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Das L, Dutta P. Unusual and lesser-known rare causes of adult growth hormone deficiency. Best Pract Res Clin Endocrinol Metab 2023; 37:101820. [PMID: 37704550 DOI: 10.1016/j.beem.2023.101820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Growth hormone is among the most common hormones to be deficient in pituitary insult. It can occur either in isolation or combined with other hormone deficiencies. Growth hormone deficiency in adults (AGHD) can be due to causes acquired in adulthood or have a childhood-onset etiology, but the former is about three times more common. Usual causes of AGHD include mass effects due to a pituitary tumour, and/or its treatment (surgery, medical therapy, or radiotherapy), or radiotherapy to the head and neck region for non-pituitary lesions. The unusual or lesser-known causes of AGHD, are usually due to non-tumoral etiology and range from vascular and infective to inflammatory and miscellaneous causes. These not only expand the spectrum of AGHD but may also contribute to increased morbidity, adverse metabolic consequences, and mortality due to the primary condition, if unrecognised. The review features these lesser-known and rare causes of AGHD and highlights their clinical and diagnostic implications.
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Affiliation(s)
- Liza Das
- Department of Telemedicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, PGIMER, Chandigarh, India.
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Warrell DA, Williams DJ. Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet 2023; 401:1382-1398. [PMID: 36931290 DOI: 10.1016/s0140-6736(23)00002-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/26/2022] [Accepted: 12/18/2022] [Indexed: 03/16/2023]
Abstract
There is increasing recognition of the public health importance of snakebite envenoming. Worldwide annual incidence is likely to be 5 million bites, with mortality exceeding 150 000 deaths, and the resulting physical and psychological morbidity leads to substantial social and economic repercussions. Prevention through community education by trained health workers is the most effective and economically viable strategy for reducing risk of bites and envenoming. Clinical challenges to effective treatment are most substantial in rural areas of low-resource settings, where snakebites are most common. Classic skills of history taking, physical examination, and use of affordable point-of-care tests should be followed by monitoring of evolving local and systemic envenoming. Despite the profusion of new ideas for interventions, hyperimmune equine or ovine plasma-derived antivenoms remain the only specific treatment for snakebite envenoming. The enormous interspecies and intraspecies complexity and diversity of snake venoms, revealed by modern venomics, demands a radical redesign of many current antivenoms.
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Affiliation(s)
- David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Experimental Medicine Division, John Radcliffe Hospital, Headington, UK.
| | - David J Williams
- Regulation and Prequalification Department, World Health Organization, Geneva, Switzerland
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3
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Das L, Dutta P. Approach to a case with an unusual cause of hypopituitarism. J Clin Endocrinol Metab 2022; 108:1488-1504. [PMID: 36573291 DOI: 10.1210/clinem/dgac747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Indexed: 12/29/2022]
Abstract
Hypopituitarism refers to insufficiency of one or more hormones of the pituitary and can be due to myriad causes. The clinical and radiological spectrum of the condition is heterogeneous, based on the age, gender, clinical setting and/or other past medical history. Hypopituitarism includes central hypocortisolism, hypothyroidism, hypogonadism and growth hormone deficiency. Both hypo- and hyperprolactinemia can be associated with hypopituitarism, with low prolactin signifying more extensive pituitary damage. Posterior pituitary insufficiency (arginine vasopressin deficiency), occurs either in isolation or with anterior pituitary hormone deficiency. Clinical symptomatology of hypopituitarism is usually non-specific and insidious in onset and progression. Overall, the most common cause of hypopituitarism is a pituitary adenoma and/or its management (surgery, radiotherapy, pharmacotherapy or a combination of these). However, it is this subset of patients which is more likely to be identified and managed timely, possibly alleviating the premature mortality associated with hypopituitarism. What is more challenging is the recognition of hypopituitarism in less common settings, which may be either due to direct involvement of the pituitary (infection, traumatic brain injury, or infiltrative causes) or indirectly as a consequence of the primary process (thalassemia, vasculotoxic snakebite, subarachnoid hemorrhage). These entities are often under-recognised, and increased awareness can help in greater recognition of the problem burden. Further, pituitary insufficiency in most of these settings is dynamic, which may progress, or rarely, show recovery of function. This renders complexity to the problem, but makes it even more imperative to suspect, screen and appropriately manage patients with less common causes of hypopituitarism.
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Affiliation(s)
- Liza Das
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh
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Gopalakrishnan M, Saurabh S, Sagar P, Bammigatti C, Dutta TK. A simple mortality risk prediction score for viper envenoming in India (VENOMS): A model development and validation study. PLoS Negl Trop Dis 2022; 16:e0010183. [PMID: 35192642 PMCID: PMC8896694 DOI: 10.1371/journal.pntd.0010183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 03/04/2022] [Accepted: 01/20/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Snakebite is a neglected problem with a high mortality in India. There are no simple clinical prognostic tools which can predict mortality in viper envenomings. We aimed to develop and validate a mortality-risk prediction score for patients of viper envenoming from Southern India. METHODS We used clinical predictors from a prospective cohort of 248 patients with syndromic diagnosis of viper envenoming and had a positive 20-minute whole blood clotting test (WBCT 20) from a tertiary-care hospital in Puducherry, India. We applied multivariable logistic regression with backward elimination approach. External validation of this score was done among 140 patients from the same centre and its performance was assessed with concordance statistic and calibration plots. FINDINGS The final model termed VENOMS from the term "Viper ENvenOming Mortality Score included 7 admission clinical parameters (recorded in the first 48 hours after bite): presence of overt bleeding manifestations, presence of capillary leak syndrome, haemoglobin <10 g/dL, bite to antivenom administration time > 6.5 h, systolic blood pressure < 100 mm Hg, urine output <20 mL/h in 24 h and female gender. The lowest possible VENOMS score of 0 predicted an in-hospital mortality risk of 0.06% while highest score of 12 predicted a mortality of 99.1%. The model had a concordance statistic of 0·86 (95% CI 0·79-0·94) in the validation cohort. Calibration plots indicated good agreement of predicted and observed outcomes. CONCLUSIONS The VENOMS score is a good predictor of the mortality in viper envenoming in southern India where Russell's viper envenoming burden is high. The score may have potential applications in triaging patients and guiding management after further validation.
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Affiliation(s)
- Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences Jodhpur, Rajasthan, India
| | - Suman Saurabh
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pramod Sagar
- Department of Cardiology, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Chanaveerappa Bammigatti
- Department of Medicine, Jawaharlal Institute of Medical Education and Research, Puducherry, India
| | - Tarun Kumar Dutta
- Department of Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
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Affiliation(s)
- Ravikar Ralph
- Department of Internal Medicine, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | | | - Sanjib Kumar Sharma
- Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, 76500, Nepal
| | - Isabela Ribeiro
- Dynamic Portfolio, Drugs for Neglected Diseases initiative (DNDi), 15 Chemin Louis-Dunant, 1202, Geneva, Switzerland
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 6, Geneva, CH 1211, Switzerland
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Kamalanathan S, Roy A, Suryadevara V, Nagarajan K, Sahoo J, Naik D, Perumal N, Narayanan N, Merugu C, Patel D, Patil M. Pituitary Dysfunction Following Snakebite Envenomation: A Clinico–Radiological Assessment of 15 Cases and Review of the Literature. Neurol India 2022; 70:2093-2099. [DOI: 10.4103/0028-3886.359201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Yerawar C, Punde D, Pandit A, Deokar P. Russell's viper bite and the empty sella syndrome. QJM 2021; 114:255-257. [PMID: 32539122 DOI: 10.1093/qjmed/hcaa197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/02/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- C Yerawar
- Department of Endocrinology, Shree Narayana Institute of Medical Superspeciality, Nanded, Maharashtra, 431602, India
| | - D Punde
- Department of medicine, Punde Hospital, Mukhed, Nanded, Maharashtra, 431715, India
| | - A Pandit
- Department of Endocrinology, Shree Narayana Institute of Medical Superspeciality, Nanded, Maharashtra, 431602, India
| | - P Deokar
- Department of Biochemistry, Shree Narayana Institute of Medical Superspeciality, Nanded, Maharashtra, 431602, India
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Senthilkumaran S, Williams HF, Patel K, Trim SA, Thirumalaikolundusubramanian P, Vaiyapuri S. Priapism following a juvenile Russell's viper bite: An unusual case report. PLoS Negl Trop Dis 2021; 15:e0009242. [PMID: 33764978 PMCID: PMC7993604 DOI: 10.1371/journal.pntd.0009242] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Following a bite from a juvenile Russell's viper (Daboia russelii), a priapism (painful erection) developed rapidly in a 16-year-old male and only subsided after administration of antivenom 3 hours later. Potential mechanisms for this snakebite-induced priapism are unclear but likely due to venom toxins causing nitric oxide (NO) release and subsequent vasodilation of endothelium in the corpus cavernosum, although the possible involvement of other mechanisms cannot be ruled out. We strongly believe that this unusual case report may lead to further scientific research in order to improve the clinical understanding of the pathophysiology of envenomation due to Russell's viper bites. Although it is too early to speculate, further research may also discover the possibilities of developing venom-based candidate molecules to treat sexual dysfunction in males and females.
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Affiliation(s)
| | | | - Ketan Patel
- School of Biological Sciences, University of Reading, Reading, United Kingdom
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Sathish K, Shaha KK, Patra AP, Rekha JS. Histopathological profile of fatal snake bite autopsy cases in a tertiary care center in South India. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2021. [DOI: 10.1186/s41935-021-00218-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Snake bite is a major public health problem, especially in the tropical areas of the world, which the World Health Organization aims to eradicate. According to the National Crime Records Bureau in India, where agriculture is the mainstay of employment attributes about 8660 mortalities in a year. Histopathological results are of immense help in establishing the cause of death in those snake bite cases where other circumstantial shreds of evidence are lacking.
Results
An autopsy-based prospective study was conducted on fatal cases of snake bite reported at a tertiary care center in south India over a period of 2 years. A total of 38 fatal snake bite cases were included in the study. Epidemiological data were collected and analyzed. Histopathological findings of the kidneys, heart, and endocrine glands (pituitary, adrenals, thyroid, and pancreas) were analyzed. The significant findings of the kidneys were distinct corticomedullary demarcation on the gross surface (65.8%) and congestion and acute tubular necrosis (55.3%) on histology. On the other hand, in the set of endocrine glands, adrenals and pituitary showed predominantly hemorrhagic infarction on the histological analysis (18.4% and 52.6%) respectively.
Conclusion
The results of the current study enlighten the findings such as distinct corticomedullary demarcation and acute tubular necrosis in the kidneys and hemorrhagic infarction in the endocrine glands in a case of snake bite. It highlights the need for histopathological analysis in the cases of a fatal snake bite when other circumstantial and gross features become indecisive. This can aid immensely in a medico-legal investigation of snake bite cases.
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Bhattacharya S, Krishnamurthy A, Gopalakrishnan M, Kalra S, Kantroo V, Aggarwal S, Surana V. Endocrine and Metabolic Manifestations of Snakebite Envenoming. Am J Trop Med Hyg 2020; 103:1388-1396. [PMID: 32602439 DOI: 10.4269/ajtmh.20-0161] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Snakebite envenoming is a neglected, public health problem in tropical and subtropical regions. Local tissue necrosis, neurotoxic, and hemo-vasculotoxic effects are well-recognized features, whereas the endocrine and metabolic derangements are not as well known. In addition to contributing to morbidity, some of these manifestations can be potentially life-threatening if not recognized early. The most prominent endocrine manifestation is hypopituitarism (HP), which can manifest acutely or remain asymptomatic and present years later. Unexplained recurrent hypoglycemia and refractory hypotension are early clinical clues to suspect corticotroph axis involvement in acute settings. Chronic pituitary failure may present, like Sheehan's syndrome, several years after the bite. The occurrence of acute kidney injury, capillary leak syndrome, and disseminated intravascular coagulation are predictors of HP. Adrenal hemorrhages are documented in autopsy series; however, primary adrenal insufficiency is very rare and confounded by the presence of HP. Hyponatremia, hypokalemia or hyperkalemia, and dysglycemia can occur, but the mechanisms involved are only partially understood. Awareness, a high index of suspicion, correct interpretation of hormonal parameters, and timely treatment of these abnormalities can be lifesaving.
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Affiliation(s)
| | | | - Maya Gopalakrishnan
- Department of General Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
| | - Viny Kantroo
- Department of Respiratory Critical Care and Sleep Medicine, Apollo Hospitals, New Delhi, India
| | - Sameer Aggarwal
- Department of Endocrinology, Apex Plus Superspeciality Hospital, Rohtak, India
| | - Vineet Surana
- Department of Endocrinology, Manipal Hospital, New Delhi, India
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Rucavado A, Escalante T, Kalogeropoulos K, Camacho E, Gutiérrez JM, Fox JW. Analysis of wound exudates reveals differences in the patterns of tissue damage and inflammation induced by the venoms of Daboia russelii and Bothrops asper in mice. Toxicon 2020; 186:94-104. [PMID: 32781076 DOI: 10.1016/j.toxicon.2020.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/11/2020] [Accepted: 07/26/2020] [Indexed: 01/19/2023]
Abstract
Clinical manifestations of envenomings by bites of the viperid snakes Bothrops asper and Daboia russelii show marked differences. Both venoms elicit the typical effects induced by viperid venoms (local tissue damage, bleeding, coagulopathies, shock). In addition, envenomings by D. russelii are characterized by a high incidence of acute kidney injury and by systemic capillary leak syndrome. The present investigation aimed to compare the local pathological and inflammatory events induced by the intramuscular injection of these venoms in a mouse model. B. asper venom induced stronger local hemorrhage, whereas D. russelii venom caused a higher extent of myonecrosis, and both venoms induced inflammation. Exudates collected from the site of tissue damage showed higher proteolytic activity in the case of samples from B. asper venom-treated mice. This activity was abrogated by antivenoms, indicating that it is the result of the action of venom proteinases. In addition, an increase in matrix metalloproteinases (MMPs) over time was detected in exudates induced by both venoms. Proteome analysis of exudates revealed higher abundance of extracellular matrix (ECM)-derived protein fragments in samples collected from B. asper venom-injected mice, whereas those from D. russelii venom-injected animals had higher amounts of intracellular proteins. Analysis of the subproteome of inflammatory mediators in exudates showed various patterns of change over time. Some mediators peaked at 180 min and decreased afterwards, whereas others increased and remained elevated during the 360 min observation period. Interestingly, various mediators (MIP-1α, MIP-1β, KC, MIP-2, GM-CSF, VEGF, and LIX) increased and then decreased in the case of B. asper venom, while they remained elevated at 360 min in the case of D. russelii venom. Our findings show that these venoms induce a different pattern of local tissue damage and suggest that the venom of D. russelii induces a more sustained inflammatory reaction, an observation that may have implications for the pathophysiology of envenomings.
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Affiliation(s)
- Alexandra Rucavado
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501, Costa Rica.
| | - Teresa Escalante
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501, Costa Rica
| | - Konstantinos Kalogeropoulos
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800, Kongens, Lyngby, Denmark
| | - Erika Camacho
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501, Costa Rica
| | - José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501, Costa Rica
| | - Jay W Fox
- University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.
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Das L, Bhansali A, Ahuja CK, Korbonits M, Dutta P. ACQUIRED ECTOPIC POSTERIOR PITUITARY BRIGHT SPOT DUE TO VASCULOTOXIC SNAKEBITE. AACE Clin Case Rep 2020; 6:e207-e211. [PMID: 32984522 DOI: 10.4158/accr-2020-0094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 04/12/2020] [Indexed: 11/15/2022] Open
Abstract
Objective Vasculotoxic envenomation is an uncommon cause of hypopituitarism. Most described cases have varying extent of anterior pituitary dysfunction, but posterior pituitary involvement is extremely rare. Methods Clinical, biochemical, and radiologic evaluation of a young female who presented with secondary amenorrhea was performed. A brief literature review of envenomation-induced hypopituitarism is included. Results A 26-year-old female presented with secondary amenorrhea since the age of 20 years. She had normal stature. Her past medical history was significant for a vasculotoxic snakebite 12 years back requiring hemodialysis, but no hormonal testing was done at that time. Current evaluation showed anterior hypopituitarism. An insulin-induced hypoglycemia test confirmed deficiencies of cortisol and growth hormone axes (peak values 348 nmol/L and 0.03 ng/mL). There was no diabetes insipidus. Magnetic resonance imaging revealed a hypoplastic anterior pituitary with an ectopic posterior pituitary. In view of normal stature and secondary amenorrhea, a diagnosis of envenomation-induced hypopituitarism with ectopic posterior pituitary (EPP) was made. A brief literature review of envenomation-induced hypopituitarism showed both acute and delayed presentation, male predominance, and variable lag period (weeks to years). Nearly half of all patients were asymptomatic. The most common axis involved in acute presentation was the cortisol axis, whereas the thyroid and gonadotroph axes were commonly involved in delayed hypopituitarism. Conclusion Vasculotoxic envenomation is a rare cause of acquired hypopituitarism. EPP in the index case was probably due to the "axonal dieback" phenomenon and subsequent regeneration of the axons at a more caudal site. This case, being the first instance of acquired EPP following envenomation, expands the spectrum of envenomation-induced hypopituitarism.
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Affiliation(s)
- Liza Das
- Department of Endocrinology, PGIMER, Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, PGIMER, Chandigarh, India
| | | | - Márta Korbonits
- Department of Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Pinaki Dutta
- Department of Endocrinology, PGIMER, Chandigarh, India
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Huang TI, Hsieh CL. Effect of Traditional Chinese Medicine on Long-Term Outcomes of Snakebite in Taiwan. Toxins (Basel) 2020; 12:E132. [PMID: 32093388 PMCID: PMC7076781 DOI: 10.3390/toxins12020132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 11/16/2022] Open
Abstract
Herein, we review the characteristics of the six predominant venomous snakes in Taiwan and the effects of traditional Chinese medicine on the long-term outcomes of snakebite venom. We electronically searched databases, including PubMed, ClinicalKey, China National Knowledge Infrastructure, National Digital Library of Theses and Dissertations in Taiwan, and Airiti Library, from their inception to November 2019 by using the following Medical Subject Headings' keywords: snakebite, long-term, chronic, Chinese medicine, CAM, herb, and Taiwan. The most common long-term effects of snakebite envenomation include "migraine-like syndrome", brain injuries caused by hypoxia or intracranial hemorrhage, and chronic kidney disease. In addition, hypopituitarism is also worth mentioning. Traditional Chinese medicine can potentially be used in a complementary or alternative treatment for these effects, but additional studies are needed.
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Affiliation(s)
- Teng-I Huang
- Department of Chinese Medicine, China Medical University Hospital, Taichung 40447, Taiwan;
| | - Ching-Liang Hsieh
- Department of Chinese Medicine, China Medical University Hospital, Taichung 40447, Taiwan;
- Chinese Medicine Research Center, China Medical University, Taichung 40402, Taiwan
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, Taichung 40402, Taiwan
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14
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Bhat S, Mukhopadhyay P, Raychaudhury A, Chowdhury S, Ghosh S. Predictors of hypopituitarism due to vasculotoxic snake bite with acute kidney injury. Pituitary 2019; 22:594-600. [PMID: 31556012 DOI: 10.1007/s11102-019-00990-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Hypopituitarism frequently develops following vasculotoxic snake bite complicated by acute kidney injury (AKI). Well defined prospective studies of prevalence of hypopituitarism and its predictors in vasculotoxic snake bites complicated by AKI are unavailable. METHODS Fifty-one consecutive patients of AKI following vasculotoxic snake bite were evaluated for various clinical/biochemical parameters (including Free T4, TSH, Cortisol, ACTH, total testosterone, FSH, LH, prolactin, and IGF-1). Diabetes insipidus was evaluated in relevant cases. Twenty minutes whole blood clotting time (WBCT) at presentation was measured in all. MRI of hypothalamo-pituitary region was done at 3 months in subjects with hypopituitarism to rule out structural lesion. RESULTS 21.6% (11/51) patients developed hypopituitarism at baseline (within 7 days), 39.3% (13 /33) at 3 months developed hypopituitarism. Cortisol deficiency was the commonest abnormality. Subjects who developed hypopituitarism at baseline were younger compared to those without hypopituitarism (35.67 years vs. 46.59 years, p = 0.032) and required more sessions of hemodialysis (8 vs. 3, p = 0.041). Binary logistic regression confirmed that development of hypopituitarism could be predicted by increased number of sessions of hemodialysis (OR 1.51, p = 0.008) and 20 min WBCT (OR 1.2, p = 0.038). CONCLUSION Hypopituitarism is common following vasculotoxic snake bite in subjects who develop AKI requiring hemodialysis. Hypopituitarism can develop as early as 7 days following snake bite and should be evaluated for particularly in younger subjects, especially those requiring increasing number of sessions of hemodialysis and in subjects with abnormal 20 min WBCT at presentation.
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Affiliation(s)
- Sowrabha Bhat
- Dept. of Endocrinology, IPGME&R, Kolkata, 700020, India
| | | | | | | | - Sujoy Ghosh
- Dept. of Endocrinology, IPGME&R, Kolkata, 700020, India.
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Pla D, Sanz L, Quesada-Bernat S, Villalta M, Baal J, Chowdhury MAW, León G, Gutiérrez JM, Kuch U, Calvete JJ. Phylovenomics of Daboia russelii across the Indian subcontinent. Bioactivities and comparative in vivo neutralization and in vitro third-generation antivenomics of antivenoms against venoms from India, Bangladesh and Sri Lanka. J Proteomics 2019; 207:103443. [PMID: 31325606 DOI: 10.1016/j.jprot.2019.103443] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/14/2019] [Indexed: 02/07/2023]
Abstract
Russell's viper (Daboia russelii) is, together with Naja naja, Bungarus caeruleus and Echis carinatus, a member of the medically important 'Big Four' species responsible for causing a large number of morbidity and mortality cases across the Indian subcontinent. Despite the wide distribution of Russell's viper and the well-documented ubiquity of the phenomenon of geographic variability of intraspecific snake venom composition, Indian polyvalent antivenoms against the "Big Four" venoms are raised against venoms sourced mainly from Chennai in the southeastern Indian state of Tamil Nadu. Biochemical and venomics investigations have consistently revealed notable compositional, functional, and immunological differences among geographic variants of Russell's viper venoms across the Indian subcontinent. However, these studies, carried out by different laboratories using different protocols and involving venoms from a single geographical region, make the comparison of the different venoms difficult. To bridge this gap, we have conducted bioactivities and proteomic analyses of D. russelii venoms from the three corners of the Indian subcontinent, Pakistan, Bangladesh, and Tamil Nandu (India) and Sri Lanka, along with comparative in vivo neutralization and in vitro third-generation antivenomics of antivenoms used in India, Bangladesh and Sri Lanka. These analyses let us to propose two alternative routes of radiation for Russell's viper in the Indian subcontinent. Both radiations, towards the northeast of India and Bangladesh and towards south India and Sri Lanka, have a common origin in Pakistan, and provide a phylovenomics ground for rationalizing the geographic variability in venom composition and their distinct immunoreactivity against available antivenoms. BIOLOGICAL SIGNIFICANCE: Russell's viper (Daboia russelii), the Indian cobra (Naja naja), the common krait (Bungarus caeruleus), and the saw-scaled viper (Echis carinatus) constitute the 'Big Four' snake species responsible for most snakebite envenomings and deaths in the Indian subcontinent. Despite the medical relevance of Daboia russelii, and the well documented variations in the clinical manifestations of envenomings by this wide distributed species, which are doubtless functionally related to differences in venom composition of its geographic variants, antivenoms for the clinical treatment of envenomings by D. russelii across the Indian subcontinent are invariably raised using venom sourced mainly from the southeastern Indian state of Tamil Nadu. We have applied a phylovenomics approach to compare the venom proteomes of Russell's vipers from the three corners of the Indian subcontinent, Pakistan, Bangladesh, and South India/Sri Lanka, and have assessed the in vitro (third-generation antivenomics) and in vivo preclinical efficacy of a panel of homologous antivenoms. The identification of two dispersal routes of ancestral D. russelii into the Indian subcontinent provides the ground for rationalizing the variability in composition and immunoreactivity of the venoms of extant geographic variants of Russell's viper. Such knowledge is relevant for envisioning strategies to improve the clinical coverage of anti- D. russelii antivenoms.
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Affiliation(s)
- Davinia Pla
- Evolutionary and Translational Venomics Laboratory, Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain
| | - Libia Sanz
- Evolutionary and Translational Venomics Laboratory, Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain
| | - Sarai Quesada-Bernat
- Evolutionary and Translational Venomics Laboratory, Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain
| | - Mauren Villalta
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501-2060, Costa Rica
| | - Joshua Baal
- Technische Universität Kaiserslautern, Erwin-Schrödinger-Straße 52, 67663 Kaiserslautern, Germany
| | | | - Guillermo León
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501-2060, Costa Rica.
| | - José M Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501-2060, Costa Rica.
| | - Ulrich Kuch
- Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Germany.
| | - Juan J Calvete
- Evolutionary and Translational Venomics Laboratory, Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain.
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Abstract
Long-term effects of envenoming compromise the quality of life of the survivors of snakebite. We searched MEDLINE (from 1946) and EMBASE (from 1947) until October 2018 for clinical literature on the long-term effects of snake envenoming using different combinations of search terms. We classified conditions that last or appear more than six weeks following envenoming as long term or delayed effects of envenoming. Of 257 records identified, 51 articles describe the long-term effects of snake envenoming and were reviewed. Disability due to amputations, deformities, contracture formation, and chronic ulceration, rarely with malignant change, have resulted from local necrosis due to bites mainly from African and Asian cobras, and Central and South American Pit-vipers. Progression of acute kidney injury into chronic renal failure in Russell's viper bites has been reported in several studies from India and Sri Lanka. Neuromuscular toxicity does not appear to result in long-term effects. Endocrine anomalies such as delayed manifestation of hypopituitarism following Russell's viper bites have been reported. Delayed psychological effects such as depressive symptoms, post-traumatic stress disorder and somatisation have been reported. Blindness due to primary and secondary effects of venom is a serious, debilitating effect. In general, the available studies have linked a clinical effect to a snakebite in retrospect, hence lacked accurate snake authentication, details of acute management and baseline data and are unable to provide a detailed picture of clinical epidemiology of the long-term effects of envenoming. In the future, it will be important to follow cohorts of snakebite patients for a longer period of time to understand the true prevalence, severity, clinical progression and risk factors of long-term effects of snake envenoming.
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Shivaprasad C, Aiswarya Y, Sridevi A, Anupam B, Amit G, Rakesh B, Annie PA, Anish K. Delayed hypopituitarism following Russell's viper envenomation: a case series and literature review. Pituitary 2019; 22:4-12. [PMID: 30317419 DOI: 10.1007/s11102-018-0915-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE Hypopituitarism (HP) is an uncommon consequence of Russell's viper envenomation (RVE). Delayed hypopituitarism (DHP) presents months to years after recovering from snake bites (SB). The clinical presentation, manifestations, and outcomes of DHP following RVE have not been systematically studied. Here, we present a case series of HP following RVE with delayed diagnosis and conduct a literature review. METHODS We retrospectively reviewed data of eight DHP cases and literature to outline the presentation, manifestations, hormonal profiles, and radiological features of DHP following RVE. RESULTS Three men and five women, with a mean age at diagnosis of 39.5 ± 11.6 years, were included. The mean duration between snake bite (SB) and HP diagnosis was 8.1 ± 3.6 years. Secondary hypothyroidism and hypogonadotropic hypogonadism were present in all patients. Growth hormone deficiency (GHD) and secondary hypocortisolism were present in 6 (75%) patients. Magnetic resonance imaging (MRI) revealed empty sella and partially empty sella in three patients each (75%). The literature review revealed additional 20 DHP cases (mean age at diagnosis 32.4 ± 10.8 years), with 65% of patients being men. Fatigue, reduced libido, and loss of weight were the commonest symptoms among men. Secondary amenorrhea, fatigue, and loss of appetite were common manifestations among women. Acute kidney injury, GHD, secondary hypothyroidism, hypogonadism, and adrenal insufficiency were reported in 75%, 79%, 95%, 100%, and 85% of patients, respectively. CONCLUSIONS DHP is an important complication of RVE, and a delay in its diagnosis is associated with significant morbidity. Patients with RVE should be followed up for a long term to identify DHP.
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Affiliation(s)
- Channabasappa Shivaprasad
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India.
| | - Yalamanchi Aiswarya
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India
| | - Atluri Sridevi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India
| | - Biswas Anupam
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India
| | - Goel Amit
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India
| | - Boppana Rakesh
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India
| | - Pulikkal A Annie
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India
| | - Kolly Anish
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India
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White J, Alfred S, Bates D, Mahmood MA, Warrell D, Cumming R, Thwin KT, Thein MM, Thant M, Naung ZM, Naing YH, San SSS, Nwe MT, Peh CA. Twelve month prospective study of snakebite in a major teaching hospital in Mandalay, Myanmar; Myanmar Snakebite Project (MSP). Toxicon X 2018; 1:100002. [PMID: 32831343 PMCID: PMC7286100 DOI: 10.1016/j.toxcx.2018.100002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 11/21/2018] [Accepted: 11/26/2018] [Indexed: 11/18/2022] Open
Abstract
The Myanmar Snakebite Project is an Australian government (Department of Foreign Affairs and Trade) supported foreign aid project in collaboration with the Myanmar government with the aim of improving outcomes for snakebite patients in Myanmar. As part of the project a case record database was established to document prospective cases of snakebite presenting to Mandalay General Hospital, in Upper Myanmar. The study period was 12 months (1-2-2016 to 31-1-2017). Snake identity was based on a mixture of identified dead snakes brought with patients, doctor's clinical opinion and patient identification. 965 patients were enrolled during the 12 month period, of whom 948 were included for analysis. The male: female ratio was 1.58:1. Most cases involved bites to the lower limbs (82.5%) and adults involved in farm work, confirming snakebite as an occupational disease in this community. Motorised transport was by far the most common form of transport to health care and most patients sought care from the health system (87.7%), not traditional healers (11.5%) as their first point of contact. The officially promoted application of a pressure pad, bandage and immobilisation as first aid for snakebite was almost never used, while most patients used some form of tourniquet (92.0%). 85.4% of cases where a snake ID was listed were bitten by Russell's vipers. Russell's viper bites were responsible for all fatalities (9.8% of cases) and all cases of Acute Kidney Injury (AKI). For all cases, clinical features included local swelling (76.5%), local pain (62.6%), AKI (59.8%), incoagulable blood (57.9%), regional lymphadenopathy (39.8%), nausea/vomiting (40.4%), thrombocytopenia (53.6%), abdominal pain (28.8%), shock (11.8%), secondary infection (8.6%), panhypopituitarism (2.1%). AKI required renal replacement therapy (RRT) in 23.9% of cases, all ascribed to Russell's viper bite. Green pit viper bites were the next most common cause of bites (7.6%) and were associated with incoagulable blood (29%) and occasionally shock (5%) and local necrosis (3%), and in one case AKI not requiring RRT. In contrast to Russell's viper bites, green pit viper bite was most likely to occur in the home (49%). Some green pit viper patients were treated with Russell's viper antivenom (15%), presumably because they had incoagulable blood, although this antivenom is not effective against green pit viper envenoming. For the entire patient group, antivenom was given in 80.5% of cases. The most common indications were presence of coagulopathy/non-clotting blood (59.8%), local swelling (47.4%), oliguria/anuria (19.8%), heavy proteinuria (19.4%). A febrile reaction to antivenom was reported in 47.9% of cases, while anaphylaxis, occurred in 7.9% of cases. Reports 12 month prospective observational study of snakebite patients at Mandalay General Hosp. Snakebite was an occupational disease of farm workers, tourniquets the most common first aid. Russell's viper (RV) responsible for most bites, causing coagulopathy, thrombocytopenia, AKI. Green pit viper bites were the next most common, potentially causing diagnostic confusion with RV.
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Affiliation(s)
- Julian White
- Toxinology Dept., Women's & Children's Hospital, North Adelaide, SA, 5006, Australia
- University of Adelaide, Adelaide, SA, 5000, Australia
- Corresponding author. Toxinology Dept., Women's & Children's Hospital, North Adelaide, SA, 5006, Australia.
| | - Sam Alfred
- Emergency Department, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
- University of Adelaide, Adelaide, SA, 5000, Australia
| | - David Bates
- Toxinology Dept., Women's & Children's Hospital, North Adelaide, SA, 5006, Australia
- University of Adelaide, Adelaide, SA, 5000, Australia
| | | | - David Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | | | | | - Myo Thant
- Myanmar Snakebite Project Mandalay Office, Myanmar
| | | | | | | | | | - Chen Au Peh
- University of Adelaide, Adelaide, SA, 5000, Australia
- Department of Renal Medicine, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
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19
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Gopalakrishnan M, Vinod KV, Dutta TK, Shaha KK, Sridhar MG, Saurabh S. Exploring circulatory shock and mortality in viper envenomation: a prospective observational study from India. QJM 2018; 111:799-806. [PMID: 30107433 DOI: 10.1093/qjmed/hcy175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Viper envenomation contributes to nearly 50% of snake-bite deaths in India, chiefly due to circulatory shock. The mechanisms leading to circulatory shock include bleeding, capillary leak syndrome (CLS) and myocardial depression. Pituitary-adrenal axis involvement in circulatory shock, though described, has not been fully elucidated. AIM To identify predictors of circulatory shock and mortality in viper envenomation and explore the role of pituitary-adrenal axis in circulatory shock. DESIGN Prospective hospital-based observational study. METHODS Once a syndromic diagnosis of viper envenomation was made, relevant clinical and laboratory data were collected. Serum cortisol was estimated in those with circulatory shock. Post-mortem examination of pituitary, kidneys and adrenals was performed. Adjusted odds-ratios were calculated for respective risk-factors for shock and mortality using multivariable logistic regression with backward elimination strategy. RESULTS Of 248 patients of viper envenomation treated at our hospital, circulatory shock was present in 19% and in-hospital mortality was 23%. CLS, circulatory shock, bleeding and requirement of > 20 vials of antivenom predicted mortality. Ischaemic and haemorrhagic necrosis of pituitary or adrenals was present in 51% of post-mortem specimens. Disseminated intravascular coagulation (DIC) and CLS were strong predictors of pituitary haemorrhage. CONCLUSION Predictors of mortality - bleeding, CLS and requirement of high antivenom doses are warning signs which can alert clinicians to patients who may have poor outcomes. Our study points to a definite role of pituitary-adrenal axis in circulatory shock supports the hypothesis that pituitary involvement in viper envenomation closely resembles Sheehan syndrome. The mechanism of pituitary involvement appears to be a result of increased susceptibility of the swollen gland secondary to CLS and micro thrombi deposition in DIC.
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Affiliation(s)
- M Gopalakrishnan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
| | - K V Vinod
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
| | - T K Dutta
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
| | - K K Shaha
- Department of Forensic Medicine and Toxicology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
| | - M G Sridhar
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
| | - S Saurabh
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
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Faisal T, Tan KY, Sim SM, Quraishi N, Tan NH, Tan CH. Proteomics, functional characterization and antivenom neutralization of the venom of Pakistani Russell's viper (Daboia russelii) from the wild. J Proteomics 2018; 183:1-13. [PMID: 29729992 DOI: 10.1016/j.jprot.2018.05.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 04/26/2018] [Accepted: 05/02/2018] [Indexed: 11/21/2022]
Abstract
The venom proteome of wild Pakistani Russell's viper (Daboia russelii) was investigated through nano-ESI-LCMS/MS of the reverse-phase HPLC fractions. A total of 54 venom proteins were identified and clustered into 11 protein families. Phospholipase A2 (PLA2, 63.8%) and Kunitz-type serine protease inhibitor (KSPI, 16.0%) were most abundant, followed by snake venom serine protease (SVSP, 5.5%, mainly Factor V activating enzyme), vascular endothelial growth factor (VEGF, 4.3%), snake venom metalloproteinase (SVMP, 2.5%, mainly Factor X activating enzyme) and phosphodiesterase (PDE, 2.5%). Other minor proteins include cysteine-rich secretory protein (CRiSP), snake venom C-type lectin/lectin-like protein (snaclec), nerve growth factor, L-amino acid oxidase and 5'-nucleotidase. PLA2, KSPI, SVSP, snaclec and SVMP are hemotoxic proteins in the venom. The study indicated substantial venom variation in D. russelii venoms of different locales, including 3 Pakistani specimens kept in the USA. The venom exhibited potent procoagulant activity on human plasma (minimum clotting dose = 14.5 ng/ml) and high lethality (rodent LD50 = 0.19 μg/g) but lacked hemorrhagic effect locally. The Indian VINS Polyvalent Antivenom bound the venom immunologically in a concentration-dependent manner. It moderately neutralized the venom procoagulant and lethal effects (normalized potency against lethality = 2.7 mg venom neutralized per g antivenom). BIOLOGICAL SIGNIFICANCE Comprehensive venom proteomes of D. russelii from different locales will facilitate better understanding of the geographical variability of the venom in both qualitative and quantitative terms. This is essential to provide scientific basis for the interpretation of differences in the clinical presentation of Russell's viper envenomation. The study revealed a unique venom proteome of the Pakistani D. russelii from the wild (Indus Delta), in which PLA2 predominated (~60% of total venom proteins). The finding unveiled remarkable differences in the venom compositions between the wild (present study) and the captive specimens reported previously. The integration of toxicity tests enabled the correlation of the venom proteome with the envenoming pathophysiology, where the venom showed potent lethality mediated through coagulopathic activity. The Indian VINS Polyvalent Antivenom (VPAV) showed binding activity toward the venom protein antigens; however the immunorecognition of small proteins and PLA2-dominating fractions was low to moderate. Consistently, the antivenom neutralized the toxicity of the wild Pakistani Russell's viper venom at moderate efficacies. Our results suggest that it may be possible to enhance the Indian antivenom potency against the Pakistani viper venom by the inclusion of venoms from a wider geographical range including that from Pakistan into the immunogen formulation.
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Affiliation(s)
- Tasnim Faisal
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kae Yi Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Si Mui Sim
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Naeem Quraishi
- ASV/ARV Serology Laboratory, Peoples Medical University, Nawabshah, Pakistan
| | - Nget Hong Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Choo Hock Tan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
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Tan KY, Tan NH, Tan CH. Venom proteomics and antivenom neutralization for the Chinese eastern Russell's viper, Daboia siamensis from Guangxi and Taiwan. Sci Rep 2018; 8:8545. [PMID: 29867131 PMCID: PMC5986800 DOI: 10.1038/s41598-018-25955-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/06/2018] [Indexed: 01/19/2023] Open
Abstract
The eastern Russell's viper (Daboia siamensis) causes primarily hemotoxic envenomation. Applying shotgun proteomic approach, the present study unveiled the protein complexity and geographical variation of eastern D. siamensis venoms originated from Guangxi and Taiwan. The snake venoms from the two geographical locales shared comparable expression of major proteins notwithstanding variability in their toxin proteoforms. More than 90% of total venom proteins belong to the toxin families of Kunitz-type serine protease inhibitor, phospholipase A2, C-type lectin/lectin-like protein, serine protease and metalloproteinase. Daboia siamensis Monovalent Antivenom produced in Taiwan (DsMAV-Taiwan) was immunoreactive toward the Guangxi D. siamensis venom, and effectively neutralized the venom lethality at a potency of 1.41 mg venom per ml antivenom. This was corroborated by the antivenom effective neutralization against the venom procoagulant (ED = 0.044 ± 0.002 µl, 2.03 ± 0.12 mg/ml) and hemorrhagic (ED50 = 0.871 ± 0.159 µl, 7.85 ± 3.70 mg/ml) effects. The hetero-specific Chinese pit viper antivenoms i.e. Deinagkistrodon acutus Monovalent Antivenom and Gloydius brevicaudus Monovalent Antivenom showed negligible immunoreactivity and poor neutralization against the Guangxi D. siamensis venom. The findings suggest the need for improving treatment of D. siamensis envenomation in the region through the production and the use of appropriate antivenom.
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Affiliation(s)
- Kae Yi Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nget Hong Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Choo Hock Tan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
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Aye KP, Thanachartwet V, Soe C, Desakorn V, Chamnanchanunt S, Sahassananda D, Supaporn T, Sitprija V. Predictive Factors for Death After Snake Envenomation in Myanmar. Wilderness Environ Med 2018; 29:166-175. [PMID: 29572088 DOI: 10.1016/j.wem.2018.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Factors predictive for death from snake envenomation vary between studies, possibly due to variation in host genetic factors and venom composition. This study aimed to evaluate predictive factors for death from snake envenomation in Myanmar. METHODS A prospective study was performed among adult patients with snakebite admitted to tertiary hospitals in Yangon, Myanmar, from May 2015 to August 2016. Data including clinical variables and laboratory parameters, management, and outcomes were evaluated. Multivariate regression analysis was performed to evaluate factors predictive for death at the time of presentation to the hospital. RESULTS Of the 246 patients with snake envenomation recruited into the study, 225 (92%) survived and 21 (8%) died during hospitalization. The snake species responsible for a bite was identified in 74 (30%) of the patients; the majority of bites were from Russell's vipers (63 patients, 85%). The independent factors predictive for death included 1) duration from bite to arrival at the hospital >1 h (odds ratio [OR]: 9.0, 95% confidence interval [CI]: 1.1-75.2; P=0.04); 2) white blood cell counts >20 ×103 cells·μL-1 (OR: 8.9, 95% CI: 2.3-33.7; P=0.001); and 3) the presence of capillary leakage (OR: 3.7, 95% CI: 1.2-11.2; P=0.02). A delay in antivenom administration >4 h increases risk of death (11/21 deaths). CONCLUSIONS Patients who present with these independent predictive factors should be recognized and provided with early appropriate intervention to reduce the mortality rate among adults with snake envenomation in Myanmar.
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Affiliation(s)
- Kyi-Phyu Aye
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (Drs Aye, Thanachartwet, Desakorn, and Chamnanchanunt); Medical Ward, Medical Department, Naypyitaw, Myanmar (Dr Aye)
| | - Vipa Thanachartwet
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (Drs Aye, Thanachartwet, Desakorn, and Chamnanchanunt).
| | - Chit Soe
- Department of Rheumatology, University of Medicine 1, Yangon, Myanmar (Dr Soe)
| | - Varunee Desakorn
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (Drs Aye, Thanachartwet, Desakorn, and Chamnanchanunt)
| | - Supat Chamnanchanunt
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (Drs Aye, Thanachartwet, Desakorn, and Chamnanchanunt)
| | - Duangjai Sahassananda
- Information Technology Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (Dr Sahassananda)
| | - Thanom Supaporn
- Division of Nephrology, Phramongkutklao Hospital, Bangkok, Thailand (Dr Supaporn)
| | - Visith Sitprija
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand (Dr Sitprija); Queen Saovabha Memorial Institute, Thai Red Cross, Bangkok, Thailand (Dr Sitprija)
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23
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Yee KT, Tongsima S, Vasieva O, Ngamphiw C, Wilantho A, Wilkinson MC, Somparn P, Pisitkun T, Rojnuckarin P. Analysis of snake venom metalloproteinases from Myanmar Russell's viper transcriptome. Toxicon 2018; 146:31-41. [PMID: 29567103 DOI: 10.1016/j.toxicon.2018.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 02/25/2018] [Accepted: 03/17/2018] [Indexed: 11/23/2022]
Abstract
Snake venom metalloproteinases (SVMPs) are the key enzymes in Russell's viper (RV) venom which target all important components of haemostasis, such as clotting factors, platelets, endothelial cells and basement membrane. The structural diversity of SVMPs contributes to the broad spectrum of biological activities. The aim of the study was to investigate the SVMP transcript profile to gain better insights into the characteristic clinical manifestations of the Myanmar Russell's viper (MRV) bites that distinguish it from the RVs of other habitats. Next generation sequencing (RNA-Seq) of mRNA from MRV venom glands (2 males and 1 female) was performed on an Illumina HiSeq2000 platform and then de novo assembled using Trinity software. A total of 59 SVMP contigs were annotated through a Blastn search against the serpent nucleotide database from NCBI. Among them, disintegrins were the most abundant transcripts (75%) followed by the P-III class SVMPs (25%). The P-II SVMPs were scarce (0.002%), while no P-I SVMPs were detectable in the transcriptome. For detailed structural analysis, contigs were conceptually translated and compared with amino acid sequences from other RVs and other vipers using Clustal Omega. The RTS-disintegrin (jerdostatin homolog) was the most abundant among transcripts corresponding to 5 disintegrin isoforms. From 10 isoforms of SVMPs, RVV-X, and Vipera lebetina apoptosis-inducing protease (VLAIP) homolog, hereby termed Daboia siamensis AIP (DSAIP), were found to be highly expressed. Venom protein analysis using SDS-PAGE followed by mass spectrometry revealed that the disintegrin was scarce, while the latter two SVMPs were abundant. These two proteins can contribute to severe clinical manifestations caused by MRV envenomation.
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Affiliation(s)
- Khin Than Yee
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Biochemistry Research Division, Department of Medical Research, Yangon, Myanmar
| | - Sissades Tongsima
- Genome Technology Research Unit, National Center for Genetic Engineering and Biotechnology, PathumThani, Thailand
| | - Olga Vasieva
- Institute of Integrative Biology, University of Liverpool, Liverpool, United Kingdom; Ingenet Limited, London, United Kingdom
| | - Chumpol Ngamphiw
- Genome Technology Research Unit, National Center for Genetic Engineering and Biotechnology, PathumThani, Thailand
| | - Alisa Wilantho
- Genome Technology Research Unit, National Center for Genetic Engineering and Biotechnology, PathumThani, Thailand
| | - Mark C Wilkinson
- Institute of Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | | | - Trairak Pisitkun
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Sasidaran MN, Samuel SP, ChinnaRaju S, Antonysamy M, Bulfone TC, Lewin MR. Parotid swelling after Russell's viper envenomation: an unusual and poor prognostic sign. Clin Case Rep 2018; 6:262-266. [PMID: 29445459 PMCID: PMC5799621 DOI: 10.1002/ccr3.1105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/10/2017] [Accepted: 03/29/2017] [Indexed: 11/11/2022] Open
Abstract
Parotid swelling, an unusual and poorly understood sign, is associated with poor prognosis in the setting of Russell's viper envenomation. The large, aggressive Russell's viper is one of the most deadly snakes causing severe hematological and neurological manifestations. Research into this sign should be initiated and understanding could lead to improved outcomes.
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Affiliation(s)
- Maanoj N Sasidaran
- TCR Multispeciality Hospital and Snakebite Research Centre Krishnagiri Tamilnadu India.,Department of Microbiology PSG College of Arts and Science Coimbatore Tamilnadu India
| | - Stephen P Samuel
- TCR Multispeciality Hospital and Snakebite Research Centre Krishnagiri Tamilnadu India.,General Medicine Queen Elizabeth Hospital King's Lynn Norfolk UK
| | | | - Michael Antonysamy
- Department of Microbiology PSG College of Arts and Science Coimbatore Tamilnadu India
| | | | - Matthew R Lewin
- Center for Exploration and Travel Health California Academy of Sciences San Francisco California USA
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Slagboom J, Kool J, Harrison RA, Casewell NR. Haemotoxic snake venoms: their functional activity, impact on snakebite victims and pharmaceutical promise. Br J Haematol 2017; 177:947-959. [PMID: 28233897 PMCID: PMC5484289 DOI: 10.1111/bjh.14591] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 01/09/2017] [Indexed: 12/22/2022]
Abstract
Snake venoms are mixtures of numerous proteinacious components that exert diverse functional activities on a variety of physiological targets. Because the toxic constituents found in venom vary from species to species, snakebite victims can present with a variety of life-threatening pathologies related to the neurotoxic, cytotoxic and haemotoxic effects of venom. Of the 1·8 million people envenomed by snakes every year, up to 125 000 die, while hundreds of thousands survive only to suffer with life-changing long-term morbidity. Consequently, snakebite is one of the world's most severe neglected tropical diseases. Many snake venoms exhibit strong haemotoxic properties by interfering with blood pressure, clotting factors and platelets, and by directly causing haemorrhage. In this review we provide an overview of the functional activities of haemotoxic venom proteins, the pathologies they cause in snakebite victims and how their exquisite selectivity and potency make them amenable for use as therapeutic and diagnostic tools relevant for human medicine.
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Affiliation(s)
- Julien Slagboom
- Alistair Reid Venom Research Unit, Parasitology Department, Liverpool School of Tropical Medicine, Liverpool, UK
- Division of BioAnalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jeroen Kool
- Division of BioAnalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Robert A Harrison
- Alistair Reid Venom Research Unit, Parasitology Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nicholas R Casewell
- Alistair Reid Venom Research Unit, Parasitology Department, Liverpool School of Tropical Medicine, Liverpool, UK
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Doknić M, Pekić S, Miljić D, Soldatović I, Popović V, Stojanović M, Petakov M. Etiology of Hypopituitarism in Adult Patients: The Experience of a Single Center Database in the Serbian Population. Int J Endocrinol 2017; 2017:6969286. [PMID: 28702053 PMCID: PMC5494080 DOI: 10.1155/2017/6969286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 03/27/2017] [Indexed: 11/26/2022] Open
Abstract
There are only a few published studies related to the population-based etiology of hypopituitarism. New risks for developing hypopituitarism have been recognized in the last 10 years. Aim. To present data regarding the etiology of hypopituitarism collected in a tertiary center over the last decade. This is a cross-sectional database study. Patients and Methods. We included 512 patients (pts) with hypopituitarism, with a mean age of 45.9 ± 1.7 yrs (range: 18-82; male: 57.9%). Results. Nonfunctional pituitary adenomas were presented in 205 pts (40.5%), congenital causes in 74 pts (14.6%), while acromegaly and prolactinomas were presented in 37 (7.2%) and 36 (7.0%) patients, respectively. Craniopharyngiomas were detected in 30 pts (5.9%), and head trauma due to trauma brain injury-TBI and subarachnoid hemorrhage-SAH in 27 pts (5.4%). Survivors of hemorrhagic fever with renal syndrome (HFRS) and those with previous cranial irradiation were presented in the same frequency (18 pts, 3.5% each). Conclusion. The most common causes of hypopituitarism in our database are pituitary adenomas. Increased awareness of the other causes of pituitary dysfunction, such as congenital, head trauma, extrapituitary cranial irradiation, and infections, is the reason for a higher frequency of these etiologies of hypopituitarism in the presented database.
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Affiliation(s)
- M. Doknić
- Neuroendocrine Department, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- *M. Doknić:
| | - S. Pekić
- Neuroendocrine Department, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - D. Miljić
- Neuroendocrine Department, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - I. Soldatović
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Institute of Medical Statistics and Informatics, Belgrade, Serbia
| | - V. Popović
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - M. Stojanović
- Neuroendocrine Department, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - M. Petakov
- Neuroendocrine Department, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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Namal Rathnayaka RMMK, Kularatne SAM, Kumarasinghe KDM, Ranaweera J, Nishanthi Ranathunga PEA. Ischemic brain infarcts and intracranial haemorrhages following Russell's viper (Daboia russelii) bite in Sri Lanka. Toxicon 2017; 125:70-73. [PMID: 27871786 DOI: 10.1016/j.toxicon.2016.11.253] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 11/12/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022]
Abstract
Snakebite is an important medical problem in Sri Lanka. Of the deadly venomous snakes, Russell's viper (Daboia russelii) is widely distributed and responsible for most of the fatalities of snakebite in the country. It is not uncommon to see atypical manifestations in Russell's viper bite. We report the events of intracranial haemorrhages and multiple ischemic brain infarcts following Russell's viper (Daboia russelii) bite of a previously healthy 43-years-old male who succumbed to envenoming.
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Affiliation(s)
- R M M K Namal Rathnayaka
- Intensive Care Unit, Provincial General Hospital, Ratnapura, Sri Lanka; Department of Veterinary Pathobiology, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Sri Lanka.
| | - S A M Kularatne
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka
| | | | - Janaka Ranaweera
- Intensive Care Unit, Provincial General Hospital, Ratnapura, Sri Lanka
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Fualal J, Ehrenkranz J. Access, availability, and infrastructure deficiency: The current management of thyroid disease in the developing world. Rev Endocr Metab Disord 2016; 17:583-589. [PMID: 27565137 DOI: 10.1007/s11154-016-9376-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Thyroid disease, a neglected tropical disease and the most common noncommunicable disease in the developing world, is overlooked, under-diagnosed, and inadequately managed. The spectrum of thyroid disorders in the developing world is qualitatively different from that found in industrialized countries. This qualitative difference has resulted in limited access to clinical, laboratory, and imaging resources that are necessary for the care of patients with thyroid disease. The management of thyroid disease in the developing world is comparable to the care provided for disorders of the thyroid in North America fifty years ago.This article reviews public health and clinical aspects of developing world medical and surgical thyroid disease. Topics covered include iodine deficiency disorders, congenital hypothyroidism, goiter, thyroid cancer, and hyper- and hypothyroidism. The review concludes with a description of programs based on smartphone technology to improve the availability, affordability, and quality of thyroid disease care.
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Affiliation(s)
- Jane Fualal
- Department of Surgery, Mulago Hospital, Makerere University Faculty of Medicine, Kampala, Uganda
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Ratnakaran B, Punnoose VP, Das S, Kartha A. Psychosis in Secondary Empty Sella Syndrome following a Russell's Viper Bite. Indian J Psychol Med 2016; 38:254-6. [PMID: 27335524 PMCID: PMC4904765 DOI: 10.4103/0253-7176.183079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hypopituitarism can present with psychiatric symptoms. We report a unique case of psychosis in clear consciousness in a case of hypopituitarism due to the secondary empty sella syndrome following a Russell's viper bite which was untreated and presented with psychotic symptoms for past 13 years following the snake bite. After the diagnosis of psychosis due to hypopituitarism was made, the patient was treated with levothyroxine and prednisolone supplements and his psychotic symptoms subsided without any psychotropic drugs. Vasculotoxic snake bites can cause hypopituitarism and can present with psychosis. Further research will be needed into the prevalence of this phenomenon.
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Affiliation(s)
- Badr Ratnakaran
- Department of Psychiatry, Dr. Kunhalu's Nursing Home, Ernakulam, Kerala, India
| | - Varghese P Punnoose
- Department of Psychiatry, Government Medical College, Kottayam, Kerala, India
| | - Soumitra Das
- Department of Psychiatry, Government Thirumala Devaswom Medical College, Alleppey, Kerala, India
| | - Arjun Kartha
- Department of Psychiatry, Government Thirumala Devaswom Medical College, Alleppey, Kerala, India
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Mukhopadhyay P, Mishra R, Mukherjee D, Mishra R, Kar M. Snakebite mediated acute kidney injury, prognostic predictors, oxidative and carbonyl stress: A prospective study. Indian J Nephrol 2016; 26:427-433. [PMID: 27942175 PMCID: PMC5131382 DOI: 10.4103/0971-4065.175987] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Snake bite is an occupational hazard in India and important preventable cause of acute kidney injury (AKI). This study was done to estimate the magnitude of snakebite-induced AKI (SAKI) who required renal replacement therapy, prognostic predictors, and final outcome, and to measure the oxidative and carbonyl stress (CS) level in SAKI patient who underwent hemodialysis (HD). All SAKI patients dialyzed between April 2010 and July 2011 in NRS Medical College were included. Demographical, clinical, and biochemical data were analyzed, and patients are followed to discharge or death. Oxidative and CS markers (advanced oxidation protein product [AOPP], advanced glycation end product, pentosidine, dityrosine, thioberbituric acid reactive substance, and methylglyoxal [MG]) were measured in 48 SAKI patient requiring HD. About 155 SAKI patients (M: F 2.2:1) received HD. Of them. The age was 36.2 (range 4–74) years. The most common site of the bite was lower limb (88.7%). Oliguria and bleeding manifestation were the common presentation. Hypotension was found in 52 (33.5%) cases, cellulitis and inflammation were found in about 63%. Mean creatinine was 4.56 ± 0.24 mg/dl. About 42 (27.1%) had disseminated intravascular coagulation (DIC). 36 (78.2%) had cellulites, 24 (52.2%) had hypotension or shock at initial presentation (P < 0.05), bleeding manifestation was found in 37 (80.4%), and 22 (47.8%) had DIC (P < 0.05). Forty-six (29.7%) patient died. DIC and hypotension/shock at initial presentation came out as an independent predictor of death. Among all markers measured for oxidative and CS (n = 48) AOPP and MG came out as an independent predictor (P < 0.05) of adverse outcome. Hypotension, DIC, AOPP, and MG were a poor prognostic marker in SAKI patients requiring dialysis.
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Affiliation(s)
- P Mukhopadhyay
- Department of Nephrology, NRS Medical College and Hospital, Kolkata, West Bengal, India
| | - R Mishra
- Department of Physiology, Ananda Mohan College, University of Calcutta, Kolkata, West Bengal, India
| | - D Mukherjee
- Department of Physiology, University of Calcutta, Kolkata, West Bengal, India
| | - R Mishra
- Department of Physiology, University of Calcutta, Kolkata, West Bengal, India
| | - M Kar
- Department of Biochemistry, NRS Medical College and Hospital, Kolkata, West Bengal, India
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Tan NH, Fung SY, Tan KY, Yap MKK, Gnanathasan CA, Tan CH. Functional venomics of the Sri Lankan Russell's viper (Daboia russelii) and its toxinological correlations. J Proteomics 2015; 128:403-23. [PMID: 26342672 DOI: 10.1016/j.jprot.2015.08.017] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 08/16/2015] [Accepted: 08/25/2015] [Indexed: 12/01/2022]
Abstract
UNLABELLED The venom proteome (venomics) of the Sri Lankan Daboia russelii was elucidated using 1D SDS PAGE nano-ESI-LCMS/MS shotgun proteomics. A total of 41 different venom proteins belonging to 11 different protein families were identified. The four main protein families are phospholipase A2 (PLA2, 35.0%), snaclec (SCL, 22.4%, mainly platelet aggregation inhibitors), snake venom serine proteinase (SVSP, 16.0%, mainly Factor V activating enzyme) and snake venom metalloproteinase (SVMP, 6.9%, mainly heavy chain of Factor X activating enzyme). Other protein families that account for more than 1% of the venom protein include l-amino acid oxidase (LAAO, 5.2%), Kunitz-type serine proteinase inhibitor (KSPI, 4.6%), venom nerve growth factor (VNGF. 3.5%), 5'-nucleotidase (5'NUC, 3.0%), cysteine-rich secretory protein (CRISP, 2.0%) and phosphodiesterase (PDE, 1.3%). The venom proteome is consistent with the enzymatic and toxic activities of the venom, and it correlates with the clinical manifestations of Sri Lankan D. russelii envenomation which include hemorrhage, coagulopathy, renal failure, neuro-myotoxicity and intravascular hemolysis. The venom exhibited remarkable presypnatic neurotoxicity presumably due to the action of basic PLA2 in high abundance (35.0%). Besides, SCLs, Factor X activating enzymes (SVMPs), SVSPs, and LAAOs are potential hemotoxins (50.5%), contributing to coagulopathy and hemorrhagic syndrome in Sri Lankan D. russelii envenomation. SIGNIFICANCE The study demonstrated the proteomic profile of the Sri Lankan Russell's viper venom, unraveling its complex composition of toxins and correlations with major toxic activities. The types, numbers, and relative abundances of toxins were reported. The venom content was dominated by the neurotoxic basic phospholipases A2 (>30% of total protein abundance) and several hemotoxic or coagulopathic protein families (approximately 50% in total). The proteome correlates with the functional and toxinological characterizations of the venom, and reflects the pathophysiological effects of envenomation by the Sri Lankan Russell's viper. The venom proteomics may serve to propel the understanding on pathogenesis and treatment strategy for envenomation by this viper in Sri Lanka. The enriched database contributed by the proteomic findings will be useful for comparing venom variations among Russell's vipers from different geographical areas.
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Affiliation(s)
- Nget Hong Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Shin Yee Fung
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kae Yi Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Michelle Khai Khun Yap
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Choo Hock Tan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur Malaysia.
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Rajagopala S, Thabah MM, Ariga KK, Gopalakrishnan M. Acute hypopituitarism complicating Russell's viper envenomation: case series and systematic review. QJM 2015; 108:719-28. [PMID: 25630907 DOI: 10.1093/qjmed/hcv011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Chronic hypopituitarism following Russell viper envenomation (RVE) is a rare but well-recognized syndrome. The clinical features, associations, management and outcomes of RVE associated-acute hypopituitarism (AHP) are not well described. AIMS To describe the clinical features, intensive care unit (ICU) management and outcomes of a series of patients with RVE-AHP and identify the clinical associations of RVE-AHP. METHODS We describe a series of patients with prospectively identified AHP related to RVE and describe our findings comparing RVE with and without AHP and a systematic search of literature on AHP related to RVE. RESULTS We identified nine cases of AHP related to RVE. Unexplained hypoglycemia (100%) and hypotension (66.7%) were the most common findings at presentation. AHP occurred after a median of 9 (range, 2-14) days after severe envenomation and was associated with multi-organ dysfunction, lower platelet counts, more bleeding and transfusions when compared to patients with RVE alone. The presence of clinically defined capillary leak syndrome, disseminated intravascular coagulation and mortality were not different from those without AHP. Our systematic search yielded 12 cases of AHP related to RVE; data on associated clinical manifestations, therapy and ASV administration were not available in most reports. CONCLUSION AHP is a very rare complication of RVE. Unexplained hypoglycemia and hypotension should prompt evaluation for AHP in RVE. AHP is associated with severe RVE, multi-organ dysfunction, bleeding and need for transfusion. Prompt treatment with steroids may reduce mortality related to AHP in RVE.
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Affiliation(s)
- S Rajagopala
- From the Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Dhanvantri Nagar, Puducherry 605006, India
| | - M M Thabah
- From the Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Dhanvantri Nagar, Puducherry 605006, India
| | - K K Ariga
- From the Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Dhanvantri Nagar, Puducherry 605006, India
| | - M Gopalakrishnan
- From the Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Dhanvantri Nagar, Puducherry 605006, India
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Inflammation and oxidative stress in viper bite: An insight within and beyond. Toxicon 2015; 98:89-97. [DOI: 10.1016/j.toxicon.2015.02.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/16/2014] [Accepted: 02/25/2015] [Indexed: 12/20/2022]
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Abstract
Venomous snakebite is considered the single most important cause of human injury from venomous animals worldwide. Coagulopathy is one of the commonest important systemic clinical syndromes and can be complicated by serious and life-threatening haemorrhage. Venom-induced consumption coagulopathy (VICC) is the commonest coagulopathy resulting from snakebite and occurs in envenoming by Viperid snakes, certain elapids, including Australian elapids, and a few Colubrid (rear fang) snakes. Procoagulant toxins activate the clotting pathway, causing a broad range of factor deficiencies depending on the particular procoagulant toxin in the snake venom. Diagnosis and monitoring of coagulopathy is problematic, particularly in resource-poor countries where further research is required to develop more reliable, cheap clotting tests. MEDLINE and EMBASE up to September 2013 were searched to identify clinical studies of snake envenoming with VICC. The UniPort database was searched for coagulant snake toxins. Despite preclinical studies demonstrating antivenom binding toxins (efficacy), there was less evidence to support clinical effectiveness of antivenom for VICC. There were no placebo-controlled trials of antivenom for VICC. There were 25 randomised comparative trials of antivenom for VICC, which compared two different antivenoms (ten studies), three different antivenoms (four), two or three different doses or repeat doses of antivenom (five), heparin treatment and antivenom (five), and intravenous immunoglobulin treatment and antivenom (one). There were 13 studies that compared two groups in which there was no randomisation, including studies with historical controls. There have been numerous observational studies of antivenom in VICC but with no comparison group. Most of the controlled trials were small, did not use the same method for assessing coagulopathy, varied the dose of antivenom, and did not provide complete details of the study design (primary outcomes, randomisation, and allocation concealment). Non-randomised trials including comparison groups without antivenom showed that antivenom was effective for some snakes (e.g., Echis), but not others (e.g., Australasian elapids). Antivenom is the major treatment for VICC, but there is currently little high-quality evidence to support effectiveness. Antivenom is not risk free, and adverse reactions can be quite common and potentially severe. Studies of heparin did not demonstrate it improved outcomes in VICC. Fresh frozen plasma appeared to speed the recovery of coagulopathy and should be considered in bleeding patients.
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Grace M, Shanoj KC. An unusual complication of snake bite. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2014. [DOI: 10.4103/1110-7782.139583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Golay V, Roychowdhary A, Dasgupta S, Pandey R. Hypopituitarism in patients with vasculotoxic snake bite envenomation related acute kidney injury: a prospective study on the prevalence and outcomes of this complication. Pituitary 2014; 17:125-31. [PMID: 23456212 DOI: 10.1007/s11102-013-0477-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Acute kidney injury (AKI) is common in patients with vasculotoxic snake bite (SB) envenomation but hypopituitarism (HP) is an uncommonly reported complication. We conducted a prospective observational study on survivors of SB-AKI who were evaluated and followed up from September 2010 till September 2012. Pituitary function tests were done if they developed any symptoms of HP. MRI of the hypothalamo-pituitary axis was done in those with documented HP. Response to therapy in the form of improvement in the quality of life (QoL) was evaluated by asking patients to mark on a visual analogue scale marked over 0-100 mm which was reported as percentage improvement. 126 patients were included for this study (30 were lost to follow up and were excluded). 25 cases were clinically suspected to have pituitary dysfunction and underwent evaluation with 9 (9.37%, n = 96) found to have evidence of HP. One child had partial empty sella on MRI with anterior as well as posterior pituitary abnormality and stunting; imaging was normal in others. Higher number of patients with HP had hypotension (p = 0.005, n = 7), coagulation abnormalities (p = 0.005, n = 9), severe clinical snake bite envenomation (p = 0.024, n = 9) and progression to chronic kidney disease (CKD) (p = 0.001, n = 5) as compared to those who did not. Dialysis dependence at presentation was not significantly different (p = 0.348, n = 9). Only development of CKD on follow up predicted the development of HP. Patients had an improvement in the QoL after treatment with mean score on the visual analogue scale of 66.67 ± 14.14%. HP is not very uncommon in patients with severe vasculotoxic SB-AKI. Threshold of clinical suspicion and evaluation should be low as it causes significant morbidity.
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Affiliation(s)
- Vishal Golay
- Department of Nephrology, Institute of Postgraduate Medical Education and Research, 244, AJC Bose Road, Kolkata, 700020, West Bengal, India,
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Kularatne SAM, Silva A, Weerakoon K, Maduwage K, Walathara C, Paranagama R, Mendis S. Revisiting Russell's viper (Daboia russelii) bite in Sri Lanka: is abdominal pain an early feature of systemic envenoming? PLoS One 2014; 9:e90198. [PMID: 24587278 PMCID: PMC3936006 DOI: 10.1371/journal.pone.0090198] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 01/27/2014] [Indexed: 11/19/2022] Open
Abstract
The Russell's viper (Daboia russelii) is responsible for 30-40% of all snakebites and the most number of life-threatening bites of any snake in Sri Lanka. The clinical profile of Russell's viper bite includes local swelling, coagulopathy, renal dysfunction and neuromuscular paralysis, based on which the syndromic diagnostic tools have been developed. The currently available Indian polyvalent antivenom is not very effective in treating Russell's viper bite patients in Sri Lanka and the decision regarding antivenom therapy is primarily driven by clinical and laboratory evidence of envenoming. The non-availability of early predictors of Russell's viper systemic envenoming is responsible for considerable delay in commencing antivenom. The objective of this study is to evaluate abdominal pain as an early feature of systemic envenoming following Russell's viper bites. We evaluated the clinical profile of Russell's viper bite patients admitted to a tertiary care centre in Sri Lanka. Fifty-five patients were proven Russell's viper bite victims who produced the biting snake, while one hundred and fifty-four were suspected to have been bitten by the same snake species. Coagulopathy (159, 76.1%), renal dysfunction (39, 18.7%), neuromuscular paralysis (146, 69.9%) and local envenoming (192, 91.9%) were seen in the victims, ranging from mono-systemic involvement to various combinations. Abdominal pain was present in 79.5% of these patients, appearing 5 minutes to 4 hours after the bite. The severity of the abdominal pain, assessed using a scoring system, correlated well with the severity of the coagulopathy (p<0.001) and the neurotoxicity (p<0.001). Its diagnostic validity to predict systemic envenoming is - Sensitivity 81.6%, Specificity 82.4%, Positive predictive value 91.2%. Thus, abdominal pain is an early clinical feature of systemic Russell's viper bite envenoming in Sri Lanka. However, it is best to judge abdominal pain together with other clinical manifestations on decision making.
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Affiliation(s)
| | - Anjana Silva
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
| | - Kosala Weerakoon
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
| | - Kalana Maduwage
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
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Kularatne S, Senanayake N. Venomous snake bites, scorpions, and spiders. HANDBOOK OF CLINICAL NEUROLOGY 2014; 120:987-1001. [DOI: 10.1016/b978-0-7020-4087-0.00066-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Keyler D, Gawarammana I, Gutiérrez J, Sellahewa K, McWhorter K, Malleappah R. Antivenom for snakebite envenoming in Sri Lanka: The need for geographically specific antivenom and improved efficacy. Toxicon 2013; 69:90-7. [DOI: 10.1016/j.toxicon.2013.01.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 01/27/2013] [Accepted: 01/30/2013] [Indexed: 10/27/2022]
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Venkatesh M, Prasad N, Sing T, Gowda V. Purification, characterization, and chemical modification of neurotoxic peptide from Daboia russelii snake venom of India. J Biochem Mol Toxicol 2013; 27:295-304. [PMID: 23629951 DOI: 10.1002/jbt.21486] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 03/15/2013] [Accepted: 03/25/2013] [Indexed: 11/10/2022]
Abstract
Comprehensive knowledge of venom composition is very important for effective management of snake envenomation and antivenom preparation. Daboia russelii venom from the eastern region of India is the most neurotoxic among the four venom samples investigated. From the eastern D. russelii venom sample, neurotoxic peptide has been purified by combined method of ion exchange gel permeation chromatography and reversed phase high performance liquid chromatography. Molecular weight of Daboia neurotoxin III (DNTx-III) found to be 6,849 Da (as measured on matrix-assisted laser desorption/ionisation-time of flight mass spectrometer), and N-terminal amino acid sequences is I K C F I T P D U T S Q A. Approximate LD50 dosage was 0.24 mg/kg body weight. It produced concentration- and time-dependent inhibition of indirectly stimulated twitches of Rana hexadactyla sciatic nerve gastrocnemius muscle preparations. Chemical modification of DNTx-III tryptophan residue(s) reduced the twitch height inhibition property of toxin, signifying the importance of tryptophan residues for the neurotoxic function. This type of neurotoxic peptide is unique to east Indian regional D. russelii venom.
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Affiliation(s)
- Madhukumar Venkatesh
- Department of Studies in Biochemistry, University of Mysore, Mysore, 570 006, India
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Jeevagan V, Katulanda P, Gnanathasan CA, Warrell DA. Acute pituitary insufficiency and hypokalaemia following envenoming by Russell's viper (Daboia russelii) in Sri Lanka: Exploring the pathophysiological mechanisms. Toxicon 2013; 63:78-82. [PMID: 23212048 DOI: 10.1016/j.toxicon.2012.11.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 11/01/2012] [Accepted: 11/15/2012] [Indexed: 11/17/2022]
Abstract
Russell's viper envenoming is associated with a high incidence of morbidity and mortality. Hypopituitarism following envenoming by Russell's vipers is a well recognized sequel in Burma and parts of India but has been reported only once in Sri Lanka. Hypokalaemia following envenoming by Russell's viper has not been described. Here we describe the association of acute pituitary insufficiency and hypokalaemia following Russell's viper envenoming in Sri Lanka and review the literature in order to understand its pathophysiological basis. A previously healthy 21-year-old man was envenomed by a Russell's viper and treated with antivenom. Ten hours after the bite, he developed persistent hypotension, which responded promptly to intravenous dexamethasone. His hormone profiles were consistent with hypocortisolism secondary to acute pituitary insufficiency. He also developed hypokalaemia. Analysis of urine and serum electrolytes suggested redistribution of potassium in to the cells rather than renal loss. Hypotension and hypoglycaemic coma are life-threatening manifestations of acute pituitary insufficiency. Therefore prompt steroid administration in these setting is life saving. Awareness of these complications among physicians would help to make prompt diagnosis and initiate immediate life saving treatment.
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Deepak M, Basavaprabhu A, Ramapuram JT, Nithyananda C, Mahalingam S. Bilateral parotid enlargement following snake bite: a rare sign. Asian Pac J Trop Biomed 2013; 3:154-5. [PMID: 23593596 PMCID: PMC3627177 DOI: 10.1016/s2221-1691(13)60041-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 01/20/2013] [Indexed: 11/28/2022] Open
Abstract
Snakebite is a common medical emergency in India. Unusual complications may occur after viper bite. Bilateral parotid enlargement after viper bite is a rare entity. An 18-year old gentleman presented to our hospital with history of viper bite. On examination he had cellulitis of right lower limb. He developed swelling of both the parotid glands 12 h after admission. He developed coagulopathy, acute renal failure and died within 48 h of hospital admission. Development of parotid swelling after snake bite is associated with poor prognosis. This case is found worth reporting as it is an unusual complication having prognostic value.
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Affiliation(s)
- Madi Deepak
- Department of Medicine, Kasturba Medical College, Mangalore (Manipal University), Karnataka, India
| | - Achappa Basavaprabhu
- Department of Medicine, Kasturba Medical College, Mangalore (Manipal University), Karnataka, India
| | - John T Ramapuram
- Department of Medicine, Kasturba Medical College, Mangalore (Manipal University), Karnataka, India
| | - Chowta Nithyananda
- Department of Medicine, Kasturba Medical College, Mangalore (Manipal University), Karnataka, India
| | - Soundarya Mahalingam
- Department of Paediatrics, Kasturba Medical College, Mangalore (Manipal University), Karnataka, India
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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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Vantyghem MC, Douillard C, Balavoine AS. Hypotensions d’origine endocrinienne. Presse Med 2012; 41:1137-50. [DOI: 10.1016/j.lpm.2012.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 03/14/2012] [Indexed: 11/24/2022] Open
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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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Abstract
Hypopituitarism, a disease of varied etiologies, is a serious endocrine illness that requires early recognition and prompt treatment to avoid its severe deleterious effects. In adults it is often missed due to non-specific symptoms of growth hormone deficiency and hypogonadism or mild deficiencies of other pituitary hormones. In some it may present with acute onset of symptoms suggestive of acute adrenal (corticotropin) insufficiency or symptoms due to mass lesion in/or around pituitary. High index of suspicion is required to seek hypopituitarism in patients with non-specific symptoms such as fatigue and malaise. Treatment of isolated hormone deficiency, partial or panhypopituitarism, has gratifying results although they require lifelong treatment and follow-up.
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Affiliation(s)
- K. S. Brar
- Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantt, New Delhi, India
| | - M. K. Garg
- Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantt, New Delhi, India
| | - K. M. Suryanarayana
- Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantt, New Delhi, India
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