Therapeutic outcome of quercetin nanoparticles on Cerastes cerastes venom-induced hepatorenal toxicity: a preclinical study.

Aim: The objective of this study was to investigate the therapeutic potential of quercetin (QT) and QT-loaded poly(lactic-co-glycolic acid) nanoparticles (QT-NPs) on Cerastes cerastes venom-mediated inflammation, redox imbalance, hepatorenal tissue damage and local hemorrhage. Methods: The developed QT-NPs were first submitted to physicochemical characterization and then evaluated in the 'challenge then treat' and 'preincubation' models of envenoming. Results: QT-NPs efficiently alleviated hepatorenal toxicity, inflammation and redox imbalance and significantly attenuated venom-induced local hemorrhage. Interestingly, QT-NPs were significantly more efficient than free QT at 24 h postenvenoming, pointing to the efficacy of this drug-delivery system. Conclusion: These findings highlight the therapeutic potential of QT-NPs on venom-induced toxicity and open up the avenue for their use in the management of snakebite envenoming.

Hump-Nosed Pit Viper Envenomation in Western Coastal India: A Case Series.

The hump-nosed pit viper (HNPV) has historically been considered less medically significant, causing local envenomation, renal injury, and coagulopathy; however, now, it is known to cause life-threatening complications. We describe the clinical presentation, treatment, and complications of 3 confirmed HNPV bites from the state of Karnataka (southwest coastal India). Patient 1, an 88-y-old woman, reported with the live specimen and developed venom-induced consumption coagulopathy (VICC) and thrombotic microangiopathy leading to acute kidney injury requiring blood product transfusions and dialysis. Patient 2, a 60-y-old woman, reported 3 d after envenomation followed by treatment at another hospital where 30 vials of polyvalent anti-snake venom (ASV) were given. She developed VICC and acute kidney injury requiring dialysis. On Day 9 of treatment, she developed a pontine hemorrhage. She died after a transfer to another treatment center closer to her residence. Patient 3, a 25-y-old man, was brought to our emergency department 6 h after being envenomed. He received topical ayurvedic treatment before arrival. He was unconscious and found to have severe VICC with a massive middle cerebral artery infarct. All 3 patients received Indian polyvalent ASV, which does not cover HNPV envenomation, clearly demonstrating the absence of paraspecificity and neutralization in a clinical setting. To our knowledge, Hypnale hypnale envenomation has not previously been reported from Karnataka state. The diagnosis of HNPV envenomation in a country without snake venom detection kits, under-reporting despite serious complications, financial burdens on rural populations afflicted, and poor outcomes due to the lack of a specific antivenom are discussed.

Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis.

Snakebite is a neglected tropical disease with significant morbidity and mortality. Thrombotic microangiopathy (TMA) is an important but poorly understood complication of snakebite associated with acute kidney injury (AKI). Numerous treatments have been attempted based on limited evidence. We conducted a systematic review of TMA following snakebite using a pre-determined case definition of blood film red cell schistocytes or histologically diagnosed TMA. The search strategy included major electronic databases and grey literature. We present a descriptive synthesis for the outcomes of AKI, dialysis free survival (DFS), other end-organ damage, overall survival, and interventions with antivenom and therapeutic plasmapheresis (TPE). This study was prospectively registered with PROSPERO (CRD42019121436). Seventy-two studies reporting 351 cases were included, predominantly small observational studies. Heterogeneity for study selection, design, reporting and outcomes were observed. The commonest envenoming species were hump-nosed vipers (Hypnale spp.), Russell's viper (Daboia russelii) and Australian brown snakes (Pseudechis spp.). The prevalence of TMA was at least 5.4% in proven and probable Hypnale bites, and 10-15% of Australian elapid envenomings, AKI occurred in 94% (293/312) of TMA cases, excluding case reports. The majority of cases with AKI required dialysis. Included prospective and retrospective cohort studies reporting interventions and renal outcomes showed no evidence for benefit from antivenom or TPE with respect to DFS in dialysis dependant AKI. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment for quality of accumulated evidence for interventions was low. The major complication of TMA following snakebite is AKI. AKI improves in most cases. We found no evidence to support benefit from antivenom in snakebite associated TMA, but antivenom remains the standard of care for snake envenoming. There was no evidence for benefit of TPE in snakebite associated TMA, so TPE cannot be recommended. The quality of accumulated evidence was low, highlighting a need for high quality larger studies.

Venom-Induced Consumption Coagulopathy Following Hump-Nosed Pit Viper (Genus: Hypnale) Envenoming in Sri Lanka: Uncertain Efficacy of Fresh Frozen Plasma.

INTRODUCTION: Hump-nosed pit vipers (Hypnale spp) cause the highest number of venomous snakebites in Sri Lanka. Bites commonly cause local envenoming leading to local pain, swelling, and necrosis of the site of the bite. Acute kidney injury is the most common systemic manifestation, and some patients develop venom-induced consumption coagulopathy (VICC). Genus Hypnale comprises 3 species. Of them, H hypnale is found in Sri Lanka and the Western Ghats region of India. The other 2 (H nepa and H zara) are endemic species in Sri Lanka. METHODS: This study included 500 patients with hump-nosed viper bites studied prospectively over 4.5 y starting June 2014. All patients were assessed and the data were collected by the principal investigator (primary data). A subgroup of patients who developed VICC is described. There were 2 groups, including proven (patients with the specimen of the snake) and probable (specimen of snake not available) bites. RESULTS: Thirty (n=500; 6%) patients developed VICC; of them, 17 (3%) were proven cases, and 13 (2%) were probable cases. In both groups, 24 (80%) recovered, 2 (7%) progressed to chronic kidney disease, 1 (3%) died of severe hemostatic dysfunction, and 3 (10%) were lost to follow-up. Systemic bleeding was observed in 16 patients (53%), including hematuria (microscopic and gross) in 8 (27%) and venipuncture bleeding in 5 (17%). Eleven (37%) developed local bleeding at the site of the bite. Fresh frozen plasma was administered to 20 patients (67%), among whom only 11 (55%) experienced early correction of VICC. In both groups, 15 (50%) developed acute kidney injury, and 2 (7%) progressed to chronic kidney disease. Microangiopathic hemolysis was observed in 18 patients (60%) and thrombocytopenia in 16 (53%). Thrombotic microangiopathy was detected in 13 patients (43%), of whom 10 (33%) developed hemolytic uremic syndrome and 2 (7%) had thrombotic thrombocytopenic purpura. Of patients with VICC in the proven group, 94% (n=16) was caused by H hypnale and 1 (6%) was caused by H zara. In the proven group, median international normalized ratio was 3.7 (interquartile range 1.6-5.0); in the probable group, it was 5.0 (interquartile range 2.1-5.4). CONCLUSIONS: We found that 6% of patients develop hemostatic dysfunction after hump-nosed viper bites. However, which patients will develop coagulopathy or die of envenoming is unpredictable. Reliable and accessible treatments are unmet essential needs because antivenoms for these bites are currently not available in the country. Therapy with fresh frozen plasma has doubtful efficacy in early correction of VICC and needs further evaluation.

Thrombotic Microangiopathy Following Hypnale zara (Hump-Nosed Pit Viper) Envenoming: The First Known Case Report from Sri Lanka.

A 65-y-old previously healthy farmer developed thrombotic microangiopathy (TMA) comprising the triad of acute kidney injury, microangiopathic haemolysis, and thrombocytopenia after a proven Hypnale zara (hump-nosed pit viper) bite. He developed coagulopathy, which was treated with fresh frozen plasma, and underwent 8 cycles of hemodialysis. He is being followed up in the nephrology clinic for acute kidney injury. TMA caused by Hypnale hypnale, the commonest species of genus Hypnale, has previously been reported, but this is the first known case of TMA following a bite by H zara, the endemic species in Sri Lanka.

White-Lipped Tree Viper (Cryptelytrops albolabris) Envenomation in an American Viper Keeper.

BACKGROUND: Snakebites are common in many regions of the United States. Bites from exotic species, however, are rare. The white-lipped tree viper, Cryptelytrops (formerly Trimeresurus) albolabris, is a pit viper native to Southeast Asia. Bites are common in countries such as Myanmar, India, Thailand, Indonesia, and China. In this report, we describe an envenomation in an American viper keeper. CASE REPORT: A healthy 28-year-old right-handed man who collects venomous snakes experienced a bite to the distal left thumb from a neonatal C. albolabris while feeding it. Upon arrival to the Emergency Department 30 min after the bite, the patient complained of significant pain and swelling that had progressed across his entire hand. He also experienced nausea, lightheadedness, mild dyspnea, and a burning sensation in his lungs. After discussing the risks and benefits, we elected to treat with five vials of Thai Red Cross Green Pit Viper antivenin. The patient was also treated with intravenous fluids, parenteral opioids, and ondansetron. He received an additional five vials due to worsening hematologic laboratory values. His laboratory tests normalized and his local findings improved significantly. He was asymptomatic at discharge and at multiple follow-up visits. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Envenomation by C. albolabris is characterized by local tissue injury and hematotoxicity. Supportive care and specific antivenom therapy comprise the management of these bites. This case reminds physicians that not all bites that present to the hospital will be from native snakes and helps direct emergency physicians to specific expertise and uncommon antivenoms.

[Lymphoedema after an adder bite].

Bites from the adder, Vipera berus, are well known for causing local and general toxicity. We report a case of a 63-year-old female who was bitten in one of her lower extremities. She was seen twice in the emergency department with symptoms and signs consistent with severe envenomation. Despite treatment with antihistamines and corticosteroids the oedema persisted. A lymphoscintigraphy was performed showing dermal backflow in the right leg, confirming the diagnosis of lymphoedema. Based on the present case report and review of the literature antivenom therapy should be considered more actively.

Acute hypopituitarism complicating Russell's viper envenomation: case series and systematic review.

BACKGROUND: Chronic hypopituitarism following Russell viper envenomation (RVE) is a rare but well-recognized syndrome. The clinical features, associations, management and outcomes of RVE associated-acute hypopituitarism (AHP) are not well described. AIMS: To describe the clinical features, intensive care unit (ICU) management and outcomes of a series of patients with RVE-AHP and identify the clinical associations of RVE-AHP. METHODS: We describe a series of patients with prospectively identified AHP related to RVE and describe our findings comparing RVE with and without AHP and a systematic search of literature on AHP related to RVE. RESULTS: We identified nine cases of AHP related to RVE. Unexplained hypoglycemia (100%) and hypotension (66.7%) were the most common findings at presentation. AHP occurred after a median of 9 (range, 2-14) days after severe envenomation and was associated with multi-organ dysfunction, lower platelet counts, more bleeding and transfusions when compared to patients with RVE alone. The presence of clinically defined capillary leak syndrome, disseminated intravascular coagulation and mortality were not different from those without AHP. Our systematic search yielded 12 cases of AHP related to RVE; data on associated clinical manifestations, therapy and ASV administration were not available in most reports. CONCLUSION: AHP is a very rare complication of RVE. Unexplained hypoglycemia and hypotension should prompt evaluation for AHP in RVE. AHP is associated with severe RVE, multi-organ dysfunction, bleeding and need for transfusion. Prompt treatment with steroids may reduce mortality related to AHP in RVE.

Biochemical and pharmacological characterization of a toxic fraction and its cytotoxin-like component isolated from Russell's viper (Daboia russelii russelii) venom.

The pathophysiological significance of a toxic fraction (GF-VI DEAE-II) isolated from Russell's viper venom (RVV) is characterized. GF-VI DEAE-II represents 1.6% of the total RVV protein and it comprises of a 27.6kDa minor component (RP-I) (0.04%, w/w) and a major 6.6kDa non-enzymatic peptide (1.11%, w/w), named Rusvitoxin. The LC-MS/MS analysis of RP-I showed its identity to snake venom serine proteases, whereas Rusvitoxin demonstrated its close identity with snake venom three finger toxins, cytotoxins and cardiotoxins particularly from Naja sp. GF-VI DEAE-II was found to be non-cytotoxic to the tested mammalian cancer cells and non-hemolytic; nevertheless, it demonstrated α-fibrin(ogen)ase activity and in vivo toxicity in BALB/c mice with an LD50 (i.p.) of 2.3mg/kg. GF-VI DEAE-II induced lethargy and hind-leg paralysis in mice within 10min of i.p. injection. GF-VI DEAE-II induced hyperfibrinogenomia, and significantly altered (p<0.05) the plasma levels of factor X, pro- and anti-inflammatory cytokines viz. TNF-α, IL-6 and IL-10 in treated mice. Histological observations of tissues and biochemical properties of serum from GF-VI DEAE-II-treated mice suggested multiple organ dysfunctions. Conversely, Rusvitoxin at a dose of 5mg/kg did not induce toxicity in BALB/c mice. At 1:15 (antigen: antivenom, w/w) ratio, commercially polyvalent and monovalent antivenoms neutralized more than 80% of the fibrinolytic and anticoagulant activities of GF-VI DEAE-II. The present study suggests the significant role of GF-VI DEAE-II in RVV-induced pathogenesis in victim/prey.

Galatrox is a C-type lectin in Bothrops atrox snake venom that selectively binds LacNAc-terminated glycans and can induce acute inflammation.

Previous studies indicate that snake venom contains glycan-binding proteins (GBPs), although the binding specificity and biological activities of many of these GBPs is unclear. Here we report our studies on the glycan binding specificity and activities of galatrox, a Bothrops atrox snake venom-derived GBP. Glycan microarray analysis indicates that galatrox binds most strongly to glycans expressing N-acetyllactosamine (LacNAc), with a significant preference for Galß1-4GlcNAcß over Galß1-3GlcNAcß compounds. Galatrox also bound immobilized laminin, a LacNAc-dense extracellular matrix component, suggesting that this GBP can bind LacNAc-bearing glycoproteins. As several endogenous mammalian GBPs utilize a similar binding LacNAc binding preference to regulate neutrophil and monocyte activity, we hypothesized that galatrox may mediate B. atrox toxicity through regulation of leukocyte activity. Indeed, galatrox bound neutrophils and promoted leukocyte chemotaxis in a carbohydrate-dependent manner. Similarly, galatrox administration into the mouse peritoneal cavity induced significant neutrophil migration and the release of pro-inflammatory cytokines IL-1α and IL-6. Exposure of bone marrow-derived macrophages to galatrox induced generation of pro-inflammatory mediators IL-6, TNF-α, and keratinocyte-derived chemokine. This signaling by galatrox was mediated via its carbohydrate recognition domain by activation of the TLR4-mediated MyD88-dependent signaling pathway. These results indicate that galatrox has pro-inflammatory activity through its interaction with LacNAc-bearing glycans on neutrophils, macrophages and extracellular matrix proteins and induce the release of pro-inflammatory mediators.

Life threatening intracerebral haemorrhage following saw-scaled viper (Echis carinatus) envenoming--authenticated case report from Sri Lanka.

BACKGROUND: Echis carinatus (Saw scaled viper {SSV}) is a venomous snake found in the parts of Middle East and Central Asia. SSV envenoming is characterized by local swelling and coagulopathy. Various bleeding manifestations are commonly seen with SSV envenoming. In contrast to other part of Asia, saw scale viper envenoming has not been reported to cause life threatening haemorrhagic manifestations in Sri Lanka. CASE PRESENTATION: We report a 19 years old healthy boy who developed massive left temporo-parietal intra cerebral haemorrhage following Echis carinatus (Saw scaled viper) bite in Sri Lanka. CONCLUSION: Although subspecies of SSV in Sri Lanka is regarded as a 'non lethal venomous snake', the occurrence of rare potentially fatal complications such as intracerebral haemorrhage should be considered in their management. This case report is intended to bring the awareness of this fatal complication of SSV envenoming in Sri Lanka.

Chronic kidney disease in snake envenomed patients with acute kidney injury in Sri Lanka: a descriptive study.

BACKGROUND: Data on the long-term outcomes of acute kidney injury (AKI) in envenomed patients leading to chronic kidney disease (CKD) are scarce. The aim of the study was to investigate this issue and to determine the predictive factors in developing CKD. METHODS: The records of a series of 54 patients who had AKI following a snakebite during the period 2004-2009 and who had been followed up were reviewed in the nephrology unit, Kandy, Sri Lanka. The primary outcome measure was the failure of renal functions to return to normal within 1 year. The renal histology was studied in seven patients. RESULTS: The mean age of the group was 50 years (SD 13 years) and 39 (72%) patients were men. The offending snakes were Russell's viper and hump-nosed viper in 15 (28%) and 13 (24%) patients, respectively. At 1 year, 20 patients (37%) had developed CKD (CKD group) and the rest (63%) had recovered (recovered group). The acute stage serum creatinine was high in both groups with no difference (on admission, p=0.134; on discharge, p=0.323), but the CKD group showed significantly high serum creatinine at 2 months after AKI (p=0.004). Mean duration of renal replacement therapy (RRT) of the recovered group and CKD group were 7 (SD 5) and 16 (SD 12) days, respectively (p=0.015). Renal histology of six CKD patients showed predominant glomerular sclerosis and interstitial nephritis. CONCLUSIONS: CKD is an outcome of severe AKI following snake envenoming probably predicted by the length of RRT.

[Management of the common European viper's bite--a case report]. / A keresztesvipera-marás ellátásának aktuális szempontjai egy eset kapcsán.

The common European viper is widespread throughout Europe. In Hungary it can be found mainly in the Zemplén Mountains, on the upper course of the Tisza River, and Zala and Somogy counties. Viper's bite is one of the rarest injuries that requires emergency medical care. The venom contains polypeptides and hydrolytic enzymes which have neurotoxic, cytotoxic, hemolytic and hemorrhagic effects. Local symptoms may include double points, pain, swelling, and suffusion at the site of the bite. Very occasionally, particularly in case of small children and elderly people, viper bite can cause life threatening angioedema, as well as shock and, therefore, professional medical help should always be sought preferably in a hospital that has a toxicology and poison control centre. Authors present the history of a 64-year-old nature enthusiast, who, after having been bitten by a viper, lost consciousness and experienced persistent local redness and pain. Soon after the viper bite, the patient suffered another potentially fatal accident, a stroke of lightning that he also survived. In connection with the case, authors provide an overview of the clinical symptoms caused by viper venom, and current issues of professional care.

Inhibition of hemorrhagic activity of viper venoms by N-acetyl cysteine: involvement of N-acetyl and thiol groups.

The mortality rate due to snakebite is reduced markedly by the use of anti-venoms, which are the only medically approved remedial agents available. The anti-venoms effectively neutralize the systemic toxicity but offer no protection towards local tissue degradation. In viperid snake envenomations, SVMPs and SVHYs are the major agents responsible for brutal local tissue damage as they degrade ECM and basement membrane surrounding the blood vessels. Thus, the usage of inhibitor(s) against ECM degrading enzymes in the treatment of viper bites is an affirmative therapeutic choice. The present study assessed the efficacy of N-acetyl cysteine (NAC) to inhibit gelatinase, hyaluronidase, hemorrhagic and defibrinogenating activities of Vipera russelli and Echis carinatus venoms. NAC inhibited these activities dosedependently, but it did not inhibit the PLA2, 5' nucleotidase, procoagulant and edema inducing activities of both the venoms. NAC showed complete inhibition of hemorrhagic activity when incubated with venom prior to testing. Whereas little inhibition was observed when venom and NAC were injected independently. Inhibition of the basement membrane degradation and accumulation of inflammatory leukocytes at the site of venom injection in histological sections further corroborate the inhibitory property of NAC. The observed inhibition of hemorrhage was likely due to zinc chelation as supported by spectral studies. Further, docking predictions suggested the role of -SH and -NH-CO-CH3 groups of NAC in the inhibition of SVMPs and SVHYs. Future studies related to the protective role of NAC against the venom induced systemic hemorrhage and secondary complications are highly exciting.

The polyphenol 3, 4, 5 - tri-hydroxy benzoic acid inhibits indian daboia russelli venom and its hemorrhagic complex induced local toxicity.

Despite a long history on treatment and management of snakebite, as of now, no satisfactory cure exists to treat local toxicity, including anti-venom therapy. Several natural compounds from plants and their synthetic analogs have shown to be protective. In this study 3, 4, 5-tri-hydroxy benzoic acid, the gallic acid (GA) was tested against the local toxicity of Daboia russelli (DR) venom and its purified hemorrhagic complex (HC). GA inhibited in vitro proteolytic activity of both DR venom and HC but, it did not inhibit phospholipase activity of DR venom. GA inhibited hemorrhage, edema forming, dermo- and myonecrotic activities of both HC and DR venom in in vivo experiments. GA was particularly effective against hemorrhagic activity but, GA inhibition had a greater effect on HC when compared to DR venom. The inhibition was likely due to GA induced structural changes in HC as revealed by alterations in fluorescence emission and CD spectral properties. However, the inhibition was not due to chelating property of GA as suggested by UV-visible spectral studies. Inhibition of collagen type IV, laminin and fibronectin degradation essentially provided the biochemical basis for GA which inhibited local effects of HC as well as DR venom. Thus, the study appears highly promising to explore GA and its generics against ruthless local effects and perhaps systemic hemorrhage of DR and other snake bites as well. Further, these agents will possibly find an immense value in the regulation of matrix metalloproteases (MMPs) in processes such as wound healing, inflammation and in the treatment of cancer.

Accidents caused by Bothrops and Bothropoides in the State of Paraiba: epidemiological and clinical aspects.

INTRODUCTION: Bothrops and Bothropoides snakes cause 70% of the ophidic accidents in Brazil. The species that cause ophidic accidents in State of Paraíba are Bothropoides erythromelas, Bothrops leucurus and Bothropoides neuwiedi. METHODS: This is a prospective and transverse study, following a quantitative approach of accidents involving Bothrops and Bothropoides admitted to the Toxicological Assistance and Information Centers of Campina Grande and João Pessoa (Ceatox-CG and Ceatox-JP), aimed at identifying the epidemiological and clinical profile of such accidents. All of the patients admitted had medical diagnoses and were monitored at Ceatox-CG or Ceatox-JP. RESULTS: The genera Bothrops and Bothropoides caused 91.7% of the ophidic accidents reported. Snake bites were frequent in men (75.1%), rural workers (65.1%), literate individuals (69%) between 11 and 20 years-old (21.7%), and toes the most common area attacked (52.7%). Most (86.6%) patients were admitted within 6 hours after the accident/bite, with a predominance of mild cases (64.6%). The annual occurrence in Paraíba was 5.5 accidents/100,000 inhabitants and lethality was 0.2%. CONCLUSIONS: Positive changes in the profiles of these accidents were verified, such as the non-application of inadequate solutions, including the use of tourniquet, coffee grounds, garlic, suction and/or cutting the bitten area. Moreover, the Itinerant Laboratory project, linked to Paraíba State University in partnership with Ceatox-CG, has contributed positively, providing several cities of the state with information regarding the prevention of accidents involving venomous animals. The local press has also contributed, reporting the educational work developed by the centers.