Cardiovascular manifestations and patient outcomes following snake envenomation: a pilot study

Pulmonary involvement from animal toxins: the cellular mechanisms

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.

Kaempferol from Moringa oleifera demonstrated potent antivenom activities via inhibition of metalloproteinase and attenuation of Bitis arietans venom-induced toxicities

Bitis arietans venom (BAV) can induce severe pathophysiological disorders after envenoming. However, studies have shown that the Moringa oleifera fraction is effective against BAV toxicities and contains bioactive compounds with significant antivenom potency. This research aimed to identify the main active antivenom compound in the M. oleifera fraction responsible for neutralizing the toxicities induced by BAV. The compounds identified from M. oleifera fraction were docked in silico against the catalytic site of the Snake Venom Metalloproteinase (SVMP) to determine the lead inhibitor compound. The antivenom potency of the lead inhibitor compound was tested against BAV toxicities and metalloproteinase isolated from BAV using in vitro and in vivo methods, while EchiTab-Plus polyvalent antivenom served as a standard drug. The in silico prediction revealed kaempferol as the lead inhibitor compound with a docking score of -7.0 kcal/mol. Kaempferol effectively inhibited metalloproteinase activity at 0.2 mg/ml, compared to antivenom (0.4 mg/ml) and demonstrated significant antihaemorrhagic, antihaemolytic and coagulant effects against BAV activities. Furthermore, kaempferol showed a significant dose-dependent effect on altered haematological indices observed in rats challenged with LD50 of BAV. Envenomed rats also showed an increase in oxidative stress biomarkers and antioxidant enzyme activity in the heart and kidney. However, treatment with kaempferol significantly (P < 0.05) decreased malondialdehyde levels and SOD activity with concomitant enhancement of glutathione levels. Severe histopathological defects noticed in the organ tissues of envenomed rats were ameliorated after kaempferol treatment. Kaempferol is identified as the main active antivenom compound in M. oleifera, and this research highlights the potential of the compound as an effective alternative to snakebite treatment.

Effects of Cobra Cardiotoxins on Intracellular Calcium and the Contracture of Rat Cardiomyocytes Depend on Their Structural Types

Cardiotoxins (CaTx) of the three-finger toxin family are one of the main components of cobra venoms. Depending on the structure of the N-terminal or the central polypeptide loop, they are classified into either group I and II or P- and S-types, respectively, and toxins of different groups or types interact with lipid membranes variably. While their main target in the organism is the cardiovascular system, there is no data on the effects of CaTxs from different groups or types on cardiomyocytes. To evaluate these effects, a fluorescence measurement of intracellular Ca²⁺ concentration and an assessment of the rat cardiomyocytes' shape were used. The obtained results showed that CaTxs of group I containing two adjacent proline residues in the N-terminal loop were less toxic to cardiomyocytes than group II toxins and that CaTxs of S-type were less active than P-type ones. The highest activity was observed for Naja oxiana cobra cardiotoxin 2, which is of P-type and belongs to group II. For the first time, the effects of CaTxs of different groups and types on the cardiomyocytes were studied, and the data obtained showed that the CaTx toxicity to cardiomyocytes depends on the structures both of the N-terminal and central polypeptide loops.

Takotsubo cardiomyopathy following envenomation: An updated review

BACKGROUND

Takotsubo cardiomyopathy (TTC) can be diagnosed in patients presenting with clinical features of acute coronary syndrome (ACS) by using Mayo clinic criteria. Multiple precipitators have been attributed to causing TTC. Rarely it has been reported to occur following an acute envenomation.

AIM

This review describes the various patterns, mechanisms, and outcomes of envenomation induced TTC.

METHODS

In this review, we included all studies on “TTC” and “envenomation “published in the various databases before June 2022. To be included in the review articles had to have a distinct diagnosis of TTC and an envenomation

RESULTS

A total of 20 patients with envenomation induced TTC were identified. Most episodes of envenomation induced TTC were reported following a bee sting, scorpion sting, and snake envenomation. Fear and anxiety related to the sting, direct catecholamine toxicity and administration of exogenous beta-adrenergic agents have been commonly postulated to precipitate TTC in these patients. 95% of these patients presented with a clinical picture of ACS. Most of these patients also fulfill at least 3 out of 4 criteria of Mayo clinic criteria for TTC. Echocardiographic evidence of Apical TTC was noted in 72% of patients. 94% of these patients had clinical improvement following optimal management and 35% of these patients were treated with guideline directed medications for heart failure.

CONCLUSION

Envenomation following multiple insect stings and reptile bites can precipitate TTC. Most reported envenomation related TTC has been due to bee stings and scorpion bites. Common mechanisms causing TTC were fear, anxiety, and stress of envenomation. Most of these patients present with clinical presentation of ACS, ST elevation, and elevated troponin. The most common type of TTC in these patients is Apical, which improved following medical management.

Snakebite Envenomation and Heart: Systematic Review

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.

The effect of myocardial injury on the clinical course of snake envenomation in South Korea

CONTENT

This study investigated the incidence, progression and clinical course of myocardial injury-related snake envenomation in South Korea. In addition, this study evaluated whether antivenom guidelines are appropriate to control envenomation in patients with myocardial injury.

METHODS

The study included 198 patients who received antivenom after a snakebite, and they were divided into two groups according to evidence of myocardial injury (defined as elevated troponin I or ischemic change on electrocardiogram) at presentation. Data including serial troponin I, echocardiogram/coronary angiogram findings, the clinical course, and treatment were collected and analyzed.

RESULTS

The incidence of myocardial injury at presentation was 15.2%. The troponin I level was 0.11 (0.07-0.56) ng/ml at presentation and tended to decrease over 24 h. Echocardiograms revealed neither regional wall motion abnormalities nor left ventricular dysfunction in 15 of 17 patients, while two patients showed signs of coronary artery stenosis on echocardiograms and coronary angiograms. However, compared with patients without myocardial injury, patients with myocardial injury had a higher frequency of systemic envenomation complications, including bleeding, respiratory failure, hypotension, acute kidney injury, thrombocytopenia and venom-induced consumption coagulopathy (VICC). The patients with myocardial injury at presentation needed significantly more frequent and larger doses of antivenom than indicated by the initial severity of envenomation. Multivariate analysis showed that myocardial injury was associated with the need for additional antivenom administration after initial administration.

DISCUSSION AND CONCLUSION

Myocardial injury is not uncommon after snake envenomation in Korea. Although myocardial injury itself seems to be benign, the clinical course of patients with myocardial injury is complicated, and myocardial injury is associated with the need for additional antivenom administration. The optimal use of antivenom to control envenomation in patents with myocardial injury after snake envenomation in South Korea should be established.