Intravenous dose-lethality study of American pit viper venoms in mice using standardized methods

Retrospective comparison of three antivenoms for the treatment of dogs with crotalid envenomation

OBJECTIVE

To retrospectively compare clinical outcomes associated with 3 commercially available antivenom products (2 F[ab']2 products and 1 IgG product) in dogs with crotalid envenomation.

ANIMALS

282 dogs with evidence of crotalid envenomation treated with antivenom at a single high-volume private emergency facility in southwestern Arizona from 2014 to 2018.

PROCEDURES

Data were collected on all dogs regarding signalment, coagulation test results, snakebite characteristics, type and number of units of antivenom received (1 of 3 products), survival to hospital discharge (yes or no), and complications following discharge. Survival rates and other variables were compared among antivenoms by means of bivariable analyses.

RESULTS

271 of 282 (96.1%) dogs survived to discharge; 11 (3.9%) were euthanized or died in the hospital. No significant difference in survival rates was found among the 3 antivenom products. Infusion reaction rates were higher for the IgG product than for each F(ab')2 product. A higher percentage of dogs treated with the IgG product (vs either F[ab']2 product) received only 1 unit of antivenom. Variables associated with a lower probability of survival included older age and lower body weight, thoracic (vs other) location of snakebites, and presence of an antivenom infusion reaction.

CONCLUSIONS AND CLINICAL RELEVANCE

Given that survival rates were high for all 3 antivenom products, clinicians may consider other factors when selecting an antivenom, such as preference for a fractionated versus whole immunoglobulin product, risk of infusion reaction, cost, shelf life, availability, ease of use and administration, species of crotalids used for antivenom production, approval by federal regulatory bodies, and clinical preference.

Comparison of thromboelastography versus conventional coagulation tests in simulated Crotalus atrox envenomation using human blood

INTRODUCTION

Pit viper bites are a source of significant morbidity and mortality. Pit viper bites can cause venom-induced consumptive coagulopathy (VICC), typically evaluated with laboratory-based conventional coagulation tests (CCTs). However, CCTs require a laboratory and average 1 h to conduct. Thromboelastography (TEG) provides real-time, point-of-care tests of coagulation that are fast and require no separate laboratory facilities, which could be advantageous in both hospital and austere settings. However, the relative efficacy of TEG versus CCTs was unclear, particularly at low venom concentrations. Therefore, the objectives of this study were to test human blood with various concentrations of pit viper venom using CCTs and TEG to determine dose-dependent changes, lowest observed effect concentration (LOEC), and sensitivity to detecting samples out of normal diagnostic range.

METHODS

Blood samples from 20 volunteers were mixed with varying concentrations of western diamond back rattlesnake (Crotalus atrox) venom based on the mouse LD50_IV (none, 0.5%, 1%, 2%, 33%, 66%, and 100% LD50_IV). Samples were split and assessed with both CCTs including prothrombin time (PT), international normalized ratio (INR), partial thromboplastin time (PTT), fibrinogen, and D-dimer, along with TEG measures of reaction time (R), kinetic time (K), rate of clot formation (α-angle), and clot strength (MA). Data were analyzed as dose-dependent concentration-based changes in raw values and in percent of samples exceeding diagnostic thresholds using ANOVA and nonparametric statistics at the p < .05 threshold.

RESULTS

All evaluations showed significant concentration-dependent changes, and 100% of samples exceeded diagnostic thresholds at 33%LD50_IV and above, save D-dimer. At 0.5%LD50_IV, R, K, α-angle, PT, and INR were significantly different from controls, and at 1%LD50_IV, mean values exceeded diagnostic thresholds for R, K, α-angle, MA, PT, and INR, but not for PTT, D-dimer, or fibrinogen. At 2%LD50_IV, 100% of samples were out of normal range for K, α-angle, and PT_. CONCLUSION: TEG is effective in coagulopathy evaluations of in vitro simulated pit viper envenomation. At low venom concentrations, TEG performed as well or better than the majority of CCTs. These findings provide empirical evidence supporting the use of TEG to rapidly and accurately evaluate VICC.

Acute physiopathological effects of honeybee (Apis mellifera) envenoming by subcutaneous route in a mouse model

Bee stings are a health concern in the Americas, where fatal envenomings due to massive attacks by Africanized honeybees have been documented in the last decades. Most studies on the toxic effects of honeybee venom in experimental animals have been performed using the intravenous or intraperitoneal injection routes. The aim of this study was to develop a mouse model that would better resemble a massive honeybee attack by using the subcutaneous (s.c.) route to induce a severe, sublethal systemic envenoming. An array of acute venom effects were characterized, including biochemical, hematological, histological, and inflammatory alterations, after the s.c. injection of 0.5 median lethal dose of venom. Rapid increases in serum alanine (ALT) and aspartate (AST) transaminases, creatinine, urea nitrogen, uric acid, sodium and chloride electrolytes, and creatine kinase (CK) were recorded, indicating damage to liver, kidneys, and skeletal muscle. Also, coagulation disturbances (fibrinogen decrease, and moderate delay in prothrombin and partial thromboplastin times) were demonstrated. Circulating platelet and leukocyte numbers remained unaltered, but a hemoconcentration effect (hematocrit and hemoglobin increase) was observed. This effect might be related to the marked edema induced by the venom. In addition, this inflammatory response included a systemic increase in cytokines (IL-1 beta, IL-6, TNF-alpha), together with an elevation of serum malondialdehyde and nitric oxide. The myotoxic effects of venom, melittin, and phospholipase A(2) were demonstrated after injection by s.c. route. No synergistic myotoxicity between melittin and PLA(2) was observed. Moreover, these two components, when injected at equivalent concentrations to those present in venom, induced a lower increase in serum CK than venom, suggesting that other components also contribute to its strong systemic toxicity towards skeletal muscle. The model here presented may be useful in preclinical studies to assess therapeutic antivenoms developed to cope with the problem of massive bee attacks.

Disintegrin, hemorrhagic, and proteolytic activities of Mohave rattlesnake, Crotalus scutulatus scutulatus venoms lacking Mojave toxin

Venom from the Mohave rattlesnake, Crotalus scutulatus scutulatus, has been reported to be either: (1) neurotoxic; (2) hemorrhagic, or both (3) neurotoxic and hemorrhagic. In this study, 14 Mohave rattlesnakes from Arizona and Texas (USA) were analyzed for the presence of disintegrins and Mojave toxin. All venom samples were analyzed for the presence of hemorrhagic, proteolytic and disintegrin activities. The venoms were each chromatographed by reverse phase and their fractions tested for disintegrin activity. All specimens containing Mojave toxin were the most toxic and lacked proteolytic, hemorrhagic and disintegrin activities. In contrast, the venoms containing these activities lacked Mojave toxin. Two disintegrin genes, scutustatin and mojavestatin, were identified by PCR of genomic sequences. Scutustatin is a highly conserved disintegrin, while mojavestatin shows low conservation to other known disintegrins. Venoms with the highest LD50 measurements lacked both disintegrin genes, while the specimens with intermediate and low LD50 contained both genes. The intermediate LD50 group contained Mojave toxin and both disintegrin genes, but lacked hemorrhagic and disintegrin activity. Our results raise the possibility that scutustatin and mojavestatin are not expressed in the intermediate LD50 group, or that they may not be the same disintegrins responsible for the disintegrin activity found in the venom. Therefore, it is possible that Mohave rattlesnakes may produce more than two disintegrins.

Neutralization of venoms from two Southern Pacific Rattlesnakes (Crotalus helleri) with commercial antivenoms and endothermic animal sera

The Southern Pacific Rattlesnake (Crotalus helleri) is found in southwestern California (USA), southward through north Baja California (MX) into the northern part of southern Baja California (MX). In this study, the venoms from two Southern Pacific Rattlesnakes were characterized. The two venoms were different in color, concentration, and enzyme activities. Two commercial antivenoms neutralized both C. helleri venoms differently. Antivipmyn (Fab2H) and CroFab (FabO) neutralized both venoms but had different ED50. Four times more Fab2H antivenom was required to neutralize the C. helleri venom No. 011-084-009 than the venom from the snake No. 010-367-284. The hemorrhagic activity of two C. helleri venoms were neutralized differently by endothermic animal sera having a natural resistance to hemorrhagic activity of snake venoms. Opossums and Mexican ground squirrel sera did not neutralize the hemorrhagic activity of the venom No. 010-367-284. The sera of gray woodrats and hispid cotton rats neutralized all hemorrhagins in both C. helleri venoms. This is the first reported case in which opossum serum has not neutralized hemorrhagic activity of pit viper venom. Differences in the compositions of C. helleri venoms and their ability to be neutralized may help explain why snakebites are a difficult medical problem to treat and why effective polyvalent antivenoms are difficult to produce.

The efficacy of two antivenoms against the venom of North American snakes

Mortality due to snake envenomation is not a major problem in the United States with approximately 8-12 deaths per year, but envenomation is a serious problem that can result in functional disability, loss of extremities, and a costly recovery. Physicians encounter different clinical situations with each new snakebite victim because of the geographical variations in snake venoms. The best and most acceptable form of treatment is the use of antivenom; however, it must be administered as soon as possible since it is not so effective at reducing local signs of envenomation such as necrosis. The antivenom in the United States is in short supply, expensive and may not even be the most effective for neutralizing all North American snake venoms. In this study, we tested two antivenoms. The first was a Crotalidae Polyvalent Fab fragment with Ovine origin (FabO) manufactured in London, and the second was Antivipmyn, a Mexican manufactured antivenom that is F(ab')(2) fragment produced in horse (Fab(2)H). The efficacy of the two antivenoms was tested with 15 different snake venoms found in North America. Three different assays were used to test the efficacy of the antivenoms, the in vivo serum protection test (ED(50)), antihemorrhagic and anticoagulant. The Fab(2)H antivenom was most effective in neutralizing the hemorrhagic activity of 78% of the hemorrhagic venoms used in this study. In the ED(50) assay, the Fab(2)H antivenom was effective in neutralizing all venoms used in this study, while FabO neutralized all but C. m. molossus venom. However, in most cases, FabO required less antivenom than Fab(2)H antivenom to neutralize three LD(50).

Heat and motion stability of polyvalent Crotalidae antivenin, ovine Fab

This study was conducted to test the hypothesis that a Fab-based crotalid antivenin (FabAV) in commercially packaged vials will remain effective under more extreme heat and motion conditions than would be expected in field settings. Vials containing FabAV were subjected to heat or motion. The effect of heat or motion on the ED50 of FabAV was determined using a mouse model of crotalid snake envenomation. The ED50 for the heat stability groups (expressed as a ratio of mg antivenin to mg venom) were as follows: 4 degrees C x 60 days (control) = 26.5, 70 degrees C x 60 days = 66.3, 70 degrees C x 30 days = 52.4, 50 degrees C x 60 days = 25.8, 50 degrees C x 30 days = 34.0. The ED50 for the two motion stability groups were similar: 4 degrees C x 60 days = 40.3 and 70 degrees C x 60 days = 48.3. These results indicate that FabAV is heat stable at 50 degrees C for 60 days, but had less potency when heated to 70 degrees C for 30 days. FabAV appears less potent after agitation, but remains effective in the mouse model. We conclude that FabAV can be safely stored for at least 60 days without refrigeration under most field conditions where snake envenomation may occur.