[Evidence of snakes in urban areas. Analysis of cases in the province of Cuneo and public health issues]. / Riscontri di ofidi in ambiente urbano. Analisi della ca- sistica in provincia di Cuneo e problematiche di sanità pubblicao.

In this paper the authors analyse the cases of intrusion of snakes into urban environments in southern Piedmont (province of Cuneo) in the years 2010-2012 (up to may). In the study period there were 83 cases of intrusions in urban and domestic areas, mostly due to native harmless species (97.6%), while in 2.4% (n=2) of the cases alien species were responsible, and in 4.8% (n=4) poisonous native species were involved (Vipera aspis). The incidence of bites after a domestic intrusion is found to be 6% (n=5). All bites have resulted in loco-regional minor symptoms and occurred as a result of an accidental contact. In order to limit the risk of poisoning, the authors recommend the intrusions to be handled by properly trained personnel, since it can never be ruled out the presence of dangerous alien species on the national territory.

Stings from Euscorpius flavicaudis (De Geer, 1778) (Scorpiones, Euscorpiidae) during pregnancy: a clinical case report

We report a case in which a 21-week pregnant woman was stung by a Euscorpius flavicaudis (De Geer, 1778) scorpion. Symptoms and signs experienced by the patient were the same as those documented in the literature and with no ill-effects for the pregnancy. Envenoming was local and of low degree of intensity. It is important to emphasize that the patient was stung in her home, which differs from stings in most other parts of the world, in which scorpionism is mostly a risk in outdoor areas.(AU)

Dangerous scorpion fauna of Mali

Although the main Malian scorpion species of medical interest, Androctonus amoreuxi, is responsible for severe envenomings and perhaps some deaths, it has hitherto been considered not dangerous for humans. This population is located in the Saharian North-Eastern regions of Mali where it is accompanied by Leiurus quinquestriatus, a well known dangerous species of the Sahara. In the Gao district, divided by the Niger River, less desolate than the Tessalit and Kidal regions, one specimen of the dangerous species Androctonus australis was found. To summarize, Mali harbors at least three dangerous scorpion species: Leiurus quinquestriatus, Androctonus amoreuxi and A. australis, the latter recently having been identified in Mali for the first time. The absence of Androctonus aeneas is surprising in this context because it is found in neighboring countries (Algeria, Niger) and should be detected by new surveys. The possibility of preparing a single scorpion antivenom intended for Saharian and sub-Saharian populations is discussed.(AU)

Scorpion envenoming in the north of Mali (West Africa): epidemiological, clinical and therapeutic aspects.

Scorpion envenomation remains a poorly known problem in sub-Saharan Africa, particularly in Mali, where the incidence is high in Northern area of the country (Sahara desert). We conducted a prospective study in two district health centers, Kidal and Tessalit (North-east of Mali), to describe the epidemiological, clinical and therapeutic features of scorpion stings. This study consisted of an exhaustive follow-up from admission to discharge of all patients stung by scorpions. Of a total of 282 cases recorded during one year, 207 (73.4%) occurred in Kidal, and the remaining 75 (26.6%) took place in Tessalit. The annual incidence was significantly higher in Tessalit (437 cases/100,000 population/year) than in Kidal (243 cases/100,000 population/year) (p < 10⁻6). Two hundred two (71.6%) stings occurred inside human dwellings, 142 (50.4%) during sleeping/resting, especially in August. One hundred ninety-one (67.7%) were on the lower extremities. Nocturnal stings, 168 (59.6%), occurred more often than diurnal stings, 114 (40.4%). Most patients, 163 (57.8%), were admitted less than 1 h after being stung. Local pain at the sting site was the common primary complaint. However, moderate and severe clinical signs were significantly higher in children than in adults (p < 0.05). The death rate (3.9%) was higher in children (3.5%) than in adults (0.3%) (p = 8.10⁻6; RR = 0.90 [IC: 0.84-0.06]). Of the 22 scorpion species identified, 13 (59.1%) were Leiurus quinquestriiatus, 8 (36.4%) were Androctonus amoreuxi, and 1 (4.5%) specimen was Buthiscus bicalcaratus. From these species, L. quinquestriiatus and A. amoreuxi were responsible of stings. The medical treatment was only symptomatic, and one hundred twenty-eight (45.3%) patients received traditional remedies before seeking medical attention. Our findings suggest that scorpion stings are common in the north of Mali and are a significant threat to human health.

Epidemiology of scorpionism: a global appraisal.

The scorpionism is an actual public health problem in several parts of the world because, either incidence, or severity of envenomations is high and managed with difficulty by health services, or for these two reasons at the same time. The treatment of scorpion envenomation is complex and controversial, in particular regarding the utility of the antivenoms and symptomatic treatments that must be associated. The authors reviewed the literature of last 30 years to discuss the epidemiologic importance of scorpionism and to point out the principal therapeutic or preventive measures. According to the most recent studies, seven areas were identified as at risk: north-Saharan Africa, Sahelian Africa, South Africa, Near and Middle-East, South India, Mexico and South Latin America, east of the Andes. These involve 2.3 billion at risk population. The annual number of scorpion stings exceeds 1.2 million leading to more than 3250 deaths (0.27%). Although adults are more often concerned, children experience more severe envenomations and among them, mortality is higher. Improvement of therapeutic management would reduce the lethality very significantly.

[Haemostasis disorders caused by snake venoms]. / Troubles de l'hémostase induits par les venins de serpents.

Various haemostasis disorders can occur following snakebite. Almost all ophidian species that are responsible for serious, even lethal, human envenomations are concerned. Venoms of these snakes are rich in proteins interfering with haemostasis, including many enzymes. These proteins can be classified in four groups according to their action. The haemorrhagins induce capillary permeability disorders. The proteins disturbing the primary haemostasis can activate as well as inhibit platelets: phospholipases A2, serine proteases and metalloproteinases, L-amino-acido-oxydases, phosphoesterases, disintegrins, C-type lectins, dendropeptin, agregoserpentin, thrombolectin. The proteins interfering with coagulation are separated into procoagulant proteases (prothrombin activator, thrombin-like enzymes, factor X and factor V activators) and anticoagulant proteases (factor IX and X inhibitors, protein C activator, anticoagulant phospholipases A2). The venom components acting on fibrinolysis are the fibrinolytic enzymes and the plasminogene activators. The clinical consequence of these mechanisms is a local as well as diffuse haemorrhagic syndrome. A hypofibrinogenemy, even an afibrinogenemy is frequently noted. Other haemostasis parameters are disturbed: PT collapse, a patient's ACT several times higher than the control and non-systematic thrombopenia. Ophidian venoms take part in many medical, diagnostic or therapeutic, applications in medicine. Currently, the antivenomous immunotherapy is the only efficient treatment in these haemorrhagic disorders.

[Neurotoxins from snake venom]. / Neurotoxines ophidiennes.

Many snakes are able to quickly immobilize prey, thanks to their venom neurotoxins. Most of these snakes belong to families Elapidae or Hydrophidae but neurotoxins were also isolated from families Viperidae and Colubridae. Ophidian neurotoxins can be classified into several categories: neurotoxins which inhibit synaptic transmission (postsynaptic and presynaptic neurotoxins) and neurotoxins which facilitate it excessively (dendrotoxin and fasciculin). Their toxicity is dose-dependent, and venom effects are extremely fast. The clinical feature is a potentially fatal neurological syndrome, the so called cobraic syndrome. Because death by respiratory arrest may occur quickly with cobraic syndrome, immunotherapy is a true emergency, because toxins irreversible fixing makes immunotherapy effect uncertain after a few hours passed.

[Envenomations VI. Scorpionism in Africa]. / Envenimations vi--le scorpionisme en Afrique.

Scorpionism is a serious public health problem in North Africa, sub-Saharan countries, and South Africa. The number of species involved is small, but some have large geographic areas of distribution. Fatal outcomes sometimes occur in children and young adults. In most cases the only symptom after a scorpion sting is intense, persistent pain. Appearance of digestive symptoms within a few hours after the sting (5% of cases) is a sign of severe envenomation. These symptoms can be followed by pulmonary edema and cardiovascular manifestations (arrhythmia and hypotension). Early death can occur due to cardiovascular failure (1 to 2% of untreated cases). Progression is rapid and, after a period of 24 hours, the patient is out of danger and will recover quickly with not sequels. Specific (serotherapy) and symptomatic treatment must be initiated as soon as possible after the sting. Envenomation of a child by a dangerous adult scorpion (more than 5 cm long) in summer should be considered as a medical emergency. Declining production of antivenom is a disturbing development.

[Venomous and poisonous animals--I. Overview]. / Envenimations et intoxications par les animaux venimeux ou vénéneux--I. Généralits.

Venomous animals that are able to innoculate or inject venom and poisonous animals that cannot inject venom but are toxic when ingested belong to all zoological groups. They can be encountered worldwide in any ecosystem on land and at sea but they are more common and more dangerous in tropical areas. This first article of a series to appear in the next issues of Medecine Tropicale presents an overview of species involved in envenomations and poisonings. In addition to a brief reviewing geographic risks and circumstances in which bites, stings or ingestion occur, some information is provided about antivenim therapy, the only etiological treatment.

[Recombinant antibodies: a new application in scorpion envenomation?]. / Anticorps recombinants: vers un renouveau de la sérothérapie anti-scorpionique?

Serotherapy is the only specific treatment for envenomation. The antibodies are obtained after the purification of serum from hyperimmunised horses and are used after fragmentation in the form of polyclonal Fab or F(ab)'2. The anti-venom sera are heterogeneous, and their protective effect is often weak. The administration of these preparations induces risks of immediate or delayed side effects: hypersensitivity reactions, anaphylactic shock and serum sickness. This observation led us to develop new forms of antibodies produced by molecular engineering, capable of specifically neutralizing the neurotoxins responsible for the toxicity of the venom of Androctonus australis Hector. The recombinant antibody fragments are more homogeneous than conventional antivenoms and perfectly characterized in terms of specific activity. The method used to obtain them eliminates the risk of transmission by non-conventional transmissible agents. The earliest results confirm the importance of these new molecules (scFv recombinant Fab, diabody, triabody) and their ability to neutralize the action of scorpion neurotoxins. They could open the path to a new generation of more homogeneous antivenoms that are better tolerated and have well-characterized intrinsic properties.

[Dangerous scorpions from Niger]. / Scorpions dangereux du Niger.

Two dangerous scorpion species are responsible for the severe human envenomations in Niger, Leiurus quinquestriatus (H. et E.), the most abundant, and Androctonus aeneas C.L. Koch, less frequent and described in a Sahel country for the first time. Up to now, A. aeneas was known in North Africa only. Its venom is highly toxic for humans, similar to those of the most dangerous species living in Africa, such as L. quinquestriatus and other species belonging to the genus Androctonus, A. australis (L.) and A. mauretanicus (Poc.), for the envenoming treatment of which specific antivenoms are prepared. Taking into account the absence of a specific antivenom for A. aeneas, the paraspecific neutralising effect of these antivenoms should be tested.

Round table of November 20th, 2004: recommendations for improving the management of envenomations.

The round table underlines the necessity to follow the epidemiological and clinical surveys in order to precise the incidence and severity of snakebites and inform the health authorities that could thus arrange to take in charge envenomation accidents. Simple therapeutic protocols adapted to epidemiological and clinical data will be elaborated according to each level of health pyramid. They will be included in the health staff training and integrate traditional practitioners whose role must be clearly defined. An experimental and clinical validation must confirm its appropriateness with countries and victims needs. Some microeconomic surveys are necessary to identify adapted funding and thus improve their accessibility

[Scorpion stings: a public health problem in Morelos (Mexico)]. / Les piqûres de scorpion: un problème de santé publique à Morelos (Mexique).

Scorpion stings represent a major public health problem in Mexico. Their annual incidence is estimated at 150,000 cases; 800-1,000 people die from them each year, 72.5% of whom are children younger than 5 years old. The states most affected are Aguascalientes, Colima, Durango, Guanajuato, Guerrero, Jalisco, Michoacán, Morelos, Oaxaca, Puebla, Sinaloa, and Zacatecas. Morelos is an endemic zone, and scorpion stings are relatively frequent, but the indigenous population underestimates the risks. In this locality, scorpion stings lead to high morbidity, with an average of 10,219 cases each year, and a prevalence varying from 584.86 per 100,000 inhabitants in 1994 to 2043.3 per 100,000 inhabitants in 2003. Because of this upsurge, systematic medical supervision and serum therapy are necessary if scorpion poisoning is suspected in a child. The indigenous community as well as tourists visiting Mexico must be informed about the substantial risk of scorpion poisoning.

Design and evaluation of a diabody to improve protection against a potent scorpion neurotoxin.

Diabodies are recombinant, dimeric, antibody-based molecules composed of two non-covalently associated single-chain antibody fragments that bind to an antigen in a divalent manner. In an attempt to develop more effective therapeutic molecules against scorpion venoms, we designed a diabody derived from monoclonal antibody 9C2, which neutralizes the toxicity of scorpion neurotoxin AahI in mammals. The recombinant diabody produced in the periplasm of Escherichia coli was purified to homogeneity in a single step by protein L-agarose affinity chromatography. It was functional, and possessed a high binding affinity to AahI (8 x 10(-11) M). The bivalence of the diabody was confirmed by size-exclusion chromatography, isoelectrofocussing and electron microscopic observations. Finally, the diabody showed high thermal stability in serum and demonstrated protective activity when injected intraperitoneally in mice experimentally envenomed with toxin AahI. In conclusion, the diabody format gives the 9C2 molecule advantageous properties that are particularly important for potential clinical applications in the treatment of envenomations.

[Action of venoms on blood coagulation: diagnosis of hemorrhagic syndromes]. / Action des venins sur la coagulation sanguine: diagnostic des syndromes hémorragiques.

Venoms from Viperidae, Crotalidae, some Australian Elapidae and few Colubridae are a mixture of enzymes which impact on blood coagulation in several ways. These proteins can be classified as haemorragins which induce disorders of the capillary permeability, disintegrins and related proteins which disturb the clotting time while acting on plate adhesion, and proteases which cleave peptides. Venoms contain molecules directed against several targets of the coagulation system. The same molecule may present different activities. Components of snake venoms are used in diagnostic coagulation tests, fundamental research and as drugs against infectious agents, cancer or haematological disorders. The structural differences between proteins from snake venoms and natural coagulation factors and the target diversity of the venom components explain why it remains illusory to treat bleedings when acting just at symptom level. Conversely, antivenom, whose components are directed against the venom proteins, is the only aetiological therapy effective against snake envenomations.

[Clinical and biological surveillance of envenomed patients]. / Surveillance clinique et biologique des patients envenimés.

Faced with an envenomation, the problem is to take sufficiently rapidly the decision to administer the only effective treatment--immunotherapy--, to know which antivenom to choose and how long to administrate it. If the snake is not identified, symptoms and initial development give information on the type of venom. It is convenient to classify the symptoms according to four clinical types: i) the cobra syndrome with a potentially fatal evolution within two to ten hours and which resembles an Elapid bite, ii) the viper syndrome associating bleeding and inflammation, which can be due either to a viper, pit viper or, in Australia, to Elapids, iii) disturbance of blood circulating functions and iv) disturbance of other live functions. Between the third to the half of snakebite victims present no envenomation. Severe envenomations must be monitored in an intensive care unit, with experience in emergency management and monitoring of patients with major life-threatening conditions. Throughout the world, snakebites induce more than 100,000 deaths every year. Schematically, the emergency may be considered in terms of seconds for blood circulation disorders, minutes for respiratory paralysis, and hours for the coagulopathy.

[Scorpion stings in sub-Saharan Africa]. / Le scorpionisme en Afrique sub-saharienne.

Scorpionism in Sub-Saharan Africa is a poorly known problem but regarded as a public health preoccupation in several countries, especially Niger. The lack of knowledge of this question is due to non-existent information concerning mainly the composition of the scorpion fauna in Sub-Saharan areas, the distribution and density of dangerous species and the frequency and severity of scorpion stings in the Sub-Saharan areas. Until now, only the presence of Leiurus quinquestriatus and its involvement in fatal accidents have been attested to. In many areas, the presence of other classically dangerous species has not been confirmed, nor the dangerous potential of certain species belonging for example to the genera Androctonus. Buthus or Hottentota. The efficacy of prevention, treatment and scorpion control depend necessarily on further study of the fauna and medical investigations. Such studies are entirely feasible.

Round table and synthesis of the meeting.

Our knowledge of the epidemiology of scorpion stings and snakebites remains fragmentary but sufficient, nevertheless, to be able to confirm that envenomations constitute a real public health problem throughout Africa. In order for the health authorities to be able to improve management of this problem, data collection must be enhanced. The objective should be to determine what kinds of intervention are necessary (quantity of antivenom serum and drugs, in particular) and where they should be applied. Specialists must come to a rapid consensus for a simple therapeutic protocol to be used in peripheral health centres where means are often scarce. Training for health personnel is also insufficient. Appropriate courses must be organised for medical doctors and nurses within both their basic and on-going training. These courses must necessarily involve health personnel from rural zones must affected by envenomations. The availability of antivenom serum--the only specific, efficacious drug--must be improved as soon as possible. If quantitative and geographic needs can be determined by epidemiological studies, then distribution must be developed by original means (grouping orders at national level, direct orders) and diversified financial support (purchase on the open market, local authority grants, community participation). The symposium attendees agreed to meet again within two years' time to evaluate progress in the area.