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Pandit K, Rawal A, Maskey HMS, Nepal G. Neurological and neuro-ophthalmological manifestations of snake bite: a systematic review. Ann Med Surg (Lond) 2024; 86:392-400. [PMID: 38222724 PMCID: PMC10783398 DOI: 10.1097/ms9.0000000000001523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/09/2023] [Indexed: 01/16/2024] Open
Abstract
Objective Snakebites, a major health concern in developing countries, affect rural farming communities. Venom, primarily neurotoxin, injected during a snake bite disrupts the nervous system, causing symptoms like muscle weakness, paralysis, altered sensation, and coordination issues. This review focuses on evaluating neurological and neuro-ophthalmological manifestations associated with snakebites. Methods A database search was conducted in EMBASE and PubMed for studies published from 2000 to 2023. The investigation centered on examining neurological and neuro-ophthalmological symptoms and signs, treatment approaches, treatment outcomes, and long-term complications of snake bites. Results Neurological and neuro-ophthalmological symptoms were common in both neurotoxic and hemotoxic snake bites, especially in neurotoxic cases. Ptosis was a prevalent manifestation across various snake bites, along with respiratory paralysis, limb weakness, dysphasia, and visual disturbances in some instances. However, most patients improved without residual neurological symptoms after treatment. Conclusions Understanding patterns of neurological manifestations contributes valuable insights for the comprehensive management of snakebite.
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Affiliation(s)
- Kamal Pandit
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Aastha Rawal
- Department of Pharmacy, Manmohan Memorial Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Himang Man Singh Maskey
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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Dobaja Borak M, Babić Ž, Caganova B, Grenc D, Karabuva S, Kolpach Z, Krakowiak A, Kolesnikova V, Lukšić B, Pap C, Puljiz I, Piekarska-Wijatkowska A, Radenkova-Saeva J, Vučinić S, Zacharov S, Eddleston M, Brvar M. Viper envenomation in Central and Southeastern Europe: a multicentre study. Clin Toxicol (Phila) 2023; 61:656-664. [PMID: 37988116 DOI: 10.1080/15563650.2023.2273761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Snakebite incidence varies across Europe. However, there is limited research from Central and Southeastern Europe. These regions are notable for the presence of the common European adder (Vipera berus) and the more venomous nose-horned viper (Vipera ammodytes). No standard European antivenom protocol exists. The aim was to assess the epidemiology and treatment of viper bites in this region, focusing on a comparison of bites from Vipera berus and Vipera ammodytes. METHODS We conducted a prospective multicenter study in Central and Southeastern Europe from 2018 to 2020. This study included poison centres and toxicology-associated hospital wards in Poland, the Czech Republic, Slovakia, Hungary, Slovenia, Croatia, Serbia, and Bulgaria. The following data were collected: age, gender, Vipera species, snakebite site, clinical picture, laboratory results, Audebert's clinical severity grading score, and antivenom therapy. RESULTS The annual incidence of viper bites in Central and Southeast Europe was estimated at 2.55 bites per million population. Within their respective geographical distribution areas, the incidence of Vipera ammodytes bites (1.61 bites per million population) was higher than Vipera berus bites (1.00 bites per million population). Patients bitten by Vipera ammodytes more frequently reported local pain and developed thrombocytopenia. Antivenom treatment was more commonly administered in Vipera ammodytes bites (72%) compared to Vipera berus bites (39%). The incidence of Vipera ammodytes bites treated with antivenom within its geographical distribution area was three times higher than Vipera berus bites treated with antivenom (1.16 bites per million population versus 0.39 bites per million population). No deaths were reported. CONCLUSIONS The estimated incidence of viper bites in Central and Southeastern Europe is at least 2.55 per million population. Vipera ammodytes bites are more common and severe, characterized by higher frequencies of pain and thrombocytopenia. Antivenom is needed more often for Vipera ammodytes bites. It is vital that enough European Medicines Agency-approved Vipera ammodytes antivenom is produced and offered affordably.
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Affiliation(s)
- Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Željka Babić
- Poison Centre, Institute for Medical Research and Occupational Health, Zagreb, Croatia
| | - Blažena Caganova
- National Toxicological Information Centre, University Hospital, Bratislava, Slovakia
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital of Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Zuzana Kolpach
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Anna Krakowiak
- Nofer Institute of Occupational Medicine, Łódź, Poland
- Clinic of Anesthesiology and Intensive Care, Toxicology Unit, Central Clinical Hospital of the Medical University of Łódź, Łódź, Poland
| | - Viktoriia Kolesnikova
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital of Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Csaba Pap
- Department of Toxicology, Péterfy Hospital, Budapest, Hungary
| | - Ivan Puljiz
- University hospital for infectious diseases "Dr. Fran Mihaljević", Zagreb, Croatia
| | | | - Julia Radenkova-Saeva
- Clinic of Toxicology, University Hospital for Emergency Medicine "N.I.Pirogov", Sofia, Bulgaria
| | - Slavica Vučinić
- National Poison Centre, Military Medical Academy, Medical Faculty University of Defense, Belgrade, Serbia
| | - Sergej Zacharov
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Michael Eddleston
- Department of Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Gamulin E, Mateljak Lukačević S, Halassy B, Kurtović T. Snake Antivenoms-Toward Better Understanding of the Administration Route. Toxins (Basel) 2023; 15:398. [PMID: 37368699 DOI: 10.3390/toxins15060398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Envenomations induced by animal bites and stings constitute a significant public health burden. Even though a standardized protocol does not exist, parenterally administered polyclonal antivenoms remain the mainstay in snakebite therapy. There is a prevailing opinion that their application by the i.m. route has poor efficacy and that i.v. administration should preferentially be chosen in order to achieve better accomplishment of the antivenom therapeutic activity. Recently, it has been demonstrated that neutralization not only in the systemic circulation but also in the lymphatic system might be of great importance for the clinical outcome since it represents another relevant body compartment through which the absorption of the venom components occurs. In this review, the present-day and summarized knowledge of the laboratory and clinical findings on the i.v. and i.m. routes of antivenom administration is provided, with a special emphasis on the contribution of the lymphatic system to the process of venom elimination. Until now, antivenom-mediated neutralization has not yet been discussed in the context of the synergistic action of both blood and lymph. A current viewpoint might help to improve the comprehension of the venom/antivenom pharmacokinetics and the optimal approach for drug application. There is a great need for additional dependable, practical, well-designed studies, as well as more practice-related experience reports. As a result, opportunities for resolving long-standing disputes over choosing one therapeutic principle over another might be created, improving the safety and effectiveness of snakebite management.
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Affiliation(s)
- Erika Gamulin
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Sanja Mateljak Lukačević
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia
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4
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Le Roux G, Guillon M, Bernard L, de Haro L, Lourdais O, Descatha A. What drives the risk of being bitten by a viper? A fine spatial scale study in western France. Toxicon 2023; 228:107130. [PMID: 37080341 DOI: 10.1016/j.toxicon.2023.107130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 04/22/2023]
Abstract
Previous studies on viper bites in France have focused on clinical consequences of envenomation, efficacy of antivenom and epidemiology of bites. Herein, we wanted to clarify temporal and spatial patterns in bite incidence using a fine spatial scale (municipality level). We focused on viper bites recorded over the last 10 years in 4 regions of western France. We addressed the determinants of bite occurrence and number of bites considering the following variables: predicted probability of viper presence, species (V. aspis or V. berus), climatic data, tourism function rate, soil transformation and landscape use. 703 bite cases were retained with significant disparities between areas. Bites occurred either during a garden-related activity (339 cases, 51.2%) or during an activity in the countryside (300 cases, 45.3%). The probability of presence of a viper at the municipality level positively influenced the risk of being bitten (multiplied by 3 for a variation in probability of 0.25 from 0.5) but varied between species (lower in V. berus than V. aspis). Artificial land development had a positive effect on bite risks. Finally, a tourism function rate above 50 beds/100 inhabitants was strongly associated with an increase in the risk of occurrence and frequency of bites. Overall, viper bites recorded in our study were concentrated on the south coastline of Pays de la Loire region. The coastal towns are significant areas of tourist attraction and are located close to preserved semi-natural landscapes that provide favorable habitats for vipers. This convergence may favor human/wildlife encounters.
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Affiliation(s)
- Gaël Le Roux
- Poison Control Center, Academic Hospital CHU Angers, F-49000, Angers, France; University of Angers, Academic Hospital CHU Angers CHU Angers, University of Rennes, INSERM, École des Hautes études en Santé Publique, Institut de Recherche en Santé, Environnement et Travail (Irset) UMR_S 1085, F-49000, Angers, France.
| | - Michaël Guillon
- Centre D'Etudes Biologiques de Chizé, CNRS UMR 7372- Université de La Rochelle, 79360, Villiers-en-Bois, France; Cistude Nature, Chemin Du Moulinat, 33185, Le Haillan, France
| | - Lise Bernard
- Poison Control Center, Academic Hospital CHU Angers, F-49000, Angers, France
| | - Luc de Haro
- Poison Control Center, Academic Hospital APHM, F-13000, Marseille, France
| | - Olivier Lourdais
- Centre D'Etudes Biologiques de Chizé, CNRS UMR 7372- Université de La Rochelle, 79360, Villiers-en-Bois, France
| | - Alexis Descatha
- Poison Control Center, Academic Hospital CHU Angers, F-49000, Angers, France; University of Angers, Academic Hospital CHU Angers CHU Angers, University of Rennes, INSERM, École des Hautes études en Santé Publique, Institut de Recherche en Santé, Environnement et Travail (Irset) UMR_S 1085, F-49000, Angers, France
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5
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Bites by Non-Native Reptiles in France: Species, Circumstances and Outcome. Toxins (Basel) 2022; 14:toxins14080570. [PMID: 36006232 PMCID: PMC9412768 DOI: 10.3390/toxins14080570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to make an exhaustive assessment of circumstances of bites by exotic reptiles bred in France. A retrospective observational study was conducted in all the reported cases from 2000 to 2020 in French poison control centers (PCCs). Two hundred and eighteen cases of bites were recorded. The sex ratio (M/F) of the patients was 1.79 and the mean age of the patients was 29.0 ± 15.8 years. Twenty-two cases (10.1%) occurred during the deep night. One hundred and eighty-six bites (85.7%) occurred in a private context; however, there were more cases of high severity when it occurred in a professional setting (60.0% vs. 11.2%, p < 0.01). The feeding/nursing activity accounted for 54.7% cases. Forty-three species of snake were identified; 28 were considered venomous. There were no deaths among the patients in the study. Most of the cases (85.8%) were of mild severity. All of the patients bitten by a venomous reptile were hospitalized: 10 patients received an antivenom; and 2 required surgery. Bites occurred at home and by a small number of popular non-venomous reptile species (pythons and boas, colubrids). These occurred mainly when handling the animals. The rare envenomations were mainly by Asian and American crotalids, followed by elapids. One-third of them were treated with antivenom when available.
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Neurotoxicity and Other Clinical Manifestations of a Common European Adder (Vipera berus) Bite in Romania. Toxins (Basel) 2022; 14:toxins14070500. [PMID: 35878238 PMCID: PMC9318827 DOI: 10.3390/toxins14070500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/07/2022] [Accepted: 07/13/2022] [Indexed: 11/26/2022] Open
Abstract
Most cases of envenomation by common European vipers (Vipera berus) have not been reported to have neurotoxic manifestations. However, these manifestations have been demonstrated in some cases of envenomation by subspecies of V. berus, found in the Carpathian Basin region of south-eastern Europe. Here, we report the case of a 5-year-old girl from the south of Romania who presented symptoms of neurotoxicity, as well as other systemic and local symptoms, after being bitten by an adder of the V. berus subspecies. Treatment consisted of monovalent antivenom, a corticosteroid, and prophylactic enoxaparin. Neurotoxic manifestations of envenomation as well as other local and systemic symptoms improved within 5 days of treatment. The presented case shows that venom from V. berus subspecies found in the Carpathian Basin can have neurotoxic effects. This case also confirmed the efficacy of monospecific antivenom treatment in bringing about rapid and complete remission, following envenomation.
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7
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Blasco Mariño R, Soteras Martínez I, Hernandez Roca AI, Zafren K. Isolated Ptosis Following a Vipera aspis Bite. Wilderness Environ Med 2022; 33:245-247. [PMID: 35367125 DOI: 10.1016/j.wem.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/18/2022]
Abstract
In Spain, snakebites are uncommon medical emergencies that cause barely 100 hospitalizations annually. Most of the venomous bites are by snakes of the Viperidae family. Venom from Vipera snakes is reported to have cytotoxic and hematotoxic effects, and neurological effects have also been described. Ptosis (cranial nerve III palsy) is the most common sign, although any cranial nerve can be affected. We describe isolated ptosis, which was very likely after a Vipera aspis bite in the East Catalonian Pyrenees. No antivenom was administered. The ptosis resolved spontaneously within 10 h. Although neurologic findings are usually mild, they indicate a moderate or severe envenomation. Treating snakebites can be challenging for clinicians, especially when there are uncommon clinical manifestations. A toxicologist at a poison center should be consulted to help guide management. Development of local protocols may provide clinical support.
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Affiliation(s)
- Robert Blasco Mariño
- Department of Anesthesiology, Vall d'Hebron University Hospital, Barcelona, Spain; Department of Medical Science, Faculty of Medicine, University of Girona, Girona, Spain.
| | - Iñigo Soteras Martínez
- Department of Medical Science, Faculty of Medicine, University of Girona, Girona, Spain; Department of Emergency, Cerdanya Hospital, Puigcerdà, Spain; Sistema Emergències Mèdiques (SEM), Catalonia, Spain
| | | | - Ken Zafren
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, Alaska; Department of Emergency Medicine, Stanford University Medical Center, Stanford, California; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland
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8
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Boels D, Courtois A, Paradis C, Caillet P, Labadie M. First step in assessment of VipGrade ®, a computerized clinical decision system to assess Vipera envenomation grading: a single-center interrater reliability study. Clin Toxicol (Phila) 2021; 60:514-520. [PMID: 34709955 DOI: 10.1080/15563650.2021.1993241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
METHODS We conducted a retrospective review of Vipera spp. snakebite cases registered by the PCC of Bordeaux, France, between January 1, 2018, and December 31, 2020, evaluating the agreement between VipGrade® assessments, toxicologists' assessments, and current guidelines. RESULTS 133 patients with Vipera aspis snakebites were included. There was 100% agreement in severity grading by PCC guidelines and VipGrade®. However, grading by toxicologists and VipGrade® diverged in 19 cases (85% agreement; κ = 0.80; 95% CI: 0.71 to 0.87). CONCLUSIONS The VipGrade® tool's grading reflects current PCC guidelines, which are authoritative in France, and may allow for a more rapid and standardized determination of management and follow-up of viper-bitten patients. It should be noted, however, that the more complex and dynamic aspects of management are not included in VipGrade®. Its purpose is to supplement, not replace, the advice of the PCC's clinical toxicologists, and this advice should be sought whenever a viper bite is encountered in clinical practice.
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Affiliation(s)
- David Boels
- Clinical Toxicology Unit, Pharmacology Department, Nantes University Hospital, Nantes, France.,SPIN Unit, Public Health Department, Nantes University Hospital, Nantes, France.,Inserm UMR-1144, Descartes University, Paris, France
| | - Arnaud Courtois
- Poison Control Center, Bordeaux University Hospital, Bordeaux, France
| | - Camille Paradis
- Poison Control Center, Bordeaux University Hospital, Bordeaux, France
| | - Pascal Caillet
- SPIN Unit, Public Health Department, Nantes University Hospital, Nantes, France
| | - Magali Labadie
- Poison Control Center, Bordeaux University Hospital, Bordeaux, France
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Marano M, Pisani M, Zampini G, Pontrelli G, Roversi M. Acute Exposure to European Viper Bite in Children: Advocating for a Pediatric Approach. Toxins (Basel) 2021; 13:toxins13050330. [PMID: 34063282 PMCID: PMC8170888 DOI: 10.3390/toxins13050330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 11/16/2022] Open
Abstract
Viper bite is an uncommon but serious cause of envenoming in Europe, especially in children. Our study aim is to better describe and analyze the clinical course and treatment of viper bite envenoming in a pediatric population. We retrospectively reviewed 24 cases of pediatric viper bites that were admitted to the Pediatric Emergency Department and the Pediatric Intensive Care Unit of the Bambino Gesù Children Hospital in Rome between 2000 and 2020. Epidemiological characteristics of the children, localization of the bite, clinical and laboratory findings, and treatment approaches were evaluated. The median age of the patients was 4.2 years, with male predominance. Most cases of viper bite occurred in the late summer. Most patients required admission to the ward for prolonged observation. The most common presenting signs were pain, local oedema, and swelling. Patients with a high severity score also had a significantly higher white blood cell count and an increase of INR, LDH, and CRP levels. No fatality was reported. Viper bite envenomation is a rare pediatric medical emergency in Italy but may sometimes be severe. A new pediatric severity score may be implemented in the screening of children with viper bites to favor a selective and prompt administration of antivenom.
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Affiliation(s)
- Marco Marano
- Pediatric Intensive Care Unit, Pediatric Clinical Toxicology Center, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.M.); (G.Z.)
| | - Mara Pisani
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Giorgio Zampini
- Pediatric Intensive Care Unit, Pediatric Clinical Toxicology Center, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.M.); (G.Z.)
| | - Giuseppe Pontrelli
- Clinical Trial Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Marco Roversi
- Clinical Trial Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
- Correspondence:
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Lamb T, Stewart D, Warrell DA, Lalloo DG, Jagpal P, Jones D, Thanacoody R, Gray LA, Eddleston M. Moderate-to-severe Vipera berus envenoming requiring ViperaTAb antivenom therapy in the UK. Clin Toxicol (Phila) 2021; 59:992-1001. [PMID: 33720783 DOI: 10.1080/15563650.2021.1891245] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Bites by the European adder (Vipera berus) in the UK are uncommon but potentially life threatening, and can be associated with marked limb swelling and disability. Following an interruption in Zagreb Imunološki zavod antivenom supply around 2012, the UK changed its national choice of antivenom for Vipera berus to ViperaTAb, an ovine Fab monospecific antivenom. In the absence of randomised controlled trials, we established an audit to review its use in clinical practice. METHODS A prospective audit of ViperaTAb use was conducted from March 2016 until November 2020 by the UK National Poison Information Service (NPIS). Users of the NPIS online toxicology database, TOXBASE, considering the use of antivenom for V. berus envenoming were invited to discuss the case with the on-call clinical toxicology consultant. Information was collected prospectively on indications, administration, adverse reactions and outcome of patients administered ViperaTAb antivenom. RESULTS One hundred and seventy patients were administered ViperaTAb antivenom over five years. One hundred and thirty-two were adults and 38 children (median age and range: 38, 2-87 years). Bites occurred across the UK, but most commonly in coastal regions of Wales and of South-West and East England. Median time to presentation was 2.1 (IQR 1.5-4.0) h and to antivenom administration from presentation was 2.0 (IQR 0.9-3.6) h. A minority of patients presented to hospital more than 12 h after being bitten (n = 19, 11.2%) or received antivenom more than 12 h after presenting to hospital (n = 17, 10.0%). Features of systemic envenoming were present in 64/170 (37.6%) patients, including 23 (13.5%) with anaphylaxis and 26 (15.3%) with hypotension (nine with both). Clinician assessment considered the initial antivenom to have been effective in 122/169 (72.2%) patients. Repeated dosing was common, occurring in 55/169 (32.5%), predominantly due to persisting or worsening local effects (46/51, 90.2%). There were three cases of probable early adverse reaction. No deaths occurred during the study. Complications of envenoming were rare but included four patients that underwent surgery, three patients each with acute kidney injury, mild coagulopathy, or thrombocytopenia (one severe). The median duration of hospital stay was 43.7 (IQR 22.5-66.5) h, longer for children than adults (52.5 vs 41.3 h). CONCLUSION ViperaTAb antivenom appears to be effective and safe and should be administered as soon as possible for patients meeting clinical criteria. Patients require close observation following antivenom to detect adverse reactions and progression or recurrence of envenoming. Close collaboration with expert NPIS consultant advice can help optimise antivenom timing, ensure repeated dosing is given appropriately, and avoid unnecessary surgical intervention. All hospitals, particularly those located in areas of relatively high incidence, should stock sufficient antivenom available at short notice, 24 h a day.
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Affiliation(s)
- Thomas Lamb
- National Poisons Information Service - Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.,Myanmar Oxford Clinical Research Unit, University of Oxford, Oxford, UK.,Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - David Stewart
- National Poisons Information Service - Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - Pardeep Jagpal
- National Poisons Information Service - Birmingham, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Dacia Jones
- National Poisons Information Service - Newcastle, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Ruben Thanacoody
- National Poisons Information Service - Newcastle, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Laurence A Gray
- National Poisons Information Service - Cardiff, University Hospital Llandough, Cardiff, UK
| | - Michael Eddleston
- National Poisons Information Service - Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Pharmacology, Toxicology, Therapeutics, University/BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
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11
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Kurtović T, Lang Balija M, Brvar M, Dobaja Borak M, Mateljak Lukačević S, Halassy B. Comparison of Preclinical Properties of Several Available Antivenoms in the Search for Effective Treatment of Vipera ammodytes and Vipera berus Envenoming. Toxins (Basel) 2021; 13:toxins13030211. [PMID: 33805701 PMCID: PMC8001446 DOI: 10.3390/toxins13030211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/05/2021] [Accepted: 03/10/2021] [Indexed: 11/16/2022] Open
Abstract
Snakebites are a relatively rare medical emergency in Europe. In more than half of the annual cases caused by Vipera ammodytes, Vipera berus, and Vipera aspis, immunotherapy with animal-derived antivenom is indicated. Among eight products recently identified as available against European medically relevant species, only Zagreb antivenom, Viperfav, and ViperaTAb have been used almost exclusively for decades. Zagreb antivenom comprises V. ammodytes-specific F(ab')2 fragments. Viperfav is a polyspecific preparation based on F(ab')2 fragments against V. aspis, V. berus, and V. ammodytes venoms. ViperaTAb contains Fab fragments against the venom of V. berus. In 2014 the production of Zagreb antivenom was discontinued. Additionally, in the period of 2017 to 2018 a shortage of Viperfav occurred. Due to a lack of the product indicated for the treatment of V. ammodytes bites, other antivenoms were implemented into clinical practice without comparative assessment of their eligibility. The aim of our work was to identify a high-quality antivenom that might ensure the successful treatment of V. ammodytes and V. berus bites at the preclinical level. Differentiation between bites from these two species is difficult and unreliable in clinical practice, so the availability of a unique antivenom applicable in the treatment of envenoming caused by both species would be the most advantageous for Southeastern Europe. Zagreb antivenom, Viperfav, and ViperaTAb, as well as Viper venom antitoxin for V. berus envenoming and the in-development Inoserp Europe, which was designed to treat envenoming caused by all medically important European snakes, were comparatively tested for the first time. Emphasis was placed on their physicochemical properties, primarily purity and aggregate content, as well as their in vivo protective efficacies. As Zagreb antivenom is no longer available on the European market, Viperfav is the highest-quality product currently available and the only antivenom whose neutralisation potency against V. ammodytes and V. berus venoms was above regulatory requirements.
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Affiliation(s)
- Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
- Correspondence: (T.K.); (B.H.)
| | - Maja Lang Balija
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000 Ljubljana, Slovenia; (M.B.); (M.D.B.)
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Zaloška Cesta 4, 1000 Ljubljana, Slovenia
| | - Mojca Dobaja Borak
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000 Ljubljana, Slovenia; (M.B.); (M.D.B.)
| | - Sanja Mateljak Lukačević
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, 10000 Zagreb, Croatia; (M.L.B.); (S.M.L.)
- Centre of Excellence for Virus Immunology and Vaccines, CERVirVac, Rockefellerova 10, 10000 Zagreb, Croatia
- Correspondence: (T.K.); (B.H.)
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Paolino G, Di Nicola MR, Pontara A, Didona D, Moliterni E, Mercuri SR, Grano M, Borgianni N, Kumar R, Pampena R. Vipera snakebite in Europe: a systematic review of a neglected disease. J Eur Acad Dermatol Venereol 2020; 34:2247-2260. [PMID: 32530549 DOI: 10.1111/jdv.16722] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022]
Abstract
In 2009, snakebites were included in the list of the World Health Organization (WHO) neglected diseases. Dermatological literature lacks current and up-to-date articles about snakebites and their management, despite the fact that dermatologists, especially from rural hospitals, can be called into the emergency room to consult the management of suspected snakebites. In this systematic review, we highlighted the main clinical and laboratory aspects of snakebites from Vipera spp. in Europe, by reviewing 3574 studies initially retrieved from PubMed, Embase and Cochrane CENTRAL databases. Of these, 78 were finally included in the systematic review. We found that the most involved taxon was V. berus in 63.3% and the most involved anatomic site of the bite was the upper limbs 53.1% with fang marks reported in 90.5%. The mean age of the patients was 32.9 years, and bites were slightly more common among males (58.2%). A wound washing was performed in 86.9% of cases before the hospitalization. The most frequently reported grade of envenomation was G2 (42.2%). In addition to local dermatological symptoms (extended erythema, oedema, cutaneous necrosis, hives, purpura, petechiae, acute compartment syndrome), numerous systemic symptoms have also been reported, including fatigue (14.4%), pain (75.3%), fever (49.2%), direct anaphylactoid reaction (5.3%), anxiety (60.8%), cranial nerve neurotoxicity (14.8%), dysesthesia/paraesthesia (7.9%), vomiting (33.7%), abdominal pain (23.3%), diarrhoea (15.4%), dyspnoea (6.3%), proteinuria (10.6%) and haematuria (9.3%). Secondary infections were present in 3.5% and disseminated intravascular coagulation in 3.1% of cases, and fasciotomy was performed in 4.2% cases, while an amputation in 6.9%. Only 0.9% of patients died. Antivenom was administered in 3053 cases. In conclusion, there is a pressing need for robust multi-centre randomized control trials, standardized protocol for snakebite management and antivenom administration across Europe and a National snakebite register for each European country.
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Affiliation(s)
- G Paolino
- Clinica Dermatologica, La Sapienza University of Rome, Rome, Italy.,Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - A Pontara
- Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - D Didona
- Department of Dermatology and Allergology, Philipps Medical University of Marburg, Marburg, Germany
| | - E Moliterni
- Clinica Dermatologica, La Sapienza University of Rome, Rome, Italy
| | - S R Mercuri
- Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | - M Grano
- Via Valcenischia, Rome, Italy
| | | | - R Kumar
- Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
| | - R Pampena
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Boels D, Hamel JF, Le Roux G, Labadie M, Paret N, Delcourt N, Langrand J, Puskarczyk E, Nisse P, Sinno-Tellier S, de Haro L. Snake bites by European vipers in Mainland France in 2017-2018: comparison of two antivenoms Viperfav ® and Viperatab ®. Clin Toxicol (Phila) 2020; 58:1050-1057. [PMID: 32134691 DOI: 10.1080/15563650.2020.1726377] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Context: Today, immunotherapy with Fab or F(ab')2 fragments is considered as a gold standard treatment for patients bitten by vipers. We compared the efficiency of two antivenoms, Viperfav® and Viperatab®, in mainland France in 2017-2018 with data provided by the French poison control centre (PCC).Methods: Patients with a moderate (2a and 2b) or severe (3) envenomation after a European viper bite and treated with immunotherapy were included and the markers chosen were the risk of post-antivenom treatment worsening, duration of hospital stay and persistent functional discomfort on day 15. Statistical studies were based on multivariate data analysis.Results: Two hundred and ninety-seven cases were recorded. One hundred and eighty-two (61.3%) patients received Viperfav® and 115 (38.7%) received Viperatab®. Compared to Viperfav®, use of Viperatab® significantly increased the risk of post-antivenom treatment worsening (OR* 12.05; 95%CI [3.11; 46.70]; p < .001). No significant difference between these antivenoms was recorded with respect to the duration of hospital stay and persistent functional discomfort on day 15. Viperfav® and Viperatab® have a similar tolerance (p > .21). Otherwise, duration of hospitalisation was significantly increased by a delay of immunotherapy infusion of more than 12 h (OR 2.70; 95%CI [1.45-5.06]; p = .002) or a preventive administration of LMWH (OR 6.55; 95%CI [1.58-27.13]; p=.02).Discussion: While Viperfav® and Viperatab® have a similar tolerance, our data show that Viperatab® was associated with a higher risk of post-antivenom treatment worsening compared to Viperfav®. Furthermore, this study confirms that the antivenom should be used as soon as possible. Indeed, patients receiving the immunotherapy infusion from the grade 2b presented significantly more frequent exacerbated symptoms (OR 3.99; 95%CI [1.16-13.73]; p=.028) after the antivenom infusion compared to grade 2a group.Conclusions: Whereas no significant difference between these antivenoms was recorded with respect to the duration of hospital stay and persistent functional discomfort on day 15, use of Viperatab®, compared to Viperfav®, significantly increased the risk of post-antivenom treatment worsening (OR* 12.05; 95%CI [3.11; 46.70]; p < .001). Taken together, these data show that Viperfav® is the treatment of choice for the management of snake bites in France.
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Affiliation(s)
- David Boels
- Pharmacology and Toxicology Department, Nantes University Hospital, Nantes, France, and Inserm UMRS 1144, University of Paris, France
| | - Jean François Hamel
- Representative of Clinical Research and Innovation, Angers University Hospital, Angers, France
| | - Gaël Le Roux
- Poison Control Centre, Angers University Hospital, Angers, France
| | - Magali Labadie
- Poison Control Centre, Bordeaux University Hospital, Bordeaux, France
| | - Nathalie Paret
- Poison Control Centre, Lyon University Hospital, Lyon, France
| | - Nicolas Delcourt
- Poison Control Centre, Toulouse University Hospital, Toulouse, France
| | - Jérôme Langrand
- Poison Control Centre, Paris University Hospital, Paris, France
| | | | - Patrick Nisse
- Poison Control Centre, Lille University Hospital, Lille, France
| | - Sandra Sinno-Tellier
- ANSES, French Agency for Food, Environmental and Occupational Health Safety, Maisons-Alfort, France
| | - Luc de Haro
- Poison Control Centre, Marseille University Hospital, Marseille, France
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Venomics of the asp viper Vipera aspis aspis from France. J Proteomics 2020; 218:103707. [PMID: 32087377 DOI: 10.1016/j.jprot.2020.103707] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 12/15/2022]
Abstract
The asp viper Vipera aspis aspis is a venomous snake found in France, and despite its medical importance, the complete toxin repertoire produced is unknown. Here, we used a venomics approach to decipher the composition of its venom. Transcriptomic analysis revealed 80 venom-annotated sequences grouped into 16 gene families. Among the most represented toxins were snake venom metalloproteases (23%), phospholipases A2 (15%), serine proteases (13%), snake venom metalloprotease inhibitors (13%) and C-type lectins (12%). LC-MS of venoms revealed similar profiles regardless of the method of extraction (milking vs defensive bite). Proteomic analysis validated 57 venom-annotated transcriptomic sequences (>70%), including one for each of the 16 families, but also identified 7 sequences not initially annotated as venom proteins, including a serine protease, a disintegrin, a glutaminyl-peptide cyclotransferase, a proactivator polypeptide-like and 3 aminopeptidases. Interestingly, phospholipases A2 were the dominant proteins in the venom, among which included an ammodytoxin B-like sequence, which may explain the reported neurotoxicity following some asp viper envenomations. In total, 87 sequences were retrieved from the Vipera aspis aspis transcriptome and proteome, constituting a valuable resource that will help in understanding the toxinological basis of clinical signs of envenoming and for the mining of useful pharmacological compounds. BIOLOGICAL SIGNIFICANCE: The asp viper (Vipera aspis aspis) causes several hundred envenomations annually in France, including unusual cases with neurological signs, resulting in one death per year on average. Here, we performed a proteotranscriptomic analysis of V. a. aspis venom in order to provide a better understanding of its venom composition. We found that, as in other Vipera species, phospholipase A2 dominates in the venom, and the presence of a sequence related to ammodytoxin B may explain the reported neurotoxicity following some asp viper envenomations. Thus, this study will help in informing the toxinological basis of clinical signs of envenoming.
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García-Arredondo A, Martínez M, Calderón A, Saldívar A, Soria R. Preclinical Assessment of a New Polyvalent Antivenom (Inoserp Europe) against Several Species of the Subfamily Viperinae. Toxins (Basel) 2019; 11:E149. [PMID: 30841582 PMCID: PMC6468668 DOI: 10.3390/toxins11030149] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 11/17/2022] Open
Abstract
The European continent is inhabited by medically important venomous Viperinae snakes. Vipera ammodytes, Vipera berus, and Vipera aspis cause the greatest public health problems in Europe, but there are other equally significant snakes in specific regions of the continent. Immunotherapy is indicated for patients with systemic envenoming, of which there are approximately 4000 annual cases in Europe, and was suggested as an indication for young children and pregnant women, even if they do not have systemic symptoms. In the present study, the safety and venom-neutralizing efficacy of Inoserp Europe-a new F(ab')₂ polyvalent antivenom, designed to treat envenoming by snakes in the Eurasian region-were evaluated. In accordance with World Health Organization recommendations, several quality control parameters were applied to evaluate the safety of this antivenom. The venom-neutralizing efficacy of the antivenom was evaluated in mice and the results showed it had appropriate neutralizing potency against the venoms of several species of Vipera, Montivipera, and Macrovipera. Paraspecificity of the antivenom was demonstrated as well, since it neutralized venoms of species not included in the immunization schemes and contains satisfactory levels of total proteins and F(ab')₂ fragment concentration. Therefore, this new polyvalent antivenom could be effective in the treatment of snake envenoming in Europe, including Western Russia and Turkey.
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Affiliation(s)
- Alejandro García-Arredondo
- Laboratorio de Investigación Química y Farmacológica de Productos Naturales, Facultad de Química, Universidad Autónoma de Querétaro, Querétaro 76010, Mexico.
| | - Michel Martínez
- Veteria Labs, S.A. de C.V. Lucerna 7, Col. Juárez, Del. Cuauhtémoc, Ciudad de México 06600, Mexico.
| | - Arlene Calderón
- Inosan Biopharma, S.A. Arbea Campus Empresarial, Edificio 2, Planta 2, Carretera Fuencarral a Alcobendas, Km 3.8, 28108 Madrid, Spain.
| | - Asunción Saldívar
- Veteria Labs, S.A. de C.V. Lucerna 7, Col. Juárez, Del. Cuauhtémoc, Ciudad de México 06600, Mexico.
| | - Raúl Soria
- Inosan Biopharma, S.A. Arbea Campus Empresarial, Edificio 2, Planta 2, Carretera Fuencarral a Alcobendas, Km 3.8, 28108 Madrid, Spain.
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16
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Boels D. Envenimations ophidiennes en France métropolitaine et outre-mer : les centres antipoison au cœur de la prise en charge. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2018. [DOI: 10.1016/j.toxac.2018.07.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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17
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Mordedura por víbora de Seoane. Descripción de un caso y revisión de la literatura. Semergen 2017; 43:e25-e28. [DOI: 10.1016/j.semerg.2016.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 07/01/2016] [Accepted: 07/10/2016] [Indexed: 11/24/2022]
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Lamb T, de Haro L, Lonati D, Brvar M, Eddleston M. Antivenom for European Vipera species envenoming. Clin Toxicol (Phila) 2017; 55:557-568. [PMID: 28349771 DOI: 10.1080/15563650.2017.1300261] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND European viper bite is relatively uncommon but can cause serious envenoming, particularly swelling and hemorrhage spreading from limb to trunk that can cause long term disability. Systemic features are relatively mild compared to many other venomous species. Moderate-to-severe envenoming requires antivenom, which is given many hundreds of times each year across the continent. Several Vipera spp antivenoms are produced in Europe, but there is little comparative information available for the antivenoms and none is licensed with the European Medicines Agency. We aimed to collect descriptive data on European viper antivenoms and assess their relative effectiveness. METHODS A systematic review of articles relating to antivenom in Europe was performed using the Medline medical database. The following keywords "Europ*" or the individual names of each European country and "antiven*" or "immun*" or "envenom*" and "snake" or "viper*" or "adder" were used. Articles published between 1 January 1996 and 11 March 2016 pertaining to clinical outcome, including case reports, were selected. Referenced articles in the indexed articles were explored for suitability and included if they met any of the criteria: specific antivenom used, route of antivenom administration, adverse reactions to antivenom therapy and length of hospital admission. All accepted abstracts from EAPCCT conferences since 2000 were searched and abstracts relating to Vipera spp envenoming were assessed for suitability. We extracted data on study type, safety and effectiveness. We sought information on antivenoms from manufacturers and individual patient data from authors of publications. Since individual patient data were only rarely available, we compared median length of stay between case series reporting each antivenom. We identified 40 papers and six published abstracts, and one unpublished paper that reported clinical cases and case series of envenomed patients treated with antivenom. No publication reported randomized controlled trials comparing any European Vipera antivenom with either placebo or another antivenom. 25 reports were of retrospective hospital- (n = 13) or poison center-based (n = 12) case series including five or more patients; a further 12 reports were either case reports or case series with less than five patients and one paper was a limited literature review. An additional nine papers reported prospective data; seven collected data remotely through poison service telephone communication with the attending physicians. Antivenoms available in Europe: Eight antivenoms are available for European Vipera spp envenoming; a material safety data sheet providing information on manufacture was available for seven. Six are raised against V. berus or V. ammodytes venom; the seventh is raised against a mixture of V. ammodytes, V. aspis and V. berus venom and the eighth is raised against V. ammodytes, Macrovipera lebetina and Montivipera xanthina venom. Six manufacturers recommended intramuscular administration while two recommended intravenous administration. No randomized control trials comparing the effectiveness of antivenoms were identified. Pre-clinical data: We found two papers presenting comparative preclinical data. Clinical data: Clinical studies were predominantly retrospective and contained clinical data on antivenom used in 2602 patients; where the antivenom was identified (n = 2174), 2061 (94.8%) received Zagreb, ViperFAV or ViperaTAb antivenoms. There were few published data on the other antivenoms. Repeated use of antivenom: Repeat doses were reported in 230/1491 of cases (15.4%) where this information was recorded. Outcome and length of hospital stay: Intravenous administration of antivenom was associated with shorter length of hospital stay (median length of hospital stay in studies of intravenous ViperFAV or ViperaTAb ranged from 1 to 4.8 days versus 2 to 18 days for intramuscular Bulbio or Zagreb antivenoms). Antivenom versus no antivenom: Some small studies demonstrated no difference in the length of hospital stay in patients with equivalent envenomation grading who either did or did not receive antivenom. Adverse events: Adverse reactions were reported in 37 of 2408 cases (1.5%) including seven cases of anaphylaxis. CONCLUSIONS There are very limited pre-clinical comparative data and no randomised controlled trials assessing effectiveness of the antivenoms against different Vipera species. Most descriptive data suggest the efficacy of Zagreb, ViperFAV and ViperaTAb antivenoms by the intravenous route but not intramuscular route, although this is level D evidence. Reported adverse reactions were rare, suggesting that the modern intravenous antivenoms are of good quality. Better and more systematic data, including perhaps randomized controlled trials comparing different antivenoms, are required for the many hundreds of antivenom administrations that occur annually across Europe.
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Affiliation(s)
- Thomas Lamb
- a Department of Pharmacology, Toxicology, and Therapeutics , University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
| | - Luc de Haro
- b Centre Antipoison , Hôpital Sainte Marguerite , Marseilles , France
| | - Davide Lonati
- c Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Istituti Clinici Scientifici Maugeri , IRCCS Maugeri Hospital and University of Pavia , Pavia , Italy
| | - Miran Brvar
- d Centre for Clinical Toxicology and Pharmacology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Michael Eddleston
- a Department of Pharmacology, Toxicology, and Therapeutics , University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
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Brvar M, Kurtović T, Grenc D, Lang Balija M, Križaj I, Halassy B. Vipera ammodytes bites treated with antivenom ViperaTAb: a case series with pharmacokinetic evaluation. Clin Toxicol (Phila) 2017; 55:241-248. [PMID: 28092984 DOI: 10.1080/15563650.2016.1277235] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONTEXT In clinical practice it is difficult to differentiate between V. berus and V. ammodytes venomous bites. In the past this was not a concern, but due to the current shortage in Viperfav™ and European viper venom antiserum availability, V. a. ammodytes venomous bites have recently been treated with ViperaTAb®, which is a pharmaceutical formulation containing a monospecific ovine Fab fragments against the venom of V. berus. OBJECTIVE To evaluate ViperaTAb® in V. a. ammodytes envenomations. MATERIALS AND METHODS This is a prospective case series of three consecutive patients envenomed by V. a. ammodytes snakebite treated with ViperaTAb®. V. ammodytes venom, neurotoxic ammodytoxins, and Fab fragment levels were determined in serum samples and a pharmacokinetic analysis of the antivenom Fab fragments was carried out. RESULTS Three patients bitten by V. a. ammodytes with extensive local swelling, neurological symptoms and recurrent thrombocytopenia were treated with ViperaTAb®. V. ammodytes venom was detected in serum of all three patients. Ammodytoxins were detected in the serum of only the most severely envenomed patient who developed neurological symptoms. In the presented moderate cases, a dose of 8 mL of ViperaTAb® reduced swelling and improved systemic effects, such as thrombocytopenia. However, this dose of ViperaTAb® was not effective in the most severely envenomed patient with the highest serum values of V. ammodytes venom. In this case ViperaTAb® did not stop local swelling and it had no effect on neurological signs. ViperaTAb®'s systemic clearance, distribution and elimination half-lives were 4.3-13.4 mL/h/kg, 1.2-3.2 h and 14.1-55.4 h, respectively. CONCLUSIONS In patients envenomed by V. a. ammodytes venom, ViperaTAb® reduces moderate swelling and temporarily improves systemic effects, except neurological symptoms. ViperaTAb® application induces a decrement of V. ammodytes venom level in the blood, but did not affect serum concentration of neurotoxic ammodytoxins in the one patient with measurable concentrations.
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Affiliation(s)
- Miran Brvar
- a Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Faculty of Medicine , Institute of Pathophysiology, University of Ljubljana , Ljubljana , Slovenia
| | - Tihana Kurtović
- c Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb , Zagreb , Croatia
| | - Damjan Grenc
- a Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Maja Lang Balija
- c Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb , Zagreb , Croatia
| | - Igor Križaj
- d Department of Molecular and Biomedical Sciences , Jožef Stefan Institute , Ljubljana , Slovenia.,e Faculty of Chemistry and Chemical Technology , University of Ljubljana , Ljubljana , Slovenia
| | - Beata Halassy
- c Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb , Zagreb , Croatia
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Karabuva S, Brizić I, Latinović Z, Leonardi A, Križaj I, Lukšić B. Cardiotoxic effects of the Vipera ammodytes ammodytes venom fractions in the isolated perfused rat heart. Toxicon 2016; 121:98-104. [PMID: 27623431 DOI: 10.1016/j.toxicon.2016.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/31/2016] [Accepted: 09/01/2016] [Indexed: 01/16/2023]
Abstract
The nose-horned viper (Vipera ammodytes ammodytes) is the most venomous European snake. Its venom is known as haematotoxic, myotoxic and neurotoxic but it exerts also cardiotoxic effects. To further explore the cardiotoxicity of the venom we separated it into four fractions by gel filtration chromatography. Three fractions that contain polypeptides (A, B, and C) were tested for their effects on isolated rat heart. Heart rate (HR), incidence of arrhythmias (atrioventricular (AV) blocks, ventricular tachycardia, ventricular fibrillation, and asystolia), coronary flow (CF), systolic, developed and diastolic left ventricular pressure (LVP) were measured before, during, and after the application of venom fractions in three different concentrations. Fraction A, containing proteins of 60-100 kDa, displayed no effect on the rat heart. Fractions B and C disturbed heart functioning in similar way, but with different potency that was higher by the latter. This was manifested by significant decrease of HR and CF, the increase of diastolic, and the decrease of systolic and developed LVPs. All hearts treated with fraction C in the final CF concentrations 22.5 and 37.5 μg/mL suffered rapid and irreversible asystolia without AV blockade. They underwent also ventricular fibrillation and ventricular tachycardia. Fraction B affected hearts only at the highest dose inducing asystolia in all hearts, ventricular fibrillation in 80% and ventricular tachycardia in 70% of the hearts. Venom fraction C induced 71% of all recorded heart rhythm disturbances, significantly more than fraction B, which induced 29%. Most abundant proteins in fraction C were secreted phospholipases A2 among which the venom component acting on the heart is most probably to be looked for.
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Affiliation(s)
- Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia.
| | - Ivica Brizić
- Department of Pharmacology, Mostar University School of Medicine, Bijeli brijeg bb, Mostar, Bosnia and Herzegovina.
| | - Zorica Latinović
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia; Jožef Stefan International Postgraduate School, Jamova cesta 39, Ljubljana, Slovenia.
| | - Adrijana Leonardi
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia.
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia; Department of Chemistry and Biochemistry, Faculty of Chemistry and Chemical Technology, University of Ljubljana, Aškerčeva cesta 5, Ljubljana, Slovenia.
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia; University of Split School of Medicine, Šoltanska 2, Split, Croatia.
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Kurtović T, Brvar M, Grenc D, Lang Balija M, Križaj I, Halassy B. A Single Dose of Viperfav(TM) May Be Inadequate for Vipera ammodytes Snake Bite: A Case Report and Pharmacokinetic Evaluation. Toxins (Basel) 2016; 8:toxins8080244. [PMID: 27548220 PMCID: PMC4999860 DOI: 10.3390/toxins8080244] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/11/2016] [Indexed: 11/26/2022] Open
Abstract
ViperfavTM is a commercial F(ab’)2 antivenom prepared against European vipers venom. It is safe and effective for treating envenomation caused by Vipera aspis and Vipera berus. Therapeutic efficacy for treating Vipera ammodytes ammodytes (V. a. ammodytes) envenoming has not been yet described, although protective efficacy has been demonstrated in preclinical studies. We report on a 32-year-old man bitten by V. a. ammodytes who was treated with Viperfav™. Viperfav™ promptly reduced local extension and improved systemic pathological signs, but 24 h after the incident a recurrence of thrombocytopenia occurred despite a favorable pharmacokinetic profile with systemic clearance (1.64 (mL·h−1)·kg−1) and elimination half-life (97 h) among the highest ever reported. The recommended dose of Viperfav™ for V. aspis and V. berus bites may be inadequate for serious V. a. ammodytes envenomations. Following V. a. ammodytes bite, serial blood counts and coagulation profiles should be performed to help guide Viperfav™ treatment, along with supplemental administration as indicated.
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Affiliation(s)
- Tihana Kurtović
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, HR-10000 Zagreb, Croatia.
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia.
- Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, 1000 Ljubljana, Slovenia.
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia.
| | - Maja Lang Balija
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, HR-10000 Zagreb, Croatia.
| | - Igor Križaj
- Department of Molecular and Biomedical Sciences, Jožef Stefan Institute, Jamova 39, 1000 Ljubljana, Slovenia.
- Faculty of Chemistry and Chemical Technology, University of Ljubljana, Večna pot 113, 1000 Ljubljana, Slovenia.
| | - Beata Halassy
- Centre for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Rockefellerova 10, HR-10000 Zagreb, Croatia.
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22
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Schmitt C, Baleine J, Beaupertuis O, Bragança C, Simon N, de Haro L. Persistance des signes neurologiques malgré le traitement antidotique par Viperfav® après morsure de vipères aspics, à propos de 2 observations. Presse Med 2016; 45:601-2. [DOI: 10.1016/j.lpm.2016.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/22/2016] [Accepted: 04/13/2016] [Indexed: 10/21/2022] Open
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Bart G, Pineau S, Biron C, Connault J, Artifoni M. Bilateral Pulmonary Embolism Following a Viper Envenomation in France: A Case Report and Review. Medicine (Baltimore) 2016; 95:e2798. [PMID: 27175626 PMCID: PMC4902468 DOI: 10.1097/md.0000000000002798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Complications following snake bites are not common in France. We report the case of a bilateral pulmonary embolism following a viper envenomation in France.A healthy 72-year-old female presented with a lower limb hematoma following a viper bite. She was admitted at the hospital 2 days later and received low-molecular-weight heparin because of bed rest. Seven days later, she complained of thoracic pain and respiratory failure, and a bilateral pulmonary was diagnosed, without biological sign of neither disseminated intravascular coagulation nor coagulation trouble. Repeated lower limbs Doppler ultrasound were normal.This case is particularly interesting because it is only the 7th reported case of pulmonary embolism following a snake envenomation; moreover, it happened in France where poisonous snakes are very rare.Several hypotheses have been made to explain this late localized coagulopathy: an increased level of unstable fibrin produced by thrombin-like glycoproteins from the venom is one of them.
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Affiliation(s)
- Géraldine Bart
- From the Rheumatology Unit (GB); Internal Medicine Unit (JC, MA), and Department of Infectious Diseases, Nantes University Hospital, Nantes, France (SP, CB)
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Karabuva S, Vrkić I, Brizić I, Ivić I, Lukšić B. Venomous snakebites in children in southern Croatia. Toxicon 2016; 112:8-15. [PMID: 26802624 DOI: 10.1016/j.toxicon.2016.01.057] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/09/2016] [Accepted: 01/19/2016] [Indexed: 11/15/2022]
Abstract
This retrospective study represents observation of 160 children and adolescents aged up to 18 years that experienced venomous snakebites in southern Croatia and were treated in the Clinical Department of Infectious Diseases in the University Hospital Centre Split from 1979 to 2013. The main purpose of this research was to determine the epidemiological characteristics, clinical presentation, local and general complications, and received treatment. Most bites occurred during warm months, from early May to late August (80%), mostly in May and June. Upper limb bites were more frequent (59%) than lower limb bites (40%). Out of the total number of poisoned children, 24% developed local, and 25% general complications. The most common local complications were haemorrhagic blisters that occurred in 20% children, followed by compartment syndrome presented in 7.5% patients. The most dominated general complication was cranial nerve paresis or paralysis, which was identified in 11.2% patients, whereas shock symptoms were registrated in 7% children. According to severity of poisoning, 9.4% children had minor, 35% mild, 30.6% moderate, and 24.4% had severe clinical manifestation of envenomation. Only one (0.6%) child passed away because of snakebite directly on the neck. All patients received antivenom produced by the Institute of Immunology in Zagreb, tetanus prophylaxis as well, and almost all of them received antibiotics, and a great majority of them also received corticosteroids and antihistamines. Neighter anaphylactic reaction nor serum disease were noticed in our patients after administrating antivenom. A total of 26% children underwent surgical interventions, and incision of haemorrhagic blister was the most common applied surgical treatment, which was preformed in 15.6% patients, while fasciotomy was done in 7.5% subjects. All of our surgically treated patients recovered successfully.
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Affiliation(s)
- Svjetlana Karabuva
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia.
| | - Ivana Vrkić
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia.
| | - Ivica Brizić
- Department of Pharmacology, Mostar University School of Medicine, Bijeli brijeg bb, Mostar, Bosnia and Herzegovina.
| | - Ivo Ivić
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia; University of Split School of Medicine, Šoltanska 2, Split, Croatia.
| | - Boris Lukšić
- Clinical Department of Infectious Diseases, University Hospital Centre Split, Šoltanska 1, Split, Croatia; University of Split School of Medicine, Šoltanska 2, Split, Croatia.
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