Comparing modified Lee and White method against 20-minute whole blood clotting test as bedside coagulation screening test in snake envenomation victims

Abstract Background: Twenty-minute whole blood clotting test (20WBCT) and Modified Lee and White (MLW) method are the most routinely employed bedside tests for detecting coagulopathic snake envenomation. Our study compared the diagnostic utility of MLW and 20WBCT for snakebite victims at a tertiary care hospital in Central Kerala, South India. Methods: This single-center study recruited 267 patients admitted with snake bites. 20WBCT and MLW were performed simultaneously at admission along with the measurement of Prothrombin Time (PT). The diagnostic utility of 20WBCT and MLW was determined by comparing the sensitivity (Sn), specificity (Sp), positive and negative predictive values, likelihood ratios, and accuracy at admission with an INR value > 1.4. Results: Out of 267 patients, 20 (7.5%) patients had VICC. Amongst those who had venom-induced consumption coagulopathy (VICC), MLW was prolonged for 17 patients, (Sn 85% 95% confidence interval [CI]: 61.1-96.0) whereas 20WBCT was abnormal for 11 patients (Sn 55%, 95% CI: 32.04-76.17). MLW and 20WBCT were falsely positive for the same patient (Sp 99.6%, 95% CI: 97.4-99.9%). Conclusion: MLW is more sensitive than 20WBCT to detect coagulopathy at the bedside amongst snakebite victims. However, further studies are necessary for standardizing bedside coagulation tests in snakebite cases.

Taiwan cobra envenoming: serum venom concentration before and after specific treatment and relationship with debridement of necrotic wound tissue

Background: Bivalent freeze-dried neurotoxic (FN) antivenom has been the primary treatment since the 1980s for Taiwan cobra (Naja atra) envenomation in Taiwan. However, envenomation-related wound necrosis is a significant problem after cobra snakebites. In the present study, we analyzed the changes in serum venom concentration before and after antivenom administration to discover their clinical implications and the surgical treatment options for wound necrosis. Methods: The patients were divided into limb swelling and wound necrosis groups. The clinical outcome was that swelling started to subside 12 hours after antivenom treatment in the first group. Serum venom concentrations before and after using antivenoms were measured to assess the antivenom's ability to neutralize the circulating cobra venom. The venom levels in wound wet dressing gauzes, blister fluids, and debrided tissues were also investigated to determine their clinical significance. We also observed the evolutional changes of wound necrosis and chose a better wound debridement timing. Results: We prospectively enrolled 15 Taiwan cobra snakebite patients. Males accounted for most of this study population (n = 11, 73%). The wound necrosis group received more antivenom doses than the limb swelling group (4; IQR:2-6 vs 1; IQR:1-2, p = 0.05), and less records of serum venom concentrations changed before/after antivenom use (p = 0.0079). The necrotic wound site may release venom into circulation and cause more severe envenomation symptoms. Antivenom can efficiently diminish limb swelling in cobra bite patients. However, antivenom cannot reduce wound necrosis. Patients with early debridement of wound necrosis had a better limb outcome, while late or without debridement may have long-term hospital stay and distal limb morbidity. Conclusions: Antivenom can efficiently eliminate the circulating cobra venom in limb swelling patients without wound necrosis. Early debridement of the bite site wound and wet dressing management are suggestions for preventing extended tissue necrosis and hospital stay.(AU)

Guidelines for the diagnosis and differential diagnosis of snakebite envenoming of ruminants in Brazil / Diretrizes para o diagnóstico e diagnóstico diferencial de envenenamento por picadas de cobra em ruminantes no Brasil

In Brazil, snakebites are often cited as a cause of mortality in ruminants, but there are discrepancies in the literature regarding its actual prevalence, either by lack of diagnosis or by mistakes in the differential diagnosis. Among the factors that hinder the diagnosis are included the inconsistencies to distinguish between accidents caused by Bothrops and Crotalus, responsible for over 90% of the cases. For the diagnosis of accidents involving Lachesis muta, both the neurotropic and the proteolytic/hemolytic effects must be considered, similar to what is described in Crotalus scutulatus. This article describes the main clinical, pathological, and laboratory findings observed in envenoming by the aforementioned snakes and suggests procedures for establishing the diagnosis and differential diagnosis starting from a logical sequence, based on epidemiological evidence, clinical, laboratory, and pathological findings.

No Brasil, acidentes ofídicos são frequentemente citados como causa de mortalidade em ruminantes, mas existem discrepâncias em relação a sua atual prevalência, seja por falta de diagnóstico ou por erros no diagnóstico diferencial. Entre os fatores que dificultam o diagnóstico estão as inconsistências para distinguir entre os acidentes causados por Bothrops e Crotalus, responsáveis por mais de 90% dos casos. Para o diagnóstico de envenenamentos por Lachesis muta, devem ser considerados os efeitos neurotrópico e proteolítico/hemolíticos concomitantes, a exemplo do que ocorre com algumas cascavéis norte-americanas (Crotalus scutulatus, entre elas). Este artigo descreve os principais achados clinicopatológicos e laboratoriais observados em casos de envenenamento pelas serpentes citadas e sugere um roteiro simplificado para o estabelecimento do diagnóstico e diagnóstico diferencial, a partir de uma sequência lógica, baseada em evidências epidemiológicas e achados clínicos, laboratoriais e patológicos.

Bothrops envenomation in dogs: local and systemic manifestations

Background: Snakebite envenoming is a condition that affects humans and domestic animals worldwide. Identification of the snake species involved in the envenomation is infrequent. Bothrops envenomation presents typical clinicopathological features. This report describes epidemiological, clinical, and pathological data of 2 cases of Bothrops envenomation in dogs, including the first case of Bothrops moojeni snake striking a domestic animal in Brazil. Cases: Case 1. A dog was witnessed to have a Bothrops moojeni snakebite on a farm. In the first 24 h, acute lameness, pain, diffuse swelling, focal bleeding at the left forelimb, and increased whole-blood clotting time were observed in the envenomed dog. Polyvalent antivenom was administered in addition to fluid therapy, analgesics, corticosteroids, and antibiotics. On the 5th day, the animal presented spontaneous bleeding at the wound site, thrombocytopenia, and increased whole-blood clotting time. An additional dose of polyvalent antivenom was administered, and local treatment at the snakebite site was initiated. After 13 days, the dog showed no clinical or laboratory changes and recovered entirely. Case 2. A mongrel dog was taken for a necropsy to determine the cause of death. Grossly, major findings included swelling in the nasal plane that extended to the neck and dissecting hemorrhage in the subcutaneous tissue and adjacent musculature. Hemorrhages were observed in the heart, parietal pleura, left forelimb, lumbar region, and perirenal tissue. Marked necrosis and disruption of small blood vessels and lymphatics within the deep dermis and subcutaneous tissue were the main microscopic findings close to the snakebite site. Additionally, degeneration and necrosis of muscle fibers and dissecting hemorrhage were observed in the head and neck tissues surrounding the snakebite site. Kidneys showed marked interstitial hemorrhage and acute tubular nephrosis. Discussion: Bothrops envenoming is characterized by local (hemorrhage, dermonecrosis, and myonecrosis) and systemic (coagulative disorders, systemic hemorrhage, and acute kidney injury) changes due to the effect of the main venom components such as phospholipase A2 and metalloproteinases. These changes are hallmarks for the bothropic envenomation, supporting the diagnosis in cases 1 and 2. In case 1, the dog developed a Bothrops moojeni snakebite envenomation, but the immediate treatment with antivenom allowed a favorable outcome. In case 2, gross and microscopic findings supported the presumptive diagnosis of fatal bothropic envenomation. A marked local reaction such as swelling, pain, bleeding, bruising, and tissue necrosis was observed in case 1. In case 2, the most significant local changes were swelling and edema at the head and neck, hemorrhage in the subcutaneous tissue, and adjacent musculature. Systemic effects were observed clinically as spontaneous bleeding, thrombocytopenia, increased whole-blood clotting time (Case 1), systemic hemorrhages, and acute tubular nephrosis (Case 2). A proper treatment probably prevented the development of acute renal failure in Case 1. Herein, we show the first case of accidental snakebite envenomation by B. moojeni in a dog in Brazil. Information is scarce on the identification of venomous snake species striking domestic animals. Fast detection of well-determined clinical and pathological findings of Bothrops envenomation is essential for a correct diagnosis, therapeutics, and a good prognosis, even in cases with an unknown history.

King Cobra and snakebite envenomation: on the natural history, human-snake relationship and medical importance of Ophiophagus hannah

King Cobra (Ophiophagus hannah) has a significant place in many cultures, and is a medically important venomous snake in the world. Envenomation by this snake is highly lethal, manifested mainly by neurotoxicity and local tissue damage. King Cobra may be part of a larger species complex, and is widely distributed across Southeast Asia, southern China, northern and eastern regions as well as the Western Ghats of India, indicating potential geographical variation in venom composition. There is, however, only one species-specific King Cobra antivenom available worldwide that is produced in Thailand, using venom from the snake of Thai origin. Issues relating to the management of King Cobra envenomation (e.g., variation in the composition and toxicity of the venom, limited availability and efficacy of antivenom), and challenges faced in the research of venom (in particular proteomics), are rarely addressed. This article reviews the natural history and sociocultural importance of King Cobra, cases of snakebite envenomation caused by this species, current practice of management (preclinical and clinical), and major toxinological studies of the venom with a focus on venom proteomics, toxicity and neutralization. Unfortunately, epidemiological data of King Cobra bite is scarce, and venom proteomes reported in various studies revealed marked discrepancies in details. Challenges, such as inconsistency in snake venom sampling, varying methodology of proteomic analysis, lack of mechanistic and antivenomic studies, and controversy surrounding antivenom use in treating King Cobra envenomation are herein discussed. Future directions are proposed, including the effort to establish a standard, comprehensive Pan-Asian proteomic database of King Cobra venom, from which the venom variation can be determined. Research should be undertaken to characterize the toxin antigenicity, and to develop an antivenom with improved efficacy and wider geographical utility. The endeavors are aligned with the WHO´s roadmap that aims to reduce the disease burden of snakebite by 50% before 2030.(AU)

Acute kidney injury caused by venomous animals: inflammatory mechanisms

Either bites or stings of venomous animals comprise relevant public health problems in tropical countries. Acute kidney injury (AKI) induced by animal toxins is related to worse prognostic and outcomes. Being one the most important pathways to induce AKI following envenoming due to animal toxins, inflammation is an essential biological response that eliminates pathogenic bacteria and repairs tissue after injury. However, direct nephrotoxicity (i.e. apoptotic and necrotic mechanisms of toxins), pigmenturia (i.e. rhabdomyolysis and hemolysis), anaphylactic reactions, and coagulopathies could contribute to the renal injury. All these mechanisms are closely integrated, but inflammation is a distinct process. Hence, it is important to improve our understanding on inflammation mechanisms of these syndromes to provide a promising outlook to reduce morbidity and mortality. This literature review highlights the main scientific evidence of acute kidney injury induced by bites or stings from venomous animals and their inflammatory mechanisms. It included observational, cross-sectional, casecontrol and cohort human studies available up to December 2019. Descriptors were used according to Medical Subject Headings (MeSH), namely: "Acute kidney injury" or "Venom" and "Inflammation" on Medline/Pubmed and Google Scholar; "Kidney disease" or "Acute kidney injury" on Lilacs and SciELO. The present review evidenced that, among the described forms of renal inflammation, it can occur either directly or indirectly on renal cells by means of intravascular, systemic and endothelial hemolysis, activation of inflammatory pathway, as well as direct action of venom cytotoxic components on kidney structures.(AU)

De novo venom gland transcriptomics of Calliophis bivirgata flaviceps: uncovering the complexity of toxins from the Malayan blue coral snake

The Malayan blue coral snake, Calliophis bivirgata flaviceps, is a medically important venomous snake in Southeast Asia. However, the complexity and diversity of its venom genes remain little explored. Methods: To address this, we applied high-throughput next-generation sequencing to profile the venom gland cDNA libraries of C. bivirgata flaviceps. The transcriptome was de novo assembled, followed by gene annotation, multiple sequence alignment and analyses of the transcripts. Results: A total of 74 non-redundant toxin-encoding genes from 16 protein families were identified, with 31 full-length toxin transcripts. Three-finger toxins (3FTx), primarily delta-neurotoxins and cardiotoxin-like/cytotoxin-like proteins, were the most diverse and abundantly expressed. The major 3FTx (Cb_FTX01 and Cb_FTX02) are highly similar to calliotoxin, a delta-neurotoxin previously reported in the venom of C. bivirgata. This study also revealed a conserved tyrosine residue at position 4 of the cardiotoxin-like/cytotoxin-like protein genes in the species. These variants, proposed as Y-type CTX-like proteins, are similar to the H-type CTX from cobras. The substitution is conservative though, preserving a less toxic form of elapid CTX-like protein, as indicated by the lack of venom cytotoxicity in previous laboratory and clinical findings. The ecological role of these toxins, however, remains unclear. The study also uncovered unique transcripts that belong to phospholipase A2 of Groups IA and IB, and snake venom metalloproteinases of PIII subclass, which show sequence variations from those of Asiatic elapids. Conclusion: The venom gland transcriptome of C. bivirgata flaviceps from Malaysia was de novo assembled and annotated. The diversity and expression profile of toxin genes provide insights into the biological and medical importance of the species.(AU)

De novo venom gland transcriptomics of Calliophis bivirgata flaviceps: uncovering the complexity of toxins from the Malayan blue coral snake

The Malayan blue coral snake, Calliophis bivirgata flaviceps, is a medically important venomous snake in Southeast Asia. However, the complexity and diversity of its venom genes remain little explored. Methods: To address this, we applied high-throughput next-generation sequencing to profile the venom gland cDNA libraries of C. bivirgata flaviceps. The transcriptome was de novo assembled, followed by gene annotation, multiple sequence alignment and analyses of the transcripts. Results: A total of 74 non-redundant toxin-encoding genes from 16 protein families were identified, with 31 full-length toxin transcripts. Three-finger toxins (3FTx), primarily delta-neurotoxins and cardiotoxin-like/cytotoxin-like proteins, were the most diverse and abundantly expressed. The major 3FTx (Cb_FTX01 and Cb_FTX02) are highly similar to calliotoxin, a delta-neurotoxin previously reported in the venom of C. bivirgata. This study also revealed a conserved tyrosine residue at position 4 of the cardiotoxin-like/cytotoxin-like protein genes in the species. These variants, proposed as Y-type CTX-like proteins, are similar to the H-type CTX from cobras. The substitution is conservative though, preserving a less toxic form of elapid CTX-like protein, as indicated by the lack of venom cytotoxicity in previous laboratory and clinical findings. The ecological role of these toxins, however, remains unclear. The study also uncovered unique transcripts that belong to phospholipase A2 of Groups IA and IB, and snake venom metalloproteinases of PIII subclass, which show sequence variations from those of Asiatic elapids. Conclusion: The venom gland transcriptome of C. bivirgata flaviceps from Malaysia was de novo assembled and annotated. The diversity and expression profile of toxin genes provide insights into the biological and medical importance of the species.(AU)

Case report of a coral snake bite (Micrurus ibiboboca) in the state of Pernambuco, northeast Brazil / Relato de caso de picada de cobra coral (Micrurus ibiboboca) no estado de Pernambuco, nordeste do Brasil / Informe de caso de mordedura de serpiente coral (Micrurus ibiboboca) en el estado de Pernambuco, noreste de Brasil

The Elapidae family comprises 35 snake species in Brazil, with Micrurus ibiboboca being widely distributed in the northeast of the country. Despite the high number of Micrurus species in Brazil, there are few cases of human envenomation in literature. This study describes a clinical report of envenomation due to the bite of M. ibiboboca in the State of Pernambuco, Northeast Brazil, that took place in 2017. The patient presented symptoms of muscle paralysis and sweating. He was admitted to the intensive care unit. A total of 10 ampoules of anti-elapidic serum were administered. The patient complained of local pain that extended through the arm, paresthesia in the lower limbs, headache, and chest pain. Changes in the visual, respiratory, and neurological systems were not observed. This clinical case report on coral snake poisoning is useful for increasing the knowledge on the toxicological action of snake poison and its effect on injured individuals, thereby helping in the clinical evaluation and treatment.(AU)

A família Elapidae compreende 35 espécies de serpentes no Brasil, com Micrurus ibiboboca amplamente distribuída no Nordeste. Apesar do elevado número de espécies de Micrurus no Brasil, são poucos os casos de envenenamento humano na literatura. Descrevemos aqui um relato clínico de envenenamento por picada de M. ibiboboca no Estado de Pernambuco, Nordeste do Brasil, ocorrido em 2017. O paciente apresentava sintomas de paralisia muscular e sudorese. Ele foi internado na Unidade de Terapia Intensiva. Um total de 10 ampolas de soro anti-elapídico foi administrado. O paciente queixava-se de dor local que se estendia pelo braço, parestesia em membros inferiores, cefaleia e dor torácica. Não foram observados alterações nos sistemas de visão, respiratório e neurológico. Este relato de caso clínico de intoxicação por cobra coral é útil para aumentar o conhecimento sobre a ação toxicológica da peçonha da serpente e seu efeito sobre os acidentados, auxiliando na avaliação clínica e no tratamento.(AU)

La familia Elapidae comprende 35 especies de serpientes en Brasil como la Micrurus ibiboboca ampliamente distribuidas en el Noreste. A pesar de lo alto número de especies de Micrurus en Brasil, hay pocos casos de envenenamiento humano en la literatura. Describimos aquí un informe clínico de envenenamiento por mordedura de M. ibiboboca en el estado de Pernambuco, Noreste de Brasil, ocurrido en 2017. El paciente presentaba síntomas de parálisis muscular y sudoración. Fue ingresado en la unidad de cuidados intensivos. Se administraron un total de 10 ampollas de suero antielapídico. El paciente se quejaba de dolor local que se extendía por el brazo, parestesias en las extremidades inferiores, cefalea y dolor torácico. No se observaron cambios en los sistemas visual, respiratorio y neurológico. Este informe de caso clínico sobre la intoxicación por serpiente coral es útil para aumentar el conocimiento sobre la acción toxicológica del veneno de serpientes y su efecto en los individuos lesionados, ayudando así en la evaluación clínica y el tratamiento.(AU)

Maintenance of venomous snakes in captivity for venom production at Butantan Institute from 1908 to the present: a scoping history

Maintenance of snakes at Butantan Institute started in the last century, intending to produce a different antivenom serum to reduce death caused by snakebites. Through a successful campaign coordinated by Vital Brazil, farmers sent venomous snakes to Butantan Institute by the railway lines with no cost. From 1908 to 1962, the snakes were kept in an outdoor serpentarium, where venom extraction was performed every 15 days. During this period, the snake average survival was 15 days. In 1963, the snakes were transferred to an adapted building, currently called Laboratory of Herpetology (LH), to be maintained in an intensive system. Although the periodicity of venom extraction remained the same, animal average survival increased to two months. With the severe serum crisis in 1983, the Ministry of Health financed remodeling for the three public antivenom producers, and with this support, the LH could be improved. Air conditioning and exhausting systems were installed in the rooms, besides the settlement of critical hygienic-sanitary managements to increase the welfare of snakes. In the early 1990s, snake survival was ten months. Over the years to the present day, several improvements have been made in the intensive serpentarium, as the establishment of two quarantines, feeding with thawed rodents, an interval of two months between venom extraction routines, and monitoring of snake health through laboratory tests. With these new protocols, average snake survival increased significantly, being eight years for the genus Bothrops, ten years for genus Crotalus and Lachesis, and four years for the genus Micrurus. Aiming the production of venoms of good quality, respect for good management practices is essential for the maintenance of snakes in captivity. New techniques and efficient management must always be sought to improve animal welfare, the quality of the venom produced, and the safety of those working directly with the venomous snakes.(AU)

Maintenance of venomous snakes in captivity for venom production at Butantan Institute from 1908 to the present: a scoping history

Maintenance of snakes at Butantan Institute started in the last century, intending to produce a different antivenom serum to reduce death caused by snakebites. Through a successful campaign coordinated by Vital Brazil, farmers sent venomous snakes to Butantan Institute by the railway lines with no cost. From 1908 to 1962, the snakes were kept in an outdoor serpentarium, where venom extraction was performed every 15 days. During this period, the snake average survival was 15 days. In 1963, the snakes were transferred to an adapted building, currently called Laboratory of Herpetology (LH), to be maintained in an intensive system. Although the periodicity of venom extraction remained the same, animal average survival increased to two months. With the severe serum crisis in 1983, the Ministry of Health financed remodeling for the three public antivenom producers, and with this support, the LH could be improved. Air conditioning and exhausting systems were installed in the rooms, besides the settlement of critical hygienic-sanitary managements to increase the welfare of snakes. In the early 1990s, snake survival was ten months. Over the years to the present day, several improvements have been made in the intensive serpentarium, as the establishment of two quarantines, feeding with thawed rodents, an interval of two months between venom extraction routines, and monitoring of snake health through laboratory tests. With these new protocols, average snake survival increased significantly, being eight years for the genus Bothrops, ten years for genus Crotalus and Lachesis, and four years for the genus Micrurus. Aiming the production of venoms of good quality, respect for good management practices is essential for the maintenance of snakes in captivity. New techniques and efficient management must always be sought to improve animal welfare, the quality of the venom produced, and the safety of those working directly with the venomous snakes.(AU)

Diagnóstico e tratamento de acidente ofídico por serpente do gênero Bothrops em cão / Diagnosis and treatment of ophidic accident by Bothrops snake in a dog

Refere-se como acidente ofídico todo quadro de envenenamento decorrente da inoculação de veneno, através de presas de serpentes. O veneno das espécies do gênero Bothrops, ao ser inoculado no animal, causa sinais clínicos graves que, se não tratados o mais rapidamente possível, podem levar o animal ao óbito. O gênero Bothrops (jararacas) está distribuído por todo o território nacional sendo responsável pela maioria dos acidentes ofídicos no país. Diante disso, o objetivo do presente relato foi descrever o diagnóstico e tratamento hospitalar bem sucedido de acidente botrópico em cão.

Ophidic accident refers to any picture of poisoning resulting from the inoculation of poison through snake prey. The venom of the Bothrops species, when inoculated into the animal, causes severe clinical signs that, if not treated as soon as possible, can lead to death. The Bothrops gender (jararacas) is distributed for all national territory as its responsible for the most ophidic accidents in the country. Therefore, the objective of the present report was to describe the diagnosis and successful hospital treatment of botropic accident in a dog.

Diagnóstico e tratamento de acidente ofídico por serpente do gênero Bothrops em cão / Diagnosis and treatment of ophidic accident by Bothrops snake in a dog

Refere-se como acidente ofídico todo quadro de envenenamento decorrente da inoculação de veneno, através de presas de serpentes. O veneno das espécies do gênero Bothrops, ao ser inoculado no animal, causa sinais clínicos graves que, se não tratados o mais rapidamente possível, podem levar o animal ao óbito. O gênero Bothrops (jararacas) está distribuído por todo o território nacional sendo responsável pela maioria dos acidentes ofídicos no país. Diante disso, o objetivo do presente relato foi descrever o diagnóstico e tratamento hospitalar bem sucedido de acidente botrópico em cão.(AU)

Ophidic accident refers to any picture of poisoning resulting from the inoculation of poison through snake prey. The venom of the Bothrops species, when inoculated into the animal, causes severe clinical signs that, if not treated as soon as possible, can lead to death. The Bothrops gender (jararacas) is distributed for all national territory as its responsible for the most ophidic accidents in the country. Therefore, the objective of the present report was to describe the diagnosis and successful hospital treatment of botropic accident in a dog.(AU)

Epidemiological and clinical aspects of snakebites in the upper Juruá River region, western Brazilian Amazonia / Aspectos clínicos e epidemiológicos de acidentes ofídicos na região do Alto Juruá, oeste da Amazônia brasileira

This study addresses the clinical and epidemiological aspects of envenoming cases resulting from snakebites treated at a hospital in Cruzeiro do Sul, in the upper Juruá River region, western Brazilian Amazonia. The specific identity of snakes that caused the envenomings was inferred (a) from the diagnosis of patient symptoms and signs upon hospital admission, (b) by enzyme immunoassay for detection of Bothrops atrox and Lachesis muta venom from serum samples taken from patients before antivenom therapy, or (c) by direct identification of the snake, when it was brought along to the hospital or photographed. There were 133 snakebites (76.2 cases per 100,000 inhabitants) registered during one year (July 2017 to June 2018). Most snakebites (88.7%) were caused by Bothrops spp., and the rest by non-venomous snakes or dry bites. Snakebites tended to occur more often during the rainy season, coinciding with the period of greater reproductive activity of the snakes and greater availability of their prey. In addition, the increase in the water level of rivers and lakes during the rainy season tends to concentrate snakes in dry places and, thus, to increase encounters with humans. Information campaigns on prevention and first aid, specially among the most vulnerable groups (indigenous people, farmers, and children and teenagers in rural areas), and the importance of using protective equipment (boots, leggings, leather gloves) in certain high risk activities (e.g. agriculture and extractivism in forests) are fundamental for the reduction of snakebite morbidity.(AU)

Este estudo aborda os aspectos clínicos e epidemiológicos dos envenenamentos ofídicos tratados em um hospital em Cruzeiro do Sul, Acre, resultantes de acidentes que ocorreram na região do Alto Juruá, no oeste da Amazônia brasileira. A identidade específica das serpentes que causaram os envenenamentos foi inferida (a) pelos sinais e sintomas apresentados pelo paciente na admissão hospitalar, (b) por imunoensaio enzimático para detecção de veneno de Bothrops atrox e Lachesis muta em amostras de soro retiradas de pacientes antes da soroterapia, e (c) pela identificação direta da serpente, quando esta foi levada para o hospital ou fotografada. Houve 133 casos (76,2 casos por 100.000 habitantes) de acidentes ofídicos registrados durante um ano (julho 2017 a junho 2018). A maioria das picadas de serpentes (88,7%) foi causada por Bothrops spp., e o restante por espécies não peçonhentas ou picadas secas. Os acidentes ofídicos tenderam a ocorrer com maior frequência durante a estação chuvosa, coincidindo com o período de maior atividade reprodutiva das serpentes e maior disponibilidade de suas presas. Além disso, o aumento dos níveis de rios e lagos pode fazer com que esses animais procurem locais mais secos, aumentando a frequência de encontro com seres humanos. Campanhas educativas sobre prevenção e primeiros socorros, principalmente entre os grupos mais vulneráveis (indígenas, agricultores, crianças e adolescentes em áreas rurais), e sobre a importância da utilização de equipamentos de proteção (botas, perneiras, luvas de couro) em determinadas atividades de maior risco (e.g., agricultura e extrativismo em florestas), são fundamentais para reduzir a morbidade de picadas de serpentes.(AU)

South American rattlesnake (Crotalus durissus spp) envenomation in dogs in the semiarid region of Brazil

Background: South American rattlesnake (Crotalus durissus spp.) envenomation is rarely reported in small animals andlivestock in Brazil. Minor swelling at the snakebite site, skeletal muscle, and renal damage, and severe neurological signscharacterize the crotalic envenomation. This case report aims to present epidemiological, clinical, and pathological dataof two cases of Crotalus durissus spp envenomation in dogs in the Northeast of Brazil.Cases: Envenomation by Crotalus durissus spp. was recorded in two dogs in Patos, State of Paraíba, Brazil. In Case 1,the dog presented flaccid paralysis, hyporeflexia, a deficit of cranial nerves, epistaxis, and gingival hemorrhages. Laboratory assay showed proteinuria, myoglobinuria, regenerative thrombocytopenia, and increased serum activities of creatinekinase (CK), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP). The dogwas medicated with crotalic antivenom and wholly recovered from local and systemic clinical signs. In Case 2, the dogdied and was detected fang marks at the ventral region of the left mandible (two small parallel perforations spaced 2.0 cmapart) at the snakebite site. Cyanosis of the oral cavity, congestion, and hemorrhages in several organs were observed atnecropsy. Tubular nephrosis, muscular necrosis, hepatocytes swelling were observed. The owners witnessed snakebites,and the rattlesnakes (Crotalus durissus spp.) identified by the rattle at the end portion of the tail in both cases.Discussion: Natural South American rattlesnake envenomation presents complex clinical signs that makes diagnosis achallenge for veterinary practitioners. The criteria for the correct diagnosis and observed in the two dogs include witness ofthe snakebite, identification of the snake, detection of fang marks, clinical-pathological findings, and therapeutic responseto treatment with specific anti-venom....

South American rattlesnake (Crotalus durissus spp) envenomation in dogs in the semiarid region of Brazil

Background: South American rattlesnake (Crotalus durissus spp.) envenomation is rarely reported in small animals andlivestock in Brazil. Minor swelling at the snakebite site, skeletal muscle, and renal damage, and severe neurological signscharacterize the crotalic envenomation. This case report aims to present epidemiological, clinical, and pathological dataof two cases of Crotalus durissus spp envenomation in dogs in the Northeast of Brazil.Cases: Envenomation by Crotalus durissus spp. was recorded in two dogs in Patos, State of Paraíba, Brazil. In Case 1,the dog presented flaccid paralysis, hyporeflexia, a deficit of cranial nerves, epistaxis, and gingival hemorrhages. Laboratory assay showed proteinuria, myoglobinuria, regenerative thrombocytopenia, and increased serum activities of creatinekinase (CK), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP). The dogwas medicated with crotalic antivenom and wholly recovered from local and systemic clinical signs. In Case 2, the dogdied and was detected fang marks at the ventral region of the left mandible (two small parallel perforations spaced 2.0 cmapart) at the snakebite site. Cyanosis of the oral cavity, congestion, and hemorrhages in several organs were observed atnecropsy. Tubular nephrosis, muscular necrosis, hepatocytes swelling were observed. The owners witnessed snakebites,and the rattlesnakes (Crotalus durissus spp.) identified by the rattle at the end portion of the tail in both cases.Discussion: Natural South American rattlesnake envenomation presents complex clinical signs that makes diagnosis achallenge for veterinary practitioners. The criteria for the correct diagnosis and observed in the two dogs include witness ofthe snakebite, identification of the snake, detection of fang marks, clinical-pathological findings, and therapeutic responseto treatment with specific anti-venom....(AU)

Antibiotic therapy for snakebite envenoming

There are numerous conflicting recommendations available on the use of antibiotics following snakebite. The present letter to the editor presents some recommendations based on recent studies, and aims to stimulate debate on this topic.(AU)

Chronic kidney failure following lancehead bite envenoming: a clinical report from the Amazon region

Snakebite envenoming can be a life-threatening condition, for which emergency care is essential. The Bothrops (lancehead) genus is responsible for most snakebite-related deaths and permanent loss of function in human victims in Latin America. Bothrops spp. venom is a complex mixture of different proteins that are known to cause local necrosis, coagulopathy, and acute kidney injury. However, the long-term effects of these viper envenomings have remained largely understudied. Case presentation: Here, we present a case report of a 46-years old female patient from Las Claritas, Venezuela, who was envenomed by a snake from the Bothrops genus. The patient was followed for a 10-year period, during which she presented oliguric renal failure, culminating in kidney failure 60 months after the envenoming. Conclusion: In Latin America, especially in Brazil, where there is a high prevalence of Bothrops envenoming, it may be relevant to establish long-term outpatient programs. This would reduce late adverse events, such as chronic kidney disease, and optimize public financial resources by avoiding hemodialysis and consequently kidney transplantation.(AU)

Antibiotic therapy for snakebite envenoming

There are numerous conflicting recommendations available on the use of antibiotics following snakebite. The present letter to the editor presents some recommendations based on recent studies, and aims to stimulate debate on this topic.(AU)

Venomics and antivenomics of the poorly studied Brazil's lancehead, Bothrops brazili (Hoge, 1954), from the Brazilian State of Pará

The Brazil's lancehead, Bothrops brazili, is a poorly studied pit viper distributed in lowlands of the equatorial rainforests of southern Colombia, northeastern Peru, eastern Ecuador, southern and southeastern Venezuela, Guyana, Suriname, French Guiana, Brazil, and northern Bolivia. Few studies have been reported on toxins isolated from venom of Ecuadorian and Brazilian B. brazili. The aim of the present study was to elucidate the qualitative and quantitative protein composition of B. brazili venom from Pará (Brazil), and to carry out a comparative antivenomics assessment of the immunoreactivity of the Brazilian antibothropic pentavalent antivenom [soro antibotrópico (SAB) in Portuguese] against the venoms of B. brazili and reference species, B. jararaca. Methods: We have applied a quantitative snake venomics approach, including reverse-phase and two-dimensional electrophoretic decomplexation of the venom toxin arsenal, LC-ESI-MS mass profiling and peptide-centric MS/MS proteomic analysis, to unveil the overall protein composition of B. brazili venom from Pará (Brazil). Using third-generation antivenomics, the specific and paraspecific immunoreactivity of the Brazilian SAB against homologous (B. jararaca) and heterologous (B. brazili) venoms was investigated. Results: The venom proteome of the Brazil's lancehead (Pará) is predominantly composed of two major and three minor acidic (19%) and two major and five minor basic (14%) phospholipase A2 molecules; 7-11 snake venom metalloproteinases of classes PI (21%) and PIII (6%); 10-12 serine proteinases (14%), and 1-2 L-amino acid oxidases (6%). Other toxins, including two cysteine-rich secretory proteins, one C-type lectin-like molecule, one nerve growth factor, one 5'-nucleotidase, one phosphodiesterase, one phospholipase B, and one glutaminyl cyclase molecule, represent together less than 2.7% of the venom proteome. Third generation antivenomics profile of the Brazilian pentabothropic antivenom showed paraspecific immunoreactivity against all the toxin classes of B. brazili venom, with maximal binding capacity of 132.2 mg venom/g antivenom. This figure indicates that 19% of antivenom's F(ab')2 antibodies bind B. brazili venom toxins. Conclusion: The proteomics outcome contribute to a deeper insight into the spectrum of toxins present in the venom of the Brazil's lancehead, and rationalize the pathophysiology underlying this snake bite envenomings. The comparative qualitative and quantitative immunorecognition profile of the Brazilian pentabothropic antivenom toward the venom toxins of B. brazili and B. jararaca (the reference venom for assessing the bothropic antivenom's potency in Brazil), provides clues about the proper use of the Brazilian antibothropic polyvalent antivenom in the treatment of bites by the Brazil's lancehead.(AU)