Efficacy of a low dose of antivenom for severe neuroparalysis in Bungarus caeruleus (common krait) envenomation: a pilot study.

Introduction: Despite the widespread use of antivenom for the treatment of snakebite envenoming in the Indian subcontinent, the ideal dose of antivenom has been a point of contention. Low-dose regimens can economize on a scarce resource in low- and middle-income countries. This study assessed the effectiveness of a low-dose (10 vials) antivenom regimen compared to the usual 20 vials in patients with krait bite neuroparalysis requiring mechanical ventilation. Methods: This study was a prospective controlled pilot study conducted in a tertiary-care hospital in north India. Participants were eligible if they were ≥12 years old, had krait bite neurotoxicity, showed severe paralysis requiring mechanical ventilation, and had access to antivenom therapy within 24 h of the bite. The primary outcome was the duration of mechanical ventilation, and the secondary outcomes were the length of hospital stay and in-hospital survival. Results: Fifteen patients received 10 vials of antivenom, and 25 received 20 vials. The two treatment groups had similar baseline demographics, clinical and laboratory features, snakebite severity scores, and median time from snakebite to initiation of antivenom therapy. The low-dose regimen was as effective as the standard dose concerning the median duration of mechanical ventilation (41 h vs. 55 h, P = 0.094), the median length of stay (78 h vs. 85.5 h, P = 0.360), and in-hospital deaths (1 vs. 3, P = 1.000). The incidence of ventilator-associated pneumonia was similar between the two groups (1 vs 3, P = 1.000). Conclusion: A low dose of antivenom effectively treats patients with severe krait bite neuroparalysis.

Potential of herbal cocktail of medicinal plant extracts against 'big four' snake venoms from India.

BACKGROUND: Venomous snake bites cause acute medical emergencies and are fatal. India accounts for large proportion of snake-bite deaths globally. Medically important 'BIG FOUR' snakes of India are Bungarus caeruleus (krait), Naja naja (cobra), Echis carinatus (saw-scaled viper) and Daboia russelii (Russell's viper). Polyherbal formulations have been proved to be effective in treatment of diseases than a single formulation. OBJECTIVE(S): To evaluate aqueous ethanolic extract cocktail of Azadirachata indica, Butea monosperma, Citrus limon, Clerodendrum serratum and Areca catechu for antidote potential against BIG FOUR venoms in ex vivo and in vivo model. MATERIALS AND METHODS: Anti-hemorrhagic and venom neutralization studies were performed in seven-day old chick embryo model for ex vivo studies. In vivo studies were performed using male Swiss albino mice for antivenom potential of herbal cocktail by performing anti-edematic, anti-hemorrhagic, anti-myotoxic activity, and venom neutralization. RESULTS: Herbal cocktail exhibited differential venom inhibition potential against four venoms tested. Hemorrhagic activity was completely neutralized by the herbal cocktail; myotoxic activities of krait and Russell's viper venom were neutralized; while anti-edematic activity was observed for krait and cobra venom. Herbal cocktail completely neutralized venom lethality (3∗LD50) of krait and saw-scaled viper venom. CONCLUSION: Inhibitions of various venom components of all four venoms suggests presence of phytochemicals in herbal cocktail with therapeutic properties. Further studies would help in the development of a formulation as a first-aid towards treatment of snake bite victims.

Unusually prolonged neuromuscular weakness caused by krait (Bungarus caeruleus) bite: Two case reports.

Snakebites are common in India and the most common neurotoxic snakebites in India are due to Common krait (Bungarus caeruleus) and cobra (Naja naja). Severe envenomation may mimic brain death or a locked-in state with flaccid paralysis in a descending manner and total ophthalmoplegia. Usually, patients who receive timely antivenom and ventilator support recover completely without any sequalae. We are reporting two cases of krait bite with an unusually long period of flaccid paralysis, which required prolong ventilation. While case 1 required 10 days of mechanical ventilation followed by 5 days of non-invasive ventilation, case 2 required 11 days of mechanical ventilation followed by 5 days of non-invasive ventilation. Both the cases had delayed recovery and residual weakness at 3-month follow up. These case reports suggest that krait bite may cause prolong neuromuscular weakness in children, which has implications for both acute and chronic management.

Bungarus caeruleus venom neutralization activity of Azima tetracantha Lam. Extract.

Azima tetracantha Lam. is native to Africa and India. The plant and its parts are used for treating various ailments including snake bites. The different concentrations of ethyl acetate leaf extract of A. tetracantha were used to neutralize the toxic effect of venom through dose dependent enzyme studies and in vivo studies. The extract was able to neutralize the 5' nucleotidase, phospholipase A2, Phosphodiesterae, phosphomonoesterase, acetylcholinesterase and hyaluronidase in a dose dependent manner with concentrations ranging from 43.98 -340.1 µg/mL of extract. The extract could retain the lysis of fibrinogen at the concentration of 1:10 (venom: extract, w/w) and also the lysis of lecithin was reduced at a concentration of 1:25 (venom: extract, w/w). The extract was able to neutralize the LD50 of venom in both mice and embryo and also reduce the myotoxic and edema properties of the venom in mice models. The venom did not show any procoagulant and hemorrhagic effect. The leaf extract possess adequate compounds/phytochemicals that could neutralize the toxic properties/activity of the B. caeruleus venom.

Bilateral Parotid Enlargement and Trismus: An Unexpected Clinical Finding in a Patient with Common Krait (Bungarus caeruleus) bite.

We report a case of bilateral parotid enlargement and trismus due to the bite of common krait (Bungarus caeruleus). These clinical findings have not been reported in literature after the bite with this species.

Venomics of Bungarus caeruleus (Indian krait): Comparable venom profiles, variable immunoreactivities among specimens from Sri Lanka, India and Pakistan.

The Indian krait (Bungarus caeruleus) is one of the "Big Four" venomous snakes widely distributed in South Asia. The present venomic study reveals that its venom (Sri Lankan origin) is predominated by phospholipases A2 (64.5% of total proteins), in which at least 4.6% are presynaptically-acting ß-bungarotoxin A-chains. Three-finger toxins (19.0%) are the second most abundant, comprising 15.6% κ-neurotoxins, the potent postsynaptically-acting long neurotoxins. Comparative chromatography showed that venom samples from Sri Lanka, India and Pakistan did not exhibit significant variation. These venoms exhibited high immunoreactivity toward VINS Indian Polyvalent Antivenom (VPAV). The Pakistani krait venom, however, had a relatively lower degree of binding, consistent with its moderate neutralization by VPAV (potency=0.3mg venom neutralized per ml antivenom) while the Sri Lankan and Indian venoms were more effectively neutralized (potency of 0.44 mg/ml and 0.48 mg/ml, respectively). Importantly, VPAV was able to neutralize the Sri Lankan and Indian venoms to a comparable extent, supporting its use in Sri Lanka especially in the current situation where Sri Lanka-specific antivenom is unavailable against this species. The findings also indicate that the Pakistani B. caeruleus venom is immunologically less comparable and should be incorporated in the production of a pan-regional, polyspecific antivenom. BIOLOGICAL SIGNIFICANCE: The Indian krait or blue krait, Bungarus caeruleus, is a highly venomous snake that contributes to the snakebite envenoming problem in South Asia. This is a less aggressive snake species but its accidental bite can cause rapid and severe neurotoxicity, in which the patient may succumb to paralysis, respiratory failure and death within a short frame of time. The proteomic analysis of its venom (sourced from Sri Lanka) unveils its content that well correlates to its envenoming pathophysiology, driven primarily by the abundant presynaptic and postsynaptic neurotoxins (ß-bungarotoxins and κ-neurotoxins, respectively). The absence of cytotoxins in the venom proteome also correlates with the lack of local envenoming sign (pain, swelling), and explains why the bite may be insidious until later stage when paralysis sets in. The muscarinic toxin-like proteins in the venom may be the cause of severe abdominal pain that precedes paralysis in many cases, and justifies the need of closely monitoring this symptom in suspected cases. Venom samples from Sri Lanka, India and Pakistan exhibited no remarkable variation in protein profiling and reacted immunologically toward the VINS Indian Polyvalent Antivenom, though to a varying extent. The antivenom is effective in neutralizing the Sri Lankan and Indian venoms, confirming its clinical use in the countries. The antivenom efficacy against the Pakistani venom, however, may be further optimized by incorporating the Pakistani venom in the antivenom production.

Two rare case reports of confirmed Ceylon krait (Bungarus ceylonicus) envenoming in Sri Lanka.

The Ceylon krait (Bungarus ceylonicus) is a deadly venomous elapid snake endemic to Sri Lanka. Its habitat is mainly in the wet zone of the island. Despite its frequent encounters in and near human dwellings, reports of envenoming are rare and limited to four in the literature. The first and last fatal reports envenoming by B. ceylonicus was in 1993. After over two decades, we report two confirmed cases of B. ceylonicus bites-one a dry bite and the other with signs and symptoms of moderate envenoming. The envenoming occurred at night while the victim was asleep, causing tightness in the chest and dyspnoea on waking up, followed by neuromuscular paralysis that did not cause respiratory failure and complete recovery was observed three days following the bite.

In vivo and in vitro antileishmanial activity of Bungarus caeruleus snake venom through alteration of immunomodulatory activity.

Leishmaniasis threatens more than 350 million people worldwide specially in tropical and subtropical region. Antileishmanial drugs that are currently available have various limitations. The search of new drugs from natural products (plants, animals) possessing antileishmanial activity is ventured throughout the world. The present study deals with the antileishmanial activity of Bungarus caeruleus snake venom (BCV) on in vitro promastigotes and amastigotes of Leishmania donovani parasite and leishmania infected BALB/c mice. The effect of BCV on peritoneal macrophage, release of cytokines from the activated macrophages, production of nitric oxide, reactive oxygen species and cytokines were studied in vivo and in vitro. IC50 value of BCV on L. donovani promastigote was 14.5 µg/ml and intracellular amastigote was 11.2 µg/ml. It activated peritoneal macrophages, significantly increased cytokines and interleukin production. BCV (20 µg/kg and 40 µg/kg body weight of mice) decreased parasite count by 54.9% and 74.2% in spleen and 41.4% and 60.4% in liver of infected BALB/c mice. BCV treatment significantly increased production of TNF-α, IFN-γ, ROS, NO in infected mice. Histological studies showed decreased granuloma formation in treated liver as compared with control. Liver and spleen structure was partially restored due to BCV treatment in infected mice. The present study revealed that BCV possessed antileishmanial activity against L. donovani parasite in vivo and in vitro and this activity was partly mediated through immunomodulatory activity involving macrophages.

Deep coma and hypokalaemia of unknown aetiology following Bungarus caeruleus bites: Exploration of pathophysiological mechanisms with two case studies.

Bungarotoxin present in Bungarus caeruleus (BC) causes life threatening respiratory muscle paralysis. Deep coma and hypokalaemia have been observed in a significant proportion of patients, but the cause is unknown. We postulate the likely mechanism behind these two phenomena. We studied clinical details of two patients admitted with deep coma and performed electroencephalograms (EEG) and brain stem auditory and visual evoked potentials (BAEP and VEP). Daily serum potassium was measured along with urinary potassium excretion as a marker of total extracellular body potassium. Both patients had no brain stem reflexes on admission and the EEG revealed absent alpha and delta activity and presence of dominant theta activity. Alpha rhythm returned on the 3(rd) day in one patient, while in the other it did not, and the latter patient died on the 13(th) day due to disseminated intravascular coagulation. BAEP were delayed and VEP were absent in the deceased patient. Both had low serum potassium and low urinary potassium excretion. Replacement of potassium (up to 1.5mmol/kg/day) did not improve serum potassium and urinary potassium excretion. Absent alpha and delta activity in EEG and delayed BAEP and absent VEP are suggestive of a central action of the venom on both the cortical and brain stem neurones. Persistently low serum potassium and reduced urinary potassium excretion are suggestive of intracellular shift as the causative mechanism of hypokalaemia.

Purification of an L-amino acid oxidase from Bungarus caeruleus (Indian krait) venom

Snake venoms are rich in enzymes such as phospholipase A2, proteolytic enzymes, hyaluronidases and phosphodiesterases, which are well characterized. However, L-amino acid oxidase (LAO EC.1.4.3.2) from snake venoms has not been extensively studied. A novel L-amino acid oxidase from Bungarus caeruleus venom was purified to homogeneity using a combination of ion-exchange by DEAE-cellulose chromatography and gel filtration on Sephadex® G-100 column. The purified monomer of LAO showed a molecular mass of 55 ±1 kDa estimated by SDS-PAGE. The specific activity of purified LAO was 6,230 ± 178 U/min/mg, versus 230 ± 3.0 U/min/mg for the whole desiccated venom, suggesting a 27-fold purification with a 25% yield. Optimal pH and temperature for maximum purified enzyme activity were 6.5 and 37ºC, respectively. Platelet aggregation studies show that purified LAO inhibited ADP-induced platelet aggregation dose-dependently at 0.01 to 0.1 µM with 50% inhibitory concentration (IC50) of 0.04 µM, whereas at a 0.08 µM concentration it did not induce appreciable aggregation on normal platelet-rich plasma (PRP). The purified protein catalyzed oxidative deamination of L-amino acids while the most specific substrate was L-leucine. The purified LAO oxidizes only L-forms, but not D-forms of amino acids, to produce H2O2. The enzyme is important for the purification and determination of certain amino acids and for the preparation of α-keto acids.(AU)

Preliminary studies with a neurotoxin obtained from Bungarus caeruleus venom

The neurotoxin purified from the venom of Bungarus caeruleus causes a neuromuscular blockade on acetylcholine-induced muscle twitch response in isolated frog rectus abdominis muscle preparation. Neuromuscular blockade produced by d-tubocurarine on acetylcholine-induced muscle twitch response in an isolated frog rectus abdominis muscle preparation was reversed to normal muscle twitch response in presence of neostigmine. Whereas the purified neurotoxin produced an irreversible neuromuscular blockade in presence of the same strength of neostigmine. As it is already known, botulinum toxin, which also brings about neuromuscular blockade, is effectively used as a drug in the treatment of painful movement disorders. Since the purified toxin also causes paralysis of the muscle, we propose its possible efficacy in the treatment of neuromuscular disorders.(AU)