Pit Viper Envenomation in Two Pregnant Bitches.

Snake envenomation is relatively common in small animals, particularly in endemic areas. Effects and outcomes of envenomation during pregnancy are poorly described in humans and more so in veterinary patients. Two young pregnant female dogs presented to a university teaching hospital with a history of acute soft tissue swelling and bleeding. History, physical examination findings, and diagnostics were consistent with envenomation by crotalid snakes. Medical management of one of the dogs included administration of antivenin. Both dogs survived envenomation with minimal complications and went on to whelp without complications, and all fetuses survived. This is the first description of the management of pit viper envenomation in pregnant dogs.

Neutralization of the lethal activity from Bothrops atrox venom by hyperimune llama serum (Lama glama). / Neutralización de la actividad letal del veneno de serpiente Bothrops atrox por suero hiperinmune de llama (Lama glama).

OBJECTIVES: To evaluate the capacity of the hyperimmune llama serum (Lama glama) to neutralize the lethal activity of Bothrops atrox venom in laboratory mice. MATERIALS AND METHODS: Mean lethal dose (LD50) was calculated from a Bothrops atrox venom sample pool from Peru. The antibody titers were measured by ELISA assay; and the immune serum neutralization potency was measured by calculating the mean effective dose (ED50) during the immunization period. RESULTS: The venom's LD50 was 3.96 µg/g; similar to what was found in other studies about Bothrops atrox carried out in Peru. The titers of antibodies against the venom increased rapidly in the llama, demonstrating a fast immune response; however, the neutralization capacity increased slowly and required several doses and immunization reinforcements, obtaining a ED50 of 3.30 µL/g mouse and a neutralization potency of 3.6 mg/mL after 15 immunizations. CONCLUSIONS: The hyperimmune llama serum is able to neutralize the lethality of the Bothrops atrox venom from Peru in laboratory mice.

OBJETIVOS: Evaluar la capacidad del suero hiperinmune de llama (Lama glama) para neutralizar la letalidad del veneno de la serpiente Bothrops atrox en ratones de laboratorio. MATERIALES Y MÉTODOS: Se calculó la dosis letal media (DL50) de un pool de venenos de serpientes de Bothrops atrox de Perú, y se midieron los títulos de anticuerpos por ensayo ELISA; así como la potencia de neutralización del suero inmune por el cálculo de la dosis efectiva media (DE50) durante el periodo de inmunización. RESULTADOS: La DL50 del veneno fue de 3,96 µg/g, similar a otros trabajos realizados en Bothrops atrox en Perú. Los títulos de anticuerpos contra el veneno se incrementan rápidamente en la llama mostrando una rápida respuesta inmune; sin embargo, la capacidad de neutralización se incrementa más lentamente y requiere de varias dosis y refuerzos de las inmunizaciones alcanzado una DE50 de 3,30 µL/g ratón y una potencia de neutralización 3,6 mg/mL después de 15 inmunizaciones. CONCLUSIONES: El suero hiperinmune de llama es capaz de neutralizar la letalidad del veneno de la serpiente Bothrops atrox de Perú en ratones de laboratorio.

Fatal brain hemorrhage after Bothrops asper bite in the Catatumbo region of Colombia / [Hemorragia cerebral fatal después de una mordedura de serpiente Bothrops asper en la región del Catatumbo, Colombia].

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.

Biochemical characterization of Bothrops roedingeri Mertens, 1942 snake venom and its edematogenic, hemorrhagic, and myotoxic activities / [Caracterización bioquímica del veneno de la serpiente Bothrops roedingeri Mertens, 1942, y sus actividades edematógena, hemorrágica y miotóxica].

Introduction: Snakebite envenoming is considered by the World Health Organization (WHO) as a neglected tropical disease. Currently, Bothrops snake venoms are being studied intensively, but there is little knowledge about Bothrops roedingeri venom. Objectives: To biochemically characterize B. roedingeri total venom and evaluate its myotoxic, edematogenic, and hemorrhagic activity. Materials and methods: We characterized B. roedingeri venom enzymatic activity by determining the phospholipase A2 and the proteolytic and fibrinogenolytic action using SDSPAGE electrophoresis while we characterized its venom toxicity by determining the minimum hemorrhagic dose, the minimum edema dose, and the local and systemic myotoxic effects. Results: Bothrops roedingeri venom showed a PLA2 activity of 3.45 ± 0.11 nmoles/min, proteolytic activity of 0.145 ± 0.009 nmoles/min, and a fibrinogen coagulation index of 6.67 ± 1.33 seconds. On the other hand, it produced an minimum hemorrhagic dose of 24.5 µg, an minimum edema dose of 15.6 µg, and a pronounced local myotoxic effect evidenced by the elevation of plasma creatine kinase levels after intramuscular inoculation. The venom showed no systemic myotoxicity. Conclusions: Bothrops roedingeri venom has local hemorrhagic, edematogenic, and myotoxic activity. Enzymatically, it has high PLA2 activity, which would be responsible for the myotoxic and edematogenic effects. It also has proteolytic activity, which could affect coagulation given its ability to degrade fibrinogen, and it causes bleeding through the metalloproteases.

Introducción. El envenenamiento por mordedura de serpiente es considerado por la Organización Mundial de la Salud (OMS) una enfermedad tropical desatendida. Si bien los venenos de otras serpientes Bothrops se vienen estudiado ampliamente, poco se conoce del de Bothrops roedingeri. Objetivos. Caracterizar bioquímicamente el veneno total de la serpiente B. roedingeri y evaluar su actividad miotóxica, edematógena y hemorrágica. Materiales y métodos. Se hizo la caracterización enzimática del veneno de B. roedingeri determinando la actividad de la fosfolipasa A2 (PLA2) y de las enzimas proteolíticas, así como su acción fibrinogenolítica mediante electroforesis en gel de poliacrilamida con duodecilsulfato sódico (sodium dodecyl sulfate polyacrylamide gel electrophoresis, SDSPAGE), y la caracterización tóxica del veneno estableciendo la dosis hemorrágica mínima, la dosis edematógena mínima y el efecto miotóxico local y sistémico. Resultados. La actividad de las PLA2 del veneno total de B. roedingeri fue de 3,45 ± 0,11 nmoles/minuto, la proteolítica, de 0,145 ± 0,009 nmoles/minuto, en tanto que el índice de coagulación del fibrinógeno fue de 6,67 ± 1,33 segundos. Por otro lado, el veneno produjo una dosis hemorrágica mínima de 24,5 µg, una dosis edematógena mínima de 15,6 µg y un pronunciado efecto miotóxico local evidenciado por la elevación de los niveles plasmáticos de creatina cinasa después de la inoculación por vía intramuscular. No se registró miotoxicidad sistémica. Conclusiones. El veneno de B. roedingeri tiene efectos hemorrágicos, edematógenos y miotóxicos locales, así como una elevada actividad de la PLA2, que sería responsable de los efectos miotóxico y edematógeno. También presentó actividad proteolítica, la cual podría afectar la coagulación, dada su capacidad para degradar el fibrinógeno y producir hemorragia por acción de las metaloproteasas.

Neutralización de la actividad letal del veneno de serpiente Bothrops atrox por suero hiperinmune de llama (Lama glama) / Neutralization of the lethal activity from Bothrops atrox venom by hyperimune llama serum (Lama glama)

RESUMEN Objetivos: Evaluar la capacidad del suero hiperinmune de llama (Lama glama) para neutralizar la letalidad del veneno de la serpiente Bothrops atrox en ratones de laboratorio. Materiales y métodos: Se calculó la dosis letal media (DL50) de un pool de venenos de serpientes de Bothrops atrox de Perú, y se midieron los títulos de anticuerpos por ensayo ELISA; así como la potencia de neutralización del suero inmune por el cálculo de la dosis efectiva media (DE50) durante el periodo de inmunización. Resultados: La DL50 del veneno fue de 3,96 µg/g, similar a otros trabajos realizados en Bothrops atrox en Perú. Los títulos de anticuerpos contra el veneno se incrementan rápidamente en la llama mostrando una rápida respuesta inmune; sin embargo, la capacidad de neutralización se incrementa más lentamente y requiere de varias dosis y refuerzos de las inmunizaciones alcanzado una DE50 de 3,30 µL/g ratón y una potencia de neutralización 3,6 mg/mL después de 15 inmunizaciones. Conclusiones: El suero hiperinmune de llama es capaz de neutralizar la letalidad del veneno de la serpiente Bothrops atrox de Perú en ratones de laboratorio.

ABSTRACT Objectives: To evaluate the capacity of the hyperimmune llama serum (Lama glama) to neutralize the lethal activity of Bothrops atrox venom in laboratory mice. Materials and methods: Mean lethal dose (LD50) was calculated from a Bothrops atrox venom sample pool from Peru. The antibody titers were measured by ELISA assay; and the immune serum neutralization potency was measured by calculating the mean effective dose (ED50) during the immunization period. Results: The venom's LD50 was 3.96 μg/g; similar to what was found in other studies about Bothrops atrox carried out in Peru. The titers of antibodies against the venom increased rapidly in the llama, demonstrating a fast immune response; however, the neutralization capacity increased slowly and required several doses and immunization reinforcements, obtaining a ED50 of 3.30 μL/g mouse and a neutralization potency of 3.6 mg/mL after 15 immunizations. Conclusions: The hyperimmune llama serum is able to neutralize the lethality of the Bothrops atrox venom from Peru in laboratory mice.

A case of envenomation by the false fer-de-lance snake Leptodeira annulata (Linnaeus, 1758) in the department of La Guajira, Colombia. / Un caso de envenenamiento por mordedura de una serpiente falsa cabeza de lanza, Leptodeira annulata (Linnaeus, 1758), en el departamento de La Guajira, Colombia

Envenomations by colubrid snakes in Colombia are poorly known, consequently, the clinical relevance of these species in snakebite accidents has been historically underestimated. Herein, we report the first case of envenomation by opisthoglyphous snakes in Colombia occurred under fieldwork conditions at the municipality of Distracción, in the department of La Guajira. A female biologist was bitten on the index finger knuckle of her right hand when she tried to handle a false fer-de-lance snake (Leptodeira annulata). Ten minutes after the snakebite, the patient started to have symptoms of mild local envenomation such as edema, itching, and pain in the wound. After 40 minutes, the edema reached its maximum extension covering the dorsal surface of the right hand and causing complete loss of mobility. The clinical treatment focused on pain and swelling control. No laboratory tests were performed. The patient showed good progress with the total regression of the edema 120 hours after the snake-bite accident and complete recovery of the movement of the limb in one week. Venomous bites of "non-venomous snakes" (opisthoglyphous colubrid snakes) must be considered as a significant public health problem because patients lose their work capability during hours or even days and they are forced to seek medical assistance to treat the envenomation manifestations.

Los envenenamientos por colúbridos en Colombia son poco conocidos, por lo que la relevancia clínica de estas especies de serpientes en los accidentes ofídicos ha sido históricamente subestimada. Se presenta el primer caso de envenenamiento por una serpiente opistoglifa en Colombia, ocurrido bajo condiciones de trabajo de campo en el municipio de Distracción, departamento de La Guajira. Una bióloga fue mordida en el nudillo del dedo índice de la mano derecha cuando trató de manipular una falsa cabeza de lanza o falsa mapanare (Leptodeira annulata). Diez minutos después de la mordedura de la serpiente, la paciente presentó síntomas de envenenamiento local leve, como edema, picazón y dolor en la herida. Después de 40 minutos, el edema alcanzó su extensión máxima, cubriendo la superficie dorsal de la mano derecha y causando la pérdida completa de la movilidad. El tratamiento clínico se centró en el control del dolor y la inflamación. No se hicieron pruebas de laboratorio. La paciente tuvo una buena evolución, con la regresión total del edema 120 horas después del accidente ofídico y la normalización de los movimientos de la extremidad a la semana. Las mordeduras venenosas de serpientes "no venenosas" (serpientes colúbridas opistoglifas) deben considerarse un problema de salud pública importante, ya que los pacientes pierden la capacidad de trabajo durante horas o días y se ven obligados a buscar asistencia médica para contrarrestar las manifestaciones locales de envenenamiento.

A life-threatening complication due to pulmonary haemorrhage following hump-nosed viper bite.

BACKGROUND: Hump-nosed viper bite, the commonest venomous snake bite in Sri Lanka, is associated with significant morbidity. Specific anti-venom is not available for hump-nosed viper envenomation which is usually managed with supportive treatment. Pulmonary haemorrhage is an unusual manifestation of hump-nosed viper bite. Here we present a case of hump-nosed viper envenomation which complicated by pulmonary haemorrhage and was successfully treated with systemic steroids. To the best of our knowledge, it has not been reported in the literature before. CASE PRESENTATION: A previously healthy 55-year-old man presented to the local hospital 18 h after a hump-nosed viper bite. He developed bilateral severe pulmonary haemorrhages, evidenced by rapid desaturation which needed intubation and mechanical ventilation, bleeding from the endotracheal tube and bilateral alveolar shadows in a chest x-ray. He had no other bleeding manifestations. Because of the life-threatening situation, he was treated with methylprednisolone pulse therapy. There was a rapid improvement of hypoxia with a resolution of x-ray changes. He was successfully weaned off from the ventilation after 24 h. CONCLUSION: This case highlights the importance of suspecting pulmonary haemorrhage in a patient who develops desaturation and alveolar shadow following hump-nosed viper bite even in the absence of other bleeding manifestation. Early and timely treatment with systemic steroid can be lifesaving in such patients.

Review of North American pit viper antivenoms.

PURPOSE: For the first time in nearly 20 years, 2 antigen-binding fragment (Fab) antivenoms are available to treat patients who incur North American pit viper snakebites: Crotalidae polyvalent immune Fab (ovine), or simply FabAV; and Crotalidae immune F(ab')2 (equine), or simply F(ab')2. Pharmacists are in a key position for the selection, dosing, reconstitution, administration, and monitoring of antivenom therapy; however, they encounter inconsistent exposure and experience with these drugs. Thus, an updated review of the literature is necessary. METHODS: The search strategy and selection incorporated both controlled vocabulary terms and keywords to describe concepts relevant to the search. Retrieval was limited to literature published from 1997 to the present in English, Portuguese, or Spanish. RESULTS: Given the paucity of available prospective literature, the authors elected to include all prospective evidence to best describe the role of antivenom. For the primary literature review, manuscripts were excluded if they were observational studies, conference abstracts, narrative or opinion articles, letters to the editor, or in-progress studies. CONCLUSION: While there is limited evidence-based guidance on the superiority of F(ab')2 to FabAV, or vice versa, individual and regional considerations should contribute to formulary decisions. Pharmacists must play a role in the development of clinical pathways to ensure appropriate evaluation, supportive care, and antivenom procurement, administration, and monitoring.

Envenenamientos por mordedura de serpiente en Guatemala: revisión de literatura / Snakebite envenomings in Guatemala: literature review

El accidente ofídico es una enfermedad tropical desatendida que ocasiona un problema de salud pública en el mundo, siendo una de las principales causas de morbilidad y mortalidad en las áreas empobrecidas de América Latina. En Guatemala se distribuyen 23 especies de serpientes venenosas de importancia médica. La composición de los venenos es compleja y diversa, resultando en una variedad de manifestaciones clínicas. Los departamentos con mayor incidencia de ofidismo son Petén, Alta Verapaz, Quiché, Escuintla e Izabal. Estos accidentes afectan más a hombres que a mujeres, siendo la mayoría agricultores; el rango de edad más comprometido es de 10-19 años y principalmente ocurren en miembros inferiores. El tiempo medio que tarda la víctima en llegar al hospital es de 5.6 h, siendo el retraso en la atención médica, un factor de riesgo para severidad y mortalidad. Los servicios de salud en ocasiones no cuentan con recursos idóneos para atender a las víctimas, brindando tratamiento sintomático. Simultáneamente, el tratamiento empírico tiene gran aceptación, sin embargo, los resultados de investigaciones realizadas con algunas plantas de uso común en casos de ofidismo, concluyeron que no es recomendable su uso aislado en el tratamiento del envenenamiento. Dada la falta de información se debe promover más investigación sobre el ofidismo en el país, siendo indispensable la elaboración de una ficha de reporte obligatoria. Además, deben elaborarse guías de tratamiento e identificación de serpientes para uso del personal médico, incluyendo programas de educación a nivel comunitario.

Snakebite envenoming is a neglected tropical disease that causes a public health problem in the world, being one of the main causes of morbidity and mortality in impoverished areas of Latin America. 23 species of poi-sonous snakes of medical importance are distributed in Guatemala. The composition of venoms is complex and diverse, resulting in a variety of clinical manifestations. The departments with the highest incidence of snakebites are Petén, Alta Verapaz, Quiché, Escuintla and Izabal. These accidents affect more men than women, the majo-rity being farmers; the most compromised age range is 10-19 years and they mainly occur in the lower limbs. The average time it takes for the victim to reach the hospital is 5.6 hours, with delay in medical care being a risk factor for severity and mortality. Health services sometimes do not have adequate resources to care for victims, providing symptomatic treatment. Simultaneously, empirical treatment is widely accepted, however, the results of research carried out with some plants commonly used in cases of envenoming concluded that their isolated use is not recommended in the treatment. Given the lack of information, more research on snakebite envenoming in the country should be promoted, making the preparation of a mandatory report form essential. In addition, snake identification and treatment guides should be developed for use by medical personnel, including education pro-grams at the community level.

Presumed Copperhead Snakebite and Antivenom Administration in the Third Trimester.

Snake envenomation during pregnancy is an uncommon emergency with several potential complications associated with the poisoning and its treatment. This case discusses a 27-y-old gravida 3, para 1102 (3 total pregnancies, 1 term birth, 1 premature birth, 0 abortions, 2 living births, twins) at 36 wk gestation who was bitten by a presumed Agkistrodon contortrix (copperhead snake). She had worsening pain and swelling in the right lower limb. Crotalidae polyvalent immune Fab was administered. The patient felt significantly better with improvement in swelling. She had a reactive nonstress test and reassuring coagulation studies. She gave birth to a healthy female infant 12 d later. This case supports the use of Crotalidae polyvalent immune Fab for venomous snakebites in pregnant patients to prevent possible maternal and fetal morbidity and mortality.

Systemic bleeding including pulmonary haemorrhage following hump-nosed pit viper (Hypnale hypnale) envenoming: A case report from Sri Lanka.

Out of seven venomous land snake species of Sri Lanka, hump-nosed pit viper (Hypnale spp.) causes the commonest venomous snakebites. It is widely distributed all over the country except in the peninsula of Jaffna. The genus has three species naming H. hypnale, H. zara and H. nepa. They frequently cause local envenoming and rarely cause coagulopathy and acute kidney injury. Systemic bleeding is the most trivial complication associated with coagulopathy caused by these snakes and pulmonary haemorrhages are one of them which are rarely reported. Antivenoms are currently not available for genus Hypnale bites in Sri Lanka. We describe a fatal case of pulmonary haemorrhage caused by a proven hump-nosed viper (Hypnale hypnale) bite associated with other systemic bleeding manifestations and thrombotic microangiopathy. This is the first known case of pulmonary and intracranial haemorrhages caused by hump-nosed viper bite.

Bothrops alternatus snake venom induces apoptosis of skeletal muscle cells in a rabbit model / O veneno da serpente Bothrops alternatus induz apoptose nas células musculares de coelhos

Este estudo objetiva reportar a ocorrência de apoptose in vivo induzida pelo veneno da serpente Bothrops alternatus em células musculares esqueléticas. Cinco coelhos machos, adultos, receberam 150µg/kg de veneno no músculo vasto lateral, enquanto outros cinco animais receberam 0,1% de BSA diluído em PBS no mesmo local. Após 12 horas, os animais foram eutanasiados, e amostras do local de inoculação foram coletadas para análise histopatológica. Foram evidenciadas necrose e hemorragia nas células musculares. Além disso, a análise imuno-histoquímica para identificação de caspase-3 ativada revelou marcações granulares e agregadas no citoplasma das células musculares, compatíveis com o processo de apoptose. Este é o primeiro relato que confirma o veneno de B. alternatus como causador de apoptose in vivo em células musculares esqueléticas.(AU)

Thrombotic microangiopathy following Bothrops jararaca snakebite: case report.

CONTEXT: Thrombotic microangiopathy (TMA) is an uncommon and severe complication of snakebites, and is similar, in general, to hemolytic-uremic syndrome (HUS). We describe a case of TMA following envenomation by Bothrops jararaca. CASE DETAILS: A 56-y-old-woman with controlled hypertension was transferred from a primary hospital to our ER ∼7 h after being bitten by B. jararaca in the distal left leg. She developed edema extending from the bite site to the proximal thigh, associated with intense radiating local pain, local paresthesia and ecchymosis at the bite site. Laboratory features upon admission revealed coagulopathy (20 min whole blood clotting time - WBCT20 > 20 min), thrombocytopenia (76,000 platelets/mm3) and slight increase in serum creatinine (1.58 mg/dL; RV < 1.2 mg/dL). Upon admission, the patient was treated with bothropic antivenom and fluids replacement. During evolution, her thrombocytopenia and anemia worsened, with blood films showing fragmented red cells, haptoglobin consumption, increase in serum lactate dehydrogenase, and progressive increase of serum creatinine (KDIGO stage = 3). No RBC transfusion, renal replacement therapy or plasmapheresis was done. The patient showed progressive improvement from day nine (D9) onwards and was discharged on D20; there was complete recovery of hemoglobin levels at follow-up (D50). ADAMTS-13 activity, assayed 10 months post-bite, was within reference values. DISCUSSION: TMA following snakebite has been reported mainly in India, Sri Lanka and Australia, with several patients needing renal replacement therapy. Although controversial, plasmapheresis has also been used in some cases. Our patient developed microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury, a triad of features compatible with TMA similar to HUS. Despite the severity, the outcome following conservative treatment was good, with complete recovery.

Severe snakebite envenomation in French Guiana: When antivenom is not available.

In French Guiana, Bothrops atrox, Bothrops brazili, Bothrops bilineatus, Lachesis muta and Micrurus sp are responsible for most cases of snakebite envenomation. The clinical features in patients suffering from envenomations by viperid snakes involve local tissue damage and systemic manifestations, such as hemorrhage, coagulopathies and hemodynamic instability. We report a severe case of envenomation in a patient bitten by a large unidentified pit viper in French Guiana. Due to lack of antivenom, the patient only received symptomatic management. Severe manifestations of local and systemic envenomation developed, and the patient needed multiple debridement procedures and ultimately required a transfemoral amputation. In addition, Aeromonas hydrophila was cultivated from the affected tissue, suggesting that infection contributed to necrotizing fasciitis. This case highlights the clinical features of a severe viperid snakebite envenomation, and illustrates the urgent need to ensure accessibility of effective and safe polyvalent viperid antivenom in French Guiana.

Cardiac arrest and atrial fibrillation in a patient after hump-nosed pit viper (Hypnale hypnale) bite.

A 42-year-old previously healthy male patient died 16 days after a proven hump-nosed pit viper (Hypnale hypnale) envenoming due to multi-organ failure. On admission he had cardiac arrest that recovered from cardiopulmonary resuscitation then developed atrial fibrillation which was reverted to normal rhythm by application of synchronized electrical cardioversion. He also had persistent coagulopathy and thrombotic microangiopathy comprising the triad of microangiopathic haemolysis, acute kidney injury and thrombocytopenia. This is the second reported case with cardiac complications following hump-nosed pit viper bites in Sri Lanka.

Epidemiology and clinical features of Green pit viper (Trimeresurus trigonocephalus) envenoming in Sri Lanka.

Green pit viper is a venomous endemic snake in Sri Lanka. But little is known regarding its envenoming in the country. This study was carried out in order to find out epidemiology and clinical profile of its bites. A series of 17 patients with Sri Lankan Green pit viper (Trimeresurus trigonocephalus) bites was prospectively studied over 4 years. The mean age was 36 ½ years (range 12-61 years) and comprised 14 (82%) males. Except one case, all bites occurred during day time (0600 h-1800 h) due to inadvertent provocation. In 13 cases (76%) bite took place in estates (tea or cinnamon) and 8 patients (47%) were estate workers. The bitten sites were upper limbs in 11 cases (65%) and lower limbs in 6 cases (35%). Ten patients (59%) brought the offending snake to the hospital and one patient was asymptomatic. Sixteen (94%) developed local envenoming features- 16 (94%) local pain and swelling, 6 (35%) local bleeding and lymphadenopathy and blistering in 4 (24%) patients. Systemic envenoming developed in 4 (24%) patients including 3 (18%) with coagulopathy that was treated with fresh frozen plasma. One (6%) patient developed bradycardia. Sri Lankan Green pit viper bites commonly occurs in estates and causes local envenoming frequently and coagulopathy occasionally.

Effects of photobiomodulation therapy on Bothrops moojeni snake-envenomed gastrocnemius of mice using enzymatic biomarkers.

Bothropic venom contains a range of biologically active substances capable of causing severe local and systemic envenoming symptomatology within its victims. The snake anti-venom is effective against systemic effects but has no neutralizing effect against the fast developing local effects. Herein, mice gastrocnemius injected with Bothrops moojeni venom (40 µg/kg) or saline solution were irradiated with HeNe (632.8 nm) and GaAs (904 nm) lasers (daily energy density of 4 J/cm2; 0.03/0.21 power density; 0.07/0.16 spot size; 1.2/0.04 total energy, 1 cm off contact, for HeNe and GaAs lasers, respectively) and euthanized in periods ranging from 3 h to 21 days. Blood biochemistry for creatine kinase (CK), alkaline phosphatase (ALP), acid phosphatase (AP), lactate dehydrogenase (LDH), aspartate transaminase (AST), and myoglobin and histopathological analysis, for assessing the degree of myonecrosis and regeneration of gastrocnemius, were done at every time interval. GaAs laser promoted faster photobiomodulation therapy (PBMT) effects, and the GaAs group exhibited a better clinical outcome than the HeNe group. Within the GaAs group, the serum levels of CK, LDH, AP, AST, and myoglobin, which were increased by the physiological effects of the venom, were reduced to initial baseline before snake envenomation in less time than those irradiated by the HeNe laser. However, the group receiving irradiation from the HeNe laser returned the levels of ALP activity to baseline faster than those of the GaAs group. Histopathological analysis revealed enhanced muscle regeneration in mice groups treated with both lasers. PBM promoted by GaAs and HeNe showed well-developed centrally nucleate regenerating cells and an increased number of newly formed blood vessels when compared to unirradiated muscle. We therefore suggest that GaAs had the best outcomes likely derived from a deeper penetrating longer wavelength. We conclude that PMBT is a promising, non-invasive approach to be further tested in pre-clinical studies with a goal to further its clinical use in skeletal muscle recovery in snakebite victims.

The Efficacy of Crotalidae Polyvalent Immune Fab (Ovine) Antivenom Versus Placebo Plus Optional Rescue Therapy on Recovery From Copperhead Snake Envenomation: A Randomized, Double-Blind, Placebo-Controlled, Clinical Trial.

STUDY OBJECTIVE: Copperhead snake (Agkistrodon contortrix) envenomation causes limb injury resulting in pain and disability. It is not known whether antivenom administration improves limb function. We determine whether administration of antivenom improves recovery from limb injury in patients envenomated by copperhead snakes. METHODS: From August 2013 through November 2015, we performed a multicenter, randomized, double-blind, placebo-controlled, clinical trial to evaluate the effect of ovine Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV) antivenom therapy on recovery of limb function in patients with copperhead snake envenomation at 14 days postenvenomation. The study setting was 18 emergency departments in regions of the United States where copperhead snakes are endemic. Consecutive patients aged 12 years or older with mild- to moderate-severity envenomation received either FabAV or placebo. The primary outcome was limb function 14 days after envenomation, measured by the Patient-Specific Functional Scale. Additional outcomes included the Patient-Specific Functional Scale at other points; the Disorders of the Arm, Shoulder, and Hand, Lower Extremity Functional Scale, and Patient's Global Impression of Change instruments; grip strength; walking speed; quality of life (Patient-Reported Outcomes Measurement Information System Physical Fucntion-10); pain; and analgesic use. RESULTS: Seventy-four patients received study drug (45 FabAV, 29 placebo). Mean age was 43 years (range 12 to 86 years). Fifty-three percent were men, 62% had lower extremity envenomation, and 88% had mild initial severity. The primary outcome, the least square mean Patient-Specific Functional Scale score at 14 days postenvenomation, was 8.6 for FabAV-treated subjects and 7.4 for placebo recipients (difference 1.2; 95% confidence interval 0.1 to 2.3; P=.04). Additional outcome assessments generally favored FabAV. More FabAV-treated subjects experienced treatment-emergent adverse events (56% versus 28%), but few were serious (1 in each group). CONCLUSION: Treatment with FabAV reduces limb disability measured by the Patient-Specific Functional Scale 14 days after copperhead envenomation.