[Afibrinogenemia secondary to crotalid snake bite (Crotalus durissus terrificus)]

Evaluation of Protection by Caffeic Acid, Chlorogenic Acid, Quercetin and Tannic Acid against the In Vitro Neurotoxicity and In Vivo Lethality of Crotalus durissus terrificus (South American Rattlesnake) Venom

Systemic envenomation by Crotalus durissus terrificus (South American rattlesnake) can cause coagulopathy, rabdomyolysis, acute kidney injury, and peripheral neuromuscular blockade, the latter resulting in flaccid paralysis. Previous studies have shown that plant products such as tannic acid and theaflavin can protect against the neuromuscular blockade caused by C. d. terrificus venom in vitro. In this work, we used mouse-isolated phrenic nerve-diaphragm preparations to examine the ability of caffeic acid, chlorogenic acid, and quercetin to protect against C. d. terrificus venom-induced neuromuscular blockade in vitro. In addition, the ability of tannic acid to protect against the systemic effects of severe envenomation was assessed in rats. Preincubation of venom with caffeic acid (0.5 mg/mL), chlorogenic acid (1 mg/mL), or quercetin (0.5 mg/mL) failed to protect against venom (10 μg/mL)-induced neuromuscular blockade. In rats, venom (6 mg kg⁻¹, i.p.) caused death in ~8 h, which was prevented by preincubation of venom with tannic acid or the administration of antivenom 2 h post-venom, whereas tannic acid given 2 h post-venom prolonged survival (~18.5 h) but did not prevent death. Tannic acid (in preincubation protocols or given 2 h post-venom) had a variable effect on blood creatinine and urea and blood/urine protein levels and prevented venom-induced leukocytosis. Tannic acid attenuated the histological lesions associated with renal damage in a manner similar to antivenom. The protective effect of tannic acid appeared to be mediated by interaction with venom proteins, as assessed by SDS-PAGE. These findings suggest that tannic acid could be a potentially useful ancillary treatment for envenomation by C. d. terrificus.

Experimental model for removal of snake venom via hemoperfusion in rats

OBJECTIVE

To examine the efficiency of hemoperfusion in removing South American rattlesnake (Crotalus durissus terrificus) venom from rats compared with neutralization by antivenom.

DESIGN

An exploratory experimental investigation in rats involving the injection of snake venom with or without subsequent hemoperfusion or antivenom administration.

SETTING

Basic animal research laboratory in a private university.

ANIMALS

Normal, healthy male Wistar rats (0.29-0.40 kg, 3-6 months old) from a commercial breeder.

INTERVENTIONS

Four experimental groups of randomly allocated rats (n = 3/group) were studied: Group 1: rats were injected with a single dose of venom (5 mg/kg, IM, in the right thigh) with no other treatment; blood samples were collected minutes before death to determine leukocyte, platelet, and erythrocyte counts; Group 2 (Control): rats underwent hemoperfusion alone for 60 min using a hemoperfusion cartridge designed for protein adsorption (by granulated charcoal) and protein precipitation (by tannic acid); Group 3 (Venom + antivenom): rats were injected with venom (5 mg/kg, IM) and, 10 min later, were treated with antivenom at the venom:antivenom ratio recommended by the manufacturer; Group 4 (Venom + hemoperfusion): Rats were injected with venom (5 mg/kg, IM) and, 10 min later, were hemoperfused for 60 min. In groups 2-4, blood samples were collected for leukocyte, platelet, and erythrocyte counts 24 h after venom.

MEASUREMENTS AND MAIN RESULTS

Rats injected with venom alone (Group 1) developed signs of neurotoxicity and ataxia and died in 9.0 ± 0.43 h but showed no changes in leukocyte or erythrocyte counts. In contrast, there were no deaths in groups 2-4. The lack of deaths in Groups 3 and 4 indicated that antivenom and hemoperfusion, respectively, protected against the lethal effects of the venom.

CONCLUSIONS

Hemoperfusion with a double-action hemoperfusion cartridge capable of protein adsorption and precipitation protected rats against C. d. terrificus venom.

Evaluation of systemic inflammatory response and lung injury induced by Crotalus durissus cascavella venom

This study investigated the systemic inflammatory response and mechanism of pulmonary lesions induced by Crotalus durissus cascavella venom in murine in the state of Bahia. In order to investigate T helper Th1, Th2 and Th17 lymphocyte profiles, we measured interleukin (IL) -2, IL-4, IL-6, IL-10, IL-17, tumor necrosis factor (TNF) and interferon gamma (IFN-γ) levels in the peritoneal fluid and macerated lungs of mice and histopathological alterations at the specific time windows of 1h, 3h, 6h, 12h, 24h and 48h after inoculation with Crotalus durissus cascavella venom. The data demonstrated an increase of acute-phase cytokines (IL-6 and TNF) in the first hours after inoculation, with a subsequent increase in IL-10 and IL-4, suggesting immune response modulation for the Th2 profile. The histopathological analysis showed significant morphological alterations, compatible with acute pulmonary lesions, with polymorphonuclear leukocyte (PMN) infiltration, intra-alveolar edema, congestion, hemorrhage and atelectasis. These findings advance our understanding of the dynamics of envenomation and contribute to improve clinical management and antiophidic therapy for individuals exposed to venom.

Clinical, Laboratory, and Therapeutic Aspects of Crotalus durissus (South American Rattlesnake) Victims: A Literature Review

Snakebite envenoming is a neglected public health issue in many tropical and subtropical countries. To diagnosis and treat snakebites may be challenging to health care personnel since sufficient information has not been yet provided. This review presents the clinical, therapeutic, and laboratory aspects of Crotalus durissus (South American rattlesnakes) victims. The clinical setting may show local effects such as little or no pain, mild edema, and recurrent erythema. In contrast, the systemic effects may be quite remarkable, such as changes due to neurological damage, intense rhabdomyolysis, incoagulability of the blood, and variations in the peripheral blood elements. The main complication is acute kidney injury. The appropriate treatment depends mainly on the correct recognition of the aggressor snake and the symptoms expressed by the victim. Rattlesnake venom can cause irreparable damage and lead to death. Therefore, a prompt diagnosis allows the immediate onset of proper serotherapy.

New immunization protocol to produce crotalic antivenom combining Crotalus durissus terrificus venom and its PLA2

Antivenoms are usually obtained by animal immunization with successive inoculations of increasing sublethal amounts of venom, which may impair the animal health. The high lethality of venom requires prolonged immunization plans with small amounts of venom. Thus, we propose an alternative plan that includes a pre-immunization of the animal with phospholipase A2, the main crotoxin component, which is responsible for the whole venom lethality. For comparison, three different immunization schemes were designed: high dose protocol (HDP; 0.5-27 mg of venom), low dose protocol (LDP; 0.1-7 mg of venom) and Mix protocol (MP; preimmunization 0.1-1.2 mg of crotalic PLA2, and then 4.5-8 mg of venom). Antibody titers were determined by ELISA, in blood plasma obtained from the marginal vein of the ear. The neutralizing ability of the different sera obtained by all protocols (HDS, LDS and MS) was tested against the most important pharmacological activities of whole venom: PLA2 activity, myotoxicity, thrombin like activity and lethality. MS showed the best neutralizing efficacy and at the same time, it was obtained by an immunization protocol that takes account of animal health care, since it requires low quantities of venoms in comparison to traditional protocols.

Bilateral posterior circulation stroke secondary to a crotalid envenomation: case report

Snake bite envenoming is a disease with potential serious neurological complications. We report a case of an adolescent who was bitten by a rattlesnake and developed bilateral posterior circulation stroke. The rattlesnake was later identified as being Crotalus durissus terrificus. Stroke was probably due to toxic vasculitis or toxin-induced vascular spasm and endothelial damage.

Individual venom variability in the South American rattlesnake Crotalus durissus cumanensis

Crotalus durissus cumanensis snake venoms from different Venezuelan regions, showed biochemical and hemostatic variations. Fibrino(geno)lytic, hemorrhagic and procoagulant activities and gel-filtration chromatography and SDS-PAGE profiles were analyzed. Differences were observed in fibrinolytic activity: kallikrein-like amidolytic activity was highest in venoms of Santa Teresa, and Margarita. Lagunetica and Carrizales venoms showed the maximum fibrin lysis. The highest hemorrhagic activity was seen in Lagunetica venom. Margarita had the lowest LD(50) of 0.18. Lagunetica, Carrizales and Anzoátegui induced a rapid degradation of fibrinogen alpha chains and slower degradation on beta chains, which could possibly due to a higher content of alpha fibrinogenases in these venoms. This fibrinogenolytic activity is decreased by metalloprotease inhibitors. All venoms, except Carrizales, presented thrombin-like activity. Anzoátegui, Carrizales and Lagunetica, in which fibrinolytic activity was present, showed the largest concentration of high molecular mass components. These results represent a new finding, not previously described, of fibrinolytic activity in South American C. durissus venoms. Santa Teresa and Margarita had fibrinolytic activity, and lack of hemorrhagic activity, representing an important finding in Venezuelan venoms since the description of a fibrinolytic molecule without hemorrhagic activity can have valuable potential in thrombolytic therapy.

Intraspecific variation in the venoms of the South American rattlesnake (Crotalus durissus terrificus)

The venom of eight individual Crotalus durissus terrificus snakes from the State of Minas Gerais, Brazil, in addition to pooled venom from Butantan Institute, were compared. Snakes were captured in distinct locations, some of them 600 km apart: Conselheiro Lafaiete, Entre Rios de Minas, Itauna, Itapecerica, Lavras, Patos de Minas, Paracatu, and Santo Antonio do Amparo. The crude venoms were tested for proteolytic, phospholipase A2, platelet aggregating, and hemagglutinating activities. The venoms were also analyzed by polyacrylamide gel electrophoresis (PAGE) and isoelectric focusing (IEF). Chromatographic patterns of venom proteins on both gel-filtration and anion-exchange chromatographies were also performed. All venoms presented high phospholipase A2 and platelet-aggregating activities, but only minimal hemagglutinating or proteolytic activities were found. Gel-filtration chromatography showed a characteristic profile for most venoms where four main peaks were separated, including the typical ones where convulxin and crotoxin were identified; however, peaks with high amounts of lower molecular weight proteins were found in the venoms from the Santo Antonio do Amparo location and Butantan Institute, characterizing these venoms as crotamine positive. Anion-exchange chromatographies presented a similar protein distribution pattern, although the number of peaks (up to ten) distinguished some venom samples. Consistent with these results, polyacrylamide gels that were silver stained after venom separation by PAGE or IEF presented a similar qualitative band distribution, although a quantitative heterogeneity was detected among venoms. Our results suggest that the variability found in venom components of C. d. terrificus venoms captured in Minas Gerais State may be genetically inherited and/or environmentally induced.

Cross-reactivity and heterologous neutralization of crotaline antivenoms used in Argentina

The immunochemical cross-reactivity and neutralizing capacity of four crotalinae antivenoms consisting in equine F(ab')2 fragments and available in Argentina (bothropic Bivalent, against Bothrops alternatus and B. neuwiedii venoms; bothropic Tetravalent, against B. alternatus, B. neuwiedii; B. jararaca and B. jararacussu venoms; bothropic crotalic Trivalent, against B. alternatus, B. neuwiedii and Crotalus (C.) durissus terrificus venoms and anticrotalic against C. d. terrificus venom) were studied against B. alternatus, B. ammodytoides; B. jararaca; B. jararacussu, B. moojeni; B. neuwiedii and C. d. terrificus venoms. SDS-PAGE analysis of the Bothrops venoms showed protein bands of high (>40 kDa) medium (20-40 kDa) and low (<15 kDa) molecular weights, while that of C. d. terrificus exhibited a large amount of material with molecular weight of 15.0 kDa or lower. Immunoblotting showed a high cross-reactivity of all the major protein bands with all the antivenoms (even heterologous) tested. All the antivenoms were effective in neutralizing the lethal activity of the venoms tested, and in some cases (B. jararaca and B. jararacussu) heterologous antivenoms exhibited similar neutralizing capacity than the homologous ones. In spite of the differences in biochemical composition and pharmacology, Bothropic antivenoms displayed a significant neutralizing capacity on lethal activity of C. d. terrificus venom. In addition, all the antivenoms (including the anticrotalic) were highly effective in neutralizing the hemorragic, necrotizing, procoagulant, and proteolytic activities. The antivenoms tested produced different degrees of inhibition of phospholipase A2 activity, which exhibited a certain specificity but was also related to the enzyme content in the venom.

Bothrops sp. snake venoms: comparison of some biochemical and physicochemical properties and interference in platelet functions

Procoagulant, proteolytic, phospholipase and platelet pro-aggregating and inhibiting activities were screened for pooled venoms of seven Bothrops species as well as Crotalus durissus terrificus and Lachesis muta snakes typical of the Brazilian territory. As reported by other authors, we also found that examination of the electrophoretic and gel filtration patterns of Bothrops snakes venoms could not be used for identification of the species of a given venom because of the lack of marked interspecific differences within the same genus. Our data indicated that B. cotiara, B. alternatus and B. atrox possess no platelet pro-aggregating activity, low inhibitory effect on platelet aggregation and very low or intermediate levels for the other activities. B. moojeni, B. neuwiedi and B. jararacussu whose venoms possess high procoagulant, platelet pro-aggregating and phospholipase activities are low in both proteolytic and platelet inhibitory activities. B. jararaca venom showed the highest inhibitory effect on platelet aggregation and very low platelet pro-aggregating activity. Compared with the Bothrops venoms studied, L. muta venom showed that highest proteolytic activity while C. d. terrificus venom presented remarkable high platelet pro-aggregating and phospholipase activities. In all venoms, proteolytic activity could be completely inhibited by EDTA (2 mM) alone. In contrast, the presence of phenylmethylsulfonyl fluoride (5 mM) inhibited partially the caseinolytic activity of all venoms, except that L. muta venom, which was almost completely blocked by this reagent. Altogether, these data confirm the presence of high levels of metalloproteinases in the venoms of Crotalinae snakes. Most of these enzymes are dependent of the availability of Ca2+, being much less the same concerning the presence of serine residues in their active sites. The data indicated that the presence and levels of procoagulant, azocaseinolytic and phospholipase A2 activities alone could not differentiated the species of the Bothrops venoms studied, particularly in the cases of B. jararaca, B. moojeni and B. atrox. However, the platelet inhibiting property of low doses of B. jararaca venom can be useful to differentiate it from B. moojeni venom. In the same way, the platelet pro-aggregating activity of high doses of B. jararaca venom may be used to distinguish it from B. atrox crude venom, otherwise very similar but incapable to activate platelets. In conclusion, our comparative screening of biological properties has indicated that platelet studies may serve as a tool to distinguish among venoms that otherwise behave biochemically in a very similar way. Although promising, the general applicability of platelet activation studies by snake venoms for classification or taxanomical purposes has yet to be extended to other family of snakes to be proven useful.

Local inflammation, lethality and cytokine release in mice injected with Bothrops atrox venom

We have provided evidence that: (a) lethality of mice to crude Bothrops venom varies according the isogenic strain (A/J > C57Bl/6 > A/Sn > BALB/c > C3H/HePas > DBA/2 > C3H/He); (b)BALB/c mice (LD50=100.0 microg) were injected i.p. with 50 microg of venom produced IL-6, IL-10, INF-gamma, TNF-alpha and NO in the serum. In vitro the cells from the mice injected and challenged with the venom only released IL-10 while peritoneal macrophages released IL-10, INF-gamma and less amounts of IL-6; (c) establishment of local inflammation and necrosis induced by the venom, coincides with the peaks of TNF-alpha, IFN-gamma and NO and the damage was neutralized when the venom was incubated with a monoclonal antibody against a 60 kDa haemorrhagic factor. These results suggest that susceptibility to Bothrops atrox venom is genetically dependent but MHC independent; that IL-6, IL-10, TNF-alpha, IFN-gamma and NO can be involved in the mediation of tissue damage; and that the major venom component inducers of the lesions are haemorrhagins.

Epidemiologia e quadro clínico do acidente por cascavel sul-americana (Crotalus durissus)

Foram estudados 249 casos de acidentes por cascavel sul-americana (Crotalus durissus) atendidos no HVB-IB, São Paulo, Brasil, de 1974 a 1990. Os acidentes foram mais comuns no período da tarde, nos meses de janeiro a abril e de outubro a dezembro. Dentre cem serpentes classificadas quanto à subespécie 99 eram C. d. terrificus. Pertenciam ao sexo masculino 80,7% dos pacientes. Os membros inferiores e superiores foram picados em, respectivamente, 66,4% e 29,2% dos casos. As manifestações clínicas mais freqüentes foram dor (61,0%) e edema (55,0%) no local da picada, ptose palpebral (75,9%), escurecimento da urina atribuível à mioglobinúria (38,6%) e mialgia (36,1%). Nove pacientes foram submetidos a diálise devido a insuficiência renal aguda (3,6%), três apresentavam insuficiência respiratória que motivou intubação e/ou traqueostomia e um apresentou acidente vascular cerebral isquêmico. A alteração da coagulação sanguínea ocorreu em 48,1% dos pacientes. Oito amostras de sangue colhidas horas após a picada mostraram leucocitose sendo 6 com desvio a esquerda e, nos dias subseqüentes, tendência à normalização do número de leucócitos e aparecimento de eosinofilia. Atividade sérica da creatinoquinase apresentou-se aumentada em 20 dentre 21 pacientes, sendo maior no final das primeiras 24 horas após a picada, chegando a 2.377 vezes o valor de referência. A letalidade foi de 0,8%.

[Crotalid bites in children: clinical, laboratory, epidemiologic aspects and treatment approach]

At the Hospital of Clinics of the Faculty of Medicine of Ribeirão Preto/USP during the years 1980-1989 21 children have been attended after rattlesnake bite: 16 severe and 5 with moderate envenomation. Four (20%) developed acute tubular necrosis 2 necessitating dialysis. One patient died 13 days after the bite and grave complications including digestive hemorrhage and acute respiratory insufficiency. All patients preserved clinical laboratory and epidemiological characteristics of Crotalus durissus terrificus envenomation. We also comment on the correct management of such patients specially related to antivenin dosage and the prevention of acute tubular the most serious complication of such an accident.