Clinical profile of confirmed scorpion stings in a referral center in Manaus, Western Brazilian Amazon.

Scorpion envenomations are a major public health problem in Brazil, and most medically important cases are attributable to the Tityus genus. The objective of this study is to describe the clinical and epidemiological aspects of a series of 151 cases of confirmed scorpion stings, which were treated at the hospitals of two cities in the Western Brazilian Amazon, between June 2014 and December 2019. This study shows that the genus Tityus was the most prevalent. Tityus (Atreus) metuendus (Pocock, 1897) was responsible for the greatest number of cases (68.2%), followed by Tityus (Archaeotityus) silvestris (Pocock, 1897) (14.6%). Most of the envenomations involved males (53.6%), and analysis showed a slight predominance in the group from 40 to 49 years (22.5%). The most affected body regions were feet (49.0%) and hands (31.8%). The time elapsed between the accident and medical care was ≤6 h in 92.1% of cases. Regarding clinical severity, classes I (80.8%) and II (15.9%) predominated. However, there were five (3.3%) class III cases; four for T. metuendus and one for T. silvestris. The most frequent local and systemic manifestations were, respectively, pain (84.1%), paresthesia (34.4%) and mild edema (25.8%), and nausea (9.3%) and myoclonia (8.6%). The clinical manifestations were similar among the patients stung by the different species of scorpions. There were no differences between the manifestations of envenomation caused by T. metuendus, T. silvestris and T. raquelae. For victims of T. apiacas, a higher frequency of piloerection and myoclonia was observed, and was described by the affected patients as a 'sensation of receiving an electric shock' throughout the body. No deaths were registered. The species of greatest epidemiological importance in Manaus is T. metuendus, a species that leads to clinical pictures that do not differ substantially from those observed in other Brazilian regions. T. apiacas causes neurological manifestations that differed from other Tityus species. Our findings suggest that the available antivenoms have little effectiveness when used in the treatment of envenomations by some Amazonian scorpions.

Neutralization of the edema-forming and myotoxic activities of the venom of Potamotrygon motoro Müller and Henle, 1841 (Chondrichthyes - Potamotrygoninae) by antivenoms and circulating immunoglobulins.

Freshwater stingrays are cartilaginous fish with stingers at the base of their tail. The stinger is covered with an epithelium containing mucous and venom glands. Human envenomation usually occurs when a person steps on a stingray hiding in the sand and the fish sinks its stinger into the victim, causing an extremely painful wound which generally leads to tissue necrosis. Medical treatment is based on the use of painkillers, anti-inflammatory drugs and antibiotics, as there is to date no specific antidote for envenomation by freshwater stingrays. The aim of this study was therefore to investigate whether sera containing anti-P. motoro antibodies can neutralize the edema-forming and myotoxic activities of Potamotrygon motoro venom. To this end, two protocols were used: seroneutralization and vaccination of mice. The seroneutralization protocol involved intramuscular injection of the P. motoro venom in the mice gastrocnemius followed by administration of hyperimmune mouse serum anti P. motoro dorsal extract and stinger extract via the ophthalmic venous plexus. The vaccination protocol involved immunizing the mice with dorsal or stinger extract adsorbed to aluminum hydroxide followed by intramuscular challenge with the P. motoro venom. The gastrocnemii of all the animals were removed for histopathological and stereological analyses, and blood was collected via the ophthalmic venous plexus to measure IL-2, IL-4, IL-6, IL-10, IL-17A, IFN-γ, TNF, C-reactive protein and total creatine kinase. Protocols did not neutralize the edema-forming or local myotoxic induced by P. motoro venom under the experimental conditions tested. But systemic rhabdomyolysis was only completely neutralized in animals vaccinated with the stinger extract. Cytokine analysis revealed that under the experimental conditions used here, seroneutralization induced release of Th1, Th2, Th17 and Treg cytokines whereas vaccination induced a Th1 response.

"Bad things come in small packages": predicting venom-induced coagulopathy in Bothrops atrox bites using snake ontogenetic parameters.

Introduction: Snake venom composition shows significant inter- and intra-species variation. In the case of the viperid species Bothrops atrox, responsible for the majority of snakebites in the Amazon region, geographical and ontogenetic variables affect venom composition, with ecological and medical implications. Previous studies had shown that venom from neonate and juvenile Bothrops specimens have a higher in vitro coagulant activity. The aim of this investigation was to assess the association of clinical outcomes, such as venom-induced coagulopathy and local complications, with B. atrox ontogenetic variables.Methods: This study explored the relationship between some clinical parameters in patients suffering envenomations by B. atrox in the Amazon and several morphometric parameters of the snake specimens causing the bites.Results: There were 248 specimens confirmed as agents of envenomation, mostly female snakes (70.5%) and classified as juveniles (62.7%). Patients bitten by neonates compared to adult snakes [OR = 2.70 (95%CI 1.15-6.37); p = .021] and by snakes with white tail tip [OR = 1.98 (95%CI 1.15-3.41); p = .013] were more likely to develop coagulopathy. Time from patient admission to the unclottable blood reversion was not affected by the snake gender (p = .214) or age (p = .254). Patients bitten by neonate (p = .024) or juvenile snakes (p < .0001) presented a lower frequency of moderate to severe edema, as compared to those bitten by adult snakes. In agreement with experimental observations, patients bitten by neonates and by snakes with a white tail tip were more likely to develop coagulopathy than those bitten by adult snakes. In contrast, envenomations by adult snakes were associated with a higher incidence of severe local edema.Conclusion: Despite these variations, no difference was observed in the time needed to recover blood clotting in these patients after Bothrops antivenom administration.

Assessment of the anti-snakebite properties of extracts of Aniba fragrans Ducke (Lauraceae) used in folk medicine as complementary treatment in cases of envenomation by Bothrops atrox.

ETHNOPHARMACOLOGICAL RELEVANCE: Extracts of leaves and bark of Aniba fragrans are used as tea (decoction) to treat snakebites in communities in the Brazilian Amazon. The aqueous extract of the leaves of A. fragrans has been proven to be effective against Bothrops venom, but only when pre-incubated with the venom. This study sought to assess the potential of different types of extract of this species to inhibit the biological activities of Bothrops atrox venom (BaV) when used the same way as in folk medicine. The main classes of secondary metabolites and the concentrations of phenolics in the extracts were also determined. MATERIALS AND METHODS: Four types of extract of A. fragrans were prepared: aqueous extract of the leaf (AEL), aqueous extract of the bark (AEB), hydroalcoholic leaf extract (HLE) and extract of the residue from hydrodistillation of the leaf (ERHL). The phytochemical profiles of the aqueous extracts were determined using thin layer chromatography (TLC), and the concentrations of phenolics were measured by colorimetric assays. To investigate the potential of the extracts to inhibit the biological activities of BaV, in vitro tests for antiphospholipase and antifibrinolytic activities were performed. In vivo tests for antihemorrhagic and antidefibrinating activities were also carried out, as well as antimicrobial tests for activity against the main bacteria found in the oral cavity of snakes. Interaction between the extracts and the proteins in BaV was assessed by electrophoresis (SDS-PAGE) and Western blot (WB). The cytotoxicity of the extracts was assessed in a strain of MRC-5 human fibroblasts. RESULTS: Terpenoids, flavonoids and condensed and hydrolysable tannins were detected in all the extracts. Metabolites such as coumarins, fatty acids and alkaloids were present in some extracts but not in others, indicating different phytochemical profiles. Phenolics content varied between extracts, and there were more tannins in AEB and HLE. In the in vitro tests, the extracts inhibited the phospholipase and fibrinolytic activities of BaV in the two ratios of venom to extract used. HLE exhibited effective antimicrobial action as it inhibited growth of 11 of the 15 bacteria investigated, including Morganella morganii, the main bacteria described in the oral cavity of snakes. The extracts failed to inhibit the defibrinating activity of BaV, and only the Bothrops antivenom had a significant effect (96.1%) on this activity. BaV-induced hemorrhage was completely inhibited by AEL and AEB when the pre-incubation (venom:extract) protocol was used. When administered orally, as in folk medicine, both AEB and AEL produced significant inhibition of hemorrhagic activity (maximum inhibition 46.5% and 39.2%, respectively). SDS-PAGE and WB of the extracts pre-incubated with BaV showed that the main proteins in the venom had been precipitated by the extracts. None of the four extracts showed cytotoxic effects in the tests carried out with a human fibroblast cell line. CONCLUSION: In addition to being effective in reducing hemorrhage when administered orally, the extracts displayed a high antimicrobial potential against microorganisms involved in secondary infections at the site of the snakebite. Once the extracts have been tested in accordance with the appropriate regulations, this species could potentially be used to produce a phytomedicine for complementary treatment of the secondary infections due to bacteria that aggravate the local signs and symptoms after snakebite envenomation.

Snakebite by Micrurus averyi (Schmidt, 1939) in the Brazilian Amazon basin: Case report.

Micrurus snakes, commonly known as coral snakes, are responsible for 0.4% of the snakebites envenomings in Brazil. In this report, we describe a case of envenoming by Micrurus averyi, the black-headed coral snake, recorded in the western Brazilian Amazon. To the best of our knowledge, this is the first published case perpetrated by this species. The major complaint of the patient was an intense local pain and paresthesia. Examination of the bite site revealed edema extending from the left foot up the left leg that was accompanied by erythema involving the foot and distal third of the leg. Systemic signs at admission included nausea and drooling. The patient was treated with 100 mL of coral snake antivenom and intravenous analgesics (dipyrone) and was discharged 48 h post-admission with no complaints. The patient showed more intense local edema than that generally described in several other cases of Micrurus bites in Brazil.

The potential of aqueous extracts of Bellucia dichotoma Cogn. (Melastomataceae) to inhibit the biological activities of Bothrops atrox venom: A comparison of specimens collected in the states of Pará and Amazonas, Brazil.

ETHNOPHARMACOLOGICAL IMPORTANCE: The effectiveness of aqueous extract of Bellucia dichotoma Cogn. (Melastomataceae) specimems collected in Santarém, PA, against some biological activities of Bothrops atrox venom (BaV) has been scientifically proven. Here, we analyzed the components and assessed the anti-snakebite potential of aqueous extracts of bark of B. dichotoma collected in Manaus, AM, (AEBd-MAO) and Santarém, PA, (AEBd-STM), both in Brazil. MATERIALS AND METHODS: The phytochemical profiles of the aqueous extracts were identified using thin layer chromatography (TLC), and the concentrations of phenolics were determined by colorimetric assay. The inhibitory potential of the extracts was tested against the phospholipase A2, coagulant and gelatinolytic activities of BaV in vitro and its defibrinating and edema-inducing activities in vivo. Interaction between BaV and the extracts was investigated using SDS-Page electrophoresis and Western blotting. Extract cytotoxicity and antioxidant potential were assessed using the human fibroblast cell line MRC-5 and the DPPH assay in cell culture, respectively. RESULTS: While there was no difference between the phytochemical profiles of the extracts, AEBd-MAO had higher concentrations of total phenolics, total tannins and hydrolysable tannins. The extracts inhibited 100% of the phospholipase and coagulant activity of BaV when pre-incubated. Without pre-incubation, however, there was no reduction in phospholipase activity, although significant inhibition of coagulant activity was observed. In the doses used in folk medicine, without pre-incubation, both extracts inhibited 100% of the coagulant activity of BaV. In vivo, the extracts were unable to inhibit the defibrinating activity of the venom but were effective in inhibiting its edema-inducing activity. In the profiles of the extracts pre-incubated with BaV, not all the protein bands revealed by SDS-PAGE and Western blot were observed. Both extracts had a high antioxidant potential and neither had a cytotoxic effect. CONCLUSION: Although the concentrations of phenolics in each extract were different, the anti-snakebite potential was similar for the concentrations of extract tested. Our findings are of importance for the quality control of this raw material, which, once tested in accordance with Brazilian National Health Surveillance Agency recommendations, may be suitable for use as a phytomedicine to complement treatment of the local effects induced by Bothrops venoms.

The inhibitory potential of the condensed-tannin-rich fraction of Plathymenia reticulata Benth. (Fabaceae) against Bothrops atrox envenomation.

ETHNOPHARMACOLOGICAL RELEVANCE: Ethnobotanical studies have shown that Plathymenia reticulata Benth. (Fabaceae) has been widely used in cases of snake envenomation, particularly in Northern Brazil. In light of this, the aim of this study was to evaluate the inhibitory potential of the condensed-tannin-rich fraction obtained from the bark of P. reticulata against the main biological activities induced by Bothrops atrox venom (BaV). MATERIALS AND METHODS: The chemical composition of the aqueous extract of P. reticulata (AEPr) was first investigated by thin-layer chromatography (TLC) and the extract was then fractionated by column chromatography on Sephadex LH-20. This yielded five main fractions (Pr1, Pr2, Pr3, Pr4 and Pr5), which were analyzed by colorimetry to determine their concentrations of total phenolics, total tannins and condensed tannins and to assess their potential for blocking the phospholipase activity of BaV. The Pr5 fraction was defined as the fraction rich in condensed tannins (CTPr), and its inhibitory potential against the activities of the venom was evaluated. CTPr was evaluated in different in vivo and in vitro experimental protocols. The in vivo protocols consisted of (1) pre-incubation (venom:CTPr, w/w), (2) pre-treatment (orally administered) and (3) post-treatment (orally administered) to evaluate the effect on the hemorrhagic and edematogenic activities of BaV; in the in vitro protocol the effect on phospholipase and coagulant activity using pre-incubation in both tests was evaluated. RESULTS: There was statistically significant inhibition (p<0.05) of hemorrhagic activity by CTPr when the pre-incubation protocol was used [55% (1:5, w/w) and 74% (1:10, w/w)] and when pre-treatment with doses of 50 and 100mg/kg was used (19% and 13%, respectively). However, for the concentrations tested, there was no statistically significant inhibition in the group subjected to post-treatment administered orally. CTPr blocked 100% of phospholipase activity and 63.3% (1:10, w/w) of coagulant activity when it was pre-incubated with BaV. There was a statistically significant reduction (p<0.05) in edema induced by BaV in the oral protocols. Maximum inhibition was 95% (pre-treatment). CONCLUSION: Our findings indicate that CTPr could be a good source of natural inhibitors of the components of snake venom responsible for inducing local inflammation.

Plants used to treat snakebites in Santarém, western Pará, Brazil: an assessment of their effectiveness in inhibiting hemorrhagic activity induced by Bothrops jararaca venom.

ETHNOPHARMACOLOGICAL RELEVANCE: The poor distribution and limited availability of antivenoms in Brazil have led to greater use of plants to treat snakebites. Very often such plants are the only alternative available to riverside communities. MATERIALS AND METHODS: Direct questionnaire-based interviews were conducted with members of the Cucurunã, São Pedro and Alter do Chão communities in Santarém, Pará, Brazil. For each of the 12 most frequently mentioned species aqueous extracts were prepared and the phytochemical profiles determined by thin layer chromatography. The concentrations of phenolic compounds (tannins and flavonoids) in the aqueous extracts were determined by colorimetric assays. To assess inhibition of the hemorrhagic activity of Bothrops jararaca venom, solutions containing the venom mixed with aqueous extracts in the ratios 1:12 and 1:48 were tested (w/w). SDS-PAGE and Western blot were used to assess the action of the extracts on Bothrops jararaca venom. RESULTS: In all, 24 plants belonging to 19 families were mentioned in the survey as being used to treat snakebites. Leaves (84%), seeds (60.9%) and inner bark (53%) were cited as the most frequently used parts in folk remedies, which were usually prepared in the form of a decoction (62.5%), tincture (45%) or maceration (22.5%). Hemorrhage induced by Bothrops jararaca venom was completely inhibited by aqueous extracts of Bellucia dichotoma, Connarus favosus, Plathymenia reticulata and Philodendron megalophyllum, which had a high phenolic content and contained condensed and hydrolyzable tannins. The results of SDS-PAGE showed that some venom protein bands were not visible when the venom was preincubated with the extracts that had completely inhibited hemorrhagic activity of the venom. Western blot showed that the extracts did not have any enzymatic action on the proteins in the venom as it failed to detect low-molecular-weight bands, which are indicative of possible enzymatic cleavage. CONCLUSIONS: Traditional use of plants to treat snakebites is a common practice in the western region of Pará, Brazil. Our findings show that some plant extracts were able to inhibit snake venom-induced hemorrhage in vitro. In vivo studies are being carried out to validate the traditional use of these species to treat snakebites.