RESUMEN
Envenomation of dogs by the common European adder (Vipera berus) is associated with high morbidity. The cytotoxic venom of Vipera berus contains enzymes with the potential to cause acute kidney injury, among other insults, however robust biomarkers for such effects are lacking. A prospective observational follow-up study of naturally envenomated dogs and controls was conducted to fill knowledge gaps regarding canine Vipera berus envenomation, attempt to identify novel biomarkers of envenomation and related kidney injury, and elucidate potential long-term effects. Blood and urine samples were analyzed with a global metabolomics approach using liquid chromatography-mass spectrometry, uncovering numerous features significantly different between cases and controls. After data processing and feature annotation, eight features in blood and 24 features in urine were investigated in order to elucidate their biological relevance. Several of these are associated with AKI, while some may also originate from disturbed fatty acid ß-oxidation and soft tissue damage. A metabolite found in both blood and a venom reference sample may represent identification of a venom component in case dogs. Our findings suggest that envenomated dogs treated according to current best practice are unlikely to suffer permanent injury.
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Enfermedades de los Perros , Metaboloma , Mordeduras de Serpientes , Vipera , Animales , Perros , Femenino , Masculino , Lesión Renal Aguda/veterinaria , Lesión Renal Aguda/orina , Lesión Renal Aguda/sangre , Biomarcadores/orina , Biomarcadores/sangre , Enfermedades de los Perros/orina , Enfermedades de los Perros/sangre , Estudios Longitudinales , Estudios Prospectivos , Mordeduras de Serpientes/veterinaria , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/orina , Venenos de Víboras/orinaRESUMEN
INTRODUCTION: Myotoxicity is an important toxidrome that can occur with envenoming from multiple Australian snake types. Early antivenom administration is an important strategy to reduce the incidence and severity of myotoxicity. The current gold standard biomarker, serum creatine kinase activity, does not rise early enough to facilitate early antivenom administration. Several other skeletal muscle biomarkers have shown promise in other animal models and scenarios. The aim of this study was to examine the predictive values of six skeletal muscle biomarkers in a rat model of Australian snake myotoxicity. METHODS: Sprague-Dawley rats were anaesthetised and administered either Pseudechis porphyriacus (red-bellied black snake) or Notechis scutatus (tiger snake) venom, or normal saline via intramuscular injection. Blood samples were collected. Assays were performed for serum creatine kinase skeletal muscle troponin-I concentration, skeletal muscle troponin-C concentration, myoglobin activity, skeletal muscle myosin light chain-1 concentration, and creatine kinase-MM activity. Serum markers were plotted against time, with comparison of area under the concentration (or activity)-time curve. The predictive values of six skeletal muscle biomarkers were examined using receiver operating characteristic curves. RESULTS: There was no difference in area under the serum creatine kinase activity-time curve between venom and control groups. Serum creatine kinase-MM activity rose early in the venom treated rats, which had a significantly greater area under the serum activity-time curve. No difference in area under the serum concentration-time curve was demonstrated for the other biomarkers. Creatine kinase-MM activity had a superior predictive values than creatine kinase activity at 0-4 hours and 0-10 hours after venom administration, as indicated by area under the receiver operating characteristic curves (95 per cent confidence intervals) of 0.91 (0.78-1.00) and 0.88 (0.73-1.00) versus 0.79 (0.63-0.95) and 0.66 (0.51-0.80). DISCUSSION: The limitations of serum creatine kinase activity in early detection of myotoxicity were demonstrated in this rat model. CONCLUSION: Serum creatine kinase-MM activity was superior for early detection of Australian myotoxic snake envenoming.
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Biomarcadores , Modelos Animales de Enfermedad , Venenos Elapídicos , Músculo Esquelético , Ratas Sprague-Dawley , Mordeduras de Serpientes , Animales , Biomarcadores/sangre , Músculo Esquelético/efectos de los fármacos , Músculo Esquelético/metabolismo , Proyectos Piloto , Mordeduras de Serpientes/sangre , Ratas , Australia , Masculino , Venenos Elapídicos/toxicidad , Miotoxicidad , Elapidae , Antivenenos/farmacología , Mioglobina/sangre , Cadenas Ligeras de Miosina/sangre , Cadenas Ligeras de Miosina/metabolismo , Creatina Quinasa/sangre , Diagnóstico Precoz , Forma MM de la Creatina-Quinasa/sangreRESUMEN
BACKGROUND: Hump-nosed pit viper (HNV; Hypnale spp.) bites account for most venomous snakebites in Sri Lanka. Acute kidney injury (AKI) is the most serious systemic manifestation (1-10%) following HNV envenoming. We aimed to identify the value of functional and injury biomarkers in predicting the development of AKI early following HNV bites. METHODS: We conducted a prospective cohort study of patients with confirmed HNV envenoming presenting to two large tertiary care hospitals in Sri Lanka. Demographics, bite details, clinical effects, complications and treatment data were collected prospectively. Blood and urine samples were collected from patients for coagulation and renal biomarker assays on admission, at 0-4h, 4-8h, 8-16h and 16-24h post-bite and daily until discharge. Follow-up samples were obtained 1 and 3 months post-discharge. Creatinine (sCr) and Cystatin C (sCysC) were measured in serum and kidney injury molecule-1 (uKIM-1), clusterin (uClu), albumin (uAlb), ß2-microglobulin (uß2M), cystatin C (uCysC), neutrophil gelatinase associated lipocalin (uNGAL), osteopontin (uOPN) and trefoil factor-3 (uTFF-3) were measured in urine. Definite HNV bites were based on serum venom specific enzyme immunoassay. Kidney Disease: Improving Global Outcomes (KDIGO) criteria were used to stage AKI. Two patients had chronic kidney disease at 3 month follow-up, both with pre-existing abnormal sCr, and one developed AKI following HNV envenoming. RESULTS: There were 52 patients with confirmed HNV envenoming; median age 48y (Interquartile range [IQR]:40-59y) and 29 (56%) were male. Median time to admission was 1.87h (IQR:1-2.75h). Twelve patients (23%) developed AKI (AKI stage 1 = 7, AKI stage 2 = 1, AKI stage 3 = 4). Levels of five novel biomarkers, the functional marker serum Cystatin C and the damage markers urinary NGAL, cystatin C, ß2-microglobulin and clusterin, were elevated in patients who developed moderate/severe acute kidney injury. sCysC performed the best at 0-4 h post-bite in predicting moderate to severe AKI (AUC-ROC 0.95;95%CI:0.85-1.0) and no biomarker performed better than sCr at later time points. CONCLUSIONS: sCysC appears to be a better marker than sCr for early prediction of moderate to severe AKI following HNV envenoming.
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Lesión Renal Aguda/sangre , Lesión Renal Aguda/orina , Venenos de Crotálidos/toxicidad , Crotalinae/fisiología , Mordeduras de Serpientes/complicaciones , Lesión Renal Aguda/etiología , Adulto , Animales , Biomarcadores/sangre , Biomarcadores/orina , Creatinina/sangre , Creatinina/orina , Cistatina C/sangre , Cistatina C/orina , Femenino , Estudios de Seguimiento , Receptor Celular 1 del Virus de la Hepatitis A/sangre , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/orina , Sri Lanka , Microglobulina beta-2/sangre , Microglobulina beta-2/orinaRESUMEN
BACKGROUND: The 20-minute whole blood clotting test (20WBCT) has been used to detect coagulopathy following snakebite for almost 50 years. A systematic review and meta-analysis of the 20WBCT was conducted to evaluate the accuracy of the 20WBCT to detect coagulopathy, indicative of systemic envenoming. METHODS AND FINDINGS: Databases were searched from inception up to 09/12/2020 to identify studies that compared the 20WBCT and INR/fibrinogen on five or more subjects. Data was extracted from full-text articles by two reviewers using a predetermined form. Authors of 29 studies that lacked sufficient details in the manuscript were contacted and included if data meeting the inclusion criteria were provided. Included studies were evaluated for bias using a tailored QUADAS-2 checklist. The study protocol was prospectively registered on PROSPERO database (CRD42020168953). The searches identified 3,599 studies, 15 met the inclusion criteria and 12 were included in the meta-analysis. Data was reported from 6 countries and included a total of 2,270 patients. The aggregate weighted sensitivity of the 20WBCT at detecting INR >1.4 was 0.84 (CI 0.61 to 0.94), the specificity was 0.91 (0.76 to 0.97) and the SROC AUC was 0.94 (CI 0.91 to 0.96). The aggregate weighted sensitivity of the 20WBCT at detecting fibrinogen <100 mg/dL was 0.72 (CI 0.58 to 0.83), the specificity was 0.94 (CI 0.88 to 0.98) and the SROC AUC was 0.93 (0.91 to 0.95). Both analyses that used INR and fibrinogen as the reference test displayed considerable heterogeneity. CONCLUSIONS: In the absence of laboratory clotting assays, the 20WBCT remains a highly specific and fairly sensitive bedside test at detecting coagulopathy following snakebite. However, clinicians should be aware of the importance of operator training, standardized equipment and the lower sensitivity of the 20WBCT at detecting mild coagulopathy and resolution of coagulopathy following antivenom.
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Mordeduras de Serpientes/diagnóstico , Antivenenos/uso terapéutico , Coagulación Sanguínea , Pruebas de Coagulación Sanguínea , Fibrinógeno/análisis , Humanos , Relación Normalizada Internacional , Sensibilidad y Especificidad , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/terapiaRESUMEN
Palearctic vipers are medically significant snakes in the genera Daboia, Macrovipera, Montivipera, and Vipera which occur throughout Europe, Central Asia, Near and Middle East. While the ancestral condition is that of a small-bodied, lowland species, extensive diversification has occurred in body size, and niche specialization. Using 27 venom samples and a panel of in vitro coagulation assays, we evaluated the relative coagulotoxic potency of Palearctic viper venoms and compared their neutralization by three antivenoms (Insoserp Europe, VIPERFAV and ViperaTAb) and two metalloprotease inhibitors (prinomastat and DMPS). We show that variation in morphology parallels variation in the Factor X activating procoagulant toxicity, with the three convergent evolutions of larger body sizes (Daboia genus, Macrovipera genus, and Vipera ammodytes uniquely within the Vipera genus) were each accompanied by a significant increase in procoagulant potency. In contrast, the two convergent evolutions of high altitude specialization (the Montivipera genus and Vipera latastei uniquely within the Vipera genus) were each accompanied by a shift away from procoagulant action, with the Montivipera species being particularly potently anticoagulant. Inoserp Europe and VIPERFAV antivenoms were both effective against a broad range of Vipera species, with Inoserp able to neutralize additional species relative to VIPERFAV, reflective of its more complex antivenom immunization mixture. In contrast, ViperaTAb was extremely potent in neutralizing V. berus but, reflective of this being a monovalent antivenom, it was not effective against other Vipera species. The enzyme inhibitor prinomastat efficiently neutralized the metalloprotease-driven Factor X activation of the procoagulant venoms. In contrast, DMPS (2,3-dimercapto-1-propanesulfonic acid), which as been suggested as another potential treatment option in the absence of antivenom, DMPS failed against all venoms tested. Overall, our results highlight the evolutionary variations within Palearctic vipers and help to inform clinical management of viper envenomation.
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Antivenenos/farmacología , Coagulación Sanguínea/efectos de los fármacos , Fragmentos Fab de Inmunoglobulinas/farmacología , Inhibidores de la Metaloproteinasa de la Matriz/farmacología , Compuestos Orgánicos/farmacología , Mordeduras de Serpientes/tratamiento farmacológico , Unitiol/farmacología , Venenos de Víboras/antagonistas & inhibidores , Viperidae , Animales , Pruebas de Coagulación Sanguínea , Evolución Molecular , Humanos , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/enzimología , Especificidad de la Especie , Factores de Tiempo , Venenos de Víboras/enzimologíaRESUMEN
BACKGROUND: Acute kidney injury (AKI) is associated with high morbidity and mortality in dogs, but diagnosis may be impaired due the insensitivity of routine renal function biomarkers to detect earlier or milder forms of injury. Snake envenomation is one of several causes of AKI in dogs and humans. Dogs are commonly envenomated by the European adder (Vipera berus) between April and October each year, but few studies exist examining serial serum creatinine (sCr) and symmetric dimethylarginine (SDMA) measurements and AKI biomarkers in these dogs. Novel urinary biomarkers could improve clinical outcome by allowing earlier diagnosis of and intervention in AKI. The aim of this study was to assess the presence of AKI in dogs envenomated by V. berus at 12, 24 and 36 h after bite, as well as 14 days later, using sCr, SDMA and a panel of urinary AKI biomarkers normalised to urine creatinine (uCr), compared to a group of healthy control dogs. RESULTS: Thirty-five envenomated dogs and 35 control dogs were included. Serum creatinine did not exceed the upper reference limit at any time point in any dog after envenomation. Serum SDMA did not exceed 0.89 µmol/L in any dog. Compared to controls, urinary albumin/uCr, neutrophil gelatinase-associated lipocalin/uCr and monocyte chemotactic protein-1/uCr were significantly elevated 12 h (P < 0.0001, P < 0.0001, P = 0.01), 24 h (P < 0.001, P < 0.001, P = 0.002) and 36 h (P < 0.001, P < 0.001, P = 0.0008) after bite. Osteopontin/uCr was higher 24 and 36 h after bite (P < 0.0001), kidney injury molecule-1/uCr, interleukin-8/uCr and γ- glutamyl transferase/uCr were significantly higher 36 h after bite (P = 0.003, P = 0.0005, P = 0.001). Urinary cystatin C/uCr was not significantly different to controls at any timepoint. Biomarker/uCr ratios were not significantly different 14 days after envenomation compared to controls. CONCLUSION: Urinary biomarker/Cr ratios are indicative of mild transient, non-azotaemic AKI in dogs envenomated by V. berus.
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Lesión Renal Aguda/veterinaria , Biomarcadores/orina , Mordeduras de Serpientes/veterinaria , Viperidae , Lesión Renal Aguda/sangre , Lesión Renal Aguda/orina , Animales , Arginina/análogos & derivados , Arginina/sangre , Biomarcadores/sangre , Creatinina/sangre , Enfermedades de los Perros/sangre , Enfermedades de los Perros/orina , Perros , Femenino , Masculino , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/orinaRESUMEN
OBJECTIVES: Understanding the time course of venom exposure in snakebite patients is important for the optimisation of treatment including antivenom dose and timing. We aimed to investigate the pharmacokinetics of red-bellied black snake (RBBS; Pseudechis porphyriacus) venom in envenomed patients. METHODS: Timed venom concentration data were obtained from patients with RBBS envenomation recruited to the Australian Snakebite Project (ASP), including demographics and antivenom treatment. Venom concentrations were measured using an enzyme immunoassay. Data were modelled using NONMEM version 7.3. Uncertainty in venom "dose" was accounted for by arbitrarily fixing the average amount to 1 mg and incorporating between-subject variability on relative bioavailability. A scale parameter for venom clearance was implemented to account for the rapid venom clearance following antivenom dosing. A sensitivity analysis was performed to determine the magnitude of venom clearance amplification. RESULTS: There were 457 venom concentrations in 114 patients (median age 41, 2-90 y; 80 male). Antivenom was administered to 54 patients a median of 4.2 h post-bite (0.67 to 32 h). A one-compartment model with first-order absorption and elimination provided the best description of the data. The estimated clearance and volume of distribution were 5.21 L/h and 39.9 L, respectively. The calculated elimination half-life of P. porphyriacus venom from the final pharmacokinetic model was 5.35 ± 0.36 h. The variability in the relative dose of injected venom was 140%. Antivenom administration increased venom clearance by 40-fold. Ten patients showed evidence of a double peak in the absorption profile. CONCLUSION: The information on the exposure time of venom in the body following envenomation will help improve treatment and the timing of antivenom.
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Venenos Elapídicos/farmacocinética , Elapidae , Modelos Biológicos , Mordeduras de Serpientes/sangre , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Animales , Antivenenos/administración & dosificación , Niño , Preescolar , Esquema de Medicación , Venenos Elapídicos/antagonistas & inhibidores , Venenos Elapídicos/sangre , Femenino , Semivida , Humanos , Masculino , Tasa de Depuración Metabólica , Persona de Mediana Edad , Mordeduras de Serpientes/diagnóstico , Mordeduras de Serpientes/tratamiento farmacológico , Resultado del Tratamiento , Adulto JovenRESUMEN
Background: The immunologic pathways activated during snakebite envenoming (SBE) are poorly described, and their association with recovery is unclear. The immunologic response in SBE could inform a prognostic model to predict recovery. The purpose of this study was to develop pre- and post-antivenom prognostic models comprised of clinical features and immunologic cytokine data that are associated with recovery from SBE. Materials and Methods: We performed a prospective cohort study in an academic medical center emergency department. We enrolled consecutive patients with Crotalinae SBE and obtained serum samples based on previously described criteria for the Surgical Critical Care Initiative (SC2i)(ClinicalTrials.gov Identifier: NCT02182180). We assessed a standard set of clinical variables and measured 35 unique cytokines using Luminex Cytokine 35-Plex Human Panel pre- and post-antivenom administration. The Patient-Specific Functional Scale (PSFS), a well-validated patient-reported outcome of functional recovery, was assessed at 0, 7, 14, 21 and 28 days and the area under the patient curve (PSFS AUPC) determined. We performed Bayesian Belief Network (BBN) modeling to represent relationships with a diagram composed of nodes and arcs. Each node represents a cytokine or clinical feature and each arc represents a joint-probability distribution (JPD). Results: Twenty-eight SBE patients were enrolled. Preliminary results from 24 patients with clinical data, 9 patients with pre-antivenom and 11 patients with post-antivenom cytokine data are presented. The group was mostly female (82%) with a mean age of 38.1 (SD ± 9.8) years. In the pre-antivenom model, the variables most closely associated with the PSFS AUPC are predominantly clinical features. In the post-antivenom model, cytokines are more fully incorporated into the model. The variables most closely associated with the PSFS AUPC are age, antihistamines, white blood cell count (WBC), HGF, CCL5 and VEGF. The most influential variables are age, antihistamines and EGF. Both the pre- and post-antivenom models perform well with AUCs of 0.87 and 0.90 respectively. Discussion: Pre- and post-antivenom networks of cytokines and clinical features were associated with functional recovery measured by the PSFS AUPC over 28 days. With additional data, we can identify prognostic models using immunologic and clinical variables to predict recovery from SBE.
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Venenos de Crotálidos/inmunología , Crotalinae/inmunología , Citocinas/sangre , Mordeduras de Serpientes/inmunología , Adulto , Anciano , Animales , Antivenenos/uso terapéutico , Biomarcadores/sangre , Venenos de Crotálidos/antagonistas & inhibidores , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos Inmunológicos , Valor Predictivo de las Pruebas , Estudios Prospectivos , Recuperación de la Función , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/tratamiento farmacológico , Factores de Tiempo , Resultado del TratamientoRESUMEN
Snake envenomation can result in hemorrhage, local necrosis, swelling, and if not treated properly can lead to adverse systemic effects such as coagulopathy, nephrotoxicity, neurotoxicity, and cardiotoxicity, which can result in death. As such, snake venom metalloproteinases (SVMPs) and disintegrins are two toxic components that contribute to hemorrhage and interfere with the hemostatic system. Administration of a commercial antivenom is the common antidote to treat snake envenomation, but the high-cost, lack of efficacy, side effects, and limited availability, necessitates the development of new strategies and approaches for therapeutic treatments. Herein, we describe the neutralization ability of anti-disintegrin polyclonal antibody on the activities of isolated disintegrins, P-II/P-III SVMPs, and crude venoms. Our results show disintegrin activity on platelet aggregation in whole blood and the migration of the SK-Mel-28 cells that can be neutralized with anti-disintegrin polyclonal antibody. We characterized a SVMP and found that anti-disintegrin was also able to inhibit its activity in an in vitro proteolytic assay. Moreover, we found that anti-disintegrin could neutralize the proteolytic and hemorrhagic activities from crude Crotalus atrox venom. Our results suggest that anti-disintegrin polyclonal antibodies have the potential for a targeted approach to neutralize SVMPs in the treatment of snakebite envenomations.
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Anticuerpos Neutralizantes/farmacología , Antivenenos/farmacología , Venenos de Crotálidos/antagonistas & inhibidores , Crotalus , Desintegrinas/antagonistas & inhibidores , Metaloproteasas/antagonistas & inhibidores , Inhibidores de Proteasas/farmacología , Mordeduras de Serpientes/tratamiento farmacológico , Regulación Alostérica , Animales , Especificidad de Anticuerpos , Línea Celular Tumoral , Movimiento Celular/efectos de los fármacos , Proliferación Celular/efectos de los fármacos , Reacciones Cruzadas , Venenos de Crotálidos/enzimología , Venenos de Crotálidos/inmunología , Modelos Animales de Enfermedad , Desintegrinas/inmunología , Desintegrinas/metabolismo , Hemorragia/enzimología , Hemorragia/etiología , Hemorragia/prevención & control , Humanos , Metaloproteasas/inmunología , Metaloproteasas/metabolismo , Ratones Endogámicos BALB C , Agregación Plaquetaria/efectos de los fármacos , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/enzimología , Mordeduras de Serpientes/inmunologíaRESUMEN
Disseminated intravascular coagulation, a severe clinical condition caused by an underlying disease, involves a markedly continuous and widespread activation of coagulation in the circulating blood and the formation of numerous microvascular thrombi. A snakebite, including that of the Yamakagashi (Rhabdophis tigrinus), demonstrates this clinical condition. Thus, an animal model using Yamakagashi venom was constructed. Yamakagashi venom was administered to rats, and its lethality and the changes in blood coagulation factors were detected after venom injection. When 300 µg venom was intramuscularly administered to 12-week-old rats, (1) they exhibited hematuria with plasma hemolysis and died within 48 h; (2) Thrombocytopenia in the blood was observed in the rats; (3) irreversible prolongation of prothrombin time in the plasma to the measurement limit occurred; (4) fibrinogen concentration in the plasma irreversibly decreased below the measurement limit; and (5) A transient increase in the plasma concentration of D-dimer was observed. In this model, a fixed amount of Rhabdophis tigrinus venom injection resulted in the clinical symptom similar to the human pathology with snakebite. The use of the rat model is very effective in validating the therapeutic effect of human disseminated intravascular coagulation condition due to snakebite.
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Coagulación Sanguínea , Colubridae , Coagulación Intravascular Diseminada/etiología , Mordeduras de Serpientes/complicaciones , Venenos de Serpiente , Animales , Biomarcadores/sangre , Modelos Animales de Enfermedad , Progresión de la Enfermedad , Coagulación Intravascular Diseminada/sangre , Productos de Degradación de Fibrina-Fibrinógeno/metabolismo , Fibrinógeno/metabolismo , Hematuria/etiología , Masculino , Ratas Sprague-Dawley , Mordeduras de Serpientes/sangre , Trombocitopenia/etiología , Factores de TiempoRESUMEN
Snake envenomation is a serious public health issue in many tropical and subtropical countries. Accurate diagnosis and immediate antivenom treatment are critical for effective management. However, the venom concentration in the victims' plasma is usually low, representing one of the bottlenecks in developing clinically applicable assays for venom detection and snakebite diagnosis. In this study, we attempted to develop a simple method for rapid enrichment of venom proteins from human plasma to facilitate detection. Our experiments showed that several major protein components of both Naja atra (N. atra) and Bungarus multicinctus (B. multicinctus) venoms have higher isoelectric point (pI) values relative to high-abundance human plasma proteins and could be separated via strong cation exchange-high-performance liquid chromatography (SCX-HPLC). Based on this principle, we developed an SCX tip column-based protocol for rapid enrichment of N. atra and B. multicinctus venom proteins from human plasma. Application of liquid chromatography-tandem mass spectrometry (LC-MS/MS) led to the identification of cytotoxin and beta-bungarotoxin as the major proteins enriched by the SCX tip column in each venom sample. The entire process of venom enrichment could be completed within 10-15 min. Combination of this method with our previously developed lateral flow strip assays (rapid test) significantly enhanced the sensitivity of the rapid test, mainly via depletion of the plasma protein background, as well as increase in venom protein concentration. Notably, the SCX tip column-based enrichment method has the potential to efficiently enrich other Elapidae snake venoms containing proteins with higher pI values, thereby facilitating venom detection with other assays. This simple and rapid sample preparation method should aid in improving the clinical utility of diagnostic assays for snakebite.
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Bungarus , Resinas de Intercambio de Catión/química , Cromatografía Líquida de Alta Presión , Cromatografía por Intercambio Iónico , Venenos Elapídicos/sangre , Naja naja , Proteínas de Reptiles/sangre , Mordeduras de Serpientes/diagnóstico , Animales , Biomarcadores , Bungarotoxinas/sangre , Humanos , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Mordeduras de Serpientes/sangre , Espectrometría de Masas en Tándem , Factores de Tiempo , Flujo de TrabajoRESUMEN
OBJECTIVE: This retrospective study investigated the nature and severity of venom-induced consumption coagulopathy (VICC) and determined the clotting factors involved in VICC in patients after envenomation by South Korea's snakes. Additionally, we studied the effectiveness of antivenom for the treatment of VICC after envenomation. METHODS: Included patients were divided into three groups according to the severity of VICC (no VICC, partial VICC, and complete VICC). Data, including changes in coagulation parameters during hospitalization and clotting factors at presentation, were collected and analyzed. RESULTS: One hundred nineteen patients who presented at our emergency department within 3 h after snake envenomation were included. VICC developed in 34 patients (27 patients with partial VICC and 7 patients with complete VICC). Two of 34 patients with VICC required blood transfusions. Five patients with complete VICC had an undetectable fibrinogen concentration at presentation. Three patients with complete VICC had an unmeasurable INR and aPTT within 24 h. The median times of the most extreme values were 10 h for INR, 12 h for aPTT, and 16 h for fibrinogen after presentation in the VICC group. The D-dimer concentration peaked at a median of 63.5 h after presentation. The activities of factors II and X were significantly reduced in the complete VICC group (factor II: 88 (84-99.3)% in the non-VICC group vs. 69 (49.5-83.5)% in the complete VICC group; factor X:94 (83-102) in the non-VICC group vs. 70 (66.5-79.8)% in the complete VICC group), while there was no difference in factor V activity at presentation. The time from bite to first antivenom administration did not correlate with the time course and most extreme concentrations for fibrinogen and D-dimer within the VICC groups. DISCUSSION AND CONCLUSION: VICC occurs in approximately one-quarter of snakebite patients in South Korea; however, VICC itself does not appear to lead to clinical deterioration. Fibrinogen is an early diagnostic maker for complete VICC. Clotting factors II and X are involved in VICC. Future investigations should explore the mechanism of VICC from Korean snakebites and the effect of antivenom on VICC.
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Coagulación Sanguínea , Coagulación Intravascular Diseminada/etiología , Mordeduras de Serpientes/complicaciones , Venenos de Serpiente/antagonistas & inhibidores , Serpientes , Anciano , Animales , Antivenenos/uso terapéutico , Biomarcadores/sangre , Coagulación Sanguínea/efectos de los fármacos , Pruebas de Coagulación Sanguínea , Coagulación Intravascular Diseminada/sangre , Coagulación Intravascular Diseminada/diagnóstico , Coagulación Intravascular Diseminada/tratamiento farmacológico , Factor X/metabolismo , Femenino , Fibrinógeno/metabolismo , Humanos , Masculino , Persona de Mediana Edad , Protrombina/metabolismo , República de Corea , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/diagnóstico , Mordeduras de Serpientes/tratamiento farmacológico , Venenos de Serpiente/metabolismo , Factores de Tiempo , Resultado del TratamientoRESUMEN
Snakes of the genera Pseudocerastes and Eristicophis (Viperidae: Viperinae) are known as the desert vipers due to their association with the arid environments of the Middle East. These species have received limited research attention and little is known about their venom or ecology. In this study, a comprehensive analysis of desert viper venoms was conducted by visualising the venom proteomes via gel electrophoresis and assessing the crude venoms for their cytotoxic, haemotoxic, and neurotoxic properties. Plasmas sourced from human, toad, and chicken were used as models to assess possible prey-linked venom activity. The venoms demonstrated substantial divergence in composition and bioactivity across all experiments. Pseudocerastes urarachnoides venom activated human coagulation factors X and prothrombin and demonstrated potent procoagulant activity in human, toad, and chicken plasmas, in stark contrast to the potent neurotoxic venom of P. fieldi. The venom of E. macmahonii also induced coagulation, though this did not appear to be via the activation of factor X or prothrombin. The coagulant properties of P. fieldi and P. persicus venoms varied among plasmas, demonstrating strong anticoagulant activity in the amphibian and human plasmas but no significant effect in that of bird. This is conjectured to reflect prey-specific toxin activity, though further ecological studies are required to confirm any dietary associations. This study reinforces the notion that phylogenetic relatedness of snakes cannot readily predict venom protein composition or function. The significant venom variation between these species raises serious concerns regarding antivenom paraspecificity. Future assessment of antivenom is crucial.
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Coagulación Sanguínea/efectos de los fármacos , Unión Neuromuscular/efectos de los fármacos , Conducta Predatoria , Proteínas de Reptiles/toxicidad , Mordeduras de Serpientes/metabolismo , Ponzoñas/toxicidad , Viperidae/metabolismo , Animales , Anuros , Línea Celular Tumoral , Pollos , Humanos , Masculino , Unión Neuromuscular/fisiopatología , Proteoma , Proteómica , Proteínas de Reptiles/metabolismo , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/fisiopatología , Especificidad de la Especie , Ponzoñas/metabolismoRESUMEN
The toxin composition of snake venoms and, thus, their functional activity, can vary between and within species. Intraspecific venom variation across a species' geographic range is a major concern for antivenom treatment of envenomations, particularly for countries like French Guiana that lack a locally produced antivenom. Bothrops asper and Bothrops atrox are the most medically significant species of snakes in Latin America, both producing a variety of clinical manifestations, including systemic bleeding. These pathophysiological actions are due to the activation by the venom of the blood clotting factors Factor X and prothrombin, thereby causing severe consumptive coagulopathy. Both species are extremely wide-ranging, and previous studies have shown their venoms to exhibit regional venom variation. In this study, we investigate the differential coagulotoxic effects on human plasma of six venoms (four B. asper and two B. atrox samples) from different geographic locations, spanning from Mexico to Peru. We assessed how the venom variation of these venom samples affects neutralisation by five regionally available antivenoms: Antivipmyn, Antivipmyn-Tri, PoliVal-ICP, Bothrofav, and Soro Antibotrópico (SAB). The results revealed both inter- and intraspecific variations in the clotting activity of the venoms. These variations in turn resulted in significant variation in antivenom efficacy against the coagulotoxic effects of these venoms. Due to variations in the venoms used in the antivenom production process, antivenoms differed in their species-specific or geographical neutralisation capacity. Some antivenoms (PoliVal-ICP, Bothrofav, and SAB) showed species-specific patterns of neutralisation, while another antivenom (Antivipmyn) showed geographic-specific patterns of neutralisation. This study adds to current knowledge of Bothrops venoms and also illustrates the importance of considering evolutionary biology when developing antivenoms. Therefore, these results have tangible, real-world implications by aiding evidence-based design of antivenoms for treatment of the envenomed patient. We stress that these in vitro studies must be backed by future in vivo studies and clinical trials before therapeutic guidelines are issued regarding specific antivenom use in a clinical setting.
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Anticuerpos Neutralizantes/farmacología , Antivenenos/farmacología , Coagulación Sanguínea/efectos de los fármacos , Bothrops , Venenos de Crotálidos/antagonistas & inhibidores , Hemorragia/tratamiento farmacológico , Mordeduras de Serpientes/tratamiento farmacológico , Animales , Especificidad de Anticuerpos , Bothrops/inmunología , Bothrops/metabolismo , Reacciones Cruzadas , Venenos de Crotálidos/inmunología , Venenos de Crotálidos/metabolismo , Hemorragia/sangre , Hemorragia/inmunología , Humanos , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/inmunología , Especificidad de la EspecieRESUMEN
INTRODUCTION: Protobothrops mucrosquamatus bite induces wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and acute renal failure. The severity of the hematological derangements and associated factors for wound necrosis and subsequent surgery and the appropriate management of these conditions have not been well characterized. Although severe renal failure requiring hemodialysis has been reported following P. mucrosquamatus bite, the culprit snake may be erroneously classified. MATERIALS AND METHODS: A total of 186 patients with P. mucrosquamatus bites were retrospectively evaluated. They were categorized into group 1 (patients receiving debridement or finger/toe amputation) and group 2 (all other patients) to identify the associated factors for surgery. Characteristic data were compared between groups 1 and 2 and between definite and suspected cases. RESULTS: No differences were observed between definite and suspected cases in terms of symptomatology and management. Of the 186 patients, 7 (3.8%) were asymptomatic, 179 (96.2%) experienced tissue swelling and pain, and 107 (57.5%) had local ecchymosis. Coagulopathy, thrombocytopenia, and renal impairment were found in 13 (7%), 19 (10.2%), and 7 (3.8%) patients, respectively. None of the patients required transfusion therapy or hemodialysis. Furthermore, no systemic bleeding or death occurred. Antivenom was administered to all 179 envenomed patients at a median of 1.5 h post-bite. The median total dose of the specific antivenom was 5.5 vials. In multivariate logistic regression analysis, finger as the bite site, bullae and blister formation, and wound infection were significantly associated with wound necrosis; whereas finger as the bite site and bullae and blister formation were related to debridement or finger/toe amputation. DISCUSSION AND CONCLUSIONS: Protobothrops mucrosquamatus envenomation mainly exerts effects on local tissue. Systemic effects are uncommon and generally nonsevere and transient after the treatment with the specific antivenom. We speculated that severe renal failure requiring hemodialysis is not a typical finding of P. mucrosquamatus envenomation. Patients with finger as the bite site and bullae or blister formation should be carefully examined for wound necrosis, secondary infection, and subsequent surgery. Further evaluations of the efficacy of antivenom against local tissue effects and the effect of selective antibiotics in the management of bite wound infection are urgently required. Although the antivenom manufacturer suggested a skin test prior to use, we believed that it could be omitted because it does not accurately predict the allergic responses.
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Amputación Quirúrgica , Antivenenos/uso terapéutico , Venenos de Crotálidos/antagonistas & inhibidores , Desbridamiento , Dedos/cirugía , Mordeduras de Serpientes/terapia , Dedos del Pie/cirugía , Trimeresurus , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Animales , Antibacterianos/uso terapéutico , Antivenenos/efectos adversos , Niño , Preescolar , Protocolos Clínicos , Venenos de Crotálidos/metabolismo , Femenino , Dedos/patología , Humanos , Masculino , Persona de Mediana Edad , Necrosis , Diálisis Renal , Insuficiencia Renal/etiología , Insuficiencia Renal/terapia , Estudios Retrospectivos , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/complicaciones , Mordeduras de Serpientes/patología , Taiwán , Dedos del Pie/patología , Trimeresurus/metabolismo , Infección de Heridas/microbiología , Infección de Heridas/terapia , Adulto JovenRESUMEN
CONTEXT: Echis coloratus is endemic to the Middle East. Clinical reports describing E. coloratus envenomation in humans are scarce, while natural envenomations of animals were not reported. Such envenomations may induce systemic coagulopathy. This report describes a confirmed E. coloratus envenomation in a dog, with assessment of the global hemostasis by thromboelastometry. CASE DETAILS: A 6-year old Belgian Shepherd dog was presented in shock, mucosal bleeding and swelling due to snakebite. Laboratory tests showed prolonged prothrombin and activated partial thromboplastin times. Because Daboia palaestinae is the most common venomous snake in Israel, immunoglobulin-G monovalent D. palaestinae antivenom was administered, with supportive care. The dog improved clinically, was discharged, and was readmitted, with active bleeding from the bite site. The dead snake was only then identified as E. coloratus. Thromboelastometry demonstrated severe hypocoagulability. The dog was treated with polyvalent antivenom directed against venoms of several Middle Eastern snakes, fresh-frozen plasma and packed red blood cells. Bleeding completely ceased, and thromboelastometry results improved. The dog was discharged. 3 days later, all hemostatic test results had normalized. DISCUSSION: Thromboelastometry is useful for assessing the hemostatic status in E. coloratus envenomation, and for monitoring and managing the venom-induced coagulopathy, and guide plasma and polyvalent antivenom treatment.
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Enfermedades de los Perros/terapia , Mordeduras de Serpientes/veterinaria , Tromboelastografía/métodos , Venenos de Víboras/toxicidad , Animales , Antivenenos/uso terapéutico , Trastornos de la Coagulación Sanguínea/etiología , Enfermedades de los Perros/sangre , Perros , Femenino , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/complicaciones , Mordeduras de Serpientes/terapiaRESUMEN
Snakebite is a neglected tropical disease with significant morbidity and mortality. Thrombotic microangiopathy (TMA) is an important but poorly understood complication of snakebite associated with acute kidney injury (AKI). Numerous treatments have been attempted based on limited evidence. We conducted a systematic review of TMA following snakebite using a pre-determined case definition of blood film red cell schistocytes or histologically diagnosed TMA. The search strategy included major electronic databases and grey literature. We present a descriptive synthesis for the outcomes of AKI, dialysis free survival (DFS), other end-organ damage, overall survival, and interventions with antivenom and therapeutic plasmapheresis (TPE). This study was prospectively registered with PROSPERO (CRD42019121436). Seventy-two studies reporting 351 cases were included, predominantly small observational studies. Heterogeneity for study selection, design, reporting and outcomes were observed. The commonest envenoming species were hump-nosed vipers (Hypnale spp.), Russell's viper (Daboia russelii) and Australian brown snakes (Pseudechis spp.). The prevalence of TMA was at least 5.4% in proven and probable Hypnale bites, and 10-15% of Australian elapid envenomings, AKI occurred in 94% (293/312) of TMA cases, excluding case reports. The majority of cases with AKI required dialysis. Included prospective and retrospective cohort studies reporting interventions and renal outcomes showed no evidence for benefit from antivenom or TPE with respect to DFS in dialysis dependant AKI. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment for quality of accumulated evidence for interventions was low. The major complication of TMA following snakebite is AKI. AKI improves in most cases. We found no evidence to support benefit from antivenom in snakebite associated TMA, but antivenom remains the standard of care for snake envenoming. There was no evidence for benefit of TPE in snakebite associated TMA, so TPE cannot be recommended. The quality of accumulated evidence was low, highlighting a need for high quality larger studies.
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Lesión Renal Aguda/etiología , Antivenenos/uso terapéutico , Daboia/metabolismo , Plasmaféresis , Mordeduras de Serpientes/complicaciones , Microangiopatías Trombóticas/etiología , Venenos de Víboras/efectos adversos , Lesión Renal Aguda/sangre , Lesión Renal Aguda/terapia , Animales , Australia/epidemiología , Femenino , Humanos , Masculino , Prevalencia , Estudios Prospectivos , Estudios Retrospectivos , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/terapia , Microangiopatías Trombóticas/sangre , Microangiopatías Trombóticas/terapiaRESUMEN
Snake bites are a public health problem in tropical and subtropical regions of the world. They occur especially in rural workers and are an important source of disability and mortality. We present the case of a 59-year-old farmer from the Catatumbo region of Colombia who was bitten by a B. asper snake and suffered a fatal brain hemorrhage after the event. We draw attention to the severe bleeding disorder in contrast with the slight changes at the site of the bite, as well as on the importance of the early treatment of poisoning with antivenom even in the absence of significant skin manifestations.
Las mordeduras de serpientes son un problema de salud pública en regiones tropicales y subtropicales del mundo. Ocurren, especialmente, en trabajadores rurales, y son una importante fuente de discapacidad y mortalidad. Se presenta el caso de un hombre de 59 años, agricultor de la región del Catatumbo (Colombia), quien sufrió la mordedura de una serpiente Bothrops asper, la cual le produjo una hemorragia cerebral fatal. Se llama la atención sobre el grave trastorno hemorrágico en contraste con los leves cambios en el sitio de la mordedura, así como sobre la necesidad del tratamiento temprano de la intoxicación con el suero antiofídico, incluso, en ausencia de manifestaciones cutáneas significativas.
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Bothrops , Venenos de Crotálidos/envenenamiento , Hemorragias Intracraneales/etiología , Mordeduras de Serpientes/complicaciones , Animales , Colombia , Resultado Fatal , Humanos , Hemorragias Intracraneales/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Mordeduras de Serpientes/sangre , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Detection and quantification of snake venom in envenomed patients' blood is important for identifying the species responsible for the bite, determining administration of antivenom, confirming whether sufficient antivenom has been given, detecting recurrence of envenoming, and in forensic investigation. Currently, snake venom detection is not available in clinical practice in Sri Lanka. This study describes the development of enzyme immunoassays (EIA) to differentiate and quantify venoms of Russell's viper (Daboia russelii), saw-scaled viper (Echis carinatus), common cobra (Naja naja), Indian krait (Bungarus caeruleus), and hump-nosed pit viper (Hypnale hypnale) in the blood of envenomed patients in Sri Lanka. METHODOLOGY / PRINCIPAL FINDINGS: A double sandwich EIA of high analytical sensitivity was developed using biotin-streptavidin amplification for detection of venom antigens. Detection and quantification of D. russelii, N. naja, B. caeruleus, and H. hypnale venoms in samples from envenomed patients was achieved with the assay. Minimum (less than 5%) cross reactivity was observed between species, except in the case of closely related species of the same genus (i.e., Hypnale). Persistence/ recurrence of venom detection following D. russelii envenoming is also reported, as well as detection of venom in samples collected after antivenom administration. The lack of specific antivenom for Hypnale sp envenoming allowed the detection of venom antigen in circulation up to 24 hours post bite. CONCLUSION: The EIA developed provides a highly sensitive assay to detect and quantify five types of Sri Lankan snake venoms, and should be useful for toxinological research, clinical studies, and forensic diagnosis.
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Técnicas para Inmunoenzimas , Mordeduras de Serpientes/sangre , Mordeduras de Serpientes/diagnóstico , Venenos de Serpiente/análisis , Adolescente , Adulto , Animales , Antivenenos/uso terapéutico , Reacciones Cruzadas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mordeduras de Serpientes/tratamiento farmacológico , Serpientes , Sri Lanka , Adulto JovenRESUMEN
The management of snakebite (SB) envenoming in French Guiana (FG) is based on symptomatic measures and antivenom (AV) administration (Antivipmyn Tri®; Instituto Bioclon-Mexico). Our study aimed to assess clinical manifestations, the efficacy, and safety of Antivipmyn Tri® in the management of SB. Our study is a prospective observational work. It was conducted in the Intensive Care Unit (ICU) of Cayenne General Hospital between 1 January 2016 and 31 December 2019. We included all patients hospitalized for SB envenoming. Our study contained three groups (without AV, three vials, and six vials Antivipmyn Tri®). During the study period, 133 patients were included. The main clinical symptoms were edema (98.5%), pain (97.7%), systemic hemorrhage (18%), blister (14.3%), and local hemorrhage (14.3%). AV was prescribed for 83 patients (62.3%), and 17 of them (20%) developed early adverse reactions. Biological parameters at admission showed defibrinogenation in 124 cases (93.2%), International Normalized Ratio (INR) > 2 in 104 cases (78.2%), and partial thromboplastin time (PTT) > 1.5 in 74 cases (55.6%). The time from SB to AV was 9:00 (5:22-20:40). The median time from SB to achieve a normal dosage of fibrinogen was 47:00 vs. 25:30, that of Factor II was 24:55 vs. 15:10, that of Factor V was 31:42 vs. 19:42, and that of Factor VIII was 21:30 vs. 10:20 in patients without and with AV, respectively, (p < 0.001 for all factors). Patients receiving Antivipmyn Tri® showed a reduction in the time to return to normal clotting tests, as compared to those who did not. We suggest assessing other antivenoms available in the region to compare their efficacy and safety with Antivipmyn Tri® in FG.