Probable Transmission of SARS-CoV-2 from African Lion to Zoo Employees, Indiana, USA, 2021.

We describe animal-to-human transmission of SARS-CoV-2 in a zoo setting in Indiana, USA. A vaccinated African lion with physical limitations requiring hand feeding tested positive for SARS-CoV-2 after onset of respiratory signs. Zoo employees were screened, monitored prospectively for onset of symptoms, then rescreened as indicated; results were confirmed by using reverse transcription PCR and whole-genome virus sequencing when possible. Traceback investigation narrowed the source of infection to 1 of 6 persons. Three exposed employees subsequently had onset of symptoms, 2 with viral genomes identical to the lion's. Forward contact tracing investigation confirmed probable lion-to-human transmission. Close contact with large cats is a risk factor for bidirectional zoonotic SARS-CoV-2 transmission that should be considered when occupational health and biosecurity practices at zoos are designed and implemented. SARS-CoV-2 rapid testing and detection methods for big cats and other susceptible animals should be developed and validated to enable timely implementation of One Health investigations.

Antivenom for critically ill children with neurotoxicity from scorpion stings.

BACKGROUND: Clinically significant scorpion envenomation by Centruroides sculpturatus produces a dramatic neuromotor syndrome and respiratory insufficiency that often necessitate intensive supportive care. We hypothesized that a scorpion-specific F(ab')(2) antivenom would promptly resolve clinical symptoms in children with this syndrome. METHODS: In a randomized, double-blind study, the efficacy of scorpion-specific F(ab')(2) antivenom, as compared with placebo, was assessed in 15 children 6 months to 18 years of age who were admitted to a pediatric intensive care unit with clinically significant signs of scorpion envenomation. The primary end point was the resolution of the clinical syndrome within 4 hours after administration of the study drug. Secondary end points included the total dose of concomitant midazolam for sedation and quantitative plasma venom levels, before and after treatment. RESULTS: The clinical syndrome resolved more rapidly among recipients of the antivenom than among recipients of placebo, with a resolution of symptoms in all eight antivenom recipients versus one of seven placebo recipients within 4 hours after treatment (P=0.001). More midazolam was administered in the placebo recipients than in the antivenom recipients (mean cumulative dose, 4.61 vs. 0.07 mg per kilogram of body weight; P=0.01). Plasma venom concentrations were undetectable in all eight antivenom recipients but in only one placebo recipient 1 hour after treatment (P=0.001). CONCLUSIONS: Among critically ill children with neurotoxic effects of scorpion envenomation, intravenous administration of scorpion-specific F(ab')(2) antivenom resolved the clinical syndrome within 4 hours, reduced the need for concomitant sedation with midazolam, and reduced the levels of circulating unbound venom. (ClinicalTrials.gov number, NCT00685230.)

Toxic Exposure Surveillance System (TESS)-based characterization of U.S. non-native venomous snake exposures, 1995-2004.

BACKGROUND: Non-native (exotic) snake exposures in the United States have not been systematically characterized. METHODS: The Toxic Exposure Surveillance System (TESS) database of the American Association of Poison Control Centers was analyzed to quantify the number and types, demographic associations, clinical presentations, managements and outcomes, and the health resource utilization of non-native snake exposures. RESULTS: From 1995 through 2004, there were 399 non-native exposures in the TESS database. Of these, 350 snakes (87%) were identified by genus and species, comprising at least 77 different varieties. Roughly equal percentages of snakes originated in Asia, Africa and Latin America, with a smaller number from the Middle-East, Australia, and Europe. Nearly half were viperids and a little more than a third were elapids. The vast majority of exposed individuals were adults. However, almost 15% were aged 17 years or less, and almost 7% were children aged 5 years or younger. Eighty-four percent were males. The vast majority of exposures occurred at the victim's own residence. Over 50% were evaluated at a healthcare facility, with 28.7% admitted to an ICU. Overall, 26% of patients were coded as receiving antivenom treatment. Coded outcomes were similar between viperid and elapid envenomations. There were three deaths, two involving viperid snakes and one elapid. Enhancements to the TESS database are required for better precision in and more complete characterization of non-native snake envenomations.

Thrombelastographic characterization of the thrombin-like activity of Crotalus simus and Bothrops asper venoms.

: Annually, thousands suffer venomous snake-bite from Crotalus simus and Bothrops asper vipers in central and South America. The goals of the present study were to generally characterize the thrombin-like effects of venom from these snakes in human plasma with viscoelastic methods. Human plasma was exposed to the venom of three different C. simus subspecies and venoms obtained from B. asper vipers located in three different locations in Mexico. To characterize the factor X-activating and thrombin-like activity of these venoms, plasma (normal or factor XIII deficient) was pretreated with a variety of additives (e.g., heparin) in the absence or presence of calcium prior to exposure to 2.0 µg/ml of each viper's venom. These profiles were compared with plasma without venom that had contact activation of coagulation. Coagulation kinetics were determined with thrombelastography. All venoms had thrombin-like activity, with C. s. simus creating a slow growing, weak clot that was likely mediated by metalloproteinases. In contrast, B. asper venoms had rapid onset of coagulation and a high velocity of thrombus growth. Further, B. asper venom activity was calcium-independent, activated prothrombin, activated factor XIII, and independently polymerized fibrinogen. The viscoelastic methods used were able to differentiate subspecies of C. simus and specimens of B. asper, and provide insight into the mechanisms by which the venoms acted on plasma. These methods may be useful in the profiling of similar venoms and perhaps can assist in the assessment of interventions designed to treat envenomation (e.g., antivenom).

Resistance of antivenom proteins to foaming-induced denaturation.

Reconstitution of lyophilized antivenom is usually accomplished by gentle swirling for sometimes as much as 45min. Gentle resuspension is employed in order to avoid foaming the antivenom, which could have a variety of consequences including unfolding and denaturation of the protein, thus rendering it inactive. However, foaming of antivenom might cause only a small portion of the total protein to unfold or the protein may refold as foaming subsides. In this report, the effects of intentional severe foaming of three antivenom preparations are tested. Samples of gently resuspended antivenoms were subject to severe foaming by mechanical means, then tested for precipitation by examining the amounts of protein remaining in solution, for structural changes by circular dichroism spectroscopy and for activity changes by ELISA. In all cases, either no or minimal changes in antivenom properties were observed. These results indicate that severe intentional foaming does not substantially affect the properties of the antivenoms. It may be possible to employ more vigorous resuspension methods without affecting the efficacy of the antivenom. This could lead to a significant decrease in the time between envenomation and administration of antivenom.

Iron and carbon monoxide attenuate degradation of plasmatic coagulation by Crotalus atrox venom.

Hypofibrinogenemia is an important clinical consequence following envenomation by Crotalus species, usually attenuated or prevented by administration of antivenom. It has been determined that iron and carbon monoxide (CO) enhance fibrinogen as a thrombin substrate, likely secondary to conformational changes in molecular structure. We tested the hypothesis that pretreatment of plasma with iron and CO could attenuate the effects of exposure to Crotalus atrox venom. Human plasma was exposed to 0 to 10 µmol/l ferric chloride (iron source) and 0 to 100 µmol/l CO-releasing molecule-2 (CO source) followed by exposure to 0 to 0.5 µg/ml venom for 5 to 20 min. Changes in coagulation kinetics were determined with thrombelastography. Iron and CO significantly attenuated venom-mediated degradation of plasmatic coagulation in terms of onset time, velocity of clot growth and final clot strength. Further preclinical investigation of iron and CO administration as a 'bridge-to-antivenom' to preserve plasmatic coagulation is justified.

Iron and carbon monoxide attenuate Crotalus atrox venom-enhanced tissue-type plasminogen activator-initiated fibrinolysis.

In addition to degrading fibrinogen as a source of consumptive coagulopathy, rattlesnake venom has also been demonstrated to enhance fibrinolysis and degrade alpha-2-antiplasmin. The goals of this investigation was to characterize the kinetic fibrinolytic profile of Crotalus atrox venom in the absence and presence of tissue-type plasminogen activator (tPA), and to also ascertain if iron and carbon monoxide (CO, a positive modulator of alpha-2-antiplasmin) could attenuate venom-enhanced fibrinolysis. Utilizing thrombelastographic methods, the coagulation and fibrinolytic kinetic profiles of human plasma exposed to C. atrox venom (0-2 µg/ml) were determined in the absence or presence of tPA (0-100 IU/ml). Then, either separately or in combination, plasma was exposed to iron (ferric chloride, 10 µmol/l) or CO (carbon monoxide-releasing molecule-2, 100 µmol/l) prior to incubation with venom; the plasma sample was subsequently subjected to thrombelastographic analysis with addition of tPA. Venom exposure in the absence of tPA did not result in detectable fibrinolysis. In the presence of tPA, venom markedly enhanced fibrinolysis. Iron and CO, markedly attenuated venom enhancement of fibrinolysis. C. atrox venom enhances tPA-mediated fibrinolysis, and interventions that enhance/protect alpha-2-antiplasmin activity significantly attenuate venom-enhanced fibrinolysis. Future preclinical investigation is required to determine if iron and CO can attenuate venom-mediated degradation of alpha-2-antiplasmin-dependent fibrinolytic resistance.

Biodistribution and Lymphatic Tracking of the Main Neurotoxin of Micrurus fulvius Venom by Molecular Imaging.

The venom of the Eastern coral snake Micrurus fulvius can cause respiratory paralysis in the bitten patient, which is attributable to ß-neurotoxins (ß-NTx). The aim of this work was to study the biodistribution and lymphatic tracking by molecular imaging of the main ß-NTx of M. fulvius venom. ß-NTx was bioconjugated with the chelator diethylenetriaminepenta-acetic acid (DTPA) and radiolabeled with the radionuclide Gallium-67. Radiolabeling efficiency was 60%-78%; radiochemical purity ≥92%; and stability at 48 h ≥ 85%. The median lethal dose (LD50) and PLA2 activity of bioconjugated ß-NTx decreased 3 and 2.5 times, respectively, in comparison with native ß-NTx. The immune recognition by polyclonal antibodies decreased 10 times. Biodistribution of ß-NTx-DTPA-(67)Ga in rats showed increased uptake in popliteal, lumbar nodes and kidneys that was not observed with (67)Ga-free. Accumulation in organs at 24 h was less than 1%, except for kidneys, where the average was 3.7%. The inoculation site works as a depot, since 10% of the initial dose of ß-NTx-DTPA-(67)Ga remains there for up to 48 h. This work clearly demonstrates the lymphatic system participation in the biodistribution of ß-NTx-DTPA-(67)Ga. Our approach could be applied to analyze the role of the lymphatic system in snakebite for a better understanding of envenoming.

Post-exposure treatment of Ebola virus using passive immunotherapy: proposal for a new strategy.

BACKGROUND: Better treatments are urgently needed for the management of Ebola virus epidemics in Equatorial Africa. METHODS: We conducted a systematic review of the literature on the use of passive immunotherapy for the treatment or prevention of Ebola virus disease. We placed findings from this review into the context of passive immunotherapy currently used for venom-induced disease, and recent improvements in manufacturing of polyvalent antivenom products. RESULTS: Passive immunotherapy appears to be one of the most promising specific treatments for Ebola. However, its potential has been incompletely evaluated, considering the overall experience and recent improvement of immunotherapy. Development and use of heterologous serum derivatives could protect people exposed to Ebola viruses with reasonable cost and logistics. CONCLUSION: Hyperimmune equine IgG fragments and purified polyclonal whole IgG deserve further consideration as treatment for exposure to the Ebola virus.

Comparison of F(ab')2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial.

BACKGROUND: Crotalidae Polyvalent Immune Fab (Ovine) has been the only antivenom commercially available in the US since 2007 for treatment of Crotalinae envenomation. Late coagulopathy can occur or recur after clearance of Fab antivenom, often after hospital discharge, lasting in some cases more than 2 weeks. There have been serious, even fatal, bleeding complications associated with recurrence phenomena. Frequent follow-up is required, and additional intervention or hospitalization is often necessary. F(ab')2 immunoglobulin derivatives have longer plasma half life than do Fab. We hypothesized that F(ab')2 antivenom would be superior to Fab in the prevention of late coagulopathy following treatment of patients with Crotalinae envenomation. METHODS: We conducted a prospective, double-blind, randomized clinical trial, comparing late coagulopathy in snakebitten patients treated with F(ab')2 with maintenance doses [F(ab')2/F(ab')2], or F(ab')2 with placebo maintenance doses [F(ab')2/placebo], versus Fab with maintenance doses [Fab/Fab]. The primary efficacy endpoint was coagulopathy (platelet count < 150 K/mm(3), fibrinogen level < 150 mg/dL) between end of maintenance dosing and day 8. RESULTS: 121 patients were randomized at 18 clinical sites and received at least one dose of study drug. 114 completed the study. Of these, 11/37 (29.7%) in the Fab/Fab cohort experienced late coagulopathy versus 4/39 (10.3%, p < 0.05) in the F(ab')2/F(ab')2 cohort and 2/38 (5.3%, p < 0.05) in the F(ab')2/placebo cohort. The lowest heterologous protein exposure was with F(ab')2/placebo. No serious adverse events were related to study drug. In each study arm, one patient experienced an acute serum reaction and one experienced serum sickness. CONCLUSIONS: In this study, management of coagulopathic Crotalinae envenomation with longer-half-life F(ab')2 antivenom, with or without maintenance dosing, reduced the risk of subacute coagulopathy and bleeding following treatment of envenomation.

Non-native (exotic) snake envenomations in the U.S., 2005-2011.

Non-native (exotic) snakes are a problematic source of envenomation worldwide. This manuscript describes the current demographics, outcomes and challenges of non-native snakebites in the United States (U.S.). We performed a retrospective case series of the National Poison Data System (NPDS) database between 2005 and 2011. There were 258 human exposures involving at least 61 unique exotic venomous species (average = 37 per year; range = 33-40). Males comprised 79% and females 21%. The average age was 33 years with 16% less than 20 years old. 70% of bites occurred in a private residence and 86% were treated at a healthcare facility. 35% of cases received antivenom and 10% were given antibiotics. This study is compared to our previous study (1994-2004) in which there was a substantial coding error rate. Software modifications significantly reduced coding errors. Identification and acquisition of appropriate antivenoms pose a number of logistical difficulties in the management of these envenomations. In the U.S., poison centers have valuable systems and clinical roles in the provision of expert consultation and in the management of these cases.

Is scorpion antivenom cost-effective as marketed in the United States?

PURPOSE: The purpose of this study was to analyze the cost-effectiveness of scorpion antivenom compared to no antivenom, in the United States, using a decision analysis framework. METHODS: A decision analytic model was created to assess patient course with and without antivenom. Costs were determined from the perspective of a health care payer. Cost data used in the model were extracted from Arizona Medicaid. The probability of clinical events occurring with and without antivenom was obtained from the published literature, medical claims obtained from Arizona Medicaid, and results of recent clinical trials. Patients that became so ill that mechanical ventilator support was necessary were considered treatment failures. A Monte Carlo simulation was run 1000 times and sampled simultaneously across all variable distributions in the model. RESULTS: The mean success rate was 99.87% (95% CI 99.64%-99.98%) with scorpion antivenom and 94.31% (95% CI 91.10%-96.61%) without scorpion antivenom. The mean cost using scorpion antivenom was $10,708 (95% CI $10,556 - $11,010) and the mean cost without scorpion antivenom was $3178 (95% CI $1627 - $5184). Since the 95% CIs do not overlap for either the success or cost, use of the scorpion antivenom was significantly more effective and significantly more expensive than no antivenom. Cost-effectiveness analysis found that the scorpion antivenom was not cost-effective at its current price as marketed in the United States. CONCLUSION: The scorpion antivenom marketed in the United States is extremely effective, but too costly to justify its use in most clinical situations. Formulary committees should restrict the use of this antivenom to only the most severe scorpion envenomations.

Subacute coagulopathy in a randomized, comparative trial of Fab and F(ab')2 antivenoms.

BACKGROUND: Envenomation by pit vipers is associated with coagulation disorders including hypofibrinogenemia and thrombocytopenia. These abnormalities correct following antivenom treatment during the acute phase of the disease. Delayed or recurrent coagulation abnormalities have been reported following use of Fab antivenom, resulting in risk of hemorrhage or death. METHODS: We hypothesized that the longer plasma persistence of F(ab')2 antivenom, relative to Fab, in patients at risk of coagulopathy would result in decreased venonemia and coagulopathy one week after treatment. We conducted a Phase 2, randomized comparative clinical trial of rattlesnake bitten adults presenting for care in Tucson, Arizona, USA. Patients were randomly assigned to receive either Fab or F(ab')2 antivenom using a predefined treatment schedule. Endpoints included platelet counts, fibrinogen levels, and venom and antivenom ELISAs. Measurements were conducted at baseline and at various times over the following two weeks. RESULTS: Twelve patients were studied, with 6 randomly assigned to each treatment group. Early response of platelet counts, fibrinogen, and venom levels to acute treatment was similar in the two groups. One week following treatment, platelet counts and fibrinogen levels were lower in the Fab group than in the F(ab')2 group, following a characteristic pattern that reached its lowest point approximately one week after initial treatment. Venom levels dropped below detection limits in all patients following initial treatment but subsequently rebounded into the measurable range in 4 of 6 Fab cases. F(ab')2 antivenom levels demonstrated a longer plasma persistence than Fab levels, with a less rapid drop during the two days following treatment. Two patients in the Fab group had significant adverse events involving coagulation abnormalities, for which additional antivenom was administered following the initial treatment period. CONCLUSIONS: Following the acute phase of presentation and treatment for pit viper envenomation, there appears to be a roughly 2-week subacute phase of the disease during which ongoing presence of venom may result in serious delayed or recurrent coagulation defects. Late hypofibrinogenemia and thrombocytopenia are associated with recurrent venonemia and drop in antivenom levels. This pattern was apparent in patients treated with Fab antivenom but was not seen among F(ab')2 recipients in this Phase 2 study, consistent with pharmacokinetic differences between the two products. Improved understanding of Fab pharmacokinetics is important for the management of coagulopathy-prone pit viper envenomation. Use of F(ab')2 antivenom may prevent recurrent venom effects, but larger studies are necessary for statistical confirmation of this observation.

Post-exposure treatment of Ebola virus using passive immunotherapy: proposal for a new strategy

Background: Better treatments are urgently needed for the management of Ebola virus epidemics in Equatorial Africa. Methods: We conducted a systematic review of the literature on the use of passive immunotherapy for the treatment or prevention of Ebola virus disease. We placed findings from this review into the context of passive immunotherapy currently used for venom-induced disease, and recent improvements in manufacturing of polyvalent antivenom products. Results: Passive immunotherapy appears to be one of the most promising specific treatments for Ebola. However, its potential has been incompletely evaluated, considering the overall experience and recent improvement of immunotherapy. Development and use of heterologous serum derivatives could protect people exposed to Ebola viruses with reasonable cost and logistics. Conclusion: Hyperimmune equine IgG fragments and purified polyclonal whole IgG deserve further consideration as treatment for exposure to the Ebola virus.