1
|
Lin CC, Wang CC, Ou Yang CH, Liu CC, Yu JS, Fann WC, Chen YC, Shih CP. The changes and the potential clinical applications of cytokines in Taiwan's major venomous snakebites patients. Toxicon 2024; 247:107843. [PMID: 38964621 DOI: 10.1016/j.toxicon.2024.107843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/13/2024] [Accepted: 06/28/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Taiwan habu (Protobothrops mucrosquamatus), green bamboo viper (Viridovipera stejnegeri), and Taiwan cobra (Naja atra) are the most venomous snakebites in Taiwan. Patients commonly present with limb swelling but misdiagnosis rates are high, and currently available diagnostic tools are limited. This study explores the immune responses in snakebite patients to aid in differential diagnosis. METHODS This prospective observational study investigated the changes in cytokines in snakebite patients and their potential for diagnosis. RESULTS Elevated pro-inflammatory cytokines IL-6 and TNF-α were observed in all snakebite patients compared to the healthy control group. While no significant disparities were observed in humoral immune response cytokines, there were significant differences in IFN-γ levels, with significantly higher IL-10 levels in patients bitten by cobras. Patients with TNF-α levels exceeding 3.02 pg/mL were more likely to have been bitten by a cobra. CONCLUSION This study sheds light on the immune responses triggered by various venomous snakebites, emphasizing the potential of cytokine patterns for snakebite-type differentiation. Larger studies are needed to validate these findings for clinical use, ultimately improving snakebite diagnosis and treatment.
Collapse
Affiliation(s)
- Chih-Chuan Lin
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Cheng Wang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan
| | - Chun-Hsiang Ou Yang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan
| | - Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Tao-Yuan, Taiwan
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Tao-Yuan, Taiwan; Department of Cell and Molecular Biology, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan; Liver Research Center, Chang Gung Memorial Hospital, Linkou, Tao-Yuan, Taiwan; Research Center for Food and Cosmetic Safety, Research Center for Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan
| | - Wen-Chih Fann
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yen-Chia Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Emergency Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Pang Shih
- Department of Healthcare Management, Yuanpei University of Medical Technology, HsinChu, Taiwan.
| |
Collapse
|
2
|
Hsu JY, Chiang SO, Yang CC, Mao YC. A Nationwide Study on the Risks of Complications and Healthcare Costs of Snakebite Envenomation in Taiwan. Am J Trop Med Hyg 2024; 111:205-215. [PMID: 38714189 PMCID: PMC11229656 DOI: 10.4269/ajtmh.24-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/04/2024] [Indexed: 05/09/2024] Open
Abstract
In Taiwan, six medically important venomous snakes, Trimeresurus stejnegeri stejnegeri, Protobothrops mucrosquamatus, Deinagkistrodon acutus, Daboia siamensis, Naja atra, and Bungarus multicinctus, are found. However, comprehensive research on the complications and associated healthcare costs of snakebite envenomation (SBE) is lacking. We retrospectively analyzed pertinent information from the Taiwan National Health Insurance Research Database dated January 2002 to December 2014. We investigated the risk factors for complications and their impact on healthcare costs. Among the 12,542 patients with SBE, those from N. atra or B. multicinctus were more likely to experience wound infections and neurological complications than were those from T. s. stejnegeri or P. mucrosquamatus. In addition, being female, being elderly, and having a Charlson Comorbidity Index equal to or greater than 3 points were associated with an increased likelihood of wound infections and psychological complications. The annual national economic burden averaged US$1,083,624, with an average healthcare cost of US$1,129 per SBE. Snakebite envenomations from N. atra or B. multicinctus, as well as various complications, resulted in significantly higher costs. It is crucial to comprehend the risk factors for complications and their role in increasing expenses to provide insight for tailored healthcare interventions, mitigate complications, and reduce the economic burdens associated with SBEs.
Collapse
Affiliation(s)
- Jen-Yu Hsu
- Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Shu-O Chiang
- ESTAT Statistical Consulting Co., Ltd, Taipei, Taiwan
| | - Chen-Chang Yang
- Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Environmental and Occupational Health Sciences, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yan-Chiao Mao
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| |
Collapse
|
3
|
Chuang PC, Chen JW, Chan YY, Tse TC, Chiang YW, Tsai TS. In vitro immunoreactivity and in vivo neutralization of Trimeresurus gracilis venom with antivenoms targeting four pit viper species. PLoS Negl Trop Dis 2024; 18:e0012070. [PMID: 38527073 PMCID: PMC10994551 DOI: 10.1371/journal.pntd.0012070] [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: 12/22/2023] [Revised: 04/04/2024] [Accepted: 03/14/2024] [Indexed: 03/27/2024] Open
Abstract
Snakebite envenomation is a significant global health issue that requires specific antivenom treatments. In Taiwan, available antivenoms target a variety of snakes, but none specifically target Trimeresurus gracilis, an endemic and protected species found in the high mountain areas of Taiwan. This study evaluated the effectiveness of existing antivenoms against T. gracilis venom, focusing on a bivalent antivenom developed for Trimeresurus stejnegeri and Protobothrops mucrosquamatus (TsPmAV), as well as monovalent antivenoms for Deinagkistrodon acutus (DaAV) and Gloydius brevicaudus (GbAV). Our research involved in vivo toxicity testing in mice and in vitro immunobinding experiments using (chaotropic) enzyme-linked immunosorbent assays, comparing venoms from four pit viper species (T. gracilis, T. stejnegeri, P. mucrosquamatus, and D. acutus) with three types of antivenoms. These findings indicate that TsPmAV partially neutralized T. gracilis venom, marginally surpassing the efficacy of DaAV. In vitro tests revealed that GbAV displayed higher binding capacities toward T. gracilis venom than TsPmAV or DaAV. Comparisons of electrophoretic profiles also reveal that T. gracilis venom has fewer snake venom C-type lectin like proteins than D. acutus, and has more P-I snake venom metalloproteases or fewer phospholipase A2 than G. brevicaudus, T. stejnegeri, or P. mucrosquamatus. This study highlights the need for antivenoms that specifically target T. gracilis, as current treatments using TsPmAV show limited effectiveness in neutralizing local effects in patients. These findings provide crucial insights into clinical treatment protocols and contribute to the understanding of the evolutionary adaptation of snake venom, aiding in the development of more effective antivenoms for human health.
Collapse
Affiliation(s)
- Po-Chun Chuang
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Jia-Wei Chen
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Yuen-Ying Chan
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung, Taiwan
| | - Tsz-Chun Tse
- Institute of Wildlife Conservation, National Pingtung University of Science and Technology, Pingtung, Taiwan
| | - Yu-Wei Chiang
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Biology and Anatomy, National Defense Medical Centre, Taipei, Taiwan
| | - Tein-Shun Tsai
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung, Taiwan
- Institute of Wildlife Conservation, National Pingtung University of Science and Technology, Pingtung, Taiwan
| |
Collapse
|
4
|
Hung YL, Chen YC, Tsai TS, Chang YI, Chuang PC. Incidence and Risk Factors for Wound Infections after Trimeresurus stejnegeri Snakebites in Taiwan. Am J Trop Med Hyg 2024; 110:295-302. [PMID: 38109772 PMCID: PMC10859800 DOI: 10.4269/ajtmh.23-0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/30/2023] [Indexed: 12/20/2023] Open
Abstract
Snakebite envenomation is a neglected tropical disease. Taiwan, with its subtropical and Southeast Asian environment, provides suitable habitat for several venomous snake species. Trimeresurus stejnegeri, an arboreal pit viper, is the most common cause of venomous snakebite in Taiwan. Trimeresurus stejnegeri envenomation can cause local swelling, occasional ecchymosis, and wound infection. The primary treatment of T. stejnegeri envenomation is the binary antivenom, vacuum freeze-dried F(ab')2 fragments of equine antibodies, against T. stejnegeri and Protobothrops mucrosquamatus. This study aimed to analyze the incidence of post-envenomation wound infections caused by T. stejnegeri based on data collected over a decade from institutions affiliated with the Chang Gung Memorial Hospital in Taiwan. A total of 254 patients were enrolled in this study. Clinical and laboratory data, treatment information, and patient outcomes were extracted from electronic medical records. Wound infection was associated with delay in antivenom initiation (adjusted odds ratio: 3.987; 95% CI: 1.406-11.302). The infection rates were 20.5%, 12.5%, 31.3%, and 48.1% for antivenom administration within 2 hours, 2-4 hours, 4-6 hours, and > 6 hours, respectively. Therefore, early initiation of antivenom treatment (within 6 hours) is recommended. Morganella morganii was cultured from wounds of the patients, whereas Enterobacter cloacae and Enterococcus faecalis were cultured from both the oral cavity of snakes and the wounds of the patients. For post-envenomation patients who develop a local infection, empiric antibiotics such as third-generation cephalosporins, quinolones, and piperacillin/tazobactam are recommended because snakebite wound infections are often polymicrobial in nature.
Collapse
Affiliation(s)
- Yu-Lun Hung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yi-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tein-Shun Tsai
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung, Taiwan
| | - Ye-In Chang
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Po-Chun Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| |
Collapse
|
5
|
He D, Hu S, Huang Z, Mo C, Cheng X, Song P, Li Y, Song T, Guan Z, Zhou Y, Zhang X, Liao M. Metabolomics analyses of serum metabolites perturbations associated with Naja atra bite. PLoS Negl Trop Dis 2023; 17:e0011507. [PMID: 37639406 PMCID: PMC10461852 DOI: 10.1371/journal.pntd.0011507] [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: 12/04/2022] [Accepted: 07/06/2023] [Indexed: 08/31/2023] Open
Abstract
Naja atra bite is one of the most common severe snakebites in emergency departments. Unfortunately, the pathophysiological changes caused by Naja atra bite are unclear due to the lack of good animal models. In this study, an animal model of Naja atra bite in Guangxi Bama miniature pigs was established by intramuscular injection at 2 mg/kg of Naja atra venom, and serum metabolites were systematically analyzed using untargeted metabolomic and targeted metabolomic approaches. Untargeted metabolomic analysis revealed that 5045 chromatographic peaks were obtained in ESI+ and 3871 chromatographic peaks were obtained in ESI-. Screening in ESI+ modes and ESI- modes identified 22 and 36 differential metabolites compared to controls. The presence of 8 core metabolites of glutamine, arginine, proline, leucine, phenylalanine, inosine, thymidine and hippuric acid in the process of Naja atra bite was verified by targeted metabolomics significant difference (P<0.05). At the same time, during the verification process of the serum clinical samples with Naja atra bite, we found that the contents of three metabolites of proline, phenylalanine and inosine in the serum of the patients were significantly different from those of the normal human serum (P<0.05). By conducting functional analysis of core and metabolic pathway analysis, we revealed a potential correlation between changes in key metabolites after the Naja atra bite and the resulting pathophysiological alterations, and our research aims to establish a theoretical foundation for the prompt diagnosis and treatment of Naja atra bite.
Collapse
Affiliation(s)
- Dongling He
- Life Science Institute Guangxi Medical University, Nanning, PR China
| | - Shaocong Hu
- Life Science Institute Guangxi Medical University, Nanning, PR China
| | - Zhi Huang
- Life Science Institute Guangxi Medical University, Nanning, PR China
| | - Caifeng Mo
- Life Science Institute Guangxi Medical University, Nanning, PR China
| | - Xiaoyang Cheng
- Life Science Institute Guangxi Medical University, Nanning, PR China
| | - Pengshu Song
- Life Science Institute Guangxi Medical University, Nanning, PR China
| | - Yalan Li
- Life Science Institute Guangxi Medical University, Nanning, PR China
| | - Tianlin Song
- Life Science Institute Guangxi Medical University, Nanning, PR China
| | - Zhezhe Guan
- Life Science Institute Guangxi Medical University, Nanning, PR China
| | - Yi Zhou
- Life Science Institute Guangxi Medical University, Nanning, PR China
| | - Xuerong Zhang
- Life Science Institute Guangxi Medical University, Nanning, PR China
| | - Ming Liao
- Life Science Institute Guangxi Medical University, Nanning, PR China
| |
Collapse
|
6
|
Hsu JY, Chiang SO, Yang CC, Hsieh TW, Chung CJ, Mao YC. Nationwide and long-term epidemiological research of snakebite envenomation in Taiwan during 2002-2014 based on the use of snake antivenoms: A study utilizing National Health Insurance Database. PLoS Negl Trop Dis 2023; 17:e0011376. [PMID: 37289739 DOI: 10.1371/journal.pntd.0011376] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/12/2023] [Indexed: 06/10/2023] Open
Abstract
INTRODUCTION In Taiwan, six venomous snake species with medical importance have been found; however, long-term epidemiological data of snakebite envenomation (SBE) is lacking. This study aimed to explore the epidemiology of SBE based on the distribution and use of different antivenoms in different parts of Taiwan to facilitate the development of prevention strategies and resource allocation. METHODS AND RESULTS This retrospective study was conducted using the Taiwan National Health Insurance Research Database from 2002 to 2014. A total of 12,542 patients were treated with antivenoms. The directly standardized cumulative incidence was 3.6 cases per 100,000 individuals based on the 2000 World Standard Population. The incidence of SBEs peaked in the summer (35.9%). The relative risk (RR) of male patients versus female patients was 2.5 (p < 0.0001). The RRs of patients aged 18-64 and ≥65 years versus those aged <18 years were 6.0 (p < 0.0001) and 14.3 (p < 0.0001), respectively. Furthermore, the RR of eastern Taiwan versus northern Taiwan was 6.8 (p < 0.0001). The RR of agricultural workers versus laborers was 5.5 (p < 0.0001). Compared with patients envenomed by Trimeresurus stejnegeri stejnegeri or Protobothrops mucrosquamatus, those envenomed by Naja atra or Bungarus multicinctus multicinctus were more likely to occur in central (adjusted odds ratio [aOR] = 2.6, p < 0.0001) or southern (aOR = 3.2, p < 0.0001) Taiwan, but less frequently among agricultural workers (aOR = 0.6, p < 0.0001). The overall case-fatality rate was 0.11%. CONCLUSIONS Among Asian countries, Taiwan had low incidence and case-fatality rates of SBE. Risk factors included male gender, old age, summer season, being in eastern Taiwan, and being an agricultural worker. Differences of the epidemiological findings between snake species should be focused on when developing strategies for snakebite prevention.
Collapse
Affiliation(s)
- Jen-Yu Hsu
- Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan
- Office of Preventive Medicine, Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-O Chiang
- ESTAT Statistical Consulting Co., Ltd., Taipei, Taiwan
| | - Chen-Chang Yang
- Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Environmental and Occupational Health Sciences, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tan-Wen Hsieh
- Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Jung Chung
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Yan-Chiao Mao
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| |
Collapse
|
7
|
Lu HY, Mao YC, Liu PY, Lai KL, Wu CY, Tsai YC, Yen JH, Chen IC, Lai CS. Clinical predictors of early surgical intervention in patients with venomous snakebites. Eur J Med Res 2023; 28:131. [PMID: 36945006 PMCID: PMC10029284 DOI: 10.1186/s40001-023-01101-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/16/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Venomous snakebites induce tissue destruction and secondary infection; however, the optimal timing of surgical intervention for these complications remains unknown. This study assessed the clinical predictors of early surgical intervention in patients with snakebites. METHODS This retrospective study included 63 patients (45 men and 18 women) with venomous snakebites. In addition to the snake species, the demographics, affected body parts, clinical characteristics, and ultrasound findings of the patients in the surgical (32 patients) and nonsurgical (31 patients) groups were analyzed and compared. RESULTS A higher incidence of acute compartment syndrome, local ecchymosis, skin necrosis, bullae, blisters, and fever was found in the surgical group than in the nonsurgical group, and ultrasound findings of the absence of Doppler flow were more frequently noted in the surgical group than in the nonsurgical group. After adjustment using a multivariate logistic regression model, only advanced age, Naja atra bite, local ecchymosis, and bulla or blister formation remained significant factors for surgical intervention. Furthermore, comparison of the outcomes of patients who received early (≤ 24 h) and late (> 24 h) surgical intervention revealed that the duration of continuous negative pressure wound therapy (6 vs. 15 days; P = 0.006), duration of hospital stay (13 vs. 26 days; P = 0.002), and duration of outpatient follow-up (15 vs. 36 days; P < 0.001) were significantly lower in patients who received early surgical intervention. The final reconstructive surgery was simple among the patients who received surgical intervention within 24 h of being bitten (P = 0.028). CONCLUSION In patients with snakebites, advanced age, high-risk clinical manifestations (e.g., local ecchymosis and bulla or blister formation), and Naja atra envenomation are predictors of surgical intervention within 24 h.
Collapse
Affiliation(s)
- Hsiao-Yu Lu
- Department of Orthopedic, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Yan-Chiao Mao
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Republic of China
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Po-Yu Liu
- Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan, Republic of China
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Cheng-Yeu Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Yueh-Chi Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, Republic of China
| | - Jung-Hsing Yen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - I-Chen Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, Republic of China.
| |
Collapse
|
8
|
Yeh H, Gao SY, Lin CC. Wound Infection of Snakebite from Venomous Protobothrops mucrosquamatus, Viridovipera stejnegeri and Naja atra in Taiwan: Validation of BITE and Cobra BITE Scoring Systems and their Bacteriological Differences in Wound Cultures. Toxins (Basel) 2023; 15:78. [PMID: 36668897 PMCID: PMC9861491 DOI: 10.3390/toxins15010078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/08/2023] [Accepted: 01/10/2023] [Indexed: 01/17/2023] Open
Abstract
Patients bitten by Protobothrops mucrosquamatus, Viridovipera stejnegeri, and Naja atra develop different degrees of wound infection. This study validated BITE and Cobra BITE scoring systems that we established previously. Bacteriological studies of patients with wound infection were conducted. The operating characteristic curves and area under the curve (AUC) and wound infection rates were compared between the derivation set (our previous study patient population) and the validation set (new patient cohorts enrolled between June 2017 and May 2021). No significant differences in the AUC for both the BITE (0.84 vs. 0.78, p = 0.27) and Cobra BITE (0.88 vs. 0.75, p = 0.21) scoring systems were observed between the derivation and validation sets. Morganella morganii and Enterococcus faecalis were the two most commonly detected bacteria in the microbiological study. More bacterial species were cultured from N. atra-infected wounds. Antibiotics such as amoxicillin with clavulanic acid, oxacillin, and ampicillin may not be suitable for treating patients with P. mucrosquamatus, V. stejnegeri, and N. atra bites in Taiwan. Carbapenem, third-generation cephalosporins, and fluoroquinolone may be superior alternatives.
Collapse
Affiliation(s)
- Heng Yeh
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shi-Ying Gao
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Chih-Chuan Lin
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| |
Collapse
|
9
|
Xie RH, Ye XL, Tang CY, Wang YH, Zhong LX. Associated Clinical Factors for Coagulation Dysfunction due to Trimeresurus stejnegeri: A Retrospective Observational Study. J Toxicol 2023; 2023:8832355. [PMID: 37168533 PMCID: PMC10164868 DOI: 10.1155/2023/8832355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/13/2023] Open
Abstract
Background Trimeresurus stejnegeri (T.s) accounts for most snakebites in southern China, which always leads to coagulation dysfunction. Coagulopathy due to venom is widely considered to be a characteristic phenomenon of the DIC-like syndrome. It is vitally important for first-line clinicians to improve this condition as soon as possible. However, clinical factors associated with coagulation function in Trimeresurus stejnegeri has not been well characterized yet. Materials Patients bitten by vipers were admitted to the Emergency Department of a hospital in Shenzhen, southern China, from 2021 to 2022 and were retrospectively reviewed. Patient clinical characteristics and laboratory data were compared in the eligible patients bitten by T.s by their prothrombin time (PT), fibrinogen level (FIB), and platelet count on 2-3 days after bitten. Results 105 patients were included in this study. The mean values of PT, FIB, and PLT are as follows: 12.8 ± 0.79 s, 2.25 ± 0.47 g/L, and 196.2 ± 57.1 × 109/L. Uric acid (UA) (367.9 ± 103.85), blood glucose (6.53 + 1.64) show negative trend of correlation, while CRP (2.12 + 4.17) shows positive trend of association with coagulation function. The smoke and systolic blood pressure may exert negative effects on PT and PLT, respectively. Logistic regression analysis indicated that uric acid (UA) shows significant connection with PT (OR = 1.15 and P value <0.0001), FIB (OR = 0.89 and P value = 0.026), and PLT (OR = 0.79 and P value = 0.007). CRP is also shown to be associated with FIB (OR = 1.33 and P value = 0.043). Conclusion : Uric acid (UA) shows a significant association with PT, FIB, and PLT. CRP is related to FIB. Blood glucose shows a negative trend of correlation with PT. We do recommend physician should low the level of UA in some degree on the basis of injection of an antivenom serum.
Collapse
Affiliation(s)
- Run-Hua Xie
- Shenzhen Hospital, Beijing University of Chinese Medicine, Shenzhen, China
| | - Xiao-Lu Ye
- Shenzhen Hospital, Beijing University of Chinese Medicine, Shenzhen, China
| | - Cong-Yao Tang
- Shenzhen Hospital, Beijing University of Chinese Medicine, Shenzhen, China
| | - Yu-Huai Wang
- Shenzhen Hospital, Beijing University of Chinese Medicine, Shenzhen, China
| | - Long-Xin Zhong
- Shenzhen Hospital, Beijing University of Chinese Medicine, Shenzhen, China
| |
Collapse
|
10
|
Nascimento TP, Vilhena Silva-Neto A, Baia-da-Silva DC, da Silva Balieiro PC, Baleiro AADS, Sachett J, Brasileiro L, Sartim MA, Martinez-Espinosa FE, Wen FH, Pucca MB, Gerardo CJ, Sampaio VS, Ferreira de Aquino P, Monteiro WM. Pregnancy outcomes after snakebite envenomations: A retrospective cohort in the Brazilian Amazonia. PLoS Negl Trop Dis 2022; 16:e0010963. [PMID: 36469516 PMCID: PMC9754599 DOI: 10.1371/journal.pntd.0010963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/15/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
Snakebite envenomations (SBEs) in pregnant women can result in adverse maternal or neonatal effects, such as abortion, placental abruption, preterm labor, fetal malformations, and maternal, fetal or neonatal deaths. Despite the high incidence of SBEs in the Brazilian Amazon, there is no literature on the impact of SBEs on pregnancy outcomes. The objective of this study was to describe clinical epidemiology and outcomes associated with SBEs in women of childbearing age and pregnant women in the state of Amazonas, Western Brazilian Amazon, from 2007 to 2021. Information on the population was obtained from the Reporting Information System (SINAN), Mortality Information System (SIM) and Live Birth Information System (SINASC) for the period from 2007 to 2021. A total of 36,786 SBEs were reported, of which 3,297 (9%) involved women of childbearing age, and 274 (8.3%) involved pregnant women. Severity (7.9% in pregnant versus 8.7% in non-pregnant women) (P = 0.87) and case-fatality (0.4% in pregnant versus 0.3% in non-pregnant women) rates were similar between groups (P = 0.76). Pregnant women who suffered snakebites were at higher risk for fetal death (OR: 2.17, 95%CI: 1.74-2.67) and neonatal death (OR = 2.79, 95%CI: 2.26-3.40). This study had major limitations related to the completeness of the information on the pregnancy outcomes. Although SBE incidence in pregnant women is low in the Brazilian Amazon, SBEs increased the risk of fetal and neonatal deaths.
Collapse
Affiliation(s)
- Thaís P. Nascimento
- Leônidas & Maria Deane Institute, Oswaldo Cruz Foundation, Manaus, Amazonas, Brazil
| | - Alexandre Vilhena Silva-Neto
- Amazonas State University, Manaus, Amazonas, Brazil
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Djane Clarys Baia-da-Silva
- Leônidas & Maria Deane Institute, Oswaldo Cruz Foundation, Manaus, Amazonas, Brazil
- Amazonas State University, Manaus, Amazonas, Brazil
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
- Amazonas Federal University, Manaus, Amazonas, Brazil
| | | | | | - Jacqueline Sachett
- Amazonas State University, Manaus, Amazonas, Brazil
- Butantan Institute, São Paulo, Brazil
| | - Lisele Brasileiro
- Amazonas State University, Manaus, Amazonas, Brazil
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Marco A. Sartim
- Amazonas State University, Manaus, Amazonas, Brazil
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Flor Ernestina Martinez-Espinosa
- Leônidas & Maria Deane Institute, Oswaldo Cruz Foundation, Manaus, Amazonas, Brazil
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | | | | | - Charles J. Gerardo
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Vanderson S. Sampaio
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | | | - Wuelton M. Monteiro
- Amazonas State University, Manaus, Amazonas, Brazil
- Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| |
Collapse
|
11
|
Uncommon defibrinogenation and coagulopathy caused by Trimeresurus stejnegeri stejnegeri envenomation in a patient with swelling above the ankle. Toxicon 2022; 217:143-147. [PMID: 35987354 DOI: 10.1016/j.toxicon.2022.08.011] [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: 06/08/2022] [Revised: 07/27/2022] [Accepted: 08/11/2022] [Indexed: 11/22/2022]
Abstract
In Taiwan, Trimeresurus stejnegeri stejnegeri (Stejneger's Bamboo pitviper) is responsible for more than half of all venomous snakebites annually. This species often causes local envenoming characterized by tissue swelling and pain, occasional local ecchymosis, bullae and blister formation, and lymphangitis and lymphadenitis. The pathophysiology and treatment of potentially life-threatening coagulopathy and defibrinogenation induced by T. s. stejnegeri systemic envenoming have not been specifically addressed. Here, we describe the case of a man who was bitten by T. s. stejnegeri on his right first toe, which later developed into swelling above the ankle. It was found that there was severe hypofibrinogenemia, prolonged prothrombin time, and reduced activities of factors V and XI, plasminogen, and α2-antiplasmin. Even though a favorable outcome was achieved after repeatedly administering specific antivenom, fresh frozen plasma, and cryoprecipitate, probably low effectiveness of antivenom against the coagulopathy and prodigious amounts of replacement products were observed. To control coagulopathy early and avoid the needless replacement of coagulation factor, which are associated with inherent adverse reactions, more frequent serial blood assessment (e.g., every 6 h) and higher initial antivenom doses may be helpful. Knowledge of the specific coagulation factor deficiencies may improve our understanding of the relationship between hemotoxins and the resulting envenoming syndromes in this snakebite.
Collapse
|
12
|
Luo Y, Mao YC, Liu PY, Chiang LC, Lai CS, Lin WL, Huang CC. Case Report: Management of an Uncommon Crotaline Snakebite (Ovophis makazayazaya). Am J Trop Med Hyg 2022; 107:tpmd220255. [PMID: 35914686 PMCID: PMC9490670 DOI: 10.4269/ajtmh.22-0255] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/22/2022] [Indexed: 11/07/2022] Open
Abstract
Ovophis makazayazaya bite is an uncommon cause of snakebite that humans may sustain as a result of the continuous overexploitation of forest habitats and excessive development in Taiwan. Although the Taiwanese government has produced four antivenoms against medically important snakebite accidents, O. makazayazaya is not among the snakes for which an antivenom has been produced. A case of O. makazayazaya snakebite on a patient's right foot, which later swelled into the hip, is reported. In vitro studies have reported that monovalent antivenoms for Gloydius brevicaudus and Trimeresurus albolabris, and polyvalent antivenom for Calloselasma rhodostoma, Daboia siamensis, and T. albolabris show reactivity toward Ovophis venoms. However, these antivenoms are unavailable in Taiwan. Thus, bivalent antivenom for Trimeresurus stejnegeri stejnegeri and Protobothrops mucrosquamatus was used, assuming similar immunoreactivity and a possible para-specific effect of green pit viper antivenom against this Ovophis venom. A favorable outcome was observed, without significant extension in prothrombin time and activated partial thromboplastin time. In addition, no systemic bleeding occurred. Nonetheless, further venom and antivenom evaluations should ascertain the efficacy of this para-specific antivenoms against this crotaline snakebite.
Collapse
Affiliation(s)
- Yi Luo
- Liuzhou Integrated Chinese and Western Medicine Snake Injury Treatment Center, Liuzhou Traditional Chinese Medicine Hospital, Liuzhou, Guangxi, China
| | - Yan-Chiao Mao
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Po-Yu Liu
- College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Liao-Chun Chiang
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- College of Medicine, National Chung Hsing University, Taichung, Taiwan
- National Tsing Hua University, College of Life Sciences, Hsinchu, Taiwan
| | - Chih-Sheng Lai
- College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Loung Lin
- Taichung Wildlife Conservation Group, Taichung, Taiwan
| | - Chia-Chun Huang
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- College of Medicine, National Chung Hsing University, Taichung, Taiwan
| |
Collapse
|
13
|
Cerebral Complications of Snakebite Envenoming: Case Studies. Toxins (Basel) 2022; 14:toxins14070436. [PMID: 35878174 PMCID: PMC9320586 DOI: 10.3390/toxins14070436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 02/01/2023] Open
Abstract
There are an estimated 5.4 million snakebite cases every year. People with snakebite envenoming suffer from severe complications, or even death. Although some review articles cover several topics of snakebite envenoming, a review of the cases regarding cerebral complications, especially rare syndromes, is lacking. Here, we overview 35 cases of snakebite by front-fanged snakes, including Bothrops, Daboia, Cerastes, Deinagkistrodon, Trimeresurus, and Crotalus in the Viperidae family; Bungarus and Naja in the Elapidae family, and Homoroselaps (rare cases) in the Lamprophiidae family. We also review three rare cases of snakebite by rear-fanged snakes, including Oxybelis and Leptodeira in the Colubridae family. In the cases of viper bites, most patients (17/24) were diagnosed with ischemic stroke and intracranial hemorrhage, leading to six deaths. We then discuss the potential underlying molecular mechanisms that cause these complications. In cases of elapid bites, neural, cardiac, and ophthalmic disorders are the main complications. Due to the small amount of venom injection and the inability to deep bite, all the rear-fanged snakebites did not develop any severe complications. To date, antivenom (AV) is the most effective therapy for snakebite envenoming. In the six cases of viper and elapid bites that did not receive AV, three cases (two by viper and one by elapid) resulted in death. This indicates that AV treatment is the key to survival after a venomous snakebite. Lastly, we also discuss several studies of therapeutic agents against snakebite-envenoming-induced complications, which could be potential adjuvants along with AV treatment. This article organizes the diagnosis of hemotoxic and neurotoxic envenoming, which may help ER doctors determine the treatment for unidentified snakebite.
Collapse
|
14
|
Chuang PC, Lin WH, Chen YC, Chien CC, Chiu IM, Tsai TS. Oral Bacteria and Their Antibiotic Susceptibilities in Taiwanese Venomous Snakes. Microorganisms 2022; 10:microorganisms10050951. [PMID: 35630396 PMCID: PMC9147925 DOI: 10.3390/microorganisms10050951] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/15/2022] [Accepted: 04/28/2022] [Indexed: 12/07/2022] Open
Abstract
Wound infections after venomous snakebites are clinically important. Information regarding the nature and antibiotic susceptibilities of snake oral bacterial flora could support empiric antibiotic therapy. Wild venomous snakes were collected from southern Taiwan: a total of 30 each of Bungarus multicinctus, Naja atra, Protobothrops mucrosquamatus, and Trimeresurus stejnegeri; 3 Deinagkistrodon acutus; and 4 Daboia siamensis. The species and antibiotic susceptibilities of their oral bacteria were determined. Aerobic gram-negative bacteria, especially Pseudomonas aeruginosa and Proteus vulgaris, were the most abundant. Proteus vulgaris were more abundant in B. multicinctus, N. atra, and P. mucrosquamatus than in T. stejnegeri (40%, 43.3%, and 40% vs. 13.3%, respectively). The gram-negative species were less susceptible to first- and second-generation cephalosporins and ampicillin-sulbactam than to third-generation cephalosporins, fluoroquinolones, carbapenems, or piperacillin-tazobactam. The most abundant aerobic gram-positive species cultured was Enterococcus faecalis, which was more abundant in N. atra than in other snakes (p < 0.001) and was highly susceptible to ampicillin, high-level gentamicin, penicillin, teicoplanin, and vancomycin. Bacteroides fragilis and Clostridium species were the most common anaerobic bacteria. The anaerobic organisms were highly susceptible to metronidazole and piperacillin. As a reference for empiric antimicrobial therapy, third-generation cephalosporins, fluoroquinolones, carbapenems, or piperacillin-tazobactam can be initiated in venomous snakebites wound infections.
Collapse
Affiliation(s)
- Po-Chun Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan; (P.-C.C.); (I.-M.C.)
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
| | - Wen-Hao Lin
- Institute of Wildlife Conservation, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan;
| | - Yi-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan;
| | - Chun-Chih Chien
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan;
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan; (P.-C.C.); (I.-M.C.)
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
| | - Tein-Shun Tsai
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan
- Correspondence: or
| |
Collapse
|
15
|
Zeng ZY, Huang PY, Du JY, Liu YX, Guo SG, Zeng LS, Zhang CC, Li Y. Effect of Agkistrodon halys antivenom in patients bit by green pit viper and the prognostic role of the disease - a retrospective cohort study. Clin Toxicol (Phila) 2022; 60:808-817. [PMID: 35225104 DOI: 10.1080/15563650.2022.2041200] [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: 11/03/2022]
Abstract
BACKGROUND AND AIMS In Mainland China and Hong Kong, health authorities utilize Agkistrodon halys antivenom in the treatment of patients who sustained bites from green pit vipers. However, the treatment benefit of Agkistrodon halys antivenom among such patients is still controversial. The purpose of this study is to evaluate the coagulation parameters normalization time of Agkistrodon halys antivenom in patients who sustained green pit viper bites and explore independent risk factors of patient prognosis. METHODS Data were extracted from the Donghua Hospital Information System. Comparison of the two groups of patients - who used antivenom (GPUA) and who did not use antivenom (GPNUA) were performed using stratified analysis, univariate and multivariate ordered logistic regression models to evaluate the coagulation parameters normalization time. Univariate and multivariate ordered logistic regression models were used to explore independent risk factors of patient prognosis. RESULTS Between the GPUA and GPNUA groups, there is no significant difference in the coagulation parameters normalization time with the treatment of Agkistrodon halys antivenom. GPNUA consumed more cryoprecipitate and platelets and had a lower cost. The patient's severity of the bite, first coagulation profile, and dosages of fresh frozen plasma, platelet, and red cell suspension was found to be risk factors for the normalization time of coagulation parameters. CONCLUSIONS The therapeutic effect of Agkistrodon halys antivenom in green pit vipers bite patients is not quite satisfying. In addition, more attention should be paid to the first coagulation profile, blood clotting factors indices, platelet count (PLT), and hemoglobin when treating such patients.
Collapse
Affiliation(s)
- Zhong-Yi Zeng
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Pei-Ying Huang
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, PR China.,Emergency Department, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, PR China
| | - Jia-Yu Du
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Yu-Xiang Liu
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Shi-Gong Guo
- Department of Rehabilitation Medicine, Southmead Hospital, Bristol, UK
| | - Lin-Sheng Zeng
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Cong-Cong Zhang
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Yi Li
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, PR China
| |
Collapse
|
16
|
Guan Z, Li Y, Hu S, Mo C, He D, Huang Z, Liao M. Screening and identification of differential metabolites in serum and urine of bamaxiang pigs bitten by trimeresurus stejnegeri based on UPLC-Q-TOF/MS metabolomics technology. J Toxicol Sci 2022; 47:389-407. [PMID: 36104186 DOI: 10.2131/jts.47.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Trimeresurus stejnegeri is one of the top ten venomous snakes in China, and its bite causes acute and severe diseases. Elucidating the metabolic changes of the body caused by Trimeresurus stejnegeri bite will be beneficial to the diagnosis and treatment of snakebite. Thus, an animal pig model of Trimeresurus stejnegeri bite was established, and then the metabolites of serum and urine were subsequently screened and identified in both ESI+ and ESI- modes identified by ultra-performance liquid chromatography-quadrupole-time of flight-mass spectrometry (UPLC-Q-TOF-MS) methods. There are 9 differential metabolites in serum, including Oleic acid, Lithocholic acid, Deoxycholic acid, Hypoxanthine, etc. There are 11 differential metabolites in urine, including Dopamine, Thiocysteine, Arginine, Indoleacetaldehyde, etc. Serum enrichment pathway analysis showed that 5 metabolic pathways, including Tryptophanuria, Liver disease due to cystic fibrosis, Hartnup disease, Hyperbaric oxygen exposure and Biliary cirrhosis, the core metabolites in these pathways, including deoxycholic acid, lithocholic acid, tryptophan and hypoxanthine, changed significantly. Urine enrichment pathway analysis showed that 4 metabolic pathways, including Aromatic L-Amino Acid Decarboxylase, Vitiligo, Blue Diaper Syndrome and Hyperargininemia, the core metabolites in these pathways including dopamine, 5-hydroxyindole acetic acid and arginine. Taken together, the current study has successfully established an animal model of Trimeresurus stejnegeri bite, and identified the metabolic markers and metabolic pathways of Trimeresurus stejnegeri bite. These metabolites and pathways may have potential application value and provide a therapeutic basis for the treatment of Trimeresurus stejnegeri bite.
Collapse
Affiliation(s)
- ZheZhe Guan
- Institute of Life Sciences of Guangxi Medical University, China
| | - YaLan Li
- Institute of Life Sciences of Guangxi Medical University, China
| | - ShaoCong Hu
- Institute of Life Sciences of Guangxi Medical University, China
| | - CaiFeng Mo
- Institute of Life Sciences of Guangxi Medical University, China
| | - DongLing He
- Institute of Life Sciences of Guangxi Medical University, China
| | - Zhi Huang
- Institute of Life Sciences of Guangxi Medical University, China
| | - Ming Liao
- Institute of Life Sciences of Guangxi Medical University, China
| |
Collapse
|
17
|
Yong MY, Tan KY, Tan CH. Potential para-specific and geographical utility of Thai Green Pit Viper (Trimeresurus albolabris) Monovalent Antivenom: Neutralization of procoagulant and hemorrhagic activities of diverse Trimeresurus pit viper venoms. Toxicon 2021; 203:85-92. [PMID: 34600909 DOI: 10.1016/j.toxicon.2021.09.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/01/2021] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Abstract
The Trimeresurus complex consists of diverse medically important venomous pit vipers that cause snakebite envenomation. Antivenoms, however, are in limited supply, and are specific to only two out of the many species across Asia. This study thus investigated the immunoreactivities of regional pit viper antivenoms toward selected Trimeresurus pit viper venoms, and examined the neutralization of their hemotoxic activities. Trimeresurus albolabris Monovalent Antivenom (TaMAV, Thailand) exhibited a higher immunoreactivity than Hemato Bivalent Antivenom (HBAV, raised against Trimeresurus stejnegeri and Protobothrops mucrosquamatus, Taiwan) and Gloydius brevicaudus Monovalent Antivenom (GbMAV, China), attributed to its monovalent nature and conserved antigens in the Trimeresurus pit viper venoms. The venoms showed moderate-to-strong in vitro procoagulant and in vivo hemorrhagic effects consistent with hemotoxic envenomation, except for the Sri Lankan Trimeresurus trigonocephalus venom which lacked hemorrhagic activity. TaMAV was able to differentially neutralize both in vitro and in vivo hemotoxic effects of the venoms, with the lowest efficacy shown against the procoagulant effect of T. trigonocephalus venom. The findings suggest that TaMAV is a potentially useful treatment for envenomation caused by hetero-specific Trimeresurus pit vipers, in particular those in Southeast Asia and East Asia. Clinical study is warranted to establish its spectrum of para-specific effectiveness, and dosages need be tailored to the different species in respective regions.
Collapse
Affiliation(s)
- Mun Yee Yong
- Venom Research and Toxicology Laboratory, Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kae Yi Tan
- Protein and Interactomics Laboratory, Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Choo Hock Tan
- Venom Research and Toxicology Laboratory, Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| |
Collapse
|
18
|
Mao YC, Chuang HN, Shih CH, Hsieh HH, Jiang YH, Chiang LC, Lin WL, Hsiao TH, Liu PY. An investigation of conventional microbial culture for the Naja atra bite wound, and the comparison between culture-based 16S Sanger sequencing and 16S metagenomics of the snake oropharyngeal bacterial microbiota. PLoS Negl Trop Dis 2021; 15:e0009331. [PMID: 33857127 PMCID: PMC8078740 DOI: 10.1371/journal.pntd.0009331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 04/27/2021] [Accepted: 03/25/2021] [Indexed: 01/11/2023] Open
Abstract
Naja atra is a major venomous snake found in Taiwan. The bite of this snake causes extensive wound necrosis or necrotizing soft tissue infection. Conventional microbial culture-based techniques may fail to identify potential human pathogens and render antibiotics ineffective in the management of wound infection. Therefore, we evaluated 16S Sanger sequencing and next-generation sequencing (NGS) to identify bacterial species in the oropharynx of N. atra. Using conventional microbial culture methods and the VITEK 2 system, we isolated nine species from snakebite wounds. On the basis of the 16S Sanger sequencing of bacterial clones from agar plates, we identified 18 bacterial species in the oropharynx of N. atra, including Morganella morganii, Proteus vulgaris, and Proteus mirabilis, which were also present in the infected bite wound. Using NGS of 16S metagenomics, we uncovered more than 286 bacterial species in the oropharynx of N. atra. In addition, the bacterial species identified using 16S Sanger sequencing accounted for only 2% of those identified through NGS of 16S metagenomics. The bacterial microbiota of the oropharynx of N. atra were modeled better using NGS of 16S metagenomics compared to microbial culture-based techniques. Stenotrophomonas maltophilia, Acinetobacter baumannii, and Proteus penneri were also identified in the NGS of 16S metagenomics. Understanding the bacterial microbiota that are native to the oropharynx of N. atra, in addition to the bite wound, may have additional therapeutic implications regarding empiric antibiotic selection for managing N. atra bites. Naja atra bites induce extensive wound necrotizing soft tissue infections in a substantial proportion of patients. Empiric antibiotic administration in snakebite patients is a common practice, but clinical reports indicate that this treatment was ineffective in preventing secondary infection given that the microbiota of the infected wound and oropharynx of the culprit snake were not properly established. In this study, only 9 species were detected in cobra bites using a conventional microbial culture method and the VITEK 2 system, whereas 18 species were detected in the cobra oropharynx using microbial culture-based 16S Sanger sequencing. Among these, Morganella morganii, Proteus vulgaris, and Proteus mirabilis were identified as common bacteria. Compared to microbial culture-based 16S Sanger sequencing, NGS-based 16S metagenomic sequencing detected more than 286 bacterial species. Stenotrophomonas maltophilia, Acinetobacter baumannii, and Proteus penneri only appeared with 16S metagenomic sequencing. These results suggest that NGS-based 16S metagenomic sequencing is a better tool for uncovering the bacterial microbiota of the N. atra oropharynx, which may help in developing a proper therapeutic strategy for patients with N. atra bites.
Collapse
Affiliation(s)
- Yan-Chiao Mao
- Department of Emergency Medicine, Division of Clinical Toxicology, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Medicine, Division of Clinical Toxicology and Occupational Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Han-Ni Chuang
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Precision Medicine Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chien-Hung Shih
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Precision Medicine Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Han-Hsueh Hsieh
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Precision Medicine Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Han Jiang
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Liao-Chun Chiang
- Department of Emergency Medicine, Division of Clinical Toxicology, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Medicine, Division of Clinical Toxicology and Occupational Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- National Tsing Hua University, College of Life Sciences, Hsinchu, Taiwan
| | - Wen-Loung Lin
- Taichung Wildlife Conservation Group, Taichung, Taiwan
| | - Tzu-Hung Hsiao
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Precision Medicine Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Public Health, Fu Jen Catholic University, New Taipei City, Taiwan
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung, Taiwan
- * E-mail: (T-HH); (P-YL)
| | - Po-Yu Liu
- Department of Internal Medicine, Division of Infectious Diseases, Taichung Veterans General Hospital, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- * E-mail: (T-HH); (P-YL)
| |
Collapse
|