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Dobaja Borak M, Babić Ž, Caganova B, Grenc D, Karabuva S, Kolpach Z, Krakowiak A, Kolesnikova V, Lukšić B, Pap C, Puljiz I, Piekarska-Wijatkowska A, Radenkova-Saeva J, Vučinić S, Zacharov S, Eddleston M, Brvar M. Viper envenomation in Central and Southeastern Europe: a multicentre study. Clin Toxicol (Phila) 2023; 61:656-664. [PMID: 37988116 DOI: 10.1080/15563650.2023.2273761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Snakebite incidence varies across Europe. However, there is limited research from Central and Southeastern Europe. These regions are notable for the presence of the common European adder (Vipera berus) and the more venomous nose-horned viper (Vipera ammodytes). No standard European antivenom protocol exists. The aim was to assess the epidemiology and treatment of viper bites in this region, focusing on a comparison of bites from Vipera berus and Vipera ammodytes. METHODS We conducted a prospective multicenter study in Central and Southeastern Europe from 2018 to 2020. This study included poison centres and toxicology-associated hospital wards in Poland, the Czech Republic, Slovakia, Hungary, Slovenia, Croatia, Serbia, and Bulgaria. The following data were collected: age, gender, Vipera species, snakebite site, clinical picture, laboratory results, Audebert's clinical severity grading score, and antivenom therapy. RESULTS The annual incidence of viper bites in Central and Southeast Europe was estimated at 2.55 bites per million population. Within their respective geographical distribution areas, the incidence of Vipera ammodytes bites (1.61 bites per million population) was higher than Vipera berus bites (1.00 bites per million population). Patients bitten by Vipera ammodytes more frequently reported local pain and developed thrombocytopenia. Antivenom treatment was more commonly administered in Vipera ammodytes bites (72%) compared to Vipera berus bites (39%). The incidence of Vipera ammodytes bites treated with antivenom within its geographical distribution area was three times higher than Vipera berus bites treated with antivenom (1.16 bites per million population versus 0.39 bites per million population). No deaths were reported. CONCLUSIONS The estimated incidence of viper bites in Central and Southeastern Europe is at least 2.55 per million population. Vipera ammodytes bites are more common and severe, characterized by higher frequencies of pain and thrombocytopenia. Antivenom is needed more often for Vipera ammodytes bites. It is vital that enough European Medicines Agency-approved Vipera ammodytes antivenom is produced and offered affordably.
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Affiliation(s)
- Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Željka Babić
- Poison Centre, Institute for Medical Research and Occupational Health, Zagreb, Croatia
| | - Blažena Caganova
- National Toxicological Information Centre, University Hospital, Bratislava, Slovakia
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital of Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Zuzana Kolpach
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Anna Krakowiak
- Nofer Institute of Occupational Medicine, Łódź, Poland
- Clinic of Anesthesiology and Intensive Care, Toxicology Unit, Central Clinical Hospital of the Medical University of Łódź, Łódź, Poland
| | - Viktoriia Kolesnikova
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital of Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Csaba Pap
- Department of Toxicology, Péterfy Hospital, Budapest, Hungary
| | - Ivan Puljiz
- University hospital for infectious diseases "Dr. Fran Mihaljević", Zagreb, Croatia
| | | | - Julia Radenkova-Saeva
- Clinic of Toxicology, University Hospital for Emergency Medicine "N.I.Pirogov", Sofia, Bulgaria
| | - Slavica Vučinić
- National Poison Centre, Military Medical Academy, Medical Faculty University of Defense, Belgrade, Serbia
| | - Sergej Zacharov
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Michael Eddleston
- Department of Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Dobaja Borak M, Grenc D, Reberšek K, Podgornik H, Leonardi A, Kurtović T, Halassy B, Križaj I, Brvar M. Reversible and transient thrombocytopenia of functional platelets induced by nose-horned viper venom. Thromb Res 2023; 229:152-154. [PMID: 37454466 DOI: 10.1016/j.thromres.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/04/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katarina Reberšek
- Department of Haematology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Helena Podgornik
- Department of Haematology, University Medical Centre Ljubljana, Ljubljana, Slovenia; Department of Clinical Biochemistry, Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Adrijana Leonardi
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Ljubljana, Slovenia
| | - Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Zagreb, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Zagreb, Croatia
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Ljubljana, Slovenia
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia; Center for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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Kurtović T, Karabuva S, Grenc D, Dobaja Borak M, Križaj I, Lukšić B, Halassy B, Brvar M. Intravenous Vipera berus Venom-Specific Fab Fragments and Intramuscular Vipera ammodytes Venom-Specific F(ab') 2 Fragments in Vipera ammodytes-Envenomed Patients. Toxins (Basel) 2021; 13:toxins13040279. [PMID: 33919927 PMCID: PMC8070888 DOI: 10.3390/toxins13040279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 11/25/2022] Open
Abstract
Vipera ammodytes (V. ammodytes) is the most venomous European viper. The aim of this study was to compare the clinical efficacy and pharmacokinetic values of intravenous Vipera berus venom-specific (paraspecific) Fab fragments (ViperaTAb) and intramuscular V. ammodytes venom-specific F(ab’)2 fragments (European viper venom antiserum, also called “Zagreb” antivenom) in V.ammodytes-envenomed patients. This was a prospective study of V.ammodytes-envenomed patients that were treated intravenously with ViperaTAb or intramuscularly with European viper venom antiserum that was feasible only due to the unique situation of an antivenom shortage. The highest venom concentration, survival, length of hospital stay and adverse reactions did not differ between the groups. Patients treated with intravenous Fab fragments were sicker, with significantly more rhabdomyolysis and neurotoxicity. The kinetics of Fab fragments after one or more intravenous applications matched better with the venom concentration in the early phase of envenomation compared to F(ab’)2 fragments that were given intramuscularly only on admission. F(ab’)2 fragments given intramuscularly had 25-fold longer apparent total body clearance and 14-fold longer elimination half-time compared to Fab fragments given intravenously (2 weeks vs. 24 h, respectively). In V.ammodytes-envenomed patients, the intramuscular use of specific F(ab’)2 fragments resulted in a slow rise of antivenom serum concentration that demanded their early administration but without the need for additional doses for complete resolution of all clinical signs of envenomation. Intravenous use of paraspecific Fab fragments resulted in the immediate rise of antivenom serum concentration that enabled their use according to the clinical progress, but multiple doses might be needed for efficient therapy of thrombocytopenia due to venom recurrence, while the progression of rhabdomyolysis and neurotoxic effects of the venom could not be prevented.
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Affiliation(s)
- Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia;
- Center of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital of Split, Šoltanska 1, 21000 Split, Croatia; (S.K.); (B.L.)
- School of Medicine, University of Split, Šoltanska 2, 21000 Split, Croatia
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (D.G.); (M.D.B.)
| | - Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (D.G.); (M.D.B.)
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova 39, 1000 Ljubljana, Slovenia;
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital of Split, Šoltanska 1, 21000 Split, Croatia; (S.K.); (B.L.)
- School of Medicine, University of Split, Šoltanska 2, 21000 Split, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia;
- Center of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
- Correspondence: (B.H.); (M.B.)
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (D.G.); (M.D.B.)
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, 1000 Ljubljana, Slovenia
- Correspondence: (B.H.); (M.B.)
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Kurtović T, Lang Balija M, Brvar M, Dobaja Borak M, Mateljak Lukačević S, Halassy B. Comparison of Preclinical Properties of Several Available Antivenoms in the Search for Effective Treatment of Vipera ammodytes and Vipera berus Envenoming. Toxins (Basel) 2021; 13:toxins13030211. [PMID: 33805701 PMCID: PMC8001446 DOI: 10.3390/toxins13030211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/05/2021] [Accepted: 03/10/2021] [Indexed: 11/16/2022] Open
Abstract
Snakebites are a relatively rare medical emergency in Europe. In more than half of the annual cases caused by Vipera ammodytes, Vipera berus, and Vipera aspis, immunotherapy with animal-derived antivenom is indicated. Among eight products recently identified as available against European medically relevant species, only Zagreb antivenom, Viperfav, and ViperaTAb have been used almost exclusively for decades. Zagreb antivenom comprises V. ammodytes-specific F(ab')2 fragments. Viperfav is a polyspecific preparation based on F(ab')2 fragments against V. aspis, V. berus, and V. ammodytes venoms. ViperaTAb contains Fab fragments against the venom of V. berus. In 2014 the production of Zagreb antivenom was discontinued. Additionally, in the period of 2017 to 2018 a shortage of Viperfav occurred. Due to a lack of the product indicated for the treatment of V. ammodytes bites, other antivenoms were implemented into clinical practice without comparative assessment of their eligibility. The aim of our work was to identify a high-quality antivenom that might ensure the successful treatment of V. ammodytes and V. berus bites at the preclinical level. Differentiation between bites from these two species is difficult and unreliable in clinical practice, so the availability of a unique antivenom applicable in the treatment of envenoming caused by both species would be the most advantageous for Southeastern Europe. Zagreb antivenom, Viperfav, and ViperaTAb, as well as Viper venom antitoxin for V. berus envenoming and the in-development Inoserp Europe, which was designed to treat envenoming caused by all medically important European snakes, were comparatively tested for the first time. Emphasis was placed on their physicochemical properties, primarily purity and aggregate content, as well as their in vivo protective efficacies. As Zagreb antivenom is no longer available on the European market, Viperfav is the highest-quality product currently available and the only antivenom whose neutralisation potency against V. ammodytes and V. berus venoms was above regulatory requirements.
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Affiliation(s)
- Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
- Correspondence: (T.K.); (B.H.)
| | - Maja Lang Balija
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000 Ljubljana, Slovenia; (M.B.); (M.D.B.)
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Zaloška Cesta 4, 1000 Ljubljana, Slovenia
| | - Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000 Ljubljana, Slovenia; (M.B.); (M.D.B.)
| | - Sanja Mateljak Lukačević
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
- Correspondence: (T.K.); (B.H.)
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Abstract
Introduction: Tiamulin is a semisynthetic pleuromutilin diterpene veterinary antibiotic, widely used in farms. We present a case of prolonged QT-interval and ventricular tachyarrhythmia after tiamulin inhalation.Case presentation: A 43-year-old veterinarian without previous medical history was dividing granulated powder of antibiotic gravimetrically without wearing personal protective equipment. Half an hour after exposure, nausea occurred; four hours later he started to vomit and soon after that he experienced syncope. He was unconscious three minutes; afterwards he became somnolent, dizzy and nauseated with sweating and salivation. On admission to hospital five hours after exposure, he was conscious and had heart rate 70 beats/min and blood pressure 140/80 mmHg. Initial laboratory results were normal. Electrocardiography showed a prolonged QTc-interval of 730 ms with numerous polymorphic ventricular extrasystoles and episodes of non-sustained polymorphic ventricular tachycardia that resolved after treatment with lidocaine and magnesium. Subsequent electrocardiography revealed gradual shortening of QTc-interval with QTc-interval normalization (430 ms) between 24 and 32 hours after tiamulin exposure. Laboratory tests, morphologic heart diagnostics and genetic testing excluded other potential causes of QTc-interval prolongation. Subsequent toxicology analysis by LC-MS/MS confirmed tiamulin in his serum samples on admittance (500 ng/mL).Conclusion: Tiamulin inhalation can be associated with prolonged QT-interval and ventricular tachyarrhythmia. QT-interval prolongation could be expected in overdoses of emerging human pleuromutilins.
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Affiliation(s)
- Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Lucija Sarc
- Centre for Clinical Toxicology and Pharmacology, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Darja Gnezda Mugerli
- Department for Cardiology, General Hospital "Dr. Franca Derganca" Nova Gorica, Šempeter pri Gorici, Slovenia
| | - Bor Antolic
- Department for Cardiology, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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