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Perananthan V, Wijerathna T, Mohamed F, Gawarammana IB, Dawson AH, Buckley NA. Circulating intestinal fatty acid binding protein and intestinal toxicity in Russell's viper envenomation. Clin Toxicol (Phila) 2022; 60:311-318. [PMID: 34378471 DOI: 10.1080/15563650.2021.1965160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/24/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Abdominal pain is known to be an early clinical predictor of severe systemic Russell's viper (RV) envenomation and is often associated with the later development of coagulopathy and neurotoxicity. The mechanism of abdominal pain is unknown, but we postulated it might be due to intestinal microvascular endothelial gut damage. Gut-toxicity can be detected using the novel biomarker Intestinal Fatty Acid Binding Protein (IFABP). We also wanted to explore the mechanisms and consequences of this toxicity by measuring procalcitonin as a specific marker of sepsis triggered by bacterial endotoxin, and serum cystatin-C (CysC) as a measure of acute kidney injury. We hypothesised that severe gut-injury might lead to gut-barrier failure, translocation of gastrointestinal microorganisms, associated sepsis and systemic inflammatory response syndrome (SIRS), with a possible exacerbation of snake-bite severity, including acute kidney injury that was previously attributed to direct venom effects. METHODS Serial plasma samples previously collected from 16 RV envenomations with abdominal pain, 15 RV envenomations without abdominal pain and 25 healthy controls were assayed for IFABP. A subgroup of these RV envenomations were assayed for procalcitonin (n = 24) and serum CysC (n = 11). RESULTS The median peak IFABP for RV envenomations was much higher than healthy controls [3703.0 pg/mL (IQR 2250.1-13702.0 pg/mL) vs. 270.1 pg/mL (IQR 153.5-558.0 pg/mL) (p < 0.001)]. There was no difference in those with and without abdominal pain [3801.4 pg/mL (IQR 2080.5-22446.3 pg/mL) vs. 3696.6 pg/mL (IQR 2280.3-4664.7 pg/mL) (p = 1.0)]. Peak procalcitonin levels were elevated in envenomed patients 30.1 ng/ml (IQR: 13.1-59.7 ng/ml) with a level >2ng/mL indicative of severe sepsis] and also correlated with peak IFABP (r = 0.55, p = 0.006, n = 24). Peak serum CysC was also elevated and also correlated with IFABP (r = 0.71, p = 0.037, n = 9). CONCLUSION IFABP is significantly elevated indicating enterocyte damage occurs in RV envenomation. IFABP correlated with markers of sepsis (procalcitonin) and acute kidney injury (serum CysC) suggesting that enterocyte damage resulting in translocation of microbial associated molecular patterns (MAMPs) contributes to RV envenomation associated SIRS and sepsis.
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Affiliation(s)
- Varan Perananthan
- Edith Collins Research Institute, Royal Prince Alfred Hospital, Sydney, Australia
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Disciplines of Pharmacology/Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Thilini Wijerathna
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Disciplines of Pharmacology/Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Pharmacy, Faculty of Allied Health Sciences, University of Peradeniya
- Australian Kidney Biomarker Reference Laboratory, Department of Nephrology, Prince of Wales Hospital and Clinical School, University of New South Wales, Sydney, Australia
| | - Indika B Gawarammana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Andrew H Dawson
- Edith Collins Research Institute, Royal Prince Alfred Hospital, Sydney, Australia
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Disciplines of Pharmacology/Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Nicholas A Buckley
- Edith Collins Research Institute, Royal Prince Alfred Hospital, Sydney, Australia
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Disciplines of Pharmacology/Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia
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Lamb T, Abouyannis M, de Oliveira SS, Shenoy K. R, Geevar T, Zachariah A, Sharma SK, Bhatt N, Mukaka M, Harriss E, Lalloo DG, Ashley EA, Monteiro WM, Smithuis F, Eddleston M. The 20-minute whole blood clotting test (20WBCT) for snakebite coagulopathy-A systematic review and meta-analysis of diagnostic test accuracy. PLoS Negl Trop Dis 2021; 15:e0009657. [PMID: 34375338 PMCID: PMC8405032 DOI: 10.1371/journal.pntd.0009657] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/30/2021] [Accepted: 07/16/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The 20-minute whole blood clotting test (20WBCT) has been used to detect coagulopathy following snakebite for almost 50 years. A systematic review and meta-analysis of the 20WBCT was conducted to evaluate the accuracy of the 20WBCT to detect coagulopathy, indicative of systemic envenoming. METHODS AND FINDINGS Databases were searched from inception up to 09/12/2020 to identify studies that compared the 20WBCT and INR/fibrinogen on five or more subjects. Data was extracted from full-text articles by two reviewers using a predetermined form. Authors of 29 studies that lacked sufficient details in the manuscript were contacted and included if data meeting the inclusion criteria were provided. Included studies were evaluated for bias using a tailored QUADAS-2 checklist. The study protocol was prospectively registered on PROSPERO database (CRD42020168953). The searches identified 3,599 studies, 15 met the inclusion criteria and 12 were included in the meta-analysis. Data was reported from 6 countries and included a total of 2,270 patients. The aggregate weighted sensitivity of the 20WBCT at detecting INR >1.4 was 0.84 (CI 0.61 to 0.94), the specificity was 0.91 (0.76 to 0.97) and the SROC AUC was 0.94 (CI 0.91 to 0.96). The aggregate weighted sensitivity of the 20WBCT at detecting fibrinogen <100 mg/dL was 0.72 (CI 0.58 to 0.83), the specificity was 0.94 (CI 0.88 to 0.98) and the SROC AUC was 0.93 (0.91 to 0.95). Both analyses that used INR and fibrinogen as the reference test displayed considerable heterogeneity. CONCLUSIONS In the absence of laboratory clotting assays, the 20WBCT remains a highly specific and fairly sensitive bedside test at detecting coagulopathy following snakebite. However, clinicians should be aware of the importance of operator training, standardized equipment and the lower sensitivity of the 20WBCT at detecting mild coagulopathy and resolution of coagulopathy following antivenom.
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Affiliation(s)
- Thomas Lamb
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
- Centre of Tropical Medicine and Global Health Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Michael Abouyannis
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- KEMRI–Wellcome Research Programme, Kilifi, Kenya
| | - Sâmella Silva de Oliveira
- Dr. Heitor Viera Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Unit Manaus, Manaus, Brazil
- College of Health Sciences, University of the State of Amazonas, Manaus, Brazil
| | | | | | | | | | | | - Mavuto Mukaka
- Centre of Tropical Medicine and Global Health Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Eli Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, United Kingdom
| | - David G. Lalloo
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth A. Ashley
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
- Centre of Tropical Medicine and Global Health Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao People’s Democratic Republic
| | - Wuelton Marcelo Monteiro
- Dr. Heitor Viera Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Unit Manaus, Manaus, Brazil
- College of Health Sciences, University of the State of Amazonas, Manaus, Brazil
| | - Frank Smithuis
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
- Centre of Tropical Medicine and Global Health Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Michael Eddleston
- Pharmacology, Toxicology & Therapeutics, University/BHF Centre for Cardiovascular Science University of Edinburgh, Edinburgh, United Kingdom
- South Asian Clinical Toxicology Research Collaboration Dept of Clinical Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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Maduwage KP, Gawarammana IB, Gutiérrez JM, Kottege C, Dayaratne R, Premawardena NP, Jayasingha S. Enzyme immunoassays for detection and quantification of venoms of Sri Lankan snakes: Application in the clinical setting. PLoS Negl Trop Dis 2020; 14:e0008668. [PMID: 33017411 PMCID: PMC7561112 DOI: 10.1371/journal.pntd.0008668] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/15/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022] Open
Abstract
Background Detection and quantification of snake venom in envenomed patients’ blood is important for identifying the species responsible for the bite, determining administration of antivenom, confirming whether sufficient antivenom has been given, detecting recurrence of envenoming, and in forensic investigation. Currently, snake venom detection is not available in clinical practice in Sri Lanka. This study describes the development of enzyme immunoassays (EIA) to differentiate and quantify venoms of Russell’s viper (Daboia russelii), saw-scaled viper (Echis carinatus), common cobra (Naja naja), Indian krait (Bungarus caeruleus), and hump-nosed pit viper (Hypnale hypnale) in the blood of envenomed patients in Sri Lanka. Methodology / Principal findings A double sandwich EIA of high analytical sensitivity was developed using biotin-streptavidin amplification for detection of venom antigens. Detection and quantification of D. russelii, N. naja, B. caeruleus, and H. hypnale venoms in samples from envenomed patients was achieved with the assay. Minimum (less than 5%) cross reactivity was observed between species, except in the case of closely related species of the same genus (i.e., Hypnale). Persistence/ recurrence of venom detection following D. russelii envenoming is also reported, as well as detection of venom in samples collected after antivenom administration. The lack of specific antivenom for Hypnale sp envenoming allowed the detection of venom antigen in circulation up to 24 hours post bite. Conclusion The EIA developed provides a highly sensitive assay to detect and quantify five types of Sri Lankan snake venoms, and should be useful for toxinological research, clinical studies, and forensic diagnosis. Snakebite is a major medical and public health problem in tropical agricultural world. Detection of the type of snake venom and measurement of venom levels in blood are important for snakebite research, selecting the appropriate antivenom, and assessing venom levels in blood at the clinical setting. Currently, a snake venom detection platform is not available in clinical practice in Sri Lanka. This study aimed to develop a double sandwich enzyme immunoassays (EIA) to differentiate and quantify venoms of Russell’s viper (Daboia russelii), saw-scaled viper (Echis carinatus), common cobra (Naja naja), Indian krait (Bungarus caeruleus), and hump-nosed pit viper (Hypnale hypnale) in blood samples of envenomed patients in Sri Lanka. The EIA developed used biotin-streptavidin amplification for detection of venom antigens and showed high analytical sensitivity. The assay allowed the quantification of venoms of the five species in blood samples from envenomed patients. Low level of cross reactivity was noted between species, except in the case of closely related Hypnale species. The presence of D. russelii venom after antivenom treatment is reported, a finding that has implications in the dosing of antivenom in these envenomings. Lack of specific antivenom for H. hypnale envenoming offered an opportunity of study the remaining venom antigen in circulation up to 24 hr post bite. The EIA developed constitutes a useful tool to detect and quantify the five types of Sri Lankan snake venoms, and should be useful for research purposes, as well as for the diagnosis and therapy evaluation of clinical cases of envenomings in this country, and for forensic purposes.
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Affiliation(s)
- Kalana Prasad Maduwage
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- * E-mail:
| | | | - José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
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Silva de Oliveira S, Campos Alves E, Dos Santos Santos A, Freitas Nascimento E, Tavares Pereira JP, Mendonça da Silva I, Sachett J, Dos Santos Ibiapina HN, Santos Sarraf LK, Contreras Bernal JC, Freitas de Sousa LA, Colombini M, Oliveira Marques H, Guimarães de Lacerda MV, Moura-da-Silva AM, Wen Fan H, de Lima Ferreira LC, Sigueko Sano Martins I, Monteiro WM. Bothrops snakebites in the Amazon: recovery from hemostatic disorders after Brazilian antivenom therapy. Clin Toxicol (Phila) 2019; 58:266-274. [PMID: 31264481 DOI: 10.1080/15563650.2019.1634273] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Bothrops atrox snakebites are a major public health problem in the Amazon region and also cause hemostatic disorders. In this study, we assessed the recovery from hemostatic disorders in Bothrops snakebite patients after being given antivenom therapy.Methods: This is a prospective study of Bothrops snakebite patients (n = 100) treated at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazilian Amazon, between January 2016 and December 2017. Blood samples were taken for the measurement of venom concentrations, platelets, clotting time and factors of patients on admission, 12, 24 and 48 h after antivenom therapy, and taken again on discharge. The presence of systemic bleeding was recorded during the follow-up.Results: On admission, systemic bleeding was observed in 14% of the patients. Thrombocytopenia was noted in 10% of the patients. A total of 54% of the patients presented unclottable blood with low levels of fibrinogen and alpha 2-antiplasmin, and high levels of fibrin/fibrinogen degradation product (FDP) and D-dimers. Unclottable blood and systemic bleeding were overcome in most patients 12 h after the antivenom therapy. Three patients developed systemic bleeding 48 h after antivenom therapy. Levels of fibrinogen and alpha 2-antiplasmin, FDP and D-dimer returned to normal around 48 h after the treatment or on discharge. The frequency of thrombocytopenia with high mean platelet volume increased in the first 24 h after antivenom therapy, and decreased on discharge. Bothrops venom levels in patients decreased 12 h after antivenom therapy and were not correlated with coagulation and fibrinolytic parameters. There were no deaths.Conclusion: Laboratorial parameters of coagulopathy returned to normal values within 48 h after the antivenom therapy until discharge. A few patients still presented bleeding signs within 48 h after beginning antivenom therapy. However, the Brazilian antivenom was able to overcome the hemostatic disorders in these cases of envenomation.
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Affiliation(s)
- Sâmella Silva de Oliveira
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil.,College of Health Sciences, University of the State of Amazonas, Manaus, Brazil
| | - Eliane Campos Alves
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil.,College of Health Sciences, University of the State of Amazonas, Manaus, Brazil
| | - Alessandra Dos Santos Santos
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil
| | - Elizandra Freitas Nascimento
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil
| | - João Pedro Tavares Pereira
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil
| | - Iran Mendonça da Silva
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil.,College of Health Sciences, University of the State of Amazonas, Manaus, Brazil
| | - Jacqueline Sachett
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil.,College of Health Sciences, University of the State of Amazonas, Manaus, Brazil
| | - Hiochelson Najibe Dos Santos Ibiapina
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil.,College of Health Sciences, University of the State of Amazonas, Manaus, Brazil
| | - Lybia Kássia Santos Sarraf
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil
| | - Jorge Carlos Contreras Bernal
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil.,College of Health Sciences, University of the State of Amazonas, Manaus, Brazil
| | | | - Mônica Colombini
- Immunopathology Laboratory, Butantan Institute, São Paulo, Brazil
| | | | | | | | - Hui Wen Fan
- Bioindustrial Division, Butantan Institute, São Paulo, Brazil
| | - Luiz Carlos de Lima Ferreira
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil
| | | | - Wuelton Marcelo Monteiro
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Carlos Borborema Clinical Research Institute, Manaus, Brazil.,College of Health Sciences, University of the State of Amazonas, Manaus, Brazil
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Ratnayake I, Mohamed F, Buckley NA, Gawarammana IB, Dissanayake DM, Chathuranga U, Munasinghe M, Maduwage K, Jayamanne S, Endre ZH, Isbister GK. Early identification of acute kidney injury in Russell's viper (Daboia russelii) envenoming using renal biomarkers. PLoS Negl Trop Dis 2019; 13:e0007486. [PMID: 31260445 PMCID: PMC6625728 DOI: 10.1371/journal.pntd.0007486] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 07/12/2019] [Accepted: 05/23/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a major complication of snake envenoming, but early diagnosis remains problematic. We aimed to investigate the time course of novel renal biomarkers in AKI following Russell's viper (Daboia russelii) bites. METHODOLOGY/PRINCIPAL FINDINGS We recruited a cohort of patients with definite Russell's viper envenoming and collected serial blood and urine samples on admission (<4h post-bite), 4-8h, 8-16h, 16-24h, 1 month and 3 months post-bite. AKI stage (1-3) was defined using the Acute Kidney Injury Network criteria. AKI stages (1-3) were defined by the Acute Kidney Injury Network (AKIN) criteria. There were 65 Russell's viper envenomings and 49 developed AKI: 24 AKIN stage 1, 13 stage 2 and 12 stage 3. There was a significant correlation between venom concentrations and AKI stage (p = 0.007), and between AKI stage and six peak biomarker concentrations. Although most biomarker concentrations were elevated within 8h, no biomarker performed well in diagnosing AKI <4h post-bite. Three biomarkers were superior to serum creatinine (sCr) in predicting AKI (stage 2/3) 4-8h post-bite: serum cystatin C (sCysC) with an area under the receiver operating curve (AUC-ROC), 0.78 (95%CI:0.64-0.93), urine neutrophil gelatinase-associated lipocalin (uNGAL), 0.74 (95%CI:0.59-0.87) and urine clusterin (uClu), 0.81 (95%CI:0.69-0.93). No biomarker was better than sCr after 8h. Six other urine biomarkers urine albumin, urine beta2-microglobulin, urine kidney injury molecule-1, urine cystatin C, urine trefoil factor-3 and urine osteopontin either had minimal elevation, and/or minimal prediction for AKI stage 2/3 (AUC-ROC<0.7). CONCLUSIONS/SIGNIFICANCE AKI was common and sometimes severe following Russell's viper bites. Three biomarkers uClu, uNGAL and sCysC, appeared to become abnormal in AKI earlier than sCr, and may be useful in early identification of envenoming.
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Affiliation(s)
- Indira Ratnayake
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- TACT, Department of Pharmacology, Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Pharmacy, Faculty of Allied Health Science, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Nephrology, Prince of Wales Hospital and Clinical School, University of New South Wales, Sydney, Australia
| | - Nicholas A. Buckley
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- TACT, Department of Pharmacology, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Indika B. Gawarammana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Dhammika M. Dissanayake
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Pathology, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Umesh Chathuranga
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Mahesh Munasinghe
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Kalana Maduwage
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Shaluka Jayamanne
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Zoltan H. Endre
- Department of Nephrology, Prince of Wales Hospital and Clinical School, University of New South Wales, Sydney, Australia
| | - Geoffrey K. Isbister
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
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Wijewickrama ES, Kurukulasooriya I, Gunatilake M, Priyani AA, Gnanathasan A, Gawarammana I, Isbister GK. Determination of the sub-lethal nephrotoxic dose of Russell's viper (Daboia russelii) venom in Wistar rats. Toxicon 2018; 152:43-45. [PMID: 30055257 DOI: 10.1016/j.toxicon.2018.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 07/18/2018] [Accepted: 07/24/2018] [Indexed: 11/23/2022]
Abstract
Wistar rats were administered increasing doses of Russell's viper venom (RVV; 0.025-0.4 mg/kg) intraperitoneally to investigate acute kidney injury (AKI) by measuring creatinine (1.5-fold increase in serum creatinine above baseline) and examining kidney histology. Approximately 50% of rats receiving 0.25-0.4 mg/kg venom died within 72 h. An increase in serum creatinine only occurred at a venom dose of 0.4 mg/kg, except in two rats. Acute tubular necrosis, glomerular necrosis, cortical necrosis and interstitial inflammation were observed at venom doses of ≥0.25 mg/kg in 12/36 rats. However, of those 12 rats only four survived to 48 h compared to the 24 rats not developing nephrotoxicity, in which 18 were alive at 48 h. There was poor correlation between histological nephrotoxicity and AKI based on creatinine measurement. The early death in rats with AKI makes this a poor model for studying RVV-induced AKI.
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Affiliation(s)
- Eranga S Wijewickrama
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 08, Sri Lanka
| | - Ishani Kurukulasooriya
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 08, Sri Lanka
| | - Mangala Gunatilake
- Department of Physiology, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 08, Sri Lanka
| | - Amarathunga Ah Priyani
- Department of Pathology, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 08, Sri Lanka
| | - Ariaranee Gnanathasan
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 08, Sri Lanka
| | - Indika Gawarammana
- Department of Medicine and South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Galaha Road, Peradeniya, Sri Lanka
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia; South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Galaha Road, Peradeniya, Sri Lanka
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Isbister GK, Jayamanne S, Mohamed F, Dawson AH, Maduwage K, Gawarammana I, Lalloo DG, de Silva HJ, Scorgie FE, Lincz LF, Buckley NA. A randomized controlled trial of fresh frozen plasma for coagulopathy in Russell's viper (Daboia russelii) envenoming. J Thromb Haemost 2017; 15:645-654. [PMID: 28106331 PMCID: PMC5408386 DOI: 10.1111/jth.13628] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Indexed: 11/29/2022]
Abstract
Essentials Russell's viper envenoming is a major health issue in South Asia and causes coagulopathy. We studied the effect of fresh frozen plasma and two antivenom doses on correcting coagulopathy. Fresh frozen plasma did not hasten recovery of coagulopathy. Low-dose antivenom did not worsen coagulopathy. SUMMARY Background Russell's viper (Daboia russelii) envenoming is a major health issue in South Asia and causes venom-induced consumption coagulopathy (VICC). Objectives To investigate the effects of fresh frozen plasma (FFP) and two antivenom doses in correcting VICC. Methods We undertook an open-label randomized controlled trial in patients with VICC at two Sri Lankan hospitals. Patients with suspected Russell's viper bites and coagulopathy were randomly allocated (1 : 1) to high-dose antivenom (20 vials) or low-dose antivenom (10 vials) plus 4 U of FFP. The primary outcome was the proportion of patients with an International Normalized Ratio (INR) of < 2 at 6 h after antivenom administration. Secondary outcomes included anaphylaxis, major hemorrhage, death, and clotting factor recovery. Results From 214 eligible patients, 141 were randomized: 71 to high-dose antivenom, and 70 to low-dose antivenom/FFP; five had no post-antivenom blood tests. The groups were similar except for a delay of 1 h in antivenom administration for FFP patients. Six hours after antivenom administration, 23 of 69 (33%) patients allocated to high-dose antivenom had an INR of < 2, as compared with 28 of 67 (42%) allocated to low-dose antivenom/FFP (absolute difference 8%; 95% confidence interval - 8% to 25%). Fifteen patients allocated to FFP did not receive it. Severe anaphylaxis occurred equally frequently in each group. One patient given FFP developed transfusion-related acute lung injury. Three deaths occurred in low-dose antivenom/FFP patients, including one intracranial hemorrhage. There was no difference in recovery rates of INR or fibrinogen, but there was more rapid initial recovery of factor V and FX in FFP patients. Conclusion FFP after antivenom administration in patients with Russell's viper bites did not hasten recovery of coagulopathy. Low-dose antivenom/FFP did not worsen VICC, suggesting that low-dose antivenom is sufficient.
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Affiliation(s)
- G. K. Isbister
- Clinical Toxicology Research GroupUniversity of NewcastleNewcastleNew South WalesAustralia
- South Asian Clinical Toxicology Research CollaborationFaculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka
| | - S. Jayamanne
- South Asian Clinical Toxicology Research CollaborationFaculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka
- Department of MedicineFaculty of MedicineUniversity of KelaniyaRagamaSri Lanka
| | - F. Mohamed
- South Asian Clinical Toxicology Research CollaborationFaculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka
| | - A. H. Dawson
- South Asian Clinical Toxicology Research CollaborationFaculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka
- Department of PharmacologySOMSSydney Medical SchoolUniversity of SydneyNew South WalesAustralia
| | - K. Maduwage
- Clinical Toxicology Research GroupUniversity of NewcastleNewcastleNew South WalesAustralia
- South Asian Clinical Toxicology Research CollaborationFaculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka
- Department of BiochemistryFaculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka
| | - I. Gawarammana
- South Asian Clinical Toxicology Research CollaborationFaculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka
- Department of MedicineFaculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka
| | - D. G. Lalloo
- Clinical Sciences and International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - H. J. de Silva
- South Asian Clinical Toxicology Research CollaborationFaculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka
- Department of MedicineFaculty of MedicineUniversity of KelaniyaRagamaSri Lanka
| | - F. E. Scorgie
- Hunter Haematology Research GroupCalvary Mater NewcastleNewcastleNew South WalesAustralia
| | - L. F. Lincz
- Hunter Haematology Research GroupCalvary Mater NewcastleNewcastleNew South WalesAustralia
| | - N. A. Buckley
- South Asian Clinical Toxicology Research CollaborationFaculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka
- Department of PharmacologySOMSSydney Medical SchoolUniversity of SydneyNew South WalesAustralia
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8
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Ratnayake I, Shihana F, Dissanayake DM, Buckley NA, Maduwage K, Isbister GK. Performance of the 20-minute whole blood clotting test in detecting venom induced consumption coagulopathy from Russell's viper (Daboia russelii) bites. Thromb Haemost 2017; 117:500-507. [PMID: 28150853 DOI: 10.1160/th16-10-0769] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 11/23/2016] [Indexed: 02/01/2023]
Abstract
The 20-minute whole blood clotting test (WBCT20) is used as a bedside diagnostic test for coagulopathic snake envenoming. We aimed to assess the performance of the WBCT20 in diagnosis of venom induced consumption coagulopathy (VICC) in Russell's viper envenoming. Adult patients admitted with suspected snake bites were recruited from two hospitals. WBCT20 and prothrombin time (PT) test were performed on admission. WBCT20 was done by trained clinical research assistants using 1 ml whole blood in a 5 ml borosilicate glass tube with a 10 mm internal diameter. The PT was measured by a semi-automated coagulation system and international normalised ratio (INR) calculated. VICC was defined as present if the INR was >1.4. The diagnostic utility of WBCT20 was determined by calculating the sensitivity and specificity of the WBCT20 on admission for detecting VICC. There were 987 snake bites where both WBCT20 and PT were done on admission samples. This included 79 patients (8 %) with VICC. The WBCT20 was positive in 65/79 patients with VICC (sensitivity 82 %; 95 % confidence interval [CI]: 72-90 %) and was falsely positive in 13/908 with no coagulopathy. The WBCT20 was negative in 895/908 snake bites with no coagulopathy (specificity: 98 % 95 % CI: 97-99 %) and was falsely negative in 14/79 with VICC. Using trained clinical staff, the WBCT20 test had a relatively good sensitivity for the detection of VICC, but still missed almost one fifth of cases where antivenom was potentially indicated.
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Affiliation(s)
| | | | | | | | | | - Geoffrey K Isbister
- Geoffrey K. Isbister, School of Medicine and Public Health, University of Newcastle, c/o Calvary Mater Newcastle, Edith Street, Waratah NSW 2298, Australia, Tel.: +612 4921 1211, Fax: +612 4921 1870, E-mail:
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9
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Maduwage K, Silva A, O’Leary MA, Hodgson WC, Isbister GK. Efficacy of Indian polyvalent snake antivenoms against Sri Lankan snake venoms: lethality studies or clinically focussed in vitro studies. Sci Rep 2016; 6:26778. [PMID: 27231196 PMCID: PMC4882578 DOI: 10.1038/srep26778] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 05/06/2016] [Indexed: 11/09/2022] Open
Abstract
In vitro antivenom efficacy studies were compared to rodent lethality studies to test two Indian snake antivenoms (VINS and BHARAT) against four Sri Lankan snakes. In vitro efficacy was tested at venom concentrations consistent with human envenoming. Efficacy was compared statistically for one batch from each manufacturer where multiple vials were available. In binding studies EC50 for all VINS antivenoms were less than BHARAT for D. russelii [553 μg/mL vs. 1371 μg/mL;p = 0.016), but were greater for VINS antivenoms compared to BHARAT for N. naja [336 μg/mL vs. 70 μg/mL;p < 0.0001]. EC50 of both antivenoms was only slighty different for E. carinatus and B. caeruleus. For procoagulant activity neutralisation, the EC50 was lower for VINS compared to BHARAT - 60 μg/mL vs. 176 μg/mL (p < 0.0001) for Russell's viper and 357 μg/mL vs. 6906μg/mL (p < 0.0001) for Saw-scaled viper. Only VINS antivenom neutralized in vitro neurotoxicity of krait venom. Both antivenoms partially neutralized cobra and didn't neutralize Russell's viper neurotoxicity. Lethality studies found no statistically significant difference in ED50 values between VINS and BHARAT antivenoms. VINS antivenoms appeared superior to BHARAT at concentrations equivalent to administering 10 vials antivenom, based on binding and neutralisation studies. Lethality studies were inconsistent suggesting rodent death may not measure relevant efficacy outcomes in humans.
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Affiliation(s)
- Kalana Maduwage
- Clinical Toxicology Research Group, University of Newcastle, NSW, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Anjana Silva
- Department of Pharmacology, Monash Venom Group, Monash University, Clayton, Victoria, Australia
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
| | | | - Wayne C. Hodgson
- Department of Pharmacology, Monash Venom Group, Monash University, Clayton, Victoria, Australia
| | - Geoffrey K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, NSW, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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10
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Maduwage KP, O'Leary MA, Silva A, Isbister GK. Detection of Snake Venom in Post-Antivenom Samples by Dissociation Treatment Followed by Enzyme Immunoassay. Toxins (Basel) 2016; 8:toxins8050130. [PMID: 27136587 PMCID: PMC4885045 DOI: 10.3390/toxins8050130] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/03/2016] [Accepted: 04/11/2016] [Indexed: 11/16/2022] Open
Abstract
Venom detection is crucial for confirmation of envenomation and snake type in snake-bite patients. Enzyme immunoassay (EIA) is used to detect venom, but antivenom in samples prevents venom detection. We aimed to detect snake venom in post-antivenom samples after dissociating venom-antivenom complexes with glycine-HCl (pH 2.2) and heating for 30 min at 950 °C. Serum samples underwent dissociation treatment and then Russell’s viper venom or Australian elapid venom measured by EIA. In confirmed Russell’s viper bites with venom detected pre-antivenom (positive controls), no venom was detected in untreated post-antivenom samples, but was after dissociation treatment. In 104 non-envenomed patients (negative controls), no venom was detected after dissociation treatment. In suspected Russell’s viper bites, ten patients with no pre-antivenom samples had venom detected in post-antivenom samples after dissociation treatment. In 20 patients with no venom detected pre-antivenom, 13 had venom detected post-antivenom after dissociation treatment. In another 85 suspected Russell’s viper bites with no venom detected pre-antivenom, 50 had venom detected after dissociation treatment. Dissociation treatment was also successful for Australian snake envenomation including taipan, mulga, tiger snake and brown snake. Snake venom can be detected by EIA in post-antivenom samples after dissociation treatment allowing confirmation of diagnosis of envenomation post-antivenom.
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Affiliation(s)
- Kalana P Maduwage
- Clinical Toxicology Research Group, University of Newcastle, Newcastle 2298, Australia.
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka.
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
| | - Margaret A O'Leary
- Clinical Toxicology Research Group, University of Newcastle, Newcastle 2298, Australia.
| | - Anjana Silva
- Monash Venom Group, Monash University, Melbourne 3168, Australia.
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle 2298, Australia.
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka.
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11
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Neuromuscular Effects of Common Krait (Bungarus caeruleus) Envenoming in Sri Lanka. PLoS Negl Trop Dis 2016; 10:e0004368. [PMID: 26829229 PMCID: PMC4734751 DOI: 10.1371/journal.pntd.0004368] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 12/16/2015] [Indexed: 11/19/2022] Open
Abstract
Objective We aimed to investigate neurophysiological and clinical effects of common krait envenoming, including the time course and treatment response. Methodology Patients with definite common krait (Bungarus caeruleus) bites were recruited from a Sri Lankan hospital. All patients had serial neurological examinations and stimulated concentric needle single-fibre electromyography (sfEMG) of orbicularis oculi in hospital at 6wk and 6–9mth post-bite. Principal Findings There were 33 patients enrolled (median age 35y; 24 males). Eight did not develop neurotoxicity and had normal sfEMG. Eight had mild neurotoxicity with ptosis, normal sfEMG; six received antivenom and all recovered within 20–32h. Seventeen patients developed severe neurotoxicity with rapidly descending paralysis, from ptosis to complete ophthalmoplegia, facial, bulbar and neck weakness. All 17 received Indian polyvalent antivenom a median 3.5h post-bite (2.8–7.2h), which cleared unbound venom from blood. Despite this, the paralysis worsened requiring intubation and ventilation within 7h post-bite. sfEMG showed markedly increased jitter and neuromuscular blocks within 12h. sfEMG abnormalities gradually improved over 24h, corresponding with clinical recovery. Muscle recovery occurred in ascending order. Myotoxicity was not evident, clinically or biochemically, in any of the patients. Patients were extubated a median 96h post-bite (54–216h). On discharge, median 8 days (4–12days) post-bite, patients were clinically normal but had mild sfEMG abnormalities which persisted at 6wk post-bite. There were no clinical or neurophysiological abnormalities at 6–9mth. Conclusions Common krait envenoming causes rapid onset severe neuromuscular paralysis which takes days to recover clinically consistent with sfEMG. Subclinical neuromuscular dysfunction lasts weeks but was not permanent. Antivenom effectively cleared venom but did not prevent worsening or reverse neuromuscular paralysis. Common krait bites cause muscular paralysis due to the venom disrupting communication between the nerves and muscles. This becomes life-threatening for the patient if there is paralysis of the muscles used for breathing. We studied the severity of paralysis, long term effects and the value of antivenom treatment in authenticated Indian krait bite patients from Sri Lanka. In addition to standard treatment with antivenom, the patients had single-fibre electromyography done, a sensitive neurophysiological test that detects the abnormalities of communication between the nerves and muscles. Half of the patients had severe paralysis and required mechanical ventilation, and the remainder had mild or no effects. Antivenom was given to all patients with severe paralysis and most with mild effects. However, despite antivenom binding all free venom after it was administered, it did not prevent or reverse already developed paralysis. Clinically evident paralysis resolved after a few days, but the neurophysiological abnormalities lasted for weeks. No permanent neurological damages were noted at 6 to 9 months after the snake bite.
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12
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Isbister GK, Maduwage K, Scorgie FE, Shahmy S, Mohamed F, Abeysinghe C, Karunathilake H, O’Leary MA, Gnanathasan CA, Lincz LF. Venom Concentrations and Clotting Factor Levels in a Prospective Cohort of Russell's Viper Bites with Coagulopathy. PLoS Negl Trop Dis 2015; 9:e0003968. [PMID: 26296235 PMCID: PMC4546603 DOI: 10.1371/journal.pntd.0003968] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 07/09/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Russell's viper envenoming is a major problem in South Asia and causes venom induced consumption coagulopathy. This study aimed to investigate the kinetics and dynamics of venom and clotting function in Russell's viper envenoming. METHODOLOGY/PRINCIPAL FINDINGS In a prospective cohort of 146 patients with Russell's viper envenoming, we measured venom concentrations, international normalised ratio [INR], prothrombin time (PT), activated partial thromboplastin time (aPTT), coagulation factors I, II, V, VII, VIII, IX and X, and von Willebrand factor antigen. The median age was 39 y (16-82 y) and 111 were male. The median peak INR was 6.8 (interquartile range [IQR]: 3.7 to >13), associated with low fibrinogen [median,<0.01 g/L; IQR: <0.01-0.9 g/L), low factor V levels [median,<5%; IQR: <5-4%], low factor VIII levels [median,40%; IQR: 12-79%] and low factor X levels [median, 48%; IQR: 29-67%]. There were smaller reductions in factors II, IX and VII over time. All factors recovered over 48 h post-antivenom. The median INR remained >3 at 6 h post-antivenom but had reduced to <2, by 24 h. The aPTT had also returned to close to normal (<50 sec) at 24 h. Factor VII, VIII and IX levels were unusually high pre-antivenom, median peak concentrations of 393%, 307% and 468% respectively. Pre-antivenom venom concentrations and the INR (r = 0.20, p = 0.02) and aPTT (r = 0.19, p = 0.03) were correlated (non-parametric Spearman analysis). CONCLUSIONS Russell's viper coagulopathy results in prolonged aPTT, INR, low fibrinogen, factors V, VIII and X which recover over 48 h. Severity of clotting abnormalities was associated with venom concentrations.
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Affiliation(s)
- Geoffrey K. Isbister
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Kalana Maduwage
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fiona E. Scorgie
- Hunter Haematology Research Group, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Seyed Shahmy
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | | | | | - Margaret A. O’Leary
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | | | - Lisa F. Lincz
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Haematology Research Group, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
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13
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Isbister GK, Maduwage K, Saiao A, Buckley NA, Jayamanne SF, Seyed S, Mohamed F, Chathuranga U, Mendes A, Abeysinghe C, Karunathilake H, Gawarammana I, Lalloo DG, de Silva HJ. Population Pharmacokinetics of an Indian F(ab')2 Snake Antivenom in Patients with Russell's Viper (Daboia russelii) Bites. PLoS Negl Trop Dis 2015; 9:e0003873. [PMID: 26135318 PMCID: PMC4489840 DOI: 10.1371/journal.pntd.0003873] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 06/02/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is limited information on antivenom pharmacokinetics. This study aimed to investigate the pharmacokinetics of an Indian snake antivenom in humans with Russell's viper bites. METHODS/PRINCIPAL FINDINGS Patient data and serial blood samples were collected from patients with Russell's viper (Daboia russelii) envenoming in Sri Lanka. All patients received Indian F(ab')2 snake antivenom manufactured by VINS Bioproducts Ltd. Antivenom concentrations were measured with sandwich enzyme immunoassays. Timed antivenom concentrations were analysed using MONOLIXvs4.2. One, two and three compartment models with zero order input and first order elimination kinetics were assessed. Models were parameterized with clearance (CL), intercompartmental clearance (Q), central compartment volume (V) and peripheral compartment volume (VP). Between-subject-variability (BSV) on relative bioavailability (F) was included to account for dose variations. Covariates effects (age, sex, weight, antivenom batch, pre-antivenom concentrations) were explored by visual inspection and in model building. There were 75 patients, median age 57 years (40-70 y) and 64 (85%) were male. 411 antivenom concentration data points were analysed. A two compartment model with zero order input, linear elimination kinetics and a combined error model best described the data. Inclusion of BSV on F and weight as a covariate on V improved the model. Inclusion of pre-antivenom concentrations or different batches on BSV of F did not. Final model parameter estimates were CL,0.078 L h(-1), V,2.2L, Q,0.178 L h(-1) and VP,8.33L. The median half-life of distribution was 4.6 h (10-90%iles:2.6-7.1 h) and half-life of elimination, 140 h (10th-90th percentilesx:95-223h). CONCLUSION Indian F(ab')2 snake antivenom displayed biexponential disposition pharmacokinetics, with a rapid distribution half-life and more prolonged elimination half-life.
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Affiliation(s)
- Geoffrey K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Kalana Maduwage
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Ana Saiao
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
| | - Nicholas A. Buckley
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Shaluka F. Jayamanne
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Shahmy Seyed
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Umesh Chathuranga
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Alexandre Mendes
- School of Electrical Engineering and Computer Science, University of Newcastle, Newcastle, New South Wales, Australia
| | | | | | - Indika Gawarammana
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - David G. Lalloo
- Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - H. Janaka de Silva
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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