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Chiang LC, Chien KY, Su HY, Chen YC, Mao YC, Wu WG. Comparison of Protein Variation in Protobothrops mucrosquamatus Venom between Northern and Southeast Taiwan and Association with Human Envenoming Effects. Toxins (Basel) 2022; 14:toxins14090643. [PMID: 36136582 PMCID: PMC9501293 DOI: 10.3390/toxins14090643] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 12/03/2022] Open
Abstract
Reports of bite from Protobothrops mucrosquamatus (Pmu) are frequent in Taiwan, and its wide-spread distribution and diverse habitats drove us to investigate its envenoming effects and relevant venom variations. We used reversed-phase high-performance liquid chromatography and mass spectrometry to analyze 163 Pmu venom samples collected from northern and southeastern Taiwan. Twenty-two major protein fractions were separated and analyzed, and their contents were determined semi-quantitatively. The results showed that despite the trivial differences in the protein family, there is an existing variation in acidic phospholipases A2s, serine proteinases, metalloproteinases, C-type lectin-like proteins, and other less abundant components in the Pmu venoms. Moreover, clinical manifestations of 209 Pmu envenomed patients hospitalized in northern or southeastern Taiwan revealed significant differences in local symptoms, such as ecchymosis and blistering. The mechanism of these local effects and possibly relevant venom components were examined. Further analysis showed that certain venom components with inter-population variation might work alone or synergistically with others to aggravate the local effects. Therefore, our findings of the venom variation may help one to improve antivenom production and better understand and manage Pmu bites.
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Affiliation(s)
- Liao-Chun Chiang
- College of Life Sciences, National Tsing Hua University, Hsinchu City 300, Taiwan
| | - Kun-Yi Chien
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan County 333, Taiwan
- Clinical Proteomics Core Laboratory, Chang Gung Memorial Hospital, Taoyuan County 333, Taiwan
- Department of Biochemistry and Molecular Biology, College of Medicine, Chang Gung University, Taoyuan County 333, Taiwan
| | - Hung-Yuan Su
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung County 824, Taiwan
- The School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung County 840, Taiwan
- Department of Safety, Health and Environmental Engineering, National Kaohsiung University of Science and Technology, Kaohsiung County 811, Taiwan
| | - Yen-Chia Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei City 112, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei City 112, Taiwan
- Department of Emergency Medicine, National Defense Medical Center, Taipei City 114, Taiwan
| | - Yan-Chiao Mao
- Department of Emergency Medicine, National Defense Medical Center, Taipei City 114, Taiwan
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung City 407, Taiwan
- College of Medicine, National Chung Hsing University, Taichung City 402, Taiwan
- Correspondence: (Y.-C.M.); (W.-G.W.)
| | - Wen-Guey Wu
- College of Life Sciences, National Tsing Hua University, Hsinchu City 300, Taiwan
- Correspondence: (Y.-C.M.); (W.-G.W.)
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Lai CS, Liu PY, Lee CH, Ho CH, Chen WL, Lai KL, Su HY, Lin WL, Chung KC, Yang YY, You CW, Chen KT, Mao YC. The development of surgical risk score and evaluation of necrotizing soft tissue infection in 161 Naja atra envenomed patients. PLoS Negl Trop Dis 2022; 16:e0010066. [PMID: 35143522 PMCID: PMC8830662 DOI: 10.1371/journal.pntd.0010066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 12/06/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Naja atra bites cause wound necrosis, secondary infection, and necrotizing soft tissue infection (NSTI) requiring repetitive surgeries. Little information is known about the predictors for surgery after these bites. MATERIALS AND METHODS We retrospectively evaluated 161 patients envenomed by N. atra, 80 of whom underwent surgery because of wound necrosis and infection. We compared the patients' variables between surgical and non-surgical groups. To construct a surgical risk score, we converted the regression coefficients of the significant factors in the multivariate logistic regression into integers. We also examined the deep tissue cultures and pathological findings of the debrided tissue. RESULTS A lower limb as the bite site, a ≥3 swelling grade, bullae or blister formation, gastrointestinal (GI) effects, and fever were significantly associated with surgery in the multivariate logistic regression analysis. The surgical risk scores for these variables were 1, 1, 2, 1, and 2, respectively. At a ≥3-point cutoff value, the model has 71.8% sensitivity and 88.5% specificity for predicting surgery, with an area under the receiver operating characteristic curve of 0.88. The histopathological examinations of the debrided tissues supported the diagnosis of snakebite-induced NSTI. Twelve bacterial species were isolated during the initial surgery and eleven during subsequent surgeries. DISCUSSION AND CONCLUSIONS From the clinical perspective, swelling, bullae or blister formation, GI effects, and fever appeared quickly after the bite and before surgery. The predictive value of these factors for surgery was acceptable, with a ≥3-point risk score. The common laboratory parameters did not always predict the outcomes of N. atra bites without proper wound examination. Our study supported the diagnosis of NSTI and demonstrated the changes in bacteriology during the surgeries, which can have therapeutic implications for N. atra bites.
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Affiliation(s)
- Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Po-Yu Liu
- Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University
| | - Chi-Hsin Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Core Laboratory of Antibody Generation and Research, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Hsuan Ho
- Department of Emergency Medicine, Tri-Service General Hospital, Taipei, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Ling Chen
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Psychiatry Department, Chiayi Branch, Taichung Veterans General Hospital, Chiayi, Taiwan
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hung-Yuan Su
- Department of Emergency Medicine, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan
- The School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan
| | - Wen-Loung Lin
- Taichung Wildlife Conservation Group, Taichung, Taiwan
| | - Kuo-Chen Chung
- Division of Traumatology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Yuan Yang
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Core Laboratory of Antibody Generation and Research, Taipei Medical University, Taipei, Taiwan
| | | | | | - Yan-Chiao Mao
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- * E-mail:
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Su HY, Huang SW, Mao YC, Liu MW, Lee KH, Lai PF, Tsai MJ. Clinical and laboratory features distinguishing between Deinagkistrodon acutus and Daboia siamensis envenomation. J Venom Anim Toxins Incl Trop Dis 2018; 24:43. [PMID: 30607144 PMCID: PMC6307318 DOI: 10.1186/s40409-018-0179-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/06/2018] [Indexed: 12/17/2022] Open
Abstract
Background There are 6 species of venomous snakes in Taiwan. Two of them, Deinagkistrodon acutus (D. acutus) and Daboia siamensis (D. siamensis), can cause significant coagulopathy. However, a significant proportion of patients with snakebites cannot identify the correct snake species after envenomation, which hampers the application of antivenom. Hence, the differential diagnosis between the two snakebites by clinical presentations is important. This study aims to compare their clinical and laboratory features for the purpose of differential diagnosis between the two snakebites. Methods We retrospectively reviewed the medical records of patients who arrived at the emergency department due to D. acutus or D. siamensis envenomation, between 2003 and 2016, in one medical center in eastern Taiwan. Since these snakebites are rare, we also included 3 cases reported from another hospital in central Taiwan. Results In total, 15 patients bitten by D. acutus and 12 patients by D. siamensis were analyzed. Hemorrhagic bulla formation and the need for surgical intervention only presented for D. acutus envenomation cases (Both 53.3% vs. 0.0%, P = 0.003). As to laboratory features, lower platelet counts (20.0 × 103/μL [interquartile range, 14–66 × 103/μL] vs. 149.0 × 103/μL [102.3–274.3 × 103/μL], P = 0.001), lower D-dimer level (1423.4 μg/L [713.4–4212.3 μg/L] vs. 12,500.0 μg/L [2351.4–200,000 μg/L], P = 0.008), higher proportion of patients with moderate-to-severe thrombocytopenia (platelet count < 100 × 103/μL) (80% vs. 16.7%, odds ratio (OR) = 20.0, 95% CI, 2.77–144.31; P = 0.002), and lower proportion of patients with extremely high D-dimer (> 5000 ng/mL) (16.7% vs. 66.7%, adjusted OR = 0.1 (95% CI, 0.01–0.69; P = 0.036) were found among cases of D. acutus envenomation compared to D. siamensis envenomation. The combination of hemorrhagic bulla, thrombocytopenia, and a lack of extremely high D-dimer had good discriminatory power (area under the curve (AUC) = 0.965; 95% CI, 0.904–1.00) for distinguishing D. acutus from D. siamensis envenomation. Conclusions The presentation of moderate to severe thrombocytopenia (platelet count < 100 × 103/μL) and hemorrhagic bulla formation may indicate D. acutus envenomation. However, the envenomed patient with extremely high D-dimer levels may indicate a D. siamensis envenomation. These findings may help diagnose and select the right antivenom in patients with unknown snakebites who present significant coagulopathy.
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Affiliation(s)
- Hung-Yuan Su
- 1Department of Emergency Medicine, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan.,2The School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan
| | - Shih-Wei Huang
- 3Department of Emergency Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Yan-Chiao Mao
- 4Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Wen Liu
- 3Department of Emergency Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Kuo-Hsin Lee
- 1Department of Emergency Medicine, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan.,2The School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan
| | - Pei-Fang Lai
- 3Department of Emergency Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Ming-Jen Tsai
- 5Department of Emergency Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, No. 539, Zhongxiao Road, East District, Chiayi City, 600 Taiwan
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