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Di Nicola MR, Crevani M, Avella I, Cerullo A, Dorne JLCM, Paolino G, Zattera C. A Guide to the Clinical Management of Vipera Snakebite in Italy. Toxins (Basel) 2024; 16:255. [PMID: 38922149 PMCID: PMC11209566 DOI: 10.3390/toxins16060255] [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: 04/30/2024] [Revised: 05/22/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024] Open
Abstract
The genus Vipera encompasses most species of medically significant venomous snakes of Europe, with Italy harbouring four of them. Envenomation by European vipers can result in severe consequences, but underreporting and the absence of standardised clinical protocols hinder effective snakebite management. This study provides an updated, detailed set of guidelines for the management and treatment of Vipera snakebite tailored for Italian clinicians. It includes taxonomic keys for snake identification, insights into viper venom composition, and recommendations for clinical management. Emphasis is placed on quick and reliable identification of medically relevant snake species, along with appropriate first aid measures. Criteria for antivenom administration are outlined, as well as indications on managing potential side effects. While the protocol is specific to Italy, its methodology can potentially be adapted for other European countries, depending on local resources. The promotion of comprehensive data collection and collaboration among Poison Control Centres is advocated to optimise envenomation management protocols and improve the reporting of epidemiological data concerning snakebite at the country level.
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Affiliation(s)
- Matteo Riccardo Di Nicola
- Unit of Dermatology and Cosmetology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
- Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Wildlife Health Ghent, Ghent University, 9820 Merelbeke, Belgium
- Asociación Herpetológica Española, Apartado de correos 191, 28911 Leganés, Spain
| | - Marta Crevani
- Poison Control Centre, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Ignazio Avella
- Landes-Offensive zur Entwicklung Wissenschaftlich-ökonomischer Exzellenz-Centre for Translational Biodiversity Genomics, Senckenberganlage 25, 60325 Frankfurt Am Main, Germany
- Institute for Insect Biotechnology, Justus-Liebig University Giessen, Heinrich-Buff-Ring 26-32, 35392 Giessen, Germany
| | - Anna Cerullo
- Department of Veterinary Sciences, University of Turin, L.go Braccini 2, 10095 Grugliasco, Italy
| | - Jean-Lou C. M. Dorne
- Methodological and Scientific Support Unit, European Food Safety Authority, Via Carlo Magno 1A, 43100 Parma, Italy
| | - Giovanni Paolino
- Unit of Dermatology and Cosmetology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Caterina Zattera
- Unit of Emergency Medicine, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo University Hospital, University of Pavia, P.Le Golgi, 19, 27100 Pavia, Italy
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Sassoè-Pognetto M, Cavalcante R, Paonessa M. Acute compartment syndrome and fasciotomy after a viper bite in Italy: a case report. Ital J Pediatr 2024; 50:70. [PMID: 38627836 PMCID: PMC11020867 DOI: 10.1186/s13052-024-01638-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/28/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Bites caused by European vipers are rare medical emergencies but can occasionally cause life-threatening complications. Viper venom causes local symptoms, which can be accompanied by systemic manifestations in severe cases. The local effects of snakebites include edema and, more rarely, necrosis and compartment syndrome. The consequences of envenomation are often more pronounced in children due to their smaller body size. CASE PRESENTATION We present the case of a 6-year-old girl who experienced multiple viper bites in the lower limb in northwest Italy. The girl received supportive care but progressed to develop compartment syndrome that required emergency fasciotomy. The patient's condition improved promptly after surgical decompression and administration of antivenom, but full recovery required prolonged hospitalization and rehabilitation. CONCLUSIONS This case highlights the importance of obtaining a timely assessment of the severity of viper envenomation without delaying the administration of antivenom in most serious cases. The presence of multiple bite marks on the patient is one factor that may help to predict the clinical severity of snakebites and anticipate symptom progression.
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Affiliation(s)
- Marco Sassoè-Pognetto
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, C.so Massimo d'Azeglio, 52, 10126, Torino, Italy.
| | - Riccardo Cavalcante
- Centro Emys Piemonte, ELEADE Società Cooperativa a.r.l, Chiaverano, TO, Italy
| | - Matteo Paonessa
- Pediatric Orthopedic Surgery Department, "Regina Margherita" Children's Hospital, Torino, Italy
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3
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Arestakesyan H, LeFevre N, Posnack N, Sarian A, Grigoryan V, Ayvazyan N, Voskanyan A, Sarvazyan N, Karabekian Z. Changes in attachment and metabolic activity of rat neonatal cardiomyocytes and nonmyocytes caused by Macrovipera lebetina obtusa venom. Toxicol In Vitro 2024; 95:105755. [PMID: 38061605 DOI: 10.1016/j.tiv.2023.105755] [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: 07/28/2023] [Revised: 11/03/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023]
Abstract
The Caucasian viper Macrovipera lebetina obtusa (MLO) is one of the most prevalent and venomous snakes in the Caucasus and the surrounding regions, yet the effects of MLO venom on cardiac function remain largely unknown. We examined the influence of MLO venom (crude and with inhibited metalloproteinases and phospholipase A2) on attachment and metabolic activity of rat neonatal cardiomyocytes (CM) and nonmyocytes (nCM), assessed at 1 and 24 h. After exposing both CM and nCM to varying concentrations of MLO venom, we observed immediate cytotoxic effects at a concentration of 100 μg/ml, causing detachment from the culture substrate. At lower MLO venom concentrations both cell types detached in a dose-dependent manner. Inhibition of MLO venom metalloproteinases significantly improved CM and nCM attachment after 1-hour exposure. At 24-hour exposure to metalloproteinases inhibited venom statistically significant enhancement was observed only in nCM attachment. However, metabolic activity of CM and nCM did not decrease upon exposure to the lower dose of the venom. Moreover, we demonstrated that metalloproteinases and phospholipases A2 are not the components of the MLO venom that change metabolic activity of both CM and nCM. These results provide a valuable platform to study the impact of MLO venom on prey cardiac function. They also call for further exploration of individual venom components for pharmaceutical purposes.
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Affiliation(s)
- Hovhannes Arestakesyan
- Orbeli Institute of Physiology, National Academy of Sciences, 22 Orbeli Bros. St., Yerevan 0028, Armenia; Department of Pharmacology and Physiology, School of Medicine and Health Sciences, The George Washington University, Washington, DC 20037, USA
| | - Narine LeFevre
- Department of Pharmacology and Physiology, School of Medicine and Health Sciences, The George Washington University, Washington, DC 20037, USA
| | - Nikki Posnack
- Department of Pharmacology and Physiology, School of Medicine and Health Sciences, The George Washington University, Washington, DC 20037, USA; Children's National Heart Institute, Sheikh Zayed Institute of Pediatric Surgical Innovation, Washington, DC 20010, USA
| | - Arni Sarian
- Orbeli Institute of Physiology, National Academy of Sciences, 22 Orbeli Bros. St., Yerevan 0028, Armenia
| | - Vahan Grigoryan
- Orbeli Institute of Physiology, National Academy of Sciences, 22 Orbeli Bros. St., Yerevan 0028, Armenia
| | - Naira Ayvazyan
- Orbeli Institute of Physiology, National Academy of Sciences, 22 Orbeli Bros. St., Yerevan 0028, Armenia
| | - Armen Voskanyan
- Orbeli Institute of Physiology, National Academy of Sciences, 22 Orbeli Bros. St., Yerevan 0028, Armenia
| | - Narine Sarvazyan
- Orbeli Institute of Physiology, National Academy of Sciences, 22 Orbeli Bros. St., Yerevan 0028, Armenia; Department of Pharmacology and Physiology, School of Medicine and Health Sciences, The George Washington University, Washington, DC 20037, USA
| | - Zaruhi Karabekian
- Orbeli Institute of Physiology, National Academy of Sciences, 22 Orbeli Bros. St., Yerevan 0028, Armenia; Department of Pharmacology and Physiology, School of Medicine and Health Sciences, The George Washington University, Washington, DC 20037, USA.
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Gamulin E, Mateljak Lukačević S, Halassy B, Kurtović T. Snake Antivenoms-Toward Better Understanding of the Administration Route. Toxins (Basel) 2023; 15:398. [PMID: 37368699 DOI: 10.3390/toxins15060398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Envenomations induced by animal bites and stings constitute a significant public health burden. Even though a standardized protocol does not exist, parenterally administered polyclonal antivenoms remain the mainstay in snakebite therapy. There is a prevailing opinion that their application by the i.m. route has poor efficacy and that i.v. administration should preferentially be chosen in order to achieve better accomplishment of the antivenom therapeutic activity. Recently, it has been demonstrated that neutralization not only in the systemic circulation but also in the lymphatic system might be of great importance for the clinical outcome since it represents another relevant body compartment through which the absorption of the venom components occurs. In this review, the present-day and summarized knowledge of the laboratory and clinical findings on the i.v. and i.m. routes of antivenom administration is provided, with a special emphasis on the contribution of the lymphatic system to the process of venom elimination. Until now, antivenom-mediated neutralization has not yet been discussed in the context of the synergistic action of both blood and lymph. A current viewpoint might help to improve the comprehension of the venom/antivenom pharmacokinetics and the optimal approach for drug application. There is a great need for additional dependable, practical, well-designed studies, as well as more practice-related experience reports. As a result, opportunities for resolving long-standing disputes over choosing one therapeutic principle over another might be created, improving the safety and effectiveness of snakebite management.
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Affiliation(s)
- Erika Gamulin
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Sanja Mateljak Lukačević
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
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Sassoè M. Envenomation by Vipera aspis in Piedmont (Italy): A report of three cases, including one case with neurological symptoms. Toxicon 2023; 230:107154. [PMID: 37169267 DOI: 10.1016/j.toxicon.2023.107154] [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: 03/30/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 05/13/2023]
Abstract
This report describes three cases of human envenomation by the asp viper (Vipera aspis) in Piedmont, north-west Italy. A woman was bitten on the ankle while she was hiking and two herpetologists received bites on the hand while they were manipulating the animals. In the first case, the victim presented severe systemic symptoms (abdominal pain, vomiting, diarrhea) that required treatment with two vials of antivenom and hospitalization for one week. In the second case, the patient manifested neurological symptoms (blepharoptosis, ophtalmoplegia); he was treated with antivenom and discharged after five days. In the third case, the patient was bitten by a juvenile viper and showed only local symptoms (edema and bruising). All patients reported prolonged functional impairment after discharge from hospital. Although uncommon, envenomation by Vipera aspis can cause severe consequences that require immediate management and antivenom administration. These cases highlight the importance of obtaining better knowledge of the intraspecific variability of venoms and its clinical significance, as well as of the factors that determine the severity of snakebite injuries.
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Affiliation(s)
- Marco Sassoè
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, C.so Massimo d'Azeglio, 52, 10126, Torino, Italy.
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Navaeifar MR, Zakariaei Z, Ghadiri A, Soleymani M, Zakariaei A. Compartment syndrome following snakebite in a boy: A case report and literature review. Int J Surg Case Rep 2023; 105:108050. [PMID: 36989626 PMCID: PMC10074563 DOI: 10.1016/j.ijscr.2023.108050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/12/2023] [Accepted: 03/17/2023] [Indexed: 03/28/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Snake bites represent a significant public health issue worldwide, as venomous snake bites can result in lethal consequences if not treated promptly, including both local and systemic effects. The local symptoms of a snake bite commonly include tissue necrosis, edema, and compartment syndrome (CS). While CS is a rare complication following a snake bite, it may be more pronounced in children who typically have lower total dilution volume. Currently, the administration of anti-snake venom and prompt fasciotomy are the only specific treatments available for CS. CASE PRESENTATION The present report details a case of CS of the right upper extremity in a three-year-old boy who suffered a snake bite on his right hand and was brought to the emergency department of a hospital in northern Iran after a lapse of 14 h. CLINICAL DISCUSSION Snakebites frequently occur in the extremities, with about two thirds of them happening in the upper extremities. The skin of the dorsum is extremely thin, there is essentially little subcutaneous fat tissue, and there are numerous superficial veins in this area, particularly the hand. CONCLUSIONS Following snake bites, the use of proximal tourniquets should be avoided, and the public's awareness of this need should be encouraged through health education. The prognosis for recovery following fasciotomy and the significance of follow-up and rehabilitation should also be explained to patients.
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Affiliation(s)
- Mohammad Reza Navaeifar
- Pediatric Infectious Disease Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zakaria Zakariaei
- Toxicology and Forensic Medicine Division, Mazandaran Registry Center for Opioids Poisoning, Orthopedic Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Abolfazl Ghadiri
- Department of Orthopedics, Orthopedic Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mostafa Soleymani
- Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ashkan Zakariaei
- Student Research Committee, Babol Branch, Islamic Azad University, Babol, Iran
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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.
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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.
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8
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Bernasconi L, Schicchi A, Pirozzolo R, Negrini V, Scaravaggi G, Lonati D, Petrolini VM, Locatelli CA. Coronary thrombosis after European adder bite in a patient on dual antiplatelet therapy: A case report. Toxicon 2022; 220:106961. [DOI: 10.1016/j.toxicon.2022.106961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/20/2022] [Accepted: 10/28/2022] [Indexed: 11/08/2022]
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9
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Blasco Mariño R, Soteras Martínez I, Hernandez Roca AI, Zafren K. Isolated Ptosis Following a Vipera aspis Bite. Wilderness Environ Med 2022; 33:245-247. [PMID: 35367125 DOI: 10.1016/j.wem.2022.02.007] [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: 10/05/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/18/2022]
Abstract
In Spain, snakebites are uncommon medical emergencies that cause barely 100 hospitalizations annually. Most of the venomous bites are by snakes of the Viperidae family. Venom from Vipera snakes is reported to have cytotoxic and hematotoxic effects, and neurological effects have also been described. Ptosis (cranial nerve III palsy) is the most common sign, although any cranial nerve can be affected. We describe isolated ptosis, which was very likely after a Vipera aspis bite in the East Catalonian Pyrenees. No antivenom was administered. The ptosis resolved spontaneously within 10 h. Although neurologic findings are usually mild, they indicate a moderate or severe envenomation. Treating snakebites can be challenging for clinicians, especially when there are uncommon clinical manifestations. A toxicologist at a poison center should be consulted to help guide management. Development of local protocols may provide clinical support.
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Affiliation(s)
- Robert Blasco Mariño
- Department of Anesthesiology, Vall d'Hebron University Hospital, Barcelona, Spain; Department of Medical Science, Faculty of Medicine, University of Girona, Girona, Spain.
| | - Iñigo Soteras Martínez
- Department of Medical Science, Faculty of Medicine, University of Girona, Girona, Spain; Department of Emergency, Cerdanya Hospital, Puigcerdà, Spain; Sistema Emergències Mèdiques (SEM), Catalonia, Spain
| | | | - Ken Zafren
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, Alaska; Department of Emergency Medicine, Stanford University Medical Center, Stanford, California; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland
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Tunjić Pejak D, Nesek Adam V, Srzić I. VENOMOUS SNAKEBITES IN CROATIA, CLINICAL PRESENTATION, DIAGNOSIS AND TREATMENT. Acta Clin Croat 2022; 61:59-66. [PMID: 36304803 PMCID: PMC9536165 DOI: 10.20471/acc.2022.61.s1.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Venomous snake bites are recognized as a major public health problem, affecting mostly poor, underdeveloped areas in the tropical and subtropical areas. Every year, more than three million bite cases and about 100,000 deaths are registered worldwide. Over the past years, 632 people have been hospitalized in Croatia with only 3 deaths due to venomous snake bites. Favorable geographic position, warm climate and great biodiversity of Croatia have resulted in the development of a total of 15 species of snakes, of which only 3 are venomous: horned viper (Vipera ammodytes), the common European viper (Vipera berus) and meadow viper (Vipera ursinii macrops). Snake venom envenomation is called ophidism (greek ofis=snake). Snake venoms are complex mixtures of proteins and toxins that have a wide range of toxic effects. The clinical presentation of ophidism is due to hematotoxic, neurotoxic, myotoxic (cardiotoxic) and cytotoxic effects of venom. There is currently no test to identify patients with a systemic spread of the venom, the diagnosis is made by a combination of diagnostic tests, clinical symptoms and sings of systemic envenomation. Ophidism is a medical condition that requires urgent treatment. Following first aid given at the scene, the patient should be transported to the closest medical facility to assess the severity of the clinical presentation in a timely manner and take the necessary treatment measures.
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Affiliation(s)
| | - Višnja Nesek Adam
- Clinical Hospital Sveti Duh, Department of Emergency Medicine, Zagreb;,Clinic for Anesthesiology, Resuscitation and Intensive Care, Clinical Hospital Sveti Duh, Zagreb,,Faculty of Medicine in Osijek, J. J. Strossmayer University, Osijek
| | - Ivana Srzić
- Clinical Hospital Sveti Duh, Department of Emergency Medicine, Zagreb
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11
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Lamas A, Fragoso J, Ferreira M, Cipriano A, Alves R. Case Report: Anaphylactoid Shock Associated with Snakebite Envenoming in Portugal. Am J Trop Med Hyg 2021; 106:342-344. [PMID: 34695794 PMCID: PMC8733493 DOI: 10.4269/ajtmh.21-0671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/02/2021] [Indexed: 01/03/2023] Open
Abstract
Although rare in Portugal, snakebite envenoming entails severe morbidity and mortality. We present the case of a 65-year-old woman bitten on her leg in a northern coastal region in Portugal, on a walk during the COVID-19 pandemic lockdown. Despite first looking for help at the nearest pharmacy, she developed anaphylactoid shock and was promptly driven to a tertiary hospital, where antivenom was administered in a timely manner under close monitoring. Prophylactic antibiotics were started and maintained based on elevated inflammatory markers and signs of wound inflammation. She evolved favorably, with rapid weaning of vasopressors and resolution of end-organ dysfunction. This case highlights the importance of prompt recognition and describes crucial steps in envenomation management in a country where snakebite is infrequent, but potentially fatal.
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Affiliation(s)
- António Lamas
- Serviço de Medicina Interna, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Joana Fragoso
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marli Ferreira
- Serviço de Medicina Interna, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Cipriano
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Rute Alves
- Serviço de Cuidados Intensivos, Centro Hospitalar Universitário do Porto, Porto, Portugal
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12
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Kurtović T, Lang Balija M, Brvar M, Dobaja Borak M, Mateljak Lukačević S, Halassy B. Comparison of Preclinical Properties of Several Available Antivenoms in the Search for Effective Treatment of Vipera ammodytes and Vipera berus Envenoming. Toxins (Basel) 2021; 13:toxins13030211. [PMID: 33805701 PMCID: PMC8001446 DOI: 10.3390/toxins13030211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/05/2021] [Accepted: 03/10/2021] [Indexed: 11/16/2022] Open
Abstract
Snakebites are a relatively rare medical emergency in Europe. In more than half of the annual cases caused by Vipera ammodytes, Vipera berus, and Vipera aspis, immunotherapy with animal-derived antivenom is indicated. Among eight products recently identified as available against European medically relevant species, only Zagreb antivenom, Viperfav, and ViperaTAb have been used almost exclusively for decades. Zagreb antivenom comprises V. ammodytes-specific F(ab')2 fragments. Viperfav is a polyspecific preparation based on F(ab')2 fragments against V. aspis, V. berus, and V. ammodytes venoms. ViperaTAb contains Fab fragments against the venom of V. berus. In 2014 the production of Zagreb antivenom was discontinued. Additionally, in the period of 2017 to 2018 a shortage of Viperfav occurred. Due to a lack of the product indicated for the treatment of V. ammodytes bites, other antivenoms were implemented into clinical practice without comparative assessment of their eligibility. The aim of our work was to identify a high-quality antivenom that might ensure the successful treatment of V. ammodytes and V. berus bites at the preclinical level. Differentiation between bites from these two species is difficult and unreliable in clinical practice, so the availability of a unique antivenom applicable in the treatment of envenoming caused by both species would be the most advantageous for Southeastern Europe. Zagreb antivenom, Viperfav, and ViperaTAb, as well as Viper venom antitoxin for V. berus envenoming and the in-development Inoserp Europe, which was designed to treat envenoming caused by all medically important European snakes, were comparatively tested for the first time. Emphasis was placed on their physicochemical properties, primarily purity and aggregate content, as well as their in vivo protective efficacies. As Zagreb antivenom is no longer available on the European market, Viperfav is the highest-quality product currently available and the only antivenom whose neutralisation potency against V. ammodytes and V. berus venoms was above regulatory requirements.
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Affiliation(s)
- Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
- Correspondence: (T.K.); (B.H.)
| | - Maja Lang Balija
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000 Ljubljana, Slovenia; (M.B.); (M.D.B.)
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Zaloška Cesta 4, 1000 Ljubljana, Slovenia
| | - Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000 Ljubljana, Slovenia; (M.B.); (M.D.B.)
| | - Sanja Mateljak Lukačević
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
- Correspondence: (T.K.); (B.H.)
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13
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Di Nicola MR, Pontara A, Kass GEN, Kramer NI, Avella I, Pampena R, Mercuri SR, Dorne JLCM, Paolino G. Vipers of Major clinical relevance in Europe: Taxonomy, venom composition, toxicology and clinical management of human bites. Toxicology 2021; 453:152724. [PMID: 33610611 DOI: 10.1016/j.tox.2021.152724] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/09/2021] [Accepted: 02/13/2021] [Indexed: 12/14/2022]
Abstract
Snakebites in Europe are mostly due to bites from Viperidae species of the genus Vipera. This represents a neglected public health hazard with poorly defined incidence, morbidity and mortality. In Europe, fourteen species of "true vipers" (subfamily Viperinae) are present, eleven of which belong to the genus Vipera. Amongst these, the main medically relevant species due to their greater diffusion across Europe and the highest number of registered snakebites are six, namely: Vipera ammodytes, V. aspis, V. berus, V. latastei, V. seoanei and V. ursinii. Generally speaking, viper venom composition is characterised by many different toxin families, like phospholipases A2, snake venom serine proteases, snake venom metalloproteases, cysteine-rich secretory proteins, C-type lectins, disintegrins, haemorrhagic factors and coagulation inhibitors. A suspected snakebite is often associated with severe pain, erythema, oedema and, subsequently, the onset of an ecchymotic area around one or two visible fang marks. In the field, the affected limb should be immobilised and mildly compressed with a bandage, which can then be removed once the patient is being treated in hospital. The clinician should advise the patient to remain calm to reduce blood circulation and, therefore, decrease the spread of the toxins. In the case of pain, an analgesic therapy can be administered, the affected area can be treated with hydrogen peroxide or clean water. However, anti-inflammatory drugs and disinfection with alcohol or alcoholic substances should be avoided. For each patient, clinical chemistry and ECG are always a pre-requisite as well as the evaluation of the tetanus immunisation status and for which immunisation may be provided if needed. The treatment of any clinical complication, due to the envenomation, does not differ from treatments of emergency nature. Antivenom is recommended when signs of systemic envenomation exist or in case of advanced local or systemic progressive symptoms. Recommendations for future work concludes. The aim of this review is to support clinicians for the clinical management of viper envenomation, through taxonomic keys for main species identification, description of venom composition and mode of action of known toxins and provide a standardised clinical protocol and antivenom administration.
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Affiliation(s)
| | - Andrea Pontara
- Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - George E N Kass
- European Food Safety Authority, Scientific Committee and Emerging Risks unit, 43126 Parma, Italy
| | - Nynke I Kramer
- Institute for Risk Assessment Sciences, University of Utrecht, Utrecht, the Netherlands
| | - Ignazio Avella
- CIBIO/InBIO - Centro de Investigação em Biodiversidade e Recursos Genéticos da Universidade do Porto, Rua Padre Armando Quintas 7, 4485-661, Vairão, Portugal; Evolutionary and Translational Venomics Laboratory, Instituto de Biomedicina de Valencia - CSIC, Calle Jaime Roig 11, 46010, Valencia, Spain
| | - Riccardo Pampena
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
| | | | - Jean Lou C M Dorne
- European Food Safety Authority, Scientific Committee and Emerging Risks unit, 43126 Parma, Italy
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Carvalho J, Moinho R, Macao P, Oliveira G. When snakebites complicate: a paediatric case with shock and compartment syndrome. BMJ Case Rep 2021; 14:14/2/e240206. [PMID: 33563677 PMCID: PMC7875306 DOI: 10.1136/bcr-2020-240206] [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] Open
Abstract
We report the case of an 11-year-old boy brought to our emergency department 2 hours after a viper bite to his right hand. He suffered severe pain and rapidly progressive swelling with signs of haemodynamic compromise in keeping with distributive shock. The oedema progressed from his right wrist upwards to his forearm and upper arm with compartment syndrome ultimately resulting. He underwent fasciotomy of the right upper limb and antivenom serum was given. The patient required vasopressors for 48 hours and a total of nine surgical interventions were necessary. In the event of a snakebite, it is essential to promptly recognise the signs of severity, complications and indications for the administration of antivenom serum. We intend to highlight this rare shock aetiology and the need for emergency management if severe clinical signs are present. Early administration of antivenom serum is essential and it should be available in all emergency departments.
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Affiliation(s)
- Joana Carvalho
- Pediatric Department, Unidade Local de Saude de Matosinhos EPE, Senhora da Hora, Portugal .,Pediatric Intensive Care Unit, Centro Hospitalar e Universitario de Coimbra EPE Hospital Pediatrico de Coimbra, Coimbra, Coimbra, Portugal
| | - Rita Moinho
- Pediatric Intensive Care Unit, Centro Hospitalar e Universitario de Coimbra EPE Hospital Pediatrico de Coimbra, Coimbra, Coimbra, Portugal
| | - Patricia Macao
- Pediatric Emergency Service, Centro Hospitalar e Universitario de Coimbra EPE Hospital Pediátrico de Coimbra, Coimbra, Coimbra, Portugal,University Clinic of Pediatrics, Universidade de Coimbra Faculdade de Medicina, Coimbra, Coimbra, Portugal
| | - Guiomar Oliveira
- University Clinic of Pediatrics, Universidade de Coimbra Faculdade de Medicina, Coimbra, Coimbra, Portugal,Child Developmental Center, Centro Hospitalar e Universitario de Coimbra EPE Hospital Pediátrico de Coimbra, Coimbra, Coimbra, Portugal
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15
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Paolino G, Di Nicola MR, Pontara A, Didona D, Moliterni E, Mercuri SR, Grano M, Borgianni N, Kumar R, Pampena R. Vipera snakebite in Europe: a systematic review of a neglected disease. J Eur Acad Dermatol Venereol 2020; 34:2247-2260. [PMID: 32530549 DOI: 10.1111/jdv.16722] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022]
Abstract
In 2009, snakebites were included in the list of the World Health Organization (WHO) neglected diseases. Dermatological literature lacks current and up-to-date articles about snakebites and their management, despite the fact that dermatologists, especially from rural hospitals, can be called into the emergency room to consult the management of suspected snakebites. In this systematic review, we highlighted the main clinical and laboratory aspects of snakebites from Vipera spp. in Europe, by reviewing 3574 studies initially retrieved from PubMed, Embase and Cochrane CENTRAL databases. Of these, 78 were finally included in the systematic review. We found that the most involved taxon was V. berus in 63.3% and the most involved anatomic site of the bite was the upper limbs 53.1% with fang marks reported in 90.5%. The mean age of the patients was 32.9 years, and bites were slightly more common among males (58.2%). A wound washing was performed in 86.9% of cases before the hospitalization. The most frequently reported grade of envenomation was G2 (42.2%). In addition to local dermatological symptoms (extended erythema, oedema, cutaneous necrosis, hives, purpura, petechiae, acute compartment syndrome), numerous systemic symptoms have also been reported, including fatigue (14.4%), pain (75.3%), fever (49.2%), direct anaphylactoid reaction (5.3%), anxiety (60.8%), cranial nerve neurotoxicity (14.8%), dysesthesia/paraesthesia (7.9%), vomiting (33.7%), abdominal pain (23.3%), diarrhoea (15.4%), dyspnoea (6.3%), proteinuria (10.6%) and haematuria (9.3%). Secondary infections were present in 3.5% and disseminated intravascular coagulation in 3.1% of cases, and fasciotomy was performed in 4.2% cases, while an amputation in 6.9%. Only 0.9% of patients died. Antivenom was administered in 3053 cases. In conclusion, there is a pressing need for robust multi-centre randomized control trials, standardized protocol for snakebite management and antivenom administration across Europe and a National snakebite register for each European country.
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Affiliation(s)
- G Paolino
- Clinica Dermatologica, La Sapienza University of Rome, Rome, Italy.,Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - A Pontara
- Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - D Didona
- Department of Dermatology and Allergology, Philipps Medical University of Marburg, Marburg, Germany
| | - E Moliterni
- Clinica Dermatologica, La Sapienza University of Rome, Rome, Italy
| | - S R Mercuri
- Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | - M Grano
- Via Valcenischia, Rome, Italy
| | | | - R Kumar
- Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | - R Pampena
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
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16
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Boels D, Hamel JF, Le Roux G, Labadie M, Paret N, Delcourt N, Langrand J, Puskarczyk E, Nisse P, Sinno-Tellier S, de Haro L. Snake bites by European vipers in Mainland France in 2017-2018: comparison of two antivenoms Viperfav ® and Viperatab ®. Clin Toxicol (Phila) 2020; 58:1050-1057. [PMID: 32134691 DOI: 10.1080/15563650.2020.1726377] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Context: Today, immunotherapy with Fab or F(ab')2 fragments is considered as a gold standard treatment for patients bitten by vipers. We compared the efficiency of two antivenoms, Viperfav® and Viperatab®, in mainland France in 2017-2018 with data provided by the French poison control centre (PCC).Methods: Patients with a moderate (2a and 2b) or severe (3) envenomation after a European viper bite and treated with immunotherapy were included and the markers chosen were the risk of post-antivenom treatment worsening, duration of hospital stay and persistent functional discomfort on day 15. Statistical studies were based on multivariate data analysis.Results: Two hundred and ninety-seven cases were recorded. One hundred and eighty-two (61.3%) patients received Viperfav® and 115 (38.7%) received Viperatab®. Compared to Viperfav®, use of Viperatab® significantly increased the risk of post-antivenom treatment worsening (OR* 12.05; 95%CI [3.11; 46.70]; p < .001). No significant difference between these antivenoms was recorded with respect to the duration of hospital stay and persistent functional discomfort on day 15. Viperfav® and Viperatab® have a similar tolerance (p > .21). Otherwise, duration of hospitalisation was significantly increased by a delay of immunotherapy infusion of more than 12 h (OR 2.70; 95%CI [1.45-5.06]; p = .002) or a preventive administration of LMWH (OR 6.55; 95%CI [1.58-27.13]; p=.02).Discussion: While Viperfav® and Viperatab® have a similar tolerance, our data show that Viperatab® was associated with a higher risk of post-antivenom treatment worsening compared to Viperfav®. Furthermore, this study confirms that the antivenom should be used as soon as possible. Indeed, patients receiving the immunotherapy infusion from the grade 2b presented significantly more frequent exacerbated symptoms (OR 3.99; 95%CI [1.16-13.73]; p=.028) after the antivenom infusion compared to grade 2a group.Conclusions: Whereas no significant difference between these antivenoms was recorded with respect to the duration of hospital stay and persistent functional discomfort on day 15, use of Viperatab®, compared to Viperfav®, significantly increased the risk of post-antivenom treatment worsening (OR* 12.05; 95%CI [3.11; 46.70]; p < .001). Taken together, these data show that Viperfav® is the treatment of choice for the management of snake bites in France.
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Affiliation(s)
- David Boels
- Pharmacology and Toxicology Department, Nantes University Hospital, Nantes, France, and Inserm UMRS 1144, University of Paris, France
| | - Jean François Hamel
- Representative of Clinical Research and Innovation, Angers University Hospital, Angers, France
| | - Gaël Le Roux
- Poison Control Centre, Angers University Hospital, Angers, France
| | - Magali Labadie
- Poison Control Centre, Bordeaux University Hospital, Bordeaux, France
| | - Nathalie Paret
- Poison Control Centre, Lyon University Hospital, Lyon, France
| | - Nicolas Delcourt
- Poison Control Centre, Toulouse University Hospital, Toulouse, France
| | - Jérôme Langrand
- Poison Control Centre, Paris University Hospital, Paris, France
| | | | - Patrick Nisse
- Poison Control Centre, Lille University Hospital, Lille, France
| | - Sandra Sinno-Tellier
- ANSES, French Agency for Food, Environmental and Occupational Health Safety, Maisons-Alfort, France
| | - Luc de Haro
- Poison Control Centre, Marseille University Hospital, Marseille, France
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17
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Venomics of the asp viper Vipera aspis aspis from France. J Proteomics 2020; 218:103707. [PMID: 32087377 DOI: 10.1016/j.jprot.2020.103707] [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] [Received: 12/20/2019] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 12/15/2022]
Abstract
The asp viper Vipera aspis aspis is a venomous snake found in France, and despite its medical importance, the complete toxin repertoire produced is unknown. Here, we used a venomics approach to decipher the composition of its venom. Transcriptomic analysis revealed 80 venom-annotated sequences grouped into 16 gene families. Among the most represented toxins were snake venom metalloproteases (23%), phospholipases A2 (15%), serine proteases (13%), snake venom metalloprotease inhibitors (13%) and C-type lectins (12%). LC-MS of venoms revealed similar profiles regardless of the method of extraction (milking vs defensive bite). Proteomic analysis validated 57 venom-annotated transcriptomic sequences (>70%), including one for each of the 16 families, but also identified 7 sequences not initially annotated as venom proteins, including a serine protease, a disintegrin, a glutaminyl-peptide cyclotransferase, a proactivator polypeptide-like and 3 aminopeptidases. Interestingly, phospholipases A2 were the dominant proteins in the venom, among which included an ammodytoxin B-like sequence, which may explain the reported neurotoxicity following some asp viper envenomations. In total, 87 sequences were retrieved from the Vipera aspis aspis transcriptome and proteome, constituting a valuable resource that will help in understanding the toxinological basis of clinical signs of envenoming and for the mining of useful pharmacological compounds. BIOLOGICAL SIGNIFICANCE: The asp viper (Vipera aspis aspis) causes several hundred envenomations annually in France, including unusual cases with neurological signs, resulting in one death per year on average. Here, we performed a proteotranscriptomic analysis of V. a. aspis venom in order to provide a better understanding of its venom composition. We found that, as in other Vipera species, phospholipase A2 dominates in the venom, and the presence of a sequence related to ammodytoxin B may explain the reported neurotoxicity following some asp viper envenomations. Thus, this study will help in informing the toxinological basis of clinical signs of envenoming.
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18
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Vanni M, Intorre L, Corazza M, Meucci V, Parti S. A prospective multicenter observational study of Viperidae polyvalent immune F(ab') 2 antivenom administration for the treatment of viper envenomation in dogs. J Vet Emerg Crit Care (San Antonio) 2019; 30:34-40. [PMID: 31858721 DOI: 10.1111/vec.12917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 03/19/2018] [Accepted: 05/09/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To test an equine-derived polyvalent viperid antivenom (EPVA) in the treatment of dogs with evidence of viper envenomation. DESIGN Prospective, multicenter observational study. SETTING Veterinary emergency and critical care hospitals. ANIMALS A total of 82 client-owned dogs with progressive clinical signs after viperid snakebite were enrolled in the study. INTERVENTIONS Equine-derived polyvalent viperid antivenom was administered at a dosage of 1 mL/kg body weight, either by IV infusion or SC injection. MEASUREMENTS AND MAIN RESULTS A standardized snakebite severity score (SSS) was used to characterize the severity of envenomation and the clinical course after EPVA treatment. Most dogs had improved SSS both at 4 (65.8%) and 8 hours (81.7%) following EPVA administration. Five dogs died. At the 4-week assessment, 3 dogs had slightly abnormal hematological or coagulation parameters; all other surviving dogs showed no abnormalities. Antivenom-related acute or intermediate reactions occurred in 12 dogs (14.6%). CONCLUSIONS In the first study on antivenom in dogs in Italy, the effects of progressive viper envenomation were stabilized or reversed in the large majority of dogs receiving EPVA, as confirmed by the SSS analyses.
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Affiliation(s)
- Michele Vanni
- Section of Veterinary Pharmacology & Toxicology, Department of Veterinary Science, University of Pisa, Pisa, Italy
| | - Luigi Intorre
- Section of Veterinary Pharmacology & Toxicology, Department of Veterinary Science, University of Pisa, Pisa, Italy
| | - Michele Corazza
- Section of Veterinary Pharmacology & Toxicology, Department of Veterinary Science, University of Pisa, Pisa, Italy
| | - Valentina Meucci
- Section of Veterinary Pharmacology & Toxicology, Department of Veterinary Science, University of Pisa, Pisa, Italy
| | - Sandro Parti
- Sclavo Diagnostics International, Sovicille, Italy
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Morsures par vipères européennes en France métropolitaine en 2017 : utilisation de deux antivenins. Presse Med 2019; 48:723-725. [DOI: 10.1016/j.lpm.2019.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 03/12/2019] [Accepted: 05/07/2019] [Indexed: 10/26/2022] Open
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Lukšić B, Karabuva S, Markić J, Polić B, Kovačević T, Meštrović J, Križaj I. Thrombocytopenic purpura following envenomation by the nose-horned viper (Vipera ammodytes ammodytes): Two case reports. Medicine (Baltimore) 2018; 97:e13737. [PMID: 30593149 PMCID: PMC6314653 DOI: 10.1097/md.0000000000013737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Two clinical cases are reported of envenomation by the nose-horned viper (Vipera ammodytes ammodytes) venom of a 9-year-old boy and of an 84-year-old woman. PATIENT CONCERNS Both patients had been bitten on their extremities by such a snake in August near Split, a town in southern Croatia. DIAGNOSES Clinical manifestation of envenomation was severe in the case of the boy, being characterized by a severe coagulopathy. This was only just apparent in the case of the elderly woman, who suffered extensive local edema and hematoma at the site of the bite, together with a neurotoxic effect-bilateral ptosis. This was the first occasion of thrombocytopenic purpura being observed in patients envenomed by nose-horned viper venom. This unexpected clinical finding was characterized by an unusually profound thrombocytopenia of 5 and 10 × 10/L platelets of the respective patients on their admission to the hospital, together with purpura, observed on the face and thorax of both individuals. In the most serious cases, such pathology can be life threatening if not promptly recognized and treated. INTERVENTIONS The patients recovered quickly on receiving the specific antivenom along with all the usual supportive treatments. OUTCOMES No serious sequels were noticed at the moment of discharge. LESSONS Our finding constitutes an important message to clinicians to consider the possibility of such complications in the case of nose-horned viper envenomation.
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Affiliation(s)
- Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital of Split
- University of Split, School of Medicine
| | - Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital of Split
| | - Joško Markić
- University of Split, School of Medicine
- Department of Pediatrics, University Hospital of Split, Split
| | - Branka Polić
- Department of Pediatrics, University Hospital of Split, Split
| | - Tanja Kovačević
- Department of Pediatrics, University Hospital of Split, Split
| | - Julije Meštrović
- University of Split, School of Medicine
- Department of Pediatrics, University Hospital of Split, Split
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Ljubljana, Slovenia
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Zanetti G, Duregotti E, Locatelli CA, Giampreti A, Lonati D, Rossetto O, Pirazzini M. Variability in venom composition of European viper subspecies limits the cross-effectiveness of antivenoms. Sci Rep 2018; 8:9818. [PMID: 29959358 PMCID: PMC6026201 DOI: 10.1038/s41598-018-28135-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/14/2018] [Indexed: 12/17/2022] Open
Abstract
Medically relevant cases of snakebite in Europe are predominately caused by European vipers of the genus Vipera. Systemic envenoming by European vipers can cause severe pathology in humans and different clinical manifestations are associated with different members of this genus. The most representative vipers in Europe are V. aspis and V. berus and neurological symptoms have been reported in humans envenomed by the former but not by the latter species. In this study we determined the toxicological profile of V. aspis and V. berus venoms in vivo in mice and we tested the effectiveness of two antivenoms, commonly used as antidotes, in counteracting the specific activities of the two venoms. We found that V. aspis, but not V. berus, is neurotoxic and that this effect is due to the degeneration of peripheral nerve terminals at the NMJ and is not neutralized by the two tested antisera. Differently, V. berus causes a haemorrhagic effect, which is efficiently contrasted by the same antivenoms. These results indicate that the effectiveness of different antisera is strongly influenced by the variable composition of the venoms and reinforce the arguments supporting the use polyvalent antivenoms.
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Affiliation(s)
- Giulia Zanetti
- University of Padova, Department of Biomedical Sciences, Padova, 35131, Italy
| | - Elisa Duregotti
- University of Padova, Department of Biomedical Sciences, Padova, 35131, Italy
- King's College London, Department of Cardiology, James Black Centre, London, SE5 9NU, United Kingdom
| | - Carlo Alessandro Locatelli
- Istituti Clinici Scientifici Maugeri, IRCCS Maugeri Hospital and University of Pavia, Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Pavia, 27100, Italy
| | - Andrea Giampreti
- Istituti Clinici Scientifici Maugeri, IRCCS Maugeri Hospital and University of Pavia, Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Pavia, 27100, Italy
| | - Davide Lonati
- Istituti Clinici Scientifici Maugeri, IRCCS Maugeri Hospital and University of Pavia, Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Pavia, 27100, Italy
| | - Ornella Rossetto
- University of Padova, Department of Biomedical Sciences, Padova, 35131, Italy
| | - Marco Pirazzini
- University of Padova, Department of Biomedical Sciences, Padova, 35131, Italy.
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Karabuva S, Lukšić B, Brizić I, Latinović Z, Leonardi A, Križaj I. Ammodytin L is the main cardiotoxic component of the Vipera ammodytes ammodytes venom. Toxicon 2017; 139:94-100. [PMID: 29030107 DOI: 10.1016/j.toxicon.2017.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/08/2017] [Accepted: 10/08/2017] [Indexed: 11/15/2022]
Abstract
Venom of the nose-horned viper (V. a. ammodytes) as also venoms of some related European viperids can induce also cardiotoxic effects in mammals. In this work we demonstrated that the protein in the V. a. ammodytes venom acting on heart is a myotoxic secreted phospholipase A2 analogue ammodytin L (AtnL). In the isolated perfused rat heart AtnL induced significant and irreversible cardiotoxicity characterized by atrioventricular (AV) blockade. This venom protein induced appearance of high levels of creatine kinase, lactate dehydrogenase, aspartate aminotransferase and troponin I in the sinus effluent of the isolated heart, indicative for myocardial damage, which is obviously the primary cause of its cardiotoxic action. Gel filtration chromatography subfractions C1 and C2 of the V. a. ammodytes venom harboured most of the venom cardiotoxicity. As we showed, just these two subfractions contained also AtnL. Subfraction C1 in the final CF concentration 11.3 μg/mL (containing 3.1 μg/mL AtnL) induced a complete cardiac arrest while subfraction C2 in the final CF concentration 6.0 μg/mL (containing 0.8 μg/mL AtnL) and the pure AtnL (1.0 μg/mL) did not. Contrary to AtnL, subfraction C1 at 11.3 μg/mL was not able to induce the AV blockade. This exposed the only other cardiotoxic subfractions-specific venom protein, a cysteine-rich secretory protein (CRISP), as an additional venom component potentially involved in modulation of the heart activity. Cardiotoxicity reported in some cases of the adder (V. berus) venom and the asp viper (V. aspis) venom poisonings may be assigned to AtnL in these venoms.
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Affiliation(s)
- Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital of Split, Šoltanska 1, Split, Croatia.
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital of Split, Šoltanska 1, Split, Croatia; University of Split School of Medicine, Šoltanska 2, Split, Croatia.
| | - Ivica Brizić
- Department of Pharmacology, Mostar University School of Medicine, Bijeli brijeg bb, Mostar, Bosnia and Herzegovina.
| | - Zorica Latinović
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia; Jožef Stefan International Postgraduate School, Jamova cesta 39, Ljubljana, Slovenia.
| | - Adrijana Leonardi
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia.
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia.
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Malina T, Krecsák L, Westerström A, Szemán-Nagy G, Gyémánt G, M-Hamvas M, Rowan EG, Harvey AL, Warrell DA, Pál B, Rusznák Z, Vasas G. Individual variability of venom from the European adder (Vipera berus berus) from one locality in Eastern Hungary. Toxicon 2017; 135:59-70. [PMID: 28602828 DOI: 10.1016/j.toxicon.2017.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 06/06/2017] [Accepted: 06/07/2017] [Indexed: 11/28/2022]
Abstract
We have revealed intra-population variability among venom samples from several individual European adders (Vipera berus berus) within a defined population in Eastern Hungary. Individual differences in venom pattern were noticed, both gender-specific and age-related, by one-dimensional electrophoresis. Gelatin zymography demonstrated that these individual venoms have different degradation profiles indicating varying protease activity in the specimens from adders of different ages and genders. Some specimens shared a conserved region of substrate degradation, while others had lower or extremely low protease activity. Phospholipase A2 activity of venoms was similar but not identical. Interspecimen diversity of the venom phospholipase A2-spectra (based on the components' molecular masses) was detected by MALDI-TOF MS. The lethal toxicity of venoms (LD50) also showed differences among individual snakes. Extracted venom samples had varying neuromuscular paralysing effect on chick biventer cervicis nerve-muscle preparations. The paralysing effect of venom was lost when calcium in the physiological salt solution was replaced by strontium; indicating that the block of twitch responses to nerve stimulation is associated with the activity of a phospholipase-dependent neurotoxin. In contrast to the studied V. b. berus venoms from different geographical regions so far, this is the first V. b. berus population discovered to have predominantly neurotoxic neuromuscular activity. The relevance of varying venom yields is also discussed. This study demonstrates that individual venom variation among V. b. berus living in particular area of Eastern Hungary might contribute to a wider range of clinical manifestations of V. b. berus envenoming than elsewhere in Europe.
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Affiliation(s)
- Tamás Malina
- Pfizer Hungary Ltd., Medical Division, Alkotás u. 53, H-1123, Budapest, Hungary.
| | | | - Alexander Westerström
- Stockholm University, Alba Nova University Centre, Department of Physics, SE-10691, Stockholm, Sweden
| | - Gábor Szemán-Nagy
- University of Debrecen, Department of Biotechnology and Microbiology, P.O. Box 63. H-4010, Debrecen, Hungary
| | - Gyöngyi Gyémánt
- University of Debrecen, Department of Inorganic and Analytical Chemistry, Egyetem tér 1, H-4032, Debrecen, Hungary
| | - Márta M-Hamvas
- University of Debrecen, Department of Botany, Faculty of Science and Technology, Egyetem tér 1, H-4010, Debrecen, Hungary
| | - Edward G Rowan
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow, G4 0RE, United Kingdom
| | - Alan L Harvey
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow, G4 0RE, United Kingdom
| | - David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom
| | - Balázs Pál
- University of Debrecen, Medical and Health Science Centre, Department of Physiology, Nagyerdei Krt. 98, H-4012, Debrecen, Hungary
| | - Zoltán Rusznák
- University of Debrecen, Medical and Health Science Centre, Department of Physiology, Nagyerdei Krt. 98, H-4012, Debrecen, Hungary
| | - Gábor Vasas
- University of Debrecen, Department of Botany, Faculty of Science and Technology, Egyetem tér 1, H-4010, Debrecen, Hungary; CETOX - Analytical and Toxicological Research and Consultant Ltd., Egyetem tér 1, H-4032, Debrecen, Hungary
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24
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Lamb T, de Haro L, Lonati D, Brvar M, Eddleston M. Antivenom for European Vipera species envenoming. Clin Toxicol (Phila) 2017; 55:557-568. [PMID: 28349771 DOI: 10.1080/15563650.2017.1300261] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND European viper bite is relatively uncommon but can cause serious envenoming, particularly swelling and hemorrhage spreading from limb to trunk that can cause long term disability. Systemic features are relatively mild compared to many other venomous species. Moderate-to-severe envenoming requires antivenom, which is given many hundreds of times each year across the continent. Several Vipera spp antivenoms are produced in Europe, but there is little comparative information available for the antivenoms and none is licensed with the European Medicines Agency. We aimed to collect descriptive data on European viper antivenoms and assess their relative effectiveness. METHODS A systematic review of articles relating to antivenom in Europe was performed using the Medline medical database. The following keywords "Europ*" or the individual names of each European country and "antiven*" or "immun*" or "envenom*" and "snake" or "viper*" or "adder" were used. Articles published between 1 January 1996 and 11 March 2016 pertaining to clinical outcome, including case reports, were selected. Referenced articles in the indexed articles were explored for suitability and included if they met any of the criteria: specific antivenom used, route of antivenom administration, adverse reactions to antivenom therapy and length of hospital admission. All accepted abstracts from EAPCCT conferences since 2000 were searched and abstracts relating to Vipera spp envenoming were assessed for suitability. We extracted data on study type, safety and effectiveness. We sought information on antivenoms from manufacturers and individual patient data from authors of publications. Since individual patient data were only rarely available, we compared median length of stay between case series reporting each antivenom. We identified 40 papers and six published abstracts, and one unpublished paper that reported clinical cases and case series of envenomed patients treated with antivenom. No publication reported randomized controlled trials comparing any European Vipera antivenom with either placebo or another antivenom. 25 reports were of retrospective hospital- (n = 13) or poison center-based (n = 12) case series including five or more patients; a further 12 reports were either case reports or case series with less than five patients and one paper was a limited literature review. An additional nine papers reported prospective data; seven collected data remotely through poison service telephone communication with the attending physicians. Antivenoms available in Europe: Eight antivenoms are available for European Vipera spp envenoming; a material safety data sheet providing information on manufacture was available for seven. Six are raised against V. berus or V. ammodytes venom; the seventh is raised against a mixture of V. ammodytes, V. aspis and V. berus venom and the eighth is raised against V. ammodytes, Macrovipera lebetina and Montivipera xanthina venom. Six manufacturers recommended intramuscular administration while two recommended intravenous administration. No randomized control trials comparing the effectiveness of antivenoms were identified. Pre-clinical data: We found two papers presenting comparative preclinical data. Clinical data: Clinical studies were predominantly retrospective and contained clinical data on antivenom used in 2602 patients; where the antivenom was identified (n = 2174), 2061 (94.8%) received Zagreb, ViperFAV or ViperaTAb antivenoms. There were few published data on the other antivenoms. Repeated use of antivenom: Repeat doses were reported in 230/1491 of cases (15.4%) where this information was recorded. Outcome and length of hospital stay: Intravenous administration of antivenom was associated with shorter length of hospital stay (median length of hospital stay in studies of intravenous ViperFAV or ViperaTAb ranged from 1 to 4.8 days versus 2 to 18 days for intramuscular Bulbio or Zagreb antivenoms). Antivenom versus no antivenom: Some small studies demonstrated no difference in the length of hospital stay in patients with equivalent envenomation grading who either did or did not receive antivenom. Adverse events: Adverse reactions were reported in 37 of 2408 cases (1.5%) including seven cases of anaphylaxis. CONCLUSIONS There are very limited pre-clinical comparative data and no randomised controlled trials assessing effectiveness of the antivenoms against different Vipera species. Most descriptive data suggest the efficacy of Zagreb, ViperFAV and ViperaTAb antivenoms by the intravenous route but not intramuscular route, although this is level D evidence. Reported adverse reactions were rare, suggesting that the modern intravenous antivenoms are of good quality. Better and more systematic data, including perhaps randomized controlled trials comparing different antivenoms, are required for the many hundreds of antivenom administrations that occur annually across Europe.
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Affiliation(s)
- Thomas Lamb
- a Department of Pharmacology, Toxicology, and Therapeutics , University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
| | - Luc de Haro
- b Centre Antipoison , Hôpital Sainte Marguerite , Marseilles , France
| | - Davide Lonati
- c Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Istituti Clinici Scientifici Maugeri , IRCCS Maugeri Hospital and University of Pavia , Pavia , Italy
| | - Miran Brvar
- d Centre for Clinical Toxicology and Pharmacology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Michael Eddleston
- a Department of Pharmacology, Toxicology, and Therapeutics , University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
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25
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Karabuva S, Brizić I, Latinović Z, Leonardi A, Križaj I, Lukšić B. Cardiotoxic effects of the Vipera ammodytes ammodytes venom fractions in the isolated perfused rat heart. Toxicon 2016; 121:98-104. [PMID: 27623431 DOI: 10.1016/j.toxicon.2016.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/31/2016] [Accepted: 09/01/2016] [Indexed: 01/16/2023]
Abstract
The nose-horned viper (Vipera ammodytes ammodytes) is the most venomous European snake. Its venom is known as haematotoxic, myotoxic and neurotoxic but it exerts also cardiotoxic effects. To further explore the cardiotoxicity of the venom we separated it into four fractions by gel filtration chromatography. Three fractions that contain polypeptides (A, B, and C) were tested for their effects on isolated rat heart. Heart rate (HR), incidence of arrhythmias (atrioventricular (AV) blocks, ventricular tachycardia, ventricular fibrillation, and asystolia), coronary flow (CF), systolic, developed and diastolic left ventricular pressure (LVP) were measured before, during, and after the application of venom fractions in three different concentrations. Fraction A, containing proteins of 60-100 kDa, displayed no effect on the rat heart. Fractions B and C disturbed heart functioning in similar way, but with different potency that was higher by the latter. This was manifested by significant decrease of HR and CF, the increase of diastolic, and the decrease of systolic and developed LVPs. All hearts treated with fraction C in the final CF concentrations 22.5 and 37.5 μg/mL suffered rapid and irreversible asystolia without AV blockade. They underwent also ventricular fibrillation and ventricular tachycardia. Fraction B affected hearts only at the highest dose inducing asystolia in all hearts, ventricular fibrillation in 80% and ventricular tachycardia in 70% of the hearts. Venom fraction C induced 71% of all recorded heart rhythm disturbances, significantly more than fraction B, which induced 29%. Most abundant proteins in fraction C were secreted phospholipases A2 among which the venom component acting on the heart is most probably to be looked for.
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Affiliation(s)
- Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia.
| | - Ivica Brizić
- Department of Pharmacology, Mostar University School of Medicine, Bijeli brijeg bb, Mostar, Bosnia and Herzegovina.
| | - Zorica Latinović
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia; Jožef Stefan International Postgraduate School, Jamova cesta 39, Ljubljana, Slovenia.
| | - Adrijana Leonardi
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia.
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia; Department of Chemistry and Biochemistry, Faculty of Chemistry and Chemical Technology, University of Ljubljana, Aškerčeva cesta 5, Ljubljana, Slovenia.
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia; University of Split School of Medicine, Šoltanska 2, Split, Croatia.
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26
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Kurtović T, Brvar M, Grenc D, Lang Balija M, Križaj I, Halassy B. A Single Dose of Viperfav(TM) May Be Inadequate for Vipera ammodytes Snake Bite: A Case Report and Pharmacokinetic Evaluation. Toxins (Basel) 2016; 8:toxins8080244. [PMID: 27548220 PMCID: PMC4999860 DOI: 10.3390/toxins8080244] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/11/2016] [Indexed: 11/26/2022] Open
Abstract
ViperfavTM is a commercial F(ab’)2 antivenom prepared against European vipers venom. It is safe and effective for treating envenomation caused by Vipera aspis and Vipera berus. Therapeutic efficacy for treating Vipera ammodytes ammodytes (V. a. ammodytes) envenoming has not been yet described, although protective efficacy has been demonstrated in preclinical studies. We report on a 32-year-old man bitten by V. a. ammodytes who was treated with Viperfav™. Viperfav™ promptly reduced local extension and improved systemic pathological signs, but 24 h after the incident a recurrence of thrombocytopenia occurred despite a favorable pharmacokinetic profile with systemic clearance (1.64 (mL·h−1)·kg−1) and elimination half-life (97 h) among the highest ever reported. The recommended dose of Viperfav™ for V. aspis and V. berus bites may be inadequate for serious V. a. ammodytes envenomations. Following V. a. ammodytes bite, serial blood counts and coagulation profiles should be performed to help guide Viperfav™ treatment, along with supplemental administration as indicated.
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Affiliation(s)
- Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, HR-10000 Zagreb, Croatia.
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia.
- Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, 1000 Ljubljana, Slovenia.
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia.
| | - Maja Lang Balija
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, HR-10000 Zagreb, Croatia.
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova 39, 1000 Ljubljana, Slovenia.
- Faculty of Chemistry and Chemical Technology, University of Ljubljana, Večna pot 113, 1000 Ljubljana, Slovenia.
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, HR-10000 Zagreb, Croatia.
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27
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Estefanía Díez M, Alonso Peña D, García Cano P, López Gamo A. Tratamiento de la mordedura por víbora en España. Semergen 2016; 42:320-6. [DOI: 10.1016/j.semerg.2014.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 07/28/2014] [Accepted: 08/02/2014] [Indexed: 10/24/2022]
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28
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Schmitt C, Baleine J, Beaupertuis O, Bragança C, Simon N, de Haro L. Persistance des signes neurologiques malgré le traitement antidotique par Viperfav® après morsure de vipères aspics, à propos de 2 observations. Presse Med 2016; 45:601-2. [DOI: 10.1016/j.lpm.2016.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/22/2016] [Accepted: 04/13/2016] [Indexed: 10/21/2022] Open
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Bart G, Pineau S, Biron C, Connault J, Artifoni M. Bilateral Pulmonary Embolism Following a Viper Envenomation in France: A Case Report and Review. Medicine (Baltimore) 2016; 95:e2798. [PMID: 27175626 PMCID: PMC4902468 DOI: 10.1097/md.0000000000002798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Complications following snake bites are not common in France. We report the case of a bilateral pulmonary embolism following a viper envenomation in France.A healthy 72-year-old female presented with a lower limb hematoma following a viper bite. She was admitted at the hospital 2 days later and received low-molecular-weight heparin because of bed rest. Seven days later, she complained of thoracic pain and respiratory failure, and a bilateral pulmonary was diagnosed, without biological sign of neither disseminated intravascular coagulation nor coagulation trouble. Repeated lower limbs Doppler ultrasound were normal.This case is particularly interesting because it is only the 7th reported case of pulmonary embolism following a snake envenomation; moreover, it happened in France where poisonous snakes are very rare.Several hypotheses have been made to explain this late localized coagulopathy: an increased level of unstable fibrin produced by thrombin-like glycoproteins from the venom is one of them.
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Affiliation(s)
- Géraldine Bart
- From the Rheumatology Unit (GB); Internal Medicine Unit (JC, MA), and Department of Infectious Diseases, Nantes University Hospital, Nantes, France (SP, CB)
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30
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Karabuva S, Vrkić I, Brizić I, Ivić I, Lukšić B. Venomous snakebites in children in southern Croatia. Toxicon 2016; 112:8-15. [PMID: 26802624 DOI: 10.1016/j.toxicon.2016.01.057] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/09/2016] [Accepted: 01/19/2016] [Indexed: 11/15/2022]
Abstract
This retrospective study represents observation of 160 children and adolescents aged up to 18 years that experienced venomous snakebites in southern Croatia and were treated in the Clinical Department of Infectious Diseases in the University Hospital Centre Split from 1979 to 2013. The main purpose of this research was to determine the epidemiological characteristics, clinical presentation, local and general complications, and received treatment. Most bites occurred during warm months, from early May to late August (80%), mostly in May and June. Upper limb bites were more frequent (59%) than lower limb bites (40%). Out of the total number of poisoned children, 24% developed local, and 25% general complications. The most common local complications were haemorrhagic blisters that occurred in 20% children, followed by compartment syndrome presented in 7.5% patients. The most dominated general complication was cranial nerve paresis or paralysis, which was identified in 11.2% patients, whereas shock symptoms were registrated in 7% children. According to severity of poisoning, 9.4% children had minor, 35% mild, 30.6% moderate, and 24.4% had severe clinical manifestation of envenomation. Only one (0.6%) child passed away because of snakebite directly on the neck. All patients received antivenom produced by the Institute of Immunology in Zagreb, tetanus prophylaxis as well, and almost all of them received antibiotics, and a great majority of them also received corticosteroids and antihistamines. Neighter anaphylactic reaction nor serum disease were noticed in our patients after administrating antivenom. A total of 26% children underwent surgical interventions, and incision of haemorrhagic blister was the most common applied surgical treatment, which was preformed in 15.6% patients, while fasciotomy was done in 7.5% subjects. All of our surgically treated patients recovered successfully.
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Affiliation(s)
- Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia.
| | - Ivana Vrkić
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia.
| | - Ivica Brizić
- Department of Pharmacology, Mostar University School of Medicine, Bijeli brijeg bb, Mostar, Bosnia and Herzegovina.
| | - Ivo Ivić
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia; University of Split School of Medicine, Šoltanska 2, Split, Croatia.
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia; University of Split School of Medicine, Šoltanska 2, Split, Croatia.
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31
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Jollivet V, Hamel JF, de Haro L, Labadie M, Sapori JM, Cordier L, Villa A, Nisse P, Puskarczyk E, Berthelon L, Harry P, Boels D. European viper envenomation recorded by French poison control centers: A clinical assessment and management study. Toxicon 2015; 108:97-103. [PMID: 26454165 DOI: 10.1016/j.toxicon.2015.09.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 08/20/2015] [Accepted: 09/29/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Immunotherapy is the gold standard treatment for patients bitten by European vipers in France; it significantly decreases morbidity, frequency and severity of complications and length of stay. A national prospective study was performed by all Poison Control Centers (PCC) to validate the emergency protocol for viper envenomations. METHODS This prospective study included all cases of viper bites in France, treated or not with Viperfav(®) in 2013. RESULTS In 2013, 277 cases of viper bites were collected: ratio M/F 2.1; mean aged 43 years (<15 years 25% 15-65 63% > 65 12%). The final severity was divided into 68 grades 0, 58 grades I, 62 grades IIA, 71 grades IIB and 18 grades III. One death was reported. Five patients had neurological signs. For the 114 patients who received Viperfav(®), all systemic signs disappeared in 5 h and in 24 h for biological and neurological signs. No severe anaphylactic reaction with Viperfav(®) was reported. Late Viperfav(®) administration increased the risk of functional impairment 15 days after the bite (OR = 3.21 p = 0.043). The administration of Low Molecular Weight Heparin (LMWH) increased the frequency of functional impairment to 15 days after the bite (OR = 6.38 p = 0.064), although Viperfav(®) was given in the first 18 h. DISCUSSION This study confirms the efficiency, safety and recommendation of an early administration of a single dose of Viperfav(®), LMWH should not be used. It also shows the extension of neurotoxic venom of vipers in France.
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Affiliation(s)
- V Jollivet
- Poison Control Center, Angers University Hospital, France
| | - J F Hamel
- Clinical Research Center, Angers University Hospital, France
| | - L de Haro
- Poison Control Center, Marseille University Hospital, France
| | - M Labadie
- Poison Control Center, Bordeaux University Hospital, France
| | - J M Sapori
- Poison Control Center, Lyon University Hospital, France
| | - L Cordier
- Poison Control Center, Toulouse University Hospital, France
| | - A Villa
- Poison Control Center, Paris University Hospital, France
| | - P Nisse
- Poison Control Center, Lille University Hospital, France
| | - E Puskarczyk
- Poison Control Center, Nancy University Hospital, France
| | - L Berthelon
- Poison Control Center, Strasbourg University Hospital, France
| | - P Harry
- Poison Control Center, Angers University Hospital, France
| | - D Boels
- Poison Control Center, Angers University Hospital, France.
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32
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Martín C, Nogué S. Novedades en el envenenamiento por mordedura de víbora. Med Clin (Barc) 2015; 144:132-6. [DOI: 10.1016/j.medcli.2014.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 06/06/2014] [Accepted: 06/12/2014] [Indexed: 10/24/2022]
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33
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Envenimation par morsure de vipère en Provence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0464-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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34
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Lonati D, Giampreti A, Rossetto O, Petrolini VM, Vecchio S, Buscaglia E, Mazzoleni M, Chiara F, Aloise M, Gentilli A, Montecucco C, Coccini T, Locatelli CA. Neurotoxicity of European viperids in Italy: Pavia Poison Control Centre case series 2001-2011. Clin Toxicol (Phila) 2014; 52:269-76. [PMID: 24708390 DOI: 10.3109/15563650.2014.904046] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Some clinical aspects about neurotoxicity after snakebites by European viper species remain to be elucidated. OBJECTIVE This observational case series aims to analyze neurological manifestations due to viper envenomation in Italy in order to describe the characteristic of neurotoxicity and to evaluate the clinical response to the antidotic treatment, the outcome, and the influence of individual variability in determining the appearance of neurotoxic effects. MATERIALS AND METHODS All cases of snakebite referred to Pavia Poison Centre (PPC) presenting peripheral neurotoxic effects from 2001 to 2011 were included. Cases were assessed for time from bite to PPC evaluation, Grade Severity Score (GSS), onset/duration of clinical manifestations, severity/time course of local, non-neurological and neurological effects, and antidotic treatment. RESULTS Twenty-four were included (age, 3-75 years) and represented on average of 2.2 cases/year (about 5% of total envenomed patients). The mean interval time of PPC evaluation from snakebite was 10.80 ± 19.93 hours. GSS at ED-admission was 0 (1 case), 1 (10 cases), and 2 (13 cases). All patients showed local signs: 41.6%, minor; 58.4%, extensive swelling and necrosis. The main systemic non-neurological effects were as follows: vomiting (86.7%), diarrhea (66.7%), abdominal discomfort (53.3%), and hypotension (20%). Neurotoxic effects were accommodation troubles and diplopia (100%), ptosis (91.7%), ophtalmoplegia (58.3%), dysphagia (20.8%), drowsiness (16.6%), cranial muscle weakness (12.5%), and dyspnea (4.2%). Neurotoxicity was the unique systemic manifestation in 9 cases; in 4 cases, they were associated with only mild local swelling. In 10 patients the onset of neurotoxic effects followed the resolution of systemic non-neurological effects. Antidote was intravenously administered in 19 (79.2%) patients. The mean duration of manifestations in untreated versus treated groups was 53.5 ± 62.91 versus 41.75 ± 21.18 hours (p = 0.68, local effects) and 9.77 ± 3.29 versus 8.25 ± 12.23 hours (p = 0.1, systemic non-neurological effects) and 43.4 ± 14.69 versus 26.58 ± 20.62 hours (p = 0.03, neurotoxic effects). CONCLUSIONS Neurotoxicity may appear late (11 hours after the bite in 58.3% of cases), in contrast with the data reported in medical literature. Neurotoxic effects have been reversible in all cases and may be the unique systemic manifestation of envenomation. Neurotoxic effects are shorter in treated group. The antidotic treatment of patients considered as GSS 2 only for neurotoxic effects (with mild local effects) may not be necessary. Variable factors such as different amount of venom injected, concentration of PLA2 component, and individual susceptibility may explain the less percentage of patients presenting neurotoxic effects.
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Affiliation(s)
- D Lonati
- Poison Control Centre and National Toxicology Information Centre, Toxicology Unit, IRCCS Maugeri Foundation and University of Pavia , Pavia , Italy
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Epidemiology of snakebite in Europe: Comparison of data from the literature and case reporting. Toxicon 2013; 76:206-13. [DOI: 10.1016/j.toxicon.2013.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 09/23/2013] [Accepted: 10/02/2013] [Indexed: 11/18/2022]
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Malina T, Babocsay G, Krecsák L, Erdész C. Further Clinical Evidence for the Existence of Neurotoxicity in a Population of the European Adder (Vipera berus berus) in Eastern Hungary: Second Authenticated Case. Wilderness Environ Med 2013; 24:378-83. [DOI: 10.1016/j.wem.2013.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 06/07/2013] [Accepted: 06/08/2013] [Indexed: 10/26/2022]
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Malina T, Babocsay G, Krecsák L, Schuller P, Zacher G, Vasas G. [An overview on envenomings inflicted by the Common adder (Vipera berus) and their treatment in Hungary. Facts and beliefs -- part I]. Orv Hetil 2012; 153:1092-105. [PMID: 22776522 DOI: 10.1556/oh.2012.29407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Consequences of bites by the Common adder (Vipera berus) were reviewed in this study. Patients bitten by snakes from different populations may develop variable symptoms due to geographical venom variation. The correct diagnosis of snake bites and the knowledge of the distribution of venomous snake taxa have a crucial impact on snake bite therapy. The characteristic symptoms of patients bitten by V. berus in Hungary are highlighted. The habitat characteristics, seasonal activity and the Hungarian distribution of the adder are described based on literature data, museum specimens and field observations. However, envenomings are uncommon in Hungary, the annual 3 to 4 incidents have to be taken seriously, regardless of the age and actual health condition of the patients. Contrary to beliefs persisting both among laymen and professionals, the venom of V. berus is powerful. Medical observation of the patients is necessary in the first 5 to 6 hours. Any systemic symptom or progression of the edema requires hospital admission.
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Affiliation(s)
- Tamás Malina
- Debreceni Egyetem Farmakognózia Részleg Debrecen.
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Abstract
BACKGROUND Viper bites and subsequent evolution to severe envenomations are more frequent in children. AIM The aims of this study were to describe the clinical, biological, and therapeutic characteristics of children bitten by vipers in France and to identify risk factors associated with severe envenomations. METHODS A retrospective study was conducted between 2001 and 2009 in the pediatric emergency department of a tertiary-level children hospital. Collected data were age and sex of children; day and time of admission; day, time, and circumstances of the accident; snake identification; bite location; envenomation severity; presence of fang marks; prehospital care; use of specific immunotherapy and associated treatments; length of stay; and hospital course. RESULTS Fifty-eight children were included (43 boys, 15 girls). The mean age was 7.8 ± 4.1 years. Bites were most often located on the lower extremities (77%). The classification of envenomation was: 83% low grade (absence or minor envenomation) and 17% high-grade (moderate to severe envenomations). All high-grade envenomations received specific immunotherapy (Viperfav). Being bitten on an upper extremity (P < 0.001), during the afternoon (P = 0.025), feeling violent pain (P = 0.037), and high initial glucose level (P = 0.016) were associated with a significant risk of high-grade envenomation. In the multivariate analysis, 3 factors remained significant: upper-extremity location (relative risk [RR], 60.5 [3.5-1040]; P = 0.005), immediate violent pain (RR, 21.5 [1.3-364.5]; P = 0.03), and female sex (RR, 17.5 [0.9-320.3]; P = 0.053). CONCLUSIONS A certain number of criteria seem related to more significant risk of progression to high-grade envenomation. Bites to the upper extremities should be carefully observed because of the risk of evolution to a high-grade envenomation.
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Kurtović T, Leonardi A, Lang Balija M, Brgles M, Habjanec L, Križaj I, Halassy B. The standard mouse assay of anti-venom quality does not measure antibodies neutralising the haemorrhagic activity of Vipera ammodytes venom. Toxicon 2012; 59:709-17. [DOI: 10.1016/j.toxicon.2012.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 02/21/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
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Boels D, Hamel JF, Bretaudeau Deguigne M, Harry P. European viper envenomings: Assessment of Viperfav™ and other symptomatic treatments. Clin Toxicol (Phila) 2012; 50:189-96. [PMID: 22372786 DOI: 10.3109/15563650.2012.660695] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED The treatment of European viper envenomings is based on IV antivenom infusions. Viperfav™ contains purified F(ab')(2) fragments of equine antibodies, and a 4 ml vial can neutralize 500-1000 mouse LD50 of Vipera aspis, V. ammodytes and V. berus venoms and is known to be safe and efficient. Assessments of Viperfav™ (dosage and timing of infusions) and of symptomatic treatments such as low-molecular-weight heparin (LWHM), corticosteroids and the routine use of antibiotic therapy have not as yet been reported. OBJECTIVES The objective was to compare the efficacy and safety of Viperfav™ as a function of the time to infusion and to assess other symptomatic treatments given for European viper bites such as antibiotics, corticosteroids and LWMH. METHODS A prospective case review study of viper envenomings treated with Viperfav™ was compiled by the Angers Poisons Centre. The endpoints chosen were as follows: duration of hospital stay, complications (haematoma, infection) and persistent functional discomfort on day 15. Statistical studies were based on multivariate data analysis (MVA). RESULTS 268 moderate or severe envenomings (Grades II and III) recorded in adults and children between 1999 and 2009 were included in the study. A time to the Viperfav™ infusion < 10 h after the bite (179 patients vs. 72) significantly reduced the incidence of haematomas (OR 2.3; p < 0.006), functional discomfort (OR 3.7; p < 10 - 4) and length of hospital stay (OR 2.1; p < 0.03). Multiple doses of Viperfav™ (2 or 3 vials in 22 patients vs. 246 treated with 1 vial) did not improve the selected endpoints. Routine antibiotic therapy was prescribed in 102 patients (vs. 166 patients without) and no significant difference was seen with respect to the endpoints. Moreover, no local or systemic infections were recorded in the non-antibiotic group. Corticosteroids were prescribed in 36 patients (vs. 232 without) but they did not significantly improve the endpoints or oedema. LMWH in 32 patients (vs. 236 without) increased the length of hospital stay (OR 3.2; p < 0.009 and the level of significantly persistent functional discomfort at day 15 (OR 3.7; p < 0.003). CONCLUSIONS A single infusion of Viperfav™ (one vial) was effective whatever the grade of envenomation, and multiple doses did not improve the outcome. Viperfav™ was most effective when given soon (< 10 h) after envenoming. The routine use of antibiotic therapy was not necessary. Corticosteroids did not improve the endpoints selected, and we do not recommend the use of LMWH as this increased persistent functional discomfort and the length of hospital stay.
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Affiliation(s)
- David Boels
- University Hospital, Poisons and Toxicovigilance Centre, Angers, France.
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Management of snakebites in France. Toxicon 2012; 60:712-8. [PMID: 22465493 DOI: 10.1016/j.toxicon.2012.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 02/29/2012] [Accepted: 03/13/2012] [Indexed: 11/20/2022]
Abstract
Although not a major health problem in Europe, snakebite in the old continent was the focus of recent studies to evaluate their overall incidence and define management techniques. The purpose of this three-part report is to present the experience of the Marseille Poison Centre with snakebite in France. The first section deals with viper envenomation that now benefits from a validated therapeutic protocol using of purified antivenom of proven efficacy and tolerance in patients showing grade 2 and 3 symptoms. The second section describes the highly variable snakebite situation in French overseas territories that include areas where local species require specialized management, e.g. Martinique and French Guiana. The third section involves the emerging problems associated with the keeping of exotic snakes as pets with problems related to the use of antivenoms from foreign countries. The exotic-snake pets fashion was at the origin of the creation of a national antivenom bank by two French poison centers (Angers and Marseille) to ensure prompt delivery of antivenoms for exotic snake envenomation anywhere in mainland France.
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Morsures de vipères chez l’enfant. Arch Pediatr 2011; 18:1278-83. [DOI: 10.1016/j.arcped.2011.08.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/23/2011] [Accepted: 08/26/2011] [Indexed: 11/18/2022]
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Chippaux JP. Epidemiology of snakebites in Europe: a systematic review of the literature. Toxicon 2011; 59:86-99. [PMID: 22056768 DOI: 10.1016/j.toxicon.2011.10.008] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 10/07/2011] [Accepted: 10/11/2011] [Indexed: 11/19/2022]
Abstract
Snakebites are rare medical emergency cases in Europe but may sometimes be severe and lead to complications. A better knowledge of snakebite epidemiology may help health authorities to better understand therapeutic requirements, especially concerning antivenoms, and thus improve treatment of snakebite. An extensive literature search for studies and articles published between 1970 and 2010 was performed. Both indexed and non-indexed articles were examined, the analysis of which took into account the heterogeneity between the studies and weighted the studies according to size of the study population covered. Most of the articles involved hospitalized patients who represented more than 90% of snakebites. Incidence, mortality and population at risk were estimated after stratification into three regions (northern, central and southern Europe) based both on viper species distribution and climatic characteristics. There was no significant variation in incidence from the north to the south of Europe. In the whole of Europe, including European Russia and Turkey, the annual number of snakebite cases was estimated at 7992 [CI 95% = 6860-9178] bites, out of which approximately 15% were considered severe (grade 3). These bites usually occurred between May and September, with a more dispersed distribution in southern Europe. The average number of deaths per annum was 4 [0.7-7.7]. Children and male victims are more affected, contrary to what one would expect given their respective proportion in the entire population. Both upper and lower limb bites were recorded at an equal frequency while the bites in other parts of the body were very rare. Immunotherapy was prescribed in one out of three snakebites in Europe, with a very high geographical variability, in spite of excellent tolerance, at least considering highly-purified immunoglobulin fragments. Snakebites are uncommon in Europe but can cause life-threatening envenomation. Fragments of highly-purified immunoglobulins are now very well tolerated and dramatically reduce both severity and mortality of snakebites when used in treatment.
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Affiliation(s)
- Jean-Philippe Chippaux
- Institut de Recherche pour le Développement, UMR 216, Mother and Child Facing Tropical Diseases, 08 BP 841 Cotonou, Bénin.
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Archundia IG, de Roodt AR, Ramos-Cerrillo B, Chippaux JP, Olguín-Pérez L, Alagón A, Stock RP. Neutralization of Vipera and Macrovipera venoms by two experimental polyvalent antisera: a study of paraspecificity. Toxicon 2011; 57:1049-56. [PMID: 21530569 DOI: 10.1016/j.toxicon.2011.04.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 04/07/2011] [Accepted: 04/12/2011] [Indexed: 11/28/2022]
Abstract
We conducted an extensive study of neutralization of lethality of 11 species and one subspecies of snakes of the genus Vipera, and of five species of Macrovipera, by two experimental equine antisera. One antiserum was a trivalent preparation raised against the venoms of Vipera aspis aspis, Vipera berus berus and Vipera ammodytes ammodytes; the other was a pentavalent preparation that also included venoms of Vipera (now Montivipera) xanthina and Macrovipera lebetina obtusa. We measured specific neutralization of lethality against all venoms included in the immunization schemes, and paraspecific neutralization against the venoms of Vipera ammodytes montandoni, Vipera (Montivipera) bornmuelleri, Vipera latastei, Vipera (Mo.) latifii, Vipera (Mo.) lotievi, Vipera (Daboia) palaestinae, Vipera (Mo.) raddei and Vipera seoanei, as well as against Macrovipera (D.) deserti, Macrovipera lebetina cernovi, Macrovipera lebetina turanica and Macrovipera schweitzeri. We found an important degree of paraspecific protection within each genera (omitting recent reclassification) that was quite independent of both the lethal potency of the venoms and their geographic origin. This information may be of use to clinicians charged with the treatment of Vipera or Macrovipera envenomations with non-specific antivenoms.
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Affiliation(s)
- Irving G Archundia
- Instituto de Biotecnología, Universidad Nacional Autónoma de México, Av. Universidad 2001, Cuernavaca, Morelos 62210, Mexico
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Guiavarch M, Médus M, Tichadou L, Glaizal M, de Haro L. [Uneven efficacy of Viperfav® antivenom for the treatment of neurotoxic viper envenomations]. Presse Med 2011; 40:654-6. [PMID: 21397446 DOI: 10.1016/j.lpm.2011.01.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 01/18/2011] [Accepted: 01/23/2011] [Indexed: 11/19/2022] Open
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Krecsák L, Zacher G, Malina T. Clinical picture of envenoming with the Meadow Viper (Vipera(Acridophaga)ursinii). Clin Toxicol (Phila) 2011; 49:13-20. [DOI: 10.3109/15563650.2010.550049] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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First clinical experiences about the neurotoxic envenomings inflicted by lowland populations of the Balkan adder, Vipera berus bosniensis. Neurotoxicology 2010; 32:68-74. [PMID: 21145353 DOI: 10.1016/j.neuro.2010.11.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 10/19/2010] [Accepted: 11/30/2010] [Indexed: 11/23/2022]
Abstract
The first overall clinical description of envenomings by the lowland populations of the Balkan adder (Vipera berus bosniensis) is provided by this study. Fifty-four incidents have been collected retrospectively from the south-western Hungarian and the northern Croatian distribution area of the taxon. There were five (9%) asymptomatic, 24 (44%) mild, 12 (22%) moderate, 12 (22%) severe, and one fatal (2%) case according to the Poisoning Severity Score. The single death is a 60-year-old Hungarian case that was caused by V.b. bosniensis. Average hospitalisation was 2.75 days. The most common systemic symptoms were gastrointestinal disorders, ECG changes, persisting hypotension and neurological disorders. The initial phase of neurotoxic manifestations was always expressed in cranial nerve disturbances: ptosis, external ophthalmoplegia, diplopia, reduced focusing capability and blurred vision. Neuromuscular paralysis progressed to dyspnoea and lower limb paralysis in the most severe cases. Unusual symptoms were fluctuating arterial hypertension, drowsiness, and hypokalaemia. Laboratory results reveal leucocytosis, while deviation in the other laboratory values is not common. Envenomings by V.b. bosniensis significantly differ from those by the European adder (Vipera berus berus) in lower manifestation rate of extensive oedema, anaemia, CNS depression, and haematuria but the development of neuromuscular paralysis is high (20%). Their bites rather resulted in mild and moderate local symptoms in envenomed patients than those inflicted by the nominate form. This study presents the evidence of the frequent neurotoxic manifestations in Balkan adder-bitten patients for the first time, which strongly suggests that the venom of the lowland populations of V.b. bosniensis has neurotoxic activity.
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