Mordeduras de ofidios en mano pediátrica y sus complicaciones locales / Snake bites in pediatric hand and their local complications / Mordidas de serpentes de mão pediátricas e suas complicações locais

Introducción: el envenenamiento por mordedura de ofidios es reconocido como un problema de salud pública según la Organización Mundial de la Salud. La baja incidencia sumada a la diversidad de presentaciones clínicas, edades, topografías afectadas, así como los diferentes protocolos en la bibliografía existente sobre algunos aspectos del tratamiento, hacen difícil el manejo sistematizado de estos pacientes. El objetivo de este trabajo es realizar una revisión sistemática de la literatura sobre mordedura de serpientes en pacientes pediátricos con afectación en mano y miembro superior, haciendo hincapié en la conducta frente las complicaciones loco-regionales. Por importancia y frecuencia destacamos al síndrome compartimental, las flictenas y las infecciones. Metodología: se realizó una búsqueda bibliográfica en MedLine/PubMed con las palabras clave: "Snake Bite hand Children" y "Snake Bite compartimental syndrome". Se incluyeron los artículos publicados en los últimos 10 años (2012 al 2022). Resultados: la búsqueda de artículos ante las palabras "Snake Bite hand Children" resultó en 20 articulos y la busqueda ante las palabras "Snake Bite compartimental syndrome" derivó en 34. Luego de aplicar los criterios de inclusión y exclusión se obtuvieron 30 artículos para el análisis. Conclusiones: la población pediátrica se encuentra más expuesta a las mordeduras por serpientes y a su vez a presentar lesiones más severas. El tratamiento del síndrome compartimental continúa siendo un tema de debate. El veneno inoculado puede simular un síndrome compartimental que puede revertir sin fasciotomías con el tratamiento adecuado. Igualmente, ante síntomas y signos claros de síndrome compartimental se sugiere realizar fasciotomías frente a las graves secuelas potenciales. Ante la aparición de flictenas, el destechado cuidadoso de la misma es un tratamiento adecuado. La mayoría de los autores coinciden con el tratamiento profiláctico con antibioticoterapia.

Introduction: Ophidian bite poisoning is recognized as a public health problem by the World Health Organization. The low incidence added to the diversity of clinical presentations, ages, affected topographies, as well as the different protocols in the existing literature on some aspects of treatment, make the systematized management of these patients difficult. The aim of this work is to carry out a systematic review of the literature on snakebite in pediatric patients with hand and upper limb involvement, with emphasis on the management of loco-regional complications. In terms of importance and frequency, we highlight compartment syndrome, phlyctenas and infections. Methodology: a literature search was carried out in MedLine/PubMed with the keywords: "Snake Bite hand Children" and "Snake Bite compartment syndrome". Articles published in the last 10 years (2012 to 2022) were included. Results: the search for articles with the words "Snake Bite hand Children" resulted in 20 articles and the search for the words "Snake Bite compartment syndrome" resulted in 34 articles. After applying the inclusion and exclusion criteria, 30 articles were obtained for the analysis. Conclusions: the pediatric population is more exposed to snake bites and in turn to present more severe lesions. The treatment of compartment syndrome continues to be a subject of debate. Inoculated venom can simulate a compartment syndrome that can be reversed without fasciotomies with proper treatment. Likewise, in the presence of clear symptoms and signs of compartment syndrome, fasciotomies are suggested because of the serious sequelae generated. In the event of the appearance of phlyctenas, careful unroofing of the phlyctenas would be an appropriate treatment. Most authors agree with prophylactic treatment with antibiotic therapy.

Introdução: O envenenamento por mordidas ofídias é reconhecido como um problema de saúde pública pela Organização Mundial da Saúde. A baixa incidência, juntamente com a diversidade de apresentações clínicas, idades, topografias afetadas, bem como os diferentes protocolos da literatura existente sobre alguns aspectos do tratamento, tornam difícil o gerenciamento sistemático desses pacientes. O objetivo deste trabalho é realizar uma revisão sistemática da literatura sobre mordida de cobra em pacientes pediátricos com envolvimento de mãos e membros superiores, com ênfase no gerenciamento de complicações loco-regionais. Em termos de importância e freqüência, destacamos a síndrome compartimental, as flectenas e as infecções. Metodologia: foi realizada uma pesquisa bibliográfica no MedLine/PubMed com as palavras-chave: "Snake Bite hand Children" e "Snake Bite compartment syndrome". Os artigos publicados nos últimos 10 anos (2012 a 2022) foram incluídos. Resultados: a busca de artigos usando as palavras "Snake Bite hand Children" resultou em 20 artigos e a busca das palavras "Snake Bite compartment syndrome" resultou em 34 artigos. Após a aplicação dos critérios de inclusão e exclusão, foram obtidos 30 artigos para análise. Conclusões: a população pediátrica está mais exposta às picadas de cobra e, por sua vez, a lesões mais graves. O tratamento da síndrome compartimental continua a ser motivo de debate. O veneno inoculado pode simular uma síndrome de compartimento que pode ser revertida sem fasciotomias com tratamento apropriado. Da mesma forma, se houver sinais e sintomas claros de síndrome compartimental, são sugeridas fasciotomias por causa das severas seqüelas. Se as flectenas aparecerem, o desenrolamento cuidadoso das flectenas seria um tratamento apropriado. A maioria dos autores concorda com o tratamento profilático com a antibioticoterapia.

Venenos de serpentes do gênero Bothrops: impacto da glicosilação na complexidade dos proteomas e função de toxinas / Bothrops snake venoms: impact of glycosylation on the complexity of proteomes and toxins function

A variabilidade estrutural é uma característica das proteínas de venenos de serpentes, e a glicosilação é uma das principais modificações pós-traducionais que contribui para a diversificação de seus proteomas. Recentes estudos de nosso grupo demonstraram que venenos do gênero Bothrops são marcadamente definidos pelo seu conteúdo de glicoproteínas, e que a maioria das estruturas de N-glicanos dos tipos híbrido e complexo identificados em oito venenos deste gênero contêm unidades de ácido siálico. Em paralelo, em glicoproteínas do veneno de B. cotiara foi identificada a presença de uma estrutura de N-acetilglicosamina bissecada. Assim, com o objetivo de investigar a variação do conteúdo de glicoproteínas, assim como os mecanismos envolvidos na geração dos diferentes venenos de Bothrops, neste estudo foram analisados comparativamente os glicoproteomas de nove venenos do gênero Bothrops (B. atrox, B. cotiara, B. erythromelas, B. fonsecai, B. insularis, B. jararaca, B. jararacussu, B. moojeni e B. neuwiedi). As abordagens glicoproteômicas envolveram cromatografia de afinidade e ensaio de pull-down utilizando, respectivamente, as lectinas SNA (aglutinina de Sambucus nigra) e MAL I (lectina de Maackia amurensis), que mostram afinidade por unidades de ácido siálico nas posições, respectivamente, α2,6 e α2,3; e cromatografia de afinidade com a lectina PHA-E (eritroaglutinina de Phaseolus vulgaris), que reconhece N-acetilglicosamina bissecada. Ainda, eletroforese de proteínas, blot de lectina, e identificação de proteínas por espectrometria de massas foram empregadas para caracterizar os glicoproteomas. As lectinas geraram frações dos venenos enriquecidas de diferentes componentes, onde as principais classes de glicoproteínas identificadas foram metaloprotease, serinoprotease, e L-amino ácido oxidase, além de outras enzimas pouco abundantes nos venenos. Os diferentes conteúdos de proteínas reconhecidas por essas lectinas, com especificidades distintas, ressaltaram novos aspectos da variabilidade dos subproteomas de glicoproteínas desses venenos, dependendo da espécie. Ainda, considerando que metaloproteases e serinoproteases são componentes abundantes nesses venenos e fundamentais no quadro de envenenamento botrópico, e que estas enzimas contêm diversos sítios de glicosilação, o papel das unidades de ácido siálico na atividade proteolítica das mesmas foi avaliado. Assim, a remoção enzimática de ácido siálico (i) alterou o padrão de gelatinólise em zimografia da maioria dos venenos, (ii) diminuiu a atividade proteolítica de alguns venenos sobre o fibrinogênio e a atividade coagulante do plasma humano de todos os venenos, e (iii) alterou o perfil de hidrólise de proteínas plasmáticas pelo veneno de B. jararaca, indicando que este carboidrato pode desempenhar um papel na interação das proteases com seus substratos proteicos. Em contraste, o perfil da atividade amidolítica dos venenos não se alterou após a remoção de ácido siálico e incubação com o substrato Bz-Arg-pNA, indicando que ácido siálico não é essencial em N-glicanos de serinoproteases atuando sobre substratos não proteicos. Em conjunto, esses resultados expandem o conhecimento sobre a variabilidade de proteomas de venenos do gênero Bothrops e apontam a importância das cadeias de carboidratos contendo ácido siálico nas atividades enzimáticas das proteases desses venenos

Structural variability is a feature of snake venom proteins, and glycosylation is one of the main post-translational modifications that contributes to the diversification of venom proteomes. Recent studies by our group have shown that Bothrops venoms are markedly defined by their glycoprotein content, and that most hybrid and complex N-glycan structures identified in eight venoms of this genus contain sialic acid units. In parallel, the presence of a bisected N-acetylglucosamine structure was identified in B. cotiara venom glycoproteins. Thus, with the aim of investigating the variation in the content of glycoproteins, as well as the mechanisms involved in the generation of different Bothrops venoms, in this study the glycoproteomes of nine Bothrops venoms (B. atrox, B. cotiara, B. erythromelas, B. fonsecai, B. insularis, B. jararaca, B. jararacussu, B. moojeni e B. neuwiedi) were comparatively analyzed. The glycoproteomic approaches involved affinity chromatography and pulldown using, respectively, the lectins SNA (Sambucus nigra agglutinin) and MAL I (Maackia amurensis lectin), which show affinity for sialic acid units at positions, respectively, α2,6 and α2,3, and affinity chromatography with PHA-E (Phaseolus vulgaris erythroagglutinin), which recognizes bisected N-acetylglucosamine. In addition, protein electrophoresis, lectin blot, and protein identification by mass spectrometry were employed for glycoproteome characterization. The lectins generated venom fractions enriched with different components, where the main classes of glycoproteins identified were metalloprotease, serine protease, and L-amino acid oxidase, in addition to other low abundant enzymes. The different contents of proteins recognized by these lectins of distinct specificities highlighted new aspects of the variability of the glycoprotein subproteomes of these venoms, depending on the species. Furthermore, considering that metalloproteases and serine proteases are abundant components of these venoms and essential in Bothrops envenomation, and that these enzymes contain several glycosylation sites, the role of sialic acid units in their proteolytic activities was evaluated. Thus, enzymatic removal of sialic acid (i) altered the pattern of gelatinolysis in zymography of most venoms, (ii) decreased the proteolytic activity of some venoms on fibrinogen and the clotting activity of human plasma of all venoms, and (iii) altered the hydrolysis profile of plasma proteins by B. jararaca venom, indicating that this carbohydrate may play a role in the interaction of proteases with their protein substrates. In contrast, the profile of amidolytic activity of the venoms did not change after removal of sialic acid and incubation with the substrate Bz-Arg-pNA, indicating that sialic acid is not essential in N-glycans of serine proteases acting on small substrates. Together, these results expand the knowledge about the variability of proteomes of Bothrops venoms and point to the importance of carbohydrate chains containing sialic acid in the enzymatic activities of venom proteases

Effect of Bitis gabonica and Dendroaspis angusticeps snake venoms on apoptosis-related genes in human thymic epithelial cells

Certain environmental toxins permanently damage the thymic epithelium, accelerate immune senescence and trigger secondary immune pathologies. However, the exact underlying cellular mechanisms and pathways of permanent immune intoxication remain unknown. The aim of the present study was to demonstrate gene expressional changes of apoptosis-related cellular pathways in human thymic epithelial cells following exposure to snake venom from Bitis gabonica and Dendroaspis angusticeps. Methods: Snake venoms were characterized by analytical methods including reversed phase high-performance liquid chromatography and sodium dodecyl sulphate-polyacrylamide gel electrophoresis, then applied on human thymic epithelial cells (1889c) for 24 h at 10 μg/mL (as used in previous TaqMan Array study). Gene expressional changes restricted to apoptosis were assayed by TaqMan Array (Human Apoptosis Plate). Results: The most prominent gene expressional changes were shown by CASP5 (≈ 2.5 million-fold, confirmed by dedicated quantitative polymerase chain reaction) and CARD9 (0.016-fold) for B. gabonica, and BIRC7 (6.46-fold) and CASP1 (0.30-fold) for D. angusticeps. Conclusion: The observed apoptotic environment suggests that pyroptosis may be the dominant pathway through which B. gabonica and D. angusticeps snake venoms trigger thymic epithelial apoptosis following envenomation.(AU)

Enzymes modulation by dried grape pomace from the manufacture of wines and juices

The processing of grapes for the manufacture of juices and wines, generates large quantities of by-products rich in metabolites with antioxidant, antimicrobial, anti-inflammatory and cicatrizing activities. The high homology between human enzymes and snake venoms makes the latter valuable laboratory tools for the study of pathophysiological processes. Proteases and phospholipases A2 act in processes related to hemostasis and inflammatory response. Thus, in this work, dried pomace obtained from grape (Isabel, Niagara, Bordô, BRS Violeta and Blend cultivars) processing were evaluated on phospholipase, proteolytic, hemolytic and thrombolytic activities induced by snakes venoms and the content of phenolic compounds and minerals was evaluated. The dried pomace exerted inhibitory and potentiating actions in all analyzed activities. The enzymatic modulators present in the evaluated dried pomace have potential for therapeutic use, although their broad characterization is still necessary, in order to define adequate amounts and formulations to obtain efficacy and safety in their use.

Snakebite in Korea: A Guideline to Primary Surgical Management

PURPOSE: Snakebite is an emergency which causes local symptoms such as pain and edema around the bite. Systemic symptoms may also develop, such as dizziness or renal failure, and may even cause death. The purpose of this research was to assess the validity and safety of snakebite protocol for surgery when treating snakebite patients. MATERIALS AND METHODS: Retrospective research was performed on patients who were admitted after being treated at the emergency center from January 2008 to December 2012. When necessary, debridement was also performed, and 46 of 111 patients (41.4%) underwent debridement. Those who had received debridement without antivenom administration due to a positive skin reaction test were classified as group A, and group B received antivenom and delayed debridement. We reviewed the emergency and admission charts of the patients in each group and recorded and compared their age, sex, bite site, severity of local and general symptoms, time to receive antivenin, and complications. RESULTS: Of the ten patients (21.7%) in group A, two (66.6%) developed cellulites, and one of them experienced skin necrosis, resulting in a skin graft. In group B, there were 36 patients (78.2%), 19 (52.7%) of whom developed cellulitis. Skin necrosis occurred in two patients, and one of these patients received a skin graft. Compartment syndrome was found in one patient, and fasciotomy and a skin graft were performed. CONCLUSION: The treatment protocol implemented to treat snakebite patients admitted to the emergency center during this research was safely and properly followed during surgical treatment.

Clinical spectrum of snake bite and therapeutic challenges

To determine the clinical spectrum, therapeutic challenges and outcome of patients of snakebite presenting to Azad Kashmir Combined Military Hospital [AK CMH] Rawalakot. It is an observational descriptive study. The study was carried out at AK CMH Rawalakot from January 2006 to August 2006. Adults above 12 years of age with definitive history of snakebite were included in this study. Detailed history and examination was carried out. Vital signs and peak expiratory flow rate were monitored regularly. Blood complete picture with platelets count, bleeding time, clotting time, and urine for red blood cells were done in all patients. All patients with local or systemic signs of envenomation were administered antisnake venom. Fifty adult cases of snakebite were studied. Typically, victims were male between 15 and 30 years of age. Thirty-five [70%] of them showed evidence of envenomation and all of them were administered polyvalent antisnake venom and three of them developed hypersensitivity to antisnake venom Most of the snakes found in this area are venomous and general population has very little knowledge of appropriate first aid measures. Delay in treatment increases mortality and morbidity therefore adequate supply of antisnake venom should be maintained in all remote health facilities

Mordedura por Philodryas chamissonis: presentación de un caso y revisión de la literature / Snake bite by Philodryas chamissonis: a case presentation and literature review

El ofidismo es el accidente provocado por la mordedura de una serpiente. En Chile se encuentran 2 tipos de culebras capaces de provocar emponzoñamiento: Philodryas chamissonis y Tachymenis peruviana. Se presenta el caso de una mordedura por P. chamissonis,ocurrida durante una actividad veraniega en la comuna de San Antonio, V Región. La mordedura comprometió la zona del dorso de la mano entre los dedos pulgar e índice de la extremidad superior izquierda, inicialmente indolora. Evolucionó las primeras 24 horas con edema equimótico que abarcó hasta la zona del hombro y pectoral, con dolor intenso, cefalea, náuseas, fiebre y posterior aparición de bulas serohemorrágicas en el pliegue del codo. La paciente se trató con antihistamínicos, corticoides sistémicos, analgesia y antimicrobianos por 7 días. Se discuten los accidentes por mordedura de culebras publicados en la literatura nacional, así como su tratamiento y las medidas de prevención.

There are two species of snakes associated with snake bite poisoning in Chile: Philodryas chamissonis and Tachymenis peruviana. A case associated with a P. chamissonis bite occuring during a summer activity in San Antonio, V Region, is presented. The bite compromised the dorsum of the right hand between the thumb and the index finger and was initially painless. During the following 24 hours equimotic edema developed up to the shoulder and pectoral region, with intense pain, headache, nausea, fever and appearance of a serohematic bulla on the elbow fold. The patient was treated with antihistamins, systemic steroids, analgesia and antibiotics for 7 days. Other cases of snake bites published in Chile are reviewed and treatment and prevention strategies are proposed.

Pattern of coagulopathy in viperidae snake bite

The study was carried out in the Department of Physiology, Isra University, Hyderabad. Seventy three cases of viperidae snake bite were studied to observe the pattern of coagulopathy. All had prolonged clotting time at the time of admission. Prothrombin time was increased in 56 cases, activated partial thromboplastin time was increased in 63 cases, bleeding time was normal in all cases. Platelet count was decreased in 28 cases and fibrinogen levels were decreased in 36 cases. Disseminated intravascular coagulation was found to be the predominant pattern of coagulopathy in viperidae snake bite cases

Acute renal failure in viperidae snake bite victims

This study included 10 cases of viperidae snake bite that developed acute renal failure out of 73 cases admitted to various wards of Liaquat Medical College hospital during the last two years. All these patients reported to the hospital 3-5 days after the bite. All had signs of severe envenomation with incoagulable blood and prolonged PT and APTT. All has bleeding manifestations. Blood urea and serum creatinine were increased in all patients and four were anuric. Leucocytosis and thrombocytopenia were found in 7 cases, serum bilirubin was increased in 4 cases, 4 patients required dialysis and 4 out of 10 cases expired. Bad prognostic features included severe envenomation, leucocytosis, thrombocytopenia, and necessity for dialysis. We conclude that acute renal failure is a serious complication of viperidae snake bite with high mortality rate and it necessitates early and effective treatment

Effect of snake venom on nucleic acids and total proteins in various normal and cancerous animal tissues

Venoms have occasional medical uses. This study was carried out to determine effect of cobra snake venom on nucleic acid and total proteins in various normal and cancerous animal tissues. In this in vitro study the venom with varying concentrations was incubated with homogenates of liver, heart and kidney of normal tissues. Reduction in RNA / DNA levels was observed. Our results indicate that nucleic acids are more sensitive. However the effect of snake venom on normal skin tissue was insignificant when compared with cancerous tissue. The dose response curve shows that the lowest concentration of venom at 25 micro g / ml [a survival dose] produced maximum inhibition of both nucleic acids. The opposite and linear response was observed in protein contents. It can be assumed from the present study that the venom might have therapeutic effect at a dose of 25 micro g /ml in cancerous tissues

Surgical implications of snakebites.

OBJECTIVE: Snakebites are a common problem in the pediatric age group. Local complications such as necrosis and compartment syndrome threaten limb survival even after control of systemic manifestations. Few recommendations exist about the nature and timing of surgical treatment. METHODS: A retrospective review of all children with snakebites presenting to the hospital was undertaken over a 6-year period. Records were reviewed with special emphasis on the type of surgical lesions seen and the treatment offered and their results. RESULTS: 44 of the 58 children required some form of local therapy. In the majority conservative treatment was successful. 28% of the patients needed debridement for local necrosis, and only 5 needed a skin graft, with good functional results over a period of 1 to 45 days. One child underwent an above knee amputation. Patients who required surgical intervention received significantly more vials of antivenin. CONCLUSION: Local complications of snakebite are frequent, but can be managed conservatively. Delayed excision of the resultant local necrosis is associated with good outcomes. The need for fasciotomy is rare.

Persistent coagulopathy in snake bite.

Bleeding diathesis is a cardinal feature of viperine bite, which has been thought to last not more than 24 hours. There is scarcity of literature about prolonged bleeding disorder in snake envenomation. Various explanations suggested in the literature include-temporary decrease in antivenin levels, rapid elimination of antivenin from circulation or continuous release of unneutralised venom from the envenomated site. Two children with prolonged coagulopathy lasting for more than a week, correction of which required more than 300 ml of antisnake venom are reported here.

Actividades hemorrágicas y coagulante del veneno de Bothrops alternatus de Argentina / Haemorrhagic and clotting activities of Argentina B. alternatus venon

Se trabajó con veneno crudo de Bothrops alternatus para determinar sus actividades hemorrágica y coagulante. Para hallar la actividad hemorrágica se inocularon ratones, en forma intradérmica, con diluciones seriadas de veneno, en un volumen de 0,1 ml de solución salina amortiguada con fosfato, pH 7,2. Luego de 2 horas, se sacrificaron con éter y se midió el área hemorrágica. La Dosis Hemorrágica Mínima (DHM) es la cantidad de veneno que produce un área hemorrágica mínima de 10 mm de diámetro, para el veneno de B. alternatus fue de 3,6 µg. El estudio de la Dosis Coagulante Mínima (DCM) se realizó confrontando diluciones seriadas de veneno con plasma humano. La DMC, capaz de coagular el plasma humano en 60 seg, fue de 14,5 µg/ml. Al igual que otras especies del género Bothrops de Latinoamérica, el veneno de B. alternatus de Argentina posee marcada actividad hemorrágica y coagulante

Dos nuevos casos de ofidismo en Chile / 2 new cases of ophidism in Chile

Se presentan dos casos de ofidismo atendidos en el Hospital Dr. Sótero del Río, Servico de Salud Metropolitano Sur Oriente durante diciembre de 1993. Dos hombres jóvenes fueron mordidos por una culebra chilena (Dromicus chamissonis) presentado con dolor agudo, edema y hemorragia local. En uno de los casos se diagnosticó además compromiso sistémico. Se presenta la evolución clínica y de laboratorio, se discute la frecuencia y características del ofidismo

Envenenamiento ofídico en Venezuela / Snake poisoning in Venezuela

El envenenamiento ofídico es considerado un problema de salud pública en toda América y gran parte del mundo. Venezuela como país tropical no escapa de esta realidad debido a que las serpientes (ofideos) ocupan un lugar preponderante en su fauna. En esta revisión se persiguen como objetivos: 1) Reunir los criterios diagnósticos precisos basados en el conocimiento de las características morfológicas de la especie responsable, 2) Evaluar las características clínicas de cada caso con miras a reconocer la gravedad y establecer precozmente un tratamiento efectivo

Valores hematológicos y de enzimas séricas en caballos inoculados con venenos de serpientes para la produción de antivenenos en Costa Rica / Hematologic values and of serum enzymes in inoculated horses with snake venoms for the production of antivenins in Costa Rica

Se estudiaron algunos componentes sanguíneos en un grupo de seis caballos inmunizados por primera vez con venenos de serpientes para la producción de suero antiofídico polivalente en Costa Rica. No hubo cambios significativos en los valores de hematocrito y hemoglobina, aunque las proteínas totales sufrieron un pequeno pero significativo aumento en la segunda mitad del esquema de inmunización, probablemente relacionado con un aumento en la producción de globulinas. No hubo cambios significativos en los niveles de CK, mientras que las enzimas TGO y TGP aumentaron levemente, sin sobrepasar el límite superior normal. Estos resultados sugieren la ausencia de lesiones tisulares importantes en músculo esquelético, músculo cardíaco e hígado. Los caballos presentan únicamente alteraciones locales en el sitio de inoculación del veneno, caracterizadas por edema, abscesos y fístulas. No se observó ningún tipo de alteración sistémica. Se observó una gran variabilidad individual en el desarrollo de la respuesta de anticuerpos anti-fosfolipasa A2