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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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An Atypical Clinical Manifestation of a Hump-Nosed Pit Viper Envenomation. Case Rep Med 2019; 2019:4172395. [PMID: 31073311 PMCID: PMC6470431 DOI: 10.1155/2019/4172395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/12/2019] [Accepted: 03/21/2019] [Indexed: 11/18/2022] Open
Abstract
Envenomations by hump-nosed pit vipers (HNVs) are frequent in Sri Lanka and in South India. Until recently, HNV was considered a moderately venomous snake. Here, we report a case of a previously healthy female developing all the known serious complications, plus some previously unreported complications following a HNV envenomation. She had muscarinic symptoms like profuse sweating and salivation within a couple of minutes and a seizure several minutes after envenomation. Her acute kidney injury (AKI) was swift onset and progressed to end-stage renal failure at three months. She had mild parotid swelling, crepitations in her lungs, and edema of the bitten leg. She had evidence of microangiopathic hemolytic anemia and hemolytic uremic syndrome as well. She developed local tissue necrosis, a non-ST-elevation myocardial infarction (non-STEMI), and anterior ischemic optic neuropathy (AION) following the envenomation. We believe the best explanation for her swift onset complication is intravascular injection of venom. We believe ischemia due to thrombotic microangiopathy has contributed to local tissue necrosis. Those ischemia and kidney failure have contributed to non-STEMI and AION. We illustrate the issue of the sluggish progress made by medicine in understanding the complications of envenomation by using HNV as an example.
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Debono J, Bos MHA, Coimbra F, Ge L, Frank N, Kwok HF, Fry BG. Basal but divergent: Clinical implications of differential coagulotoxicity in a clade of Asian vipers. Toxicol In Vitro 2019; 58:195-206. [PMID: 30930232 DOI: 10.1016/j.tiv.2019.03.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 03/27/2019] [Accepted: 03/27/2019] [Indexed: 01/06/2023]
Abstract
Envenomations by Asian pitvipers can induce multiple clinical complications resulting from coagulopathic and neuropathic effects. While intense research has been undertaken for some species, functional coagulopathic effects have been neglected. As these species' venoms affect the blood coagulation cascade we investigated their effects upon the human clotting cascade using venoms of species from the Azemiops, Calloselasma, Deinagkistrodon and Hypnale genera. Calloselasma rhodostoma, Deinagkistrodon acutus, and Hypnale hypnale produced net anticoagulant effects through pseudo-procoagulant clotting of fibrinogen, resulting in weak, unstable, transient fibrin clots. Tropidolaemus wagleri was only weakly pseudo-procoagulant, clotting fibrinogen with only a negligible net anticoagulant effect. Azemiops feae and Tropidolaemus subannulatus did not affect clotting. This is the first study to examine in a phylogenetic context the coagulotoxic effects of related genera of basal Asiatic pit-vipers. The results reveal substantial variation between sister genera, providing crucial information about clinical effects and implications for antivenom cross-reactivity.
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Affiliation(s)
- Jordan Debono
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD 4072, Australia
| | - Mettine H A Bos
- Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Francisco Coimbra
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD 4072, Australia
| | - Lilin Ge
- Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, Macau; State Key Laboratory Cultivation Base for TCM Quality and Efficacy, School of Pharmacy, Nanjing University of Chinese Medicine, 138 Xianlin Avenue, Qixia District, Nanjing 210046, China
| | | | - Hang Fai Kwok
- Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, Macau.
| | - Bryan G Fry
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, QLD 4072, Australia.
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