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Leppänen V, Mykkänen A. Suspected envenomation by the common European adder (Vipera berus berus) in 28 horses in Finland. J Equine Vet Sci 2024; 140:105145. [PMID: 38960009 DOI: 10.1016/j.jevs.2024.105145] [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: 04/03/2024] [Revised: 06/26/2024] [Accepted: 06/30/2024] [Indexed: 07/05/2024]
Abstract
Vipera berus berus is the only venomous snake present in the Nordic countries and cases of envenomation in horses are reported during the warmer months. Little is known about the presentation, treatment and survival of horses with common European adder envenomation. Clinical and laboratory findings, treatment and outcome are reported for 28 horses admitted to Helsinki University Equine Hospital in 2008-2023 due to suspicion of snake bite. Eleven of these horses received antivenom treatment. Other common treatments included non-steroidal anti-inflammatories (22/28), antimicrobials (19/28), intravenous fluid therapy (11/28), corticosteroids (9/28) and local treatment (11/28). All horses survived until discharge. No difference was detected in the length of hospital stay between horses with moderate envenomation that had or had not received antivenom treatment. Horses with moderate envenomation are more likely to receive antivenom treatment and require longer hospital stay than horses with mild envenomation. Antivenom treatment is not associated with shorter hospital stay. Little evidence supports the use of corticosteroids and antibiotics in treatment of envenomation. Studies with larger numbers of animals are warranted to evaluate the effect of treatment, including administration of antivenom, on long-term outcome and survival from envenomation.
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Affiliation(s)
- V Leppänen
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, Viikintie 47, University of Helsinki, 00014, Finland.
| | - A Mykkänen
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, Viikintie 47, University of Helsinki, 00014, Finland
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Nicolaysen TV, Rørtveit R, Vassli AØ, Sand ES, Elgstøen KBP, Rootwelt H, Lund HS, Sævik BK, Zimmer KE. A longitudinal study of the blood and urine metabolome of Vipera berus envenomated dogs. Res Vet Sci 2024; 173:105287. [PMID: 38718545 DOI: 10.1016/j.rvsc.2024.105287] [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: 01/31/2024] [Revised: 04/23/2024] [Accepted: 05/03/2024] [Indexed: 05/19/2024]
Abstract
Envenomation of dogs by the common European adder (Vipera berus) is associated with high morbidity. The cytotoxic venom of Vipera berus contains enzymes with the potential to cause acute kidney injury, among other insults, however robust biomarkers for such effects are lacking. A prospective observational follow-up study of naturally envenomated dogs and controls was conducted to fill knowledge gaps regarding canine Vipera berus envenomation, attempt to identify novel biomarkers of envenomation and related kidney injury, and elucidate potential long-term effects. Blood and urine samples were analyzed with a global metabolomics approach using liquid chromatography-mass spectrometry, uncovering numerous features significantly different between cases and controls. After data processing and feature annotation, eight features in blood and 24 features in urine were investigated in order to elucidate their biological relevance. Several of these are associated with AKI, while some may also originate from disturbed fatty acid β-oxidation and soft tissue damage. A metabolite found in both blood and a venom reference sample may represent identification of a venom component in case dogs. Our findings suggest that envenomated dogs treated according to current best practice are unlikely to suffer permanent injury.
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Affiliation(s)
- Tove V Nicolaysen
- Department of Preclinical Sciences and Pathology, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oluf Thesens vei 22, 1433 Ås, Norway.
| | - Runa Rørtveit
- Department of Preclinical Sciences and Pathology, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oluf Thesens vei 22, 1433 Ås, Norway
| | - Anja Ø Vassli
- Department of Medical Biochemistry, Oslo University Hospital, Sognsvannsveien 20, 0372 Oslo, Norway
| | - Elise S Sand
- Department of Medical Biochemistry, Oslo University Hospital, Sognsvannsveien 20, 0372 Oslo, Norway
| | - Katja B P Elgstøen
- Department of Medical Biochemistry, Oslo University Hospital, Sognsvannsveien 20, 0372 Oslo, Norway
| | - Helge Rootwelt
- Department of Medical Biochemistry, Oslo University Hospital, Sognsvannsveien 20, 0372 Oslo, Norway
| | - Heidi S Lund
- Department of Companion Animal Clinical Sciences, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oluf Thesens vei 22, 1433 Ås, Norway
| | - Bente K Sævik
- AniCura Jeløy Dyresykehus, Varnaveien 43d, 1526 Moss, Norway
| | - Karin E Zimmer
- Department of Preclinical Sciences and Pathology, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oluf Thesens vei 22, 1433 Ås, Norway
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Di Nicola MR, Crevani M, Avella I, Cerullo A, Dorne JLCM, Paolino G, Zattera C. A Guide to the Clinical Management of Vipera Snakebite in Italy. Toxins (Basel) 2024; 16:255. [PMID: 38922149 PMCID: PMC11209566 DOI: 10.3390/toxins16060255] [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: 04/30/2024] [Revised: 05/22/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024] Open
Abstract
The genus Vipera encompasses most species of medically significant venomous snakes of Europe, with Italy harbouring four of them. Envenomation by European vipers can result in severe consequences, but underreporting and the absence of standardised clinical protocols hinder effective snakebite management. This study provides an updated, detailed set of guidelines for the management and treatment of Vipera snakebite tailored for Italian clinicians. It includes taxonomic keys for snake identification, insights into viper venom composition, and recommendations for clinical management. Emphasis is placed on quick and reliable identification of medically relevant snake species, along with appropriate first aid measures. Criteria for antivenom administration are outlined, as well as indications on managing potential side effects. While the protocol is specific to Italy, its methodology can potentially be adapted for other European countries, depending on local resources. The promotion of comprehensive data collection and collaboration among Poison Control Centres is advocated to optimise envenomation management protocols and improve the reporting of epidemiological data concerning snakebite at the country level.
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Affiliation(s)
- Matteo Riccardo Di Nicola
- Unit of Dermatology and Cosmetology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
- Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Wildlife Health Ghent, Ghent University, 9820 Merelbeke, Belgium
- Asociación Herpetológica Española, Apartado de correos 191, 28911 Leganés, Spain
| | - Marta Crevani
- Poison Control Centre, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Ignazio Avella
- Landes-Offensive zur Entwicklung Wissenschaftlich-ökonomischer Exzellenz-Centre for Translational Biodiversity Genomics, Senckenberganlage 25, 60325 Frankfurt Am Main, Germany
- Institute for Insect Biotechnology, Justus-Liebig University Giessen, Heinrich-Buff-Ring 26-32, 35392 Giessen, Germany
| | - Anna Cerullo
- Department of Veterinary Sciences, University of Turin, L.go Braccini 2, 10095 Grugliasco, Italy
| | - Jean-Lou C. M. Dorne
- Methodological and Scientific Support Unit, European Food Safety Authority, Via Carlo Magno 1A, 43100 Parma, Italy
| | - Giovanni Paolino
- Unit of Dermatology and Cosmetology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Caterina Zattera
- Unit of Emergency Medicine, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo University Hospital, University of Pavia, P.Le Golgi, 19, 27100 Pavia, Italy
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Liblik K, Florica IT, Baranchuk A. Original algorithms for the detection of cardiovascular involvement of neglected tropical diseases. Expert Rev Cardiovasc Ther 2024; 22:59-74. [PMID: 38308590 DOI: 10.1080/14779072.2024.2315090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/02/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Neglected tropical diseases (NTDs) introduce considerable morbidity and mortality on a global scale, directly impacting over 1 billion individuals as well as their families and communities. Afflicted individuals may have limited access to resources and care in these regions, contributing to a high proportion of chronic, progressive, and systemic disease. The cardiovascular system is at particular risk of demise for several NTDs, yet remains largely unstudied due in part to the lack of robust data collection mechanisms in the most impacted regions. AREAS COVERED The present review is a part of the Neglected Tropical Diseases and other Infectious Diseases affecting the Heart (NET-Heart) Project, aiming at summarizing the current knowledge on cardiovascular implications of NTDs and providing diagnostic as well as management recommendations which can be tailored to low-resource settings. The diagnostic and management algorithms of 13 unique NTDs are presented and summarized. EXPERT OPINION Recognizing cardiac manifestations of NTDs can significantly alter disease trajectory and all physicians benefit from improved knowledge about NTDs. Great potential exists to advance patient care by improving data collection, communication, and international collaboration.
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Affiliation(s)
- Kiera Liblik
- Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
| | - Ioana Tereza Florica
- Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Division of Cardiology, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
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Thumtecho S, Suteparuk S, Sitprija V. Pulmonary involvement from animal toxins: the cellular mechanisms. J Venom Anim Toxins Incl Trop Dis 2023; 29:e20230026. [PMID: 37727535 PMCID: PMC10506740 DOI: 10.1590/1678-9199-jvatitd-2023-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/11/2023] [Indexed: 09/21/2023] Open
Abstract
Venomous animals and their venom have always been of human interest because, despite species differences, coevolution has made them capable of targeting key physiological components of our bodies. Respiratory failure from lung injury is one of the serious consequences of envenomation, and the underlying mechanisms are rarely discussed. This review aims to demonstrate how toxins affect the pulmonary system through various biological pathways. Herein, we propose the common underlying cellular mechanisms of toxin-induced lung injury: interference with normal cell function and integrity, disruption of normal vascular function, and provocation of excessive inflammation. Viperid snakebites are the leading cause of envenomation-induced lung injury, followed by other terrestrial venomous animals such as scorpions, spiders, and centipedes. Marine species, particularly jellyfish, can also inflict such injury. Common pulmonary manifestations include pulmonary edema, pulmonary hemorrhage, and exudative infiltration. Severe envenomation can result in acute respiratory distress syndrome. Pulmonary involvement suggests severe envenomation, thus recognizing these mechanisms and manifestations can aid physicians in providing appropriate treatment.
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Affiliation(s)
- Suthimon Thumtecho
- Division of Toxicology, Department of Medicine, Chulalongkorn
University, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society,
Bangkok, Thailand
| | - Suchai Suteparuk
- Division of Toxicology, Department of Medicine, Chulalongkorn
University, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society,
Bangkok, Thailand
| | - Visith Sitprija
- Queen Saovabha Memorial Institute and King Chulalongkorn Memorial
Hospital, the Thai Red Cross Society, Bangkok, Thailand
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Sassoè M. Envenomation by Vipera aspis in Piedmont (Italy): A report of three cases, including one case with neurological symptoms. Toxicon 2023; 230:107154. [PMID: 37169267 DOI: 10.1016/j.toxicon.2023.107154] [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: 03/30/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 05/13/2023]
Abstract
This report describes three cases of human envenomation by the asp viper (Vipera aspis) in Piedmont, north-west Italy. A woman was bitten on the ankle while she was hiking and two herpetologists received bites on the hand while they were manipulating the animals. In the first case, the victim presented severe systemic symptoms (abdominal pain, vomiting, diarrhea) that required treatment with two vials of antivenom and hospitalization for one week. In the second case, the patient manifested neurological symptoms (blepharoptosis, ophtalmoplegia); he was treated with antivenom and discharged after five days. In the third case, the patient was bitten by a juvenile viper and showed only local symptoms (edema and bruising). All patients reported prolonged functional impairment after discharge from hospital. Although uncommon, envenomation by Vipera aspis can cause severe consequences that require immediate management and antivenom administration. These cases highlight the importance of obtaining better knowledge of the intraspecific variability of venoms and its clinical significance, as well as of the factors that determine the severity of snakebite injuries.
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Affiliation(s)
- Marco Sassoè
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, C.so Massimo d'Azeglio, 52, 10126, Torino, Italy.
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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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Turetta M, Del Ben F, Londero D, Steffan A, Pillinini P. An antivenin resistant, IVIg-corticosteroids responsive Viper Induced Thrombocytopenia. Toxicol Rep 2022; 9:636-639. [PMID: 35399218 PMCID: PMC8990049 DOI: 10.1016/j.toxrep.2022.03.033] [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: 01/23/2021] [Revised: 09/13/2021] [Accepted: 03/26/2022] [Indexed: 11/01/2022] Open
Abstract
In this case report the hospital management of an acute, severe thrombocytopenia in a 57-year-old man in the north-east of Italy is reported. Thrombocytopenia developed immediately after the viper bite, despite the absence of clinical signs of envenomation. No hemorrhage, ecchymoses or other signs of coagulopathy developed during the hospitalization; two doses of antivenin FAB–Fragments had no effect on thrombocytopenia, which instead responded promptly to intravenous immunoglobulins (IVIg) and glucocorticoids. Direct and indirect anti-platelet antibodies against anti-GP IIb/IIIa and Ia/IIa were detected during the treatment and turned negative after 20 weeks. The rationale of such off-label treatment is the interpretation of the thrombocytopenia as a venom-induced immune thrombocytopenia which led to splenic sequestration of platelets. To our knowledge, there is no literature about venom-induced immune thrombocytopenia against GP IIb/IIIa and Ia/IIa protein in European countries and subsequent response to IVIg and corticosteroids. Thrombocytopenia is a known effect of viper envenomation. Antivenin FAB–Fragments may be ineffective for thrombocytopenia. Venom induced immune thrombocytopenia against GP IIb/IIIa and Ia/IIa. A treatment based on IVIg and corticosteroids led to a prompt recovery of a severe antivenin-resistant Venom induced thrombocytopenia.
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Harjen HJ, Hellum M, Rørtveit R, Oscarson M, Anfinsen KP, Moldal ER, Solbak S, Kanse SM, Henriksson CE. Persistent hypercoagulability in dogs envenomated by the European adder (Vipera berus berus). PLoS One 2022; 17:e0263238. [PMID: 35180240 PMCID: PMC8856559 DOI: 10.1371/journal.pone.0263238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/14/2022] [Indexed: 11/23/2022] Open
Abstract
Background Envenomation by the European adder, Vipera berus berus (Vbb), is a medical emergency. The overall in vivo haemostatic effects of pro- and anticoagulant components in Vbb venom, and the downstream effects of cellular injury and systemic inflammation, are unclear. Objectives To longitudinally describe the global coagulation status of dogs after Vbb envenomation and compare to healthy controls. A secondary aim was to investigate differences between dogs treated with and without antivenom. Methods Citrated plasma was collected at presentation, 12 hours (h), 24 h, 36 h and 15 days after bite from 28 dogs envenomated by Vbb, and from 28 healthy controls at a single timepoint. Thrombin generation (initiated with and without exogenous phospholipids and tissue factor), thrombin-antithrombin (TAT)-complexes and the procoagulant activity of phosphatidylserine (PS)-expressing extracellular vesicles (EVs), expressed as PS-equivalents, were measured. Results At presentation the envenomated dogs were hypercoagulable compared to controls, measured as increased thrombin generation, TAT-complexes and PS-equivalents. The hypercoagulability decreased gradually but compared to controls thrombin generation and PS-equivalents were still increased at day 15. The discrepancy in peak thrombin between envenomated dogs and controls was greater when the measurement was phospholipid-dependent, indicating that PS-positive EVs contribute to hypercoagulability. Lag time was shorter in non-antivenom treated dogs, compared to antivenom treated dogs <24 h after envenomation. Conclusions Hypercoagulability was measured in dogs up to 15 days after Vbb envenomation. Dogs treated with antivenom may be less hypercoagulable than their non-antivenom treated counterparts. Thrombin generation is a promising diagnostic and monitoring tool for Vbb envenomation.
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Affiliation(s)
- Hannah J. Harjen
- Faculty of Veterinary Medicine, Department of Companion Animal Clinical Sciences, Norwegian University of Life Sciences, Oslo, Norway
- * E-mail:
| | - Marit Hellum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The Blood Cell Research Group, Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Runa Rørtveit
- Faculty of Veterinary Medicine, Department of Preclinical Sciences and Pathology, Norwegian University of Life Sciences, Oslo, Norway
| | | | - Kristin P. Anfinsen
- Faculty of Veterinary Medicine, Department of Companion Animal Clinical Sciences, Norwegian University of Life Sciences, Oslo, Norway
| | - Elena R. Moldal
- Faculty of Veterinary Medicine, Department of Companion Animal Clinical Sciences, Norwegian University of Life Sciences, Oslo, Norway
| | - Susanna Solbak
- Anicura Dyresykehus Oslo, Oslo, Norway
- Anicura Jeløy Dyresykehus, Moss, Norway
| | - Sandip M. Kanse
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Carola E. Henriksson
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The Blood Cell Research Group, Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
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Boels D, Courtois A, Paradis C, Caillet P, Labadie M. First step in assessment of VipGrade ®, a computerized clinical decision system to assess Vipera envenomation grading: a single-center interrater reliability study. Clin Toxicol (Phila) 2021; 60:514-520. [PMID: 34709955 DOI: 10.1080/15563650.2021.1993241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
METHODS We conducted a retrospective review of Vipera spp. snakebite cases registered by the PCC of Bordeaux, France, between January 1, 2018, and December 31, 2020, evaluating the agreement between VipGrade® assessments, toxicologists' assessments, and current guidelines. RESULTS 133 patients with Vipera aspis snakebites were included. There was 100% agreement in severity grading by PCC guidelines and VipGrade®. However, grading by toxicologists and VipGrade® diverged in 19 cases (85% agreement; κ = 0.80; 95% CI: 0.71 to 0.87). CONCLUSIONS The VipGrade® tool's grading reflects current PCC guidelines, which are authoritative in France, and may allow for a more rapid and standardized determination of management and follow-up of viper-bitten patients. It should be noted, however, that the more complex and dynamic aspects of management are not included in VipGrade®. Its purpose is to supplement, not replace, the advice of the PCC's clinical toxicologists, and this advice should be sought whenever a viper bite is encountered in clinical practice.
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Affiliation(s)
- David Boels
- Clinical Toxicology Unit, Pharmacology Department, Nantes University Hospital, Nantes, France.,SPIN Unit, Public Health Department, Nantes University Hospital, Nantes, France.,Inserm UMR-1144, Descartes University, Paris, France
| | - Arnaud Courtois
- Poison Control Center, Bordeaux University Hospital, Bordeaux, France
| | - Camille Paradis
- Poison Control Center, Bordeaux University Hospital, Bordeaux, France
| | - Pascal Caillet
- SPIN Unit, Public Health Department, Nantes University Hospital, Nantes, France
| | - Magali Labadie
- Poison Control Center, Bordeaux University Hospital, Bordeaux, France
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Lu ZY, Wang XD, Yan J, Ni XL, Hu SP. Critical lower extremity ischemia after snakebite: A case report. World J Clin Cases 2021; 9:7857-7862. [PMID: 34621838 PMCID: PMC8462238 DOI: 10.12998/wjcc.v9.i26.7857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/14/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Globally, the estimated annual incidence of snakebites is approximately 5 million, and approximately 100000 deaths occur from snakebites annually. Local tissue reaction, haemorrhagic clotting disorder, nephrotoxicity, and neurotoxicity are very common effects of snake envenomation, but other rarer complications, such as thrombosis, may also occur as a result of underlying disease. In the treatment of snakebite patients, attention should be paid to the patient’s underlying diseases to avoid serious and catastrophic consequences secondary to snakebite.
CASE SUMMARY We report a 69-year-old man with critical right lower extremity pain after left foot snakebite 10 d prior without intermittent claudication or atrial fibrillation history. He was diagnosed with acute right lower extremity arterial thrombosis, which may have been caused by coagulopathy after snakebite and lower extremity atherosclerotic occlusive disease. Lower extremity computed tomography angiography at another hospital revealed that the aortoiliac and femoral arteries had neither filling defects nor atherosclerosis, but the right popliteal artery was occluded 2.3 cm below the tibial plateau. The patient received emergency catheter-directed thrombolysis, but amputation was carried out 11 d after admission because the patient had been admitted to the hospital too late to save the extremity.
CONCLUSION Acute ischaemia of the lower extremity due to snakebite is a rare event, and physicians should bear in mind the serious complications that may occur, especially in patients with atherosclerotic disease.
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Affiliation(s)
- Zi-Ying Lu
- Department of Vascular Surgery, Tongde Hospital of Zhejiang Province, Hangzhou 310000, Zhejiang Province, China
| | - Xiao-Dong Wang
- Department of Vascular Surgery, Tongde Hospital of Zhejiang Province, Hangzhou 310000, Zhejiang Province, China
| | - Jin Yan
- Department of Vascular Surgery, Tongde Hospital of Zhejiang Province, Hangzhou 310000, Zhejiang Province, China
| | - Xiao-Long Ni
- Department of Vascular Surgery, Tongde Hospital of Zhejiang Province, Hangzhou 310000, Zhejiang Province, China
| | - Si-Pin Hu
- Department of Vascular Surgery, Tongde Hospital of Zhejiang Province, Hangzhou 310000, Zhejiang Province, China
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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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14
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Liblik K, Byun J, Saldarriaga C, Perez GE, Lopez-Santi R, Wyss FQ, Liprandi AS, Martinez-Sellés M, Farina JM, Mendoza I, Burgos LM, Baranchuk A. Snakebite Envenomation and Heart: Systematic Review. Curr Probl Cardiol 2021; 47:100861. [PMID: 33992425 DOI: 10.1016/j.cpcardiol.2021.100861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/27/2021] [Indexed: 12/15/2022]
Abstract
Snakebite envenomation is a neglected tropical disease which can result in morbidity and mortality. Cardiac implications are poorly understood due to the low frequency of cardiotoxicity combined with a lack of robust information, as snakebites commonly occur in remote and rural areas. This review aims to assess cardiovascular implications of snakebite envenoming and proposes an algorithm for screening of cardiovascular manifestations. A systematic review was performed and 29 articles relating to cardiovascular involvement in snakebite envenomation were selected. Cardiovascular involvement seems to be rare and includes a wide spectrum of outcomes, such as myocardial infarction, ventricular dysfunction, hypotension, cardiac arrest, and myocarditis. In a significant proportion of the cases analyzed (24.39%), the cardiovascular manifestations had major consequences (cardiac arrest, myocardial infarction, malignant ventricular arrhythmias, or death). Clinical monitoring, physical examination, and early electrocardiogram should be considered as key measures to detect cardiovascular involvement in patients with evidence of systemic illness.
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Affiliation(s)
- Kiera Liblik
- Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
| | - Jin Byun
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Clara Saldarriaga
- Department of Cardiology and Heart Failure Clinic, Cardiovascular Clinic Santa Maria, University of Antioquia, Medellín, Colombia
| | - Gonzalo E Perez
- Division of Cardiology, Clínica Olivos, Buenos Aires, Argentina
| | - Ricardo Lopez-Santi
- Division of Cardiology, Hospital Italiano de la Plata, Buenos Aires, Argentina
| | - Fernando Q Wyss
- Division of Cardiology, Clínica Olivos, Buenos Aires, Argentina
| | - Alvaro S Liprandi
- Guatemala Cardiovascular Services and Technology, Cardiosolutions, Guatemala City
| | | | - Juan M Farina
- Hospital General Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Ivan Mendoza
- Tropical Cardiology, Tropical Medicine Institute, Central University of Venezuela, Caracas, Venezuela
| | - Lucrecia M Burgos
- Department of Heart Failure, Pulmonary Hypertension and Heart Transplant, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Adrian Baranchuk
- Division of Cardiology, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada.
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Lamb T, Stewart D, Warrell DA, Lalloo DG, Jagpal P, Jones D, Thanacoody R, Gray LA, Eddleston M. Moderate-to-severe Vipera berus envenoming requiring ViperaTAb antivenom therapy in the UK. Clin Toxicol (Phila) 2021; 59:992-1001. [PMID: 33720783 DOI: 10.1080/15563650.2021.1891245] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Bites by the European adder (Vipera berus) in the UK are uncommon but potentially life threatening, and can be associated with marked limb swelling and disability. Following an interruption in Zagreb Imunološki zavod antivenom supply around 2012, the UK changed its national choice of antivenom for Vipera berus to ViperaTAb, an ovine Fab monospecific antivenom. In the absence of randomised controlled trials, we established an audit to review its use in clinical practice. METHODS A prospective audit of ViperaTAb use was conducted from March 2016 until November 2020 by the UK National Poison Information Service (NPIS). Users of the NPIS online toxicology database, TOXBASE, considering the use of antivenom for V. berus envenoming were invited to discuss the case with the on-call clinical toxicology consultant. Information was collected prospectively on indications, administration, adverse reactions and outcome of patients administered ViperaTAb antivenom. RESULTS One hundred and seventy patients were administered ViperaTAb antivenom over five years. One hundred and thirty-two were adults and 38 children (median age and range: 38, 2-87 years). Bites occurred across the UK, but most commonly in coastal regions of Wales and of South-West and East England. Median time to presentation was 2.1 (IQR 1.5-4.0) h and to antivenom administration from presentation was 2.0 (IQR 0.9-3.6) h. A minority of patients presented to hospital more than 12 h after being bitten (n = 19, 11.2%) or received antivenom more than 12 h after presenting to hospital (n = 17, 10.0%). Features of systemic envenoming were present in 64/170 (37.6%) patients, including 23 (13.5%) with anaphylaxis and 26 (15.3%) with hypotension (nine with both). Clinician assessment considered the initial antivenom to have been effective in 122/169 (72.2%) patients. Repeated dosing was common, occurring in 55/169 (32.5%), predominantly due to persisting or worsening local effects (46/51, 90.2%). There were three cases of probable early adverse reaction. No deaths occurred during the study. Complications of envenoming were rare but included four patients that underwent surgery, three patients each with acute kidney injury, mild coagulopathy, or thrombocytopenia (one severe). The median duration of hospital stay was 43.7 (IQR 22.5-66.5) h, longer for children than adults (52.5 vs 41.3 h). CONCLUSION ViperaTAb antivenom appears to be effective and safe and should be administered as soon as possible for patients meeting clinical criteria. Patients require close observation following antivenom to detect adverse reactions and progression or recurrence of envenoming. Close collaboration with expert NPIS consultant advice can help optimise antivenom timing, ensure repeated dosing is given appropriately, and avoid unnecessary surgical intervention. All hospitals, particularly those located in areas of relatively high incidence, should stock sufficient antivenom available at short notice, 24 h a day.
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Affiliation(s)
- Thomas Lamb
- National Poisons Information Service - Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.,Myanmar Oxford Clinical Research Unit, University of Oxford, Oxford, UK.,Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - David Stewart
- National Poisons Information Service - Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - Pardeep Jagpal
- National Poisons Information Service - Birmingham, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Dacia Jones
- National Poisons Information Service - Newcastle, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Ruben Thanacoody
- National Poisons Information Service - Newcastle, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Laurence A Gray
- National Poisons Information Service - Cardiff, University Hospital Llandough, Cardiff, UK
| | - Michael Eddleston
- National Poisons Information Service - Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Pharmacology, Toxicology, Therapeutics, University/BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
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Kurtović T, Lang Balija M, Brvar M, Dobaja Borak M, Mateljak Lukačević S, Halassy B. Comparison of Preclinical Properties of Several Available Antivenoms in the Search for Effective Treatment of Vipera ammodytes and Vipera berus Envenoming. Toxins (Basel) 2021; 13:toxins13030211. [PMID: 33805701 PMCID: PMC8001446 DOI: 10.3390/toxins13030211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/05/2021] [Accepted: 03/10/2021] [Indexed: 11/16/2022] Open
Abstract
Snakebites are a relatively rare medical emergency in Europe. In more than half of the annual cases caused by Vipera ammodytes, Vipera berus, and Vipera aspis, immunotherapy with animal-derived antivenom is indicated. Among eight products recently identified as available against European medically relevant species, only Zagreb antivenom, Viperfav, and ViperaTAb have been used almost exclusively for decades. Zagreb antivenom comprises V. ammodytes-specific F(ab')2 fragments. Viperfav is a polyspecific preparation based on F(ab')2 fragments against V. aspis, V. berus, and V. ammodytes venoms. ViperaTAb contains Fab fragments against the venom of V. berus. In 2014 the production of Zagreb antivenom was discontinued. Additionally, in the period of 2017 to 2018 a shortage of Viperfav occurred. Due to a lack of the product indicated for the treatment of V. ammodytes bites, other antivenoms were implemented into clinical practice without comparative assessment of their eligibility. The aim of our work was to identify a high-quality antivenom that might ensure the successful treatment of V. ammodytes and V. berus bites at the preclinical level. Differentiation between bites from these two species is difficult and unreliable in clinical practice, so the availability of a unique antivenom applicable in the treatment of envenoming caused by both species would be the most advantageous for Southeastern Europe. Zagreb antivenom, Viperfav, and ViperaTAb, as well as Viper venom antitoxin for V. berus envenoming and the in-development Inoserp Europe, which was designed to treat envenoming caused by all medically important European snakes, were comparatively tested for the first time. Emphasis was placed on their physicochemical properties, primarily purity and aggregate content, as well as their in vivo protective efficacies. As Zagreb antivenom is no longer available on the European market, Viperfav is the highest-quality product currently available and the only antivenom whose neutralisation potency against V. ammodytes and V. berus venoms was above regulatory requirements.
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Affiliation(s)
- Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
- Correspondence: (T.K.); (B.H.)
| | - Maja Lang Balija
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000 Ljubljana, Slovenia; (M.B.); (M.D.B.)
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Zaloška Cesta 4, 1000 Ljubljana, Slovenia
| | - Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000 Ljubljana, Slovenia; (M.B.); (M.D.B.)
| | - Sanja Mateljak Lukačević
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
- Correspondence: (T.K.); (B.H.)
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17
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Paolino G, Di Nicola MR, Pontara A, Didona D, Moliterni E, Mercuri SR, Grano M, Borgianni N, Kumar R, Pampena R. Vipera snakebite in Europe: a systematic review of a neglected disease. J Eur Acad Dermatol Venereol 2020; 34:2247-2260. [PMID: 32530549 DOI: 10.1111/jdv.16722] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022]
Abstract
In 2009, snakebites were included in the list of the World Health Organization (WHO) neglected diseases. Dermatological literature lacks current and up-to-date articles about snakebites and their management, despite the fact that dermatologists, especially from rural hospitals, can be called into the emergency room to consult the management of suspected snakebites. In this systematic review, we highlighted the main clinical and laboratory aspects of snakebites from Vipera spp. in Europe, by reviewing 3574 studies initially retrieved from PubMed, Embase and Cochrane CENTRAL databases. Of these, 78 were finally included in the systematic review. We found that the most involved taxon was V. berus in 63.3% and the most involved anatomic site of the bite was the upper limbs 53.1% with fang marks reported in 90.5%. The mean age of the patients was 32.9 years, and bites were slightly more common among males (58.2%). A wound washing was performed in 86.9% of cases before the hospitalization. The most frequently reported grade of envenomation was G2 (42.2%). In addition to local dermatological symptoms (extended erythema, oedema, cutaneous necrosis, hives, purpura, petechiae, acute compartment syndrome), numerous systemic symptoms have also been reported, including fatigue (14.4%), pain (75.3%), fever (49.2%), direct anaphylactoid reaction (5.3%), anxiety (60.8%), cranial nerve neurotoxicity (14.8%), dysesthesia/paraesthesia (7.9%), vomiting (33.7%), abdominal pain (23.3%), diarrhoea (15.4%), dyspnoea (6.3%), proteinuria (10.6%) and haematuria (9.3%). Secondary infections were present in 3.5% and disseminated intravascular coagulation in 3.1% of cases, and fasciotomy was performed in 4.2% cases, while an amputation in 6.9%. Only 0.9% of patients died. Antivenom was administered in 3053 cases. In conclusion, there is a pressing need for robust multi-centre randomized control trials, standardized protocol for snakebite management and antivenom administration across Europe and a National snakebite register for each European country.
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Affiliation(s)
- G Paolino
- Clinica Dermatologica, La Sapienza University of Rome, Rome, Italy.,Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - A Pontara
- Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - D Didona
- Department of Dermatology and Allergology, Philipps Medical University of Marburg, Marburg, Germany
| | - E Moliterni
- Clinica Dermatologica, La Sapienza University of Rome, Rome, Italy
| | - S R Mercuri
- Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | - M Grano
- Via Valcenischia, Rome, Italy
| | | | - R Kumar
- Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | - R Pampena
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
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18
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Boels D, Hamel JF, Le Roux G, Labadie M, Paret N, Delcourt N, Langrand J, Puskarczyk E, Nisse P, Sinno-Tellier S, de Haro L. Snake bites by European vipers in Mainland France in 2017-2018: comparison of two antivenoms Viperfav ® and Viperatab ®. Clin Toxicol (Phila) 2020; 58:1050-1057. [PMID: 32134691 DOI: 10.1080/15563650.2020.1726377] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Context: Today, immunotherapy with Fab or F(ab')2 fragments is considered as a gold standard treatment for patients bitten by vipers. We compared the efficiency of two antivenoms, Viperfav® and Viperatab®, in mainland France in 2017-2018 with data provided by the French poison control centre (PCC).Methods: Patients with a moderate (2a and 2b) or severe (3) envenomation after a European viper bite and treated with immunotherapy were included and the markers chosen were the risk of post-antivenom treatment worsening, duration of hospital stay and persistent functional discomfort on day 15. Statistical studies were based on multivariate data analysis.Results: Two hundred and ninety-seven cases were recorded. One hundred and eighty-two (61.3%) patients received Viperfav® and 115 (38.7%) received Viperatab®. Compared to Viperfav®, use of Viperatab® significantly increased the risk of post-antivenom treatment worsening (OR* 12.05; 95%CI [3.11; 46.70]; p < .001). No significant difference between these antivenoms was recorded with respect to the duration of hospital stay and persistent functional discomfort on day 15. Viperfav® and Viperatab® have a similar tolerance (p > .21). Otherwise, duration of hospitalisation was significantly increased by a delay of immunotherapy infusion of more than 12 h (OR 2.70; 95%CI [1.45-5.06]; p = .002) or a preventive administration of LMWH (OR 6.55; 95%CI [1.58-27.13]; p=.02).Discussion: While Viperfav® and Viperatab® have a similar tolerance, our data show that Viperatab® was associated with a higher risk of post-antivenom treatment worsening compared to Viperfav®. Furthermore, this study confirms that the antivenom should be used as soon as possible. Indeed, patients receiving the immunotherapy infusion from the grade 2b presented significantly more frequent exacerbated symptoms (OR 3.99; 95%CI [1.16-13.73]; p=.028) after the antivenom infusion compared to grade 2a group.Conclusions: Whereas no significant difference between these antivenoms was recorded with respect to the duration of hospital stay and persistent functional discomfort on day 15, use of Viperatab®, compared to Viperfav®, significantly increased the risk of post-antivenom treatment worsening (OR* 12.05; 95%CI [3.11; 46.70]; p < .001). Taken together, these data show that Viperfav® is the treatment of choice for the management of snake bites in France.
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Affiliation(s)
- David Boels
- Pharmacology and Toxicology Department, Nantes University Hospital, Nantes, France, and Inserm UMRS 1144, University of Paris, France
| | - Jean François Hamel
- Representative of Clinical Research and Innovation, Angers University Hospital, Angers, France
| | - Gaël Le Roux
- Poison Control Centre, Angers University Hospital, Angers, France
| | - Magali Labadie
- Poison Control Centre, Bordeaux University Hospital, Bordeaux, France
| | - Nathalie Paret
- Poison Control Centre, Lyon University Hospital, Lyon, France
| | - Nicolas Delcourt
- Poison Control Centre, Toulouse University Hospital, Toulouse, France
| | - Jérôme Langrand
- Poison Control Centre, Paris University Hospital, Paris, France
| | | | - Patrick Nisse
- Poison Control Centre, Lille University Hospital, Lille, France
| | - Sandra Sinno-Tellier
- ANSES, French Agency for Food, Environmental and Occupational Health Safety, Maisons-Alfort, France
| | - Luc de Haro
- Poison Control Centre, Marseille University Hospital, Marseille, France
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19
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Morsures par vipères européennes en France métropolitaine en 2017 : utilisation de deux antivenins. Presse Med 2019; 48:723-725. [DOI: 10.1016/j.lpm.2019.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 03/12/2019] [Accepted: 05/07/2019] [Indexed: 10/26/2022] Open
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20
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Vipera berus berus Venom from Russia: Venomics, Bioactivities and Preclinical Assessment of Microgen Antivenom. Toxins (Basel) 2019; 11:toxins11020090. [PMID: 30717298 PMCID: PMC6409582 DOI: 10.3390/toxins11020090] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/27/2019] [Accepted: 01/29/2019] [Indexed: 12/20/2022] Open
Abstract
The common European adder, Vipera berus berus, is a medically relevant species, which is widely distributed in Russia and thus, is responsible for most snakebite accidents in Russia. We have investigated the toxic and enzymatic activities and have determined the proteomic composition of its venom. Phospholipases A2 (PLA2, 25.3% of the venom proteome), serine proteinases (SVSP, 16.2%), metalloproteinases (SVMP, 17.2%), vasoactive peptides (bradykinin-potentiating peptides (BPPs), 9.5% and C-type natriuretic peptides (C-NAP, 7.8%), cysteine-rich secretory protein (CRISP, 8%) and L-amino acid oxidase (LAO, 7.3%) represent the major toxin classes found in V. b. berus (Russia) venom. This study was also designed to assess the in vivo and in vitro preclinical efficacy of the Russian Microgen antivenom in neutralizing the main effects of V. b. berus venom. The results show that this antivenom is capable of neutralizing the lethal, hemorrhagic and PLA2 activities. Third-generation antivenomics was applied to quantify the toxin-recognition landscape and the maximal binding capacity of the antivenom for each component of the venom. The antivenomics analysis revealed that 6.24% of the anti-V. b. berus F(ab’)2 molecules fraction are toxin-binding antibodies, 60% of which represent clinically relevant antivenom molecules.
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21
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Envenomation by the common European adder (Vipera berus): a case series of 219 patients. Eur J Emerg Med 2018; 26:362-365. [PMID: 30422928 DOI: 10.1097/mej.0000000000000577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Every year, several patients are bitten by the common European adder (Vipera berus). The aim of this study is to present a large consecutive case series of patients bitten by V. berus, and to identify signs and symptoms indicative of complicated illness. PATIENTS AND METHODS This is a retrospective case series from the Hospital of South West Jutland, Denmark. All 219 patients bitten by V. berus (diagnosed by history or clinical findings) from 1994 to 2012 were identified through hospital databases. A severity grading from 1 to 5 was applied, and epidemiology, symptoms and signs, complications, treatment and laboratory data were extracted from the hospital databases. RESULTS The most common complaints on admission were pain, nausea, abdominal pain, diarrhoea and dizziness, with discoloration and oedema being the most common symptoms. Few patients experienced syncope, palpitations or respiratory distress. Fifteen percent of all patients were transferred to the ICU and 2% (all children) were suspected of having compartment syndrome. Leucocytosis, gastrointestinal symptoms and hypotension were risk factors for complicated disease. CONCLUSION Most patients only showed symptoms of no or mild envenomation. Fifteen percent were transferred to the ICU and five patients (all children) required fasciotomy because of suspected compartment syndrome. Only 10 patients received antivenom.
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Eddleston M, Lamb T, Brvar M. Response to Halassy and colleagues. Clin Toxicol (Phila) 2018; 56:910-911. [DOI: 10.1080/15563650.2018.1452253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Michael Eddleston
- Pharmacology, Toxicology & Therapeutics, University of Edinburgh, Edinburgh, UK
| | - Thomas Lamb
- Pharmacology, Toxicology & Therapeutics, University of Edinburgh, Edinburgh, UK
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
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23
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Halassy B, Kurtović T, Lang Balija M. Comment on "Antivenom for European Vipera species envenoming". Clin Toxicol (Phila) 2018. [PMID: 29521124 DOI: 10.1080/15563650.2018.1448402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Beata Halassy
- a Centre for Research and Knowledge Transfer in Biotechnology , University of Zagreb , Zagreb , Croatia
| | - Tihana Kurtović
- a Centre for Research and Knowledge Transfer in Biotechnology , University of Zagreb , Zagreb , Croatia
| | - Maja Lang Balija
- a Centre for Research and Knowledge Transfer in Biotechnology , University of Zagreb , Zagreb , Croatia
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24
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Extending knowledge of the clinical picture of Balkan adder (Vipera berus bosniensis) envenoming: The first photographically-documented neurotoxic case from South-Western Hungary. Toxicon 2018; 143:29-35. [PMID: 29305081 DOI: 10.1016/j.toxicon.2017.12.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/11/2017] [Accepted: 12/30/2017] [Indexed: 02/05/2023]
Abstract
We report a severe envenoming associated with minimal local symptoms following a Balkan adder (Vipera berus bosniensis) bite in South-Western Hungary. A 63-year-old male with a history of hypertension and sinus bradycardia (45/min) was bitten by a sub-adult specimen of V. b. bosniensis in Somogy County on 04 May 2017. The patient was transported to and treated at the Emergency Department of "Moritz Kaposi" General Hospital, Kaposvár. Locally only pain and minimal swelling with a small haematoma developed on the bitten finger. The abdominal muscles were very tender and guarding was detected upon palpation on the way to hospital. The patient, who had taken his telmisartan (80 mg) tablet in that morning, complained of nausea and dizziness during the first medical examination. The systemic signs included fluctuations in blood pressure (115/85-165/105 mmHg), ECG changes (transient horizontal ST depression in V5-6, and sinus tachycardia (90/min)), severe diarrhoea and vomiting (in 7 episodes). Descending neuromuscular paralysis appeared in the next morning, including complete bilateral ptosis with external ophthalmoplegia, and binocular diplopia. Single-fiber electromyography confirmed the neuromuscular block in the frontalis muscle innervated by the facial nerve. Intense dizziness with uncoordinated movement emerged on the 3rd day. The laboratory findings were mild, including anaemia, hypokalaemia, elevated glutamic-pyruvic transaminase and C-reactive protein levels. The absolute neutrophil count remained almost completely normal. Supportive care and monovalent antivenom (Viper Venom Antitoxin®, Biomed, Warsaw) were applied. The patient was discharged from hospital on the 4th day, although recovery was not complete until 9 days after the bite. This is the first photographically-documented case of neurotoxic envenoming from the South-Western Hungarian distribution range of V. b. bosniensis.
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25
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Lamb T, de Haro L, Lonati D, Brvar M, Eddleston M. Antivenom for European Vipera species envenoming. Clin Toxicol (Phila) 2017; 55:557-568. [PMID: 28349771 DOI: 10.1080/15563650.2017.1300261] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND European viper bite is relatively uncommon but can cause serious envenoming, particularly swelling and hemorrhage spreading from limb to trunk that can cause long term disability. Systemic features are relatively mild compared to many other venomous species. Moderate-to-severe envenoming requires antivenom, which is given many hundreds of times each year across the continent. Several Vipera spp antivenoms are produced in Europe, but there is little comparative information available for the antivenoms and none is licensed with the European Medicines Agency. We aimed to collect descriptive data on European viper antivenoms and assess their relative effectiveness. METHODS A systematic review of articles relating to antivenom in Europe was performed using the Medline medical database. The following keywords "Europ*" or the individual names of each European country and "antiven*" or "immun*" or "envenom*" and "snake" or "viper*" or "adder" were used. Articles published between 1 January 1996 and 11 March 2016 pertaining to clinical outcome, including case reports, were selected. Referenced articles in the indexed articles were explored for suitability and included if they met any of the criteria: specific antivenom used, route of antivenom administration, adverse reactions to antivenom therapy and length of hospital admission. All accepted abstracts from EAPCCT conferences since 2000 were searched and abstracts relating to Vipera spp envenoming were assessed for suitability. We extracted data on study type, safety and effectiveness. We sought information on antivenoms from manufacturers and individual patient data from authors of publications. Since individual patient data were only rarely available, we compared median length of stay between case series reporting each antivenom. We identified 40 papers and six published abstracts, and one unpublished paper that reported clinical cases and case series of envenomed patients treated with antivenom. No publication reported randomized controlled trials comparing any European Vipera antivenom with either placebo or another antivenom. 25 reports were of retrospective hospital- (n = 13) or poison center-based (n = 12) case series including five or more patients; a further 12 reports were either case reports or case series with less than five patients and one paper was a limited literature review. An additional nine papers reported prospective data; seven collected data remotely through poison service telephone communication with the attending physicians. Antivenoms available in Europe: Eight antivenoms are available for European Vipera spp envenoming; a material safety data sheet providing information on manufacture was available for seven. Six are raised against V. berus or V. ammodytes venom; the seventh is raised against a mixture of V. ammodytes, V. aspis and V. berus venom and the eighth is raised against V. ammodytes, Macrovipera lebetina and Montivipera xanthina venom. Six manufacturers recommended intramuscular administration while two recommended intravenous administration. No randomized control trials comparing the effectiveness of antivenoms were identified. Pre-clinical data: We found two papers presenting comparative preclinical data. Clinical data: Clinical studies were predominantly retrospective and contained clinical data on antivenom used in 2602 patients; where the antivenom was identified (n = 2174), 2061 (94.8%) received Zagreb, ViperFAV or ViperaTAb antivenoms. There were few published data on the other antivenoms. Repeated use of antivenom: Repeat doses were reported in 230/1491 of cases (15.4%) where this information was recorded. Outcome and length of hospital stay: Intravenous administration of antivenom was associated with shorter length of hospital stay (median length of hospital stay in studies of intravenous ViperFAV or ViperaTAb ranged from 1 to 4.8 days versus 2 to 18 days for intramuscular Bulbio or Zagreb antivenoms). Antivenom versus no antivenom: Some small studies demonstrated no difference in the length of hospital stay in patients with equivalent envenomation grading who either did or did not receive antivenom. Adverse events: Adverse reactions were reported in 37 of 2408 cases (1.5%) including seven cases of anaphylaxis. CONCLUSIONS There are very limited pre-clinical comparative data and no randomised controlled trials assessing effectiveness of the antivenoms against different Vipera species. Most descriptive data suggest the efficacy of Zagreb, ViperFAV and ViperaTAb antivenoms by the intravenous route but not intramuscular route, although this is level D evidence. Reported adverse reactions were rare, suggesting that the modern intravenous antivenoms are of good quality. Better and more systematic data, including perhaps randomized controlled trials comparing different antivenoms, are required for the many hundreds of antivenom administrations that occur annually across Europe.
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Affiliation(s)
- Thomas Lamb
- a Department of Pharmacology, Toxicology, and Therapeutics , University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
| | - Luc de Haro
- b Centre Antipoison , Hôpital Sainte Marguerite , Marseilles , France
| | - Davide Lonati
- c Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Istituti Clinici Scientifici Maugeri , IRCCS Maugeri Hospital and University of Pavia , Pavia , Italy
| | - Miran Brvar
- d Centre for Clinical Toxicology and Pharmacology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Michael Eddleston
- a Department of Pharmacology, Toxicology, and Therapeutics , University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
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Estefanía Díez M, Alonso Peña D, García Cano P, López Gamo A. Tratamiento de la mordedura por víbora en España. Semergen 2016; 42:320-6. [DOI: 10.1016/j.semerg.2014.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 07/28/2014] [Accepted: 08/02/2014] [Indexed: 10/24/2022]
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Breivik H, Stubhaug A. Complex Regional Pain Syndrome (CRPS) after viper-bite in a pregnant young woman: Pathophysiology and treatment options. Scand J Pain 2016; 10:108-110. [PMID: 28361759 DOI: 10.1016/j.sjpain.2015.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Harald Breivik
- University of Oslo, Oslo University Hospital, Oslo, Norway
- Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
| | - Audun Stubhaug
- University of Oslo, Oslo University Hospital, Oslo, Norway
- Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway
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Claudet I, Grouteau E, Cordier L, Franchitto N, Bréhin C. Hyperglycemia is a risk factor for high-grade envenomations after European viper bites (Vipera spp.) in children. Clin Toxicol (Phila) 2015; 54:34-9. [PMID: 26582080 DOI: 10.3109/15563650.2015.1113542] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Hyperglycemia has been described in severe scorpion envenomation, we wanted to analyze if it was applicable to viper bites in children. AIM To describe clinical, biological, and therapeutic characteristics of 83 children bitten by European viper (Vipera spp.) and to confirm that hyperglycemia is a risk factor for high-grade envenomation. MATERIAL AND METHODS A retrospective study was conducted between 2001 and 2014 in the pediatric emergency department of a tertiary level children's hospital. Collected data were: age and sex of children; day and time of admission; day, time and circumstances of the accident; snake identification; bite location; envenomation severity; presence of fang marks; prehospital care; laboratory abnormalities, use of specific immunotherapy, associated treatments; length of stay; hospital course. RESULTS Eighty-three children were included (62 boys, 21 girls). The mean age was 7.4 ± 3.9 years. Bites were most often located on the lower extremities (66%). The classification of envenomation was: 83% low grade (absent or minor envenomation) and 17% high grade (moderate to severe envenomation). All high-grade envenomations received specific immunotherapy (Viperfav(TM), (Aventis Pasteur, MSD, Lyon, France). Being bitten on an upper extremity (odds ratio [OR] 51.1 95% class interval [CI] [6.1-424], p < 0.0001), during the afternoon (OR 13.4 95% CI [1.7-107.9], p = 0.015), feeling violent pain (OR 4.2 95% CI [1.1-16.5], p = 0.023), and high initial plasma glucose level (6.5 ± 1.7 mmol/L versus 5.0 ± 0.9 mmol/L, p = 0.027) were associated with a significant risk of high-grade envenomation. CONCLUSION We have confirmed a potential link between initial hyperglycemia and the risk of progression to high-grade envenomation as well as its association with other published predictive factors.
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Affiliation(s)
- I Claudet
- a Pediatric Emergency Department , Children Hospital , Toulouse , France
| | - E Grouteau
- a Pediatric Emergency Department , Children Hospital , Toulouse , France
| | - L Cordier
- b Regional Poison Centre, CHU Purpan , Toulouse , France
| | - N Franchitto
- b Regional Poison Centre, CHU Purpan , Toulouse , France
| | - C Bréhin
- a Pediatric Emergency Department , Children Hospital , Toulouse , France
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Jollivet V, Hamel JF, de Haro L, Labadie M, Sapori JM, Cordier L, Villa A, Nisse P, Puskarczyk E, Berthelon L, Harry P, Boels D. European viper envenomation recorded by French poison control centers: A clinical assessment and management study. Toxicon 2015; 108:97-103. [PMID: 26454165 DOI: 10.1016/j.toxicon.2015.09.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 08/20/2015] [Accepted: 09/29/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Immunotherapy is the gold standard treatment for patients bitten by European vipers in France; it significantly decreases morbidity, frequency and severity of complications and length of stay. A national prospective study was performed by all Poison Control Centers (PCC) to validate the emergency protocol for viper envenomations. METHODS This prospective study included all cases of viper bites in France, treated or not with Viperfav(®) in 2013. RESULTS In 2013, 277 cases of viper bites were collected: ratio M/F 2.1; mean aged 43 years (<15 years 25% 15-65 63% > 65 12%). The final severity was divided into 68 grades 0, 58 grades I, 62 grades IIA, 71 grades IIB and 18 grades III. One death was reported. Five patients had neurological signs. For the 114 patients who received Viperfav(®), all systemic signs disappeared in 5 h and in 24 h for biological and neurological signs. No severe anaphylactic reaction with Viperfav(®) was reported. Late Viperfav(®) administration increased the risk of functional impairment 15 days after the bite (OR = 3.21 p = 0.043). The administration of Low Molecular Weight Heparin (LMWH) increased the frequency of functional impairment to 15 days after the bite (OR = 6.38 p = 0.064), although Viperfav(®) was given in the first 18 h. DISCUSSION This study confirms the efficiency, safety and recommendation of an early administration of a single dose of Viperfav(®), LMWH should not be used. It also shows the extension of neurotoxic venom of vipers in France.
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Affiliation(s)
- V Jollivet
- Poison Control Center, Angers University Hospital, France
| | - J F Hamel
- Clinical Research Center, Angers University Hospital, France
| | - L de Haro
- Poison Control Center, Marseille University Hospital, France
| | - M Labadie
- Poison Control Center, Bordeaux University Hospital, France
| | - J M Sapori
- Poison Control Center, Lyon University Hospital, France
| | - L Cordier
- Poison Control Center, Toulouse University Hospital, France
| | - A Villa
- Poison Control Center, Paris University Hospital, France
| | - P Nisse
- Poison Control Center, Lille University Hospital, France
| | - E Puskarczyk
- Poison Control Center, Nancy University Hospital, France
| | - L Berthelon
- Poison Control Center, Strasbourg University Hospital, France
| | - P Harry
- Poison Control Center, Angers University Hospital, France
| | - D Boels
- Poison Control Center, Angers University Hospital, France.
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Turković V, Teichmann S, Dörfelt R. European Adder bites in dogs in southern Germany. A retrospective study over a 6.5-year period. TIERAERZTLICHE PRAXIS AUSGABE KLEINTIERE HEIMTIERE 2015; 43:221-30. [PMID: 26152480 DOI: 10.15654/tpk-140364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 03/04/2015] [Indexed: 11/13/2022]
Abstract
OBJECTIVE In some regions of Germany dogs are presented to the veterinarian due to a snake bite, especially during the summer. These patients often show multiple clinical and laboratory deviations. Without a significant history diagnosis is commonly difficult. Aim of this retrospective study was to analyze exposure, physical examination and clinical pathology results as well as course and outcome in dogs presented after European adder bites. MATERIAL AND METHODS Patient history of 15 dogs diagnosed with European adder bites over a 6.5-year-period were evaluated retrospectively. Normality of data distribution was tested by D'Agostino and Pearson omnibus normality test. Data were analyzed by T-test and Wilcoxon-matched-pairs-signed rank-test. P-values < 0.05 were considered significant. RESULTS All 15 dogs were presented within 1-48 hours after the snakebite. Most common clinical signs were local swelling and pain. Clinical pathology results on day 1 included haemoconcentration, leukocytosis and coagulopathy. On the second day of hospitalization heart rate and haematocrit declined significantly. Treatment included fluid therapy, antibiotic and antihistaminic drugs, glucocorticosteroids, antivenom and analgesics. One of 15 dogs died on the third day of hospitalization, all others were discharged. Duration of hospitalization was between 1 and 8 days (mean 4.2 ± 1.9 days). CLINICAL RELEVANCE Dogs affected by European adder bites most often present with swelling and pain at the site of the bite, most frequently on the head and limbs. Patients require intensive symptomatic therapy including antibiotics and analgesics, if indicated. With adequate therapy survival rate is high. For some patients European adder bites may be lethal.
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Affiliation(s)
| | | | - R Dörfelt
- Dr. René Dörfelt, Medizinische Kleintierklinik der Ludwig-Maximilians-Universität München, Veterinärstraße 13, 80539 München, E-Mail:
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Valenta J, Stach Z, Stříteský M, Michálek P. Common viper bites in the Czech Republic - epidemiological and clinical aspects during 15 year period (1999-2013). Prague Med Rep 2015; 115:120-7. [PMID: 25626330 DOI: 10.14712/23362936.2014.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
The aim of this study was to analyse most important epidemiological and clinical aspects of registered snakebites caused by a native common European viper Vipera berus in the Czech Republic over a period of 15 years (1999–2013). Data have been collected retrospectively from a database of the Toxinology Centre belonging to the General University Hospital in Prague. In total, 191 cases of snakebites caused by common viper were registered during the study period. Systemic envenoming occurred in 49 (25.7%) patients, local envenoming without systemic symptoms was recorded in 91 (47.6%) and asymptomatic dry bites were seen in 51 (26.7%) cases, respectively. Twenty-four patients (12.6% of all bites) were treated with administration of antivenom. None of the victims died as a result of snakebite during the observation period. Native viper snakes usually did not cause serious harm to the patients, with the exception of children. Antivenom should be administered in all cases with systemic manifestations, in children even with serious local affection and administered as soon as possible. Envenomed patients should be admitted to the hospital and treated at least under supervision of specialists with experience in snakebite treatment, who can indicate and provide administration of the antivenom.
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Affiliation(s)
- Jiří Valenta
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Zdeněk Stach
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Martin Stříteský
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Pavel Michálek
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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XXXV International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 26–29 May 2015, St Julian's, Malta. Clin Toxicol (Phila) 2015. [DOI: 10.3109/15563650.2015.1024953] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Brandeker E, Hillström A, Hanås S, Hagman R, Holst BS. The effect of a single dose of prednisolone in dogs envenomated by Vipera berus--a randomized, double-blind, placebo-controlled clinical trial. BMC Vet Res 2015; 11:44. [PMID: 25886633 PMCID: PMC4349773 DOI: 10.1186/s12917-015-0352-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 02/05/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment with glucocorticoids after snakebite in dogs is controversial and randomized clinical studies are missing. The objective of this study was to investigate the effect of a single dose of prednisolone in dogs envenomated by Vipera berus in a double-blind placebo-controlled study, after exclusion of dogs treated with antivenom. The two treatment groups were compared regarding clinical status and clinicopathological test results. A total of 75 dogs bitten by Vipera berus within the previous 24 hours were included. Clinical assessment, blood sampling and measurement of the bitten body part were done at admission (Day 1), after 24 hours (Day 2) and at a re-examination (Re-exam) after 10-28 days. Dogs were given prednisolone 1 mg/kg bodyweight (PRED) or saline (PLACEBO) subcutaneously in a randomized, double-blind clinical trial. Dogs were examined clinically and mental status and extent of edema were described. Furthermore, appetite, vomiting, diarrhea, cardiac arrhythmia and death were recorded. Concentrations of C-reactive protein (CRP) and high sensitivity cardiac Troponin I (cTnI), hematology variables and Prothrombin time (PT) were determined. Systemic inflammation was defined as present if CRP > 35 mg/l. RESULTS None of the dogs died during the study period. The mental status was reduced in 60/75 (80%) of dogs on Day 1, compared to 19/75 (25%) on Day 2. The proportion of dogs with no or only mild edema increased significantly from Day 1 to Day 2. About one-third of the dogs developed gastrointestinal signs during the study period. Cardiac arrhythmia was uncommon. Clinicopathological changes included increased total leucocyte count, CRP and troponin concentration on Day 2. The cTnI concentration was increased in dogs with systemic inflammation, compared to dogs without systemic inflammation. A single dose of prednisolone did not significantly affect any of the clinical or clinicopathological parameters studied, except for a higher monocyte count on Day 2 in dogs that had received prednisolone treatment. CONCLUSION The results of the present study do not support routine administration of a single dose of prednisolone 1 mg/kg subcutaneously in dogs bitten by Vipera berus.
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Affiliation(s)
- Erika Brandeker
- Evidensia Södra Djursjukhuset, Månskärsvägen 13, SE-141 75, Kungens Kurva, Sweden.
| | - Anna Hillström
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Box 7054, , SE-750 07, Uppsala, Sweden.
| | - Sofia Hanås
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Box 7054, , SE-750 07, Uppsala, Sweden.
| | - Ragnvi Hagman
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Box 7054, , SE-750 07, Uppsala, Sweden.
| | - Bodil Ström Holst
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Box 7054, , SE-750 07, Uppsala, Sweden.
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Abstract
This review is on the pulmonary complications of snakebites, which can have fatal consequences. We identified three common themes as reported in the literature regarding envenomation: generalized neuromuscular paralysis affecting airway and respiratory muscles, pulmonary edema, and pulmonary hemorrhages or thrombosis due to coagulopathy. Respiratory paralysis and pulmonary edema can be due to either elapid or viper bites, whereas pulmonary complications of coagulopathy are exclusively reported with viper bites. The evidence for each complication, timeline of appearance, response to treatment, and details of pathophysiology are discussed.
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Affiliation(s)
- Ariaranee Gnanathasan
- From the The Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
| | - Chaturaka Rodrigo
- From the The Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, 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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Gupta PN, Thomas J, Francis PK, Shylaja SV. +Ophitoxaemia and myocardial infarction--the issues during primary angioplasty: a review. BMJ Case Rep 2014; 2014:bcr-2013-201912. [PMID: 25342187 DOI: 10.1136/bcr-2013-201912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
'The Big four' are the most poisonous snakes in India, and especially in Kerala. These include the cobra, the viper, the krait and the sea snake. Most of the poisonous snakebites in India occur in Kerala. We believe there are only a few reports of myocardial infarction after snakebites and most of these are viper bites. We believe this is the second case of primary angioplasty for a snakebite. There are at least a few potential issues in performing a primary angioplasty in a snakebite case, namely (1) Is it a thrombus or a spasm? (2) Are the bleeding parameters deranged? Will the patient tolerate tirofiban and other glycoprotein (GB) 2b3a inhibitors? Will he develop dangerous bleeding due to the high dose of heparin needed? Further, would we save the patient from myocardial infarction only to lose him to renal failure, both due to the nephrotoxicity of the venom, the kidney being further damaged by the contrast media used for the angioplasty? We discuss all these issues as they crossed our mind, and hope it will help further treatment in others. We would like to review the available literature on these points and describe a recent case of ours.
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Affiliation(s)
- Prabha Nini Gupta
- Department of Cardiology, Medical College Hospital, Trivandrum, Kerala, India
| | - Jinesh Thomas
- Department of Cardiology, Medical College Hospital, Trivandrum, Kerala, India
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Immunological cross-reactivity and neutralisation of European viper venoms with the monospecific Vipera berus antivenom ViperaTAb. Toxins (Basel) 2014; 6:2471-82. [PMID: 25153254 PMCID: PMC4147594 DOI: 10.3390/toxins6082471] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 08/13/2014] [Accepted: 08/13/2014] [Indexed: 11/17/2022] Open
Abstract
Medically important cases of snakebite in Europe are predominately caused by European vipers of the genus Vipera. The mainstay of snakebite therapy is polyclonal antibody therapy, referred to as antivenom. Here we investigate the capability of the monospecific V. berus antivenom, ViperaTAb®, to cross-react with, and neutralise lethality induced by, a variety of European vipers. Using ELISA and immunoblotting, we find that ViperaTAb® antibodies recognise and bind to the majority of toxic components found in the venoms of the Vipera species tested at comparably high levels to those observed with V. berus. Using in vivo pre-clinical efficacy studies, we demonstrate that ViperaTAb® effectively neutralises lethality induced by V. berus, V. aspis, V. ammodytes and V. latastei venoms and at much higher levels than those outlined by regulatory pharmacopoeial guidelines. Notably, venom neutralisation was found to be superior to (V. berus, V. aspis and V. latastei), or as equally effective as (V. ammodytes), the monospecific V. ammodytes “Zagreb antivenom”, which has long been successfully used for treating European snake envenomings. This study suggests that ViperaTAb® may be a valuable therapeutic product for treating snakebite by a variety of European vipers found throughout the continent.
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Natarajan N, Basheer A, Mookkappan S, Periyasamy S. Reversible lower limb deep vein thrombosis following haemotoxic snakebite-a case report. Australas Med J 2014; 7:232-5. [PMID: 24944721 DOI: 10.4066/amj.2014.2075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Haemotoxic snakebite, presenting with coagulopathy and bleeding manifestations, is quite common. Thrombotic manifestations are infrequently observed. We describe the unusual case of a young male who developed deep vein thrombosis (DVT) of the left lower limb following snakebite, despite an ongoing coagulopathy. Investigations revealed leucocytosis, prolonged 20-minute whole blood clotting time (20'WBCT), prolonged prothrombin time (PT), and activated partial thromboplastin time (aPTT). Doppler study revealed thrombosis of common femoral vein, superficial femoral, and profunda femoris veins. The patient underwent two fasciotomies and received anticoagulation after which patency of the veins was restored. Doppler sonographic imaging in patients with haemotoxic snakebite who present with increasing local swelling may assist with early anticoagulation therapy that has a potential to be limb-saving.
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Affiliation(s)
| | - Aneesh Basheer
- Department of General Medicine, Pondicherry Institute of Medical Sciences
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Senthilkumaran S, Khamis A, Manikam R, Thirumalaikolundusubramanian P. Snakebite and severe hypertension: Looking for the Holy Grail. Indian J Crit Care Med 2014; 18:186. [PMID: 24701075 PMCID: PMC3963208 DOI: 10.4103/0972-5229.128715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Subramanian Senthilkumaran
- Department of Emergency and Critical Care Medicine, Sri Gokulam Hospital and Research Institute, Salem, Tamil Nadu, India
| | - Arbid Khamis
- Department of Medicine, Russel Hall Hospital, Dudley Group NHS, United Kingdom
| | - Rishya Manikam
- Department of Emergency Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Geier MV, Quarcoo D, Spallek MF, Joachim R, Groneberg DA. Giftschlangenbisse — eine globale Herausforderung. ZENTRALBLATT FUR ARBEITSMEDIZIN ARBEITSSCHUTZ UND ERGONOMIE 2014. [DOI: 10.1007/bf03344195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Epidemiology of snakebite in Europe: Comparison of data from the literature and case reporting. Toxicon 2013; 76:206-13. [DOI: 10.1016/j.toxicon.2013.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 09/23/2013] [Accepted: 10/02/2013] [Indexed: 11/18/2022]
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Meenakshisundaram R, Senthilkumaran S, Grootveld M, Thirumalaikolundusubramanian P. Severe hypertension in elapid envenomation. J Cardiovasc Dis Res 2013; 4:65-7. [PMID: 24023478 DOI: 10.1016/j.jcdr.2013.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 08/07/2012] [Indexed: 11/25/2022] Open
Abstract
Snakebite is not an uncommon medical emergency in India; however, symptoms of autonomic dysfunction in snakebite are rare. The elapid snake envenomation is a frequent occurrence in India, and the krait bite is prevalent in the south Indian region. Here, we present three cases of snakebite with severe hypertension and requiring intravenous nitroglycerin (NTG). As the level of blood pressure (BP) decreased significantly following antisnake venom (ASV) injection in all three cases, it is likely that snake venom-induced dysautonomia might have contributed to severe hypertension in such patients. Clinical and therapeutic challenges of these cases are highlighted, so that practitioners coping with medical emergencies in resource-limited situations can consider snake (krait) bite in the differential diagnosis, and also manage effectively according to corroborative clinical evidences.
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Affiliation(s)
- Ramachandran Meenakshisundaram
- Department of Emergency and Critical Care Medicine, Sri Gokulam Hospitals and Research Institute, 3/60, Meyyanur Road, Salem, Tamil Nadu, India ; Chennai Medical College Hospital and Research Centre, Irungalur, Trichy, Tamil Nadu, India ; Institute for Materials Research and Innovation, University of Bolton, Deane Street, Bolton BL3 5AB, United Kingdom
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Coulson JM, Cooper G, Krishna C, Thompson JP. Snakebite enquiries to the UK National Poisons Information Service: 2004-2010. Emerg Med J 2012; 30:932-4. [PMID: 23243048 DOI: 10.1136/emermed-2012-201587] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe trends regarding snakebite enquiries to the UK National Poisons Information Service (NPIS) from 2004 to 2010. METHODS The NPIS telephone enquiry database, the UK Poisons Information Database, was interrogated for enquiries to the four NPIS units from 2004 to 2010. Search terms used were 'snake' and 'snakebite'. Information from the national dataset was available from Cardiff and Edinburgh units from 2004 onwards, Birmingham from June 2005 and Newcastle from September 2006. RESULTS Five hundred and ten cases were identified, of which 69% were male and 31% female. Average age of cases was 32 years (±1 95% CI). The snake was identified as follows: British Adder in 52% of cases, an exotic species in 26%, unknown in 18% and another UK snake in 4%. 82% of cases occurred between the months of April and September. Cases peaked during August (19%). Forty-two per cent of enquiries involved features of envenoming. Eighty-five cases were assessed as requiring antivenom. Eighty-four cases received treatment with antivenom. No adverse reactions to the antivenom were reported and resolution of clinical features was reported in all treated cases. Advice to use an antidote was followed in 98.8% of cases. CONCLUSIONS Snakebites account for one to two NPIS cases per week. Adder bites account for over half of cases. A quarter of cases were due to non-UK snakes kept in captivity within the UK. Envenoming was said to have occurred in just under half of all cases. Advice given by the NPIS appears to closely reflect national practice guidelines.
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Affiliation(s)
- James Michael Coulson
- National Poisons Information Service (Cardiff), Cardiff and Vale University Health Board, Cardiff, UK
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Malina T, Babocsay G, Krecsák L, Schuller P, Zacher G, Vasas G. [An overview on envenomings inflicted by the Common adder (Vipera berus) and their treatment in Hungary. Facts and beliefs -- part I]. Orv Hetil 2012; 153:1092-105. [PMID: 22776522 DOI: 10.1556/oh.2012.29407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Consequences of bites by the Common adder (Vipera berus) were reviewed in this study. Patients bitten by snakes from different populations may develop variable symptoms due to geographical venom variation. The correct diagnosis of snake bites and the knowledge of the distribution of venomous snake taxa have a crucial impact on snake bite therapy. The characteristic symptoms of patients bitten by V. berus in Hungary are highlighted. The habitat characteristics, seasonal activity and the Hungarian distribution of the adder are described based on literature data, museum specimens and field observations. However, envenomings are uncommon in Hungary, the annual 3 to 4 incidents have to be taken seriously, regardless of the age and actual health condition of the patients. Contrary to beliefs persisting both among laymen and professionals, the venom of V. berus is powerful. Medical observation of the patients is necessary in the first 5 to 6 hours. Any systemic symptom or progression of the edema requires hospital admission.
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Affiliation(s)
- Tamás Malina
- Debreceni Egyetem Farmakognózia Részleg Debrecen.
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Abstract
BACKGROUND Viper bites and subsequent evolution to severe envenomations are more frequent in children. AIM The aims of this study were to describe the clinical, biological, and therapeutic characteristics of children bitten by vipers in France and to identify risk factors associated with severe envenomations. METHODS A retrospective study was conducted between 2001 and 2009 in the pediatric emergency department of a tertiary-level children hospital. Collected data were age and sex of children; day and time of admission; day, time, and circumstances of the accident; snake identification; bite location; envenomation severity; presence of fang marks; prehospital care; use of specific immunotherapy and associated treatments; length of stay; and hospital course. RESULTS Fifty-eight children were included (43 boys, 15 girls). The mean age was 7.8 ± 4.1 years. Bites were most often located on the lower extremities (77%). The classification of envenomation was: 83% low grade (absence or minor envenomation) and 17% high-grade (moderate to severe envenomations). All high-grade envenomations received specific immunotherapy (Viperfav). Being bitten on an upper extremity (P < 0.001), during the afternoon (P = 0.025), feeling violent pain (P = 0.037), and high initial glucose level (P = 0.016) were associated with a significant risk of high-grade envenomation. In the multivariate analysis, 3 factors remained significant: upper-extremity location (relative risk [RR], 60.5 [3.5-1040]; P = 0.005), immediate violent pain (RR, 21.5 [1.3-364.5]; P = 0.03), and female sex (RR, 17.5 [0.9-320.3]; P = 0.053). CONCLUSIONS A certain number of criteria seem related to more significant risk of progression to high-grade envenomation. Bites to the upper extremities should be carefully observed because of the risk of evolution to a high-grade envenomation.
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Kurtović T, Leonardi A, Lang Balija M, Brgles M, Habjanec L, Križaj I, Halassy B. The standard mouse assay of anti-venom quality does not measure antibodies neutralising the haemorrhagic activity of Vipera ammodytes venom. Toxicon 2012; 59:709-17. [DOI: 10.1016/j.toxicon.2012.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 02/21/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
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Boels D, Hamel JF, Bretaudeau Deguigne M, Harry P. European viper envenomings: Assessment of Viperfav™ and other symptomatic treatments. Clin Toxicol (Phila) 2012; 50:189-96. [PMID: 22372786 DOI: 10.3109/15563650.2012.660695] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED The treatment of European viper envenomings is based on IV antivenom infusions. Viperfav™ contains purified F(ab')(2) fragments of equine antibodies, and a 4 ml vial can neutralize 500-1000 mouse LD50 of Vipera aspis, V. ammodytes and V. berus venoms and is known to be safe and efficient. Assessments of Viperfav™ (dosage and timing of infusions) and of symptomatic treatments such as low-molecular-weight heparin (LWHM), corticosteroids and the routine use of antibiotic therapy have not as yet been reported. OBJECTIVES The objective was to compare the efficacy and safety of Viperfav™ as a function of the time to infusion and to assess other symptomatic treatments given for European viper bites such as antibiotics, corticosteroids and LWMH. METHODS A prospective case review study of viper envenomings treated with Viperfav™ was compiled by the Angers Poisons Centre. The endpoints chosen were as follows: duration of hospital stay, complications (haematoma, infection) and persistent functional discomfort on day 15. Statistical studies were based on multivariate data analysis (MVA). RESULTS 268 moderate or severe envenomings (Grades II and III) recorded in adults and children between 1999 and 2009 were included in the study. A time to the Viperfav™ infusion < 10 h after the bite (179 patients vs. 72) significantly reduced the incidence of haematomas (OR 2.3; p < 0.006), functional discomfort (OR 3.7; p < 10 - 4) and length of hospital stay (OR 2.1; p < 0.03). Multiple doses of Viperfav™ (2 or 3 vials in 22 patients vs. 246 treated with 1 vial) did not improve the selected endpoints. Routine antibiotic therapy was prescribed in 102 patients (vs. 166 patients without) and no significant difference was seen with respect to the endpoints. Moreover, no local or systemic infections were recorded in the non-antibiotic group. Corticosteroids were prescribed in 36 patients (vs. 232 without) but they did not significantly improve the endpoints or oedema. LMWH in 32 patients (vs. 236 without) increased the length of hospital stay (OR 3.2; p < 0.009 and the level of significantly persistent functional discomfort at day 15 (OR 3.7; p < 0.003). CONCLUSIONS A single infusion of Viperfav™ (one vial) was effective whatever the grade of envenomation, and multiple doses did not improve the outcome. Viperfav™ was most effective when given soon (< 10 h) after envenoming. The routine use of antibiotic therapy was not necessary. Corticosteroids did not improve the endpoints selected, and we do not recommend the use of LMWH as this increased persistent functional discomfort and the length of hospital stay.
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Affiliation(s)
- David Boels
- University Hospital, Poisons and Toxicovigilance Centre, Angers, France.
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Morsures de vipères chez l’enfant. Arch Pediatr 2011; 18:1278-83. [DOI: 10.1016/j.arcped.2011.08.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/23/2011] [Accepted: 08/26/2011] [Indexed: 11/18/2022]
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Chippaux JP. Epidemiology of snakebites in Europe: a systematic review of the literature. Toxicon 2011; 59:86-99. [PMID: 22056768 DOI: 10.1016/j.toxicon.2011.10.008] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 10/07/2011] [Accepted: 10/11/2011] [Indexed: 11/19/2022]
Abstract
Snakebites are rare medical emergency cases in Europe but may sometimes be severe and lead to complications. A better knowledge of snakebite epidemiology may help health authorities to better understand therapeutic requirements, especially concerning antivenoms, and thus improve treatment of snakebite. An extensive literature search for studies and articles published between 1970 and 2010 was performed. Both indexed and non-indexed articles were examined, the analysis of which took into account the heterogeneity between the studies and weighted the studies according to size of the study population covered. Most of the articles involved hospitalized patients who represented more than 90% of snakebites. Incidence, mortality and population at risk were estimated after stratification into three regions (northern, central and southern Europe) based both on viper species distribution and climatic characteristics. There was no significant variation in incidence from the north to the south of Europe. In the whole of Europe, including European Russia and Turkey, the annual number of snakebite cases was estimated at 7992 [CI 95% = 6860-9178] bites, out of which approximately 15% were considered severe (grade 3). These bites usually occurred between May and September, with a more dispersed distribution in southern Europe. The average number of deaths per annum was 4 [0.7-7.7]. Children and male victims are more affected, contrary to what one would expect given their respective proportion in the entire population. Both upper and lower limb bites were recorded at an equal frequency while the bites in other parts of the body were very rare. Immunotherapy was prescribed in one out of three snakebites in Europe, with a very high geographical variability, in spite of excellent tolerance, at least considering highly-purified immunoglobulin fragments. Snakebites are uncommon in Europe but can cause life-threatening envenomation. Fragments of highly-purified immunoglobulins are now very well tolerated and dramatically reduce both severity and mortality of snakebites when used in treatment.
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Affiliation(s)
- Jean-Philippe Chippaux
- Institut de Recherche pour le Développement, UMR 216, Mother and Child Facing Tropical Diseases, 08 BP 841 Cotonou, Bénin.
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Archundia IG, de Roodt AR, Ramos-Cerrillo B, Chippaux JP, Olguín-Pérez L, Alagón A, Stock RP. Neutralization of Vipera and Macrovipera venoms by two experimental polyvalent antisera: a study of paraspecificity. Toxicon 2011; 57:1049-56. [PMID: 21530569 DOI: 10.1016/j.toxicon.2011.04.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 04/07/2011] [Accepted: 04/12/2011] [Indexed: 11/28/2022]
Abstract
We conducted an extensive study of neutralization of lethality of 11 species and one subspecies of snakes of the genus Vipera, and of five species of Macrovipera, by two experimental equine antisera. One antiserum was a trivalent preparation raised against the venoms of Vipera aspis aspis, Vipera berus berus and Vipera ammodytes ammodytes; the other was a pentavalent preparation that also included venoms of Vipera (now Montivipera) xanthina and Macrovipera lebetina obtusa. We measured specific neutralization of lethality against all venoms included in the immunization schemes, and paraspecific neutralization against the venoms of Vipera ammodytes montandoni, Vipera (Montivipera) bornmuelleri, Vipera latastei, Vipera (Mo.) latifii, Vipera (Mo.) lotievi, Vipera (Daboia) palaestinae, Vipera (Mo.) raddei and Vipera seoanei, as well as against Macrovipera (D.) deserti, Macrovipera lebetina cernovi, Macrovipera lebetina turanica and Macrovipera schweitzeri. We found an important degree of paraspecific protection within each genera (omitting recent reclassification) that was quite independent of both the lethal potency of the venoms and their geographic origin. This information may be of use to clinicians charged with the treatment of Vipera or Macrovipera envenomations with non-specific antivenoms.
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Affiliation(s)
- Irving G Archundia
- Instituto de Biotecnología, Universidad Nacional Autónoma de México, Av. Universidad 2001, Cuernavaca, Morelos 62210, Mexico
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