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Mathis S, Carla L, Duval F, Nadal L, Solé G, Le Masson G. Acute peripheral neuropathy following animal envenomation: A case report and systematic review. J Neurol Sci 2022; 442:120448. [PMID: 36244096 DOI: 10.1016/j.jns.2022.120448] [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: 01/18/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 10/31/2022]
Abstract
Animal envenomation in humans is usually accidental or for defensive purposes. Depending on the venom composition and administration, different reactions can be observed. After reporting the first case of acute polyradiculitis in a 57-year-old healthy male after red lionfish envenomation, we propose to analyze rare similar cases of acute neuritis after animal envenomation published in the medical literature. Including our case, we found 54 patients who developed acute peripheral neuropathy after having been stung or bitten by various animals, mainly hymenoptera (in half of the cases) but also jellyfishes, snakes, corals or nonhooked arthropods. We observed two distinct patterns of peripheral neuropathy: more than half of them were polyneuropathy while the others were focal neuropathy. The prognosis was favorable in most cases. The pathophysiological mechanism associated with these rare complications remain unknown, although some hypotheses may be proposed. A direct action of certain components of the venom, such as phospholipase-A2, could explain the focal forms of peripheral neuropathy trough toxic reactions and/or vasculitis processes. The more diffuse clinical situations could be due to an allergy-triggered immune-mediated reaction (possibly linked to a molecular mimicry mechanism between venom proteins and some myelin proteins of the peripheral nervous system), or to the action of some venom components on membrane ionic channels particularly at the node of Ranvier. Even if acute peripheral neuropathies are rare after envenomation, they may occur after envenomation from various animals, and their usually favorable prognoses should be known by neurologists.
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Affiliation(s)
- Stéphane Mathis
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; ALS Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; AOC Neuromuscular Reference Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France.
| | - Louis Carla
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Fanny Duval
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; AOC Neuromuscular Reference Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Louis Nadal
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Guilhem Solé
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; AOC Neuromuscular Reference Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Gwendal Le Masson
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; ALS Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; AOC Neuromuscular Reference Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France
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Heckmann X, Lambert V, Mion G, Ehrhardt A, Marty C, Perotti F, Carod JF, Jolivet A, Boels D, Lehida Andi I, Larréché S. Failure of a Mexican antivenom on recovery from snakebite-related coagulopathy in French Guiana. Clin Toxicol (Phila) 2020; 59:193-199. [PMID: 32609546 DOI: 10.1080/15563650.2020.1786108] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In French Guiana, most snakebites are caused by crotalids, with the main signs being tissue damage and bleeding due to venom-induced coagulopathy. Since December 2014 the Western Guiana Hospital (WGH) has used Antivipmyn Tri TM, a Mexican polyvalent antivenom. The aim of the study was to assess its benefit on the correction of snakebite-related coagulopathy. METHODS This retrospective study included patients hospitalized at the WGH with snakebite and a coagulopathy defined by: a prothrombin rate (PR) lower than 45%, an activated partial thromboplastin time ratio (aPTTr) greater than 2 or a fibrinogen lower than 100 mg.dL-1. The antivenom group included patients receiving Antivipmyn Tri TM from December 2014 to September 2017. The control group included patients admitted between January 2013 and November 2014 (when antivenom was unavailable) or admitted between December 2014 and September 2017 during times of antivenom shortage. We graphically compared the time courses of PR, aPTTr and fibrinogen between groups. Other endpoints were the length of hospital stay and the need for surgery or dialysis. RESULTS 84 patients were included: 42 in the antivenom group, 42 in the control group. Both groups were similar for age, sex-ratio, proportion of bleedings, necrosis, and severity. Most patients in the antivenom group received 3 vials. There were no significant differences in recovery of PR, aPTTr and fibrinogen through the first 24 h. Fibrinogen declined again in the control group at 30 h and showed a slower rise to normal concentration. There were no significant differences in any secondary endpoint. CONCLUSION Antivipmyn Tri TM as currently used did not show any benefit in recovery from coagulopathy.
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Affiliation(s)
- Xavier Heckmann
- Department of Emergency, Western Guiana Hospital, Saint-Laurent-du-Maroni, French Guiana.,French Red Cross, Cayenne, French Guiana
| | - Véronique Lambert
- Department of Obstetrics and Gynaecology, Western Guiana Hospital, Saint-Laurent-du-Maroni, French Guiana
| | - Georges Mion
- Department of Anaesthesiology, Cochin Hospital, Paris, France
| | | | | | - Frédérique Perotti
- Department of Pharmacy, Western Guiana Hospital, Saint-Laurent-du-Maroni, French Guiana
| | - Jean-François Carod
- Department of Medical Biology, Western Guiana Hospital, Saint-Laurent-du-Maroni, French Guiana
| | - Anne Jolivet
- Department of Public Health, Western Guiana Hospital, Saint-Laurent-du-Maroni, French Guiana
| | - David Boels
- Poison Control Center, Angers University Hospital, Angers, France
| | - Ibrahim Lehida Andi
- Department of Anaesthesiology and Reanimation, Western Guiana Hospital, Saint-Laurent-du-Maroni, French Guiana
| | - Sébastien Larréché
- Department of Medical Biology, Bégin Military Teaching Hospital, Saint-Mandé, France
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Baum RA, Bronner J, Akpunonu PDS, Plott J, Bailey AM, Keyler DE. Crotalus durissus terrificus (viperidae; crotalinae) envenomation: Respiratory failure and treatment with antivipmyn TRI ® antivenom. Toxicon 2019; 163:32-35. [PMID: 30880190 DOI: 10.1016/j.toxicon.2019.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/07/2019] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
Abstract
We report an envenomation to a professional herpetologist by a South American rattlesnake (Crotalus durissus terrificus) that resulted in respiratory failure, and therapeutic improvement following antivenom administration. A 56-year-old male was bitten on the left wrist by a Crotalus durissus terrificus (C. d. terrificus) while attempting to tube the snake for maintaining safe control while performing venom extraction. The patient was intubated due to rapidly ensuing respiratory failure and administration of Antivipmyn-TRI® was initiated while being transported via ambulance. The patient was admitted to the hospital unconscious and unresponsive. Mechanical ventilation was required until 5 h after completion of antivenom administration. No significant adverse effects were observed with antivenom administration. The patient was discharged approximately 55 h following envenomation. This is the first reported case in the United States of a patient following a C. d. terrificus envenomation with consequent respiratory failure, and in which Antivipmyn-TRI® was successfully administered.
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Affiliation(s)
- R A Baum
- University of Kentucky HealthCare, Lexington, KY, 40536, USA; College of Pharmacy, University of Kentucky, Lexington, KY, 40504, USA
| | - J Bronner
- Department of Emergency Medicine, University of Kentucky-Chandler Medical Center, Lexington, KY, 40536, USA
| | - P D S Akpunonu
- Department of Emergency Medicine, University of Kentucky-Chandler Medical Center, Lexington, KY, 40536, USA
| | - J Plott
- College of Pharmacy, University of Kentucky, Lexington, KY, 40504, USA
| | - A M Bailey
- University of Kentucky HealthCare, Lexington, KY, 40536, USA; College of Pharmacy, University of Kentucky, Lexington, KY, 40504, USA
| | - D E Keyler
- Department of Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis, MN, 55455, USA.
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Abstract
The most serious complications of the central nervous system that occur after venomous snake bite are intracranial hemorrhage and ischemic stroke.We present a rarely seen central nervous system complication, acute demyelinating encephalomyelitis, after a treated Deinagkistrodon's viper bite.On April 5, 2015, a 50-year-old male farmer was bitten on his right leg by a Deinagkistrodon's viper. The bite rendered the victim unconscious for 14 days, during which he was treated with tetanus toxoid and polyvalent antisnake venom. Acute demyelinating encephalomyelitis (ADEM) was suspected after magnetic resonance imaging of the brain. After a high dose of methylprednisolone was used as diagnostic treatment, the patient started recovering fast.ADEM is a rare complication after snake bite, and is triggered by venom or antivenin. Magnetic resonance imaging helps in the early diagnosis of ADEM, and high-dose corticosteroid therapy appears to be effective in ADEM after viper bite or antivenin management.
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Affiliation(s)
- Anyi Xu
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University
| | - Renfei Shan
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University
| | - Daochao Huang
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University
| | - Jiajia Zhou
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University
| | | | - Jie Qin
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University
- Correspondence: Jie Qin, Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University. No. 150 Ximen Street, Linhai, China (e-mail: )
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Abstract
Snakebite is classified by the WHO as a neglected tropical disease. Envenoming is a significant public health problem in tropical and subtropical regions. Neurotoxicity is a key feature of some envenomings, and there are many unanswered questions regarding this manifestation. Acute neuromuscular weakness with respiratory involvement is the most clinically important neurotoxic effect. Data is limited on the many other acute neurotoxic manifestations, and especially delayed neurotoxicity. Symptom evolution and recovery, patterns of weakness, respiratory involvement, and response to antivenom and acetyl cholinesterase inhibitors are variable, and seem to depend on the snake species, type of neurotoxicity, and geographical variations. Recent data have challenged the traditional concepts of neurotoxicity in snake envenoming, and highlight the rich diversity of snake neurotoxins. A uniform system of classification of the pattern of neuromuscular weakness and models for predicting type of toxicity and development of respiratory weakness are still lacking, and would greatly aid clinical decision making and future research. This review attempts to update the reader on the current state of knowledge regarding this important issue.
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Affiliation(s)
- Udaya K. Ranawaka
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
- * E-mail:
| | - David G. Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Del Brutto OH. Neurological effects of venomous bites and stings: snakes, spiders, and scorpions. HANDBOOK OF CLINICAL NEUROLOGY 2013; 114:349-68. [PMID: 23829924 DOI: 10.1016/b978-0-444-53490-3.00028-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Snake and spider bites, as well as scorpion sting envenoming, are neglected diseases affecting millions of people all over the world. Neurological complications vary according to the offending animal, and are often directly related to toxic effects of the venom, affecting the central nervous system, the neuromuscular transmission, the cardiovascular system, or the coagulation cascade. Snake bite envenoming may result in stroke or muscle paralysis. Metalloproteinases and other substances (common in vipers and colubrids) have anticoagulant or procoagulant activity, and may induce ischemic or hemorrhagic strokes. The venom of elapids is rich in neurotoxins affecting the neuromuscular transmission at either presynaptic or postsynaptic levels. The clinical picture of scorpion sting envenoming is dominated by muscle weakness associated with arterial hypertension, cardiac arrythmias, myocarditis, or pulmonary edema. These manifestations occur as the result of release of catecholamines into the bloodstream or due to direct cardiac toxicity of the venom. Cerebrovascular complications have been reported after the sting of the Indian red scorpion. Intracranial hemorrhages occur in the setting of acute increases in arterial blood pressure related to sympathetic overstimulation, and cerebral infarctions are related to either cerebral hypoperfusion, consumption coagulopathy, vasculitis, or cardiogenic brain embolism. Three main syndromes result from spider bite envenoming: latrodectism, loxoscelism, and funnel-web spider envenoming. Latrodectism is related to neurotoxins present in the venom of widow spiders. Most cases present with headache, lethargy, irritability, myalgia, tremor, fasciculation, or ataxia. Loxoscelism is caused by envenoming by spiders of the family Sicariidae. It may present with a stroke due to a severe coagulopathy. The venom of funnel-web spiders also has neurotoxins that stimulate neurotransmitter release, resulting in sensory disturbances and muscle paralysis. Proper management of the envenomed patient, including prompt transport to the hospital, correction of the hemostatic disorder, ventilatory support, and administration of antivenom, significantly reduce the risk of neurological complications which, in turn, reduce the mortality and improve the functional outcome of survivors.
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Affiliation(s)
- Oscar H Del Brutto
- School of Medicine, Universidad Espiritu Santo, Guayaquil, Ecuador; Department of Neurological Sciences, Hospital Clinica Kennedy, Guayaquil, Ecuador.
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Abstract
Snake bite envenoming is a neglected tropical disease affecting millions of people living in the developing world. According to the offending snake species, the clinical picture may be dominated by swelling and soft tissue necrosis in the bitten limb, or by systemic or neurological manifestations. Serious neurological complications, including stroke and muscle paralysis, are related to the toxic effects of the venom, which contains a complex mixture of toxins affecting the coagulation cascade, the neuromuscular transmission, or both. Metalloproteinases, serine proteases, and C-type lentins (common in viper and colubrid venoms) have anticoagulant or procoagulant activity and may be either agonists or antagonists of platelet aggregation; as a result, ischemic or hemorrhagic strokes may occur. In contrast, the venom of elapids is rich in phospholipase A(2) and three-finger proteins, which are potent neurotoxins affecting the neuromuscular transmission at either presynaptic or post-synaptic levels. Presynaptic-acting neurotoxins (called β-neurotoxins) inhibit the release of acetylcholine, while post-synaptic-acting neurotoxins (called α-neurotoxins) cause a reversible blockage of acetylcholine receptors. Proper management of the envenomed patient, including prompt transport to the hospital, correction of the hemostatic disorder, ventilatory support, and administration of antivenom, significantly reduces the risk of neurological complications which, in turn, reduce the mortality and improve the functional outcome of survivors.
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Affiliation(s)
- O H Del Brutto
- Department of Neurological Sciences, Hospital - Clínica Kennedy, Guayaquil, Ecuador.
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Chroni E, Papapetropoulos S, Argyriou AA, Papapetropoulos T. A case of fatal progressive neuropathy. Delayed consequence of multiple bites of a non-venomous snake? Clin Neurol Neurosurg 2006; 108:45-7. [PMID: 16311145 DOI: 10.1016/j.clineuro.2004.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2003] [Revised: 09/13/2004] [Accepted: 10/14/2004] [Indexed: 11/20/2022]
Abstract
Neurotoxicity is a common feature of the acute syndrome of systemic snake envenomation. In this report a patient with delayed onset of neurological manifestations after multiple bites of a non-venomous snake is described. The neurological cascade consisted of segmental painful muscle spasms presented several days after the snake bites, which gradually subsided and within a month was followed by muscle weakness in the legs. The latter progressed to flaccid quadriplegia with additional respiratory and autonomic failure leading to death after total disease duration of 5.5 months. The possibility that this unique neurological syndrome of fatal progressive neuropathy could be caused by either tetanus or an immune reaction initiated by snakebites is discussed.
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Affiliation(s)
- Elisabeth Chroni
- Department of Neurology, University of Patras Medical School, Rion-Patras, Greece.
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Chuang TY, Lin SW, Chan RC. Guillain-Barré syndrome: an unusual complication after snake bite. Arch Phys Med Rehabil 1996; 77:729-31. [PMID: 8670005 DOI: 10.1016/s0003-9993(96)90018-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The mortality rate of the Formosan krait bite has been reported to be 23%; death is from respiratory paralysis caused by neuromuscular junctions being blocked by bungarotoxin. This article presents the first case report of Guillain-Barré syndrome after snake envenomization. The patient presented with symmetric paresis and sensory signs in the upper and lower limbs, autonomic dysfunction, facial nerve involvement, and mild elevated cerebrospinal fluid protein at about 4 weeks after the bite. Electrodiagnostic studies revealed profound sensory and motor polyneuropathy. Repeated electrophysiologic findings confirmed nerve regeneration. The patient reached satisfactory functional outcome after a short-term intensive rehabilitation program despite severe axonal degeneration. This article also discusses the possible mechanism of immunopathogenesis of Guillain-Barré syndrome after krait bite.
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Affiliation(s)
- T Y Chuang
- Department of Physical Medicine and Rehabilitation, National Yang-Ming University School of Medicine, Taipei, Taiwan ROC
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Silva MD, Resende LAL, Ueda AK, Barraviera B, Mendes R, Montenegro MRG. Ação neuro-muscular do veneno crotálico: dados preliminares. ARQUIVOS DE NEURO-PSIQUIATRIA 1996. [DOI: 10.1590/s0004-282x1996000100001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Estudamos 6 pacientes, 2 cães e um coelho com intoxicação crotálica. Avaliamos a condução nervosa periférica sensitiva e motora, a transmissão neuromuscular e eletromiografias. As biópsias de músculo foram processadas por histoquímica. Os 6 pacientes apresentaram mononeuropatia sensitiva no nervo periférico adjacente ao local da inoculação do veneno e encontramos evidências histoquímicas de miopatia mitocondrial. Os defeitos da transmissão neuromuscular foram mínimos. A maioria dos autores admite que veneno crotálico determina síndrome miastênica. Nossos achados indicam que ptose palpebral, facies miastênico e fraqueza muscular observados após acidente crotálico, correspondem provavelmente a miopatia mitocondrial, muitas vezes transitória e reversível.
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