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Lin CC, Wang CC, Ou Yang CH, Liu CC, Yu JS, Fann WC, Chen YC, Shih CP. The changes and the potential clinical applications of cytokines in Taiwan's major venomous snakebites patients. Toxicon 2024; 247:107843. [PMID: 38964621 DOI: 10.1016/j.toxicon.2024.107843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/13/2024] [Accepted: 06/28/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Taiwan habu (Protobothrops mucrosquamatus), green bamboo viper (Viridovipera stejnegeri), and Taiwan cobra (Naja atra) are the most venomous snakebites in Taiwan. Patients commonly present with limb swelling but misdiagnosis rates are high, and currently available diagnostic tools are limited. This study explores the immune responses in snakebite patients to aid in differential diagnosis. METHODS This prospective observational study investigated the changes in cytokines in snakebite patients and their potential for diagnosis. RESULTS Elevated pro-inflammatory cytokines IL-6 and TNF-α were observed in all snakebite patients compared to the healthy control group. While no significant disparities were observed in humoral immune response cytokines, there were significant differences in IFN-γ levels, with significantly higher IL-10 levels in patients bitten by cobras. Patients with TNF-α levels exceeding 3.02 pg/mL were more likely to have been bitten by a cobra. CONCLUSION This study sheds light on the immune responses triggered by various venomous snakebites, emphasizing the potential of cytokine patterns for snakebite-type differentiation. Larger studies are needed to validate these findings for clinical use, ultimately improving snakebite diagnosis and treatment.
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Affiliation(s)
- Chih-Chuan Lin
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Cheng Wang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan
| | - Chun-Hsiang Ou Yang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan
| | - Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Tao-Yuan, Taiwan
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Tao-Yuan, Taiwan; Department of Cell and Molecular Biology, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan; Liver Research Center, Chang Gung Memorial Hospital, Linkou, Tao-Yuan, Taiwan; Research Center for Food and Cosmetic Safety, Research Center for Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan
| | - Wen-Chih Fann
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yen-Chia Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Emergency Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Pang Shih
- Department of Healthcare Management, Yuanpei University of Medical Technology, HsinChu, Taiwan.
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Hung YL, Chen YC, Tsai TS, Chang YI, Chuang PC. Incidence and Risk Factors for Wound Infections after Trimeresurus stejnegeri Snakebites in Taiwan. Am J Trop Med Hyg 2024; 110:295-302. [PMID: 38109772 PMCID: PMC10859800 DOI: 10.4269/ajtmh.23-0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/30/2023] [Indexed: 12/20/2023] Open
Abstract
Snakebite envenomation is a neglected tropical disease. Taiwan, with its subtropical and Southeast Asian environment, provides suitable habitat for several venomous snake species. Trimeresurus stejnegeri, an arboreal pit viper, is the most common cause of venomous snakebite in Taiwan. Trimeresurus stejnegeri envenomation can cause local swelling, occasional ecchymosis, and wound infection. The primary treatment of T. stejnegeri envenomation is the binary antivenom, vacuum freeze-dried F(ab')2 fragments of equine antibodies, against T. stejnegeri and Protobothrops mucrosquamatus. This study aimed to analyze the incidence of post-envenomation wound infections caused by T. stejnegeri based on data collected over a decade from institutions affiliated with the Chang Gung Memorial Hospital in Taiwan. A total of 254 patients were enrolled in this study. Clinical and laboratory data, treatment information, and patient outcomes were extracted from electronic medical records. Wound infection was associated with delay in antivenom initiation (adjusted odds ratio: 3.987; 95% CI: 1.406-11.302). The infection rates were 20.5%, 12.5%, 31.3%, and 48.1% for antivenom administration within 2 hours, 2-4 hours, 4-6 hours, and > 6 hours, respectively. Therefore, early initiation of antivenom treatment (within 6 hours) is recommended. Morganella morganii was cultured from wounds of the patients, whereas Enterobacter cloacae and Enterococcus faecalis were cultured from both the oral cavity of snakes and the wounds of the patients. For post-envenomation patients who develop a local infection, empiric antibiotics such as third-generation cephalosporins, quinolones, and piperacillin/tazobactam are recommended because snakebite wound infections are often polymicrobial in nature.
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Affiliation(s)
- Yu-Lun Hung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yi-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tein-Shun Tsai
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung, Taiwan
| | - Ye-In Chang
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Po-Chun Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
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Zhao HY, He N, Sun Y, Wang YC, Zhang HB, Chen HH, Zhang YQ, Gao JF. Phylogeny-Related Variations in Venomics: A Test in a Subset of Habu Snakes ( Protobothrops). Toxins (Basel) 2023; 15:toxins15050350. [PMID: 37235384 DOI: 10.3390/toxins15050350] [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: 04/18/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
We conducted a comparative analysis to unveil the divergence among venoms from a subset of Old World habu snakes (Protobothrops) in terms of venomic profiles and toxicological and enzymatic activities. A total of 14 protein families were identified in the venoms from these habu snakes, and 11 of them were shared among these venoms. The venoms of five adult habu snakes were overwhelmingly dominated by SVMP (32.56 ± 13.94%), PLA2 (22.93 ± 9.26%), and SVSP (16.27 ± 4.79%), with a total abundance of over 65%, while the subadult P. mangshanensis had an extremely low abundance of PLA2 (1.23%) but a high abundance of CTL (51.47%), followed by SVMP (22.06%) and SVSP (10.90%). Apparent interspecific variations in lethality and enzymatic activities were also explored in habu snake venoms, but no variations in myotoxicity were found. Except for SVSP, the resemblance of the relatives within Protobothrops in other venom traits was estimated to deviate from Brownian motion evolution based on phylogenetic signals. A comparative analysis further validated that the degree of covariation between phylogeny and venom variation is evolutionarily labile and varies among clades of closely related snakes. Our findings indicate a high level of interspecific variation in the venom proteomes of habu snakes, both in the presence or absence and the relative abundance of venom protein families, and that these venoms might have evolved under a combination of adaptive and neutral mechanisms.
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Affiliation(s)
- Hong-Yan Zhao
- Herpetological Research Center, College of Life and Environmental Sciences, Hangzhou Normal University, Hangzhou 311121, China
| | - Na He
- Herpetological Research Center, College of Life and Environmental Sciences, Hangzhou Normal University, Hangzhou 311121, China
| | - Yan Sun
- Herpetological Research Center, College of Life and Environmental Sciences, Hangzhou Normal University, Hangzhou 311121, China
| | - Yong-Chen Wang
- Herpetological Research Center, College of Life and Environmental Sciences, Hangzhou Normal University, Hangzhou 311121, China
| | - Hao-Bing Zhang
- Herpetological Research Center, College of Life and Environmental Sciences, Hangzhou Normal University, Hangzhou 311121, China
| | - Hui-Hui Chen
- Herpetological Research Center, College of Life and Environmental Sciences, Hangzhou Normal University, Hangzhou 311121, China
| | - Ya-Qi Zhang
- Herpetological Research Center, College of Life and Environmental Sciences, Hangzhou Normal University, Hangzhou 311121, China
| | - Jian-Fang Gao
- Herpetological Research Center, College of Life and Environmental Sciences, Hangzhou Normal University, Hangzhou 311121, China
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Chen FC, Ismail AK, Mao YC, Hsu CH, Chiang LC, Shih CC, Tzeng YS, Lin CS, Liu SH, Ho CH. Application of Sonographic Assessments of the Rate of Proximal Progression to Monitor Protobothrops mucrosquamatus Bite-Related Local Envenomation: A Prospective Observational Study. Trop Med Infect Dis 2023; 8:tropicalmed8050246. [PMID: 37235294 DOI: 10.3390/tropicalmed8050246] [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: 03/07/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Patients bitten by Protobothrops mucrosquamatus typically experience significant pain, substantial swelling, and potentially blister formation. The appropriate dosage and efficacy of FHAV for alleviating local tissue injury remain uncertain. Between 2017 and 2022, 29 snakebite patients were identified as being bitten by P. mucrosquamatus. These patients underwent point-of-care ultrasound (POCUS) assessments at hourly intervals to measure the extent of edema and evaluate the rate of proximal progression (RPP, cm/hour). Based on Blaylock's classification, seven patients (24%) were classified as Group I (minimal), while 22 (76%) were classified as Group II (mild to severe). In comparison to Group I patients, Group II patients received more FHAV (median of 9.5 vials vs. two vials, p-value < 0.0001) and experienced longer median complete remission times (10 days vs. 2 days, p-value < 0.001). We divided the Group II patients into two subgroups based on their clinical management. Clinicians opted not to administer antivenom treatment to patients in Group IIA if their RPP decelerated. In contrast, for patients in Group IIB, clinicians increased the volume of antivenom in the hope of reducing the severity of swelling or blister formation. Patients in Group IIB received a significantly higher median volume of antivenom (12 vials vs. six vials; p-value < 0.001) than those in Group IIA. However, there was no significant difference in outcomes (disposition, wound necrosis, and complete remission times) between subgroups IIA and IIB. Our study found that FHAV does not appear to prevent local tissue injuries, such as swelling progression and blister formation, immediately after administration. When administering FHAV to patients bitten by P. mucrosquamatus, the deceleration of RPP may serve as an objective parameter to help clinicians decide whether to withhold FHAV administration.
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Affiliation(s)
- Feng-Chen Chen
- Department of Emergency Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung 80284, Taiwan
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 11402, Taiwan
| | - Ahmad Khaldun Ismail
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Malaysia
| | - Yan-Chiao Mao
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan
| | - Chih-Hsiung Hsu
- Health Service and Readiness Section, Armed Forces Taoyuan General Hospital, Taoyuan 325, Taiwan
| | - Liao-Chun Chiang
- National Tsing Hua University, College of Life Sciences, Hsinchu 300044, Taiwan
| | - Chang-Chih Shih
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 11402, Taiwan
| | - Yuan-Sheng Tzeng
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 11402, Taiwan
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 11402, Taiwan
| | - Shing-Hwa Liu
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
| | - Cheng-Hsuan Ho
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 11402, Taiwan
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
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