Picadura de escorpión en Bolivia: una revisión crítica de la literatura

Las picaduras son frecuentes y se consideran un verdadero problema de salud pública. Objetivo: describir las especies de escorpiones, propiedades del veneno, fisiopatología, manifestaciones clínicas, diagnóstico y su manejo en la unidad de cuidados intensivos. Metodología: se realizó una búsqueda de la literatura en las bases de datos SciELO, LILACS, Scopus, PubMed-MedLine, Google Académico, así como en los servicios ClinicalKeys, se extrajo la información relevante, se seleccionaron aquellos estudios de tipo serie de casos, artículos originales o revisiones narrativas, de alcance y sistemáticas. Desarrollo: en Bolivia, fue descrita la especie Tityus (Tityus) sorataensis. El 66 al 90 por ciento de las picaduras tienen signos y síntomas limitados a dolor local, parestesias y cambios en la piel. Los efectos sistémicos se hacen evidentes a los 30 minutos y por lo general, dentro de las cuatro horas posteriores a la picadura. El tratamiento puede ser empírico, aplicar medidas generales, manejo del dolor y si está presente algunas complicaciones como edema pulmonar, choque cardiogénico es necesario su manejo en una sala de cuidados intensivos. Conclusiones: la intoxicación por picadura de escorpión, es rara, es un reto terapéutico, parece ser recomendable la administración del antídoto (antiveneno) junto al tratamiento de sostén. un mejor conocimiento de los escorpiones, puede alentar el interés en realizar nuevas investigaciones.

Bites are frequent and are considered a real public health problem. Objective: describe the species of scorpions, properties of the venom, pathophysiology, clinical manifestations, diagnosis and its management in the intensive care unit. Methodology: a literature search was carried out in the SciELO, LILACS, Scopus, PubMed-MedLine, Google Scholar databases, as well as in the ClinicalKeys services, in the period February-April 2023. Relevant information was extracted, They selected case series studies, original articles or narrative, scoping and systematic reviews. Development: in Bolivia, the species Tityus (Tityus) sorataensis was described. 66 to 90 percent of bites have signs and symptoms limited to local pain, paresthesias, and skin changes. Systemic effects become apparent within 30 minutes and generally within four hours of being bitten. The treatment can be empirical, apply general measures, pain management and if some complications are present such as pulmonary edema, cardiogenic shock, it is necessary to manage it in an intensive care room. Conclusions: Scorpion sting poisoning is rare, it is a therapeutic challenge, it seems to be advisable to administer the antidote (antivenoin) together with supportive treatment. a better understanding of scorpions may encourage interest in further research.

Epidemiological characterization of ophidian accidents in a Colombian tertiary referral hospital. Retrospective study 2004-2014 / Caracterización epidemiológica de accidentes ofídicos en un hospital de tercer nivel en Colombia. Estudio retrospectivo 2004-2014

Abstract Introduction: In Colombia, there are 5 000 cases of ophidism per year. This is a public health issue that causes mortality in 8% of cases and disability in 10% due to inadequate clinical attention. Objective: To describe the clinical and epidemiological characteristics of patients diagnosed with ophidic accident in a tertiary hospital in Colombia. Materials and methods: A review of clinical charts that included a diagnosis of ophidism during the 2004-2014 period was made at Hospital Universitario de La Samaritana Empresa Social del Estado. The frequency of the variables associated with snake bites, previous treatment and in-hospital management was analyzed. Results: 42 medical charts were reviewed. Ophidism predominated in male farmers, who presented with bites in the lower limbs and were initially treated by medicine men/women. 90% of patients developed superinfections, 30% wound culture, 74% received antibiotics, 50% underwent fasciotomy and 95.2% were given antivenin. Conclusions: Significant variability in the management of patients, discrepancy in antivenin dose and in classification of poisoning severity were observed throughout the study, as well as a high incidence of infections despite antibiotic schemes and surgical procedures. Medical management of ophidic accidents must be continuously updated to reduce disability and mortality in patients.

Resumen Introducción. En Colombia se presentan 5 000 casos de ofidismo anuales, un problema de salud pública que por manejo inadecuado provoca mortalidad en el 8% de los casos y discapacidad en el 10%. Objetivo. Describir las características clínicoepidemiológicas de los pacientes diagnosticados con accidente ofídico en un hospital de tercer nivel en Colombia. Materiales y métodos. Se realizó una revisión de las historias clínicas con diagnóstico de ofidismo del Hospital Universitario De La Samaritana Empresa Social del Estado, en el período 2004-2014, analizando la frecuencia en las variables asociadas a la mordedura de serpiente, el tratamiento previo y el manejo intrahospitalario. Resultados. Se revisaron 42 historias clínicas. Predominó el ofidismo en hombres agricultores, con mordedura en miembros inferiores y asistidos inicialmente por curanderos. 90% de los pacientes presentó sobreinfección, 30% tuvo cultivo de la herida, 74% recibió antibiótico, al 50% se les realizó fasciotomía y al 95.2% se le suministró antiveneno. Conclusiones. Se evidenció variabilidad en el manejo de los pacientes y discrepancia en la dosis de antiveneno y la clasificación de severidad del envenenamiento, alta incidencia de infecciones a pesar del esquema antibiótico y procedimientos quirúrgicos reevaluados en ofidismo. El manejo médico del accidente ofídico debe estar en continua actualización para disminuir discapacidad y mortalidad en los pacientes.

Sueros antiofídicos en colombia: análisis de la producción, abastecimiento y recomendaciones para el mejoramiento de la red de producción / Anti-ophidic sera in colombia: analysis of production, supply, and recommendations for the improvement of the production network

RESUMEN La ofidiotoxicosis o accidente ofídico es un evento frecuente en Colombia. En el país hay dos familias de serpientes de importancia clínica y epidemiológica, las víboras y las corales. Para el tratamiento de la ofidiotoxicosis es obligatoria la utilización de la terapia antivenenosa; los sueros son fabricados a partir de inmunoglobulinas de caballo, estos productos a pesar de que fueron descubiertos hace más de 100 años todavía hoy están en constante cambio. Hoy su industria requiere ser altamente tecnificada, con procesos de eficacia, seguridad y con altos estándares de calidad en Colombia. Los sueros antiofídicos no son productos químico-farmacéuticos, son biológicos, por lo tanto no se caracterizan por su composición química sino por sus propiedades terapéuticas, estos se clasifican en monovalentes y polivalentes, que según su composición física permite neutralizar diferentes tipos de venenos. En el país existen dos productores nacionales (Instituto Nacional de Salud y Laboratorios Probiol) y uno importado de México (Bioclon); la capacidad neutralizante y calidad varía según su composición y proceso de fabricación asociado a la cantidad de proteínas y agregados que influenciarán en el tipo y cantidad de reacciones adversas al medicamento. Se pretende contextualizar al lector en el proceso de fabricación, en la problemática de la escasez y calidad de los sueros antiofídicos en Colombia, dando valoración de conceptos y presentando fundamentos teóricos que aporten a esta temática, además de opinar sobre sobre la actual coyuntura por la escasez de este producto en Colombia.

ABSTRACT Ophidiotoxicosis or snake accident is a recurring event in Colombia. There are two snake families of epidemiological and clinical importance in the country, vipers and coral snakes. For the snake poisoning treatment, the use of anti-poisonous therapy is mandatory. The sera are manufactured with horse immunoglobulins. Even though these products were discovered more than 100 years ago, still today are constantly changing. Today its industry in Colombia requires a high technification, with processes of efficiency, safety, and high-quality standards. The anti snake sera are not chemical-pharmaceutical products; they are biological products. Therefore, they are not characterized by their chemical composition, but by their therapeutic properties. They are classified as monovalent and polyvalent that, depending on their physical composition, allow neutralizing different kinds of poisons. There are two domestic producers in Colombia (Instituto Nacional De Salud and Probiol Laboratories), and imports are done with a producer from Mexico (Bioclon). The neutralizing capacity and quality vary depending on their composition and manufacturing process associated with some proteins and aggregates, which will influence the type and number of adverse reactions to the medicine. This article intends to contextualize the reader in the manufacturing process, in the problem of scarcity and quality of anti-snake sera in Colombia, providing a valuation to concepts and presenting theoretical foundations that contribute to this issue, and besides, commenting on the current situation of the country because of the shortage of this product.

Ação cardiovascular da peçonha de Bothrops atrox em ratos anestesiados / Cardiovascular response to Bothrops atrox snake venom in anesthetized rats

Bothrops atrox (jararaca-do-norte) é a principal causa de envenenamento ofídico na região amazônica. Vários estudos têm investigado a bioquímica desta peçonha, bem como os efeitos locais (dor, edema, hemorragia e mionecrose) que ela causa. Por outro lado, os efeitos sistêmicos têm sido menos estudados. Neste trabalho, investigamos as alterações hemodinâmicas causadas por esta peçonha em ratos anestesiados bem como os possíveis mediadores envolvidas nestas respostas. Métodos: Ratos machos Wistar (300-400 g) anestesiados com isoflurano foram canulados para o registro da pressão arterial (carótida) e para a administração intravenosa (i.v.) de diferentes substâncias (peçonha, antagonistas e inibidores) (veia femoral esquerda). Em alguns experimentos, houve administração intramuscular (i.m.) de peçonha. A frequência respiratória foi determinada manualmente e o ECG foi monitorado via eletrodos introduzidos nas patas dianteiras e traseira. Em intervalos pré-estabelecidos, foram coletadas amostras de sangue arterial para análise bioquímica e determinação da cinética da peçonha. Ao término dos experimentos, foram coletados tecidos (rim, pulmão, coração, fígado e músculo) para análise histológica. A capacidade do antiveneno botrópico comercial em neutralizar algumas atividades enzimáticas e as alterações hemodinâmicas foi avaliada pré-incubando-se a peçonha com antiveneno antes de testar a atividade residual. A peçonha também foi fracionada por gel filtração e os picos testados quanto à sua atividade sobre a pressão arterial. Resultados: A peçonha (0,4 mg/kg, i.v.) causou hipotensão imediata (máxima aos 5 min) seguida por recuperação nos 20 min seguintes; não houve alteração na frequência cardíaca, ECG ou frequência respiratória, e não houve mortes (sobrevida até o final do experimento: 120 min). Uma dose maior (0,7 mg/kg, i.v.) causou hipotensão progressiva, bradicardia e falência respiratória, com morte de todos os ratos (n=6) em 20±4 min. A administração intramuscular (músculo gastrocnêmio) de peçonha (4 mg/kg) mostrou um perfil hemodinâmico semelhante àquele observado com a dose menor i.v. A análise histológica mostrou que a dose menor i.v. causou trombose e hemorragia pulmonares, além de dano renal (descamação epitelial, deposição proteica e microaneurismos); houve proteinúria e hemoglobinúria em urina coletada no final do experimento. Não houve alteração histológica nos outros tecidos examinados (fígado, coração)...(AU)

Bothrops atrox (jararaca-do-norte) is the main cause of snakebite in the Amazon region. Various studies have examined the biochemical aspects of this venom, as well as local effects such as pain, edema, hemorrhage and myonecrosis that this species causes. In contrast, the systemic effects caused by this venom have been less studied. In this work, we investigated the hemodynamic alterations caused by B. atrox venom in anesthetized rats, as well as the possible mediators involved in this response. Methods: Male Wistar rats (300-400 g) anesthetized with isoflurane were cannulated for arterial blood pressure measurements (carotid artery) and for the intravenous (i.v., femoral vein) administration of test substances (venom, antagonists and inhibitors). In some experiments, venom was injected intramuscularly (i.m.). Respiratory rate was determined manually and ECG was monitored using conventional electrodes. At pre-established intervals, arterial blood was drawn for biochemical analyses and determination of venom kinetics. At the end of the experiments, tissue samples were collected from heart, liver, lung and muscle for histological analysis. The ability of commercial bothropic antivenom to neutralize selected venom enzymatic activities and the venom-induced hemodynamic alterations was assessed by preincubating venom with antivenom prior to testing for residual activity. Venom was also fractionated by gel filtration and the resulting peaks were screened for their activity on blood pressure. Results: Venom (0.4 mg/kg, i.v.) caused immediate hypotension (maximal at 5 min) followed by recovery over 20 min; there were no changes in heart rate, ECG or respiratory rate and no deaths (survival for up to 120 min post-venom). A higher dose of venom (0.7 mg/kg, i.v.) caused progressive hypotension, bradycardia and respiratory failure, with all rats (n=6) dying in 20±4 min. A similar hemodynamic profile to the lower dose of venom i.v. was seen with venom (4 mg/kg) given i.m. (gastrocnemius muscle). Venom given i.v. (lower dose) caused pulmonary thrombosis and hemorrhage, in addition to renal damage (epithelial desquamation, deposition of protein and microaneurysms); proteinuria and hemoglobinúria were observed in urine collected at the end of the experiment. Venom given i.m. or i.v. (higher dose) caused only pulmonary thrombosis. Renal damage (epithelial desquamation, proteinuria and hemoglobinuria) was seen with venom i.v. (0.4 mg/kg); venom given i.m. caused local hemorrhage and necrosis, and proteinuria. There were no histological alterations in the other tissues examined (heart, liver)... (AU)

Does the traditional snakebite severity score correctly classify envenomated patients?

OBJECTIVE: This study aims to help set domestic guidelines for administration of antivenom to envenomated patients after snakebites. METHODS: This retrospective observational case series comprised 128 patients with snake envenomation. The patients were divided into two groups according to the need for additional antivenom after the initial treatment based on the traditional snakebite severity grading scale. One group successfully recovered after the initial treatment and did not need any additional antivenom (n=85) and the other needed an additional administration of antivenom (n=43). RESULTS: The group requiring additional administration of antivenom showed a higher local effect score and a traditional snakebite severity grade at presentation, a shorter prothrombin and activated partial prothrombin time, a higher frequency of rhabdomyolysis and disseminated intravascular coagulopathy, and longer hospitalization than the group that did not need additional antivenom. The most common cause for additional administration was the progression of local symptoms. The independent factor that was associated with the need for additional antivenom was the local effect pain score (odds ratio, 2.477; 95% confidence interval, 1.309 to 4.689). The optimal cut-off value of the local effect pain score was 1.5 with 62.8% sensitivity and 71.8% specificity. CONCLUSION: When treating patients who are envenomated by a snake, and when using the traditional snakebite severity scale, the local effect pain score should be taken into account. If the score is more than 2, additional antivenom should be considered and the patient should be frequently assessed.

Does the Traditional Snakebite Severity Score Correctly Classify the Envenomated Patients with Snake?

PURPOSE: The aim of this study was to help set the domestic guidelines for administration of antivenom to envenomated patients with snake. METHODS: This retrospective observation case series comprised 128 patients with a snake envenomation. The patients were divided into two groups according to the need for additional antivenom after the initial treatment strategy based on the traditional snakebite severity grading scale; one group recovered successfully with the initial treatment decision and did not require an additional antivenom (N=85) and the other group required an additional administration of antivenom later (N=43). RESULTS: The group requiring additional administration of antivenom showed a higher local effect score and traditional snakebite severity grading at presentation, a shorter prothrombin and activated partial prothrombin time, a higher frequency of rhabdomyolysis and disseminated intravascular coagulopathy, and longer hospitalization than the group that did not require an antivenom later. The most common cause of additional administration was the progression of local symptoms. The independent factor associated with the need for additional antivenom administration was a local effect scoring of pain score (odds ratio, 2.477; 95% confidence interval, 1.309 to 4.689). The optimal cut off value of local effect scoring of pain was 1.5 with 62.8% sensitivity and 71.8% specificity. CONCLUSION: The local effect scoring of pain should be considered when treating patients who are envenomated with a snake using the traditional snakebite severity scale. If the local effect scoring of pain is more than 2, an increase of antivenom should be considered and the patients should be assessed frequently.

Application of Downey classification used in the diagnosis and treatment of children's snakebite / 中华实用儿科临床杂志

Objective To analyze the application of Downey classification and to improve the diagnosis and treatment for children bitten by venomous snakes.Methods The consecutive 76 snakebite children were treated according to the guidance of Downey classification in Children's Hospital of Chongqing Medical University from Jan.2005 to Dec.2011.Their epidemiological and clinical characteristics,treatment and outcomes were reviewed and analyzed.The Chinese traditional classification method was adopted to classify children of snakebites as a contrast at the same time,and the correlation of the 2 methods was studied.Correlations in Downey level,treatment time,length of hospital stay,osteofascial compartment syndrome (OCS) and the occurrence of myocardial damage were studied respectively.Results The 76 cases of snakebites all occurred from Apr.to Nov.,the time of injuries focused on the period of 18:01 to 00:00 (60 cases,78.94％),and limbs were the main injury parts(73 cases,96.05％).According to Downey's system,patients of grade 0 were 3 cases (3.95 ％),grade Ⅰ were 9 cases (11.84％),grade Ⅱ were 26 cases (34.21％),grade Ⅲ were 30 cases (39.47 ％),and grade Ⅳ were 8 cases (10.53 ％).All children victims were given comprehensive and symptomatic treatment,in which 74 cases were clinically cured and 2 cases were disabled,but no deaths.There was positive correlation between the traditional classification method and Downey classification method (r=0.85,P ＜ 0.05),and there was also positive correlation between treatment time and length of hospital stay (r =0.91,P ＜ 0.05).There was positive correlation between Downey level and OCS,the occurrence of myocardial damage,treatment time and length of hospital stay(r =0.90,0.95,0.48,0.96,respectively,all P ＜ 0.05).Conclusions The diagnosis and treatment were more specified after using the Downey classification,snake venom poisoning in children is a medical emergency requiring immediate attention,early diagnosis and proper treatment can reduce its fatality and disability rate.

Optimal Dose of Antivenin for Asymptomatic or Minor Envenomation Patient with Korean Viperidae Injuries

PURPOSE: The aim of this study was to evaluate the feasibility and safety of our antivenin treatment protocol for patients with Korean Viperidae envenomation. METHODS: We developed an antivenin treatment protocol for Korean Viperidae envenomation, based on previous data, and applied this treatment to the enrolled patients. In brief, antivenin was not used for patients with grade 0. Patients with grade I and II received one vial of antivenin. Those with grade III and IV received two and three vials of antivenin, respectively. Adult patients who visited the emergency department (ED) after receiving a snakebite between July 2008 to August 2010 were included. Follow ups were performed at 24 hours, 7 days, and 28 days after the snakebite. RESULTS: A total of 62 patients were enrolled. At the initial evaluation, 6 patients (9.7%) were grade 0, 47 patients (75.8%) were grade I, and 9 patients (14.5%) were grade II. Upon the follow-up evaluation, 14 patients (29.8%) progressed from grade I to grade II and 2 patients (22.2%) progressed from grade II to III. Coagulopathy developed in 5 patients (8.0%) and rhabdomyolysis in 5 patients (8.0%). Urticaria developed in 2 patients (3.2%) and cellulitis in 3 patients (4.8%) as delayed complications. As an antivenin-related complication, serum sickness developed in only 1 patient (1.6%). There were no severe complications and all clinical and laboratory abnormalities disappeared within 28 days. CONCLUSION: Our antivenin treatment protocol was feasible and safe. To confirm our data, multicenter validation studies are needed.

Variaciones en las actividades enzimáticas del veneno de la serpiente Bothrops atrox "jergón", de tres zonas geográficas del Perú / Variation of the enzymatic activity of Bothrops atrox "jergon" snake venom from three geographic regions, Peru

Objetivos. Estudiar la variabilidad en la composición y actividades enzimáticas entre venenos de ejemplares adultos de Bothrops atrox. Materiales y métodos. Se emplearon venenos de serpientes adultas procedentes de Amazonas, Junín y Ucayali. A cada una de las muestras se les realizó el análisis del contenido proteico y del número de bandas por PAGESDS, así como las actividades de fosfolipasa A2, hemolítica indirecta, amidolítica, coagulante, hemorrágica y proteolítica sobre caseína y mediante zimograma; además, se hicieron ensayos de inmunodifusión y neutralización in vitro con el suero antibotrópico polivalente del Instituto Nacional de Salud de Perú. Resultados. Las actividades amidolítica, coagulante, hemorrágica, proteolítica mediante zimograma, fosfolipasa A2 y hemolítica indirecta fueron variables, evidenciándose en las tres últimas una mayor actividad en los venenos de Amazonas, mientras que en la cantidad de proteína, bandas electroforéticas y actividad proteolítica sobre caseína no se observaron diferencias. Con respecto a las pruebas de neutralización, 0,5 dosis del antiveneno fueron suficientes para neutralizar con eficacia (más del 50%) la actividad coagulante y fosfolipasa A2 de todas las muestras analizadas. Conclusiones. Algunas propiedades biológicas del veneno de ejemplares adultos de Bothrops atrox de Perú son variables, sin que ello afecte la neutralización in vitro por parte del suero antibotrópico polivalente sobre las actividades coagulante y fosfolipasa A2 del veneno.

Objectives. To study the variability in the composition and enzymatic activity of venom from adult Bothrops atrox specimens. Materials and methods. We used venoms from adult snakes from Amazonas, Junín and Ucayali. Each of the venom samples underwent analysis for protein and number of bands by pagesds. Phospholipase A2, hemolytic, amidolytic, coagulant, hemorrhagic activity were analyzed, also and proteolytic activity on casein and by zymogram. Additionally, immunodiffusion and neutralization assays in vitro were done with a polyvalent botropic serum from the national institute of health of Peru. Results. The amidolytic, coagulant, hemorrhagic, proteolytic by zymogram, phospholipase A2, and indirect hemolytic activity were variable, demonstrating increased activity in the venoms from Amazonas, regarding proteolytic by zymogram, phospholipase A2, and indirect hemolytic activity. While the amount of protein electrophoretic bands and proteolytic activity on casein did not demonstrated differences. Regarding neutralization tests, a 0.5 dose of antivenom was sufficient to effectively neutralize (>50%) the coagulant activity and phospholipase A2 of all samples analyzed. Conclusions. Some biological properties of the venom from adult Bothrops atrox of Peru are variable, without interference with the in vitro neutralization by the polyvalent botropic serum on coagulant and phospholipase A2 properties of the venom.

Eficacia experimental de anticuerpos IgY producidos en huevos, contra el veneno de la serpiente peruana Bothrops atrox / Experimental efficacy of IgY antibodies produced in eggs against the venom of the Peruvian snake Bothrops atrox

Objetivos. Desarrollar un protocolo de inmunización para producir inmunoglobulinas IgY de origen aviar contra el veneno de la serpiente peruana Bothrops atrox y evaluar la capacidad neutralizante. Materiales y métodos. Se inmunizaron seis gallinas de postura de la raza hy line brown con 500 μg/dosis de veneno de B. atrox en un periodo de dos meses. Cada semana, los huevos fueron colectados para el aislamiento de inmunoglobulinas IgY a partir de la yema, usando dos pasos consecutivos con αcido caprνlico y sulfato de amonio. La detecciσn de anticuerpos se realizσ por inmunodifusiσn doble mientras que el tνtulo y reactividad cruzada se determinaron por las técnicas de ELISA y Western blot. El cálculo de DL50 y de la DE50 del antiveneno IgY producido se realizó utilizando el método de Probits. Resultados. La masa de anticuerpos aislados fue de 8,5 ± 1,35 mg de IgY/mL de yema. Asimismo, la DE50 del antiveneno aviar fue calculada en 575 μL de antiveneno/mg de veneno. Adicionalmente, los ensayos de reactividad cruzada mostraron que el veneno de B. atrox comparte mas epνtopes comunes con el veneno de B. brazili (47%) que con otros veneno del mismo género, en tanto que los venenos de Lachesis muta (19%) y Crotalus durissus (12%) mostraron una baja reactividad cruzada. Conclusiones. Se ha obtenido IgY purificada contra el veneno de B. atrox con capacidad neutralizante y se ha demostrado su utilidad como herramienta inmunoanalítica para evaluar la reactividad cruzada con venenos de otras especies.

Objectives. To develop an immunization protocol in order to produce avian IgY immunoglobulins against Bothrops atrox Peruvian snake venom and to evaluate its neutralizing capacity. Materials and methods. Six Hy Line Brown hens were immunized each two weeks using 500μg/doses of B. atrox venom in a period of two months. Each week, eggs were collected for IgY isolation from yolk using two consecutive steps with caprilic acid and ammonium sulfate. Detection of IgY anti-B. atrox were performed by double immunodiffusion, whereas title and cross-reactivity were analyzed using ELISA and Western Blot technics, respectively. Furthermore, letal dose (DL50) and Medium Effective Dose (DE50) were obtained by Probit analysis. Results. As a result of this protocol, chicken IgY’s were obtained in a concentration of 8,5 ± 1,35 mg/yolk mL. DE50 from avian antivenom was 575 μL/venom mg. Cross-reactivity studies showed Bothrops atrox venom share more commom epitopes with Bothrops brazili (47%) than others Bothrops venoms showing Lachesis muta (19%) and Crotalus durissus (12%) venoms a low crossing reactivity, instead. Conclusions. Using this procedure, we could purify chicken IgY with a neutralizant capacity of B. atrox venom which is comparable to the antivenom of equine origin and demonstrate its capacity as a immunoanalitical tool to evaluate the cross reactivity with others peruvian snakes.

Acidentes por serpentes e utilização de soroterapia antipeçonhenta / Accidents by snakes and use of anti-ophidic serotherapy

O objetivo do estudo é caracterizar a utilização de soroterapia antipeçonhenta (SAP) em acidentes por serpentes registrados em um Centro de Informação e Assistência Toxicológica. Estudo documental, descritivo, cuja população foi de indivíduos com diagnóstico médico de acidente por serpente, com indicação de SAP, cadastradas no Centro de Controle de Intoxicações do Hospital Universitário de Maringá (HUM), no período de janeiro de 2007 a dezembro de 2009. As fontes de dados foram a Ficha de Acidentes por Animais Peçonhentos e o prontuário do paciente para os casos atendidos no HUM. Analisaram-se variáveis referentes ao acidentado e ao acidente, e dados da soroterapia. Foram registrados 103 acidentes, com administrações de SAP em 40 (39%) casos. A indicação da maioria das soroterapias foi baseada em critérios clínicos, laboratoriais e epidemiológicos, sendo o gênero Bothrops spp. o maior causador de acidentes e responsável pelos acidentes graves. O tempo de coagulação e a dosagem de uréia e creatinina foram os exames laboratoriais mais realizados. O atendimento inicial aos acidentados ocorreu em tempo inferior a 120 minutos para 35 (87%) casos, no entanto, a soroterapia ocorreu em tempo inferior a cinco horas em metade (20 ? 50%) dos acidentes. Não houve relato de reação adversa, e as doses de soros administradas foram semelhantes ao estabelecido pelo Ministério da Saúde. O estudo da SAP permitiu compreender os fatores de risco dos acidentes por serpentes, avaliar a qualidade da utilização da soroterapia, e auxiliar na elaboração de ações de prevenção e tratamento deste tipo de evento.

The aim of this study was to characterize the use of anti-ophidic serotherapy (AOS) in accidents caused by snakes registered at a Toxicology Information and Assistance Center. It was a documental, descriptive study made of individuals with medical diagnosis of snakebite with indication for AOS, registered at the Center for intoxication Control from Maringá State University?s Hospital (HUM), from January 2007 to December 2009. The sources of data were both the accident files and the patient?s records for the ones seen at HUM. Variables were analyzed for the accident itself as well as the person involved, and serotherapy data. A hundred and three (103) episodes using AOS in 40 (39%) of the cases were recorded. The indication of serotherapy for most of them was based on clinical, laboratorial and epidemiological criteria. Bothrops spp. genera was the causing agent of most accidents as well as the most serious ones. The coagulation time and urea and creatinine levels were the most performed lab tests. The initial treatment for the individuals occurred in less the 120 minutes for 35 (87%) cases, however, the serotherapy occurred in less than 5 hours in half of the accidents (20 ? 50%). There was no report of adverse reactions, and the used serum doses were similar to the ones applied by the Health Ministry. The AOS study allowed to understand the snakebite risk factors, evaluate serotherapy use quality, and help in both the elaboration of preventive actions and treatment in this type of occurrence.

Ceguera bilateral y manifestaciones hemato-neurológicas producidas durante un accidente botrópico / Bilateral blindness and hematoneurological signs after bothropic bite

Agricultor de 20 años, procedente de San Miguel de Callería (Ucayali- Perú: selva nor-oriental a 842 km de Lima), mordido por una serpiente Bothrops spp, en el tobillo izquierdo, quien pese a recibir 18 horas después una única infusión de 25 mg de suero antiofídico polivalente desarrolla desde las primeras horas dolor, edema, equimosis de pierna izquierda, gingivorragia, hematuria, oliguria, cefalea, alteraciones de la conciencia, afasia, disartria, signos meníngeos, amaurosis, hemiparesia del hemicuerpo derecho, paresia de músculos oculomotores a predominio izquierdo y midriasis paralítica bilateral. Retinografía bilateral: discos retinales ópticos pálidos y vasos sanguíneos adelgazados. Respuestas visuales evocadas: ausentes, bilateral. Tomografía (TEM), cerebral: hemorragia intracerebral parieto-occipital izquierda. Resonancia magnética (RM) de vías ópticas: inflamación y tortuosidad del trayecto de ambos nervios ópticos, a predominio derecho. 50 días después del accidente botrópico, aunque el paciente camina solo, no ve nada con el ojo derecho, mientras que con el ojo izquierdo ve personas como sombras.

20 years old farmer, coming from San Miguel of Calleria (Ucayali, Perú: north-eastern jungle 842 km from Lima), bitten by a Bothrops spp snake in his left ankle, who in spite of receiving 18 hours later a unique infusion of 25 mg of antisnake polyvalent serum, develops from the first hours pain, edema and swelling of his left ankle, upward bruising of his left leg, oral bleeding, hematuria, oliguria, headache, altered consciousness, aphasia, dysarthria, meningeal signs, amaurosis, hemiparesis of his right body, ocular muscle paresis to left predominance and bilateral paralytic mydriasis. Bilateral Retinography: pale optic disc and thinned retinal blood vessels. Visual evoked response: absent waves, bilaterally. Brain Tomography (TEM): left parieto-occipital intrabrain hemorrhage. Magnetic resonance imaging (MRI), of optic pathways: inflammation and pathÆs tortuosity of both optic nerves, to right predominance. 50 days after the bothropic accident, although the patient walk alone, he does not see anything with the right eye while with the left eye sees people as shadows.

Perfil epidemiológico dos acidentes ofídicos no município de Juiz de Fora-MG no período de 2002-2007 / Epidemiologic profile of snakebite in Juiz de Fora - MG

Os acidentes causados por serpentes peçonhentas representam problema de Saúde Pública, especialmente em países tropicais. Este estudo retrospectivo-descritivo estabeleceu o perfil dos acidentes causados por serpentes, ocorridos no período de janeiro de 2002 a dezembro de 2007, no município de Juiz de Fora/MG, notificados pela vigilância Epidemiológica local. Os dados foram analisados como auxílio do software Statistical Package for the Social Sciences(SPSS) versão 14.0. Para o georreferenciamento dos dados,foi utilizada uma base cartográfica no formato shapeflie(shp) da zona urbana de Juiz de Fora inserida no softwareArcGIS 9.2. Foram notificados 294 acidentes, dos quaisa maioria na zona rural (64,3%), no período de outubro a março de cada ano (71,0%). Os indivíduos acometido seram principalmente do sexo masculino (76,8%), na faixa etária entre 16 e 60 anos (57,8%) . O gênero Bothrops foi o responsável por 68,0% dos casos, sendo os membros inferiores os mais atingidos (64,3%). Quanto ao tratamento, a soroterapia foi aplicada na maioria dos casos (71,3%) e de maneira satisfatória. Juiz de Fora apresentou um número elevado de acidentes neste período, apesar de se tratar de um município com predominância de população urbana.

Accidents caused by poisonous snakes are still a publichealth problem, especially in tropical countries. This retrospective descriptive study established the profile ofaccidents caused by snakes occurring from January 2002 to December 2007, in Juiz de Fora / MG, reported by local epidemiologic surveillance. Data were analyzed using version14.0 of the Statistical Package for the Social Sciences(SPSS) software. A shapeflie (shp) cartographic base of theurban area of Juiz de Fora was inserted into the softwareArcGIS 9.2 software for georeferencing of the data. 294accidents were reported, the majority in rural areas (64.3%)in the period from October to March of each year (71.0%).The affected individuals were primarily male (76.8%) andaged between 16 and 60 years (57.8%). The genus Bothropswas responsible for 68.0% of cases and the lower limbswere the most affected site (64.3%). Antivenom was satisfactorily applied in most cases (71.3%). Juiz de Fora hada high number of accidents in this period, although it is acity with a predominantly urban population.

Epitope analysis of cDNA sequences of Deinagkistrodon acutus snake venom metalloproteinases and observation of their immune protective effects / 第二军医大学学报

Objective: To analyze the epitopes of cDNA sequences of Deinagkistrodon acutus snake venom metalloproteinases using bioinformatical method, and to observe the immune protective effect of the new immunogen designed according to the identified epitopes. Methods: The cDNA sequences of Deinagkistrodon acutus snake venom metalloproteinases were amplified by PCR. The epitopes of the sequences were analyzed by Jameson-Wolf method and Clustal X software, then the sequences of the screened epitopes were artificially synthesized and linked to the vector pIRESneo. BALB/c mice were immunized by the resultant plasmid at 0, 2, and 4 weeks for three times, then the titers of the anti-serum were measured by ELISA. The immune protective effects of the anti-serum were tested by the neutralization of venom hemorrhagic activity and venom attacking test. Results: Bioinformatical analysis yielded 6 epitopes ( MPA-1-MPA-6). The ELISA results of anti-serum showed that these epitopes could induce immune reaction in mice, and the anti-serum was detectable even when it was diluted to 1:100. The neutralization test and venom attacking test demonstrated that the anti-serum induced by the epitodes could neutralize the venom and protect the mice from haemorrhage. Conclusion: Six epitopes of Deinagkistrodon acutus snake venom metalloproteinases have been obtained successfully using bioinformatical method, and the new immunogen designed based on these epitopes shows a primary immune protective effect.

Clinical Significance of Delayed re-evaluation in Initial Symptoms Following Snakebite Injury

PURPOSE: Antivenin is a standard therapy in snakebite victims. While the required antivenin dose can be easily estimated, based on the initial symptoms, this strategy may be unsuccessful if the initial symptoms progressively worsen. The purpose of this study was to identify the progression rate of the initial symptoms following snakebite and its associated factors. METHODS: The medical records of 44 patients treated for snakebite from give the actual dates of the study period were retrospectively examined. Thirty-two of these patients were enrolled. Demographic data, local wound grade and local effect score at initial presentation (G-0 and LES-0, respectively) and 12 hours after admission (G-12 and LES-12, respectively) were reviewed, along with laboratory data. RESULTS: The 32 patients had an average age of 54.0+/-14.5 years and were predominantly male (n=26) and presented mainly during summer. Compared to G-0 and LES-0, re-evaluated G-12 and LES-12 were significantly increased despite initial administration of proper antivenin dosage (p=0.001 and p=0.000, respectively). Total amounts of antivenin correlated with LES-12 (correlation co-efficiency 0.558, p<0.05). However, factors associated with symptom progression were not revealed. CONCLUSION: Initial snakebite symptoms might progressively worsen within hours despite acceptable initial antivenin therapy. Therefore, re-evaluation within several hours must be considered if when the initial snakebite symptoms are minimal or mild.

A Case Report of Snake bites During Pregnancy

Snake bite during pregnancy is rare condition, and when it occurs there are two patients, mother and fetus. Timing is particularly important for pregnant women bitten by a snake. The earlier in the pregnancy the bite occurs, the more hazard to the fetus there is, and there are case reports of snake-bite-induced abortion and malformation of the fetus. The usefulness of antivenin during pregnancy is debatable. We report a case of snake bite during thirdtrimester pregnancy in a patient with general symptoms of envenomation and progressing edema in the bitten leg who was successfully treated with an emergency Caesarian section following the administration of antivenin.

Envenenamento por serpentes do gênero Bothrops no Estado da Bahia: aspectos epidemiológicos e clínicos / Envenomation by Bothrops in the State of Bahia: epidemiological and clinical aspects

Descreve-se características clínico-epidemiológicas de 655 casos de acidentes botrópicos atendidos e/ou notificados ao Centro de Informações Antiveneno da Bahia, no Estado da Bahia, em 2001. A incidência anual no Estado foi de 5,0 acidentes/100.000 habitantes e a letalidade, 1 por cento. A incidência foi máxima na microrregião Litoral Norte (21,9/100.000 habitantes) e no município de Itanagra (92,9/100.000 habitantes). Os acidentes foram predominantemente diurnos, acometendo membros inferiores, em homens, de 11-30 anos, trabalhadores, no ambiente rural e no período chuvoso. Atendimento médico após 13 horas da ocorrência da picada ocorreu em 19 por cento dos casos. Predominaram os quadros clínicos moderados (47,8 por cento), seguidos dos graves (23,6 por cento). As manifestações clínicas locais e sistêmicas seguiram o padrão nacional para as serpentes do gênero Bothrops. Sintomatologias neurológicas, não usualmente atribuídas ao acidente botrópico, foram registrados em alguns casos. A soroterapia empregada (7,7 ampolas/paciente) foi compatível com o fato da maioria de casos serem moderados. Outros tipos de soro que não o univalente foram utilizados em 15 (2,3 por cento) pacientes.

This study describes the clinical and epidemiological characteristics of 655 cases of Bothrops snakebites that were attended by and/or notified to the Bahia Antivenin Information Center, State of Bahia, Brazil, in 2001. The annual incidence in the State was 5.0 cases/100,000 inhabitants and lethality was 1 percent. The incidence was greatest in the North Coast microregion (21.9/100,000 inhabitants) and the municipality of Itanagra (92.9/100,000 inhabitants). The snakebites occurred predominantly during the day, affecting the lower limbs of men aged 11-30 years who worked in rural areas during the rainy period. Medical care was obtained more than 13 hours after the snakebite in 19 percent of the cases. Moderate (47.8 percent) and severe (23.6 percent) clinical presentations prevailed. The local and systemic clinical manifestations followed the usual pattern for Bothrops snakebites in Brazil. However, a few cases presented neurological manifestations, which are not usually attributed to Bothrops snakebites. The antivenin therapy used (7.7 blisters/patient) reflected the fact that the majority of the cases were moderate. Antivenins other than the univalent type were used in 2.3 percent of the cases.

The Effectiveness of Antivenin in Treating Snake Bites Resulting in Minimal Clinical Symptoms

PURPOSE: Serious complications from snake bite envenomization are relatively rare in Korea. According to standrad treatment guidelines for local and systemic injuries, antivenin is not recommended for snake bite cases when victims show minimal clinical symptoms. However, there are no published stidies about the effectiveness of antivenin treatment in such cases in Korea. In order to provide actual documentation to support a standard for treatment, we evaluated the effectiveness of antivenin use by comparing clinical outcomes in snake bite patients exhibiting minimal clinical symptoms (traditional snake bite severity grades 0 and I). METHODS: We retrospectively reviewed 140 snake bite cases of patients with minimal clinical symptoms who visited the emergency departments of Chungnam National University Hospital, Cheonan Medical Center, and Chungnam Seosan Medical Center in Korea from January 2000 to December 2006. We categorized the patients into antivenin (group 1) and non-antivenin (group 2) treatment groups. We compared clinical outcomes and characteristics of the two groups. RESULTS: Neither demographic factors nor clinical outcomes showed statistical significance between the groups. CONCLUSION: In case of snake bite victims in Korea, antivenin treatment should not generally recommended as treatment for victims exhibiting minimlal clinical symptoms.

A case of Severe Snake Bites of the Genus Agkistrodon for Pediatric Patients: A Case Report

Venomous snakes are estimated to inflict 400,000 bites annually, resulting in approximately 40,000 deaths. There are nearly 3,500 known species of snakes worldwide, and three species exist in Korea. Venom contains toxins that effect the cardiovascular system, the kidneys, the respiratory system and the muscles. There are many modalities in treating snake bites, but most of all, neutralization of the venom is the most important. however, many doctors in Korea hesitate in using antivenom. The reason is that there are no specific antivenoms against Korean venous snakes. In this case, a 2-year-old female child with a snake bite vistied our hospital Korea via a local clinic. Severe systemic symptoms and local symptoms, including compartment syndrome, were observed. When we tried antivenom, the result was satisfactory.