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Pannu AK, Chand D, Bhalla A, Dhibar DP. Efficacy of a low dose of antivenom for severe neuroparalysis in Bungarus caeruleus (common krait) envenomation: a pilot study. Toxicol Res (Camb) 2024; 13:tfae023. [PMID: 38450179 PMCID: PMC10913380 DOI: 10.1093/toxres/tfae023] [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: 08/29/2023] [Revised: 12/26/2023] [Accepted: 02/15/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction Despite the widespread use of antivenom for the treatment of snakebite envenoming in the Indian subcontinent, the ideal dose of antivenom has been a point of contention. Low-dose regimens can economize on a scarce resource in low- and middle-income countries. This study assessed the effectiveness of a low-dose (10 vials) antivenom regimen compared to the usual 20 vials in patients with krait bite neuroparalysis requiring mechanical ventilation. Methods This study was a prospective controlled pilot study conducted in a tertiary-care hospital in north India. Participants were eligible if they were ≥12 years old, had krait bite neurotoxicity, showed severe paralysis requiring mechanical ventilation, and had access to antivenom therapy within 24 h of the bite. The primary outcome was the duration of mechanical ventilation, and the secondary outcomes were the length of hospital stay and in-hospital survival. Results Fifteen patients received 10 vials of antivenom, and 25 received 20 vials. The two treatment groups had similar baseline demographics, clinical and laboratory features, snakebite severity scores, and median time from snakebite to initiation of antivenom therapy. The low-dose regimen was as effective as the standard dose concerning the median duration of mechanical ventilation (41 h vs. 55 h, P = 0.094), the median length of stay (78 h vs. 85.5 h, P = 0.360), and in-hospital deaths (1 vs. 3, P = 1.000). The incidence of ventilator-associated pneumonia was similar between the two groups (1 vs 3, P = 1.000). Conclusion A low dose of antivenom effectively treats patients with severe krait bite neuroparalysis.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4 Floor, F Block, Nehru Hospital, Chandigarh 160012, India
| | - Duni Chand
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4 Floor, F Block, Nehru Hospital, Chandigarh 160012, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4 Floor, F Block, Nehru Hospital, Chandigarh 160012, India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4 Floor, F Block, Nehru Hospital, Chandigarh 160012, India
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2
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Pandit K, Rawal A, Maskey HMS, Nepal G. Neurological and neuro-ophthalmological manifestations of snake bite: a systematic review. Ann Med Surg (Lond) 2024; 86:392-400. [PMID: 38222724 PMCID: PMC10783398 DOI: 10.1097/ms9.0000000000001523] [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: 08/01/2023] [Accepted: 11/09/2023] [Indexed: 01/16/2024] Open
Abstract
Objective Snakebites, a major health concern in developing countries, affect rural farming communities. Venom, primarily neurotoxin, injected during a snake bite disrupts the nervous system, causing symptoms like muscle weakness, paralysis, altered sensation, and coordination issues. This review focuses on evaluating neurological and neuro-ophthalmological manifestations associated with snakebites. Methods A database search was conducted in EMBASE and PubMed for studies published from 2000 to 2023. The investigation centered on examining neurological and neuro-ophthalmological symptoms and signs, treatment approaches, treatment outcomes, and long-term complications of snake bites. Results Neurological and neuro-ophthalmological symptoms were common in both neurotoxic and hemotoxic snake bites, especially in neurotoxic cases. Ptosis was a prevalent manifestation across various snake bites, along with respiratory paralysis, limb weakness, dysphasia, and visual disturbances in some instances. However, most patients improved without residual neurological symptoms after treatment. Conclusions Understanding patterns of neurological manifestations contributes valuable insights for the comprehensive management of snakebite.
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Affiliation(s)
- Kamal Pandit
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Aastha Rawal
- Department of Pharmacy, Manmohan Memorial Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Himang Man Singh Maskey
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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3
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D’Este G, Fabris F, Stazi M, Baggio C, Simonato M, Megighian A, Rigoni M, Negro S, Montecucco C. Agonists of melatonin receptors strongly promote the functional recovery from the neuroparalysis induced by neurotoxic snakes. PLoS Negl Trop Dis 2024; 18:e0011825. [PMID: 38190386 PMCID: PMC10798625 DOI: 10.1371/journal.pntd.0011825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/19/2024] [Accepted: 12/22/2023] [Indexed: 01/10/2024] Open
Abstract
Snake envenoming is a major, but neglected, tropical disease. Among venomous snakes, those inducing neurotoxicity such as kraits (Bungarus genus) cause a potentially lethal peripheral neuroparalysis with respiratory deficit in a large number of people each year. In order to prevent the development of a deadly respiratory paralysis, hospitalization with pulmonary ventilation and use of antivenoms are the primary therapies currently employed. However, hospitals are frequently out of reach for envenomated patients and there is a general consensus that additional, non-expensive treatments, deliverable even long after the snake bite, are needed. Traumatic or toxic degenerations of peripheral motor neurons cause a neuroparalysis that activates a pro-regenerative intercellular signaling program taking place at the neuromuscular junction (NMJ). We recently reported that the intercellular signaling axis melatonin-melatonin receptor 1 (MT1) plays a major role in the recovery of function of the NMJs after degeneration of motor axon terminals caused by massive Ca2+ influx. Here we show that the small chemical MT1 agonists: Ramelteon and Agomelatine, already licensed for the treatment of insomnia and depression, respectively, are strong promoters of the neuroregeneration after paralysis induced by krait venoms in mice, which is also Ca2+ mediated. The venom from a Bungarus species representative of the large class of neurotoxic snakes (including taipans, coral snakes, some Alpine vipers in addition to other kraits) was chosen. The functional recovery of the NMJ was demonstrated using electrophysiological, imaging and lung ventilation detection methods. According to the present results, we propose that Ramelteon and Agomelatine should be tested in human patients bitten by neurotoxic snakes acting presynaptically to promote their recovery of health. Noticeably, these drugs are commercially available, safe, non-expensive, have a long bench life and can be administered long after a snakebite even in places far away from health facilities.
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Affiliation(s)
- Giorgia D’Este
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Federico Fabris
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Marco Stazi
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Chiara Baggio
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | | | - Aram Megighian
- Department of Biomedical Sciences, University of Padova, Padova, Italy
- Padua Neuroscience Center, University of Padova, Padova, Italy
| | - Michela Rigoni
- Department of Biomedical Sciences, University of Padova, Padova, Italy
- Myology Center (CIR-Myo), University of Padova, Padova, Italy
| | - Samuele Negro
- Department of Biomedical Sciences, University of Padova, Padova, Italy
- U.O.C. Clinica Neurologica, Azienda Ospedale-Università Padova, Padova, Italy
| | - Cesare Montecucco
- Department of Biomedical Sciences, University of Padova, Padova, Italy
- CNR Institute of Neuroscience, Padova, Italy
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4
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Gopal G, Muralidar S, Prakash D, Kamalakkannan A, Indhuprakash ST, Thirumalai D, Ambi SV. The concept of Big Four: Road map from snakebite epidemiology to antivenom efficacy. Int J Biol Macromol 2023; 242:124771. [PMID: 37169043 DOI: 10.1016/j.ijbiomac.2023.124771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/13/2023]
Abstract
Snake envenomation is a life-threatening disease caused by the injection of venom toxins from the venomous snake bite. Snakebite is often defined as the occupational or domestic hazard mostly affecting the rural population. India experiences a high number of envenoming cases and fatality due to the nation's diversity in inhabiting venomous snakes. The Indian Big Four snakes namely Russell's viper (Daboia russelii), spectacled cobra (Naja naja), common krait (Bungarus caeruleus), and saw-scaled viper (Echis carinatus) are responsible for majority of the snake envenoming cases and death. The demographic characteristics including occupation, stringent snake habitat management, poor healthcare facilities and ignorance of the rural victims are the primary influencers of high mortality. Biogeographic venom variation greatly influences the clinical pathologies of snake envenomation. The current antivenoms against the Big Four snakes are found to be less immunogenic against the venom toxins emphasizing the necessity of alternative approaches for antivenom generation. This review summarizes the burden of snake envenomation in India by the Big Four snakes including the geographic distribution of snake species and biogeographic venom variation. We have provided comprehensive information on snake venom proteomics that has aided the better understanding of venom induced pathological features, summarized the impact of current polyvalent antivenom therapy highlighting the need for potential antivenom treatment for the effective management of snakebites.
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Affiliation(s)
- Gayathri Gopal
- Biopharmaceutical Research Lab, Anusandhan Kendra-1, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India; School of Chemical and Biotechnology, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India
| | - Shibi Muralidar
- Biopharmaceutical Research Lab, Anusandhan Kendra-1, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India; School of Chemical and Biotechnology, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India
| | - Diwahar Prakash
- Biopharmaceutical Research Lab, Anusandhan Kendra-1, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India; School of Chemical and Biotechnology, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India
| | - Abishek Kamalakkannan
- Biopharmaceutical Research Lab, Anusandhan Kendra-1, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India; School of Chemical and Biotechnology, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India
| | - Srichandrasekar Thuthikkadu Indhuprakash
- Biopharmaceutical Research Lab, Anusandhan Kendra-1, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India; School of Chemical and Biotechnology, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India
| | - Diraviyam Thirumalai
- Biopharmaceutical Research Lab, Anusandhan Kendra-1, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India; School of Chemical and Biotechnology, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India
| | - Senthil Visaga Ambi
- Biopharmaceutical Research Lab, Anusandhan Kendra-1, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India; School of Chemical and Biotechnology, SASTRA Deemed-to-be-University, Thanjavur 613401, Tamil Nadu, India.
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Morris CAD, Donaldson RE. Mechanical ventilation in snake envenomation of dogs and cats. Front Vet Sci 2023; 10:1071257. [PMID: 37065246 PMCID: PMC10090310 DOI: 10.3389/fvets.2023.1071257] [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: 10/16/2022] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
Envenomation by snakes in Elapidae and Viperidae families have been associated with respiratory failure in dogs and cats. Mechanical ventilation may be required for hypoventilation due to neuromuscular paralysis or hypoxemia due to pulmonary hemorrhage or aspiration pneumonia. Median incidence of dogs and cats with snake envenomation that require mechanical ventilation is 13% (0.06-40%). Standard treatment of snake envenomation in dogs and cats includes prompt administration of appropriate antivenom and management of envenomation complications such as coagulopathy, rhabdomyolysis and acute kidney injury. When mechanical ventilation is required, overall prognosis is good with appropriate treatment. Standard anesthetic protocols and mechanical ventilator settings are generally appropriate, with lung protective ventilation strategies typically reserved for patients with pulmonary disease. Median survival to discharge for cats and dogs with elapid envenomation is 72% (76-84%) with 33 h (19.5-58 h) median duration of mechanical ventilation and 140 h (84-196 h) median hospitalization. This article reviews indications for mechanical ventilation in cats and dogs with snake envenomation, and discusses ventilator settings, anesthetic and nursing considerations, complications and outcomes specific to this disease.
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Affiliation(s)
- Cameron A. D. Morris
- Critical Care Department, Queensland Veterinary Specialists, Brisbane, QLD, Australia
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6
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In Vitro Efficacy of Antivenom and Varespladib in Neutralising Chinese Russell's Viper ( Daboia siamensis) Venom Toxicity. Toxins (Basel) 2023; 15:toxins15010062. [PMID: 36668882 PMCID: PMC9864994 DOI: 10.3390/toxins15010062] [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: 12/19/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
The venom of the Russell's viper (Daboia siamensis) contains neurotoxic and myotoxic phospholipase A2 toxins which can cause irreversible damage to motor nerve terminals. Due to the time delay between envenoming and antivenom administration, antivenoms may have limited efficacy against some of these venom components. Hence, there is a need for adjunct treatments to circumvent these limitations. In this study, we examined the efficacy of Chinese D. siamensis antivenom alone, and in combination with a PLA2 inhibitor, Varespladib, in reversing the in vitro neuromuscular blockade in the chick biventer cervicis nerve-muscle preparation. Pre-synaptic neurotoxicity and myotoxicity were not reversed by the addition of Chinese D. siamensis antivenom 30 or 60 min after venom (10 µg/mL). The prior addition of Varespladib prevented the neurotoxic and myotoxic activity of venom (10 µg/mL) and was also able to prevent further reductions in neuromuscular block and muscle twitches when added 60 min after venom. The addition of the combination of Varespladib and antivenom 60 min after venom failed to produce further improvements than Varespladib alone. This demonstrates that the window of time in which antivenom remains effective is relatively short compared to Varespladib and small-molecule inhibitors may be effective in abrogating some activities of Chinese D. siamensis venom.
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7
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Bickler PE, Abouyannis M, Bhalla A, Lewin MR. Neuromuscular Weakness and Paralysis Produced by Snakebite Envenoming: Mechanisms and Proposed Standards for Clinical Assessment. Toxins (Basel) 2023; 15:49. [PMID: 36668869 PMCID: PMC9861841 DOI: 10.3390/toxins15010049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/23/2022] [Accepted: 12/10/2022] [Indexed: 01/11/2023] Open
Abstract
Respiratory and airway-protective muscle weakness caused by the blockade of neuromuscular transmission is a major cause of early mortality from snakebite envenoming (SBE). Once weakness is manifest, antivenom appears to be of limited effectiveness in improving neuromuscular function. Herein, we review the topic of venom-induced neuromuscular blockade and consider the utility of adopting clinical management methods originally developed for the safe use of neuromuscular blocking agents by anesthesiologists in operating rooms and critical care units. Failure to quantify neuromuscular weakness in SBE is predicted to cause the same significant morbidity that is associated with failure to do so in the context of using a clinical neuromuscular block in surgery and critical care. The quantitative monitoring of a neuromuscular block, and an understanding of its neurophysiological characteristics, enables an objective measurement of weakness that may otherwise be overlooked by traditional clinical examination at the bedside. This is important for the initial assessment and the monitoring of recovery from neurotoxic envenoming. Adopting these methods will also be critical to the conduct of future clinical trials of toxin-inhibiting drugs and antivenoms being tested for the reversal of venom-induced neuromuscular block.
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Affiliation(s)
- Philip E. Bickler
- Center for Exploration and Travel Health, California Academy of Science, San Francisco, CA 94118, USA
- Anesthesia and Perioperative Care, University of California at San Francisco, 513 Parnassus Ave, Medical Science Room S-257, San Francisco, CA 94143-0542, USA
| | - Michael Abouyannis
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Matthew R. Lewin
- Center for Exploration and Travel Health, California Academy of Science, San Francisco, CA 94118, USA
- Ophirex, Inc., Corte Madera, CA 94925, USA
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8
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Alam MJ, Maruf M, Iqbal MA, Hasan M, Sohan MS, Shariar MR, Haidar IKA, Chowdhury MAW, Ghose A, Hoque KMF, Reza MA. Evaluation of the properties of Bungarus caeruleus venom and checking the efficacy of antivenom used in Bangladesh for its bite treatment. Toxicon X 2023; 17:100149. [PMID: 36654657 PMCID: PMC9841277 DOI: 10.1016/j.toxcx.2023.100149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 01/05/2023] Open
Abstract
As a disaster-prone country with unique geographical features, snake biting is a major public health concern in Bangladesh. The primary reasons of mortality from snakebite include late presentation to the hospital, low efficacy of antivenom, and a lack of adequate management facilities. Because snake venom characteristics vary depending on geographical location, antivenom should be manufactured from snakes native to the region in which it would be administered. Bungarus caeruleus is a highly venomous snake contributing to the major snakebite issue in Bangladesh. Therefore, the neutralization efficacy of the antivenom against B. caeruleus venom was evaluated in the current study along with the characterization of venom. For biological characterization of venom, RP-HPLC and SDS-PAGE profiling, hemolytic activity, hemorrhagic activity, phospholipases A2 (PLA2) activity, edema inducing activity and histopathological observations were carried out following standard protocol. LD50 of the venom was calculated along with neutralization potency of Incepta antivenom through probit analysis. Results showed that venom possesses phospholipase A2 activity, hemolytic activity and edema inducing activity while hemorrhagic activity was absent in the skin of envenomed mice. Histopathological alterations including necrosis, congestion and infiltrations were observed in envenomed mice organs after hematoxylin and eosin staining. Neutralization study showed that Incepta polyvalent antivenom could neutralize (potency 0.53 mg/ml) the lethal effect in in vitro study on mice. Further investigation on snakebite epidemiology and clinical observations of the envenomed patients will help in combating the snakebite problem more efficiently.
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Affiliation(s)
- Md Jahangir Alam
- Molecular Biology and Protein Science Laboratory, Department of Genetic Engineering and Biotechnology, University of Rajshahi, Rajshahi, 6205, Bangladesh
| | - Md.Mahmudul.Hasan Maruf
- Molecular Biology and Protein Science Laboratory, Department of Genetic Engineering and Biotechnology, University of Rajshahi, Rajshahi, 6205, Bangladesh
| | - Md Asif Iqbal
- Molecular Biology and Protein Science Laboratory, Department of Genetic Engineering and Biotechnology, University of Rajshahi, Rajshahi, 6205, Bangladesh
| | - Mahedi Hasan
- Molecular Biology and Protein Science Laboratory, Department of Genetic Engineering and Biotechnology, University of Rajshahi, Rajshahi, 6205, Bangladesh
| | - Md Sohanur.Rahman Sohan
- Molecular Biology and Protein Science Laboratory, Department of Genetic Engineering and Biotechnology, University of Rajshahi, Rajshahi, 6205, Bangladesh
| | - Md Ragib Shariar
- Molecular Biology and Protein Science Laboratory, Department of Genetic Engineering and Biotechnology, University of Rajshahi, Rajshahi, 6205, Bangladesh
| | - Ibrahim Khalil Al Haidar
- Venom Research Centre, Chittagong Medical College, Chattogram, 4203, Bangladesh,Department of Zoology, University of Chittagong, Chattogram, 4331, Bangladesh
| | - Mohammad Abdul Wahed Chowdhury
- Venom Research Centre, Chittagong Medical College, Chattogram, 4203, Bangladesh,Department of Zoology, University of Chittagong, Chattogram, 4331, Bangladesh
| | - Aniruddha Ghose
- Venom Research Centre, Chittagong Medical College, Chattogram, 4203, Bangladesh,Department of Medicine, Chittagong Medical College, Chattogram, 4203, Bangladesh
| | - Kazi Md Faisal Hoque
- Molecular Biology and Protein Science Laboratory, Department of Genetic Engineering and Biotechnology, University of Rajshahi, Rajshahi, 6205, Bangladesh
| | - Md Abu Reza
- Molecular Biology and Protein Science Laboratory, Department of Genetic Engineering and Biotechnology, University of Rajshahi, Rajshahi, 6205, Bangladesh,Corresponding author.
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9
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A current perspective on snake venom composition and constituent protein families. Arch Toxicol 2023; 97:133-153. [PMID: 36437303 DOI: 10.1007/s00204-022-03420-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 11/28/2022]
Abstract
Snake venoms are heterogeneous mixtures of proteins and peptides used for prey subjugation. With modern proteomics there has been a rapid expansion in our knowledge of snake venom composition, resulting in the venom proteomes of 30% of vipers and 17% of elapids being characterised. From the reasonably complete proteomic coverage of front-fanged snake venom composition (179 species-68 species of elapids and 111 species of vipers), the venoms of vipers and elapids contained 42 different protein families, although 18 were only reported in < 5% of snake species. Based on the mean abundance and occurrence of the 42 protein families, they can be classified into 4 dominant, 6 secondary, 14 minor, and 18 rare protein families. The dominant, secondary and minor categories account for 96% on average of a snake's venom composition. The four dominant protein families are: phospholipase A2 (PLA2), snake venom metalloprotease (SVMP), three-finger toxins (3FTx), and snake venom serine protease (SVSP). The six secondary protein families are: L-amino acid oxidase (LAAO), cysteine-rich secretory protein (CRiSP), C-type lectins (CTL), disintegrins (DIS), kunitz peptides (KUN), and natriuretic peptides (NP). Venom variation occurs at all taxonomic levels, including within populations. The reasons for venom variation are complex, as variation is not always associated with geographical variation in diet. The four dominant protein families appear to be the most important toxin families in human envenomation, being responsible for coagulopathy, neurotoxicity, myotoxicity and cytotoxicity. Proteomic techniques can be used to investigate the toxicological profile of a snake venom and hence identify key protein families for antivenom immunorecognition.
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Waiddyanatha S, Silva A, Weerakoon K, Siribaddana S, Isbister GK. Does snake envenoming cause chronic kidney disease? A cohort study in rural Sri Lanka. Clin Toxicol (Phila) 2023; 61:47-55. [PMID: 36440905 DOI: 10.1080/15563650.2022.2147843] [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: 11/30/2022]
Abstract
BACKGROUND There is limited information on the risk of chronic kidney disease (CKD) following snakebite and its relationship with chronic interstitial nephritis in agricultural communities (CINAC). We aimed to investigate CKD in patients with a confirmed snakebite in rural Sri Lanka. METHODS Patients prospectively recruited to the Anuradhapura snakebite cohort with authenticated bites were followed up. Two groups of patients were followed up: 199 patients in group I with a snakebite (August 2013-October 2014), reviewed after 4 years, and 168 patients in group II with a snakebite (May 2017-August 2018), reviewed after one year, with serum creatinine (estimated glomerular filtration rate [eGFR]) and urinary albumin to creatinine ratio (ACR). RESULTS There were 12/199 (6%) in group I and 9/168 (5%) in group II with AKI following snakebite; 3/12 in group I and 2/9 in group II had haemodialysis. On review after 1 and 4 years, no patient had CKD and all had an eGFR ≥60 mL/min/1.73m2. Of 234 patients with a creatinine measured on discharge, 17/140 in group I and 11/94 in group II had a low eGFR (<60mL/min/1.73m2). In group I, 14/17 had a normal eGFR after four years, including 11/12 who had AKI following snakebite, and the 3/17 with a low eGFR on review had CKD or co-morbidities for CKD. In group II, 10/11 had a normal eGFR after one year, including all nine patients with AKI following snakebite, and the one patient with a low eGFR on review had CKD. Fifty patients (25%) in group I and 43 (26%) in group II had a high urinary ACR on review, all but two in each group had microalbuminuria. Multivariate logistic regression showed in group I that only comorbidities for CKD were associated with high urinary ACR, and in group II comorbidities for CKD, snakebite associated AKI and snake type were associated with high urinary ACR. All nine patients from both groups with a low eGFR (CKD stages 3-5) had CKD prior to the snakebite or treatment for hypertension or diabetes. CONCLUSION There was no significant association between snakebite-associated AKI and CKD in patients followed up from a snakebite cohort post-bite. Microalbuminuria was common in these patients but likely associated with hypertension, diabetes mellitus and CINAC in this rural farming population.
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Affiliation(s)
- Subodha Waiddyanatha
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka.,South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Anjana Silva
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka.,South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.,Department of Pharmacology, Faculty of Medicine, Nursing and Health Sciences, Monash Venom Group, Monash University, Melbourne, VIC, Australia
| | - Kosala Weerakoon
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Sisira Siribaddana
- Department of Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Geoffrey K Isbister
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.,Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
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Senthilkumaran S, Miller SW, Williams HF, Thirumalaikolundusubramanian P, Patel K, Vaiyapuri S. Bilateral Simultaneous Optic Neuritis Following Envenomations by Indian Cobra and Common Krait. Toxins (Basel) 2022; 14:toxins14110805. [PMID: 36422979 PMCID: PMC9697512 DOI: 10.3390/toxins14110805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
In India, most snakebite envenomation (SBE) incidents are caused by the "Big Four" snakes which include Russell's viper, common krait, Indian cobra, and saw-scaled viper. Their common envenomation effects include neurotoxicity, myotoxicity, and coagulopathy. However, they also induce rare complications such as priapism, pseudoaneurysm, and sialolithiasis. Ocular manifestations such as optic neuritis develop rarely following envenomations by non-spitting snakes and they may cause temporary vision changes and blindness if untreated. While optic neuritis following Indian cobra envenomation has been reported previously, this was not encountered in victims of common kraits. Hence, for the first time, we report optic neuritis developed in a victim following envenomation by a common krait and compare its clinical features and diagnostic and therapeutic methods used with another case of optic neuritis in a victim of an Indian cobra bite. Both patients received antivenom treatment and made an initial recovery; however, optic neuritis developed several days later. The condition was diagnosed using ophthalmic examination together with computed tomography and/or magnetic resonance imaging methods. Due to very similar clinical features, both patients received intravenous corticosteroids which restored their vision and successfully treated optic neuritis. This case report suggests that the optic neuritis developed in a common krait envenomation is comparable to the one developed following a cobra bite, and therefore, the same diagnostic and therapeutic approaches can be used. This study also raises awareness of this rare complication and provides guidance for the diagnosis and treatment of SBE-induced optic neuritis.
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Affiliation(s)
| | - Stephen W. Miller
- The Poison Control Center, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Harry F. Williams
- Toxiven Biotech Private Limited, Coimbatore 641042, Tamil Nadu, India
| | | | - Ketan Patel
- School of Biological Sciences, University of Reading, Reading RG6 6UB, UK
| | - Sakthivel Vaiyapuri
- School of Pharmacy, University of Reading, Reading RG6 6UB, UK
- Correspondence:
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Waiddyanatha S, Silva A, Weerakoon K, Siribaddana S, Isbister GK. Long-term health effects perceived by snakebite patients in rural Sri Lanka: A cohort study. PLoS Negl Trop Dis 2022; 16:e0010723. [PMID: 36048902 PMCID: PMC9473613 DOI: 10.1371/journal.pntd.0010723] [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: 02/14/2022] [Revised: 09/14/2022] [Accepted: 08/06/2022] [Indexed: 11/18/2022] Open
Abstract
The acute effects of snakebite are often emphasized, with less information on long-term effects. We aimed to describe the long-term health effects perceived by patients followed up after confirmed snakebites. Two groups of snakebite patients (>18y) from the Anuradhapura snakebite cohort were reviewed: Group I had a snakebite during August 2013-October 2014 and was reviewed after 4 years, and group II had a snakebite during May 2017-August 2018, and was reviewed after one year. Patients were invited by telephone, by sending letters, or doing home visits, including 199 of 736 patients (27%) discharged alive from group I and 168 of 438 patients (38%) from group II, a total of 367 followed up. Health effects were categorised as musculoskeletal, impact on daily life, and medically unexplained. Health issues were attributed to snakebite in 107/199 patients (54%) from group I and 55/168 patients (33%) from group II, suggesting the proportion with health issues increases with time. Sixteen patients (all viperine bites) had permanent musculoskeletal problems, none with a significant functional disability affecting daily routine. 217/367 reported being more vigilant about snakes while working outdoors, but only 21/367 were using protective footwear at review. Of 275 farmers reviewed, only six (2%) had restricted farming activities due to fear of snakebite, and only one stopped farming. 104/199 (52%) of group I and 42/168 (25%) of group II attributed non-specific symptoms (fatigue, body aches, pain, visual impairment) and/or oral cavity-related symptoms (avulsed teeth, loose teeth, receding gums) to the snakebite, which cannot be explained medically. In multivariate logistic regression, farming, type of snake, antivenom administration, and time since snakebite were associated with medically unexplained symptoms. The latter suggests medically unexplained effects increased with time. Based on two groups of snakebite patients reviewed one and four years post-bite, we show that long-term musculoskeletal disabilities are uncommon and not severe in snakebite survivors in rural Sri Lanka. However, a large portion of patients complain of various non-specific general and oral symptoms, not explainable based on the known pathophysiology of snakebite. These perceived effects of snakebite were more common in patients with systemic envenoming, and were more frequent the longer the time post-bite.
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Affiliation(s)
- Subodha Waiddyanatha
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Anjana Silva
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Monash Venom Group, Department of Pharmacology, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Kosala Weerakoon
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Sisira Siribaddana
- Department of Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Geoffrey K. Isbister
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
- * E-mail:
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On characterizing the Red-headed Krait (Bungarus flaviceps) venom: Decomplexation proteomics, immunoreactivity and toxicity cross-neutralization by hetero-specific antivenoms. COMPARATIVE BIOCHEMISTRY AND PHYSIOLOGY. PART D, GENOMICS & PROTEOMICS 2022; 43:101006. [PMID: 35717758 DOI: 10.1016/j.cbd.2022.101006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 12/26/2022]
Abstract
The Red-headed Krait (Bungarus flaviceps) is a medically important venomous snake species in Southeast Asia, while there is no specific antivenom available for its envenoming. This study investigated the venom composition through a decomplexation proteomic approach, and examined the immunoreactivity as well as cross-neutralization efficacy of two hetero-specific krait antivenoms, Bungarus candidus Monovalent Antivenom (BcMAV) and Bungarus fasciatus Monovalent Antivenom (BfMAV), against the venom of B. flaviceps from Peninsular Malaysia. A total of 43 non-redundant proteoforms belonging to 10 toxin families were identified in the venom proteome, which is dominated by phospholipases A2 including beta-bungarotoxin lethal subunit (56.20 % of total venom proteins), Kunitz-type serine protease inhibitors (19.40 %), metalloproteinases (12.85 %) and three-finger toxins (7.73 %). The proteome varied in quantitative aspect from the earlier reported Indonesian (Sumatran) sample, suggesting geographical venom variation. BcMAV and BfMAV were immunoreactive toward the B. flaviceps venom, with BcMAV being more efficacious in immunological binding. Both antivenoms cross-neutralized the venom lethality with varying efficacy, where BcMAV was more potent than BfMAV by ~13 times (normalized potency: 38.04 mg/g vs. 2.73 mg/g, defined as the venom amount completely neutralized by one-gram antivenom protein), supporting the potential utility of BcMAV for para-specific neutralization against B. flaviceps venom.
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Silva A, Scorgie FE, Lincz LF, Maduwage K, Siribaddana S, Isbister GK. Indian Polyvalent Antivenom Accelerates Recovery From Venom-Induced Consumption Coagulopathy (VICC) in Sri Lankan Russell’s Viper (Daboia russelii) Envenoming. Front Med (Lausanne) 2022; 9:852651. [PMID: 35321467 PMCID: PMC8934852 DOI: 10.3389/fmed.2022.852651] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Venom-induced consumption coagulopathy (VICC) is an important clinical consequence of Russell’s viper (Daboia russelii) envenoming. There is limited evidence for antivenom effectiveness in resolving VICC. We aimed to compare the recovery of VICC in patients who received and did not receive antivenom following Russell’s viper envenoming. Patients and Methods This was a non-randomized observational study comparing patients with VICC from Russell’s viper envenoming given antivenom for systemic envenoming and those not given antivenom. Antivenom administration was decided by the treating physicians. We included 44 patients with confirmed Russell’s viper bites with one or more International Normalized Ratio (INR) value ≥ 1.5 (VICC). We compared five patients who did not receive antivenom with 39 patients who did receive antivenom. The primary outcome was the proportion of patients with an INR < 1.5 by 48 h post-bite. Results The antivenom group had higher peak serum venom concentrations [median (IQR) = 272 (96–1,076) ng/mL versus 21 (8–58) ng/mL] and more severe VICC compared to the no antivenom group. Twenty seven of 39 patients (69%) in the antivenom group had an INR < 1.5 at 48 h post-bite compared to none of the five patients (0%) in the no antivenom group (absolute difference: 69%; 95%CI: 13 to 83%; p = 0.006; Fisher’s exact test). The fibrinogen recovered in 32 of 39 patients (82%) in the antivenom group compared to one of five patients (20%) in the no antivenom group (absolute difference 62%; 95% CI: 28 to 95%; p = 0.001; Fisher’s exact test). Both INR and fibrinogen were significantly improved between 24 and 48 h post-bite in the antivenom group compared to the no antivenom group. Conclusion Antivenom accelerated the recovery of VICC in patients with Russell’s viper envenoming, compared to no recovery in a smaller group of patients with milder VICC not receiving antivenom. This supports the efficacy of antivenom in patients with VICC.
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Affiliation(s)
- Anjana Silva
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
- Monash Venom Group, Department of Pharmacology, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fiona E. Scorgie
- Hunter Haematology Research Group, Calvary Mater Newcastle, Newcastle, NSW, Australia
| | - Lisa F. Lincz
- Hunter Haematology Research Group, Calvary Mater Newcastle, Newcastle, NSW, Australia
| | - Kalana Maduwage
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Sisira Siribaddana
- Department of Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Geoffrey K. Isbister
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, The University of Newcastle, Newcastle, NSW, Australia
- *Correspondence: Geoffrey K. Isbister,
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Varespladib (LY315920) rescued mice from fatal neurotoxicity caused by venoms of five major Asiatic kraits (Bungarus spp.) in an experimental envenoming and rescue model. Acta Trop 2022; 227:106289. [PMID: 34929179 DOI: 10.1016/j.actatropica.2021.106289] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022]
Abstract
The venoms of Asiatic kraits (Bungarus spp.) contain various neurotoxic phospholipases A2 (beta-bungarotoxins) which can irreversibly damage motor nerve terminals, resulting in rapidly fatal suffocation by respiratory muscle paralysis or oral airway obstruction. Hence, there is a need of adjunct therapy at the pre-hospital stage to prevent or delay the onset of neurotoxicity, so that antivenom can be given within golden hour before the envenoming becomes antivenom-resistant. This study investigated the efficacy of varespladib, a small molecule PLA2 (phospholipase A2) inhibitor, given as a bolus subcutaneously upon the onset of krait venom-induced paralysis in a mouse experimental envenoming and rescue model, where the severity of neurotoxicity was scored and the survival rate was monitored over 24 h. Varespladib at 10 mg/kg effectively alleviated the neurotoxicity of Bungarus sindanus, Bungarus multicinctus and Bungarus fasciatus venoms, and rescued all mice from venom-induced lethality (100% survival). Varespladib at this dose, however, only partially reduced the neurotoxicity of Bungarus caeruleus and Bungarus candidus venoms, while all challenged mice were dead by 23 h (B. caeruleus) and 12 h (B. candidus). An increased dose of varespladib at 20 mg/kg markedly abated the venom neurotoxicity past 8 h of envenoming, and protected the mice from venom lethality (B. caeruleus: 75% survival; B. candidus: 100% survival). The finding is consistent with previous studies which demonstrated varespladib's inhibitory effect against some snake venoms. The findings suggest varespladib could be repurposed as an emergency drug for prevention or rescue (if given early enough) from the acute, neurotoxic envenoming syndromes caused by various major krait species in Asia.
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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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Stazi M, Fabris F, Tan KY, Megighian A, Rubini A, Mattarei A, Negro S, D'Este G, Lista F, Rossetto O, Tan CH, Montecucco C. An agonist of the CXCR4 receptor is therapeutic for the neuroparalysis induced by
Bungarus
snakes envenoming. Clin Transl Med 2022; 12:e651. [PMID: 35075797 PMCID: PMC8787102 DOI: 10.1002/ctm2.651] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/27/2021] [Accepted: 10/31/2021] [Indexed: 11/08/2022] Open
Affiliation(s)
- Marco Stazi
- Department of Biomedical Sciences University of Padova Padova Italy
| | - Federico Fabris
- Department of Biomedical Sciences University of Padova Padova Italy
| | - Kae Yi Tan
- Department of Molecular Medicine Faculty of Medicine University of Malaya Kuala Lumpur Malaysia
| | - Aram Megighian
- Department of Biomedical Sciences University of Padova Padova Italy
| | | | - Andrea Mattarei
- Department of Pharmaceutical and Pharmacological Sciences University of Padova Padova Italy
| | - Samuele Negro
- Department of Biomedical Sciences University of Padova Padova Italy
| | - Giorgia D'Este
- Department of Biomedical Sciences University of Padova Padova Italy
| | - Florigio Lista
- Center of Medical and Veterinary Research of the Ministry of Defense Policlinico Militare Rome Italy
| | - Ornella Rossetto
- Department of Biomedical Sciences University of Padova Padova Italy
| | - Choo Hock Tan
- Department of Pharmacology Faculty of Medicine University of Malaya Kuala Lumpur Malaysia
| | - Cesare Montecucco
- Department of Biomedical Sciences University of Padova Padova Italy
- CNR Institute of Neuroscience Padova Italy
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Abstract
SNAKE ENVENOMATION REPRESENTS AN IMPORTANT HEALTH PROBLEM IN much of the world. In 2009, it was recognized by the World Health Organization (WHO) as a neglected tropical disease, and in 2017, it was elevated into Category A of the Neglected Tropical Diseases list, further expanding access to funding for research and antivenoms. However, snake envenomation occurs in both tropical and temperate climates and on all continents except Antarctica. Worldwide, the estimated number of annual deaths due to snake envenomation (80,000 to 130,000) is similar to the estimate for drug-resistant tuberculosis and for multiple myeloma., In countries with adequate resources, deaths are infrequent (e.g., <6 deaths per year in the United States, despite the occurrence of 7000 to 8000 bites), but in countries without adequate resources, deaths may number in the tens of thousands. Venomous snakes kept as pets are not rare, and physicians anywhere might be called on to manage envenomation by a nonnative snake. Important advances have occurred in our understanding of the biology of venom and the management of snake envenomation since this topic was last addressed in the Journal two decades ago. For the general provider, it is important to understand the spectrum of snake envenomation effects and approaches to management and to obtain specific guidance, when needed.
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Affiliation(s)
- Steven A Seifert
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - James O Armitage
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - Elda E Sanchez
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
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Oh AMF, Tan KY, Tan NH, Tan CH. Proteomics and neutralization of Bungarus multicinctus (Many-banded Krait) venom: Intra-specific comparisons between specimens from China and Taiwan. Comp Biochem Physiol C Toxicol Pharmacol 2021; 247:109063. [PMID: 33910092 DOI: 10.1016/j.cbpc.2021.109063] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/12/2021] [Accepted: 04/18/2021] [Indexed: 12/15/2022]
Abstract
The Many-banded Krait (Bungarus multicinctus) is a medically important venomous snake in East Asia. This study investigated the venom proteomes of B. multicinctus from Guangdong, southern China (BM-China) and insular Taiwan (BM-Taiwan), and the neutralization activities of two antivenom products (produced separately in China and Taiwan) against the lethal effect of the venoms. The venom proteomes of both specimens contained similar toxin families, notwithstanding small variations in the subtypes and abundances of minor components. More than 90% of the total venom proteins belong to three-finger toxins (3FTx, including alpha-neurotoxins) and phospholipases A2 (PLA2, including beta-bungarotoxins), supporting their key involvement in the pathophysiology of krait envenomation which manifests as pre- and post-synaptic neurotoxicity. The venoms exhibited potent neurotoxic and lethal effects with extremely low i.v. LD50 of 0.027 μg/g (Bm-China) and 0.087 μg/g (Bm-Taiwan), respectively, in mice. Bungarus multicinctus monovalent antivenom (BMMAV) produced in China and Neuro bivalent antivenom (NBAV) produced in Taiwan were immunoreactive toward both venoms and their toxin fractions. The antivenoms neutralized the venom lethality variably, with BMMAV being more efficacious than NBAV by approximately two-fold. Findings suggest that the monovalent antivenom has a higher potency presumably due to its species-specificity toward the krait venom.
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Affiliation(s)
- Angeline Mei Feng Oh
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kae Yi Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nget Hong Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Choo Hock Tan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
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Gutiérrez JM, Maduwage K, Iliyasu G, Habib A. Snakebite envenoming in different national contexts: Costa Rica, Sri Lanka, and Nigeria. Toxicon X 2021; 9-10:100066. [PMID: 34124644 PMCID: PMC8175406 DOI: 10.1016/j.toxcx.2021.100066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 12/12/2022] Open
Abstract
Snakebite envenoming is a neglected tropical disease that predominantly affects impoverished rural communities in sub-Saharan Africa, Asia, and Latin America. The global efforts to reduce the impact of this disease must consider the local national contexts and, therefore, comparative studies on envenomings in different countries are necessary to identify strengths, weaknesses and needs. This work presents a comparative analysis of snakebite envenomings in Costa Rica, Sri Lanka, and Nigeria. The comparison included the following aspects: (a) burden of envenomings, (b) historical background of national efforts to confront envenomings, (c) national health systems, (d) antivenom availability and accessibility including local production, (e) training of physicians and nurses in the diagnosis and management of envenomings, (f) prevention campaigns and community-based work, (g) scientific and technological platforms in these topics, and (h) international cooperation programs. Strengths and weaknesses were identified in the three contexts and several urgent tasks to improve the management of this disease in these countries are highlighted. This comparative analysis could be of benefit for similar studies in other national and regional contexts.
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Affiliation(s)
- José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501, Costa Rica
| | - Kalana Maduwage
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, 20400, Sri Lanka
| | - Garba Iliyasu
- Infectious and Tropical Diseases Unit, Department of Medicine, College of Health Sciences, Bayero University, Kano, Nigeria
| | - Abdulrazaq Habib
- Infectious and Tropical Diseases Unit, Department of Medicine, College of Health Sciences, Bayero University, Kano, Nigeria
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21
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Paediatric cases of Ceylon krait (Bungarus ceylonicus) bites and some similar looking non-venomous snakebites in Sri Lanka: Misidentification and antivenom administration. Toxicon 2021; 198:143-150. [PMID: 33957150 DOI: 10.1016/j.toxicon.2021.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/25/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
Ceylon krait (Bungarus ceylonicus) of the family Elapidae is a highly venomous endemic species inhabiting in the wet zone and some parts of the intermediate climatic zones of Sri Lanka. Clinical records of its bites are rare and limited to five case reports in the literature. It is of interest to note that there are several non-venomous snakes in Sri Lanka having similar morphological appearance to kraits causing identification difficulties which lead to unnecessary and unindicated administration of antivenom. We report two paediatric cases of proven Ceylon krait bites and three adult patients with similar looking non-venomous snakebites. These children were 1½ and 13 years old and developed neuroparalysis without progressing to respiratory failure and recovered. Both the children were administered Indian polyvalent antivenom which has not developed against endemic Ceylon krait venom. The two adult patients also received antivenom due to the misidentification without clinical and laboratory evidence of envenoming.
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Current research into snake antivenoms, their mechanisms of action and applications. Biochem Soc Trans 2021; 48:537-546. [PMID: 32196542 DOI: 10.1042/bst20190739] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 01/11/2023]
Abstract
Snakebite is a major public health issue in the rural tropics. Antivenom is the only specific treatment currently available. We review the history, mechanism of action and current developments in snake antivenoms. In the late nineteenth century, snake antivenoms were first developed by raising hyperimmune serum in animals, such as horses, against snake venoms. Hyperimmune serum was then purified to produce whole immunoglobulin G (IgG) antivenoms. IgG was then fractionated to produce F(ab) and F(ab')2 antivenoms to reduce adverse reactions and increase efficacy. Current commercial antivenoms are polyclonal mixtures of antibodies or their fractions raised against all toxin antigens in a venom(s), irrespective of clinical importance. Over the last few decades there have been small incremental improvements in antivenoms, to make them safer and more effective. A number of recent developments in biotechnology and toxinology have contributed to this. Proteomics and transcriptomics have been applied to venom toxin composition (venomics), improving our understanding of medically important toxins. In addition, it has become possible to identify toxins that contain epitopes recognized by antivenom molecules (antivenomics). Integration of the toxinological profile of a venom and its composition to identify medically relevant toxins improved this. Furthermore, camelid, humanized and fully human monoclonal antibodies and their fractions, as well as enzyme inhibitors have been experimentally developed against venom toxins. Translation of such technology into commercial antivenoms requires overcoming the high costs, limited knowledge of venom and antivenom pharmacology, and lack of reliable animal models. Addressing such should be the focus of antivenom research.
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Gupta A, Smilie C, Bhaskar V, Batra P. Unusually prolonged neuromuscular weakness caused by krait (Bungarus caeruleus) bite: Two case reports. Toxicon 2021; 193:1-3. [PMID: 33497743 DOI: 10.1016/j.toxicon.2021.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 12/09/2020] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
Snakebites are common in India and the most common neurotoxic snakebites in India are due to Common krait (Bungarus caeruleus) and cobra (Naja naja). Severe envenomation may mimic brain death or a locked-in state with flaccid paralysis in a descending manner and total ophthalmoplegia. Usually, patients who receive timely antivenom and ventilator support recover completely without any sequalae. We are reporting two cases of krait bite with an unusually long period of flaccid paralysis, which required prolong ventilation. While case 1 required 10 days of mechanical ventilation followed by 5 days of non-invasive ventilation, case 2 required 11 days of mechanical ventilation followed by 5 days of non-invasive ventilation. Both the cases had delayed recovery and residual weakness at 3-month follow up. These case reports suggest that krait bite may cause prolong neuromuscular weakness in children, which has implications for both acute and chronic management.
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Affiliation(s)
- Ashish Gupta
- University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
| | - Chabungbam Smilie
- University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
| | - Vikram Bhaskar
- University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
| | - Prerna Batra
- University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
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Silva A, Hlusicka J, Siribaddana N, Waiddyanatha S, Pilapitiya S, Weerawansa P, Lokunarangoda N, Thalgaspitiya S, Siribaddana S, Isbister GK. Time delays in treatment of snakebite patients in rural Sri Lanka and the need for rapid diagnostic tests. PLoS Negl Trop Dis 2020; 14:e0008914. [PMID: 33253208 PMCID: PMC7728389 DOI: 10.1371/journal.pntd.0008914] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 12/10/2020] [Accepted: 10/23/2020] [Indexed: 02/07/2023] Open
Abstract
Delays in treatment seeking and antivenom administration remain problematic for snake envenoming. We aimed to describe the treatment seeking pattern and delays in admission to hospital and administration of antivenom in a cohort of authenticated snakebite patients. Adults (> 16 years), who presented with a confirmed snakebite from August 2013 to October 2014 were recruited from Anuradhapura Hospital. Demographic data, information on the circumstances of the bite, first aid, health-seeking behaviour, hospital admission, clinical features, outcomes and antivenom treatment were documented prospectively. There were 742 snakebite patients [median age: 40 years (IQR:27–51; males: 476 (64%)]. One hundred and five (14%) patients intentionally delayed treatment by a median of 45min (IQR:20-120min). Antivenom was administered a median of 230min (IQR:180–360min) post-bite, which didn’t differ between directly admitted and transferred patients; 21 (8%) receiving antivenom within 2h and 141 (55%) within 4h of the bite. However, transferred patients received antivenom sooner after admission to Anuradhapura hospital than those directly admitted (60min [IQR:30-120min] versus 120min [IQR:52-265min; p<0.0001]). A significantly greater proportion of transferred patients had features of systemic envenoming on admission compared to those directly admitted (166/212 [78%] versus 5/43 [12%]; p<0.0001), and had positive clotting tests on admission (123/212 [58%] versus 10/43 [23%]; p<0.0001). Sri Lankan snakebite patients present early to hospital, but there remains a delay until antivenom administration. This delay reflects a delay in the appearance of observable or measurable features of envenoming and a lack of reliable early diagnostic tests. Improved early antivenom treatment will require reliable, rapid diagnostics for systemic envenoming. Snakebite is a neglected tropical disease which is closely associated with underdevelopment. Poor accessibility to safe and effective antivenoms is a major issue in some regions highest-affected by snakebites. Antivenom can prevent severe effects of envenoming if given early. Therefore, educating communities and health care workers to improve treatment seeking after snakebite is a global priority. Many factors are associated with delayed presentation to hospital and early administration of antivenom. We found that most snakebite patients in Sri Lanka present to the first hospital within an hour of the bite. However, there remains a delay of about two more hours until the first dose of antivenom is administered. This delay is a reflection of a delay in the appearance of observable or measurable features of envenoming and a lack of reliable early diagnostic tests. We emphasise the need for reliable, rapid diagnostics for systemic envenoming.
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Affiliation(s)
- Anjana Silva
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
- Monash Venom Group, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- * E-mail:
| | - Jiri Hlusicka
- Charles University in Prague, 1st Faculty of Medicine, 4th Department of Internal Medicine, Prague, Czech Republic
| | - Nipuna Siribaddana
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Subodha Waiddyanatha
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
| | - Senaka Pilapitiya
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Prasanna Weerawansa
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Niroshan Lokunarangoda
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Sujeewa Thalgaspitiya
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Sisira Siribaddana
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Geoffrey K. Isbister
- Monash Venom Group, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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Adhikari R, Suriyagoda L, Premarathna A, De Silva N, Dangolla A, Mallawa C, Silva I, Gawarammana I. Development of a Treatment Protocol for Cobra ( Naja naja) Bite Envenoming in Dogs. Toxins (Basel) 2020; 12:toxins12110694. [PMID: 33147770 PMCID: PMC7694019 DOI: 10.3390/toxins12110694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/02/2020] [Accepted: 10/09/2020] [Indexed: 12/21/2022] Open
Abstract
There is limited information on clinical profiles, treatment, and management aspects of Indian cobra (Naja naja) bite envenoming in dogs in Sri Lanka. Dogs with cobra bites presented to the Veterinary Teaching Hospital (VTH), University of Peradeniya, were prospectively studied over a period of 72 months; local and systemic clinical manifestations and hematological abnormalities were recorded. We studied 116 cobra bite envenomings in dogs. A grading system was established using a combination of anatomical site of fang marks, as well as local and systemic clinical manifestations. Accordingly, treatment strategies were established using Indian polyvalent antivenom (AVS). Pain and swelling at the bite site were major clinical signs observed, while neurotoxic manifestations (mydriasis, wheezing, and crackles) were detected in most dogs. Leukocytosis was observed in 78% of them. Statistical analysis revealed that the grading scores obtained were compatible to initiate AVS administration according to the severity. The minimum number required was 2 AVS vials (range 2-12). Almost 20% of the dogs developed wheezing, crackles, hypersalivation, restlessness, and dyspnea as adverse reactions to AVS treatment. Necrotic wounds on bitten anatomical sites developed in 19% of the dogs and 2.5% developed acute kidney injuries as a consequence of envenoming crisis. Despite treatment, 3% of dogs died. No dry bites were recorded.
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Affiliation(s)
- Ranjith Adhikari
- Department of Veterinary Clinical Sciences, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Peradeniya 20400, Sri Lanka; (R.A.); (N.D.S.); (A.D.); (C.M.); (I.S.)
| | - Lalith Suriyagoda
- Department of Crop Science, Faculty of Agriculture, University of Peradeniya, Peradeniya 20400, Sri Lanka;
| | - Amal Premarathna
- Department of Veterinary Pathobiology, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Peradeniya 20400, Sri Lanka;
| | - Niranjala De Silva
- Department of Veterinary Clinical Sciences, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Peradeniya 20400, Sri Lanka; (R.A.); (N.D.S.); (A.D.); (C.M.); (I.S.)
| | - Ashoka Dangolla
- Department of Veterinary Clinical Sciences, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Peradeniya 20400, Sri Lanka; (R.A.); (N.D.S.); (A.D.); (C.M.); (I.S.)
| | - Chandima Mallawa
- Department of Veterinary Clinical Sciences, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Peradeniya 20400, Sri Lanka; (R.A.); (N.D.S.); (A.D.); (C.M.); (I.S.)
| | - Indira Silva
- Department of Veterinary Clinical Sciences, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Peradeniya 20400, Sri Lanka; (R.A.); (N.D.S.); (A.D.); (C.M.); (I.S.)
| | - Indika Gawarammana
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya 20400, Sri Lanka
- Correspondence:
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Madhushani U, Isbister GK, Tasoulis T, Hodgson WC, Silva A. In-Vitro Neutralization of the Neurotoxicity of Coastal Taipan Venom by Australian Polyvalent Antivenom: The Window of Opportunity. Toxins (Basel) 2020; 12:toxins12110690. [PMID: 33142783 PMCID: PMC7694127 DOI: 10.3390/toxins12110690] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Coastal taipan (Oxyuranus scutellatus) envenoming causes life-threatening neuromuscular paralysis in humans. We studied the time period during which antivenom remains effective in preventing and arresting in vitro neuromuscular block caused by taipan venom and taipoxin. Venom showed predominant pre-synaptic neurotoxicity at 3 µg/mL and post-synaptic neurotoxicity at 10 µg/mL. Pre-synaptic neurotoxicity was prevented by addition of Australian polyvalent antivenom before the venom and taipoxin and, reversed when antivenom was added 5 min after venom and taipoxin. Antivenom only partially reversed the neurotoxicity when added 15 min after venom and had no significant effect when added 30 min after venom. In contrast, post-synaptic activity was fully reversed when antivenom was added 30 min after venom. The effect of antivenom on pre-synaptic neuromuscular block was reproduced by washing the bath at similar time intervals for 3 µg/mL, but not for 10 µg/mL. We found an approximate 10–15 min time window in which antivenom can prevent pre-synaptic neuromuscular block. This time window is likely to be longer in envenomed patients due to the delay in venom absorption. Similar effectiveness of antivenom and washing with 3 µg/mL venom suggests that antivenom most likely acts by neutralizing pre-synaptic toxins before they interfere with neurotransmission inside the motor nerve terminals.
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Affiliation(s)
- Umesha Madhushani
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale 50300, Sri Lanka;
| | - Geoffrey K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Callaghan 2308, Australia; (G.K.I.); (T.T.)
| | - Theo Tasoulis
- Clinical Toxicology Research Group, University of Newcastle, Callaghan 2308, Australia; (G.K.I.); (T.T.)
| | - Wayne C. Hodgson
- Monash Venom Group, Department of Pharmacology, Biomedical Discovery Institute, Monash University, Clayton 3800, Australia;
| | - Anjana Silva
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale 50300, Sri Lanka;
- Monash Venom Group, Department of Pharmacology, Biomedical Discovery Institute, Monash University, Clayton 3800, Australia;
- Correspondence:
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Isbister GK, Mirajkar N, Fakes K, Brown SGA, Veerati PC. Phospholipase A2 (PLA 2) as an Early Indicator of Envenomation in Australian Elapid Snakebites (ASP-27). Biomedicines 2020; 8:biomedicines8110459. [PMID: 33138056 PMCID: PMC7692658 DOI: 10.3390/biomedicines8110459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 01/28/2023] Open
Abstract
Early diagnosis of snake envenomation is essential, especially neurotoxicity and myotoxicity. We investigated the diagnostic value of serum phospholipase (PLA2) in Australian snakebites. In total, 115 envenomated and 80 non-envenomated patients were recruited over 2 years, in which an early blood sample was available pre-antivenom. Serum samples were analyzed for secretory PLA2 activity using a Cayman sPLA2 assay kit (#765001 Cayman Chemical Company, Ann Arbor MI, USA). Venom concentrations were measured for snake identification using venom-specific enzyme immunoassay. The most common snakes were Pseudonaja spp. (33), Notechis scutatus (24), Pseudechis porphyriacus (19) and Tropidechis carinatus (17). There was a significant difference in median PLA2 activity between non-envenomated (9 nmol/min/mL; IQR: 7–11) and envenomated patients (19 nmol/min/mL; IQR: 10–66, p < 0.0001) but Pseudonaja spp. were not different to non-envenomated. There was a significant correlation between venom concentrations and PLA2 activity (r = 0.71; p < 0.0001). PLA2 activity was predictive for envenomation; area under the receiver-operating-characteristic curve (AUC-ROC), 0.79 (95% confidence intervals [95%CI]: 0.72–0.85), which improved with brown snakes excluded, AUC-ROC, 0.88 (95%CI: 0.82–0.94). A cut-point of 16 nmol/min/mL gives a sensitivity of 72% and specificity of 100% for Australian snakes, excluding Pseudonaja. PLA2 activity was a good early predictor of envenomation in most Australian elapid bites. A bedside PLA2 activity test has potential utility for early case identification but may not be useful for excluding envenomation.
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Affiliation(s)
- Geoffrey K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW 2298, Australia; (N.M.); (K.F.); (P.C.V.)
- Correspondence: ; Tel.: +61-249211211
| | - Nandita Mirajkar
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW 2298, Australia; (N.M.); (K.F.); (P.C.V.)
| | - Kellie Fakes
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW 2298, Australia; (N.M.); (K.F.); (P.C.V.)
| | - Simon G. A. Brown
- Aeromedical and Retrieval Medicine, Ambulance Tasmania, Hobart, TAS 7001, Australia;
| | - Punnam Chander Veerati
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW 2298, Australia; (N.M.); (K.F.); (P.C.V.)
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Pucca MB, Knudsen C, S. Oliveira I, Rimbault C, A. Cerni F, Wen FH, Sachett J, Sartim MA, Laustsen AH, Monteiro WM. Current Knowledge on Snake Dry Bites. Toxins (Basel) 2020; 12:toxins12110668. [PMID: 33105644 PMCID: PMC7690386 DOI: 10.3390/toxins12110668] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 11/17/2022] Open
Abstract
Snake ‘dry bites’ are characterized by the absence of venom being injected into the victim during a snakebite incident. The dry bite mechanism and diagnosis are quite complex, and the lack of envenoming symptoms in these cases may be misinterpreted as a miraculous treatment or as proof that the bite from the perpetrating snake species is rather harmless. The circumstances of dry bites and their clinical diagnosis are not well-explored in the literature, which may lead to ambiguity amongst treating personnel about whether antivenom is indicated or not. Here, the epidemiology and recorded history of dry bites are reviewed, and the clinical knowledge on the dry bite phenomenon is presented and discussed. Finally, this review proposes a diagnostic and therapeutic protocol to assist medical care after snake dry bites, aiming to improve patient outcomes.
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Affiliation(s)
- Manuela B. Pucca
- Medical School, Federal University of Roraima, Boa Vista 69310-000, Roraima, Brazil;
| | - Cecilie Knudsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800 Kongens Lyngby, Denmark; (C.K.); (C.R.); (A.H.L.)
- Bioporto Diagnostics A/S, DK-2900 Hellerup, Denmark
| | - Isadora S. Oliveira
- Department of BioMolecular Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo 14049-900, Brazil; (I.S.O.); (F.A.C.)
| | - Charlotte Rimbault
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800 Kongens Lyngby, Denmark; (C.K.); (C.R.); (A.H.L.)
| | - Felipe A. Cerni
- Department of BioMolecular Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo 14049-900, Brazil; (I.S.O.); (F.A.C.)
| | - Fan Hui Wen
- Butantan Institute, São Paulo 05503-900, Brazil;
| | - Jacqueline Sachett
- Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus 69065-001, Amazonas, Brazil;
- Department of Teaching and Research, Alfredo da Matta Foundation, Manaus 69065-130, Amazonas, Brazil
| | - Marco A. Sartim
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus 69040-000, Amazonas, Brazil;
- Institute of Biological Sciences, Amazonas Federal University, Manaus 69067-005, Amazonas, Brazil
| | - Andreas H. Laustsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800 Kongens Lyngby, Denmark; (C.K.); (C.R.); (A.H.L.)
| | - Wuelton M. Monteiro
- Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus 69065-001, Amazonas, Brazil;
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus 69040-000, Amazonas, Brazil;
- Correspondence: ; Tel.: +55-92-99165-2486
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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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Samprathi M, Gupta V, Jayashree M, Bansal A, Baranwal A, Nallasamy K. Epidemiology and Outcomes of Early Morning Neuroparalytic Syndrome Following Snake Bite-A Retrospective Study. J Trop Pediatr 2020; 66:435-440. [PMID: 32068871 DOI: 10.1093/tropej/fmz084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Snake envenomation has been poorly studied in developing countries. 'Early morning neuroparalytic syndrome' (EMNS), the classical clinical constellation caused by krait bites, refers to nighttime, indoor bites where nonspecific symptoms progress to neuroparalysis. Literature regarding EMNS in children is scarce. This study was planned to describe the clinical profile, intensive care needs and predictors of outcome in children with EMNS. METHODS It is a retrospective study of children below 12 years admitted with a clinical diagnosis of snake envenomation to the pediatric intensive care unit (PICU) of a tertiary care hospital in North India. Patient records were reviewed from the electronic patient database manager. Comparison was made between the EMNS group and the non-EMNS group and between survivors and nonsurvivors within the EMNS group. RESULTS Of the 111 children with snake envenomation, 76 had neuroparalysis (68%) and 51 had EMNS. In the EMNS cohort, 37 (72.5%) belonged to rural areas, 46 (90.2%) had indoor bites and 39 (76.5%) were witnessed. Patients with EMNS were more likely to have absent fang marks, hypoxemia at admission, bulbar palsy and need for PICU admission. Mortality rate was 13.7% in EMNS; predictors included younger age, presence of ptosis, cardiac arrest at admission and nonavailability of PICU bed (univariable analysis) but none of them independently predicted mortality. CONCLUSION Younger age, presence of ptosis, cardiac arrest at admission and nonavailability of intensive care beds increase the risk of mortality in children with EMNS. Timely recognition and respiratory support may reduce mortality in these children.
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Affiliation(s)
- Madhusudan Samprathi
- Pediatric Emergency and Intensive Care Units, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Vipul Gupta
- Department of Pediatrics, Government Medical College Hospital, Sector 32, Chandigarh, India
| | - Muralidharan Jayashree
- Pediatric Emergency and Intensive Care Units, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Arun Bansal
- Pediatric Emergency and Intensive Care Units, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Arun Baranwal
- Pediatric Emergency and Intensive Care Units, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Karthi Nallasamy
- Pediatric Emergency and Intensive Care Units, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Kularatne SAM, Colombage A, de Silva A, Weerasinghe V, Rathnayaka RMMKN. Acute neuromuscular paralysis, rhabdomyolysis and long lasting neurological deficits in Ceylon krait ( Bungarus ceylonicus) bites: Two authentic cases from a serpentarium in Sri Lanka. Toxicon X 2019; 4:100015. [PMID: 32550572 PMCID: PMC7286062 DOI: 10.1016/j.toxcx.2019.100015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/26/2019] [Accepted: 09/12/2019] [Indexed: 11/30/2022] Open
Abstract
The Ceylon krait (Bungarus ceylonicus) is a highly venomous elapid snake endemic to Sri Lanka. Its bites are rare and only seven reports are found in the literature. Therefore, the clinical manifestations and natural history of envenoming of Ceylon krait are not well studied yet. Neuroparalysis is the main clinical manifestation of their bites. We report two cases of proven Ceylon krait bites of two young snake keepers working in a serpentarium. They developed acute neuroparalysis, abdominal pain and a period of amnesia. The first patient developed myalgia and increased level of serum creatine kinase suggestive of rhabdomyolysis. One was treated with Indian polyvalent antivenom and both recovered with some long-lasting clinical disabilities namely impairment of sensation of the bitten arm and persistent refraction errors in the eyes in the first patient. The second patient had persistent marked nystagmus. Ceylon krait (Bungarus ceylonicus) is endemic to Sri Lanka and bites rarely. Two authentic bites are described. Both developed neuromuscular paralysis manageable without assisted ventilation. Long lasting deficits were sensory impairment of bitten arm, refraction errors and nystagmus.
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Affiliation(s)
- S A M Kularatne
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka
| | | | | | - Vajira Weerasinghe
- Teaching Hospital Peradeniya, Sri Lanka.,Department of Physiology, Faculty of Medicine, University of Peradeniya, Sri Lanka
| | - R M M K Namal Rathnayaka
- Intensive Care Unit, Teaching Hospital, Ratnapura, Sri Lanka.,Department of Veterinary Pathobiology, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Sri Lanka.,Postgraduate Institute of Medicine (Clinical Pharmacology and Therapeutics), University of Colombo, Sri Lanka
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Abstract
Long-term effects of envenoming compromise the quality of life of the survivors of snakebite. We searched MEDLINE (from 1946) and EMBASE (from 1947) until October 2018 for clinical literature on the long-term effects of snake envenoming using different combinations of search terms. We classified conditions that last or appear more than six weeks following envenoming as long term or delayed effects of envenoming. Of 257 records identified, 51 articles describe the long-term effects of snake envenoming and were reviewed. Disability due to amputations, deformities, contracture formation, and chronic ulceration, rarely with malignant change, have resulted from local necrosis due to bites mainly from African and Asian cobras, and Central and South American Pit-vipers. Progression of acute kidney injury into chronic renal failure in Russell's viper bites has been reported in several studies from India and Sri Lanka. Neuromuscular toxicity does not appear to result in long-term effects. Endocrine anomalies such as delayed manifestation of hypopituitarism following Russell's viper bites have been reported. Delayed psychological effects such as depressive symptoms, post-traumatic stress disorder and somatisation have been reported. Blindness due to primary and secondary effects of venom is a serious, debilitating effect. In general, the available studies have linked a clinical effect to a snakebite in retrospect, hence lacked accurate snake authentication, details of acute management and baseline data and are unable to provide a detailed picture of clinical epidemiology of the long-term effects of envenoming. In the future, it will be important to follow cohorts of snakebite patients for a longer period of time to understand the true prevalence, severity, clinical progression and risk factors of long-term effects of snake envenoming.
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Silva A, Sedgwick EM, Weerawansa P, Pilapitiya S, Weerasinghe V, Buckley N, Siribaddana S, Isbister GK. Sub-clinical neuromuscular dysfunction after envenoming by Merrem’s hump-nosed pit viper (Hypnale hypnale). TOXICOLOGY COMMUNICATIONS 2019. [DOI: 10.1080/24734306.2018.1560991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Anjana Silva
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
- Monash Venom Group, Department of Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - E. Michael Sedgwick
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Physiology, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Prasanna Weerawansa
- Department of Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Senaka Pilapitiya
- Department of Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Vajira Weerasinghe
- Department of Physiology, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Nicholas Buckley
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Pharmacology, University of Sydney, Sydney, New South Wales, Australia
| | - Sisira Siribaddana
- Department of Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - 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, New South Wales, Australia
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34
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Oh AMF, Tan CH, Tan KY, Quraishi NH, Tan NH. Venom proteome of Bungarus sindanus (Sind krait) from Pakistan and in vivo cross-neutralization of toxicity using an Indian polyvalent antivenom. J Proteomics 2019; 193:243-254. [DOI: 10.1016/j.jprot.2018.10.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 10/11/2018] [Accepted: 10/27/2018] [Indexed: 12/13/2022]
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Silva A, Cristofori-Armstrong B, Rash LD, Hodgson WC, Isbister GK. Defining the role of post-synaptic α-neurotoxins in paralysis due to snake envenoming in humans. Cell Mol Life Sci 2018; 75:4465-4478. [PMID: 30069700 PMCID: PMC11105319 DOI: 10.1007/s00018-018-2893-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/21/2018] [Accepted: 07/26/2018] [Indexed: 01/06/2023]
Abstract
Snake venom α-neurotoxins potently inhibit rodent nicotinic acetylcholine receptors (nAChRs), but their activity on human receptors and their role in human paralysis from snakebite remain unclear. We demonstrate that two short-chain α-neurotoxins (SαNTx) functionally inhibit human muscle-type nAChR, but are markedly more reversible than against rat receptors. In contrast, two long-chain α-neurotoxins (LαNTx) show no species differences in potency or reversibility. Mutant studies identified two key residues accounting for this. Proteomic and clinical data suggest that paralysis in human snakebites is not associated with SαNTx, but with LαNTx, such as in cobras. Neuromuscular blockade produced by both subclasses of α-neurotoxins was reversed by antivenom in rat nerve-muscle preparations, supporting its effectiveness in human post-synaptic paralysis.
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Affiliation(s)
- Anjana Silva
- Monash Venom Group, Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, 50008, Sri Lanka
| | - Ben Cristofori-Armstrong
- School of Biomedical Sciences, University of Queensland, St. Lucia, QLD, 4072, Australia
- Institute of Molecular Bioscience, University of Queensland, St. Lucia, QLD, 4072, Australia
| | - Lachlan D Rash
- School of Biomedical Sciences, University of Queensland, St. Lucia, QLD, 4072, Australia.
- Institute of Molecular Bioscience, University of Queensland, St. Lucia, QLD, 4072, Australia.
| | - Wayne C Hodgson
- Monash Venom Group, Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia.
| | - Geoffrey K Isbister
- Monash Venom Group, Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia.
- Clinical Toxicology Research Group, University of Newcastle, Callaghan, NSW, 2308, Australia.
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36
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Rajendran BK, Xavier Suresh M, Bhaskaran SP, Harshitha Y, Gaur U, Kwok HF. Pharmacoinformatic Approach to Explore the Antidote Potential of Phytochemicals on Bungarotoxin from Indian Krait, Bungarus caeruleus. Comput Struct Biotechnol J 2018; 16:450-461. [PMID: 30455855 PMCID: PMC6231056 DOI: 10.1016/j.csbj.2018.10.005] [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: 08/12/2018] [Revised: 10/08/2018] [Accepted: 10/12/2018] [Indexed: 12/25/2022] Open
Abstract
Venomous reptiles especially serpents are well known for their adverse effects after accidental conflicts with humans. Upon biting humans these serpents transmit arrays of detrimental toxins with diverse physiological activities that may either lead to minor symptoms such as dermatitis and allergic response or highly severe symptoms such as blood coagulation, disseminated intravascular coagulation, tissue injury, and hemorrhage. Other complications like respiratory arrest and necrosis may also occur. Bungarotoxins are a group of closely related neurotoxic proteins derived from the venom of kraits (Bungarus caeruleus) one of the six most poisonous snakes in India whose bite causes respiratory paralysis and mortality without showing any local symptoms. In the current study, by employing various pharmacoinformatic approaches, we have explored the antidote properties of 849 bioactive phytochemicals from 82 medicinal plants which have already shown antidote properties against various venomous toxins. These herbal compounds were taken and pharmacoinformatic approaches such as ADMET, docking and molecular dynamics were employed. The three-dimensional modelling approach provides structural insights on the interaction between bungarotoxin and phytochemicals. In silico simulations proved to be an effective analytical tools to investigate the toxin-ligand interaction, correlating with the affinity of binding. By analyzing the results from the present study, we proposed nine bioactive phytochemical compounds which are, 2-dodecanol, 7-hydroxycadalene, indole-3-(4'-oxo)butyric acid, nerolidol-2, trans-nerolidol, eugenol, benzene propanoic acid, 2-methyl-1-undecanol, germacren-4-ol can be used as antidotes for bungarotoxin.
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Affiliation(s)
- Barani Kumar Rajendran
- Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida de Universidade, Taipa, Macau
| | - M. Xavier Suresh
- Department of Physics, Sathyabama Institute of Science and Technology, Deemed to be University, Chennai 600119, India
| | - Shanmuga Priya Bhaskaran
- Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida de Universidade, Taipa, Macau
| | - Yarradoddi Harshitha
- Department of Physics, Sathyabama Institute of Science and Technology, Deemed to be University, Chennai 600119, India
| | - Uma Gaur
- Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida de Universidade, Taipa, Macau
| | - Hang Fai Kwok
- Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida de Universidade, Taipa, Macau
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37
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Engineered nanoparticles bind elapid snake venom toxins and inhibit venom-induced dermonecrosis. PLoS Negl Trop Dis 2018; 12:e0006736. [PMID: 30286075 PMCID: PMC6171825 DOI: 10.1371/journal.pntd.0006736] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/07/2018] [Indexed: 11/19/2022] Open
Abstract
Envenomings by snakebites constitute a serious and challenging global health issue. The mainstay in the therapy of snakebite envenomings is the parenteral administration of animal-derived antivenoms. Significantly, antivenoms are only partially effective in the control of local tissue damage. A novel approach to mitigate the progression of local tissue damage that could complement the antivenom therapy of envenomings is proposed. We describe an abiotic hydrogel nanoparticle engineered to bind to and modulate the activity of a diverse array of PLA2 and 3FTX isoforms found in Elapidae snake venoms. These two families of protein toxins share features that are associated with their common (membrane) targets, allowing for nanoparticle sequestration by a mechanism that differs from immunological (epitope) selection. The nanoparticles are non-toxic in mice and inhibit dose-dependently the dermonecrotic activity of Naja nigricollis venom.
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38
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Tan KY, Liew JL, Tan NH, Quah ESH, Ismail AK, Tan CH. Unlocking the secrets of banded coral snake (Calliophis intestinalis, Malaysia): A venom with proteome novelty, low toxicity and distinct antigenicity. J Proteomics 2018; 192:246-257. [PMID: 30243938 DOI: 10.1016/j.jprot.2018.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/27/2018] [Accepted: 09/17/2018] [Indexed: 11/15/2022]
Abstract
The Asiatic coral snakes are basal in the phylogeny of coral snakes. Although envenoming by the Asiatic coral snakes is rarely fatal, little is known about their venom properties and variability from the American coral snakes. Integrating reverse-phase high performance liquid chromatography and nano-liquid chromatography-tandem mass spectrometry, we showed that the venom proteome of the Malaysian banded or striped coral snake (Calliophis intestinalis) was composed of mainly phospholipases A2 (PLA2, 43.4%) and three-finger toxins (3FTx, 20.1%). Within 3FTx, the cytotoxins or cardiotoxins (CTX) dominated while the neurotoxins' content was much lower. Its subproteomic details contrasted with the 3FTx profile of most Micrurus sp., illustrating a unique dichotomy of venom phenotype between the Old and the New World coral snakes. Calliophis intestinalis venom proteome was correlated with measured enzymatic activities, and in vivo it was myotoxic but non-lethal to mice, frogs and geckos at high doses (5-10 μg/g). The venom contains species-specific toxins with distinct sequences and antigenicity, and the antibodies raised against PLA2 and CTX of other elapids showed poor binding toward its venom antigens. The unique venom proteome of C. intestinalis unveiled a repertoire of novel toxins, and the toxicity test supported the need for post-bite monitoring of myotoxic complication. SIGNIFICANCE: Malaysian banded or striped coral snake (Calliophis intestinalis) has a cytotoxin (CTX)-predominating venom proteome, a characteristic shared by its congener, the Malayan blue coral snake (Calliophis bivirgata). With little neurotoxins (NTX), it illustrates a CTX/NTX dichotomy of venom phenotype between the Old World and the New World coral snakes. The low toxicity of the venom imply that C. intestinalis bite envenoming can be managed via symptomatic relief of the mild to moderate pain with appropriate analgesia. Systemically, the serum creatine kinase level of patients should be monitored serially for potential complication of myotoxicity. The distinct antigenicity of the venom proteins implies that the empirical use of heterologous antivenom is mostly inappropriate and not recommended.
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Affiliation(s)
- Kae Yi Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Jia Lee Liew
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Nget Hong Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Evan S H Quah
- School of Biological Sciences, Universiti Sains Malaysia, Penang 11800, Malaysia
| | - Ahmad Khaldun Ismail
- Department of Emergency Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Malaysia
| | - Choo Hock Tan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
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39
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Isbister GK, Silva A. Addressing the global challenge of snake envenoming. Lancet 2018; 392:619-620. [PMID: 30017549 DOI: 10.1016/s0140-6736(18)31328-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/06/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Waratah, NSW 2298, Australia.
| | - Anjana Silva
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
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40
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Pharmacokinetics of Snake Venom. Toxins (Basel) 2018; 10:toxins10020073. [PMID: 29414889 PMCID: PMC5848174 DOI: 10.3390/toxins10020073] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/01/2022] Open
Abstract
Understanding snake venom pharmacokinetics is essential for developing risk assessment strategies and determining the optimal dose and timing of antivenom required to bind all venom in snakebite patients. This review aims to explore the current knowledge of snake venom pharmacokinetics in animals and humans. Literature searches were conducted using EMBASE (1974–present) and Medline (1946–present). For animals, 12 out of 520 initially identified studies met the inclusion criteria. In general, the disposition of snake venom was described by a two-compartment model consisting of a rapid distribution phase and a slow elimination phase, with half-lives of 5 to 48 min and 0.8 to 28 h, respectively, following rapid intravenous injection of the venoms or toxins. When the venoms or toxins were administered intramuscularly or subcutaneously, an initial absorption phase and slow elimination phase were observed. The bioavailability of venoms or toxins ranged from 4 to 81.5% following intramuscular administration and 60% following subcutaneous administration. The volume of distribution and the clearance varied between snake species. For humans, 24 out of 666 initially identified publications contained sufficient information and timed venom concentrations in the absence of antivenom therapy for data extraction. The data were extracted and modelled in NONMEM. A one-compartment model provided the best fit, with an elimination half-life of 9.71 ± 1.29 h. It is intended that the quantitative information provided in this review will provide a useful basis for future studies that address the pharmacokinetics of snakebite in humans.
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41
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Dalugama C, Gawarammana IB. Confirmed Ceylon krait (Bungarus ceylonicus) envenoming in Sri Lanka resulting in neuromuscular paralysis: a case report. J Med Case Rep 2017; 11:330. [PMID: 29169382 PMCID: PMC5701456 DOI: 10.1186/s13256-017-1503-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 10/25/2017] [Indexed: 11/23/2022] Open
Abstract
Background Ceylon krait (Bungarus ceylonicus) is a venomous elapid snake endemic to Sri Lanka. It inhabits shaded home gardens and forests in the wet zone of Sri Lanka and might creep into houses in the night. Despite frequent encounters with humans, reports of envenoming are very rare. Case presentation We report a case of a 26-year-old Sri Lankan Sinhalese man with confirmed Ceylon krait envenoming presenting with bilateral partial ptosis, ophthalmoplegia, facial muscle weakness, and dysphagia. Single fiber electromyography and repetitive nerve stimulation confirmed neuromuscular paralysis. He was administered polyvalent anti-venom serum immediately following admission without a prompt clinical response. Complete recovery was observed 3 days following the bite. Conclusions Because of the rarity of envenoming, precise and detailed information on the clinical manifestations following envenoming is lacking. However, Ceylon krait bite can be potentially fatal; so, treating physicians should be aware of species identification, habitat, and biting habits and clinical presentation of envenoming of Ceylon krait. This case report adds knowledge to the existing limited literature available on Ceylon krait envenoming; a rare but potentially fatal clinical entity.
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Affiliation(s)
- Chamara Dalugama
- Department of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
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42
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Mao YC, Liu PY, Chiang LC, Liao SC, Su HY, Hsieh SY, Yang CC. Bungarus multicinctus multicinctus Snakebite in Taiwan. Am J Trop Med Hyg 2017; 96:1497-1504. [PMID: 28719273 DOI: 10.4269/ajtmh.17-0005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractAlthough specific antivenom is available in Taiwan, respiratory failure and general pain frequently accompany Bungarus multicinctus envenomation and there have been few reports on the management of B. multicinctus envenomation. We retrospectively analyzed 44 cases of B. multicinctus bite admitted to Taichung Veterans General Hospital (VGH) or to Taipei VGH. Demographic data, treatment, and outcome of patients with and without respiratory failure were compared. In this study, 20.5% patients had bites without noticeable signs or symptoms of significant envenoming, 27.3% developed respiratory failure, and 27.3% experienced general pain. Bivalent specific antivenom for B. multicinctus and N. atra was administered in all envenomed cases. Respiratory failure occurred 1.5-6.5 hours post-bite and general pain occurred 1-12 hours post-bite. Specific antivenom for B. multicinctus and N. atra at the recommended dose (i.e., 2-4 vials) might not effectively prevent respiratory failure and pain. Respiratory failure, general pain, and autonomic effects after B. multicinctus bite were probably caused, at least partly, by β-bungarotoxin. Although general weakness, ptosis, dysarthria, and dilated pupils were significantly associated with respiratory failure, their predictive value could not be accurately determined in such a retrospective study. Due to the rapid onset of respiratory failure, every suspected envenomed case thus should be closely monitored in the first few hours. We recommend the initial administration of four vials of antivenom in all envenomation cases, and a subsequent four vials be considered if the patient's condition is deteriorating. Prospective evaluation of the antivenom dosing regimen is urgently needed to improve B. multicinctus envenomation treatment.
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Affiliation(s)
- Yan-Chiao Mao
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Po-Yu Liu
- Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Liao-Chun Chiang
- National Health Research Institutes, National Institute of Infectious Diseases and Vaccinology, Miaoli, Taiwan.,National Tsing Hua University, College of Life Sciences, Hsinchu, Taiwan
| | - Shu-Chen Liao
- Department of Emergency Medicine, Chang Guang Memorial Hospital, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Yuan Su
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Szu-Yin Hsieh
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chen-Chang Yang
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Mao YC, Liu PY, Chiang LC, Lai CS, Lai KL, Ho CH, Wang TH, Yang CC. Naja atra snakebite in Taiwan. Clin Toxicol (Phila) 2017; 56:273-280. [PMID: 28830248 DOI: 10.1080/15563650.2017.1366502] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Naja atra snakebite is uncommon in Taiwan and causes distinct effects on its victims. Although the Taiwan government produces its own specific antivenom, little information on the management of N. atra snakebite is available. MATERIALS AND METHODS We retrospectively evaluated 183 patients admitted to two medical centers. Of these, 45 were identified as definite cases of N. atra snakebite, 86 as suspected cases, and 52 as clinical cases. Demographic data, symptomatology, and management were compared between these case groups. RESULTS Symptomatology and management were similar in the three groups. Among the 183 patients, 10 (5.5%) were asymptomatic and nine (4.9%) had transient and partial ptosis or body weakness. The principal effects were local tissue swelling and pain in 173 patients (94.5%), followed by clinically suspected wound infection in 148 (80.9%), skin necrosis in 120 (65.6%), necrotizing soft tissue infection in 77 (42.1%), fever in 59 (32.2%), and gastrointestinal effects in 53 (29%). The median total dose of specific antivenom needed to treat N. atra envenoming was 10 vials. In the envenomed patients, debridement was required in 74 patients (42.8%), fasciotomy/fasciectomy in 46 (26.6%), and finger or toe amputation in seven (4%). The first operation was performed at a median of 3.5 days after the bite. DISCUSSION AND CONCLUSIONS Based on these typical manifestations, clinical diagnosis of N. atra snakebites may be feasible and practical. In contrast to other snakes of Elapidae family, N. atra bite did not cause serious neurological effects. Early surgical consultation should be obtained because half of the patients underwent surgery due to infectious complications. Acute compartment syndrome was the surgical indication in rare cases; however, overestimation of the incidence may have occurred. This syndrome should be confirmed by serial intracompartmental pressure monitoring instead of only physical examination, and a sufficient dose of antivenom should be given prior to surgical decompression.
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Affiliation(s)
- Yan-Chiao Mao
- a Division of Clinical Toxicology, Department of Emergency Medicine , Taichung Veterans General Hospital , Taichung , Taiwan.,b Division of Clinical Toxicology and Occupational Medicine, Department of Medicine , Taipei Veterans General Hospital , Taipei , Taiwan.,c Institute of Environmental and Occupational Health Sciences , School of Medicine, National Yang-Ming University , Taipei , Taiwan.,d School of Medicine , National Defense Medical Center , Taipei , Taiwan
| | - Po-Yu Liu
- e Division of Infection, Department of Medicine , Taichung Veterans General Hospital , Taichung , Taiwan.,f Rong Hsing Research Center for Translational Medicine , National Chung Hsing University , Taichung , Taiwan
| | - Liao-Chun Chiang
- g College of Life Sciences , National Tsing Hua University , Hsinchu , Taiwan
| | - Chih-Sheng Lai
- h Division of Plastic and Reconstructive Surgery, Department of Surgery , Taichung Veterans General Hospital , Taichung , Taiwan
| | - Kuo-Lung Lai
- i Division of Allergy, Immunology and Rheumatology, Department of Medicine , Taichung Veterans General Hospital , Taichung , Taiwan
| | - Cheng-Hsuan Ho
- d School of Medicine , National Defense Medical Center , Taipei , Taiwan.,j Department of Emergency Medicine , Tri-Service General Hospital , Taipei , Taiwan
| | - Te-Huo Wang
- b Division of Clinical Toxicology and Occupational Medicine, Department of Medicine , Taipei Veterans General Hospital , Taipei , Taiwan.,k Department of Emergency Medicine , National Yang-Ming University Hospital , Yilan , Taiwan
| | - Chen-Chang Yang
- b Division of Clinical Toxicology and Occupational Medicine, Department of Medicine , Taipei Veterans General Hospital , Taipei , Taiwan.,c Institute of Environmental and Occupational Health Sciences , School of Medicine, National Yang-Ming University , Taipei , Taiwan
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Venomics of Bungarus caeruleus (Indian krait): Comparable venom profiles, variable immunoreactivities among specimens from Sri Lanka, India and Pakistan. J Proteomics 2017; 164:1-18. [DOI: 10.1016/j.jprot.2017.04.018] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 03/27/2017] [Accepted: 04/11/2017] [Indexed: 11/17/2022]
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Antivenom for Neuromuscular Paralysis Resulting From Snake Envenoming. Toxins (Basel) 2017; 9:toxins9040143. [PMID: 28422078 PMCID: PMC5408217 DOI: 10.3390/toxins9040143] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/11/2017] [Accepted: 04/13/2017] [Indexed: 02/06/2023] Open
Abstract
Antivenom therapy is currently the standard practice for treating neuromuscular dysfunction in snake envenoming. We reviewed the clinical and experimental evidence-base for the efficacy and effectiveness of antivenom in snakebite neurotoxicity. The main site of snake neurotoxins is the neuromuscular junction, and the majority are either: (1) pre-synaptic neurotoxins irreversibly damaging the presynaptic terminal; or (2) post-synaptic neurotoxins that bind to the nicotinic acetylcholine receptor. Pre-clinical tests of antivenom efficacy for neurotoxicity include rodent lethality tests, which are problematic, and in vitro pharmacological tests such as nerve-muscle preparation studies, that appear to provide more clinically meaningful information. We searched MEDLINE (from 1946) and EMBASE (from 1947) until March 2017 for clinical studies. The search yielded no randomised placebo-controlled trials of antivenom for neuromuscular dysfunction. There were several randomised and non-randomised comparative trials that compared two or more doses of the same or different antivenom, and numerous cohort studies and case reports. The majority of studies available had deficiencies including poor case definition, poor study design, small sample size or no objective measures of paralysis. A number of studies demonstrated the efficacy of antivenom in human envenoming by clearing circulating venom. Studies of snakes with primarily pre-synaptic neurotoxins, such as kraits (Bungarus spp.) and taipans (Oxyuranus spp.) suggest that antivenom does not reverse established neurotoxicity, but early administration may be associated with decreased severity or prevent neurotoxicity. Small studies of snakes with mainly post-synaptic neurotoxins, including some cobra species (Naja spp.), provide preliminary evidence that neurotoxicity may be reversed with antivenom, but placebo controlled studies with objective outcome measures are required to confirm this.
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A Pharmacological Examination of the Cardiovascular Effects of Malayan Krait (Bungarus candidus) Venoms. Toxins (Basel) 2017; 9:toxins9040122. [PMID: 28353659 PMCID: PMC5408196 DOI: 10.3390/toxins9040122] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 03/23/2017] [Accepted: 03/24/2017] [Indexed: 11/17/2022] Open
Abstract
Cardiovascular effects (e.g., tachycardia, hypo- and/or hypertension) are often clinical outcomes of snake envenoming. Malayan krait (Bungarus candidus) envenoming has been reported to cause cardiovascular effects that may be related to abnormalities in parasympathetic activity. However, the exact mechanism for this effect has yet to be determined. In the present study, we investigated the in vivo and in vitro cardiovascular effects of B. candidus venoms from Southern (BC-S) and Northeastern (BC-NE) Thailand. SDS-PAGE analysis of venoms showed some differences in the protein profile of the venoms. B. candidus venoms (50 µg/kg-100 µg/kg, i.v.) caused dose-dependent hypotension in anaesthetised rats. The highest dose caused sudden hypotension (phase I) followed by a return of mean arterial pressure to baseline levels and a decrease in heart rate with transient hypertension (phase II) prior to a small decrease in blood pressure (phase III). Prior administration of monovalent antivenom significantly attenuated the hypotension induced by venoms (100 µg/kg, i.v.). The sudden hypotensive effect of BC-NE venom was abolished by prior administration of hexamethonium (10 mg/kg, i.v.) or atropine (5 mg/kg, i.v.). BC-S and BC-NE venoms (0.1 µg/kg-100 µg/ml) induced concentration-dependent relaxation (EC50 = 8 ± 1 and 13 ± 3 µg/mL, respectively) in endothelium-intact aorta. The concentration-response curves were markedly shifted to the right by pre-incubation with L-NAME (0.2 mM), or removal of the endothelium, suggesting that endothelium-derived nitric oxide (NO) is likely to be responsible for venom-induced aortic relaxation. Our data indicate that the cardiovascular effects caused by B. candidus venoms may be due to a combination of vascular mediators (i.e., NO) and autonomic adaptation via nicotinic and muscarinic acetylcholine receptors.
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Rodrigo C, Kirushanthan S, Gnanathasan A. Prevention of krait bites by sleeping above ground: preliminary results from an observational pilot study. J Occup Med Toxicol 2017; 12:10. [PMID: 28352289 PMCID: PMC5368888 DOI: 10.1186/s12995-017-0156-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/23/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction Neurotoxic envenoming following the bites of kraits (Bungarus spp.) is a common cause of death in the dry zone of Sri Lanka and elsewhere in South Asia. Most of these bites occur at night and are inflicted on people sleeping on the ground. Thus we hypothesized that the simple measure of sleeping above ground would help to reduce the number of observed krait bites. Methods This study was conducted in two villages of the Kilinochchi district of Sri Lanka which had reported a high number of krait bites in the two years preceding the study. Most of the residents in these two villages slept on the ground. Residents in one area were given beds free of charge, using funds available from the study. Both villages received health education on the prevention of krait bites. Results Forty five beds were distributed to 45 families in one village. This enabled 115 individuals to sleep above ground level. 6 monthly follow up visits were conducted ensuring the proper utilization of beds. Follow up was continued for 30 months (September 2013–March 2016); during this time period no krait bites were reported in either area. Conclusions We observed a dramatic decline of krait bites in both villages. Better awareness with effective health education and clearing of vegetation could have led to the decline in the number of krait bites in both villages.
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Affiliation(s)
- Chaturaka Rodrigo
- Department of Clinical Medicine, 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
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Silva A, Maduwage K, Buckley NA, Lalloo DG, de Silva HJ, Isbister GK. Antivenom for snake venom-induced neuromuscular paralysis. Hippokratia 2017. [DOI: 10.1002/14651858.cd012604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Anjana Silva
- Monash University; Department of Pharmacology; Victoria Australia
| | - Kalana Maduwage
- Faculty of Medicine, University of Peradeniya; Department of Biochemistry; Peradeniya Sri Lanka 24000
| | - Nick A Buckley
- University of Sydney; Department of Pharmacology; Blackburn Building D06 Sydney Medical School Camperdown NSW Australia 2006
| | - David G Lalloo
- Liverpool School of Tropical Medicine; Clinical Research Group; Pembroke Place Liverpool Merseyside UK L3 5QA
| | - H Janaka de Silva
- University of Kelaniya; Department of Medicine; PO Box 6 Ragama Sri Lanka
| | - Geoffrey K Isbister
- University of Newcastle; School of Medicine and Public Health; Edith St Waratah New South Wales Australia 2298
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Two rare case reports of confirmed Ceylon krait (Bungarus ceylonicus) envenoming in Sri Lanka. Toxicon 2017; 127:44-48. [DOI: 10.1016/j.toxicon.2017.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/29/2016] [Accepted: 01/03/2017] [Indexed: 11/18/2022]
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50
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Johnston CI, Ryan NM, O'Leary MA, Brown SGA, Isbister GK. Australian taipan (Oxyuranus spp.) envenoming: clinical effects and potential benefits of early antivenom therapy - Australian Snakebite Project (ASP-25). Clin Toxicol (Phila) 2016; 55:115-122. [PMID: 27903075 DOI: 10.1080/15563650.2016.1250903] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONTEXT Taipans (Oxyuranus spp.) are medically important venomous snakes from Australia and Papua New Guinea. The objective of this study was to describe taipan envenoming in Australian and its response to antivenom. METHODS Confirmed taipan bites were recruited from the Australian Snakebite Project. Data were collected prospectively on all snakebites, including patient demographics, bite circumstances, clinical effects, laboratory results, complications and treatment. Blood samples were taken and analysed by venom specific immunoassay to confirm snake species and measure venom concentration pre- and post-antivenom. RESULTS There were 40 confirmed taipan bites: median age 41 years (2-85 years), 34 were males and 21 were snake handlers. Systemic envenoming occurred in 33 patients with neurotoxicity (26), complete venom induced consumption coagulopathy (VICC) (16), partial VICC (15), acute kidney injury (13), myotoxicity (11) and thrombocytopenia (7). Venom allergy occurred in seven patients, three of which had no evidence of envenoming and one died. Antivenom was given to 34 patients with a median initial dose of one vial (range 1-4), and a median total dose of two vials (range 1-9). A greater total antivenom dose was associated with VICC, neurotoxicity and acute kidney injury. Early antivenom administration was associated with a decreased frequency of neurotoxicity, acute kidney injury, myotoxicity and intubation. There was a shorter median time to discharge of 51 h (19-432 h) in patients given antivenom <4 h post-bite, compared to 175 h (27-1104 h) in those given antivenom >4 h. Median peak venom concentration in 25 patients with systemic envenoming and a sample available was 8.4 ng/L (1-3212 ng/L). No venom was detected in post-antivenom samples, including 20 patients given one vial initially and five patients bitten by inland taipans. DISCUSSION Australian taipan envenoming is characterised by neurotoxicity, myotoxicity, coagulopathy, acute kidney injury and thrombocytopenia. One vial of antivenom binds all measurable venom and early antivenom was associated with a favourable outcome.
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Affiliation(s)
| | - Nicole M Ryan
- a Clinical Toxicology Research Group, University of Newcastle , Newcastle , Australia
| | - Margaret A O'Leary
- a Clinical Toxicology Research Group, University of Newcastle , Newcastle , Australia
| | - Simon G A Brown
- b Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital and the University of Western Australia , Perth , Australia
| | - Geoffrey K Isbister
- a Clinical Toxicology Research Group, University of Newcastle , Newcastle , Australia.,c Department of Clinical Toxicology and Pharmacology , Calvary Mater Newcastle , Newcastle , Australia
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