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Chowdhury MAW, Müller J, Ghose A, Amin R, Sayeed AA, Kuch U, Faiz MA. Combining species distribution models and big datasets may provide finer assessments of snakebite impacts. PLoS Negl Trop Dis 2024; 18:e0012161. [PMID: 38768190 PMCID: PMC11142713 DOI: 10.1371/journal.pntd.0012161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/31/2024] [Accepted: 04/22/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Snakebite is a major poverty-related neglected tropical disease. An integrated scientific approach is needed to understand the dynamics of this important health issue. Our objective was to estimate snakebite occurrence in a tropical area by using a blend of ecological modelling and robust statistical analysis. METHODS The present study used climatic, environmental, and human population density data to determine the area with snakebite occurrence-probability for the first time in Bangladesh. We also analysed a large, 16-year dataset of hospitalized snakebite cases to reveal the epidemiology of snakebite in the south-eastern zone of the country. FINDINGS Our results show that cobra bite is the most commonly occurring venomous snakebite in humans (around ~12% of the total yearly snakebite records), and men are more frequently bitten than women (2/3 of human victims are men). Most bites occur during the rainy season for cobra and green pit viper, while krait bites are not restricted to any particular season. As snakebite incidents are closely related to climate conditions, we can model snakebite risk using temperature and precipitation variables. Whereas there is a lack of snakebite reports from several parts of the study area in official records, our models predict that the entire study area is favourable for snakebite incidents. Based on the combined evidence we estimate that about 200,000 snakebite events occur every year in the south-eastern part of Bangladesh alone. Considering future global climate change, our model projections show that snakebite incidence in Bangladesh might not significantly decrease in the future (- 2070-); however, the distribution of probabilities might change, with a predicted increase of snakebite incidence in the hilly areas of the country. CONCLUSIONS Using climatic data to predict snakebite incidence in Bangladesh allowed us to provide estimations of the total annual number of snakebite cases in the study area. As in most countries, the scarcity of accurate epidemiological data in official records might have masked the real magnitude of this problem. Our analysis suggests that the problem of snakebite envenoming in Bangladesh might be worse than currently perceived. A long-term sustainable snakebite program plan should be designed and institutionalized, considering climatic, geographical and human demographic variables, to obtain better data and facilitate the implementation of accurate snakebite management programs for this country.
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Affiliation(s)
- Mohammad Abdul Wahed Chowdhury
- Department of Zoology, University of Chittagong, Chattogram, Bangladesh
- Museum für Naturkunde, Leibniz-Institut für Evolutions- und Biodiversitätsforschung, Berlin, Germany
- Institut für Biologie, Humboldt-Universität zu Berlin, Berlin, Germany
- Venom Research Centre, Department of Medicine, Chittagong Medical College, Chattogram, Bangladesh
| | - Johannes Müller
- Museum für Naturkunde, Leibniz-Institut für Evolutions- und Biodiversitätsforschung, Berlin, Germany
- Institut für Biologie, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Aniruddha Ghose
- Venom Research Centre, Department of Medicine, Chittagong Medical College, Chattogram, Bangladesh
- Department of Medicine, Chittagong Medical College, Chattogram, Bangladesh
| | - Robed Amin
- Venom Research Centre, Department of Medicine, Chittagong Medical College, Chattogram, Bangladesh
- Directorate General of Health Services, Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Abdullah Abu Sayeed
- Venom Research Centre, Department of Medicine, Chittagong Medical College, Chattogram, Bangladesh
- Department of Medicine, Chittagong Medical College, Chattogram, Bangladesh
| | - Ulrich Kuch
- Venom Research Centre, Department of Medicine, Chittagong Medical College, Chattogram, Bangladesh
- Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Germany
| | - Mohammad Abul Faiz
- Venom Research Centre, Department of Medicine, Chittagong Medical College, Chattogram, Bangladesh
- Dev Care Foundation, Chattogram, Bangladesh
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D’Este G, Fabris F, Stazi M, Baggio C, Simonato M, Megighian A, Rigoni M, Negro S, Montecucco C. Agonists of melatonin receptors strongly promote the functional recovery from the neuroparalysis induced by neurotoxic snakes. PLoS Negl Trop Dis 2024; 18:e0011825. [PMID: 38190386 PMCID: PMC10798625 DOI: 10.1371/journal.pntd.0011825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/19/2024] [Accepted: 12/22/2023] [Indexed: 01/10/2024] Open
Abstract
Snake envenoming is a major, but neglected, tropical disease. Among venomous snakes, those inducing neurotoxicity such as kraits (Bungarus genus) cause a potentially lethal peripheral neuroparalysis with respiratory deficit in a large number of people each year. In order to prevent the development of a deadly respiratory paralysis, hospitalization with pulmonary ventilation and use of antivenoms are the primary therapies currently employed. However, hospitals are frequently out of reach for envenomated patients and there is a general consensus that additional, non-expensive treatments, deliverable even long after the snake bite, are needed. Traumatic or toxic degenerations of peripheral motor neurons cause a neuroparalysis that activates a pro-regenerative intercellular signaling program taking place at the neuromuscular junction (NMJ). We recently reported that the intercellular signaling axis melatonin-melatonin receptor 1 (MT1) plays a major role in the recovery of function of the NMJs after degeneration of motor axon terminals caused by massive Ca2+ influx. Here we show that the small chemical MT1 agonists: Ramelteon and Agomelatine, already licensed for the treatment of insomnia and depression, respectively, are strong promoters of the neuroregeneration after paralysis induced by krait venoms in mice, which is also Ca2+ mediated. The venom from a Bungarus species representative of the large class of neurotoxic snakes (including taipans, coral snakes, some Alpine vipers in addition to other kraits) was chosen. The functional recovery of the NMJ was demonstrated using electrophysiological, imaging and lung ventilation detection methods. According to the present results, we propose that Ramelteon and Agomelatine should be tested in human patients bitten by neurotoxic snakes acting presynaptically to promote their recovery of health. Noticeably, these drugs are commercially available, safe, non-expensive, have a long bench life and can be administered long after a snakebite even in places far away from health facilities.
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Affiliation(s)
- Giorgia D’Este
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Federico Fabris
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Marco Stazi
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Chiara Baggio
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | | | - Aram Megighian
- Department of Biomedical Sciences, University of Padova, Padova, Italy
- Padua Neuroscience Center, University of Padova, Padova, Italy
| | - Michela Rigoni
- Department of Biomedical Sciences, University of Padova, Padova, Italy
- Myology Center (CIR-Myo), University of Padova, Padova, Italy
| | - Samuele Negro
- Department of Biomedical Sciences, University of Padova, Padova, Italy
- U.O.C. Clinica Neurologica, Azienda Ospedale-Università Padova, Padova, Italy
| | - Cesare Montecucco
- Department of Biomedical Sciences, University of Padova, Padova, Italy
- CNR Institute of Neuroscience, Padova, Italy
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3
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Deka A, Bhatia S, Santra V, Bharti OK, Lalremsanga HT, Martin G, Wüster W, Owens JB, Graham S, Doley R, Malhotra A. Multilevel Comparison of Indian Naja Venoms and Their Cross-Reactivity with Indian Polyvalent Antivenoms. Toxins (Basel) 2023; 15:toxins15040258. [PMID: 37104196 PMCID: PMC10142961 DOI: 10.3390/toxins15040258] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/21/2023] [Accepted: 03/26/2023] [Indexed: 04/05/2023] Open
Abstract
Snake envenoming is caused by many biological species, rather than a single infectious agent, each with a multiplicity of toxins in their venom. Hence, developing effective treatments is challenging, especially in biodiverse and biogeographically complex countries such as India. The present study represents the first genus-wide proteomics analysis of venom composition across Naja species (N. naja, N. oxiana, and N. kaouthia) found in mainland India. Venom proteomes were consistent between individuals from the same localities in terms of the toxin families present, but not in the relative abundance of those in the venom. There appears to be more compositional variation among N. naja from different locations than among N. kaouthia. Immunoblotting and in vitro neutralization assays indicated cross-reactivity with Indian polyvalent antivenom, in which antibodies raised against N. naja are present. However, we observed ineffective neutralization of PLA2 activities of N. naja venoms from locations distant from the source of immunizing venoms. Antivenom immunoprofiling by antivenomics revealed differential antigenicity of venoms from N. kaouthia and N. oxiana, and poor reactivity towards 3FTxs and PLA2s. Moreover, there was considerable variation between antivenoms from different manufacturers. These data indicate that improvements to antivenom manufacturing in India are highly desirable.
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Affiliation(s)
- Archana Deka
- Molecular Toxinology Laboratory, Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, Assam, India
| | - Siddharth Bhatia
- CSIR-Centre for Cellular and Molecular Biology, Laboratory for Conservation of Endangered Species, Hyderabad 500048, Telangana, India
| | - Vishal Santra
- Society for Nature Conservation, Research and Community Engagement (CONCERN), Nalikul, Hooghly 712407, West Bengal, India
- Captive and Field Herpetology, Anglesey LL65 1YU, UK
- Snake Research Institute, Gujarat Forest Department, Government of Gujarat, Valsad 396050, Gujarat, India
| | - Omesh K. Bharti
- State Institute of Health and Family Welfare, Shimla 171009, Himachal Pradesh, India
| | | | | | - Wolfgang Wüster
- Molecular Ecology and Evolution @ Bangor (MEEB), School of Natural Sciences, Bangor University, Gwynedd LL57 2UW, UK
| | - John B. Owens
- Captive and Field Herpetology, Anglesey LL65 1YU, UK
- Molecular Ecology and Evolution @ Bangor (MEEB), School of Natural Sciences, Bangor University, Gwynedd LL57 2UW, UK
| | - Stuart Graham
- Molecular Ecology and Evolution @ Bangor (MEEB), School of Natural Sciences, Bangor University, Gwynedd LL57 2UW, UK
| | - Robin Doley
- Molecular Toxinology Laboratory, Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, Assam, India
| | - Anita Malhotra
- Molecular Ecology and Evolution @ Bangor (MEEB), School of Natural Sciences, Bangor University, Gwynedd LL57 2UW, UK
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Mukherjee AK, Mackessy SP. Prevention and improvement of clinical management of snakebite in Southern Asian countries: A proposed road map. Toxicon 2021; 200:140-152. [PMID: 34280412 DOI: 10.1016/j.toxicon.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/10/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
In the Southern Asian countries, snakebite takes a substantial toll in terms of human life, inflicts acute morbidity and long term disability both physical and psychological, and therefore represents a neglected socio-economic problem and severe health issue that requires immediate medical attention. The 'Big Four' venomous snakes, viz. Daboia russelii, Naja naja, Bungarus caeruleus and Echis carinatus, are prominent, medically important species and are the most dangerous snakes of this region; therefore, the commercial polyvalent antivenom (PAV) contains antibodies against the venoms of these snakes. However, envenomations by species other than the 'Big Four' snakes are grossly neglected, and PAV is only partially effective in neutralizing the venom of these snakes. Many issues confounding effective treatment of snakebite are discussed in this review, and these hurdles preventing successful treatment of snakebite must be addressed. However, in South Asian countries, the pre-hospital treatment and appropriate first aid are equally important to mitigate the problem of snakebite and therefore, these issues are also highlighted here. Further, this review suggests a roadmap and guidelines for the prevention of snakebite and improvement of hospital management of snakebite in these Southern Asian countries.
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Affiliation(s)
- Ashis K Mukherjee
- Division of Life Sciences, Institute of Advanced Study in Science and Technology, Vigyan Path Garchuk, Paschim Boragaon, Guwahati, 781035, Assam, India; Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur, 78028, Assam, India; School of Biological Sciences, University of Northern Colorado, Greeley, CO, 80639-0017, USA.
| | - Stephen P Mackessy
- School of Biological Sciences, University of Northern Colorado, Greeley, CO, 80639-0017, USA
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5
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Paediatric cases of Ceylon krait (Bungarus ceylonicus) bites and some similar looking non-venomous snakebites in Sri Lanka: Misidentification and antivenom administration. Toxicon 2021; 198:143-150. [PMID: 33957150 DOI: 10.1016/j.toxicon.2021.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/25/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
Ceylon krait (Bungarus ceylonicus) of the family Elapidae is a highly venomous endemic species inhabiting in the wet zone and some parts of the intermediate climatic zones of Sri Lanka. Clinical records of its bites are rare and limited to five case reports in the literature. It is of interest to note that there are several non-venomous snakes in Sri Lanka having similar morphological appearance to kraits causing identification difficulties which lead to unnecessary and unindicated administration of antivenom. We report two paediatric cases of proven Ceylon krait bites and three adult patients with similar looking non-venomous snakebites. These children were 1½ and 13 years old and developed neuroparalysis without progressing to respiratory failure and recovered. Both the children were administered Indian polyvalent antivenom which has not developed against endemic Ceylon krait venom. The two adult patients also received antivenom due to the misidentification without clinical and laboratory evidence of envenoming.
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Sunagar K, Khochare S, Senji Laxme RR, Attarde S, Dam P, Suranse V, Khaire A, Martin G, Captain A. A Wolf in Another Wolf's Clothing: Post-Genomic Regulation Dictates Venom Profiles of Medically-Important Cryptic Kraits in India. Toxins (Basel) 2021; 13:toxins13010069. [PMID: 33477742 PMCID: PMC7832344 DOI: 10.3390/toxins13010069] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 12/30/2020] [Accepted: 01/01/2021] [Indexed: 12/21/2022] Open
Abstract
The Common Krait (Bungarus caeruleus) shares a distribution range with many other ‘phenotypically-similar’ kraits across the Indian subcontinent. Despite several reports of fatal envenomings by other Bungarus species, commercial Indian antivenoms are only manufactured against B. caeruleus. It is, therefore, imperative to understand the distribution of genetically distinct lineages of kraits, the compositional differences in their venoms, and the consequent impact of venom variation on the (pre)clinical effectiveness of antivenom therapy. To address this knowledge gap, we conducted phylogenetic and comparative venomics investigations of kraits in Southern and Western India. Phylogenetic reconstructions using mitochondrial markers revealed a new species of krait, Romulus’ krait (Bungarus romulusi sp. nov.), in Southern India. Additionally, we found that kraits with 17 mid-body dorsal scale rows in Western India do not represent a subspecies of the Sind Krait (B. sindanus walli) as previously believed, but are genetically very similar to B. sindanus in Pakistan. Furthermore, venom proteomics and comparative transcriptomics revealed completely contrasting venom profiles. While the venom gland transcriptomes of all three species were highly similar, venom proteomes and toxicity profiles differed significantly, suggesting the prominent role of post-genomic regulatory mechanisms in shaping the venoms of these cryptic kraits. In vitro venom recognition and in vivo neutralisation experiments revealed a strong negative impact of venom variability on the preclinical performance of commercial antivenoms. While the venom of B. caeruleus was neutralised as per the manufacturer’s claim, performance against the venoms of B. sindanus and B. romulusi was poor, highlighting the need for regionally-effective antivenoms in India.
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Affiliation(s)
- Kartik Sunagar
- Evolutionary Venomics Lab, Centre for Ecological Sciences, Indian Institute of Science, Bangalore 560012, Karnataka, India; (S.K.); (R.R.S.L.); (S.A.); (P.D.); (V.S.)
- Correspondence:
| | - Suyog Khochare
- Evolutionary Venomics Lab, Centre for Ecological Sciences, Indian Institute of Science, Bangalore 560012, Karnataka, India; (S.K.); (R.R.S.L.); (S.A.); (P.D.); (V.S.)
| | - R. R. Senji Laxme
- Evolutionary Venomics Lab, Centre for Ecological Sciences, Indian Institute of Science, Bangalore 560012, Karnataka, India; (S.K.); (R.R.S.L.); (S.A.); (P.D.); (V.S.)
| | - Saurabh Attarde
- Evolutionary Venomics Lab, Centre for Ecological Sciences, Indian Institute of Science, Bangalore 560012, Karnataka, India; (S.K.); (R.R.S.L.); (S.A.); (P.D.); (V.S.)
| | - Paulomi Dam
- Evolutionary Venomics Lab, Centre for Ecological Sciences, Indian Institute of Science, Bangalore 560012, Karnataka, India; (S.K.); (R.R.S.L.); (S.A.); (P.D.); (V.S.)
| | - Vivek Suranse
- Evolutionary Venomics Lab, Centre for Ecological Sciences, Indian Institute of Science, Bangalore 560012, Karnataka, India; (S.K.); (R.R.S.L.); (S.A.); (P.D.); (V.S.)
| | - Anil Khaire
- Indian Herpetological Society, 7/47, Pune Satara Road, Pune 411009, Maharashtra, India;
| | - Gerard Martin
- The Liana Trust, Survey #1418/1419 Rathnapuri, Hunsur 571189, Karnataka, India;
| | - Ashok Captain
- 3/1 Boat Club Road, Pune 411001, Maharashtra, India;
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Braga JRM, Jorge ARC, Marinho AD, Silveira JADM, Nogueira-Junior FA, Valle MB, Alagón A, de Menezes RRPPB, Martins AMC, Feijão LX, Monteiro HSA, Jorge RJB. Renal effects of venoms of Mexican coral snakes Micrurus browni and Micrurus laticollaris. Toxicon 2020; 181:45-52. [DOI: 10.1016/j.toxicon.2020.04.095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/11/2020] [Accepted: 04/22/2020] [Indexed: 12/23/2022]
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Benjamin JM, Abo BN, Brandehoff N. Review Article: Snake Envenomation in Africa. CURRENT TROPICAL MEDICINE REPORTS 2020. [DOI: 10.1007/s40475-020-00198-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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9
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Kularatne SAM, Colombage A, de Silva A, Weerasinghe V, Rathnayaka RMMKN. Acute neuromuscular paralysis, rhabdomyolysis and long lasting neurological deficits in Ceylon krait ( Bungarus ceylonicus) bites: Two authentic cases from a serpentarium in Sri Lanka. Toxicon X 2019; 4:100015. [PMID: 32550572 PMCID: PMC7286062 DOI: 10.1016/j.toxcx.2019.100015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/26/2019] [Accepted: 09/12/2019] [Indexed: 11/30/2022] Open
Abstract
The Ceylon krait (Bungarus ceylonicus) is a highly venomous elapid snake endemic to Sri Lanka. Its bites are rare and only seven reports are found in the literature. Therefore, the clinical manifestations and natural history of envenoming of Ceylon krait are not well studied yet. Neuroparalysis is the main clinical manifestation of their bites. We report two cases of proven Ceylon krait bites of two young snake keepers working in a serpentarium. They developed acute neuroparalysis, abdominal pain and a period of amnesia. The first patient developed myalgia and increased level of serum creatine kinase suggestive of rhabdomyolysis. One was treated with Indian polyvalent antivenom and both recovered with some long-lasting clinical disabilities namely impairment of sensation of the bitten arm and persistent refraction errors in the eyes in the first patient. The second patient had persistent marked nystagmus. Ceylon krait (Bungarus ceylonicus) is endemic to Sri Lanka and bites rarely. Two authentic bites are described. Both developed neuromuscular paralysis manageable without assisted ventilation. Long lasting deficits were sensory impairment of bitten arm, refraction errors and nystagmus.
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Affiliation(s)
- S A M Kularatne
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka
| | | | | | - Vajira Weerasinghe
- Teaching Hospital Peradeniya, Sri Lanka.,Department of Physiology, Faculty of Medicine, University of Peradeniya, Sri Lanka
| | - R M M K Namal Rathnayaka
- Intensive Care Unit, Teaching Hospital, Ratnapura, Sri Lanka.,Department of Veterinary Pathobiology, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Sri Lanka.,Postgraduate Institute of Medicine (Clinical Pharmacology and Therapeutics), University of Colombo, Sri Lanka
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10
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Tongpoo A, Sriapha C, Pradoo A, Udomsubpayakul U, Srisuma S, Wananukul W, Trakulsrichai S. Krait envenomation in Thailand. Ther Clin Risk Manag 2018; 14:1711-1717. [PMID: 30271155 PMCID: PMC6145358 DOI: 10.2147/tcrm.s169581] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Purpose Three species in the genus Bungarus inhabit Thailand. Among these, Bungarus candidus (Malayan krait) is the most common and deadliest. Currently, the clinical manifestations of patients envenomed by kraits, especially Bungarus fasciatus (banded krait), have not been thoroughly investigated. This study was performed to elucidate the clinical manifestations and outcomes of patients bitten by kraits in Thailand. Materials and methods The data of krait envenomation cases that occurred during a 9-year period were obtained from the Ramathibodi Poison Center Toxic Exposure Surveillance System and retrospectively analyzed. Results In total, 78 cases of krait envenomation were included. Most patients were male (59.0%) and the median age was 28 years. All had minimal local effects. The median duration from the bite to the onset of neurological manifestations was 3 hours (range, 0.5–8 hours). Besides neurological effects, the patients also developed high blood pressure (67.4%), tachycardia (61.7%), hypokalemia (55.3%), and hyponatremia (17.6%). Severe hyponatremia (<120 mEq/L) was noted in four pediatric patients. Other clinical manifestations were bradycardia, abdominal pain, and rhabdomyolysis. The mortality rate was 6.4%, and all deaths occurred from B. candidus bites. Eighty-six percent of patients received antivenom. Most patients (75.6%) were intubated and underwent assisted ventilation for a median of 6 days (range, 1–37 days). The median length of hospital stay was 7 days. Some patients developed complications during hospitalization; the most common was pneumonia. These in-hospital complications were significantly associated with death. Conclusion Although krait bites caused only minimal local effects, the mortality rate was still high, particularly from Malayan krait bites. Besides neurological effects, other clinical manifestations were high blood pressure, tachycardia, hypokalemia, and hyponatremia. Thus, vital signs and electrolytes should be frequently and closely monitored in these patients. Apart from antivenom treatment, adequate supportive care including management of complications might help to decrease the mortality rate.
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Affiliation(s)
- Achara Tongpoo
- Ramthibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,
| | - Charuwan Sriapha
- Ramthibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,
| | - Aimon Pradoo
- Ramthibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,
| | - Umaporn Udomsubpayakul
- Section for Clinical Epidemiology and Biostatistics, Research Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sahaphume Srisuma
- Ramthibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, .,Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Winai Wananukul
- Ramthibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, .,Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Satariya Trakulsrichai
- Ramthibodi Poison Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, .,Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,
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11
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Charoenpitakchai M, Wiwatwarayos K, Jaisupa N, Rusmili MRA, Mangmool S, Hodgson WC, Ruangpratheep C, Chanhome L, Chaisakul J. Non-neurotoxic activity of Malayan krait ( Bungarus candidus) venom from Thailand. J Venom Anim Toxins Incl Trop Dis 2018; 24:9. [PMID: 29556251 PMCID: PMC5845229 DOI: 10.1186/s40409-018-0146-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/02/2018] [Indexed: 12/11/2022] Open
Abstract
Background Envenoming by kraits (genus Bungarus) is a medically significant issue in South Asia and Southeast Asia. Malayan krait (Bungarus candidus) venom is known to contain highly potent neurotoxins. In recent years, there have been reports on the non-neurotoxic activities of krait venom that include myotoxicity and nephrotoxicity. However, research on such non-neurotoxicity activities of Malayan krait venom is extremely limited. Thus, the aim of the present study was to determine the myotoxic, cytotoxic and nephrotoxic activities of B. candidus venoms from northeastern (BC-NE) and southern (BC-S) Thailand in experimentally envenomed rats. Methods Rats were administered Malayan krait (BC-NE or BC-S) venom (50 μg/kg, i.m.) or 0.9% NaCl solution (50 μL, i.m.) into the right hind limb. The animals were sacrificed 3, 6 and 24 h after venom administration. The right gastrocnemius muscle and both kidneys were collected for histopathological analysis. Blood samples were also taken for determination of creatine kinase (CK) and lactate dehydrogenase (LDH) levels. The human embryonic kidney cell line (HEK-293) was used in a cell proliferation assay to determine cytotoxic activity. Results Administration of BC-NE or BC-S venom (50 μg/kg, i.m.) caused time-dependent myotoxicity, characterized by an elevation of CK and LDH levels. Histopathological examination of skeletal muscle displayed marked muscle necrosis and myofiber disintegration 24 h following venom administration. Both Malayan krait venoms also induced extensive renal tubular injury with glomerular and interstitial congestion in rats. BC-NE and BC-S venoms (100–0.2 μg/mL) caused concentration-dependent cytotoxicity on the HEK-293 cell line. However, BC-NE venom (IC50 = 8 ± 1 μg/mL; at 24 h incubation; n = 4) was found to be significantly more cytotoxic than BC-S venom (IC50 = 15 ± 2 μg/mL; at 24 h incubation; n = 4). In addition, the PLA2 activity of BC-NE venom was significantly higher than that of BC-S venom. Conclusions This study found that Malayan krait venoms from both populations possess myotoxic, cytotoxic and nephrotoxic activities. These findings may aid in clinical diagnosis and treatment of envenomed patients in the future.
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Affiliation(s)
| | - Kulachet Wiwatwarayos
- Department of Anatomical Pathology, Army Institute of Pathology, Royal Thai Army Medical Department, Bangkok, 10400 Thailand
| | - Nattapon Jaisupa
- 3Department of Pharmacology, Phramongkutklao College of Medicine, Bangkok, 10400 Thailand
| | - Muhamad Rusdi Ahmad Rusmili
- 4Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan Campus, Bandar Indera Mahkota, 25200 Kuantan, Pahang Darul Makmur Malaysia
| | - Supachoke Mangmool
- 5Department of Pharmacology, Faculty of Pharmacy, Mahidol University, Bangkok, 10400 Thailand
| | - Wayne C Hodgson
- 6Monash Venom Group, Department of Pharmacology, Biomedical Discovery Institute, Monash University, Clayton, VIC 3800 Australia
| | - Chetana Ruangpratheep
- 1Department of Pathology, Phramongkutklao College of Medicine, Bangkok, 10400 Thailand
| | - Lawan Chanhome
- 7Queen Saovabha Memorial Institute, Thai Red Cross Society, Bangkok, 10330 Thailand
| | - Janeyuth Chaisakul
- 3Department of Pharmacology, Phramongkutklao College of Medicine, Bangkok, 10400 Thailand
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Kang TS, Chen W, Goh LC, Kini M. Identification and characterisation of novel inhibitors on extrinsic tenase complex from Bungarus fasciatus (banded krait) venom. Thromb Haemost 2017; 112:700-15. [DOI: 10.1160/th13-12-1063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 05/06/2014] [Indexed: 11/05/2022]
Abstract
SummarySnake venoms are excellent sources of pharmacologically active proteins and peptides, and hence are potential sources of leads for drug developments. It has been previously established that krait (Bungarus genus) venoms contain mainly neurotoxins. A screening for anticoagulants showed that Bungarus fasciatus venom exhibits potent anticoagulant effect in standard clotting assays. Through sequential fractionation of the venom by size exclusion and high performance liquid chromatographies, coupled with functional screening for anticoagulant activities, we have isolated and purified two anticoagulant proteins, termed BF-AC1 ( Bungarus fasciatus anticoagulant 1) and BFAC2. They have potent inhibitory activities (IC50 of 10 nM) on the extrinsic tenase complex. Structurally, these proteins each has two subunits covalently held together by disulfide bond(s). The N-terminal sequences of the individual subunits of BF-AC1 and BF-AC2 showed that the larger subunit is homologous to phospholipase A2, while the smaller subunit is homologous to Kunitz type serine proteinase inhibitor. Functionally, in addition to their anticoagulant activity, these proteins showed presynaptic neurotoxic effects in both in vivo and ex vivo experiments. Thus, BF-AC1 and BF-AC2 are structurally and functionally similar to β-bungarotoxins, a class of neurotoxins. The enzymatic activity of phospholipase A2 subunit plays a significant role in the anticoagulant activities. This is the first report on the anticoagulant activity of β-bungarotoxins and these results expand on the existing catalogue of haemostatically active snake venom proteins.
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Mao YC, Liu PY, Chiang LC, Liao SC, Su HY, Hsieh SY, Yang CC. Bungarus multicinctus multicinctus Snakebite in Taiwan. Am J Trop Med Hyg 2017; 96:1497-1504. [PMID: 28719273 DOI: 10.4269/ajtmh.17-0005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractAlthough specific antivenom is available in Taiwan, respiratory failure and general pain frequently accompany Bungarus multicinctus envenomation and there have been few reports on the management of B. multicinctus envenomation. We retrospectively analyzed 44 cases of B. multicinctus bite admitted to Taichung Veterans General Hospital (VGH) or to Taipei VGH. Demographic data, treatment, and outcome of patients with and without respiratory failure were compared. In this study, 20.5% patients had bites without noticeable signs or symptoms of significant envenoming, 27.3% developed respiratory failure, and 27.3% experienced general pain. Bivalent specific antivenom for B. multicinctus and N. atra was administered in all envenomed cases. Respiratory failure occurred 1.5-6.5 hours post-bite and general pain occurred 1-12 hours post-bite. Specific antivenom for B. multicinctus and N. atra at the recommended dose (i.e., 2-4 vials) might not effectively prevent respiratory failure and pain. Respiratory failure, general pain, and autonomic effects after B. multicinctus bite were probably caused, at least partly, by β-bungarotoxin. Although general weakness, ptosis, dysarthria, and dilated pupils were significantly associated with respiratory failure, their predictive value could not be accurately determined in such a retrospective study. Due to the rapid onset of respiratory failure, every suspected envenomed case thus should be closely monitored in the first few hours. We recommend the initial administration of four vials of antivenom in all envenomation cases, and a subsequent four vials be considered if the patient's condition is deteriorating. Prospective evaluation of the antivenom dosing regimen is urgently needed to improve B. multicinctus envenomation treatment.
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Affiliation(s)
- Yan-Chiao Mao
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Po-Yu Liu
- Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Liao-Chun Chiang
- National Health Research Institutes, National Institute of Infectious Diseases and Vaccinology, Miaoli, Taiwan.,National Tsing Hua University, College of Life Sciences, Hsinchu, Taiwan
| | - Shu-Chen Liao
- Department of Emergency Medicine, Chang Guang Memorial Hospital, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Yuan Su
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Szu-Yin Hsieh
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chen-Chang Yang
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Antivenom for Neuromuscular Paralysis Resulting From Snake Envenoming. Toxins (Basel) 2017; 9:toxins9040143. [PMID: 28422078 PMCID: PMC5408217 DOI: 10.3390/toxins9040143] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/11/2017] [Accepted: 04/13/2017] [Indexed: 02/06/2023] Open
Abstract
Antivenom therapy is currently the standard practice for treating neuromuscular dysfunction in snake envenoming. We reviewed the clinical and experimental evidence-base for the efficacy and effectiveness of antivenom in snakebite neurotoxicity. The main site of snake neurotoxins is the neuromuscular junction, and the majority are either: (1) pre-synaptic neurotoxins irreversibly damaging the presynaptic terminal; or (2) post-synaptic neurotoxins that bind to the nicotinic acetylcholine receptor. Pre-clinical tests of antivenom efficacy for neurotoxicity include rodent lethality tests, which are problematic, and in vitro pharmacological tests such as nerve-muscle preparation studies, that appear to provide more clinically meaningful information. We searched MEDLINE (from 1946) and EMBASE (from 1947) until March 2017 for clinical studies. The search yielded no randomised placebo-controlled trials of antivenom for neuromuscular dysfunction. There were several randomised and non-randomised comparative trials that compared two or more doses of the same or different antivenom, and numerous cohort studies and case reports. The majority of studies available had deficiencies including poor case definition, poor study design, small sample size or no objective measures of paralysis. A number of studies demonstrated the efficacy of antivenom in human envenoming by clearing circulating venom. Studies of snakes with primarily pre-synaptic neurotoxins, such as kraits (Bungarus spp.) and taipans (Oxyuranus spp.) suggest that antivenom does not reverse established neurotoxicity, but early administration may be associated with decreased severity or prevent neurotoxicity. Small studies of snakes with mainly post-synaptic neurotoxins, including some cobra species (Naja spp.), provide preliminary evidence that neurotoxicity may be reversed with antivenom, but placebo controlled studies with objective outcome measures are required to confirm this.
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15
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Silva A, Johnston C, Kuruppu S, Kneisz D, Maduwage K, Kleifeld O, Smith AI, Siribaddana S, Buckley NA, Hodgson WC, Isbister GK. Clinical and Pharmacological Investigation of Myotoxicity in Sri Lankan Russell's Viper (Daboia russelii) Envenoming. PLoS Negl Trop Dis 2016; 10:e0005172. [PMID: 27911900 PMCID: PMC5135039 DOI: 10.1371/journal.pntd.0005172] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/08/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Sri Lankan Russell's viper (Daboia russelii) envenoming is reported to cause myotoxicity and neurotoxicity, which are different to the effects of envenoming by most other populations of Russell's vipers. This study aimed to investigate evidence of myotoxicity in Russell's viper envenoming, response to antivenom and the toxins responsible for myotoxicity. METHODOLOGY AND FINDINGS Clinical features of myotoxicity were assessed in authenticated Russell's viper bite patients admitted to a Sri Lankan teaching hospital. Toxins were isolated using high-performance liquid chromatography. In-vitro myotoxicity of the venom and toxins was investigated in chick biventer nerve-muscle preparations. Of 245 enrolled patients, 177 (72.2%) had local myalgia and 173 (70.6%) had local muscle tenderness. Generalized myalgia and muscle tenderness were present in 35 (14.2%) and 29 (11.8%) patients, respectively. Thirty-seven patients had high (>300 U/l) serum creatine kinase (CK) concentrations in samples 24h post-bite (median: 666 U/l; maximum: 1066 U/l). Peak venom and 24h CK concentrations were not associated (Spearman's correlation; p = 0.48). The 24h CK concentrations differed in patients without myotoxicity (median 58 U/l), compared to those with local (137 U/l) and generalised signs/symptoms of myotoxicity (107 U/l; p = 0.049). Venom caused concentration-dependent inhibition of direct twitches in the chick biventer cervicis nerve-muscle preparation, without completely abolishing direct twitches after 3 h even at 80 μg/ml. Indian polyvalent antivenom did not prevent in-vitro myotoxicity at recommended concentrations. Two phospholipase A2 toxins with molecular weights of 13kDa, U1-viperitoxin-Dr1a (19.2% of venom) and U1-viperitoxin-Dr1b (22.7% of venom), concentration dependently inhibited direct twitches in the chick biventer cervicis nerve-muscle preparation. At 3 μM, U1-viperitoxin-Dr1a abolished twitches, while U1-viperitoxin-Dr1b caused 70% inhibition of twitch force after 3h. Removal of both toxins from whole venom resulted in no in-vitro myotoxicity. CONCLUSION The study shows that myotoxicity in Sri Lankan Russell's viper envenoming is mild and non-life threatening, and due to two PLA2 toxins with weak myotoxic properties.
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Affiliation(s)
- Anjana Silva
- Monash Venom Group, Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
| | - Christopher Johnston
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
| | - Sanjaya Kuruppu
- Monash Venom Group, Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Daniela Kneisz
- Monash Venom Group, Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Kalana Maduwage
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Oded Kleifeld
- Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - A. Ian Smith
- Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Sisira Siribaddana
- Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Nicholas A. Buckley
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Pharmacology, University of Sydney, Sydney, Australia
| | - Wayne C. Hodgson
- Monash Venom Group, Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Geoffrey K. Isbister
- Monash Venom Group, Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
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Eslamian L, Mobaiyen H, Bayat-Makoo Z, Piri R, Benisi R, Naghavi Behzad M. Snake bite in Northwest Iran: A retrospective study. JOURNAL OF ANALYTICAL RESEARCH IN CLINICAL MEDICINE 2016. [DOI: 10.15171/jarcm.2016.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Pandey DP, Sharma SK, Alirol E, Chappuis F, Kuch U. Fatal neurotoxic envenomation following the bite of a greater black krait (Bungarus niger) in Nepal: a case report. J Venom Anim Toxins Incl Trop Dis 2016; 22:19. [PMID: 27274722 PMCID: PMC4891907 DOI: 10.1186/s40409-016-0073-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 05/24/2016] [Indexed: 01/24/2023] Open
Abstract
Background Neurotoxic envenomation following bites by kraits (Bungarus species) is a leading cause of snakebite mortality in South Asia. Over a long time, this had been attributed only to one species, the common krait (Bungarus caeruleus). However, recent research has provided increasing evidence of the involvement of several krait species. Here, we report a fatal case of neurotoxic envenomation following the bite of a greater black krait (Bungarus niger) in Nepal. Case presentation A 33-year-old man was bitten in the outdoor corridor of his home in the eastern hills of Ilam district while handling a snake he thought to be non-venomous. He subsequently developed severe abdominal pain, frequent vomiting, and signs of neurotoxic envenomation leading to respiratory paralysis. The patient did not respond to Indian polyvalent antivenom given 4 h after the bite and died under treatment 8 h after the bite. This is the second time that a B. niger was observed in Nepal, the first documented case of envenomation by this species in the country and the sixth reported case worldwide. Conclusions Previous distribution records – from eastern India and western Nepal, from western hills in Nepal, and from lowland localities in India and Bangladesh – indicate risk of envenomation by B. niger throughout the low and intermediate elevations of Nepal up to at least 1,500 m above sea level. As very few people in Nepal bring killed snakes to healthcare centers and because there is a general belief among local people that there are no kraits in the hills, bites by B. niger are likely to be misdiagnosed and underreported.
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Affiliation(s)
| | - Sanjib Kumar Sharma
- Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Emilie Alirol
- Clinical Trial Unit, Clinical Research Centre and Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, Geneva, Switzerland ; Médecins Sans Frontières UK, London, UK
| | - François Chappuis
- Clinical Trial Unit, Clinical Research Centre and Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Ulrich Kuch
- Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Germany
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Silva A, Maduwage K, Sedgwick M, Pilapitiya S, Weerawansa P, Dahanayaka NJ, Buckley NA, Siribaddana S, Isbister GK. Neurotoxicity in Russell's viper (Daboia russelii) envenoming in Sri Lanka: a clinical and neurophysiological study. Clin Toxicol (Phila) 2016; 54:411-9. [PMID: 26923566 DOI: 10.3109/15563650.2016.1143556] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 01/08/2016] [Accepted: 01/13/2016] [Indexed: 11/13/2022]
Abstract
CONTEXT Russell's viper is more medically important than any other Asian snake, due to number of envenoming's and fatalities. Russell's viper populations in South India and Sri Lanka (Daboia russelii) cause unique neuromuscular paralysis not seen in other Russell's vipers. OBJECTIVE To investigate the time course and severity of neuromuscular dysfunction in definite Russell's viper bites, including antivenom response. METHODOLOGY We prospectively enrolled all patients (>16 years) presenting with Russell's viper bites over 14 months. Cases were confirmed by snake identification and/or enzyme immunoassay. All patients had serial neurological examinations and in some, single fibre electromyography (sfEMG) of the orbicularis oculi was performed. RESULTS 245 definite Russell's viper bite patients (median age: 41 years; 171 males) presented a median 2.5 h (interquartile range: 1.75-4.0 h) post-bite. All but one had local envenoming and 199 (78%) had systemic envenoming: coagulopathy in 166 (68%), neurotoxicity in 130 (53%), and oliguria in 19 (8%). Neurotoxicity was characterised by ptosis (100%), blurred vision (93%), and ophthalmoplegia (90%) with weak extraocular movements, strabismus, and diplopia. Neurotoxicity developed within 8 h post-bite in all patients. No bulbar, respiratory or limb muscle weakness occurred. Neurotoxicity was associated with bites by larger snakes (p < 0.0001) and higher peak serum venom concentrations (p = 0.0025). Antivenom immediately decreased unbound venom in blood. Of 52 patients without neurotoxicity when they received antivenom, 31 developed neurotoxicity. sfEMG in 27 patients with neurotoxicity and 23 without had slightly elevated median jitter on day 1 compared to 29 normal subjects but normalised thereafter. Neurological features resolved in 80% of patients by day 3 with ptosis and weak eye movements resolving last. No clinical or neurophysiological abnormality was detected at 6 weeks or 6 months. CONCLUSION Sri Lankan Russell's viper envenoming causes mild neuromuscular dysfunction with no long-term effects. Indian polyvalent antivenom effectively binds free venom in blood but does not reverse neurotoxicity.
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Affiliation(s)
- Anjana Silva
- a Monash Venom Group, Department of Pharmacology , Monash University , Clayton , VIC , Australia
- b Faculty of Medicine and Allied Sciences , Rajarata University of Sri Lanka , Saliyapura , Sri Lanka
- c South Asian Clinical Toxicology Research Collaboration , University of Peradeniya, Peradeniya , Sri Lanka
| | - Kalana Maduwage
- c South Asian Clinical Toxicology Research Collaboration , University of Peradeniya, Peradeniya , Sri Lanka
- d Clinical Toxicology Research Group , University of Newcastle , Callaghan , NSW , Australia
| | - Michael Sedgwick
- c South Asian Clinical Toxicology Research Collaboration , University of Peradeniya, Peradeniya , Sri Lanka
| | - Senaka Pilapitiya
- b Faculty of Medicine and Allied Sciences , Rajarata University of Sri Lanka , Saliyapura , Sri Lanka
| | - Prasanna Weerawansa
- b Faculty of Medicine and Allied Sciences , Rajarata University of Sri Lanka , Saliyapura , Sri Lanka
| | - Niroshana J Dahanayaka
- b Faculty of Medicine and Allied Sciences , Rajarata University of Sri Lanka , Saliyapura , Sri Lanka
| | - Nicholas A Buckley
- c South Asian Clinical Toxicology Research Collaboration , University of Peradeniya, Peradeniya , Sri Lanka
- e Clinical Pharmacology , University of Sydney , Sydney , NSW , Australia
| | - Sisira Siribaddana
- b Faculty of Medicine and Allied Sciences , Rajarata University of Sri Lanka , Saliyapura , Sri Lanka
| | - Geoffrey K Isbister
- c South Asian Clinical Toxicology Research Collaboration , University of Peradeniya, Peradeniya , Sri Lanka
- d Clinical Toxicology Research Group , University of Newcastle , Callaghan , NSW , Australia
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Neuromuscular Effects of Common Krait (Bungarus caeruleus) Envenoming in Sri Lanka. PLoS Negl Trop Dis 2016; 10:e0004368. [PMID: 26829229 PMCID: PMC4734751 DOI: 10.1371/journal.pntd.0004368] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 12/16/2015] [Indexed: 11/19/2022] Open
Abstract
Objective We aimed to investigate neurophysiological and clinical effects of common krait envenoming, including the time course and treatment response. Methodology Patients with definite common krait (Bungarus caeruleus) bites were recruited from a Sri Lankan hospital. All patients had serial neurological examinations and stimulated concentric needle single-fibre electromyography (sfEMG) of orbicularis oculi in hospital at 6wk and 6–9mth post-bite. Principal Findings There were 33 patients enrolled (median age 35y; 24 males). Eight did not develop neurotoxicity and had normal sfEMG. Eight had mild neurotoxicity with ptosis, normal sfEMG; six received antivenom and all recovered within 20–32h. Seventeen patients developed severe neurotoxicity with rapidly descending paralysis, from ptosis to complete ophthalmoplegia, facial, bulbar and neck weakness. All 17 received Indian polyvalent antivenom a median 3.5h post-bite (2.8–7.2h), which cleared unbound venom from blood. Despite this, the paralysis worsened requiring intubation and ventilation within 7h post-bite. sfEMG showed markedly increased jitter and neuromuscular blocks within 12h. sfEMG abnormalities gradually improved over 24h, corresponding with clinical recovery. Muscle recovery occurred in ascending order. Myotoxicity was not evident, clinically or biochemically, in any of the patients. Patients were extubated a median 96h post-bite (54–216h). On discharge, median 8 days (4–12days) post-bite, patients were clinically normal but had mild sfEMG abnormalities which persisted at 6wk post-bite. There were no clinical or neurophysiological abnormalities at 6–9mth. Conclusions Common krait envenoming causes rapid onset severe neuromuscular paralysis which takes days to recover clinically consistent with sfEMG. Subclinical neuromuscular dysfunction lasts weeks but was not permanent. Antivenom effectively cleared venom but did not prevent worsening or reverse neuromuscular paralysis. Common krait bites cause muscular paralysis due to the venom disrupting communication between the nerves and muscles. This becomes life-threatening for the patient if there is paralysis of the muscles used for breathing. We studied the severity of paralysis, long term effects and the value of antivenom treatment in authenticated Indian krait bite patients from Sri Lanka. In addition to standard treatment with antivenom, the patients had single-fibre electromyography done, a sensitive neurophysiological test that detects the abnormalities of communication between the nerves and muscles. Half of the patients had severe paralysis and required mechanical ventilation, and the remainder had mild or no effects. Antivenom was given to all patients with severe paralysis and most with mild effects. However, despite antivenom binding all free venom after it was administered, it did not prevent or reverse already developed paralysis. Clinically evident paralysis resolved after a few days, but the neurophysiological abnormalities lasted for weeks. No permanent neurological damages were noted at 6 to 9 months after the snake bite.
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Floriano RS, Rocha T, Carregari VC, Marangoni S, da Cruz-Höfling MA, Hyslop S, Rodrigues-Simioni L, Rowan EG. The neuromuscular activity of Bothriopsis bilineata smaragdina (forest viper) venom and its toxin Bbil-TX (Asp49 phospholipase A2) on isolated mouse nerve-muscle preparations. Toxicon 2015; 96:24-37. [DOI: 10.1016/j.toxicon.2015.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 12/30/2014] [Accepted: 01/03/2015] [Indexed: 11/16/2022]
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Abstract
This review is on the pulmonary complications of snakebites, which can have fatal consequences. We identified three common themes as reported in the literature regarding envenomation: generalized neuromuscular paralysis affecting airway and respiratory muscles, pulmonary edema, and pulmonary hemorrhages or thrombosis due to coagulopathy. Respiratory paralysis and pulmonary edema can be due to either elapid or viper bites, whereas pulmonary complications of coagulopathy are exclusively reported with viper bites. The evidence for each complication, timeline of appearance, response to treatment, and details of pathophysiology are discussed.
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Affiliation(s)
- Ariaranee Gnanathasan
- From the The Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
| | - Chaturaka Rodrigo
- From the The Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Rusmili MRA, Yee TT, Mustafa MR, Hodgson WC, Othman I. Proteomic characterization and comparison of Malaysian Bungarus candidus and Bungarus fasciatus venoms. J Proteomics 2014; 110:129-44. [PMID: 25154052 DOI: 10.1016/j.jprot.2014.08.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Revised: 08/05/2014] [Accepted: 08/06/2014] [Indexed: 01/25/2023]
Abstract
UNLABELLED Kraits (Bungarus spp.) are highly venomous elapids that are only found in Asia. In the current study, 103 and 86 different proteins were identified from Bungarus candidus and Bungarus fasciatus venoms, respectively. These proteins were classified into 18 different venom protein families. Both venoms were found to contain a high percentage of three finger toxins, phospholipase A2 enzymes and Kunitz-type inhibitors. Smaller number of high molecular weight enzymes such as L-amino acid oxidase, hyaluronidases, and acetylcholinesterase were also detected in the venoms. We also detected some unique proteins that were not known to be present in these venoms. The presence of a natriuretic peptide, vespryn, and serine protease families was detected in B. candidus venom. We also detected the presence of subunit A and B of β-bungarotoxin and α-bungarotoxin which had not been previously found in B. fasciatus venom. Understanding the proteome composition of Malaysian krait species will provide useful information on unique toxins and proteins which are present in the venoms. This knowledge will assist in the management of krait envenoming. In addition, these proteins may have potential use as research tools or as drug-design templates. BIOLOGICAL SIGNIFICANCE This study has revealed the proteome composition of Malaysian B. candidus and B. fasciatus venoms, two medically important snake species in Asia. Information on the venom proteome of these species will provide useful information for krait bite management and aid in antivenom selection. Venom proteome profiles of these venoms showed that there are significant differences in the venom protein family compositions. Detection of proteins and peptides that have not been documented in these species such as natriuretic peptides, vespryn and serine proteases provides new knowledge on the composition of these venoms. The roles of these new proteins and peptides in krait envenoming are still unknown. Discovery of these proteins and peptides may also be useful for future research tool and therapeutic development.
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Affiliation(s)
- Muhamad Rusdi Ahmad Rusmili
- Monash Venom Group, Department of Pharmacology, Faculty of Medicine, Nursing and Health Sciences, 3168 Clayton, Victoria, Australia; Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 46150 Bandar Sunway, Malaysia; Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan Campus, Bandar Indera Mahkota, 25200 Kuantan, Pahang, Malaysia
| | - Tee Ting Yee
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 46150 Bandar Sunway, Malaysia
| | - Mohd Rais Mustafa
- Department of Pharmacology, Faculty of Medicine, University of Malaya, 59100 Kuala Lumpur, Malaysia
| | - Wayne C Hodgson
- Monash Venom Group, Department of Pharmacology, Faculty of Medicine, Nursing and Health Sciences, 3168 Clayton, Victoria, Australia
| | - Iekhsan Othman
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 46150 Bandar Sunway, Malaysia.
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Harris JB, Scott-Davey T. Secreted phospholipases A2 of snake venoms: effects on the peripheral neuromuscular system with comments on the role of phospholipases A2 in disorders of the CNS and their uses in industry. Toxins (Basel) 2013; 5:2533-71. [PMID: 24351716 PMCID: PMC3873700 DOI: 10.3390/toxins5122533] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 12/02/2013] [Accepted: 12/10/2013] [Indexed: 01/02/2023] Open
Abstract
Neuro- and myotoxicological signs and symptoms are significant clinical features of envenoming snakebites in many parts of the world. The toxins primarily responsible for the neuro and myotoxicity fall into one of two categories--those that bind to and block the post-synaptic acetylcholine receptors (AChR) at the neuromuscular junction and neurotoxic phospholipases A2 (PLAs) that bind to and hydrolyse membrane phospholipids of the motor nerve terminal (and, in most cases, the plasma membrane of skeletal muscle) to cause degeneration of the nerve terminal and skeletal muscle. This review provides an introduction to the biochemical properties of secreted sPLA2s in the venoms of many dangerous snakes and a detailed discussion of their role in the initiation of the neurologically important consequences of snakebite. The rationale behind the experimental studies on the pharmacology and toxicology of the venoms and isolated PLAs in the venoms is discussed, with particular reference to the way these studies allow one to understand the biological basis of the clinical syndrome. The review also introduces the involvement of PLAs in inflammatory and degenerative disorders of the central nervous system (CNS) and their commercial use in the food industry. It concludes with an introduction to the problems associated with the use of antivenoms in the treatment of neuro-myotoxic snakebite and the search for alternative treatments.
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Affiliation(s)
- John B. Harris
- Medical Toxicology Centre and Institute of Neurosciences, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Tracey Scott-Davey
- Experimental Scientific Officer, Electron Microscopy Unit, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; E-Mail:
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Harris J, Flecknell P, Thomas A, Warrell DA. On the use of analgesia in experimental toxinology. Toxicon 2013; 64:36-7. [DOI: 10.1016/j.toxicon.2012.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 12/13/2012] [Indexed: 10/27/2022]
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Del Brutto OH. Neurological effects of venomous bites and stings: snakes, spiders, and scorpions. HANDBOOK OF CLINICAL NEUROLOGY 2013; 114:349-68. [PMID: 23829924 DOI: 10.1016/b978-0-444-53490-3.00028-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Snake and spider bites, as well as scorpion sting envenoming, are neglected diseases affecting millions of people all over the world. Neurological complications vary according to the offending animal, and are often directly related to toxic effects of the venom, affecting the central nervous system, the neuromuscular transmission, the cardiovascular system, or the coagulation cascade. Snake bite envenoming may result in stroke or muscle paralysis. Metalloproteinases and other substances (common in vipers and colubrids) have anticoagulant or procoagulant activity, and may induce ischemic or hemorrhagic strokes. The venom of elapids is rich in neurotoxins affecting the neuromuscular transmission at either presynaptic or postsynaptic levels. The clinical picture of scorpion sting envenoming is dominated by muscle weakness associated with arterial hypertension, cardiac arrythmias, myocarditis, or pulmonary edema. These manifestations occur as the result of release of catecholamines into the bloodstream or due to direct cardiac toxicity of the venom. Cerebrovascular complications have been reported after the sting of the Indian red scorpion. Intracranial hemorrhages occur in the setting of acute increases in arterial blood pressure related to sympathetic overstimulation, and cerebral infarctions are related to either cerebral hypoperfusion, consumption coagulopathy, vasculitis, or cardiogenic brain embolism. Three main syndromes result from spider bite envenoming: latrodectism, loxoscelism, and funnel-web spider envenoming. Latrodectism is related to neurotoxins present in the venom of widow spiders. Most cases present with headache, lethargy, irritability, myalgia, tremor, fasciculation, or ataxia. Loxoscelism is caused by envenoming by spiders of the family Sicariidae. It may present with a stroke due to a severe coagulopathy. The venom of funnel-web spiders also has neurotoxins that stimulate neurotransmitter release, resulting in sensory disturbances and muscle paralysis. Proper management of the envenomed patient, including prompt transport to the hospital, correction of the hemostatic disorder, ventilatory support, and administration of antivenom, significantly reduce the risk of neurological complications which, in turn, reduce the mortality and improve the functional outcome of survivors.
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Affiliation(s)
- Oscar H Del Brutto
- School of Medicine, Universidad Espiritu Santo, Guayaquil, Ecuador; Department of Neurological Sciences, Hospital Clinica Kennedy, Guayaquil, Ecuador.
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Abstract
Research is discussed in the areas of venomous snake taxonomy, epidemiology, species diagnosis, defining the clinical phenotype of human envenoming, pathophysiological mechanisms of envenoming, clinical testing of antivenoms and prevention of snake-bite through community education. This work was carried out over the past 40 years in many countries in four tropical continents. The help and friendship of a large number of collaborators is gratefully acknowledged.
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Affiliation(s)
- David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom.
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Pillai LV, Ambike D, Husainy S, Khaire A, Captain A, Kuch U. Severe Neurotoxic Envenoming and Cardiac Complications after the Bite of a 'Sind Krait' (Bungarus cf. sindanus) in Maharashtra, India. Trop Med Health 2012; 40:103-8. [PMID: 23264729 PMCID: PMC3521050 DOI: 10.2149/tmh.2012-08c] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 08/29/2012] [Indexed: 11/11/2022] Open
Abstract
We report a case of severe envenoming with unusual complications and two anecdotal cases of fatalities following proven 17-scale-row ‘Sind krait’ (Bungarus cf. sindanus) bites on people sleeping in temporary huts at construction sites in Pune District, Maharashtra, India. A 25-yr-old male developed progressive neuromuscular paralysis, abdominal pain and autonomic disturbances complicated by four prolonged episodes of pulseless ventricular tachycardia requiring defibrillation, and followed by pulmonary edema secondary to impaired left ventricular systolic function and hyperfusion. There was no response to antivenom; mechanical ventilation was required for six days. Only one other case of fatal envenoming likely caused by this species had been reported previously in India. The distribution of B. sindanus sensu lato from eastern Afghanistan to India overlaps with that of the superficially very similar common krait (Bungarus caeruleus). Thus, B. cf. sindanus envenoming may be common but routinely overlooked or misdiagnosed.
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Affiliation(s)
- Lalitha V Pillai
- Critical Care Department, Lokmanya Hospital, Chinchwad, Pune, Maharashtra, India
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28
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Abstract
Snake bite envenoming is a neglected tropical disease affecting millions of people living in the developing world. According to the offending snake species, the clinical picture may be dominated by swelling and soft tissue necrosis in the bitten limb, or by systemic or neurological manifestations. Serious neurological complications, including stroke and muscle paralysis, are related to the toxic effects of the venom, which contains a complex mixture of toxins affecting the coagulation cascade, the neuromuscular transmission, or both. Metalloproteinases, serine proteases, and C-type lentins (common in viper and colubrid venoms) have anticoagulant or procoagulant activity and may be either agonists or antagonists of platelet aggregation; as a result, ischemic or hemorrhagic strokes may occur. In contrast, the venom of elapids is rich in phospholipase A(2) and three-finger proteins, which are potent neurotoxins affecting the neuromuscular transmission at either presynaptic or post-synaptic levels. Presynaptic-acting neurotoxins (called β-neurotoxins) inhibit the release of acetylcholine, while post-synaptic-acting neurotoxins (called α-neurotoxins) cause a reversible blockage of acetylcholine receptors. Proper management of the envenomed patient, including prompt transport to the hospital, correction of the hemostatic disorder, ventilatory support, and administration of antivenom, significantly reduces the risk of neurological complications which, in turn, reduce the mortality and improve the functional outcome of survivors.
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Affiliation(s)
- O H Del Brutto
- Department of Neurological Sciences, Hospital - Clínica Kennedy, Guayaquil, Ecuador.
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Rezania K, Goldenberg FD, White S. Neuromuscular Disorders and Acute Respiratory Failure: Diagnosis and Management. Neurol Clin 2012; 30:161-85, viii. [DOI: 10.1016/j.ncl.2011.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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de Roodt AR, Lago NR, Stock RP. Myotoxicity and nephrotoxicity by Micrurus venoms in experimental envenomation. Toxicon 2012; 59:356-64. [DOI: 10.1016/j.toxicon.2011.11.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 11/09/2011] [Accepted: 11/10/2011] [Indexed: 11/30/2022]
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Dey A, De JN. Traditional use of plants against snakebite in Indian subcontinent: a review of the recent literature. AFRICAN JOURNAL OF TRADITIONAL, COMPLEMENTARY, AND ALTERNATIVE MEDICINES 2011; 9:153-74. [PMID: 23983332 DOI: 10.4314/ajtcam.v9i1.20] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Snakebite has been a major cause of mortality across the tropical countries including Indian subcontinent. The present review deals with the enormous amount of ethnobotanical work performed in the last few years involving use of different plants against snakebite in Indian subcontinent (India, Bangladesh, Pakistan and Nepal). From a variety of literature sources the data has been compiled mentioning the plants, parts used, dosage, mode of administration, name of the ethnic communities, geographical locations etc. depending on the availability of information.
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Affiliation(s)
- Abhijit Dey
- Presidency College, 86/1, College Street, Kolkata-700073, West Bengal, India.
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