1
|
Isbister GK, Jenkins S, Downes MA, Fakes K, Buckley NA. A randomized controlled trial and prospective cohort investigating antivenom for red-bellied black snake envenomation. Clin Toxicol (Phila) 2024; 62:343-351. [PMID: 38913734 DOI: 10.1080/15563650.2024.2367677] [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: 03/14/2024] [Accepted: 06/07/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION Antivenom is first line treatment for snake envenomation worldwide, despite few placebo controlled clinical trials demonstrating effectiveness. We aimed to investigate whether early antivenom in red-bellied black snake (Pseudechis porphyriacus) bites would prevent systemic myotoxicity. METHODS We undertook a multicentre randomized placebo-controlled trial of antivenom for red-bellied black snake bites with patients recruited from the Australian Snakebite Project (July 2014 to June 2020). In addition, we report all patients with red-bellied black snake bites during the same period, comparing the same outcomes. Patients over 2 years of age with definite red-bellied black snake bites and early systemic effects were randomized to receive 50 per cent glucose (placebo) or tiger snake antivenom within 6 hours post-bite, or in the cohort group received antivenom determined by the treating clinician. The primary outcome was the proportion of patients with myotoxicity (peak creatine kinase activity >1,000 U/L). Secondary outcomes were: area under the curve of total creatine kinase elevation over 48 hours, presence of venom post-antivenom, and adverse reactions. We analyzed both the randomized control trial patients and the combination of randomized control trial and cohort patients. RESULTS Fifteen patients were recruited to the randomized controlled trial, and a cohort of 68 patients who were not randomized were included in the analysis. After treatment, two of seven patients given placebo had a peak creatine kinase activity >1,000 U/L versus none of the eight given antivenom (difference in favour of antivenom; 29 per cent; 95 per cent confidence interval:-18 per cent to +70 per cent; P = 0.2). The median area under the curve of total creatine kinase elevation over 48 hours in patients given placebo was 0 U/L*h (interquartile range: 0-124 U/L*h), which was not significantly different to those given antivenom: 197 U/L*h (interquartile range: 0-66,353 U/L*h; P = 0.26). Venom was not detected post-antivenom in six patients with measured venom concentrations given antivenom. Two patients given antivenom had immediate hypersensitivity reactions, one severe anaphylaxis, and another had serum sickness. Combining randomized and not randomized patients, three of 36 (8 per cent) administered antivenom less than 6 hours post-bite had a peak creatine kinase activity >1,000 U/L versus 17/47 (36 per cent) patients not receiving antivenom less than 6 hours post-bite (difference in favour of antivenom 29 per cent; 95 per cent confidence interval: 8 per cent to 44 per cent; P < 0.004). Overall, 13/36 (36 per cent) patients administered antivenom within 6 hours had hypersensitivity reactions, six severe anaphylaxis (17 per cent). DISCUSSION We found that early antivenom was effective in red-bellied black snake bites, and only three patients need to be given antivenom within 6 hours to prevent myotoxicity in one (number needed to treat = 3). However, one in three patients administered antivenom developed a hypersensitivity reaction, and one in six had severe anaphylaxis. The major limitation of this study was the small number of patients recruited to the randomized controlled trial. CONCLUSION Administration of antivenom in red-bellied black snake envenomation within 6 hours post-bite appeared to decrease the proportion of patients with myotoxicity, but a third of patients had adverse reactions.
Collapse
Affiliation(s)
- Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- Department of Clinical Toxicology, Newcastle, Australia
- New South Wales Poison Information Centre, Childrens Hospital Westmead, Sydney, Australia
| | - Shane Jenkins
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| | - Michael A Downes
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- Department of Clinical Toxicology, Newcastle, Australia
- New South Wales Poison Information Centre, Childrens Hospital Westmead, Sydney, Australia
| | - Kellie Fakes
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| | - Nicholas A Buckley
- Department of Clinical Toxicology, Newcastle, Australia
- New South Wales Poison Information Centre, Childrens Hospital Westmead, Sydney, Australia
- Clinical Pharmacology & Toxicology Research Group, School of Medical Sciences, University of Sydney
| |
Collapse
|
2
|
Johnston CI, Silva A, Hodgson W, Isbister GK. Investigating skeletal muscle biomarkers for the early detection of Australian myotoxic snake envenoming: an animal model pilot study. Clin Toxicol (Phila) 2024; 62:280-287. [PMID: 38804832 DOI: 10.1080/15563650.2024.2349690] [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: 11/22/2023] [Accepted: 04/25/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Myotoxicity is an important toxidrome that can occur with envenoming from multiple Australian snake types. Early antivenom administration is an important strategy to reduce the incidence and severity of myotoxicity. The current gold standard biomarker, serum creatine kinase activity, does not rise early enough to facilitate early antivenom administration. Several other skeletal muscle biomarkers have shown promise in other animal models and scenarios. The aim of this study was to examine the predictive values of six skeletal muscle biomarkers in a rat model of Australian snake myotoxicity. METHODS Sprague-Dawley rats were anaesthetised and administered either Pseudechis porphyriacus (red-bellied black snake) or Notechis scutatus (tiger snake) venom, or normal saline via intramuscular injection. Blood samples were collected. Assays were performed for serum creatine kinase skeletal muscle troponin-I concentration, skeletal muscle troponin-C concentration, myoglobin activity, skeletal muscle myosin light chain-1 concentration, and creatine kinase-MM activity. Serum markers were plotted against time, with comparison of area under the concentration (or activity)-time curve. The predictive values of six skeletal muscle biomarkers were examined using receiver operating characteristic curves. RESULTS There was no difference in area under the serum creatine kinase activity-time curve between venom and control groups. Serum creatine kinase-MM activity rose early in the venom treated rats, which had a significantly greater area under the serum activity-time curve. No difference in area under the serum concentration-time curve was demonstrated for the other biomarkers. Creatine kinase-MM activity had a superior predictive values than creatine kinase activity at 0-4 hours and 0-10 hours after venom administration, as indicated by area under the receiver operating characteristic curves (95 per cent confidence intervals) of 0.91 (0.78-1.00) and 0.88 (0.73-1.00) versus 0.79 (0.63-0.95) and 0.66 (0.51-0.80). DISCUSSION The limitations of serum creatine kinase activity in early detection of myotoxicity were demonstrated in this rat model. CONCLUSION Serum creatine kinase-MM activity was superior for early detection of Australian myotoxic snake envenoming.
Collapse
Affiliation(s)
| | - Anjana Silva
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
| | - Wayne Hodgson
- Monash Venom Group, Department of Pharmacology, Biomedical Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
| |
Collapse
|
3
|
Stibbs D, Jennar K, Alfred S, White J. Antivenom surveillance: An audit of antivenom stock within South Australia. Emerg Med Australas 2024. [PMID: 38660743 DOI: 10.1111/1742-6723.14420] [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: 11/01/2023] [Revised: 03/06/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVES Antivenoms are important emergency medications to be held within Australia, particularly in regional and remote locations. We audited current antivenom holdings in hospitals and health services across South Australia (SA) and compared to recommendations in the 'Snakebite and Spiderbite Management Guidelines' from the State's Toxinology service. The process also assessed the feasibility of 'real-time' remote stock monitoring. METHODS Fifty-three sites listed in the guideline were recommended to hold antivenom, though only 49 are currently operational. Interrogation of antivenom stock for 29 sites was possible using electronic reports generated from the State Pharmacy database. The 20 remaining centres had their stock levels confirmed by calling the centres directly. Data obtained were then compared to recommended levels of antivenom holdings in the guideline with discrepancies and associated costs documented. A separate report verification process was used to determine 'real-time' accuracy of the electronic reports. RESULTS Thirty-seven sites (75%) held more than the recommended number of antivenom vials, totalling 129 vials in excess with an approximate total cost of $110 000. Twelve sites (24%) held inadequate stock to deliver a treatment dose for 19 envenoming events. The report verification revealed variances in the electronic reports. CONCLUSIONS This audit has demonstrated a significant disparity between recommended and actual antivenom holdings across most sites in SA and has also revealed that 'real-time' remote monitoring of state antivenom holdings is not currently feasible. Correction of stock levels to that recommended may result in financial benefit for State Health while also addressing inequity in regional and remote healthcare provision.
Collapse
Affiliation(s)
- David Stibbs
- Emergency Department, Flinders Medical Centre, Adelaide, South Australia, Australia
- Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Kate Jennar
- SA Pharmacy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Sam Alfred
- Emergency Department and Toxicology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- NSW Poisons Information Centre
- University of Adelaide, Adelaide, South Australia, Australia
| | - Julian White
- University of Adelaide, Adelaide, South Australia, Australia
- Toxinology Department, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| |
Collapse
|
4
|
Smith LK, Vardanega J, Smith S, White J, Little M, Hanson J. The Incidence of Infection Complicating Snakebites in Tropical Australia: Implications for Clinical Management and Antimicrobial Prophylaxis. J Trop Med 2023; 2023:5812766. [PMID: 37868739 PMCID: PMC10586896 DOI: 10.1155/2023/5812766] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/24/2023] Open
Abstract
Objective To define the incidence of infection following snakebite in tropical Australia and the resulting implications for the routine prescription of prophylactic antibiotics. Methods A retrospective study of all individuals presenting to Cairns Hospital, a tertiary referral hospital in tropical Australia, after a snakebite between December 2013 and October 2020. Results There were 732 hospitalisations, 720 (98.4%) patients presented within 8 hours of the snakebite, and 29/732 (4.0%) were envenomated. Envenomated patients were more likely to receive empirical antibiotics than nonenvenomated patients (8/29 (27.6%) versus 14/703 (2.0%), p < 0.001), although this was frequently as a bundle of care for critically ill individuals. Superficial skin infection was diagnosed by clinicians in 6/732 (0.8%) patients during their hospitalisation; infection was diagnosed more commonly in envenomated than in nonenvenomated patients (3/29 (10.3%) versus 3/703 (0.4%), p = 0.001). All 3 envenomated individuals diagnosed with infection were believed to have taipan (genus Oxyuranus) bites. Five (83%) of the six patients diagnosed with infection had received empirical antibiotics at presentation; only 1/710 (0.1%) patients who received no antibiotics developed a (superficial) infection. Conclusion Infection is a very uncommon complication of snakebite in tropical Australia. Individuals bitten by snakes in tropical Australia should not routinely receive antibiotic prophylaxis.
Collapse
Affiliation(s)
| | - John Vardanega
- Cairns Hospital, Cairns, Queensland, Australia
- QML Pathology, Murarrie, Queensland, Australia
| | - Simon Smith
- Cairns Hospital, Cairns, Queensland, Australia
| | - Julian White
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Mark Little
- Cairns Hospital, Cairns, Queensland, Australia
- NSW Poisons Information Service, Sydney NSW, Australia
| | - Josh Hanson
- Cairns Hospital, Cairns, Queensland, Australia
- The Kirby Institute, UNSW, Sydney, NSW, Australia
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Dehghani R, Monzavi SM, Mehrpour O, Shirazi FM, Hassanian-Moghaddam H, Keyler DE, Wüster W, Westerström A, Warrell DA. Medically important snakes and snakebite envenoming in Iran. Toxicon 2023; 230:107149. [PMID: 37187227 DOI: 10.1016/j.toxicon.2023.107149] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/17/2023]
Abstract
Snakebite is a common health condition in Iran with a diverse snake fauna, especially in tropical southern and mountainous western areas of the country with plethora of snake species. The list of medically important snakes, circumstances and effects of their bite, and necessary medical care require critical appraisal and should be updated regularly. This study aims to review and map the distributions of medically important snake species of Iran, re-evaluate their taxonomy, review their venomics, describe the clinical effects of envenoming, and discuss medical management and treatment, including the use of antivenom. Nearly 350 published articles and 26 textbooks with information on venomous and mildly venomous snake species and snakebites of Iran, were reviewed, many in Persian (Farsi) language, making them relatively inaccessible to an international readership. This has resulted in a revised updated list of Iran's medically important snake species, with taxonomic revisions of some, compilation of their morphological features, remapping of their geographical distributions, and description of species-specific clinical effects of envenoming. Moreover, the antivenom manufactured in Iran is discussed, together with treatment protocols that have been developed for the hospital management of envenomed patients.
Collapse
Affiliation(s)
- Ruhollah Dehghani
- Department of Environmental Health, Kashan University of Medical Sciences, Kashan, Iran; Social Determinants of Health Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Seyed Mostafa Monzavi
- Medical Toxicology Center, Mashhad University of Medical Sciences, Mashhad, Iran; Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center, Birjand University of Medical Sciences, Birjand, Iran; Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA.
| | - Farshad M Shirazi
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - Hossein Hassanian-Moghaddam
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Daniel E Keyler
- Department of Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Wolfgang Wüster
- Molecular Ecology and Evolution at Bangor, School of Natural Sciences, Bangor University, Bangor, UK
| | | | - David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
7
|
Morris CAD, Donaldson RE. Mechanical ventilation in snake envenomation of dogs and cats. Front Vet Sci 2023; 10:1071257. [PMID: 37065246 PMCID: PMC10090310 DOI: 10.3389/fvets.2023.1071257] [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: 10/16/2022] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
Envenomation by snakes in Elapidae and Viperidae families have been associated with respiratory failure in dogs and cats. Mechanical ventilation may be required for hypoventilation due to neuromuscular paralysis or hypoxemia due to pulmonary hemorrhage or aspiration pneumonia. Median incidence of dogs and cats with snake envenomation that require mechanical ventilation is 13% (0.06-40%). Standard treatment of snake envenomation in dogs and cats includes prompt administration of appropriate antivenom and management of envenomation complications such as coagulopathy, rhabdomyolysis and acute kidney injury. When mechanical ventilation is required, overall prognosis is good with appropriate treatment. Standard anesthetic protocols and mechanical ventilator settings are generally appropriate, with lung protective ventilation strategies typically reserved for patients with pulmonary disease. Median survival to discharge for cats and dogs with elapid envenomation is 72% (76-84%) with 33 h (19.5-58 h) median duration of mechanical ventilation and 140 h (84-196 h) median hospitalization. This article reviews indications for mechanical ventilation in cats and dogs with snake envenomation, and discusses ventilator settings, anesthetic and nursing considerations, complications and outcomes specific to this disease.
Collapse
Affiliation(s)
- Cameron A. D. Morris
- Critical Care Department, Queensland Veterinary Specialists, Brisbane, QLD, Australia
| | | |
Collapse
|
8
|
Lee LP, Tan CH, Khomvilai S, Sitprija V, Chaiyabutr N, Tan KY. Characterizing and applying immunoglobulins in snakebite diagnostics: A simple and rapid venom detection assay for four medically important snake species in Southeast Asia. Int J Biol Macromol 2023; 236:123727. [PMID: 36863668 DOI: 10.1016/j.ijbiomac.2023.123727] [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: 11/07/2022] [Revised: 01/28/2023] [Accepted: 02/13/2023] [Indexed: 03/04/2023]
Abstract
Snakebite envenoming is a medical emergency requiring urgent and specific treatment. Unfortunately, snakebite diagnostics are scarce, time-consuming and lacking specificity. Hence, this study aimed to develop a simple, quick and specific snakebite diagnostic assay using animal antibodies. Anti-venom horse immunoglobulin G (IgG) and chicken immunoglobulin Y (IgY) were produced against the venoms of four major medically important snake species in Southeast Asia, i.e., the Monocled Cobra (Naja kaouthia), Malayan Krait (Bungarus candidus), Malayan Pit Viper (Calloselasma rhodostoma), and White-lipped Green Pit Viper (Trimeresurus albolabris). Different capture:detection configurations of double-antibody sandwich enzyme-linked immunosorbent assay (ELISA) were constructed using both immunoglobulins, and the horse IgG:IgG-HRP configuration was found to be most selective and sensitive in detecting the corresponding venoms. The method was further streamlined to develop a rapid immunodetection assay, which is able to produce a visual color change within 30 min for discrimination between different snake species. The study shows it is feasible to develop a simple, quick and specific immunodiagnostic assay using horse IgG, which can be derived directly from antisera prepared for antivenom production. The proof-of-concept indicates it is a sustainable and affordable approach in keeping with on-going antivenom manufacturing activities for specific species in the region.
Collapse
Affiliation(s)
- Louisa Pernee Lee
- Venom Research and Toxicology Laboratory, Department of Pharmacology, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Choo Hock Tan
- Venom Research and Toxicology Laboratory, Department of Pharmacology, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Sumana Khomvilai
- Queen Saovabha Memorial Institute, Thai Red Cross Society, 10330 Bangkok, Thailand
| | - Visith Sitprija
- Queen Saovabha Memorial Institute, Thai Red Cross Society, 10330 Bangkok, Thailand
| | - Narongsak Chaiyabutr
- Queen Saovabha Memorial Institute, Thai Red Cross Society, 10330 Bangkok, Thailand
| | - Kae Yi Tan
- Protein and Interactomics Laboratory, Department of Molecular Medicine, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia.
| |
Collapse
|
9
|
Antivenom availability, delays and use in Australia. Toxicon X 2023; 17:100145. [DOI: 10.1016/j.toxcx.2022.100145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
|
10
|
Little M. Is D‐dimer the new test for venom‐induced consumption coagulopathy after snakebite? Med J Aust 2022; 217:191-192. [DOI: 10.5694/mja2.51663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Mark Little
- Cairns Hospital Cairns QLD Australia
- NSW Poisons Information Centre, Children's Hospital at Westmead Sydney NSW Australia
| |
Collapse
|
11
|
Zeng ZY, Huang PY, Du JY, Liu YX, Guo SG, Zeng LS, Zhang CC, Li Y. Effect of Agkistrodon halys antivenom in patients bit by green pit viper and the prognostic role of the disease - a retrospective cohort study. Clin Toxicol (Phila) 2022; 60:808-817. [PMID: 35225104 DOI: 10.1080/15563650.2022.2041200] [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]
Abstract
BACKGROUND AND AIMS In Mainland China and Hong Kong, health authorities utilize Agkistrodon halys antivenom in the treatment of patients who sustained bites from green pit vipers. However, the treatment benefit of Agkistrodon halys antivenom among such patients is still controversial. The purpose of this study is to evaluate the coagulation parameters normalization time of Agkistrodon halys antivenom in patients who sustained green pit viper bites and explore independent risk factors of patient prognosis. METHODS Data were extracted from the Donghua Hospital Information System. Comparison of the two groups of patients - who used antivenom (GPUA) and who did not use antivenom (GPNUA) were performed using stratified analysis, univariate and multivariate ordered logistic regression models to evaluate the coagulation parameters normalization time. Univariate and multivariate ordered logistic regression models were used to explore independent risk factors of patient prognosis. RESULTS Between the GPUA and GPNUA groups, there is no significant difference in the coagulation parameters normalization time with the treatment of Agkistrodon halys antivenom. GPNUA consumed more cryoprecipitate and platelets and had a lower cost. The patient's severity of the bite, first coagulation profile, and dosages of fresh frozen plasma, platelet, and red cell suspension was found to be risk factors for the normalization time of coagulation parameters. CONCLUSIONS The therapeutic effect of Agkistrodon halys antivenom in green pit vipers bite patients is not quite satisfying. In addition, more attention should be paid to the first coagulation profile, blood clotting factors indices, platelet count (PLT), and hemoglobin when treating such patients.
Collapse
Affiliation(s)
- Zhong-Yi Zeng
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Pei-Ying Huang
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, PR China.,Emergency Department, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, PR China
| | - Jia-Yu Du
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Yu-Xiang Liu
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Shi-Gong Guo
- Department of Rehabilitation Medicine, Southmead Hospital, Bristol, UK
| | - Lin-Sheng Zeng
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Cong-Cong Zhang
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, PR China
| | - Yi Li
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, PR China
| |
Collapse
|
12
|
Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice. Toxins (Basel) 2022; 14:toxins14010057. [PMID: 35051033 PMCID: PMC8778654 DOI: 10.3390/toxins14010057] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/05/2023] Open
Abstract
Snakebite is a significant and under-resourced global public health issue. Snake venoms cause a variety of potentially fatal clinical toxin syndromes, including venom-induced consumption coagulopathy (VICC) which is associated with major haemorrhage. A subset of patients with VICC develop a thrombotic microangiopathy (TMA). This article reviews recent evidence regarding snakebite-associated TMA and its epidemiology, diagnosis, outcomes, and effectiveness of interventions including antivenom and therapeutic plasma-exchange. Snakebite-associated TMA presents with microangiopathic haemolytic anaemia (evidenced by schistocytes on the blood film), thrombocytopenia in almost all cases, and a spectrum of acute kidney injury (AKI). A proportion of patients require dialysis, most survive and achieve dialysis free survival. There is no evidence that antivenom prevents TMA specifically, but early antivenom remains the mainstay of treatment for snake envenoming. There is no evidence for therapeutic plasma-exchange being effective. We propose diagnostic criteria for snakebite-associated TMA as anaemia with >1.0% schistocytes on blood film examination, together with absolute thrombocytopenia (<150 × 109/L) or a relative decrease in platelet count of >25% from baseline. Patients are at risk of long-term chronic kidney disease and long term follow up is recommended.
Collapse
|
13
|
Affiliation(s)
- Ravikar Ralph
- Department of Internal Medicine, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | | | - Sanjib Kumar Sharma
- Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, 76500, Nepal
| | - Isabela Ribeiro
- Dynamic Portfolio, Drugs for Neglected Diseases initiative (DNDi), 15 Chemin Louis-Dunant, 1202, Geneva, Switzerland
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 6, Geneva, CH 1211, Switzerland
| |
Collapse
|
14
|
Investigating myotoxicity following Australian red-bellied black snake (Pseudechis porphyriacus) envenomation. PLoS One 2021; 16:e0256653. [PMID: 34506531 PMCID: PMC8432874 DOI: 10.1371/journal.pone.0256653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 08/11/2021] [Indexed: 11/19/2022] Open
Abstract
Background Myotoxicity is one of the common clinical manifestations of red-bellied black snake (Pseudechis porphyriacus) envenomation characterised by elevated creatine kinase (CK) concentrations of greater than 1000 U/L. This study aimed to investigate the occurrence of myotoxicity in patients following envenomation. Methods/Principal findings Patient characteristics and serial blood samples (timed venom concentrations and CK concentrations, pre- and post- antivenom) from 114 patients (median age 41, 2-90y; 80 male) were extracted from the Australian Snakebite Project database. Patients were categorised into three groups based on peak CK concentrations [no myotoxicity (<1000 U/L), mild (1000–10,000 U/L) and severe (>10,000 U/L)]. The odds of (mild or severe) myotoxicity was lower in patients that received early antivenom (within 6 hours post-bite) compared to those that received late or no antivenom (odd ratio was 0.186; 95% confidence interval, 0.052–0.664). A population pharmacokinetic-pharmacodynamic (PKPD) model was developed to describe the relationship between the time course of venom (a mixture of toxins) and effect (elevated CK). In addition, a kinetic-pharmacodynamic (KPD) model was developed to describe the relationship between time course of a theoretical toxin and effect. Model development and parameter estimation was performed using NONMEM v7.3. No single set of parameter values from either the PKPD or KPD models were found that could accurately describe the time course of different levels of severity of myotoxicity. The predicted theoretical toxin half-life from the KPD model was 11 ± 3.9 hours compared to the half-life of venom of 5.3 ± 0.36 hours. This indicates that the putative causative toxin’s concentration-time profile does not parallel that of venom. Conclusion Early antivenom administration reduces the incidence of myotoxicity. The venom concentration profile does not appear to be the driver for myotoxicity following envenomation. Additional factors that affect the sensitivity of the patient to snake venom/toxins must be explored to understand the relationship with myotoxicity.
Collapse
|
15
|
Hamza M, Knudsen C, Gnanathasan CA, Monteiro W, Lewin MR, Laustsen AH, Habib AG. Clinical management of snakebite envenoming: Future perspectives. Toxicon X 2021; 11:100079. [PMID: 34430847 PMCID: PMC8374517 DOI: 10.1016/j.toxcx.2021.100079] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/29/2021] [Accepted: 07/30/2021] [Indexed: 11/18/2022] Open
Abstract
Snakebite envenoming is a major cause of morbidity and mortality in rural communities throughout the tropics. Generally, the main clinical features of snakebites are local swelling, tissue necrosis, shock, spontaneous systemic hemorrhage, incoagulable blood, paralysis, rhabdomyolysis, and acute kidney injury. These clinical manifestations result from complex biochemical venom constituents comprising of cytotoxins, hemotoxins, neurotoxins, myotoxins, and other substances. Timely diagnosis of envenoming and identification of the responsible snake species is clinically challenging in many parts of the world and necessitates prompt and thorough clinical assessment, which could be supported by the development of reliable, affordable, widely-accessible, point-of-care tests. Conventional antivenoms based on polyclonal antibodies derived from animals remain the mainstay of therapy along with supportive medical and surgical care. However, while antivenoms save countless lives, they are associated with adverse reactions, limited potency, and are relatively inefficacious against presynaptic neurotoxicity and in preventing necrosis. Nevertheless, major scientific and technological advances are facilitating the development of new molecular and immunologic diagnostic tests, as well as a new generation of antivenoms comprising human monoclonal antibodies with broader and more potent neutralization capacity and less immunogenicity. Repurposed pharmaceuticals based on small molecule inhibitors (e.g., marimastat and varespladib) used alone and in combination against enzymatic toxins, such as metalloproteases and phospholipase A2s, have shown promise in animal studies. These orally bioavailable molecules could serve as early interventions in the out-of-hospital setting if confirmed to be safe and efficacious in clinical studies. Antivenom access can be improved by the usage of drones and ensuring constant antivenom supply in remote endemic rural areas. Overall, the improvement of clinical management of snakebite envenoming requires sustained, coordinated, and multifaceted efforts involving basic and applied sciences, new technology, product development, effective clinical training, implementation of existing guidelines and therapeutic approaches, supported by improved supply of existing antivenoms.
Collapse
Affiliation(s)
- Muhammad Hamza
- Infectious and Tropical Diseases Unit, Bayero University Kano, Nigeria
| | - Cecilie Knudsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | | | - Wuelton Monteiro
- Department of Research, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
- School of Health Sciences, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Matthew R. Lewin
- Center for Exploration and Travel Health, California Academy of Sciences, San Francisco, USA
| | - Andreas H. Laustsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | | |
Collapse
|
16
|
Noutsos T, Currie BJ, Isoardi KZ, Brown SGA, Isbister GK. Snakebite-associated thrombotic microangiopathy: an Australian prospective cohort study [ASP30]. Clin Toxicol (Phila) 2021; 60:205-213. [PMID: 34328386 DOI: 10.1080/15563650.2021.1948559] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Snakebite-associated thrombotic microangiopathy (TMA) occurs in a subset of patients with venom-induced consumption coagulopathy (VICC) following snakebite. Acute kidney injury (AKI) is the commonest end-organ manifestation of TMA. The epidemiology, diagnostic features, outcomes, and effectiveness of interventions including therapeutic plasma-exchange (TPE), in snakebite-associated TMA are poorly understood. METHODS We reviewed all patients with suspected or confirmed snakebite recruited to the Australian Snakebite Project (2004-2018 inclusive), a prospective cohort study, from 202 participating Australian hospitals across the country. TMA was defined as anemia with schistocytosis. RESULTS 2069 patients with suspected snakebite were enrolled, with 1158 (56.0%) systemically envenomed, of which 842 (72.7%) developed VICC, from which 104 (12.4%) developed TMA. Of those systemically envenomed, TMA occurred in 26% (13/50) taipan, 17% (60/351) brown, and 8% (16/197) tiger snakebites. Thrombocytopenia was present in 90% (94/104) of TMA cases, and a further eight (8%) had a > 25% decrease in platelets from the presentation. Patients with TMA were significantly older than non-TMA patients with VICC (53 [35-61] versus 41 [24-55] years, median [IQR], p < 0.0001). AKI developed in 94% (98/104) of TMA patients, with 34% (33/98) requiring dialysis (D-AKI). There were four deaths. In D-AKI TMA cases, eventual dialysis-free survival (DFS) was 97% (32/33). TPE was used in five D-AKI cases, with no significant difference in DFS or time to independence from dialysis. >90-day follow-up for 25 D-AKI cases (130 person-years) showed no end-stage kidney disease but 52% (13/25) had ≥ stage 3 chronic kidney disease (CKD). CONCLUSION Our findings support a definition of snakebite-associated TMA as anemia with schistocytosis and either thrombocytopenia or >25% drop in platelet count. AKI occurring with snakebite-associated TMA varied in severity, with most achieving DFS, but with a risk of long-term CKD in half. We found no evidence of benefit for TPE in D-AKI.
Collapse
Affiliation(s)
- Tina Noutsos
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Bart J Currie
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Katherine Z Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia.,Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| | - Simon G A Brown
- Centre for Clinical Research in Emergency Medicine, University of Western Australia, Perth, Australia.,Aeromedical and Medical Retrieval Division, Ambulance Tasmania, Hobart, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| |
Collapse
|
17
|
Knudsen C, Jürgensen JA, Føns S, Haack AM, Friis RUW, Dam SH, Bush SP, White J, Laustsen AH. Snakebite Envenoming Diagnosis and Diagnostics. Front Immunol 2021; 12:661457. [PMID: 33995385 PMCID: PMC8113877 DOI: 10.3389/fimmu.2021.661457] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Snakebite envenoming is predominantly an occupational disease of the rural tropics, causing death or permanent disability to hundreds of thousands of victims annually. The diagnosis of snakebite envenoming is commonly based on a combination of patient history and a syndromic approach. However, the availability of auxiliary diagnostic tests at the disposal of the clinicians vary from country to country, and the level of experience within snakebite diagnosis and intervention may be quite different for clinicians from different hospitals. As such, achieving timely diagnosis, and thus treatment, is a challenge faced by treating personnel around the globe. For years, much effort has gone into developing novel diagnostics to support diagnosis of snakebite victims, especially in rural areas of the tropics. Gaining access to affordable and rapid diagnostics could potentially facilitate more favorable patient outcomes due to early and appropriate treatment. This review aims to highlight regional differences in epidemiology and clinical snakebite management on a global scale, including an overview of the past and ongoing research efforts within snakebite diagnostics. Finally, the review is rounded off with a discussion on design considerations and potential benefits of novel snakebite diagnostics.
Collapse
Affiliation(s)
- Cecilie Knudsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
- BioPorto Diagnostics A/S, Hellerup, Denmark
| | - Jonas A. Jürgensen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Sofie Føns
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Aleksander M. Haack
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Rasmus U. W. Friis
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Søren H. Dam
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Sean P. Bush
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Julian White
- Toxinology Department, Women’s and Children’s Hospital, North Adelaide, SA, Australia
| | - Andreas H. Laustsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| |
Collapse
|
18
|
Sanhajariya S, Duffull SB, Isbister GK. Population pharmacokinetics of Pseudechis porphyriacus (red-bellied black snake) venom in snakebite patients. Clin Toxicol (Phila) 2021; 59:956-962. [PMID: 33832399 DOI: 10.1080/15563650.2021.1896731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Understanding the time course of venom exposure in snakebite patients is important for the optimisation of treatment including antivenom dose and timing. We aimed to investigate the pharmacokinetics of red-bellied black snake (RBBS; Pseudechis porphyriacus) venom in envenomed patients. METHODS Timed venom concentration data were obtained from patients with RBBS envenomation recruited to the Australian Snakebite Project (ASP), including demographics and antivenom treatment. Venom concentrations were measured using an enzyme immunoassay. Data were modelled using NONMEM version 7.3. Uncertainty in venom "dose" was accounted for by arbitrarily fixing the average amount to 1 mg and incorporating between-subject variability on relative bioavailability. A scale parameter for venom clearance was implemented to account for the rapid venom clearance following antivenom dosing. A sensitivity analysis was performed to determine the magnitude of venom clearance amplification. RESULTS There were 457 venom concentrations in 114 patients (median age 41, 2-90 y; 80 male). Antivenom was administered to 54 patients a median of 4.2 h post-bite (0.67 to 32 h). A one-compartment model with first-order absorption and elimination provided the best description of the data. The estimated clearance and volume of distribution were 5.21 L/h and 39.9 L, respectively. The calculated elimination half-life of P. porphyriacus venom from the final pharmacokinetic model was 5.35 ± 0.36 h. The variability in the relative dose of injected venom was 140%. Antivenom administration increased venom clearance by 40-fold. Ten patients showed evidence of a double peak in the absorption profile. CONCLUSION The information on the exposure time of venom in the body following envenomation will help improve treatment and the timing of antivenom.
Collapse
Affiliation(s)
- Suchaya Sanhajariya
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia.,Otago Pharmacometrics Group, School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Stephen B Duffull
- Otago Pharmacometrics Group, School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| |
Collapse
|
19
|
Current research into snake antivenoms, their mechanisms of action and applications. Biochem Soc Trans 2021; 48:537-546. [PMID: 32196542 DOI: 10.1042/bst20190739] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 01/11/2023]
Abstract
Snakebite is a major public health issue in the rural tropics. Antivenom is the only specific treatment currently available. We review the history, mechanism of action and current developments in snake antivenoms. In the late nineteenth century, snake antivenoms were first developed by raising hyperimmune serum in animals, such as horses, against snake venoms. Hyperimmune serum was then purified to produce whole immunoglobulin G (IgG) antivenoms. IgG was then fractionated to produce F(ab) and F(ab')2 antivenoms to reduce adverse reactions and increase efficacy. Current commercial antivenoms are polyclonal mixtures of antibodies or their fractions raised against all toxin antigens in a venom(s), irrespective of clinical importance. Over the last few decades there have been small incremental improvements in antivenoms, to make them safer and more effective. A number of recent developments in biotechnology and toxinology have contributed to this. Proteomics and transcriptomics have been applied to venom toxin composition (venomics), improving our understanding of medically important toxins. In addition, it has become possible to identify toxins that contain epitopes recognized by antivenom molecules (antivenomics). Integration of the toxinological profile of a venom and its composition to identify medically relevant toxins improved this. Furthermore, camelid, humanized and fully human monoclonal antibodies and their fractions, as well as enzyme inhibitors have been experimentally developed against venom toxins. Translation of such technology into commercial antivenoms requires overcoming the high costs, limited knowledge of venom and antivenom pharmacology, and lack of reliable animal models. Addressing such should be the focus of antivenom research.
Collapse
|
20
|
Abstract
BACKGROUND Myotoxicity is a recognised but poorly characterised effect of snake envenoming worldwide. We aimed to describe the clinical effects, complications and effectiveness of antivenom in myotoxicity from Australian snake envenoming. METHODS Patients were recruited to the Australian Snakebite Project (ASP), a prospective, observational study of patients with suspected or proven snakebite countrywide. After informed consent data is collected and stored in a dedicated database and blood samples are taken and stored. We included patients with envenoming and biochemical evidence of myotoxicity (peak creatine kinase [CK] > 1000 U/L). Snake species was determined by expert identification or venom specific enzyme immunoassay. Analysis included patient demographics, clinical findings, pathology results, treatment and outcomes (length of hospital stay, complications). RESULTS 1638 patients were recruited January 2003-December 2016, 935 (57%) were envenomed, 148 developed myotoxicity (16%). Snake species most commonly associated with myotoxicity were Notechis spp. (30%), Pseudechis porphyriacus (20%) and Pseudechis australis (13%). Bite site effects occurred in 19 patients. Non-specific systemic symptoms occurred in 135 patients (91%), specific signs and symptoms in 83. In 120 patients with early serial CK results, the median peak CK was 3323 U/L (IQR;1050-785100U/L), the median time to first CK >500 U/L was 11.1 h and median time to peak CK of 34.3 h. White cell count was elevated in 136 patients (93%; median time to elevation, 4.9 h). 37 patients had elevated creatinine, six were dialysed. Two patients died from complications of severe myotoxicity. Antivenom given before the first abnormal CK (>500 U/L) was associated with less severe myotoxicity (2976 versus 7590 U/L). Non-envenomed patients with elevated CK had rapid rise to abnormal CK (median 3.5 h) and less had elevated WCC (32%). CONCLUSION Myotoxicity from Australian snakes is relatively common and has systemic effects, with significant associated morbidity and mortality. CK is not a good early biomarker of mytoxicity. Early antivenom may play a role in reducing severity.
Collapse
|
21
|
Isbister GK, Mirajkar N, Fakes K, Brown SGA, Veerati PC. Phospholipase A2 (PLA 2) as an Early Indicator of Envenomation in Australian Elapid Snakebites (ASP-27). Biomedicines 2020; 8:biomedicines8110459. [PMID: 33138056 PMCID: PMC7692658 DOI: 10.3390/biomedicines8110459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 01/28/2023] Open
Abstract
Early diagnosis of snake envenomation is essential, especially neurotoxicity and myotoxicity. We investigated the diagnostic value of serum phospholipase (PLA2) in Australian snakebites. In total, 115 envenomated and 80 non-envenomated patients were recruited over 2 years, in which an early blood sample was available pre-antivenom. Serum samples were analyzed for secretory PLA2 activity using a Cayman sPLA2 assay kit (#765001 Cayman Chemical Company, Ann Arbor MI, USA). Venom concentrations were measured for snake identification using venom-specific enzyme immunoassay. The most common snakes were Pseudonaja spp. (33), Notechis scutatus (24), Pseudechis porphyriacus (19) and Tropidechis carinatus (17). There was a significant difference in median PLA2 activity between non-envenomated (9 nmol/min/mL; IQR: 7–11) and envenomated patients (19 nmol/min/mL; IQR: 10–66, p < 0.0001) but Pseudonaja spp. were not different to non-envenomated. There was a significant correlation between venom concentrations and PLA2 activity (r = 0.71; p < 0.0001). PLA2 activity was predictive for envenomation; area under the receiver-operating-characteristic curve (AUC-ROC), 0.79 (95% confidence intervals [95%CI]: 0.72–0.85), which improved with brown snakes excluded, AUC-ROC, 0.88 (95%CI: 0.82–0.94). A cut-point of 16 nmol/min/mL gives a sensitivity of 72% and specificity of 100% for Australian snakes, excluding Pseudonaja. PLA2 activity was a good early predictor of envenomation in most Australian elapid bites. A bedside PLA2 activity test has potential utility for early case identification but may not be useful for excluding envenomation.
Collapse
Affiliation(s)
- Geoffrey K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW 2298, Australia; (N.M.); (K.F.); (P.C.V.)
- Correspondence: ; Tel.: +61-249211211
| | - Nandita Mirajkar
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW 2298, Australia; (N.M.); (K.F.); (P.C.V.)
| | - Kellie Fakes
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW 2298, Australia; (N.M.); (K.F.); (P.C.V.)
| | - Simon G. A. Brown
- Aeromedical and Retrieval Medicine, Ambulance Tasmania, Hobart, TAS 7001, Australia;
| | - Punnam Chander Veerati
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW 2298, Australia; (N.M.); (K.F.); (P.C.V.)
| |
Collapse
|
22
|
Tibballs J, Padula AM, Winkel KD, Jackson HD. Delayed antivenom for life-threatening tiger snake bite: Lessons learnt. Anaesth Intensive Care 2020; 48:399-403. [PMID: 33017183 DOI: 10.1177/0310057x20946047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An adolescent victim of an urban snakebite developed respiratory failure, rhabdomyolysis and consumption procoagulopathy but recovered with two vials of tiger snake antivenom administered after a delay of 48 hours. The clinical significance of a post-bite collapse was not initially appreciated. Tiger snake (Notechis spp.) venom antigen was measurable in blood before antivenom but not after whereas antivenom was measurable in blood for nine ensuing days. This case adds to growing evidence that further pharmacokinetic research of venom-antivenom interaction is required to establish the correct dose and timing of tiger snake antivenom. Antivenom therapy, even when delayed, facilitates recovery from snake envenomation.
Collapse
Affiliation(s)
- James Tibballs
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, Australia
| | - Andrew M Padula
- Department of Pharmacology and Therapeutics, The University of Melbourne, Melbourne, Australia
| | - Kenneth D Winkel
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Hamish D Jackson
- Neonatal and Paediatric Intensive Care Unit, Royal Hobart Hospital, Hobart, Australia
| |
Collapse
|
23
|
Stazi M, D’Este G, Mattarei A, Negro S, Lista F, Rigoni M, Megighian A, Montecucco C. An agonist of the CXCR4 receptor accelerates the recovery from the peripheral neuroparalysis induced by Taipan snake envenomation. PLoS Negl Trop Dis 2020; 14:e0008547. [PMID: 32898186 PMCID: PMC7537909 DOI: 10.1371/journal.pntd.0008547] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 10/06/2020] [Accepted: 06/19/2020] [Indexed: 01/15/2023] Open
Abstract
Envenomation by snakes is a major neglected human disease. Hospitalization and use of animal-derived antivenom are the primary therapeutic supports currently available. There is consensus that additional, not expensive, treatments that can be delivered even long after the snake bite are needed. We recently showed that the drug dubbed NUCC-390 shortens the time of recovery from the neuroparalysis caused by traumatic or toxic degeneration of peripheral motor neurons. These syndromes are characterized by the activation of a pro-regenerative molecular axis, consisting of the CXCR4 receptor expressed at the damaged site in neuronal axons and by the release of its ligand CXCL12α, produced by surrounding Schwann cells. This intercellular signaling axis promotes axonal growth and functional recovery from paralysis. NUCC-390 is an agonist of CXCR4 acting similarly to CXCL12α. Here, we have tested its efficacy in a murine model of neuroparalytic envenoming by a Papuan Taipan (Oxyuranus scutellatus) where a degeneration of the motor axon terminals caused by the presynaptic PLA2 toxin Taipoxin, contained in the venom, occurs. Using imaging of the neuromuscular junction and electrophysiological analysis, we found that NUCC-390 administration after injection of either the purified neuroparalytic Taipoxin or the whole Taipan venom, significantly accelerates the recovery from paralysis. These results indicate that NUCC-390, which is non-toxic in mice, should be considered for trials in humans to test its efficacy in accelerating the recovery from the peripheral neuroparalysis induced by Taipans. NUCC-390 should be tested as well in the envenomation by other snakes that cause neuroparalytic syndromes in humans. NUCC-390 could become an additional treatment, common to many snake envenomings, that can be delivered after the bite to reduce death by respiratory deficits and to shorten and improve functional recovery.
Collapse
Affiliation(s)
- Marco Stazi
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Giorgia D’Este
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Andrea Mattarei
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Padova, Italy
| | - Samuele Negro
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Florigio Lista
- Department of Medical and Veterinary Research, the Ministry of Defense, Rome, Italy
| | - Michela Rigoni
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Aram Megighian
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Cesare Montecucco
- Department of Biomedical Sciences, University of Padova, Padova, Italy
- CNR Institute of Neuroscience, Department of Biomedical Sciences, Padua, Italy
| |
Collapse
|
24
|
Kang K, Sharp CR, Boyd CJ, Turner K. Intramyocardial haematoma causing right ventricular outflow obstruction after brown snake (
Pseudonaja
species) envenomation in a dog. Aust Vet J 2020; 98:455-461. [DOI: 10.1111/avj.12989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 03/31/2020] [Accepted: 06/02/2020] [Indexed: 11/27/2022]
Affiliation(s)
- K Kang
- School of Veterinary Medicine Murdoch University Murdoch Western Australia Australia
| | - CR Sharp
- School of Veterinary Medicine Murdoch University Murdoch Western Australia Australia
| | - CJ Boyd
- School of Veterinary Medicine Murdoch University Murdoch Western Australia Australia
| | - K Turner
- School of Veterinary Medicine Murdoch University Murdoch Western Australia Australia
| |
Collapse
|
25
|
Saganuwan SA. Comparative therapeutic index, lethal time and safety margin of various toxicants and snake antivenoms using newly derived and old formulas. BMC Res Notes 2020; 13:292. [PMID: 32546265 PMCID: PMC7296648 DOI: 10.1186/s13104-020-05134-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/10/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The assessment of clinical efficacy and toxicity is very important in pharmacology and toxicology. The effects of psychostimulants (e.g. amphetamine), psychotomimetics (e.g. Cannabis sativus) and snake antivenoms are sometimes unpredictable even at lower doses, leading to serious intoxication and fatal consequences. Hence, there is need to re-assess some formulas for calculation of therapeutic index, lethal time and safety margin with a view to identifying therapeutic agents with remarkable toxicity potentials. RESULTS The therapeutic index formula [Formula: see text] was derived from T1 = LD50/ED50 and ED50 = [Formula: see text]. Findings have shown that, therapeutic index is a function of death reversal (s), safety factor (10-4) and weight of animal (Wa). However, the new safety margin formula [Formula: see text] derived from LT50 = [Formula: see text] and MS = [Formula: see text] shows that safety margin is a function of cube root of ratio between LT50 and LD50 and ED100th. Concentration (k) of toxicant at the receptor [Formula: see text] derived from D1 × Tn = K and LD1 = [Formula: see text] shows that therapeutic index, lethal time and safety margin is a function of drug or toxicant concentration at the receptor, the drug-receptor interaction and dose of toxicant or drug administered at a particular time.
Collapse
Affiliation(s)
- Saganuwan Alhaji Saganuwan
- Department of Veterinary Pharmacology and Toxicology, College of Veterinary Medicine, Federal University of Agriculture, P.M.B. 2373, Makurdi, Benue, Nigeria.
| |
Collapse
|
26
|
Park EJ, Choi S, Kim HH, Jung YS. Novel Treatment Strategy for Patients with Venom-Induced Consumptive Coagulopathy from a Pit Viper Bite. Toxins (Basel) 2020; 12:toxins12050295. [PMID: 32380672 PMCID: PMC7290867 DOI: 10.3390/toxins12050295] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/01/2020] [Accepted: 05/02/2020] [Indexed: 12/17/2022] Open
Abstract
Pit viper venom commonly causes venom-induced consumptive coagulopathy (VICC), which can be complicated by life-threatening hemorrhage. VICC has a complex pathophysiology affecting multiple steps of the coagulation pathway. Early detection of VICC is challenging because conventional blood tests such as prothrombin time (PT) and activated partial thromboplastin time (aPTT) are unreliable for early-stage monitoring of VICC progress. As the effects on the coagulation cascade may differ, even in the same species, the traditional coagulation pathways cannot fully explain the mechanisms involved in VICC or may be too slow to have any clinical utility. Antivenom should be promptly administered to neutralize the lethal toxins, although its efficacy remains controversial. Transfusion, including fresh frozen plasma, cryoprecipitate, and specific clotting factors, has also been performed in patients with bleeding. The effectiveness of viscoelastic monitoring in the treatment of VICC remains poorly understood. The development of VICC can be clarified using thromboelastography (TEG), which shows the procoagulant and anticoagulant effects of snake venom. Therefore, we believe that TEG may be able to be used to guide hemostatic resuscitation in victims of VICC. Here, we aim to discuss the advantages of TEG by comparing it with traditional coagulation tests and propose potential treatment options for VICC.
Collapse
|
27
|
Little M. Re: Review article: Let us talk about snakebite management: A discussion on many levels. Emerg Med Australas 2019; 31:1127-1128. [PMID: 31631513 DOI: 10.1111/1742-6723.13401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Mark Little
- Emergency Medicine, Cairns Hospital, Cairns, Queensland, Australia
| |
Collapse
|
28
|
Tibballs J. Australian snake antivenom dosing: What is scientific and safe? Anaesth Intensive Care 2019; 48:129-133. [PMID: 31505950 DOI: 10.1177/0310057x19865268] [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: 11/15/2022]
Abstract
Because the median dose of one vial 'clears the blood of circulating venom', the authors of the Australian Snakebite Project recommend restriction of antivenom to one vial for all envenomated victims. This is neither scientific nor safe. Methodological flaws in the case series include limited detection of venom toxins and misinterpretation of data. The recommendation fails to consider larger doses of venom than that neutralised by one vial of antivenom. Although one vial may be adequate for minor envenomation, the initial dose should be two vials with more on a clinical basis.
Collapse
|
29
|
Coggins A, Symes E, Cheeseman C, Salter M. Thromboelastography for the detection of acute anticoagulant coagulopathy associated with Black Snake envenomation. Emerg Med Australas 2019; 31:900-902. [PMID: 31419011 DOI: 10.1111/1742-6723.13367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/02/2019] [Accepted: 07/10/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Andrew Coggins
- Emergency Department, Westmead Hospital, Sydney, New South Wales, Australia.,Discipline of Emergency Medicine, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Emily Symes
- Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | | | - Mark Salter
- Emergency Department, Westmead Hospital, Sydney, New South Wales, Australia.,Discipline of Emergency Medicine, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
30
|
Turner D, Winter S, Winkel K, MacIsaac C, Padula A, Braitberg G. Review article: Let us talk about snakebite management: A discussion on many levels. Emerg Med Australas 2019; 31:542-545. [PMID: 31207174 DOI: 10.1111/1742-6723.13327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/02/2019] [Indexed: 11/27/2022]
Abstract
We want to discuss antivenom use in snakebite clinical practice guidelines. Coronial reviews in Victoria of two cases of snakebite envenomation, one described in detail below, prompted us to submit this paper for a wider audience and debate. Venom and antivenom levels were measured in the case detailed below, but not in the other. The coroner received conflicting and varied advice from experts regarding the dose of antivenom. The Victorian Department of Health and Human Services and the Australasian College for Emergency Medicine were instructed to review snakebite management guidelines, particularly with respect to antivenom dosage. The discussion that took place among medical experts led to considerable media attention. We discuss the potential fallout when there is no consensus among medical experts.
Collapse
Affiliation(s)
- Damian Turner
- Intensive Care Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Suzanne Winter
- Intensive Care Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kenneth Winkel
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher MacIsaac
- Intensive Care Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The Royal Melbourne Hospital, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Padula
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - George Braitberg
- Department of Medicine, The Royal Melbourne Hospital, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
31
|
Acute Severe Anaphylaxis in Nepali Patients with Neurotoxic Snakebite Envenoming Treated with the VINS Polyvalent Antivenom. J Trop Med 2019; 2019:2689171. [PMID: 31205473 PMCID: PMC6530221 DOI: 10.1155/2019/2689171] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/07/2019] [Accepted: 03/25/2019] [Indexed: 11/18/2022] Open
Abstract
Diagnosing and treating acute severe and recurrent antivenom-related anaphylaxis (ARA) is challenging and reported experience is limited. Herein, we describe our experience of severe ARA in patients with neurotoxic snakebite envenoming in Nepal. Patients were enrolled in a randomised, double-blind trial of high vs. low dose antivenom, given by intravenous (IV) push, followed by infusion. Training in ARA management emphasised stopping antivenom and giving intramuscular (IM) adrenaline, IV hydrocortisone, and IV chlorphenamine at the first sign/s of ARA. Later, IV adrenaline infusion (IVAI) was introduced for patients with antecedent ARA requiring additional antivenom infusions. Preantivenom subcutaneous adrenaline (SCAd) was introduced in the second study year (2012). Of 155 envenomed patients who received ≥ 1 antivenom dose, 13 (8.4%), three children (aged 5−11 years) and 10 adults (18−52 years), developed clinical features consistent with severe ARA, including six with overlapping signs of severe envenoming. Four and nine patients received low and high dose antivenom, respectively, and six had received SCAd. Principal signs of severe ARA were dyspnoea alone (n=5 patients), dyspnoea with wheezing (n=3), hypotension (n=3), shock (n=3), restlessness (n=3), respiratory/cardiorespiratory arrest (n=7), and early (n=1) and late laryngeal oedema (n=1); rash was associated with severe ARA in 10 patients. Four patients were given IVAI. Of the 8 (5.1%) deaths, three occurred in transit to hospital. Severe ARA was common and recurrent and had overlapping signs with severe neurotoxic envenoming. Optimising the management of ARA at different healthy system levels needs more research. This trial is registered with NCT01284855.
Collapse
|
32
|
Rumore SE, Heaney M. Severe protracted neuropathy and myopathy in a 3-year-old girl following tiger snake bite. J Paediatr Child Health 2018; 54:1034-1036. [PMID: 29873152 DOI: 10.1111/jpc.14066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 03/27/2018] [Accepted: 04/16/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Sarah E Rumore
- Department of Paediatric Intensive Care, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Mairead Heaney
- Department of Paediatric Intensive Care, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| |
Collapse
|
33
|
Wilkins D, Burns DS, Wilson D, Warrell DA, Lamb LEM. Snakebites in Africa and Europe: a military perspective and update for contemporary operations. J ROY ARMY MED CORPS 2018; 164:370-379. [PMID: 29626137 DOI: 10.1136/jramc-2017-000883] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 11/20/2017] [Indexed: 11/04/2022]
Abstract
Snakebite envenoming is rare among military patients, with few cases reported in recent years. Increasingly, however, military operations are taking place in remote parts of Africa, which are inhabited by numerous species of venomous snake, and in Europe, where dangerous species exist but are less common. Bites from a venomous snake may prove fatal, and therefore military medics must be adequately prepared to manage them. This paper reviews the most medically significant species of venomous snake present in Africa and Europe, before suggesting an evidence-based approach to snakebite prevention and management, including possible changes to the UK's Clinical Guidelines for Operations.
Collapse
Affiliation(s)
- Daniel Wilkins
- Royal Army Medical Corps, 3 Medical Regiment, Preston, UK
| | - D S Burns
- Department of Infection and Tropical Medicine, Heartlands Hospital, Birmingham, UK.,Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - D Wilson
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK.,Respiratory Medicine, University Hospital Birmingham, Birmingham, UK
| | - D A Warrell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - L E M Lamb
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK.,Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK
| |
Collapse
|
34
|
Pharmacokinetics of Snake Venom. Toxins (Basel) 2018; 10:toxins10020073. [PMID: 29414889 PMCID: PMC5848174 DOI: 10.3390/toxins10020073] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/01/2022] Open
Abstract
Understanding snake venom pharmacokinetics is essential for developing risk assessment strategies and determining the optimal dose and timing of antivenom required to bind all venom in snakebite patients. This review aims to explore the current knowledge of snake venom pharmacokinetics in animals and humans. Literature searches were conducted using EMBASE (1974–present) and Medline (1946–present). For animals, 12 out of 520 initially identified studies met the inclusion criteria. In general, the disposition of snake venom was described by a two-compartment model consisting of a rapid distribution phase and a slow elimination phase, with half-lives of 5 to 48 min and 0.8 to 28 h, respectively, following rapid intravenous injection of the venoms or toxins. When the venoms or toxins were administered intramuscularly or subcutaneously, an initial absorption phase and slow elimination phase were observed. The bioavailability of venoms or toxins ranged from 4 to 81.5% following intramuscular administration and 60% following subcutaneous administration. The volume of distribution and the clearance varied between snake species. For humans, 24 out of 666 initially identified publications contained sufficient information and timed venom concentrations in the absence of antivenom therapy for data extraction. The data were extracted and modelled in NONMEM. A one-compartment model provided the best fit, with an elimination half-life of 9.71 ± 1.29 h. It is intended that the quantitative information provided in this review will provide a useful basis for future studies that address the pharmacokinetics of snakebite in humans.
Collapse
|
35
|
Marano G, Franchini M, Catalano L, Vaglio S, Pupella S, Liumbruno GM. The management of a blood donor bitten by a snake. ANNALS OF TRANSLATIONAL MEDICINE 2018; 5:483. [PMID: 29299445 DOI: 10.21037/atm.2017.12.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The worldwide burden of snakebite is high and venomous snakes are found in many regions of the world and are a threat to public health. In Italy, for instance, viper bites are an infrequent but not negligible event. Although people who have been bitten by a snake rarely wish to donate blood within a "short" time, it is however important to evaluate their eligibility to donate blood or blood components as their donation could be a problem for donor management, especially if a specific policy is not in place. The aim of this manuscript is to summarise the worldwide existing donor deferral policy for snakebites and to provide some indications in order to facilitate decision-making and to guarantee maximum safety for the donors as well as for the recipients.
Collapse
Affiliation(s)
- Giuseppe Marano
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Massimo Franchini
- Italian National Blood Centre, National Institute of Health, Rome, Italy.,Department of Haematology and Transfusion Medicine, "Carlo Poma" Hospital, Mantua, Italy
| | - Liviana Catalano
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy.,Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Simonetta Pupella
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | | |
Collapse
|
36
|
Mcalees TJ, Abraham LA. Australian elapid snake envenomation in cats: Clinical priorities and approach. J Feline Med Surg 2017; 19:1131-1147. [PMID: 29068247 PMCID: PMC10816621 DOI: 10.1177/1098612x17735761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Practical relevance: No fewer than 140 species of terrestrial snakes reside in Australia, 92 of which possess venom glands. With the exception of the brown tree snake, the venom-producing snakes belong to the family Elapidae. The venom of a number of elapid species is more toxic than that of the Indian cobra and eastern diamondback rattle snake, which has earned Australia its reputation for being home to the world's most venomous snakes. Clinical challenges: The diagnosis of elapid snake envenomation is not always easy. Identification of Australian snakes is not straightforward and there are no pathognomonic clinical signs. In cats, diagnosis of envenomation is confounded by the fact that, in most cases, there is a delay in seeking veterinary attention, probably because snake encounters are not usually witnessed by owners, and also because of the tendency of cats to hide and seek seclusion when unwell. Although the administration of antivenom is associated with improved outcomes, the snake venom detection kit and antivenom are expensive and so their use may be precluded if there are financial constraints. Evidence base: In providing comprehensive guidance on the diagnosis and treatment of Australian elapid snake envenomation in cats, the authors of this review draw on the published veterinary, medical and toxicology literature, as well as their professional experience as specialists in medicine, and emergency medicine and critical care.
Collapse
Affiliation(s)
| | - Linda A Abraham
- Centre for Animal Referral and Emergency, Melbourne, Australia
| |
Collapse
|
37
|
Welton RE, Williams DJ, Liew D. Injury trends from envenoming in Australia, 2000-2013. Intern Med J 2017; 47:170-176. [PMID: 27749012 DOI: 10.1111/imj.13297] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/06/2016] [Accepted: 09/29/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Accidental injury is a major public health problem in developed countries with 20 years elapsed since a national overview of venomous bites undertaken in Australia. AIM Provide the first contemporary epidemiological insight into venomous injuries based on demographics and geography nationally in Australia in the period 2000-2013. METHODS An analysis of national hospitalisation and mortality data was undertaken to examine the incidence of injury and death due to envenoming in Australia. Rates were calculated using the intercensal population for all Australian age groups. RESULTS Over the study period, deaths occurred due to an anaphylactic event (0.16 per 100 000), snake envenoming (0.13 per 100 000) or box jellyfish envenoming (0.01 per 100 000). Only 44% of cases involving anaphylaxis reached medical care prior to death, compared to 74% of those envenomed by snakes. Over half of all deaths (52%) occurred at home, and 64% of these occurred within a major city or inner regional area, with 48% of work-related anaphylaxis deaths. Hospital admission rates of 199 per 100 000 persons over the 11 years were caused by contact with wasps or bees (31%), spiders (30%) and snakes (15%), with a predominant age range of 30-44 years. CONCLUSIONS The greatest burden of injury due to envenoming was caused by arthropods and snakes. Causes of death were led by anaphylaxis subsequent to an arthropod bite or sting, followed by death from snake envenoming. Over half the incidents resulting in death occurred at home, in areas where healthcare is accessible. Operational data routinely collected are informative, with variations of injury incidence between the States and Territories, indicating a need for a more localised approach to the management of this injury.
Collapse
Affiliation(s)
- R E Welton
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, The University of Melbourne, Melbourne, Victoria, Australia
| | - D J Williams
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, The University of Melbourne, Melbourne, Victoria, Australia
| | - D Liew
- Department of Epidemiology and Preventative Medicine, Monash Centre of Cardiovascular Research and Education in Therapeutics, Melbourne, Victoria, Australia
| |
Collapse
|
38
|
Bamford NJ, Sprinkle SB, Cudmore LA, Cullimore AM, van Eps AW, Verdegaal EJMM, Tennent-Brown BS. Elapid snake envenomation in horses: 52 cases (2006-2016). Equine Vet J 2017; 50:196-201. [PMID: 28787774 DOI: 10.1111/evj.12735] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/02/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Snake envenomation is a cause of morbidity and mortality in domestic animals worldwide. The clinical features of crotalid snake (pit viper) envenomation are widely reported and well described in horses but elapid snake envenomation is poorly characterised. OBJECTIVES To describe the presentation, clinical and laboratory findings, treatment and outcome of horses with a diagnosis of elapid snake envenomation in Australia. STUDY DESIGN Retrospective case series. METHODS Medical records of horses with a diagnosis of elapid snake envenomation (2006-2016) at several university and private veterinary practices were reviewed. Inclusion criteria comprised one or more of the following: 1) observed snakebite, 2) positive snake venom detection kit (SVDK) result, 3) appropriate clinical response to treatment with antivenom or 4) supportive post-mortem findings. RESULTS Fifty-two cases met the inclusion criteria. Most cases (94%) demonstrated clinical signs of neurotoxicity, characterised by generalised neuromuscular weakness. Associated neurologic signs included staggering gait, muscle fasciculations, recumbency, mydriasis, ptosis and tongue paresis. Concurrent clinically important conditions included rhabdomyolysis (50%) and haemolysis (19%). Of 18 urine samples evaluated with a SVDK, only three (17%) were positive. Overall survival was favourable (86%) among 49 horses who received antivenom. Eighteen surviving horses (43%) required more than one vial of antivenom. MAIN LIMITATIONS Possible cases within the searchable database were not included if horses died acutely or responded to symptomatic treatment without receiving antivenom. CONCLUSIONS Elapid snake envenomation is primarily a syndrome of neuromuscular weakness. Supportive anamnesis or an obvious bite site is rarely encountered. In endemic areas, this diagnosis should be considered for horses with generalised neuromuscular weakness, altered mentation, rhabdomyolysis and/or haemolysis; especially during spring and summer months. Diagnostic suspicion is best confirmed by response to treatment with antivenom.
Collapse
Affiliation(s)
- N J Bamford
- Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Werribee, Victoria, Australia
| | - S B Sprinkle
- Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Werribee, Victoria, Australia
| | - L A Cudmore
- Scone Equine Hospital, Scone, New South Wales, Australia
| | - A M Cullimore
- School of Veterinary and Biomedical Sciences, Murdoch University, Murdoch, Western Australia, Australia
| | - A W van Eps
- School of Veterinary Science, The University of Queensland, Gatton, Queensland, Australia
| | - E J M M Verdegaal
- School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, South Australia, Australia
| | - B S Tennent-Brown
- Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Werribee, Victoria, Australia
| |
Collapse
|
39
|
Johnston CI, Ryan NM, Page CB, Buckley NA, Brown SG, O'Leary MA, Isbister GK. The Australian Snakebite Project, 2005-2015 (ASP-20). Med J Aust 2017; 207:119-125. [PMID: 28764620 DOI: 10.5694/mja17.00094] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 06/08/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe the epidemiology, treatment and adverse events after snakebite in Australia. DESIGN Prospective, multicentre study of data on patients with snakebites recruited to the Australian Snakebite Project (2005-2015) and data from the National Coronial Information System. Setting, participants: Patients presenting to Australian hospitals with suspected or confirmed snakebites from July 2005 to June 2015 and consenting to participation. MAIN OUTCOME MEASURES Demographic data, circumstances of bites, clinical effects of envenoming, results of laboratory investigations and snake venom detection kit (SVDK) testing, antivenom treatment and adverse reactions, time to discharge, deaths. RESULTS 1548 patients with suspected snakebites were enrolled, including 835 envenomed patients (median, 87 per year), for 718 of which the snake type was definitively established, most frequently brown snakes (41%), tiger snakes (17%) and red-bellied black snakes (16%). Clinical effects included venom-induced consumption coagulopathy (73%), myotoxicity (17%), and acute kidney injury (12%); severe complications included cardiac arrest (25 cases; 2.9%) and major haemorrhage (13 cases; 1.6%). There were 23 deaths (median, two per year), attributed to brown (17), tiger (four) and unknown (two) snakes; ten followed out-of-hospital cardiac arrests and six followed intracranial haemorrhages. Of 597 SVDK test results for envenomed patients with confirmed snake type, 29 (4.9%) were incorrect; 133 of 364 SVDK test results for non-envenomed patients (36%) were false positives. 755 patients received antivenom, including 49 non-envenomed patients; 178 (24%), including ten non-envenomed patients, had systemic hypersensitivity reactions, of which 45 (6%) were severe (hypotension, hypoxaemia). Median total antivenom dose declined from four vials to one, but median time to first antivenom was unchanged (4.3 hours; IQR, 2.7-6.3 hours). CONCLUSIONS Snake envenoming is uncommon in Australia, but is often severe. SVDKs were unreliable for determining snake type. The median antivenom dose has declined without harming patients. Improved early diagnostic strategies are needed to reduce the frequently long delays before antivenom administration.
Collapse
|
40
|
Warrell DA. Snakebites: reducing their international impact. Med J Aust 2017; 207:112-113. [DOI: 10.5694/mja17.00480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 06/02/2017] [Indexed: 11/17/2022]
|
41
|
Johnston CI, Ryan NM, O'Leary MA, Brown SGA, Isbister GK. Australian taipan (Oxyuranus spp.) envenoming: clinical effects and potential benefits of early antivenom therapy - Australian Snakebite Project (ASP-25). Clin Toxicol (Phila) 2016; 55:115-122. [PMID: 27903075 DOI: 10.1080/15563650.2016.1250903] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONTEXT Taipans (Oxyuranus spp.) are medically important venomous snakes from Australia and Papua New Guinea. The objective of this study was to describe taipan envenoming in Australian and its response to antivenom. METHODS Confirmed taipan bites were recruited from the Australian Snakebite Project. Data were collected prospectively on all snakebites, including patient demographics, bite circumstances, clinical effects, laboratory results, complications and treatment. Blood samples were taken and analysed by venom specific immunoassay to confirm snake species and measure venom concentration pre- and post-antivenom. RESULTS There were 40 confirmed taipan bites: median age 41 years (2-85 years), 34 were males and 21 were snake handlers. Systemic envenoming occurred in 33 patients with neurotoxicity (26), complete venom induced consumption coagulopathy (VICC) (16), partial VICC (15), acute kidney injury (13), myotoxicity (11) and thrombocytopenia (7). Venom allergy occurred in seven patients, three of which had no evidence of envenoming and one died. Antivenom was given to 34 patients with a median initial dose of one vial (range 1-4), and a median total dose of two vials (range 1-9). A greater total antivenom dose was associated with VICC, neurotoxicity and acute kidney injury. Early antivenom administration was associated with a decreased frequency of neurotoxicity, acute kidney injury, myotoxicity and intubation. There was a shorter median time to discharge of 51 h (19-432 h) in patients given antivenom <4 h post-bite, compared to 175 h (27-1104 h) in those given antivenom >4 h. Median peak venom concentration in 25 patients with systemic envenoming and a sample available was 8.4 ng/L (1-3212 ng/L). No venom was detected in post-antivenom samples, including 20 patients given one vial initially and five patients bitten by inland taipans. DISCUSSION Australian taipan envenoming is characterised by neurotoxicity, myotoxicity, coagulopathy, acute kidney injury and thrombocytopenia. One vial of antivenom binds all measurable venom and early antivenom was associated with a favourable outcome.
Collapse
Affiliation(s)
| | - Nicole M Ryan
- a Clinical Toxicology Research Group, University of Newcastle , Newcastle , Australia
| | - Margaret A O'Leary
- a Clinical Toxicology Research Group, University of Newcastle , Newcastle , Australia
| | - Simon G A Brown
- b Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital and the University of Western Australia , Perth , Australia
| | - Geoffrey K Isbister
- a Clinical Toxicology Research Group, University of Newcastle , Newcastle , Australia.,c Department of Clinical Toxicology and Pharmacology , Calvary Mater Newcastle , Newcastle , Australia
| |
Collapse
|
42
|
Lim AYL, Singh PN, Isbister GK. Severe rhabdomyolysis from red-bellied black snake (Pseudechis porphyriacus) envenoming despite antivenom. Toxicon 2016; 117:46-8. [PMID: 27039255 DOI: 10.1016/j.toxicon.2016.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/16/2016] [Accepted: 03/23/2016] [Indexed: 11/16/2022]
Abstract
Envenoming by the Australian red-bellied black snake (Pseudechis porphyriacus) causes non-specific systemic symptoms, anticoagulant coagulopathy, myotoxicity and local effects. Current management for systemic envenoming includes administration of one vial of tiger snake antivenom within 6 h of the bite to prevent myotoxicity. We present a case of severe rhabdomyolysis in a 16 year old male which developed despite early administration of one vial of tiger snake antivenom. Free venom was detected after the administration of antivenom concurrent with rapidly decreasing antivenom concentrations. The case suggests that insufficient antivenom was administered and the use of larger doses of antivenom need to be explored for red-bellied black snake envenoming.
Collapse
Affiliation(s)
- Adeline Y L Lim
- Children's Critical Care Unit, Gold Coast University Hospital, Queensland, Australia
| | - Puneet N Singh
- Children's Critical Care Unit, Gold Coast University Hospital, Queensland, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia; NSW Poison Information Centre, Children's Hospital Westmead, Sydney, NSW, Australia.
| |
Collapse
|
43
|
Persistent anosmia and olfactory bulb atrophy after mulga (Pseudechis australis) snakebite. J Clin Neurosci 2016; 29:199-201. [PMID: 26896910 DOI: 10.1016/j.jocn.2015.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 12/17/2015] [Indexed: 11/20/2022]
Abstract
Loss of sense of smell is an intriguing yet under-recognised complication of snakebite. We report olfactory function testing and neuroimaging of the olfactory bulbs in a 30-year-old man with anosmia persisting for more than 1year after mulga (Pseudechis australis) snakebite. This problem was first noted by the patient 1week after being definitely bitten in Queensland, Australia. He had then presented to a regional hospital where his envenomation was considered mild enough to not warrant antivenom administration. A week later the patient noted a reduction of sense of smell, which progressed to complete inability to smell over the ensuing weeks. On clinical review the patient's neurologic and rhinologic examination did not reveal any structural cause for anosmia. Formal olfactory testing was performed using ''sniffin' sticks" and the patient scored 17 on this test, indicating severe hyposmia (functional anosmia <16.5, normal score >30.3 for men aged 16-35years). MRI of the brain showed no abnormalities. The olfactory bulb volumes were then measured on a volumetric T2-weighted MRI that demonstrated significantly reduced volume of both bulbs, with the right 34.86mm(3) and left 36.25mm(3) (normal volume ⩾58mm(3), 10th centile). The current patient represents a rare instance of a definite, untreated, elapid (mulga snake) envenomation with an intriguing disjunction between the mildness of the systemic features and the severity of the olfactory lesion. It is also unclear if early antivenom use attenuates this condition, and due to the delayed manifestation of the symptoms, awareness of this phenomenon may be lacking amongst physicians.
Collapse
|
44
|
Neuromuscular Effects of Common Krait (Bungarus caeruleus) Envenoming in Sri Lanka. PLoS Negl Trop Dis 2016; 10:e0004368. [PMID: 26829229 PMCID: PMC4734751 DOI: 10.1371/journal.pntd.0004368] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 12/16/2015] [Indexed: 11/19/2022] Open
Abstract
Objective We aimed to investigate neurophysiological and clinical effects of common krait envenoming, including the time course and treatment response. Methodology Patients with definite common krait (Bungarus caeruleus) bites were recruited from a Sri Lankan hospital. All patients had serial neurological examinations and stimulated concentric needle single-fibre electromyography (sfEMG) of orbicularis oculi in hospital at 6wk and 6–9mth post-bite. Principal Findings There were 33 patients enrolled (median age 35y; 24 males). Eight did not develop neurotoxicity and had normal sfEMG. Eight had mild neurotoxicity with ptosis, normal sfEMG; six received antivenom and all recovered within 20–32h. Seventeen patients developed severe neurotoxicity with rapidly descending paralysis, from ptosis to complete ophthalmoplegia, facial, bulbar and neck weakness. All 17 received Indian polyvalent antivenom a median 3.5h post-bite (2.8–7.2h), which cleared unbound venom from blood. Despite this, the paralysis worsened requiring intubation and ventilation within 7h post-bite. sfEMG showed markedly increased jitter and neuromuscular blocks within 12h. sfEMG abnormalities gradually improved over 24h, corresponding with clinical recovery. Muscle recovery occurred in ascending order. Myotoxicity was not evident, clinically or biochemically, in any of the patients. Patients were extubated a median 96h post-bite (54–216h). On discharge, median 8 days (4–12days) post-bite, patients were clinically normal but had mild sfEMG abnormalities which persisted at 6wk post-bite. There were no clinical or neurophysiological abnormalities at 6–9mth. Conclusions Common krait envenoming causes rapid onset severe neuromuscular paralysis which takes days to recover clinically consistent with sfEMG. Subclinical neuromuscular dysfunction lasts weeks but was not permanent. Antivenom effectively cleared venom but did not prevent worsening or reverse neuromuscular paralysis. Common krait bites cause muscular paralysis due to the venom disrupting communication between the nerves and muscles. This becomes life-threatening for the patient if there is paralysis of the muscles used for breathing. We studied the severity of paralysis, long term effects and the value of antivenom treatment in authenticated Indian krait bite patients from Sri Lanka. In addition to standard treatment with antivenom, the patients had single-fibre electromyography done, a sensitive neurophysiological test that detects the abnormalities of communication between the nerves and muscles. Half of the patients had severe paralysis and required mechanical ventilation, and the remainder had mild or no effects. Antivenom was given to all patients with severe paralysis and most with mild effects. However, despite antivenom binding all free venom after it was administered, it did not prevent or reverse already developed paralysis. Clinically evident paralysis resolved after a few days, but the neurophysiological abnormalities lasted for weeks. No permanent neurological damages were noted at 6 to 9 months after the snake bite.
Collapse
|
45
|
Bucaretchi F, De Capitani EM, Vieira RJ, Rodrigues CK, Zannin M, Da Silva NJ, Casais-e-Silva LL, Hyslop S. Coral snake bites (Micrurus spp.) in Brazil: a review of literature reports. Clin Toxicol (Phila) 2016; 54:222-34. [DOI: 10.3109/15563650.2015.1135337] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Fábio Bucaretchi
- Campinas Poison Control Center, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
- Department of Pediatrics, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Eduardo Mello De Capitani
- Campinas Poison Control Center, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
- Department of Clinical Medicine, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Ronan José Vieira
- Campinas Poison Control Center, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
- Department of Clinical Medicine, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Cinthia K. Rodrigues
- Santa Catarina Poison Control Center, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Marlene Zannin
- Santa Catarina Poison Control Center, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
- Department of Pathology, Health Science Center, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Nelson J. Da Silva
- Department of Biology, Pontifical Catholic University of Goiás, Goiânia, Goiás, Brazil
| | | | - Stephen Hyslop
- Campinas Poison Control Center, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
- Department of Pharmacology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| |
Collapse
|
46
|
Miller M, O'Leary MA, Isbister GK. Towards rationalisation of antivenom use in funnel-web spider envenoming: enzyme immunoassays for venom concentrations. Clin Toxicol (Phila) 2015; 54:245-51. [PMID: 26678882 DOI: 10.3109/15563650.2015.1122794] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Funnel-web spider (Atrax and Hadronyche spp.) envenoming is rare but causes severe neuromuscular, autonomic, and cardiac effects. A rabbit-derived IgG antivenom is available, but venom detection in patients has not been reported. OBJECTIVE To use serial venom and antivenom concentrations to better define envenoming and antivenom effectiveness. MATERIALS AND METHODS Serum was collected from nine patients with suspected funnel-web spider bites and clinical effects were recorded. Venom-specific enzyme immunoassays were developed to measure funnel-web spider venom and antivenom concentrations. Goat anti-rabbit whole serum was coupled to UltraLink resin and added to samples to remove bound venom and measure free venom. Antivenom efficacy was defined as antivenom binding all free venom and antivenom effectiveness as resolution of clinical features. RESULTS Venom was detectable in samples from six of nine patients. In three patients without venom detected, there were only moderate effects, which did not completely respond to antivenom in all cases and no spider was identified. In five of six cases, a male Atrax spp. (Sydney funnel-web) spider was identified. Three patients had moderate envenoming which responded to antivenom. Three patients had severe envenoming and developed catecholamine-induced myocarditis and acute pulmonary oedema. Although cholinergic and non-specific clinical features appeared to respond to antivenom, myocarditis and pulmonary oedema lasted 2-4 days. Median venom concentration pre-antivenom in five patients with samples was 5.6 ng/ml (3-35 ng/ml), and immediately post-antivenom decreased to a median of 0 ng/ml (0-1.8 ng/ml). Post-antivenom venom concentrations decreased when bound venom was removed; median, 0 ng/ml (0-0.9 ng/ml), indicating that most venom detected post-antivenom was bound. There was recurrence of venom and clinical features in one patient when a pressure bandage was removed. CONCLUSIONS Detection of venom in suspected funnel-web spider bites identified definite cases with characteristic envenoming and a spider was identified. Measurement of venom concentrations pre- and post-antivenom demonstrated that venom was bound by antivenom, but in severe cases cardiac toxicity was not reversed.
Collapse
Affiliation(s)
- Mark Miller
- a Emergency Department , John Hunter Hospital , Newcastle , NSW , Australia
| | - Margaret A O'Leary
- b Clinical Toxicology Research Group , University of Newcastle , Newcastle , NSW , Australia
| | - Geoffrey K Isbister
- b Clinical Toxicology Research Group , University of Newcastle , Newcastle , NSW , Australia ;,c Department of Clinical Toxicology and Pharmacology , Calvary Mater Hospital , Newcastle , NSW , Australia
| |
Collapse
|
47
|
Affiliation(s)
- Geoffrey K Isbister
- a Clinical Toxicology Research Group, University of Newcastle , Newcastle , Australia.,b Department of Clinical Toxicology and Pharmacology , Calvary Mater Newcastle , New South Wales , Australia.,c New South Wales Poisons information Centre, Sydney Children's Hospital Network , NSW , Australia
| | - Colin B Page
- a Clinical Toxicology Research Group, University of Newcastle , Newcastle , Australia.,b Department of Clinical Toxicology and Pharmacology , Calvary Mater Newcastle , New South Wales , Australia.,c New South Wales Poisons information Centre, Sydney Children's Hospital Network , NSW , Australia
| |
Collapse
|
48
|
Isbister GK, Maduwage K, Scorgie FE, Shahmy S, Mohamed F, Abeysinghe C, Karunathilake H, O’Leary MA, Gnanathasan CA, Lincz LF. Venom Concentrations and Clotting Factor Levels in a Prospective Cohort of Russell's Viper Bites with Coagulopathy. PLoS Negl Trop Dis 2015; 9:e0003968. [PMID: 26296235 PMCID: PMC4546603 DOI: 10.1371/journal.pntd.0003968] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 07/09/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Russell's viper envenoming is a major problem in South Asia and causes venom induced consumption coagulopathy. This study aimed to investigate the kinetics and dynamics of venom and clotting function in Russell's viper envenoming. METHODOLOGY/PRINCIPAL FINDINGS In a prospective cohort of 146 patients with Russell's viper envenoming, we measured venom concentrations, international normalised ratio [INR], prothrombin time (PT), activated partial thromboplastin time (aPTT), coagulation factors I, II, V, VII, VIII, IX and X, and von Willebrand factor antigen. The median age was 39 y (16-82 y) and 111 were male. The median peak INR was 6.8 (interquartile range [IQR]: 3.7 to >13), associated with low fibrinogen [median,<0.01 g/L; IQR: <0.01-0.9 g/L), low factor V levels [median,<5%; IQR: <5-4%], low factor VIII levels [median,40%; IQR: 12-79%] and low factor X levels [median, 48%; IQR: 29-67%]. There were smaller reductions in factors II, IX and VII over time. All factors recovered over 48 h post-antivenom. The median INR remained >3 at 6 h post-antivenom but had reduced to <2, by 24 h. The aPTT had also returned to close to normal (<50 sec) at 24 h. Factor VII, VIII and IX levels were unusually high pre-antivenom, median peak concentrations of 393%, 307% and 468% respectively. Pre-antivenom venom concentrations and the INR (r = 0.20, p = 0.02) and aPTT (r = 0.19, p = 0.03) were correlated (non-parametric Spearman analysis). CONCLUSIONS Russell's viper coagulopathy results in prolonged aPTT, INR, low fibrinogen, factors V, VIII and X which recover over 48 h. Severity of clotting abnormalities was associated with venom concentrations.
Collapse
Affiliation(s)
- Geoffrey K. Isbister
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Kalana Maduwage
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fiona E. Scorgie
- Hunter Haematology Research Group, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Seyed Shahmy
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | | | | | - Margaret A. O’Leary
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | | | - Lisa F. Lincz
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Haematology Research Group, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| |
Collapse
|
49
|
O'Leary MA, Maduwage K, Isbister GK. Detection of venom after antivenom administration is largely due to bound venom. Toxicon 2015; 93:112-8. [PMID: 25447776 DOI: 10.1016/j.toxicon.2014.11.221] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 10/31/2014] [Accepted: 11/05/2014] [Indexed: 10/24/2022]
Abstract
Detection of recurrent venom post-antivenom in snake envenoming is commonly reported and thought to be due to insufficient antivenom. However, relatively few reports of recurrence have venom measurement, and in most cases patients clinically improve, despite venom detected post-antivenom. We hypothesized that persistent or recurrent venom detection post-antivenom is due to detecting bound venom. Multiple (>4) serum samples were available from 255 Russell's viper (Daboia russelii) envenomed patients. Enzyme-linked immunosorbent assay was used to measure venom, antivenom and venom-antivenom (VAV) complexes. In 79/255 (31%) there was persistent/recurrent venom detected despite antivenom being present. In these post-antivenom samples, VAV was also detected at the same time as venom was detected. Anti-horse (aH) antiserum was bound to UltraLink (UL) resin and added to in vitro venom-antivenom mixtures, and 15 pre- and post-antivenom samples from patients. There was significantly less free venom detected in in vitro venom-antivenom mixtures to which ULaH had been added compared to those without ULaH added. In 9 post-antivenom patient samples the addition of ULaH reduced venom detected by a median of 80% (69%-88%) compared to only 20% in four pre-antivenom samples. This suggests that the detection of persistent/recurrent venom post-antivenom is due to bound and not free venom.
Collapse
Affiliation(s)
- Margaret A O'Leary
- School of Medicine and Public Health, University of Newcastle, NSW, Australia
| | - Kalana Maduwage
- Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Geoffrey K Isbister
- School of Medicine and Public Health, University of Newcastle, NSW, Australia.
| |
Collapse
|
50
|
Maduwage K, O'Leary MA, Scorgie FE, Shahmy S, Mohamed F, Abeysinghe C, Karunathilake H, Lincz LF, Gnanathasan CA, Isbister GK. Detection of venom after antivenom is not associated with persistent coagulopathy in a prospective cohort of Russell's viper (Daboia russelii) envenomings. PLoS Negl Trop Dis 2014; 8:e3304. [PMID: 25521820 PMCID: PMC4270487 DOI: 10.1371/journal.pntd.0003304] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 09/30/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Venom recurrence or persistence in the circulation after antivenom treatment has been documented many times in viper envenoming. However, it has not been associated with clinical recurrence for many snakes, including Russell's viper (Daboia spp.). We compare the recovery of coagulopathy to the recurrence or persistence of venom in patients with Russell's viper envenoming. METHODOLOGY/PRINCIPAL FINDINGS The study included patients with Russell's viper (D. russelii) envenoming presenting over a 30 month period who had Russell's viper venom detected by enzyme immunoassay. Demographics, information on the snake bite, and clinical effects were collected for all patients. All patients had serum collected for venom specific enzyme immunoassay and citrate plasma to measure fibrinogen levels and prothrombin time (international normalised ratio; INR). Patients with venom recurrence/persistence were compared to those with no detectable recurrence of venom. There were 55 patients with confirmed Russell's viper envenoming and coagulopathy with low fibrinogen concentrations: 31 with venom recurrence/persistence, and 24 with no venom detected post-antivenom. Fibrinogen concentrations increased and INR decreased after antivenom in both the recurrence and non-recurrence patients. Clinical features, laboratory parameters, antivenom dose and length of hospital were similar for both groups. Pre-antivenom venom concentrations were higher in patients with venom recurrence/persistence with a median venom concentration of 385 ng/mL (16-1521 ng/mL) compared to 128 ng/mL (14-1492 ng/mL; p = 0.008). CONCLUSION Recurrence of Russell's viper venom was not associated with a recurrence of coagulopathy and length of hospital stay. Further work is required to determine if the detection of venom recurrence is due to the venom specific enzyme immunoassay detecting both venom-antivenom complexes as well as free venom.
Collapse
Affiliation(s)
- Kalana Maduwage
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Margaret A. O'Leary
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Fiona E. Scorgie
- Hunter Haematology Research Group, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Seyed Shahmy
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Pharmacology and Toxicology Group, Professorial Medicine Unit, The Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | | | | | - Lisa F. Lincz
- Hunter Haematology Research Group, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | | | - Geoffrey K. Isbister
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| |
Collapse
|