Snakebite envenomation in the Brazilian Amazon: a descriptive study

Consistent Killers: Conservation of Thrombin-Like Action on Fibrinogen by Bushmaster (Lachesis Species) Venoms Underpins Broad Antivenom Cross-Reactivities

Snakebite represents a significant public health challenge in Central and South America, with Lachesis (Bushmaster) species posing unique clinical challenges due to their severe envenomation effects arising from a combination of potent venom and copious venom yields. Using in vitro coagulation assays, we analyzed the coagulotoxic venom effects from four distinct localities: L. muta from Surinam and French Guiana and L. stenophrys from Costa Rica and Panama. This study examined the venom's impact on human plasma and fibrinogen and evaluated the efficacy of two regionally available antivenoms (PoliVal-ICP and Antivipmyn-Tri) in neutralizing the pathophysiological effects. Our results demonstrated a remarkable consistency in the pseudo-procoagulant venom activity (also known as: thrombin-like) across different species and localities. Antivenom efficacy testing revealed that both the PoliVal-ICP and Antivipmyn-Tri antivenoms effectively neutralized the venom effects across localities for both species, with the ICP antivenom showing the highest neutralization capacity. These toxicology findings highlight the biochemical conservation of venom composition across Lachesis species which underpins effective cross-neutralization in antivenom treatment.

Plant-derived secondary metabolites against Bothrops envenomation: A review

Snakebites from the Bothrops genus are a public health issue in Brazil, particularly in the most affected rural areas. Traditional medicinal plants offer potential complementary therapies for mitigating the damages caused by Bothrops envenomation. This review summarizes current research on the antiophidic potential in medicinal plants and its secondary metabolites to neutralize Bothrops venom effects. A comprehensive literature search was conducted to identify studies detailing the biochemical mechanisms and pharmacological effects of plant-based secondary metabolites, including polyphenols, saponins, quinones, sulfated polysaccharides, steroids, coumarins, alkaloids, and coumestans, on venom-induced pathologies. Polyphenols, particularly flavonoids, exhibit significant inhibitory activity against the proteolytic, hemorrhagic, and myotoxic effects of Bothrops venom by binding to active sites of metalloproteinases and phospholipase A2 (PLA2) Saponins and quinones demonstrated anti-inflammatory and anti-myotoxic effects through protein precipitation and ion chelation. Sulfated polysaccharides from marine algae showed anticoagulant and anti-edematous properties. Additionally, plant-derived steroids and coumarins inhibited venom-induced coagulation and tissue necrosis. Alkaloids and coumestans, such as wedelolactone, effectively reduced hemorrhagic and neurotoxic damage. Medicinal plants and their secondary metabolites have substantial potential to neutralize the biological responses of bothropic venom. Further research and clinical validation are needed to establish safety, efficacy, and standardized use in snakebite management protocols.

The Versatility of Serine Proteases from Brazilian Bothrops Venom: Their Roles in Snakebites and Drug Discovery

Serine proteases are multifunctional and versatile venom components found in viper snakes, including the Bothrops species, a widely distributed genus notorious for causing the highest number of snakebites across Latin America. These enzymes, representing a significant fraction of Bothrops venom proteomes, exhibit a wide range of biological activities that influence blood coagulation, fibrinolysis, and inflammation. This review provides a comprehensive overview of serine proteases, with a particular focus on those found in the venom of Brazilian Bothrops snakes. The discussion begins with a summary of snake species found in Brazil and their medical relevance. Specifically addressing the Bothrops genus, this review explores the distribution of these species across Brazilian territory and their associated medical importance. Subsequently, the article investigates the biochemistry of Bothrops venoms and the clinical manifestations induced by envenomation. Finally, it offers an in-depth discussion on the serine proteases, highlighting their biochemical properties, mechanisms of action, and potential therapeutic applications. Furthermore, this review provides an in-depth exploration of the diverse serine proteases found in Bothrops venoms and their functional significance, from thrombin-like effects to potent fibrinogenolytic actions, which determine the clinical manifestations of envenomation. This review delves into the evolutionary adaptations and biochemical diversity of serine proteases in Bothrops venoms, emphasizing their critical roles in venom functionality and the resulting pathophysiological effects. Additionally, it opens new avenues for utilizing these enzymes in biomedical applications, underscoring their potential beyond toxinology.

Dermatopathological findings of Bothrops atrox snakebites: A case series in the Brazilian Amazon

BACKGROUND

Bothrops venom consists primarily of metalloproteinase and phospholipase A2 toxins, which are responsible for the acute inflammatory, coagulant and hemorrhagic action following snakebite. The local effects of snakebite envenomation by Bothrops species are particularly prevalent yet poorly studied, but include pain, edema, erythema, blistering, bleeding, and ecchymosis.

METHODS AND FINDINGS

In this study, we describe the dermatopathological findings observed in a series of 22 patients diagnosed with Bothrops envenomation treated in a tertiary hospital of Manaus, in the Brazilian Amazon. Clinically, pain and edema were observed in all patients, followed by fang marks (63.6%), secondary infection (36.3%), ecchymosis (31.8%), erythema (22.7%), blister (13.6%), and necrosis (4.5%). Regarding histopathological findings, epidermal alterations such as spongiosis, acanthosis and hyperkeratosis were the most observed characteristics in our cases series, with isolated cases of hyperplasia, hemorrhagic intraepidermal blister and severe necrosis. Changes in dermis and hypodermis consisted mainly of hemorrhage, inflammatory infiltrate, edema, congestion, and vascular damage, whereas cases of collagen damage, necrosis, abscess, and signs of tissue repair, indicated by the presence of granulation tissue, were also observed, with a persistence of inflammatory and hemostatic alterations even days after antivenom administration. Therefore, the tissue damage resulting from Bothrops envenomation could be related to both direct venom activity as well as inflammatory response or presence of infectious process. The histopathological analysis of human skin injury can enlighten the pathological and endogenous effects of local envenomation and could underpin new strategies, including novel treatments, adjuvants or changes in clinical management, that lead to better outcomes in snakebite patients.

The Protective Action of Coutarea hexandra (Rubiaceae) on the Neuromuscular Blockade Induced by Lachesis muta muta (Viperidae: Crotalinae) Venom

Envenomations by snakes represent a neglected health problem in tropical and subtropical countries. In South America, Lachesis muta occasionally causes severe human envenomation, with treatment being conditioned to an unspecific antivenom. In this work, we examined the neutralizing ability of Coutarea hexandra stem bark hydroalcoholic extract (Ch-E), including the commercial phytochemicals coumarin and quinine, on the neuromuscular blockade induced by L. m. muta venom in mouse phrenic nerve-diaphragm preparation. Biological assays were performed following conventional myographic technique ex vivo. Ch-E was phytochemically characterized to detect the presence of coumarin and quinine using analytical methods. Ch-E and commercial phytochemicals were tested separately or combined under pre- and post-venom incubation protocols. Ch-E attenuated the venom-induced neuromuscular blockade only under the pre-venom incubation protocol. Quinine was not detected in Ch-E. Commercial coumarin and quinine exhibited a concentration-dependent counteracting effect on the venom-induced neuromuscular blockade. The pre-venom incubation protocol showed to be efficient in attenuating the L. m. muta venom-induced neuromuscular blockade, most likely due to the presence of coumarin derivatives and unknown alkaloids in this extract.

Capacity of community health centers to treat snakebite envenoming in indigenous territories of the Brazilian Amazon

INTRODUCTION

The deaths from and morbidities associated with snakebites - amputations, loss of function in the limb, visible scarring or tissue damage - have a vast economic, social, and psychological impact on indigenous communities in the Brazilian Amazon, especially children, and represent a real and pressing health crisis in this population. Snakebite clinical and research experts have therefore proposed expanding antivenom access from only hospitals to include the community health centers (CHC) located near and within indigenous communities. However, there are no studies examining the capacity of CHCs to store, administer, and manage antivenom treatment. In response to this gap, the research team calling for antivenom decentralization developed and validated an expert-based checklist outlining the minimum requirements for a CHC to provide antivenom.

METHODS

The objective of this study was thus to survey a sample of CHCs in indigenous territories and evaluate their capacity to provide antivenom treatment according to this accredited checklist. The checklist was administered to nurses and doctors from 16 CHCs, two per indigenous district in Amazonas/Roraima states.

RESULTS

Our results can be conceptualized into three central findings: 1) most CHCs have the capacity to provide antivenom treatment, 2) challenges to capacity are human resources and specialized items, and 3) antivenom decentralization is feasible and appropriate in indigenous communities.

CONCLUSION

Decentralization would provide culturally and contextually appropriate care accessibility to a historically marginalized and underserved population of the Brazilian Amazon. Future studies should examine optimal resource allocation in indigenous territories and develop an implementation strategy in partnership with indigenous leaders. Beyond the indigenous population, the checklist utilized could be applied to community health centers treating the general population and/or adapted to other low-resource settings.

Biochemical and toxicological profiles of venoms from an adult female South American bushmaster (Lachesis muta rhombeata) and her offspring

In this work, we compared the biochemical and toxicological profiles of venoms from an adult female specimen of Lachesis muta rhombeata (South American bushmaster) and her seven offspring born in captivity, based on SDS-PAGE, RP-HPLC, enzymatic, coagulant, and hemorrhagic assays. Although adult and juvenile venoms showed comparable SDS-PAGE profiles, juveniles lacked some chromatographic peaks compared with adult venom. Adult venom had higher proteolytic (caseinolytic) activity than juvenile venoms (p < 0.05), but there were no significant inter-venom variations in the esterase, PLA2, phosphodiesterase and L-amino acid oxidase (LAAO) activities, although the latter activity was highly variable among the venoms. Juveniles displayed higher coagulant activity on human plasma, with a minimum coagulant dose ∼42% lower than the adult venom (p < 0.05), but there were no age-related differences in thrombin-like activity. Adult venom was more fibrinogenolytic (based on the rate of fibrinogen chain degradation) and hemorrhagic than juvenile venoms (p < 0.05). The effective dose of Bothrops/Lachesis antivenom (produced by the Instituto Butantan) needed to neutralize the coagulant activity was ∼57% greater for juvenile venoms (p < 0.05), whereas antivenom did not attenuate the thrombin-like activity of juvenile and adult venoms. Antivenom significantly reduced the hemorrhagic activity of adult venom (400 μg/kg, i. d.), but not that of juvenile venoms. Overall, these data indicate a compositional and functional ontogenetic shift in L. m. rhombeata venom.

Snakebites epidemiology in Mexico: a 13-year ecological analysis

BACKGROUND

Globally, snakebites have a significant impact on public health and represent substantial costs for health services. Their severity is particularly relevant in developing countries due to the lack of resources and accessibility to health facilities. Additionally, the number of cases may be underestimated, highlighting the urgent need for improved prevention measures.

METHODS

An observational ecological study was undertaken using the records identified with X200-X209 codes registered in the Ministry of Health injuries database during 2010-2022. Variables included information related to the patient, the snakebite and the healthcare provided. Statistical analysis was carried out with STATA 16 and Microsoft Excel 2020.

RESULTS

A total of 10 420 snakebites were registered. The average number of cases per year was 788 (IQR 615, 875) and 82.74% occurred during the rainy season. The median age was 35 (IQR 19, 52) y and early adulthood was the most affected age group; bites were most common on the hand and in the living place. The Eastern region of Mexico registered the highest number of cases, with 3496 (33.71%) of snakebites. The lethality rate was 18.23 per 10 000.

CONCLUSIONS

Snakebites are a significant health problem in Mexico. Most injuries occur among men in early adulthood, in households and in the upper extremities.

Multiplex lateral flow assay development for snake venom detection in biological matrices

Bothrops and Lachesis are two of Brazil's medically most relevant snake genera, causing tens of thousands of bites annually. Fortunately, Brazil has good accessibility to high-quality antivenoms at the genus and inter-genus level, enabling the treatment of many of these envenomings. However, the optimal use of these treatments requires that the snake species responsible for the bite is determined. Currently, physicians use a syndromic approach to diagnose snakebite, which can be difficult for medical personnel with limited training in clinical snakebite management. In this work, we have developed a novel monoclonal antibody-based multiplex lateral flow assay for differentiating Bothrops and Lachesis venoms within 15 min. The test can be read by the naked eye or (semi)-quantitatively by a smartphone supported by a 3D-printed attachment for controlling lighting conditions. The LFA can detect Bothrops and Lachesis venoms in spiked plasma and urine matrices at concentrations spanning six orders of magnitude. The LFA has detection limits of 10-50 ng/mL in spiked plasma and urine, and 50-500 ng/mL in spiked sera, for B. atrox and L. muta venoms. This test could potentially support medical personnel in correctly diagnosing snakebite envenomings at the point-of-care in Brazil, which may help improve patient outcomes and save lives.

Development and validation of a minimum requirements checklist for snakebite envenoming treatment in the Brazilian Amazonia

BACKGROUND

Currently, antivenoms are the only specific treatment available for snakebite envenoming. In Brazil, over 30% of patients cannot access antivenom within its critical care window. Researchers have therefore proposed decentralizing to community health centers to decrease time-to-care and improve morbidity and mortality. Currently, there is no evidence-based method to evaluate the capacity of health units for antivenom treatment, nor what the absolute minimum supplies and staff are necessary for safe and effective antivenom administration and clinical management.

METHODS

This study utilized a modified-Delphi approach to develop and validate a checklist to evaluate the minimum requirements for health units to adequately treat snakebite envenoming in the Amazon region of Brazil. The modified-Delphi approach consisted of four rounds: 1) iterative development of preliminary checklist by expert steering committee; 2) controlled feedback on preliminary checklist via expert judge survey; 3) two-phase nominal group technique with new expert judges to resolve pending items; and 4) checklist finalization and closing criteria by expert steering committee. The measure of agreement selected for this study was percent agreement defined a priori as ≥75%.

RESULTS

A valid, reliable, and feasible checklist was developed. The development process highlighted three key findings: (1) the definition of community health centers and its list of essential items by expert judges is consistent with the Brazilian Ministry of Health, WHO snakebite strategic plan, and a general snakebite capacity guideline in India (internal validity), (2) the list of essential items for antivenom administration and clinical management is feasible and aligns with the literature regarding clinical care (reliability), and (3) engagement of local experts is critical to developing and implementing an antivenom decentralization strategy (feasibility).

CONCLUSION

This study joins an international set of evidence advocating for decentralization, adding value in its definition of essential care items; identification of training needs across the care continuum; and demonstration of the validity, reliability, and feasibility provided by engaging local experts. Specific to Brazil, further added value comes in the potential use of the checklist for health unit accreditation as well as its applications to logistics and resource distribution. Future research priorities should apply this checklist to health units in the Amazon region of Brazil to determine which community health centers are or could be capable of receiving antivenom and translate this expert-driven checklist and approach to snakebite care in other settings or other diseases in low-resource settings.

Considerations for the development of a field-based medical device for the administration of adjunctive therapies for snakebite envenoming

The timely administration of antivenom is the most effective method currently available to reduce the burden of snakebite envenoming (SBE), a neglected tropical disease that most often affects rural agricultural global populations. There is increasing interest in the development of adjunctive small molecule and biologic therapeutics that target the most problematic venom components to bridge the time-gap between initial SBE and the administration antivenom. Unique combinations of these therapeutics could provide relief from the toxic effects of regional groupings of medically relevant snake species. The application a PRISMA/PICO literature search methodology demonstrated an increasing interest in the rapid administration of therapies to improve patient symptoms and outcomes after SBE. Advice from expert interviews and considerations regarding the potential routes of therapy administration, anatomical bite location, and species-specific venom delivery have provided a framework to identify ideal metrics and potential hurdles for the development of a field-based medical device that could be used immediately after SBE to deliver adjunctive therapies. The use of subcutaneous (SC) or intramuscular (IM) injection were identified as potential routes of administration of both small molecule and biologic therapies. The development of a field-based medical device for the delivery of adjunctive SBE therapies presents unique challenges that will require a collaborative and transdisciplinary approach to be successful.

Bothrops atrox and Bothrops lanceolatus Venoms In Vitro Investigation: Composition, Procoagulant Effects, Co-Factor Dependency, and Correction Using Antivenoms

Bothrops venoms are rich in enzymes acting on platelets and coagulation. This action is dependent on two major co-factors, i.e., calcium and phospholipids, while antivenoms variably neutralize venom-related coagulopathy effects. Our aims were (i) to describe the composition of B. atrox and B. lanceolatus venoms; (ii) to study their activity on the whole blood using rotational thromboelastometry (ROTEM); (iii) to evaluate the contribution of calcium and phospholipids in their activity; and (iv) to compare the effectiveness of four antivenoms (Bothrofav™, Inoserp™ South America, Antivipmyn™ TRI, and PoliVal-ICP™) on the procoagulant activity of these two venoms. Venom composition was comparable. Both venoms exhibited hypercoagulant effects. B. lanceolatus venom was completely dependent on calcium but less dependent on phospholipids than B. atrox venom to induce in vitro coagulation. The four antivenoms neutralized the procoagulant activity of the two venoms; however, with quantitative differences. Bothrofav™ was more effective against both venoms than the three other antivenoms. The relatively similar venom-induced effects in vitro were unexpected considering the opposite clinical manifestations resulting from envenomation (i.e., systemic bleeding with B. atrox and thrombosis with B. lanceolatus). In vivo studies are warranted to better understand the pathophysiology of systemic bleeding and thrombosis associated with Bothrops bites.

Who are the most affected by Bothrops snakebite envenoming in Brazil? A Clinical-epidemiological profile study among the regions of the country

Snakebite envenoming represents an important Neglected Tropical Disease (NTD) that mainly affects tropical and subtropical developing countries according to the World Health Organization (WHO). As a priority issue in the tropics, it is estimated that accidental encounter between snakes and humans is the leading cause of morbidity and mortality among all NTDs in the world. In Brazil, an extremely diverse country with continental dimensions, snakebite envenoming is the second leading cause of reported human envenoming. Treating the disease has been an unprecedented challenge for Brazilian Health Systems for decades. Despite access to Antivenom therapy and distributing it free of charge across the country, Brazil faces numerous issues regarding the notification process and accurate treatment targeting for at-risk populations. Thus, this study aimed to identify the temporal epidemiological dynamics of accidents caused by Bothrops snakes in Brazil, the country's major group of venomous snakes, based on secondary information from the online database provided by The Brazilian Notifiable Diseases Information System (SINAN). For this purpose, reported Bothrops snakebites between 2012 and 2021 were counted, then the data were analyzed. We looked at the frequency, occurrence, mortality rates, case fatality rate (CFR), age and gender distribution, and the time lapse between the incident and the initiation of Antivenom therapy. The data were also organized considering regional variations of the country. Throughout the studied period, a total of 202,604 cases of envenoming caused by Bothrops spp. were notified, resulting in 766 fatalities. These accidents were found to occur in variable proportions across different regions in Brazil, with notable concentrations observed in the North, Northeast, and Southeast regions. The epidemiological profile of patients varied greatly between the regions, revealing that snake envenoming is much more a social, economic, and ecological problem than a medical one. In conclusion, our study provides an overview of the clinical and epidemiological profile of envenoming by Bothrops snakes in Brazil. Notably, this is the first study to present such information in a country as vast and diverse as Brazil, encompassing a comparative analysis of its regions using SINAN data, that proves to be a very useful national tool to improve the control and management of envenoming.

Prototyping of a lateral flow assay based on monoclonal antibodies for detection of Bothrops venoms

BACKGROUND

Brazil is home to a multitude of venomous snakes; perhaps the most medically relevant of which belong to the Bothrops genus. Bothrops spp. are responsible for roughly 70% of all snakebites in Brazil, and envenomings caused by their bites can be treated with three types of antivenom: bothropic antivenom, bothro-lachetic antivenom, and bothro-crotalic antivenom. The choice to administer antivenom depends on the severity of the envenoming, while the choice of antivenom depends on availability and on how certain the treating physician is that the patient was bitten by a bothropic snake. The diagnosis of a bothropic envenoming can be made based on expert identification of the dead snake or a photo thereof or based on a syndromic approach wherein the clinician examines the patient for characteristic manifestations of envenoming. This approach can be very effective but requires staff that has been trained in clinical snakebite management, which, unfortunately, far from all relevant staff has.

RESULTS

In this article, we describe a prototype of the first lateral flow assay (LFA) capable of detecting venoms from Brazilian Bothrops spp. The monoclonal antibodies for the assay were generated using hybridoma technology and screened in sandwich enzyme-linked immunosorbent assays (ELISAs) to identify Bothrops spp.-specific antibody sandwich pairs. The prototype LFA is able to detect venom from several Bothrops spp. The LFA has a limit of detection (LoD) of 9.5 ng/mL in urine, when read with a commercial reader, and a visual LoD of approximately 25 ng/mL.

SIGNIFICANCE

The work presented here serves as a proof of concept for a genus-specific venom detection kit that could support physicians in diagnosing Bothrops envenomings. Although further optimisation and testing is needed before the LFA can find clinical use, such a device could aid in decentralising antivenoms in the Brazilian Amazon and help ensure optimal snakebite management for even more victims of this highly neglected disease.

Inflammatory Profile Associated with Secondary Infection from Bothrops atrox Snakebites in the Brazilian Amazon

Bothrops snakebite envenomation (SBE) is consider an important health problem in Brazil, where Bothrops atrox is mainly responsible in the Brazilian Amazon. Local effects represent a relevant clinical issue, in which inflammatory signs and symptoms in the bite site represent a potential risk for short and long-term disabilities. Among local complications, secondary infections (SIs) are a common clinical finding during Bothrops atrox SBE and are described by the appearance of signs such as abscess, cellulitis or necrotizing fasciitis in the affected site. However, the influence of SI in the local events is still poorly understood. Therefore, the present study describes for the first time the impact of SBE wound infection on local manifestations and inflammatory response from patients of Bothrops atrox SBE in the Brazilian Amazon. This was an observational study carried out at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus (Brazil), involving victims of Bothrops SBE. Clinical and laboratorial data were collected along with blood samples for the quantification of circulating cytokines and chemokines before antivenom administrations (T0) and 24 h (T1), 48 h (T2), 72 h (T3) and 7 days after (T4). From the 94 patients included in this study, 42 presented SI (44.7%) and 52 were without SI (NSI, 55.3%). Patients classified as moderate envenoming presented an increased risk of developing SI (OR = 2.69; CI 95% = 1.08-6.66, p = 0.033), while patients with bites in hands showed a lower risk (OR = 0.20; CI 95% = 0.04-0.96, p = 0.045). During follow-up, SI patients presented a worsening of local temperature along with a sustained profile of edema and pain, while NSI patients showed a tendency to restore and were highlighted in patients where SI was diagnosed at T2. As for laboratorial parameters, leukocytes, erythrocyte sedimentation ratio, fibrinogen and C-reactive protein were found increased in patients with SI and more frequently in patients diagnosed with SI at T3. Higher levels of circulating IL-2, IL-10, IL-6, TNF, INF-γ and CXCL-10 were observed in SI patients along with marked correlations between these mediators and IL-4 and IL-17, showing a plurality in the profile with a mix of Th1/Th2/Th17 response. The present study reports for the first time the synergistic effects of local infection and envenoming on the inflammatory response represented by local manifestations, which reflected on laboratorial parameters and inflammatory mediators and thus help improve the clinical management of SI associated to Bothrops SBE.

Acute mesenteric ischemia following lancehead snakebite: an unusual case report in the Northernmost Brazilian Amazon

Snakebites have a great impact in the Brazilian Amazon, being the lancehead Bothrops atrox the species responsible for most accidents, disabilities, and deaths. This study shows a case report of an indigenous patient from the Yanomami ethnicity, male, 33 years-old, envenomed by a B. atrox snake. Envenoming caused by B. atrox are characterized by local manifestations (e.g., pain and edema) and systemic manifestations, mainly coagulation disorders. The indigenous victim was admitted in the main hospital of Roraima and evolved with an unusual complication, an ischemia and necrosis of the proximal ileum, requiring segmental enterectomy with posterior side-to-side anastomosis. The victim was discharge after 27 days of hospitalization with no complaints. Snakebite envenomations may evolve with life-threatening complications, which can be treated by the antivenom following access to a healthcare unit, often late in indigenous population. This clinical case shows the need of strategies that aim improvement in the access to the healthcare by indigenous people, as well as demonstrates an unusual complication that may result from lancehead snakebites. The article also discusses the decentralization of snakebites clinical management to indigenous community healthcare centers to mitigate complications.

Ethnobotanical inventory of medicinal plants used by Cashinahua (Huni Kuin) herbalists in Purus Province, Peruvian Amazon

This study aims to document the diversity of medicinal plants used by the Cashinahua people (also known as Huni Kuin) of the Curanja River, as well as describe and compare their uses with pharmacological and phytochemical records from previously published studies. The ethnic has been studied to a limited extent from an ethnobotanical perspective. The study area is located in the Ucayali region, eastern Central Amazon, where ancestral knowledge is preserved due to the limited accessibility of the region. Between November 2010 and June 2015, a total of 11 months were spent on the survey, which included a short-term visit to complete voucher specimen collection and taxonomic identification. We conducted semi-structured interviews with 10 Cashinahua traditional healers and 10 midwives. Vernacular names, ethnomedicinal uses, plant parts used and forms of preparation and administration were recorded. Ethnopharmacological, pharmacological and phytochemical uses were checked through survey of the previously published papers indexed on Web of Science databases between 2018 and 2022. We obtained data on 467 plant taxa, among which we highlighted 79 species unreported or rarely cited for medicinal use or phytochemical analysis. These species were spread over 60 genera and 42 botanical families, with Acanthaceae being the most represented. Leaves were used the most frequently (93.56%). Among the 79 species, the most reported therapeutic activities involved pregnancy and birth disorders (13.84%), followed by poisonings, infections and infestations. The predominant application form was external (87%). Our study indicates that there are locally valuable species that have not yet been studied for their medical potential.

Treatment of a Snakebite Injury With Secondary Bacterial Infection: A Case Study

BACKGROUND

Pit viper snakebites are challenging as they often cause tissue injury and secondary bacterial infection that may impair full recovery of the affected limb. We describe the evolution of a snakebite injury with secondary infection and the use of specialized dressings to achieve tissue repair and complete closure of the wound.

CASE

Ms E., a 45-year-old woman, was bitten by a pit viper that began as a small lesion and progressed to necrosis, cellulitis, edema, and hyperemia of the perilesional skin, local inflammation, and infection. We implemented a combination of topical hydrogel therapy with calcium alginate and hydrofiber with 1.2% silver to promote autolytic debridement, combat local infection, and provide a moist wound environment. The wound required daily local treatment for 2 months due to extensive tissue damage, combined with the proteolytic action of the bothropic venom.

CONCLUSION

The care of wounds caused by snakebites is a challenge for the health care team due to tissue loss resulting from the action of the venom and secondary bacterial infection. Close follow-up with the use of systemic antibiotics and topical therapies proved effective in minimizing tissue loss in this case.

Snakebite envenoming in Brazilian children: clinical aspects, management and outcomes

Snakebite envenoming is currently considered a neglected tropical disease, which affects over 5 million people worldwide, and causes almost 150 000 deaths every year, as well as severe injuries, amputations and other sequelae. Snakebite envenoming in children, although proportionally less frequent, is generally more severe, and represents an important challenge for pediatric medicine, since they often result in worse outcomes. In Brazil, given its ecological, geographic and socioeconomic characteristics, snakebites are considered an important health problem, presenting approximately 30 000 victims per year, approximately 15% of them in children. Even with low snakebite incidence, children tend to have higher snakebite severity and complications due to the small body mass and same venom volume inoculated in comparison to adults, even though, due to the lack of epidemiological information about pediatric snakebites and induced injuries, it is difficult to measure the treatment effectiveness, outcomes and quality of emergency medical services for snakebites in children. In this review, we report how Brazilian children are affected by snakebites, describing the characteristics of this affected population, clinical aspects, management, outcomes and main challenges.

Biological characterization of the Bothrops brazili snake venom and its neutralization by Brazilian Bothrops antivenom produced by the Butantan Institute

We evaluated the ability of the Bothrops antivenom produced by the Butantan Institute to neutralize the lethal, hemorrhagic, myotoxic and phospholipase A₂ activities induced by B. brazili venom from Rondônia state, Brazil, and verified its cross-reactivity against this venom. This antivenom neutralized the cited biological activities. It also showed cross-reactivity with this venom, and preferentially recognized components with a relative mass above 66 kDa. Our results suggest that Brazilian Bothrops antivenom can be used in B. brazili envenomation in this region.

A retrospective study of clinical and epidemiological characteristics of snakebite in Napo Province, Ecuadorian Amazon

BACKGROUND

Snakebite envenoming remains a relevant public health problem in tropical and subtropical countries. In Ecuador, this is particularly true in an area of great diversity like the Amazon region. Nevertheless, there is scarce information about epidemiological and clinical characteristics of these accidents in this area.

METHODS

This was a descriptive and retrospective study of snakebite cases treated at a tertiary hospital in the Napo Province, Ecuadorian Amazon, from 2015 to 2019. We collected sociodemographic and snakebite-related information, clinical aspects and the use of antivenom and antibiotics from medical records.

RESULTS

Information from 133 snakebite accidents was reviewed in this time period. Reports of snakebite envenoming decreased over the years. In total, 67% of those bitten were from nearby indigenous communities, which were the most affected groups. When a species was identified, Bothrops atrox was responsible for the highest number of cases registered. Local clinical manifestations were more frequent than systemic signs, in keeping with the typical effects produced by bothropic venoms. Additionally, data showed that more antivenom vials were given than those suggested by the protocol of the Ecuadorian Ministry of Health, in proportion to the grade of severity. Finally, we identified a low incidence of adverse reactions with antivenom administration, as well as a frequent use of antibiotics.

CONCLUSIONS

The profile of snakebite accidents in the Napo Province is very similar to that described for other localities in the Amazon region of Ecuador and neighboring countries, with its challenges and limitations. Such aspects underlie the importance of establishing a robust and science-based public health program to respond to this frequent, but neglected, tropical disease.

The severity of acute kidney injury correlates with plasma venom levels in Bothrops atrox envenomings

The Brazilian Amazon has high rates of snakebite envenomings (SBEs), with ∼90% caused by Bothrops atrox. Envenomings by this species can trigger local and systemic effects, such as acute kidney injury (AKI). Our aim was to identify predictors of AKI in Bothrops SBEs in patients from Manaus, Western Brazilian Amazon. A total of 127 patients were enrolled, with a predominance of men between 16 and 45 years old from rural areas. Of the 127 patients, 38.6% developed AKI, with 61.2% presenting stage I, 34.7% presenting stage II and 4.1% presenting stage III severity. The age groups 0-10 years and ≥60 years presented a significantly higher frequency of AKI compared to the 11-40 years group. Moderate/severe edema in the affeccted limb was significantly associated with lower risk of AKI [p = 0.01; OR = 0.11 (95%CI 0.02-0.53)]. Nausea [p = 0.01; OR = 54.44 (95%CI = 3.26-909.27)] and high blood urea levels [p = 0.01; OR = 5.38 (95%CI = 2.12-13.66)] were risk factors for AKI. There was a significant positive correlation between circulating venom levels and the highest creatinine serum values during the hospital stay (p = 0.03) and with the difference between the maximum creatinine levels and the creatinine levels on admission (p = 0.02). A positive correlation between serum venom concentrations and creatinine levels suggests a direct or indirect dose-dependent participation of the venom toxins in the pathogenesis of AKI.

Snakebites caused by the genera Bothrops and Lachesis in the Brazilian Amazon: a study of factors associated with severe cases and death

BACKGROUND

Snakebites are a major problem in developing countries owing to their high morbidity rates, severity, and sequelae. In Brazil, most cases of envenomation are caused by Bothrops and Lachesis snakes. The present study aimed to evaluate variables associated with death, systemic complications, and amputations in victims of envenomation due to Bothrops or Lachesis snake.

METHODS

An analytical epidemiological study was performed with data from the Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação [SINAN]) relating to the Brazilian Amazon for the period 2010-2015. A hierarchical Poisson regression analysis was performed with three aspects, namely, individual characteristics, sociodemographic characteristics, and clinical conditions.

RESULTS

The following associations were observed: i) advanced age (>65 years), sepsis, renal failure, and hemorrhagic manifestations were related to two outcomes - death due to snakebite and death from all causes; ii) more advanced age (≥46 years), time to health care longer than 6 hours, renal and hemorrhagic manifestations, and region of occurrence being rural areas were associated with systemic complications; and iii) children (up to 12 years old) were associated with amputations.

CONCLUSIONS

Knowledge of the characteristics associated with severe outcomes in snakebites may help identify patients who will require more intensive care or longer follow-up and may provide the physician with counseling rationale for their possible prognosis.

Cerebral Complications of Snakebite Envenoming: Case Studies

There are an estimated 5.4 million snakebite cases every year. People with snakebite envenoming suffer from severe complications, or even death. Although some review articles cover several topics of snakebite envenoming, a review of the cases regarding cerebral complications, especially rare syndromes, is lacking. Here, we overview 35 cases of snakebite by front-fanged snakes, including Bothrops, Daboia, Cerastes, Deinagkistrodon, Trimeresurus, and Crotalus in the Viperidae family; Bungarus and Naja in the Elapidae family, and Homoroselaps (rare cases) in the Lamprophiidae family. We also review three rare cases of snakebite by rear-fanged snakes, including Oxybelis and Leptodeira in the Colubridae family. In the cases of viper bites, most patients (17/24) were diagnosed with ischemic stroke and intracranial hemorrhage, leading to six deaths. We then discuss the potential underlying molecular mechanisms that cause these complications. In cases of elapid bites, neural, cardiac, and ophthalmic disorders are the main complications. Due to the small amount of venom injection and the inability to deep bite, all the rear-fanged snakebites did not develop any severe complications. To date, antivenom (AV) is the most effective therapy for snakebite envenoming. In the six cases of viper and elapid bites that did not receive AV, three cases (two by viper and one by elapid) resulted in death. This indicates that AV treatment is the key to survival after a venomous snakebite. Lastly, we also discuss several studies of therapeutic agents against snakebite-envenoming-induced complications, which could be potential adjuvants along with AV treatment. This article organizes the diagnosis of hemotoxic and neurotoxic envenoming, which may help ER doctors determine the treatment for unidentified snakebite.

Action of Varespladib (LY-315920), a Phospholipase A2 Inhibitor, on the Enzymatic, Coagulant and Haemorrhagic Activities of Lachesis muta rhombeata (South-American Bushmaster) Venom

Varespladib (VPL) was primarily developed to treat inflammatory disturbances associated with high levels of serum phospholipase A₂ (PLA₂). VPL has also demonstrated to be a potential antivenom support agent to prevent PLA₂-dependent effects produced by snake venoms. In this study, we examined the action of VPL on the coagulant, haemorrhagic and enzymatic activities of Lachesis muta rhombeata (South-American bushmaster) venom. Conventional colorimetric enzymatic assays were performed for PLA₂, caseinolytic and esterasic activities; in vitro coagulant activities for prothrombin time (PT) and activated partial thromboplastin time (aPTT) were performed in rat citrated plasma through a quick timer coagulometer, whereas the dimensions of haemorrhagic haloes obtained after i.d. injections of venom in Wistar rats were determined using ImageJ software. Venom (1 mg/ml) exhibited accentuated enzymatic activities for proteases and PLA₂in vitro, with VPL abolishing the PLA₂ activity from 0.01 mM; VPL did not affect caseinolytic and esterasic activities at any tested concentrations (0.001–1 mM). In rat citrated plasma in vitro, VPL (1 mM) alone efficiently prevented the venom (1 mg/ml)-induced procoagulant disorder associated to extrinsic (PT) pathway, whereas its association with a commercial antivenom successfully prevented changes in both intrinsic (aPTT) and extrinsic (PT) pathways; commercial antivenom by itself failed to avoid the procoagulant disorders by this venom. Venom (0.5 mg/kg)-induced hemorrhagic activity was slightly reduced by VPL (1 mM) alone or combined with antivenom (antivenom:venom ratio 1:3 ‘v/w’) in rats, with antivenom alone producing no protective action on this parameter. In conclusion, VPL does not inhibit other major enzymatic groups of L. m. rhombeata venom, with its high PLA₂ antagonize activity efficaciously preventing the venom-induced coagulation disturbances.

Observation of Bothrops atrox Snake Envenoming Blister Formation from Five Patients: Pathophysiological Insights

In the Brazilian Amazon, Bothrops atrox snakebites are frequent, and patients develop tissue damage with blisters sometimes observed in the proximity of the wound. Antivenoms do not seem to impact blister formation, raising questions regarding the mechanisms underlying blister formation. Here, we launched a clinical and laboratory-based study including five patients who followed and were treated by the standard clinical protocols. Blister fluids were collected for proteomic analyses and molecular assessment of the presence of venom and antivenom. Although this was a small patient sample, there appeared to be a correlation between the time of blister appearance (shorter) and the amount of venom present in the serum (higher). Of particular interest was the biochemical identification of both venom and antivenom in all blister fluids. From the proteomic analysis of the blister fluids, all were observed to be a rich source of damage-associated molecular patterns (DAMPs), immunomodulators, and matrix metalloproteinase-9 (MMP-9), suggesting that the mechanisms by which blisters are formed includes the toxins very early in envenomation and continue even after antivenom treatment, due to the pro-inflammatory molecules generated by the toxins in the first moments after envenomings, indicating the need for local treatments with anti-inflammatory drugs plus toxin inhibitors to prevent the severity of the wounds.

Bleeding and Thrombosis: Insights into Pathophysiology of Bothrops Venom-Related Hemostasis Disorders

Toxins from Bothrops venoms targeting hemostasis are responsible for a broad range of clinical and biological syndromes including local and systemic bleeding, incoagulability, thrombotic microangiopathy and macrothrombosis. Beyond hemostais disorders, toxins are also involved in the pathogenesis of edema and in most complications such as hypovolemia, cardiovascular collapse, acute kidney injury, myonecrosis, compartmental syndrome and superinfection. These toxins can be classified as enzymatic proteins (snake venom metalloproteinases, snake venom serine proteases, phospholipases A₂ and L-amino acid oxidases) and non-enzymatic proteins (desintegrins and C-type lectin proteins). Bleeding is due to a multifocal toxicity targeting vessels, platelets and coagulation factors. Vessel damage due to the degradation of basement membrane and the subsequent disruption of endothelial cell integrity under hydrostatic pressure and tangential shear stress is primarily responsible for bleeding. Hemorrhage is promoted by thrombocytopenia, platelet hypoaggregation, consumption coagulopathy and fibrin(ogen)olysis. Onset of thrombotic microangiopathy is probably due to the switch of endothelium to a prothrombotic phenotype with overexpression of tissue factor and other pro-aggregating biomarkers in association with activation of platelets and coagulation. Thrombosis involving large-caliber vessels in B. lanceolatus envenomation remains a unique entity, which exact pathophysiology remains poorly understood.

Use of freeze-dried trivalent antivenom to neutralize the toxic activities of Bothrops atrox snake venoms from the Amazon

In Brazil, antivenom for snakebite is currently formulated in liquid form and requires storage at 4 °C. Here, a new freeze-dried trivalent antivenom, which would enable cold-chain free storage, was determined to have efficacy in neutralizing the biological activities of Bothrops atrox venoms from Manaus (Brazil) and Leticia (Colombia), exhibiting an efficacy similar to those of currently available liquid Bothrops antivenoms. These results indicate that freeze-dried trivalent antivenom may be beneficial for applications in the Brazilian and Colombian Amazon regions.

Snakebite envenomation in the Brazilian Amazon: a cost-of-illness study

BACKGROUND

Snakebites account for significant morbidity and mortality. Their occurrence in the Brazilian Amazon warrants an analysis that will enable better understanding of their economic impact and thus contribute to their management and prevention. This study aimed to estimate the cost of snakebite envenomation in the Brazilian Amazon in 2015.

METHODS

We conducted a cost-of-illness study of snakebite in the Brazilian Amazon in 2015 based on official surveillance data to estimate burden from a societal, patient and public health system perspective. Direct medical costs were estimated via a top-down approach. Loss of productivity was estimated by a human capital approach.

RESULTS

The study included 11 503 cases and 56 deaths. The estimated cost to the health system was US$3.115.861,28. The estimated cost due to premature death caused by snakebite was US$3031 300.38. The cost attributed to the loss of productivity due to absence from work was US$1539 518.62. The estimated cost from the patient's perspective was US$268 914.18. Therefore the total cost of snakebite in the Brazilian Amazon was estimated to be almost than US$8 million in 2015.

CONCLUSIONS

The economic burden of snakebite in Brazilian Amazon is notably high. Snakebites cause loss of productivity through inpatient treatment or deaths.

Protective action of N-acetyl-L-cysteine associated with a polyvalent antivenom on the envenomation induced by Lachesis muta muta (South American bushmaster) in rats

In this study, we examined the potential use of N-acetyl-L-cysteine (NAC) in association with a polyvalent antivenom and as stand-alone therapy to reduce the acute local and systemic effects induced by Lachesis muta muta venom in rats. Male Wistar rats (300-350 g) were exposed to L. m. muta venom (1.5 mg/kg - i.m.) and subsequently treated with anti-Bothrops/Lachesis serum (antivenom:venom ratio 1:3 'v/w' - i.p.) and NAC (150 mg/kg - i.p.) separately or in association; the animals were monitored for 120 min to assess changes in temperature, locomotor activity, local oedema formation and the prevalence of haemorrhaging. After this time, animals were anesthetized in order to collect blood samples through intracardiac puncture and then euthanized for collecting tissue samples; the hematological-biochemical and histopathological analyses were performed through conventional methods. L. m. muta venom produced pronounced local oedema, subcutaneous haemorrhage and myonecrosis, with both antivenom and NAC successfully reducing the extent of the myonecrotic lesion when individually administered; their association also prevented the occurrence of subcutaneous haemorrhage. Venom-induced creatine kinase (CK) release was significantly prevented by NAC alone or in combination with antivenom; NAC alone failed to reduce the release of hepatotoxic (alanine aminotransferase) and nephrotoxic (creatinine) serum biomarkers induced by L. m. muta venom. Venom induced significant increase of leucocytes which was also associated with an increase of neutrophils, eosinophils and monocytes; antivenom and NAC partially reduced these alterations, with NAC alone significantly preventing the increase of eosinophils whereas neither NAC or antivenom prevented the increase in monocytes. Venom did not induce changes in the erythrogram parameters. In the absence of a suitable antivenom, NAC has the potential to reduce a number of local and systemic effects caused by L. m. muta venom.

A painful journey to antivenom: The therapeutic itinerary of snakebite patients in the Brazilian Amazon (The QUALISnake Study)

Access to antivenoms is not guarranteed for vulnerable populations that inhabit remote areas in the Amazon. The study of therapeutic itineraries (TI) for treatment of snakebites would support strategies to provide timely access to users. A TI is the set of processes by which individuals adhere to certain forms of treatment, and includes the path traveled in the search for healthcare, and practices to solve their health problems. This study aims to describe TIs of snakebite patients in the Brazilian Amazon. This study was carried out at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, state of Amazonas, Brazil. The itinerary from the moment of the bite to the patient's admission to the reference unit was analyzed. Sample size was defined by saturation. After an exploratory survey to collect epidemiological variables, in-depth interviews were conducted following a semi-structured guide. Patients originated from rural areas of 11 different municipalities, including ones located >500 kilometers from Manaus. A great fragmentation was observed in the itineraries, marked by several changes of means of transport along the route. Four themes emerged from the analysis: exposure to snakebite during day-to-day activities, use of traditional therapeutic practices, and personal perception of the severity, as well as the route taken and its contingencies. Access to healthcare requires considerable effort on the part of snakebite patients. Major barriers were identified, such as the low number of hospitals that offer antivenom treatment, poor access to healthcare due to long distances and geographic barriers, low acceptability of healthcare offered in countryside, lack of use of personal protective equipment, common use of ineffective or deleterious self-care practices, late recognition of serious clinical signs and resistance to seeking medical assistance. Health education, promotion of immediate transport to health centers and decentralization of antivenom from reference hospitals to community healthcare centers in the Brazilian Amazon are more effective strategies that would to maximize access to antivenom treatment.

Association of cfDNA levels and bothrops envenomation

In the Amazon, around 90% of snakebites are caused by the Bothrops genus. Complications arising from Bothrops envenomations result from the inflammatory and coagulotoxic activities of the venom. The aim of this study was to investigate the potential of cell-free DNA (cfDNA) as a biomarker of severity in Bothrops snakebites. Patients were treated at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD), Manaus, in the Brazilian Amazon. cfDNA plasma levels were measured by amplifying the human telomerase reverse transcriptase (hTERT) sequence using quantitative RT-PCR. Median levels of cfDNA were compared between envenomed and healthy volunteers and among patients presenting different complications, such as renal failure, bleeding and infection. Of the 76 patients included, 82.9% were male, with a mean age of 32.8 years, and envenomations were mainly classified as severe (39.5%). ROC curve analysis showed a good accuracy of cfDNA levels (AUROC of 0.745) in envenomation diagnosis. A correlation analysis using laboratory variables showed positive correlation with lactate dehydrogenase (p = 0.033) and platelet count (p = 0.003). When cfDNA levels were compared with clinical complications, significant statistical differences were only found among individuals with mild and severe pain (p < 0.05). In summary, our results demonstrated that cfDNA levels are sufficiently accurate for discriminating between envenomed and non-envenomed patients, but are not able to distinguish different complications and the level of severity among envenomed patients. Thus, the role of cfDNA in the pathogenesis of the snakebite envenomations needs to be further investigated.

Envenomation and the bite rate by venomous snakes in the kingdom of Saudi Arabia over the period (2015-2018)

Snakebite being medical emergency and known cause for increased mortality needs assessment and treatment on high-priority bases, even in patients of snakebite who appear fine initially. The current retrospective study presents the snake bites in Saudi Arabia from 2015 to 2018 reported by General Administration of Statistics and Information, Ministry of Health, Kingdom of Saudi Arabia. The data presented in the current study, was extracted, analyzed, and reported after getting ethical approval from institutional committee. Totally, 14,679 cases of snakebites were reported during the four-year study period, with a higher prevalence in males (80%) in their productive age. Most patients were within the age group between 25 and 44 followed by 44 to 64 years. The majority of snakebite affected inhabitants were reported from farms of the rural areas, commonly during night hours of spring and summer seasons when snakes are very active. Only 36 (0.24%) patients out of 14,679 were reported dead and 14,643 (99.63%) were discharged after the treatment. Awareness among the general public should be encouraged and early diagnosis and usage of proper snake antivenoms could be life-saving. The delay in appropriate treatment can lead to significant morbidity and mortality.

Neutralization of hemostatic disorders induced by Lachesis muta venom using Brazilian antivenoms

We characterized the hemorrhagic, coagulant and defibrinogenant activities of Lachesis muta venom and evaluated the capacity of the Brazilian antivenoms in neutralizing these activities. The hemorrhagic activity of L. muta venom was similarly neutralized by Bothrops, Bothrops-Lachesis and Bothrops-Crotalus antivenoms. The coagulant and defibrinogenant activities were better neutralized by the Bothrops-Lachesis antivenom. Bothrops-Crotalus antivenom also neutralized these activities, indicating that it can be an alternative to treat Lachesis envenomations when Bothrops-Lachesis antivenom is unavailable.

Chronic kidney failure following lancehead bite envenoming: a clinical report from the Amazon region

Background:

Snakebite envenoming can be a life-threatening condition, for which emergency care is essential. The Bothrops (lancehead) genus is responsible for most snakebite-related deaths and permanent loss of function in human victims in Latin America. Bothrops spp. venom is a complex mixture of different proteins that are known to cause local necrosis, coagulopathy, and acute kidney injury. However, the long-term effects of these viper envenomings have remained largely understudied.

Case presentation:

Here, we present a case report of a 46-years old female patient from Las Claritas, Venezuela, who was envenomed by a snake from the Bothrops genus. The patient was followed for a 10-year period, during which she presented oliguric renal failure, culminating in kidney failure 60 months after the envenoming.

Conclusion:

In Latin America, especially in Brazil, where there is a high prevalence of Bothrops envenoming, it may be relevant to establish long-term outpatient programs. This would reduce late adverse events, such as chronic kidney disease, and optimize public financial resources by avoiding hemodialysis and consequently kidney transplantation.

Providing Antivenom Treatment Access to All Brazilian Amazon Indigenous Areas: 'Every Life Has Equal Value'

Snakebites are more frequent in the Brazilian Amazon than in other parts of Brazil, representing a high cost for the health system since antivenoms are only available through medical prescription from central municipal hospitals in most cases. The need for a cold chain and physicians usually restricts access to the only effective treatment of a snakebite, the antivenom. The complex topography of the rivers contributes to delays in treatment, and consequently increases the risk of severe complications, chronic sequelae and death. Thus, decentralization of antivenom treatment to primary healthcare facilities in the interior would increase access by indigenous population groups to proper healthcare. To standardize and evaluate the decentralization to low complexity indigenous healthcare units, we suggest the (i) development and validation of standardized operational procedures, (ii) training of professionals in the validated protocol in a referral health unit, (iii) implementation of the protocol in an indigenous healthcare unit, (iv) assessment of perceptions towards and acceptability of the protocol, and (v) estimation of the impact of the protocol's implementation. We expect that antivenom decentralization would shorten the time between diagnosis and treatment and, as such, improve the prognosis of snakebites. As health cosmology among indigenous populations has an important role in maintaining their way of life, the introduction of a new therapeutic strategy to their customs must take into account the beliefs of these peoples. Thus, antivenom administration would be inserted as a crucial therapeutic tool in a world of diverse social, natural and supernatural representations. The information presented here also serves as a basis to advocate for support and promotion of health policy initiatives focused on evidence-based care in snakebite management.

Snakebites in Rio Branco and surrounding region, Acre, Western Brazilian Amazon

INTRODUCTION

Snakebites are considered a neglected tropical disease in many countries in Latin America, including Brazil. As few studies have assessed snakebites in the Amazon region and especially in the state of Acre, epidemiological studies are of great importance. The present study aimed to describe the epidemiological characteristics of snakebites in the Rio Branco region, observing their characteristics in rural and urban areas and their correlation with rainfall and river outflow.

METHODS

This retrospective, descriptive study analyzed epidemiological information obtained from snakebite notifications registered on the Information System for Notifiable Diseases that occurred from March, 2018 to February, 2019. The cases of snakebite were correlated with rainfall and flow.

RESULTS

A total of 165 cases of snakebite were registered in the period. Most cases were caused by Bothrops and affected mainly individuals of the male sex who were between 21 and 30 years old. Most of the snakebites occurred in Rio Branco (71.52%; 29 cases per 100,000 inhabitants). Of these, 60.2% occurred in the urban area and 39.8% in the rural area and the majority occurred during the rainy season.

CONCLUSIONS

Although studies have shown that a majority of cases occur in rural areas, in this study, urbanization of snakebites was observed. The Bothrops genus was responsible for the highest number of snakebites and, during the rainy season, bites occurred more frequently. Educational prevention campaigns, population advice, and first aid in case of snakebites for the population are thus suggested.

A brief review on the natural history, venomics and the medical importance of bushmaster (Lachesis) pit viper snakes

Snakes of the genus Lachesis, commonly known as bushmasters, are the largest venomous snakes in the Americas. Because these snakes have their habitats in areas of remote forests they are difficult to find, and consequently there are few studies of Lachesis taxa in their natural ecosystems. Bushmasters are distributed in tropical forest areas of South and Central America. In Brazil they can be found in the Amazon Rainforest and the Atlantic Forest. Despite the low incidence of cases, laquetic envenoming causes severe permanent sequelae due to the high amount of inoculated venom. These accidents are characterized by local pain, hemorrhage and myonecrosis that can be confused with bothropic envenomings. However, victims of Lachesis bites develop symptoms characteristic of Lachesis envenoming, known as vagal syndrome. An important message of this bibliographic synthesis exercise is that, despite having the proteomic profiles of all the taxa of the genus available, very few structure-function correlation studies have been carried out. Therefore the motivation for this review was to fill a gap in the literature on the genus Lachesis, about which there is no recent review. Here we discuss data scattered in a number of original articles published in specialized journals, spanning the evolutionary history and extant phylogeographic distribution of the bushmasters, their venom composition and diet, as well as the pathophysiology of their bites to humans and the biological activities and possible biotechnological applicability of their venom toxins.

Bothrops atrox, the most important snake involved in human envenomings in the amazon: How venomics contributes to the knowledge of snake biology and clinical toxinology

Bothrops atrox snakes are mostly endemic of the Amazon rainforest and is certainly the South American pit viper responsible for most of the snakebites in the region. The composition of B. atrox venom is significantly known and has been used to trace the relevance of the venom phenotype for snake biology and for the impacts in the clinics of human patients involved in accidents by B. atrox. However, in spite of the wide distribution and the great medical relevance of B. atrox snakes, B. atrox taxonomy is not fully resolved and the impacts of the lack of taxonomic resolution on the studies focused on venom or envenoming are currently unknown. B. atrox venom presents different degrees of compositional variability and is generally coagulotoxic, inducing systemic hematological disturbances and local tissue damage in snakebite patients. Antivenoms are the effective therapy for attenuating the clinical signs. This review brings a comprehensive discussion of the literature concerning B. atrox snakes encompassing from snake taxonomy, diet and venom composition, towards clinical aspects of snakebite patients and efficacy of the antivenoms. This discussion is highly supported by the contributions that venomics and antivenomics added for the advancement of knowledge of B. atrox snakes, their venoms and the treatment of accidents they evoke.

Fatal Rattlesnake Envenomation in Northernmost Brazilian Amazon: A Case Report and Literature Overview

Snakebite envenomations are classified as Category A Neglected Tropical Diseases by the World Health Organization. In Brazil, 405 snake species are distributed among 11 families, with the genera Bothrops and Crotalus being the most studied and main responsible for severe and lethal envenomations. In the country, Crotalus genus (i.e., rattlesnakes) is represented by Crotalus durissus species, showing seven different subspecies distributed along the country, including Crotalus durissus ruruima, which inhabits Roraima, the Brazilian nothermost state from Amazon forest. Here, we report a fatal case of a severe envenomation following a rattlesnake bite. The patient presented classic crotalic neurological signs and symptoms such as ptosis, drooling of saliva, sluggishness, macroscopic hematuria, and oliguria, which evolved to acute kidney failure (AKF) and hemodynamic instability. Although the patient was treated with the specific antivenom therapy, the severe envenomation resulted in three cardiac arrests and death of the victim in less than 38 h. This study discusses the causes of the patient death, the features of rattlesnake venom-induced AKF, and shows evidences that the Brazilian crotalic antivenom should be improved to treat rattlesnake envenomations caused by C. d. ruruima venom in Roraima state.

Ethno-knowledge and attitudes regarding snakebites in the Alto Juruá region, Western Brazilian Amazonia

BACKGROUND

The Alto Juruá region, located in the extreme western part of the Brazilian Amazonia, possesses an indigenous and riverine population which is involved in agricultural and forest extraction activities, and is a region that stands out for its high incidence of snakebites.

OBJECTIVES

To assess the attitudes of the victims, the characteristics of the snakes and the circumstances of the snakebites which occurred in a region where human populations are highly exposed to snakes.

METHODS

The study was conducted at the Regional Hospital of Juruá in the Municipality of Cruzeiro do Sul (Acre), which regularly attends victims of snakebites in the Alto Juruá region. The snakes that caused the envenomations were identified from clinical and epidemiological diagnosis of the symptoms and signs that patients presented during hospital, and by enzyme immunoassay for venom detection using serum samples of the patients, or by identification of the snake responsible for the envenomation when it was taken to the hospital or photographed. People who suffered or witnessed the snakebite were interviewed to assess the circumstances of the bite, the attitude adopted after the accident and whether they recognized the species of snake that caused the envenomation.

RESULTS

There were 133 cases of snakebite (76.24/100.000 inhabitants), mainly involving male individuals living in the rural area and who had a low level of education. The most affected groups were farmers (48%) and children and teenagers (39%). It was observed that 8.3% of them presented a history of recurrence for bites. The lower limbs were the most affected anatomical region (84%). The Bothrops atrox snake, mainly small specimens (mostly juveniles), was the main species involved in the envenomations (83.4%). Snakebites occurred mainly in forest areas, backyards of houses in rural areas and near to aquatic environments, during activities (walking, farming, extractivism, hunting). Most of the time, the snake was on the ground and the bite occurred because of the approximation of the individual, either by trampling or by approximation of a hand. Half of the victims performed some kind of inadequate first aid (not drinking water, use of tourniquet, incision at the site of the bite, use of black stone, drinking a compound "Específico Pessoa").

CONCLUSIONS

Snakebite is an important cause of morbidity in the Alto Juruá region. Bothrops bites are mostly caused by small-sized specimens, probably due to the greater abundance of B. atrox juveniles, and also because small snakes are more difficult for people to see. People are more often bitten on the lower limbs probably due to the size of B. atrox (small and medium) and because the snakes are usually on the ground in most situations. Many victims resort to ineffective actions that can cause complications and also delay serotherapy. A low level of education is a factor that may contribute to worse outcomes in snakebites since it is associated with a lack of knowledge of preventive and first aid measures.

Lectin isolated from Bothrops jararacussu venom induces IL-10 release by TCD4+ cells and TNF-α release by monocytes and natural killer cells

BjcuL is a C-type lectin isolated from Bothrops jararacussu snake venom with specificity for binding β-d-galactose units. BjcuL is not toxic to human peripheral blood mononuclear cells (PBMCs), but it inhibits PBMC proliferation and stimulates these cells to produce superoxide anions and hydrogen peroxide primarily via lymphocyte stimulation; it does not stimulate the production of nitric oxide and PGE₂ . The purpose of this study was to investigate the effect of BjcuL on PBMC activation with a focus on cytokine release modulating PBMC proliferation. The results showed for the first time that BjcuL coupled to FITC interacted with monocytes, B cells, natural killer (NK) cells, and with subpopulations of T cells. These cell-cell interactions can lead to cell activation and inflammatory cytokines release, such as IL-6 and TNF-α, as well as the anti-inflammatory cytokine IL-10. In addition, TNF-α release was attributed to NK cells and monocytes, whereas IL-10 was attributed to TCD4⁺ and Treg cells when stimulated by BjcuL. The temporal cytokines profile produced by cells when stimulated with this lectin allows us to assert that BjcuL has immunomodulatory activity in this context.