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Robishaw-Denton J, Ramirez J, Bahadir A, Smelski G. Myocardial infarction during treatment of Crotalinae envenomation: A case report. Toxicon 2024; 250:108105. [PMID: 39303995 DOI: 10.1016/j.toxicon.2024.108105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 09/04/2024] [Accepted: 09/17/2024] [Indexed: 09/22/2024]
Abstract
While myocardial infarction is a rare, but known, potential side effect of snakebite envenomation, snake antivenom has thus far not been associated with any cardiovascular adverse events. We report the case of a 71-year-old man who developed an anterolateral MI during administration of Crotalidae immune F(ab')2 (equine) (ANAVIP), given as treatment for Crotalidae envenomation. The patient required cardiac catheterization with stenting of the left anterior descending artery and was discharged two days later on long-term clopidogrel and aspirin. Treatment of MI in the setting of envenomation should mirror typical management, with consideration of additional antivenom if the ischemia is determined to be venom-induced. Clinicians should have a high index of suspicion for patients with chest pain after snake envenomation or administration of antivenom.
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Affiliation(s)
- Jacob Robishaw-Denton
- University of Arizona College of Medicine - Tucson, University of Arizona, Tucson, AZ, USA.
| | - Jennifer Ramirez
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - Alisia Bahadir
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - Geoffrey Smelski
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
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Chander A, Samra T, Loganathan S, Mahajan V. Unmasking the ties of snake bite poisoning and COVID-19. AIN-SHAMS JOURNAL OF ANESTHESIOLOGY 2022. [PMCID: PMC9330936 DOI: 10.1186/s42077-022-00256-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Snake bite envenoming is a neglected tropical disease with variable clinical presentation, neurotoxic manifestations (respiratory paralysis), rhabdomyolysis, cardiotoxicity, autonomic hyperactivity, and/or coagulation abnormalities. There is limited data on the clinical course of the envenomation in an incidentally diagnosed COVID-19 patient. Case presentation A 17-year-old male with history of snake bite and neuroparalysis developed shortness of breath. He was treated with lyophilized polyvalent anti-snake venom (ASV) on admission in the emergency department and mechanical ventilation. Subsequently, he tested positive for COVID-19 infection. No immunomodulatory therapy was administered, and patient was extubated on the 5th day of ICU admission without any neurological deficit. Conclusions Coinfections of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus with snake bite poisoning lead to diagnostic dilemmas and controversies in management practices. Abnormalities of coagulation need to be cautiously addressed, and cause of development of pneumonia needs to be identified. The rapid recovery of the patient in our case theoretically can be explained on the organ-protective potential of snake-derived peptides; a large case series is however needed to prove the same. Supplementary Information The online version contains supplementary material available at 10.1186/s42077-022-00256-9.
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Rajkumar B, Vishwanath Vinod K, Kar R, Ramasubramani P. Venom induced consumption coagulopathy and performance of 20-min whole blood clotting test for its detection in viperid envenomation. J R Coll Physicians Edinb 2022; 52:232-239. [PMID: 36300884 DOI: 10.1177/14782715221126770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Venom induced consumption coagulopathy (VICC) and its underlying mechanisms have not been fully elucidated in viperid envenomation (VE), especially among Indian patients. We evaluated for VICC in VE, assessed the performance of 20-min whole blood clotting test (20WBCT) for VICC detection and also studied predictors of VICC. Methods: This hospital-based observational study enrolled 103 consecutive patients (age ⩾ 12 years) of snakebite admitted within 24 h of bite, with features of VE. They underwent 20WBCT, prothrombin time (PT)/international normalised ratio (INR), plasma fibrinogen and D-dimer testing during first 24 h after enrolment. Overt VICC (defined by overt bleeding), subclinical VICC (INR ⩾ 1.4 and/or fibrinogen < 2g/L, without overt bleeding), disseminated intravascular coagulation (DIC) (overt/non-overt, defined based on International Society on Thrombosis and Haemostasis (ISTH) DIC score) and primary defibrination (PDF) were evaluated among patients. Results: VICC overall was noted in 77 (≈75%) and overt VICC in 52 (≈50%). DIC (overt/non-overt) was noted in 59 (≈77%) and PDF in 2 (2.6%) patients with VICC. Sensitivity, specificity, positive predictive value and negative predictive value of 20WBCT for VICC detection were 98.7% (95%CI: 92.9–99.9%), 65.4% (95%CI: 44.3–82.8%), 89.4% (95%CI: 83.3–93.5%) and 94.4% (95%CI: 70.4–99.2%) respectively. Severe cellulitis in bitten limb predicted reduced VICC risk. Conclusion: Majority (75%) of patients with VE had VICC and 68% with VICC had overt bleeding. DIC (overt/non-overt) was the predominant contributor to VICC. Though 20WBCT is a good screening test for VICC, false positive results should be kept in mind before deciding on snake antivenom treatment.
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Affiliation(s)
- Bayye Rajkumar
- Department of General Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research [JIPMER], Puducherry, India
| | | | - Rakhee Kar
- Department of Pathology, JIPMER, Puducherry, India
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Yamamoto A, Ito T, Hifumi T. Attempt for a Recombinant Thrombomodulin Alpha Treatment in a Rat Disseminated Intravascular Coagulation Model Using Yamakagashi (Rhabdophis tigrinus) Venom. Toxins (Basel) 2022; 14:toxins14050322. [PMID: 35622569 PMCID: PMC9144121 DOI: 10.3390/toxins14050322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/30/2022] [Accepted: 05/01/2022] [Indexed: 12/10/2022] Open
Abstract
Yamakagashi (Rhabdophis tigrinus) inhabits Japan widely, and incidents involving its bites occur every year. Its bite causes disseminated intravascular coagulation when the amount of infused venom is high, and it can be fatal if treatment with Yamakagashi antivenom is delayed. Although Yamakagashi antivenom is used for treating Yamakagashi bites, it is an unapproved drug and its capacity for storage is limited. Hence, it is difficult to administer to patients promptly. As a therapeutic agent for this bite, we investigated the application of recombinant thrombomodulin alpha, a commercially available disseminated intravascular coagulation therapeutic agent. Its therapeutic effect on Yamakagashi venom was confirmed in a coagulation system of human plasma using in vitro Yamakagashi venom as well as a rat experimental model of disseminated intravascular coagulation using in vivo Yamakagashi venom. The administration of recombinant thrombomodulin alpha induced an effect that prolonged the blood coagulation time of Yamakagashi venom in vitro, and the drug was administered in vivo within 0.5 h after the administration of Yamakagashi venom to save rats. Blood coagulation markers such as platelet count, prothrombin time, fibrinogen concentration, and D-dimer levels recovered to normal values in rats. Therefore, recombinant thrombomodulin alpha may be used as a therapeutic agent for Yamakagashi bites.
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Affiliation(s)
- Akihiko Yamamoto
- Management Department of Biosafety and Laboratory Animal, and Pathogen Bank, National Institute of Infectious Diseases, Tokyo 208-0011, Japan
- Correspondence: ; Tel.: +81-42-561-0771 (ext. 3734)
| | - Takashi Ito
- Department of Biomedical Laboratory Sciences, Faculty of Life Sciences Kumamoto University, Kumamoto 860-8556, Japan;
| | - Toru Hifumi
- Emergency and Critical Care Medicine, St. Luke’s International Hospital, Tokyo 104-8560, Japan;
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Gopalakrishnan M, Saurabh S, Sagar P, Bammigatti C, Dutta TK. A simple mortality risk prediction score for viper envenoming in India (VENOMS): A model development and validation study. PLoS Negl Trop Dis 2022; 16:e0010183. [PMID: 35192642 PMCID: PMC8896694 DOI: 10.1371/journal.pntd.0010183] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 03/04/2022] [Accepted: 01/20/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Snakebite is a neglected problem with a high mortality in India. There are no simple clinical prognostic tools which can predict mortality in viper envenomings. We aimed to develop and validate a mortality-risk prediction score for patients of viper envenoming from Southern India. METHODS We used clinical predictors from a prospective cohort of 248 patients with syndromic diagnosis of viper envenoming and had a positive 20-minute whole blood clotting test (WBCT 20) from a tertiary-care hospital in Puducherry, India. We applied multivariable logistic regression with backward elimination approach. External validation of this score was done among 140 patients from the same centre and its performance was assessed with concordance statistic and calibration plots. FINDINGS The final model termed VENOMS from the term "Viper ENvenOming Mortality Score included 7 admission clinical parameters (recorded in the first 48 hours after bite): presence of overt bleeding manifestations, presence of capillary leak syndrome, haemoglobin <10 g/dL, bite to antivenom administration time > 6.5 h, systolic blood pressure < 100 mm Hg, urine output <20 mL/h in 24 h and female gender. The lowest possible VENOMS score of 0 predicted an in-hospital mortality risk of 0.06% while highest score of 12 predicted a mortality of 99.1%. The model had a concordance statistic of 0·86 (95% CI 0·79-0·94) in the validation cohort. Calibration plots indicated good agreement of predicted and observed outcomes. CONCLUSIONS The VENOMS score is a good predictor of the mortality in viper envenoming in southern India where Russell's viper envenoming burden is high. The score may have potential applications in triaging patients and guiding management after further validation.
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Affiliation(s)
- Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences Jodhpur, Rajasthan, India
| | - Suman Saurabh
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pramod Sagar
- Department of Cardiology, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Chanaveerappa Bammigatti
- Department of Medicine, Jawaharlal Institute of Medical Education and Research, Puducherry, India
| | - Tarun Kumar Dutta
- Department of Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
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Coagulopathy following Crotalinae snakebites in northeast Florida. Blood Coagul Fibrinolysis 2022; 33:220-223. [DOI: 10.1097/mbc.0000000000001123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abdeldayem A, Alanazi AA, Aljabri JN, Abid I. Challenges in the Management of an Echis coloratus Adult Snakebite Victim at a Tertiary Care Hospital: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931532. [PMID: 34103465 PMCID: PMC8197442 DOI: 10.12659/ajcr.931532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Patient: Male, 18-year-old Final Diagnosis: Snakebite envenomation Symptoms: Coagulopathy Medication:— Clinical Procedure: Anti snake venom Specialty: General and Internal Medicine • Toxicology • Tropical Medicine
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Affiliation(s)
- Ahmed Abdeldayem
- In-Charge Drug and Poison Information Center, Prince Mohamed Bin Abdulaziz Hospital, Al Madina Al Monawara, Ministry of the National Guard Health Affairs, Al Madinah Al Monawara, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Alhanouf Ayed Alanazi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.,Internal Medicine Department, Prince Mohamed Bin Abdulaziz Hospital, Al Madina Al Monawara, Ministry of the National Guard Health Affairs, Al Madinah Al Monawara, Saudi Arabia
| | - Jawaher N Aljabri
- Internal Medicine Department, National guard health Affairs, Al Madinah Al Monawara, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ijaz Abid
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.,Internal Medicine Department, Prince Mohamed Bin Abdulaziz Hospital, Al Madina Al Monawara, Ministry of the National Guard Health Affairs, Al Madinah Al Monawara, Saudi Arabia
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Moon JM, Koo YJ, Chun BJ, Park KH, Cho YS, Kim JC, Lee SD, Min YR, Park HS. The effect of myocardial injury on the clinical course of snake envenomation in South Korea. Clin Toxicol (Phila) 2020; 59:286-295. [PMID: 32840397 DOI: 10.1080/15563650.2020.1802473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
CONTENT This study investigated the incidence, progression and clinical course of myocardial injury-related snake envenomation in South Korea. In addition, this study evaluated whether antivenom guidelines are appropriate to control envenomation in patients with myocardial injury. METHODS The study included 198 patients who received antivenom after a snakebite, and they were divided into two groups according to evidence of myocardial injury (defined as elevated troponin I or ischemic change on electrocardiogram) at presentation. Data including serial troponin I, echocardiogram/coronary angiogram findings, the clinical course, and treatment were collected and analyzed. RESULTS The incidence of myocardial injury at presentation was 15.2%. The troponin I level was 0.11 (0.07-0.56) ng/ml at presentation and tended to decrease over 24 h. Echocardiograms revealed neither regional wall motion abnormalities nor left ventricular dysfunction in 15 of 17 patients, while two patients showed signs of coronary artery stenosis on echocardiograms and coronary angiograms. However, compared with patients without myocardial injury, patients with myocardial injury had a higher frequency of systemic envenomation complications, including bleeding, respiratory failure, hypotension, acute kidney injury, thrombocytopenia and venom-induced consumption coagulopathy (VICC). The patients with myocardial injury at presentation needed significantly more frequent and larger doses of antivenom than indicated by the initial severity of envenomation. Multivariate analysis showed that myocardial injury was associated with the need for additional antivenom administration after initial administration. DISCUSSION AND CONCLUSION Myocardial injury is not uncommon after snake envenomation in Korea. Although myocardial injury itself seems to be benign, the clinical course of patients with myocardial injury is complicated, and myocardial injury is associated with the need for additional antivenom administration. The optimal use of antivenom to control envenomation in patents with myocardial injury after snake envenomation in South Korea should be established.
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Affiliation(s)
- J M Moon
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea.,Department of Emergency Medicine, Chonnam National University Hwasun Hospital, Jeollanam-do, Republic of Korea
| | - Y J Koo
- Department of Agricultural Chemistry, Chonnam National University, Gwangju, Republic of Korea
| | - B J Chun
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea.,Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - K H Park
- Department of Emergency Medical Rescue, Nambu University, Gwangju, Republic of Korea.,Department of Medical science, Chonnam National University Graduate School, Gwangju, Republic of Korea
| | - Y S Cho
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - J C Kim
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - S D Lee
- Department of Emergency Medicine in Trauma Center, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Y R Min
- Department of Medical science, Chonnam National University Graduate School, Gwangju, Republic of Korea
| | - H S Park
- Department of Agricultural Chemistry, Chonnam National University, Gwangju, Republic of Korea
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