosmetologia, IRCCS Ospedale San Raffaele, Milan, Italy; Unità di Dermatologia Clinica, Università Vita-Salute San Raffaele, Milan, Italy
| | - Riccardo Pampena
- Unità di Dermatologia e Cosmetologia, IRCCS Ospedale San Raffaele, Milan, Italy
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Tippett Barr BA, Brown G, Perry M, Ridzon R, Warrell DA. Sudden death after a bite by a lowland swamp viper (Proatheris superciliaris) in Malawi: Dying of fright? Toxicon 2023; 235:107324. [PMID: 37838003 DOI: 10.1016/j.toxicon.2023.107324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 10/16/2023]
Abstract
Proatheris superciliaris, the lowland swamp viper, has a limited distribution along lakeshores and rivers in Malawi, Southern Tanzania, and central Mozambique. Its venom is known to be procoagulant. Only five P. superciliaris bites have been reported, all inflicted by captive snakes, and none was fatal. Here we present a case of sudden death following a bite by Proatheris superciliaris in rural Malawi that cannot be attributed to envenoming. A healthy 32-year-old woman was planting rice in a flooded rice paddy field when she suddenly told her sister in a quiet voice that she had been bitten by a snake. She then collapsed face-upwards into the ankle-deep water. She remained motionless while her sister and uncle carried her out of the rice paddy onto dry land a few meters away. The victim did not regain consciousness. Her uncle heard one exhalation but no further breathing. The snake responsible was killed by a friend. Although the venom of this species can cause life-threatening coagulopathy, this woman's death occurred too rapidly to be attributable to envenoming. Only two explanations seem plausible: anaphylaxis, or vasovagal shock triggered by fear. In the present case, the victim died within minutes of the bite, closely observed by her anxious relatives, but showed no features of anaphylaxis. In Malawi, as in much of sub-Saharan Africa, many people are reportedly terrified of snakes, believing that bites by almost any species can cause rapid death. In this case, death occurred less than 2 min after a bite from Proatheris superciliaris. We believe that the cause of death was most likely a severe vasovagal attack, in response to the fear and pain of the snakebite that triggered vasodilatation, bradycardia, and hypotension leading to cardiac arrest.
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Affiliation(s)
| | | | - Mike Perry
- African Reptiles & Venom, Johannesburg, South Africa
| | - Renee Ridzon
- Nyanja Health Research Institute, PO Box 579, Salima, Malawi
| | - David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, UK
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Dobaja Borak M, Babić Ž, Caganova B, Grenc D, Karabuva S, Kolpach Z, Krakowiak A, Kolesnikova V, Lukšić B, Pap C, Puljiz I, Piekarska-Wijatkowska A, Radenkova-Saeva J, Vučinić S, Zacharov S, Eddleston M, Brvar M. Viper envenomation in Central and Southeastern Europe: a multicentre study. Clin Toxicol (Phila) 2023; 61:656-664. [PMID: 37988116 DOI: 10.1080/15563650.2023.2273761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Snakebite incidence varies across Europe. However, there is limited research from Central and Southeastern Europe. These regions are notable for the presence of the common European adder (Vipera berus) and the more venomous nose-horned viper (Vipera ammodytes). No standard European antivenom protocol exists. The aim was to assess the epidemiology and treatment of viper bites in this region, focusing on a comparison of bites from Vipera berus and Vipera ammodytes. METHODS We conducted a prospective multicenter study in Central and Southeastern Europe from 2018 to 2020. This study included poison centres and toxicology-associated hospital wards in Poland, the Czech Republic, Slovakia, Hungary, Slovenia, Croatia, Serbia, and Bulgaria. The following data were collected: age, gender, Vipera species, snakebite site, clinical picture, laboratory results, Audebert's clinical severity grading score, and antivenom therapy. RESULTS The annual incidence of viper bites in Central and Southeast Europe was estimated at 2.55 bites per million population. Within their respective geographical distribution areas, the incidence of Vipera ammodytes bites (1.61 bites per million population) was higher than Vipera berus bites (1.00 bites per million population). Patients bitten by Vipera ammodytes more frequently reported local pain and developed thrombocytopenia. Antivenom treatment was more commonly administered in Vipera ammodytes bites (72%) compared to Vipera berus bites (39%). The incidence of Vipera ammodytes bites treated with antivenom within its geographical distribution area was three times higher than Vipera berus bites treated with antivenom (1.16 bites per million population versus 0.39 bites per million population). No deaths were reported. CONCLUSIONS The estimated incidence of viper bites in Central and Southeastern Europe is at least 2.55 per million population. Vipera ammodytes bites are more common and severe, characterized by higher frequencies of pain and thrombocytopenia. Antivenom is needed more often for Vipera ammodytes bites. It is vital that enough European Medicines Agency-approved Vipera ammodytes antivenom is produced and offered affordably.
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Affiliation(s)
- Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Željka Babić
- Poison Centre, Institute for Medical Research and Occupational Health, Zagreb, Croatia
| | - Blažena Caganova
- National Toxicological Information Centre, University Hospital, Bratislava, Slovakia
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital of Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Zuzana Kolpach
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Anna Krakowiak
- Nofer Institute of Occupational Medicine, Łódź, Poland
- Clinic of Anesthesiology and Intensive Care, Toxicology Unit, Central Clinical Hospital of the Medical University of Łódź, Łódź, Poland
| | - Viktoriia Kolesnikova
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital of Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Csaba Pap
- Department of Toxicology, Péterfy Hospital, Budapest, Hungary
| | - Ivan Puljiz
- University hospital for infectious diseases "Dr. Fran Mihaljević", Zagreb, Croatia
| | | | - Julia Radenkova-Saeva
- Clinic of Toxicology, University Hospital for Emergency Medicine "N.I.Pirogov", Sofia, Bulgaria
| | - Slavica Vučinić
- National Poison Centre, Military Medical Academy, Medical Faculty University of Defense, Belgrade, Serbia
| | - Sergej Zacharov
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Michael Eddleston
- Department of Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Siigur J, Siigur E. Biochemistry and toxicology of proteins and peptides purified from the venom of Vipera berus berus. Toxicon X 2022; 15:100131. [PMID: 35769869 PMCID: PMC9234072 DOI: 10.1016/j.toxcx.2022.100131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/05/2022] [Accepted: 06/06/2022] [Indexed: 12/19/2022] Open
Abstract
The isolation and characterization of individual snake venom components is important for a deeper understanding of the pathophysiology of envenomation and for improving the therapeutic procedures of patients. It also opens possibilities for the discovery of novel toxins that might be useful as tools for understanding cellular and molecular processes. The variable venom composition, toxicological and immunological properties of the common vipers (Vipera berus berus) have been reviewed. The combination of venom gland transcriptomics, bottom-up and top-down proteomics enabled comparison of common viper venom proteomes from multiple individuals. V. b. berus venom contains proteins and peptides belonging to 10–15 toxin families: snake venom metalloproteinase, phospholipases A2 (PLA2), snake venom serine proteinase, aspartic protease, L-amino acid oxidase (LAAO), hyaluronidase, 5′-nucleotidase, glutaminyl-peptide cyclotransferase, disintegrin, C-type lectin (snaclec), nerve growth factor, Kunitz type serine protease inhibitor, snake venom vascular endothelial growth factor, cysteine-rich secretory protein, bradykinin potentiating peptide, natriuretic peptides. PLA2 and LAAO from V. b. berus venom produce more pronounced cytotoxic effects in cancer cells than normal cells, via induction of apoptosis, cell cycle arrest and suppression of proliferation. Proteomic data of V. b. berus venoms from different parts of Russia and Slovakian Republic have been compared with analogous data for Vipera nikolskii venom. Proteomic studies demonstrated quantitative differences in the composition of V. b. berus venom from different geographical regions. Differences in the venom composition of V. berus were mainly driven by the age, sex, habitat and diet of the snakes. The venom variability of V. berus results in a loss of antivenom efficacy against snakebites. The effectiveness of antibodies is discussed. This review presents an overview with a special focus on different toxins that have been isolated and characterized from the venoms of V. b. berus. Their main biochemical properties and toxic actions are described. Vipera berus berus venom composition is variable among different populations. Venom contains about 15 protein/peptide families. It disturbs blood coagulation inducing pro- or anticoagulant effects. Venom contains different types of blood factor X activators. PLA2 and L-amino acid oxidase produce cytotoxic effects in cancer cells.
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Jagpal PS, Williams HA, Eddleston M, Lalloo D, Warrell D, Sandilands EA, Thanacoody R, Gray L, Bradberry SM. Bites by exotic snakes reported to the UK National Poisons Information Service 2009-2020. Clin Toxicol (Phila) 2022; 60:1044-1050. [PMID: 35853475 DOI: 10.1080/15563650.2022.2077748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Introduction: Snakebite is recognised as a neglected tropical disease and a cause of substantial morbidity and mortality. Whilst the most medically important snakes are typically native of Asia, Africa, Latin America and Oceania, the possibility of encountering these snakes is no longer limited by geography due to an increasing number of exotic (non-native) snakes being held in captivity.Methods: A retrospective review of snakebite enquiries to the UK National Poisons Information Service (NPIS) between 2009 and 2020. Enquiries about the European adder (Vipera berus) or where the identity of the snake was unknown were excluded.Results: There were 321 exotic snakebites in 300 patients involving 68 different species during this period. Ten patients were bitten on more than one occasion. The majority of patients (64.5%) were male. Most bites were inflicted by snakes of the family Colubridae (184/321, 57.3%); seventeen bites resulted in moderate symptoms (predominantly swelling of the bitten limb). There were 30 (9.3%) bites by Viperidae and 14 (4.3%) bites by Elapidae. All severe cases (n = 15) resulted from bites by either Viperidae (n = 10) or Elapidae (n = 5). Antivenom was given in 17 cases. One fatality was recorded.Conclusions: Despite their low incidence, exotic snakebites present a substantial challenge for UK healthcare professionals. Although rare, these bites typically occur in individuals (usually male) who keep snakes as part of their occupation or hobby and are therefore at risk of multiple bites. Bites can result in venom hypersensitisation and the risk of venom-induced anaphylaxis. Rapid access to expert clinical advice is available in the UK on a 24-hour basis through the National Poisons Information Service and is strongly recommended in all cases of exotic snakebite.
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Affiliation(s)
- Pardeep S Jagpal
- National Poisons Information Service Birmingham, Birmingham, United Kingdom of Great Britain and Northern Ireland
| | - Hayley A Williams
- National Poisons Information Service Birmingham, Birmingham, United Kingdom of Great Britain and Northern Ireland
| | - Michael Eddleston
- National Poisons Information Service Edinburgh, Edinburgh, United Kingdom of Great Britain and Northern Ireland
| | - David Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom of Great Britain and Northern Ireland.,Tropical and Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - David Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom of Great Britain and Northern Ireland
| | - Euan A Sandilands
- National Poisons Information Service Edinburgh, Edinburgh, United Kingdom of Great Britain and Northern Ireland
| | - Ruben Thanacoody
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Laurence Gray
- National Poisons Information Service Cardiff, Llandough, United Kingdom of Great Britain and Northern Ireland
| | - Sally M Bradberry
- National Poisons Information Service Birmingham, Birmingham, United Kingdom of Great Britain and Northern Ireland
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Neurotoxicity and Other Clinical Manifestations of a Common European Adder (Vipera berus) Bite in Romania. Toxins (Basel) 2022; 14:toxins14070500. [PMID: 35878238 PMCID: PMC9318827 DOI: 10.3390/toxins14070500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/07/2022] [Accepted: 07/13/2022] [Indexed: 11/26/2022] Open
Abstract
Most cases of envenomation by common European vipers (Vipera berus) have not been reported to have neurotoxic manifestations. However, these manifestations have been demonstrated in some cases of envenomation by subspecies of V. berus, found in the Carpathian Basin region of south-eastern Europe. Here, we report the case of a 5-year-old girl from the south of Romania who presented symptoms of neurotoxicity, as well as other systemic and local symptoms, after being bitten by an adder of the V. berus subspecies. Treatment consisted of monovalent antivenom, a corticosteroid, and prophylactic enoxaparin. Neurotoxic manifestations of envenomation as well as other local and systemic symptoms improved within 5 days of treatment. The presented case shows that venom from V. berus subspecies found in the Carpathian Basin can have neurotoxic effects. This case also confirmed the efficacy of monospecific antivenom treatment in bringing about rapid and complete remission, following envenomation.
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Nurminen I, Eskola V. Most adder bites in Finland's Lake District caused mild symptoms and severe poisoning was rare. Acta Paediatr 2022; 111:1638-1643. [PMID: 35531612 PMCID: PMC9546192 DOI: 10.1111/apa.16397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/11/2022] [Accepted: 05/06/2022] [Indexed: 11/27/2022]
Abstract
AIM This study investigated the incidence, clinical picture and treatment of paediatric adder bites in Finland's Lake District. METHODS Data were retrospectively collected on all children aged 0-15 years who were bitten by adders from 2006 to 2015 and treated at Tampere University Hospital. The severity was evaluated with the five-level Poisoning Severity Score. RESULTS We found that 109 children were treated following an adder bite, which was an incidence of 13 per 100,000 children from 0 to 15. Of these, 75 were under 8 years of age, with a median age of 3.5 years, and 34 were 8-15 years, with a median age of 10.3 years. The gender distribution was similar in both ages. Younger children were more likely to be bitten in their yards at home, whereas older children were more likely to be bitten in a forest. Older children reported more pain than younger patients. Most children were bitten on a lower limb, with minor symptoms such as localised redness and swelling, and received conservative treatment. Antivenom treatment was rarely administered and then only in severe cases or if symptoms progressed. CONCLUSION Adder bites mostly caused mild symptoms, severe poisoning was rare and antivenom was rarely given.
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Affiliation(s)
- Iiris Nurminen
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Vesa Eskola
- Faculty of Medicine and Health Technology, Tampere Center for Child, Adolescent and Maternal Health Research Tampere University and University Hospital Tampere Finland
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Weinstein SA, Warrell DA, Daoues K, Vidal N. The first reported snakebite by an African snake-eater, Polemon spp. (Atractaspididae, Aparallactinae); Local envenoming by Reinhardt's snake-eater, Polemon acanthias (Reinhardt, 1860). Toxicon 2021; 200:92-95. [PMID: 34280410 DOI: 10.1016/j.toxicon.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022]
Abstract
The first reported snakebite by an African snake-eater, Polemon spp. (Atractaspididae, Aparallactinae); Local envenoming by Reinhardt's snake-eater, Polemon acanthias (Reinhardt, 1860). Toxicon XX, xxx. A 51-yr-old male herpetologist was bitten on the left index finger by a captive male Polemon acanthias while manually removing fragments of incompletely shed skin from the specimen. The snake sustained its bite for approximately 2 mins, advancing its jaws several times. The victim rapidly developed moderate pain, erythema, progressive edema that ultimately extended to the left wrist; a blister later developed in the wound site, as well as joint stiffness in the bitten and adjacent two fingers that limited flexion and extension. These effects regressed during the week following the bite, but recurred thereafter and were similar to the effects that developed immediately post-envenoming. There were no systemic signs or symptoms. The victim sought medical advice and was treated with broad-spectrum antibiotics, antihistamines and wound care; no laboratory investigations were conducted. He improved during the subsequent month with complete resolution in 5 and one-half weeks. This is the first documented bite by a Polemon spp. and the victim's clinical course suggests the development of local effects from venom components. The phylogenetic relationship of Polemon spp. with the burrowing asps (Atractaspis spp.) and the similarity of some of the features of this local envenoming by P. acanthias with mild/moderate envenoming by some Atractaspis spp., suggests that none of these snakes should be handled; they should be considered capable of inflicting potentially serious envenoming.
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Affiliation(s)
- Scott A Weinstein
- Department of Toxinology, Women's and Children's Hospital, North Adelaide, South Australia, 5006, Australia.
| | - David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Karim Daoues
- La Ferme Tropicale, 54 rue Jenner, 75013, Paris, France
| | - Nicolas Vidal
- Muséum National d'Histoire Naturelle, UMR 7205, MNHN, CNRS, Sorbonne Université, EPHE, Université des Antilles, Institut de Systématique, Evolution et Biodiversité, CP 30, 57, Rue Cuvier, F-75005, Paris, France
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