Cases Of Envenomation Research Articles

Diagnosis and Treatment of Snake Envenomation in Dogs in Queensland, Australia.

Australia has some of the most venous snakes in the world, and envenomations of domestic dogs are common, but clinical signs as well as the diagnostic procedures and treatments of snake envenomations are poorly described. Therefore, we invited veterinary clinics in the state of Queensland, Australia, to provide detailed data on snake envenomation cases in dogs. A total of 230 cases were reported from 19 veterinary hospitals, with an average of 12.1 dogs per clinic, per year. Detailed case data were provided from 20 dogs—of these, 65.0% (13/20) were envenomated during the daytime, with collapse and paresis being the most common signs reported by owners. The median time between the onset of clinical signs and admission to the veterinary hospital was 60 min. Clinical signs were the sole diagnostic modality utilised by veterinarians in 30.0% (6/20) of cases. Activated clotting time was the most common diagnostic procedure conducted, while snake venom detection kits (SVDK) were only used in 15.0% (3/20) of cases. Of the dogs that received antivenom (85.0%, 17/20), the tiger/multibrown combination (3000 units tiger/4000 units brown) was predominately (13/17) provided. Three of the 17 dogs that received antivenom (17.6%) died or were euthanised. About 82.4% (14/17) of the dogs treated with antivenom, but only 33.3% (1/3) of the dogs not treated with antivenom, recovered (p = 0.140). Overall, veterinarians relied frequently on medical history, clinical signs, and diagnostic tests other than the SVDK and, thus, most likely, administered snake envenomation treatment based on their clinical experience.

New Data on Two Subspecies of Mesobuthus eupeus, the Most Medically Important Scorpion Species in Northwestern Iran.

Scorpions are among the most medically important arthropods in Iran, particularly northwestern areas. To date, five scorpion species, i.e. Mesobuthus eupeus, Mesobuthus caucasicus, Androctonus crassicauda, Hottentotta saulcyi, and scorpio maurus, have been identified. The family Buthidae is responsible for most cases of scorpionism in Iran. The Mesobuthus eupeus species belong to this family and is commonly distributed from Turkey to China, including Iran. Among these species, Mesobuthus eupeus is regarded as the most medically important species and responsible for most cases of envenomation in this area. Morphological differences between some species collected in the study area have been reported. The present study, thus, aimed to identify the subspecies of Mesobuthus eupeus in northwestern Iran. Scorpions were captured in the summer months from 37 localities in three northwestern provinces in Iran: West Azerbaijan, East Azerbaijan, and Ardabil. Scorpion collection was carried out using rock rolling and ultraviolet methods. A total of 376 specimens of Mesobutus eupeus (177males and 199 females) were collected and identified as Mesobuthus eupeus (98.4%) and Mesobuthus eupeus philippovitschi (1.6%). Owing to the findings of our study, M.e.philippovitschi has been added to the scorpion fauna of northwestern parts of Iran for the first time. Unlike M.e. eupeus which is widely distributed from plains to mountainous regions, M.e.philippovitschi has limited distribution and is found mostly along the borders with neighboring countries. This subspecies is the most medically important and most prevalent one in the region. The findings of the present study also provide the basis for future consideration of regional antivenom production for this medically important species.

King Cobra and snakebite envenomation: on the natural history, human-snake relationship and medical importance of Ophiophagus hannah.

King Cobra (Ophiophagus hannah) has a significant place in many cultures, and is a medically important venomous snake in the world. Envenomation by this snake is highly lethal, manifested mainly by neurotoxicity and local tissue damage. King Cobra may be part of a larger species complex, and is widely distributed across Southeast Asia, southern China, northern and eastern regions as well as the Western Ghats of India, indicating potential geographical variation in venom composition. There is, however, only one species-specific King Cobra antivenom available worldwide that is produced in Thailand, using venom from the snake of Thai origin. Issues relating to the management of King Cobra envenomation (e.g., variation in the composition and toxicity of the venom, limited availability and efficacy of antivenom), and challenges faced in the research of venom (in particular proteomics), are rarely addressed. This article reviews the natural history and sociocultural importance of King Cobra, cases of snakebite envenomation caused by this species, current practice of management (preclinical and clinical), and major toxinological studies of the venom with a focus on venom proteomics, toxicity and neutralization. Unfortunately, epidemiological data of King Cobra bite is scarce, and venom proteomes reported in various studies revealed marked discrepancies in details. Challenges, such as inconsistency in snake venom sampling, varying methodology of proteomic analysis, lack of mechanistic and antivenomic studies, and controversy surrounding antivenom use in treating King Cobra envenomation are herein discussed. Future directions are proposed, including the effort to establish a standard, comprehensive Pan-Asian proteomic database of King Cobra venom, from which the venom variation can be determined. Research should be undertaken to characterize the toxin antigenicity, and to develop an antivenom with improved efficacy and wider geographical utility. The endeavors are aligned with the WHO´s roadmap that aims to reduce the disease burden of snakebite by 50% before 2030.

Cardiotoxicity of Naja nubiae snakebites: A review and consideration

Snake bites are considered as one of the serious challenges facing people living in areas near the place of those snakes’ habitat. Antivenin treatment though being the gold standard against expected toxicities, is not always present especially when toxicology centers are out of reach during cases of acute envenomation and injuries. Nubian spitting cobra or Naja nubiae is known to be major threat of hematological and cardiac toxicities in Upper Egypt. Although the main characteristic of its venom is being neurotoxic, cardiotoxicity due to high content of cardiotoxins and generation of reactive oxygen species is profound in cases of toxicity by envenomation. This review highlights the structure of cardiotoxins as the main component of Naja nubiae venom and lists different possible cardiotoxicities associated with it especially myocardial infarction and myocarditis. As well as possible future recommendations for those who are in risk of inhabiting or travelling to where these snakes are found.

Children’s poisoning profile during the Covid-19 pandemic – Experience of Hassan II University Hospital in Fez, MOROCCO

Introduction. —The Covid-19 pandemic and the containment situation, has generated enormous risks for children. Indeed, with the closure of schools, children, forced to stay at home, found themselves in permanent contact with dangerous products (drugs, disinfectants, plants) exposing them to accidental poisoning. Objective. —To describe the epidemiological, clinical and evolutionary aspects of the cases of pediatric intoxications in the UHC during the period of Covid-19, in order to assess the repercussions of this pandemic on the profile of these intoxications, in terms of number and incriminated products. Material and method. — This is a retrospective descriptive comparative study of intoxication cases admitted to the pediatric emergency department of the University Hospital of Fez spread over 2 years; from March 1, 2019 to February 2021; comparing intoxications admitted during the period of Covid-19 with the previous year. Results. — The emergency department recorded 132 cases of intoxication during the Covid-19 period (compared to 104 cases in 2019). Fez was always the most concerned city (66.21% against 69.02% in 2019). The cases emanated from the urban environment in (58.78%). The accidental circumstance was the most frequent, with an increase from 77.88% in 2019 to 82.02%. The rate of cases of envenomation that consulted was almost similar; children are more exposed to scorpion stings (73.52%) than snake bites. The analysis of incriminated products was marked by the increase of Caustics (20.38% in 2019 to 24.24% in 2020), and the decrease of pesticides (19.41% in 2019 to 13.63%). The symptomatology was dominated by neurological signs in 25.75% of cases, followed by respiratory disorders (18.18%). The evolution was favorable in 95.46%, and death occurred in 4.54% of cases compared to 3.84% in2019. The Covid-19 pandemic has changed the use of antidotes.

Epidemiology of accidents involving venomous animals in the State of Ceará, Brazil (2007-2019).

INTRODUCTION: Envenomation remains a neglected public health problem in most tropical countries. Epidemiological studies on accidents caused by venomous animals are scarce in the Northeast region of Brazil, mainly in the state of Ceará. The present study aimed to describe the epidemiological features of envenomation cases involving venomous animals in the State of Ceará, Northeastern Brazil, from 2007 to 2019. METHODS: The online Notifiable Diseases Information System was consulted for data on all envenomation cases involving venomous terrestrial animals. Data collected were evaluated for the number of accidents/year, number of accidents/zoological group, antivenom therapy, zone of occurrence, sex, age-group distribution, and deaths. RESULTS: A total of 54,980 cases were recorded, with the highest incidence being that of scorpion stings (67.2%), predominantly in women (52.4%; odds ratio=3.6; 95% confidence interval=3.5-3.8), equally affecting people aged 10-19 years and 40-59 years (21.4%), in the urban areas (odds ratio=10.3; 95% confidence interval=9.9-10.8), especially in the rainy months. Snakebites (16.7%) had an incidence of 8.1/100,000 inhabitants, but the highest case-fatality rates were observed in bee stings (1.3%) and spider bites (0.5%). Regarding therapeutic variables, a small percentage of people had access to serotherapy (5.3%). CONCLUSIONS This study highlights the accidents caused by terrestrial venomous animals as a public health problem that must be monitored in Ceará. Thus, our findings suggest that preventive actions against scorpion and bee stings should be intensified during the months of higher incidence to improve public policies for patient care.

Rapid and Accurate Species-Specific PCR for the Identification of Lethal Chironex Box Jellyfish in Thailand.

Box jellyfish are extremely potent venom-producing marine organisms. While they have been found worldwide, the highest health burden has been anticipated to be the tropical Indo-Pacific of Southeast Asia (SEA). At least 12 Cubozoan species have now been documented in Thai waters, and many of them inflict acutely lethal strings, especially those under the order Chirodropida. Our previous study has successfully differentiated species of box jellyfish using DNA sequencing to support the morphological study. In this study, we specifically designed polymerase chain reaction (PCR) primers for the 16S ribosomal RNA (rRNA) gene and the mitochondrial DNA cytochrome oxidase subunit I (COI) gene of lethal Thai Chironex species. The SYBR green-based real-time PCR panel was performed for rapid species identification. The sensitivity and specificity of the panel were determined by testing samples of different species. Moreover, we applied the panel to the tentacle sample from a real patient, which helped confirm the animal-of-cause of envenomation. Our results show a success for species identification of box jellyfish using 16S rRNA and COI PCR panel, which revealed congruence between molecular and morphological identification. Furthermore, the panel worked very well with the unknown samples and jellyfish tissue from the real envenomation case. The results demonstrated that molecular panels were able to identify three species of Chironex box jellyfish both rapidly and accurately, and can be performed without having a complete specimen or morphological study.

Hypertensive encephalopathy with locked-in syndrome mimicking brain death: An unusual case of Krait envenomation with literature review.

Introduction: Neuroparalytic snake bite is a serious life-threatening hazard all over the world, especially in tropical countries of South-East Asia. But it is one of the most neglected tropical diseases. Patients can present with envenomation signs without a history of snakebite or an identifiable bite mark. Apart from neuroparalysis, symptoms of autonomic dysfunction can also be seen with krait envenomation. Case Report: 11-year-old girl presented with early morning sudden onset altered sensorium. On examination found to have absent spontaneous respirations, severe hypertension, dilated pupils, and absent brainstem reflexes, so labeled as probable brain death. Later with control of hypertension, she was able to respond by blinking but had severe neuroparalysis. There was no evidence of snakebite but with a strong suspicion of krait envenomation, anti-snake venom was given empirically and continued ventilatory support, following which child had a complete recovery. Discussion: As the majority of krait bites occur during sleep and due to its painless nature, they often go unnoticed. Also, krait bite leaves very fine puncture marks and the local reaction is markedly absent, so fang marks couldn’t be easily identified. Autonomic dysfunction following krait envenomation can present as abdominal pain, vomiting, sweating, mydriasis, fluctuation of heart rate and blood pressure, and paralytic ileus. In severe krait envenomation, complete paralysis of all voluntary muscles leads to quadriplegia and anathria which resembles locked-in syndrome. Locked-in syndrome when associated with internal ophthalmoplegia can mimic brain death. Conclusion: Snakebite should be considered in the differential diagnosis of unexplained neuroparalysis and hypertension. Envenomation should not be excluded by the absence of a history of snakebite or identifiable bite mark.

Severe local envenoming and mild coagulopathy following green pit viper (<em>Trimeresurus trigonocephalus</em>) bite in Sri Lanka

Green pit viper (Trimeresurus trigonocephalus) is considered a potentially highly venomous arboreal endemic pit viper which inhabits Sri Lanka. Green pit viper bites usually result in local envenoming and systemic envenoming features like coagulopathy are rare. We report an authenticated case of green pit viper envenoming which resulted in severe local inflammation which was associated with mild coagulopathy.

Envenoming by the rattlesnake Crotalus durissus ruruima in the state of roraima, Brazil.

The aim of this study was to evaluate the clinical-epidemiological factors associated with victims of rattlesnake envenoming in the state of Roraima, Brazil. In this location, rattlesnake accidents are caused by the subspecies Crotalus durissus ruruima. This is a prospective observational study carried out at the General Hospital of Roraima from april 2017 until july 2018. A total of 37 alleged rattlesnake victims had their medical records evaluated. However only one of them proved to be by C. d. ruruima. All individuals were residents from the savannas (lavrados) of Roraima. The town of Bonfim on the border between Brazil and Guyana had the highest occurrence of rattlesnake bites. The most affected group were males aged 13–20 years and farmers. The highest number of incidents occurred during daytime and lower limbs (feet) were the most major affected part of the body. Tourniquets were used as first aid after snake envenoming in 32.4% of victims. Out of 37 patients, 16.2% were classified as severe cases of snakebite envenoming and in 5.4% dry bites seem to have occurred. Among the symptomatic patients, 100% presented local manifestations and 70.3% presented systemic manifestations. The clinical setting showed local effects such as pain and edema while the systemic effects were blurred vision, myalgias, myasthenic facies, palpebral ptosis, muscle weakness and headache. Laboratory results of aspartate aminotransferase (62.2%), creatine phosphokinase (51.3%), lactic dehydrogenase (37.8%), urea level (32.4%) and serum creatinine (29.7%) were increased significantly in relation to the reference standards. In 16.2% of the cases, the victims presented acute kidney injury. Patients were treated with anticrotalic serum in 70.3% of the cases and antibotropic + anticrotalic serum in 24.3%. The victims of C. d. ruruima in Roraima showed a local symptomatology similar to Bothrops envenoming, while systemic symptoms and laboratory analysis proved kidney and muscular injuries, similar to envenoming by Crotalus d. terrificus in Brazil.

A study on clinical profile, management and outcome in pediatric patients admitted with scorpion envenomation

Background: Scorpion envenomation is a common medical emergency. The main aim is to study clinical profile, management and outcome.Methods: Prospective observational study of Scorpion envenomation cases for six months. case sheets were analysed for clinical profile, symptoms, complications, management and outcome.Results: During the study period first 50 cases were admitted and treated for the following results 66% were males and 34% were females, 46% were upper extremity and 54% were lower extremity. common clinical symptoms are pain at site, autonomic storm, palpitation, headaches, abdominal pain, altered sensorium, vomiting. 40% of patients received prazosin with 1-2 hrs. the major complications were myocarditis, encephalopathy, Peripheral circulatory failure & congestive cardiac failure. There was no mortality in this study.Conclusions: The study finding shows that early and effective use of prazosin treatment showed good outcome in patients. Less complications were seen in patients those who received the first aid. This study concludes that majority of patient were exposed to complication due to shortfall in education, awareness and pre-hospitalization. We, as a clinical pharmacist, tried to create awareness and provide education to health care workers in all primary health care center through distributing pamphlets to general public in and around hospital.

Severe acute kidney injury following Sri Lankan Hypnale spp. envenoming is associated with thrombotic microangiopathy

Context Acute kidney injury (AKI) is the most serious clinical manifestation of the Sri Lankan hump-nosed pit viper (Hypnale spp.) bites. Thrombotic microangiopathy (TMA) is increasingly recognized in association with AKI in cases of Hypnale spp envenomation. We investigated AKI in a cohort of cases of Hypnale envenomation, its association with TMA and the early diagnostic value of common biomarkers for AKI occurring. Materials and methods We conducted a prospective observational study of suspected viper bites and included 103 confirmed cases of Hypnale envenomation, based on venom specific enzyme immunoassay of blood. AKI was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Thrombotic microangiopathy was diagnosed based on thrombocytopenia (platelet count < 150,000 × 103/μL) and microangiopathic haemolytic anaemia (MAHA). We investigated the diagnostic performance of creatinine, platelet count and INR for AKI within 4 h and 8 h post-bite by area under the receiver operator characteristic curve (AUC–ROC). Results Ten patients developed AKI: seven AKI stage 1 and three AKI stage 3. Ten patients (10%) developed thrombocytopaenia while 11 (11%) had MAHA. All three AKI stage 3 had thrombocytopaenia and MAHA fulfilling the criteria for TMA. Two of them presented with oliguria/anuria and all three required haemodialysis. Serum creatinine within 4 h post-bite was the best predictor of AKI with AUC-ROC of 0.83 (95% CI: 0.67–0.99) and was no better within 8 h of the bite. Conclusions We found that AKI is uncommon in Hypnale spp. envenomation, but an important serious complication. Severe AKI was associated with TMA. A creatinine within 4 h post-bite was the best predictor of AKI.

Epidemiology, Clinical Features, and Management of Texas Coral Snake (Micrurus tener) Envenomations Reported to the North American Snakebite Registry.

Few of the 5000-8000 snakebites reported to poison control centers annually in the USA are attributed to coral snakes. This study describes Texas coral snake envenomations reported to the North American Snakebite Registry. All Texas coral snake envenomation cases reported to the registry were identified for the period from January 1, 2015, through December 31, 2019. Data reviewed for this study included details regarding the snake encounter, patient demographics, signs and symptoms, treatment, and outcomes. Descriptive statistics were used to report results. Ten men and four nonpregnant women reported coral snake bites. The median patient age was 15.5 (range 5-72years). There were 12 upper extremity bites and two bites to the lower extremity. The most common symptoms reported were paresthesias and pain. All subjects had paresthesias, often described as an "electric" sensation. Seven patients described them as painful. The most common clinical findings were erythema and swelling. No patient developed tissue damage, hematotoxicity, rhabdomyolysis, hypotension, weakness, or respiratory symptoms. Thirteen subjects were treated with opioids. Six patients were treated with antiemetics: three prophylactically and two for opioid-induced nausea. One patient developed nausea and non-bloody, nonbilious emesis within 1hour of the bite, prior to receiving opioids. No patients were treated with antivenom. Antibiotics were not administered to any patient, and no infections were reported. Envenomations from M. tener in Southeast Texas are characterized by painful paresthesias. Mild swelling and erythema are common. Neurotoxicity necessitating antivenom or mechanical ventilation did not occur.

Envenomations during pregnancy reported to the national poison data system, 2009–2018

Envenomations during pregnancy have consequences affecting both maternal and fetal outcomes. U.S. poison center data on envenomations offers a comparative view of envenomations in pregnant and non-pregnant women. The National Poison Data System of the American Association of Poison Control Centers was searched for cases of envenomation during pregnancy between January 1, 2009 and December 31, 2018 and compared with exposures to non-pregnant females of childbearing age. Odds ratios and descriptive statistics were used where appropriate. There were a total of 3,555 venomous animal exposures in pregnant women during this 10-year period, most commonly with scorpion stings. These were compared with 87,553 envenomations in non-pregnant women of childbearing age during that time period. Overall, drug treatment was administered in 350 (9.9%) cases of envenomation in pregnant women compared with 21,381 (24.4%) of non-pregnant patients. Antihistamines were less likely to be used in pregnant patients with scorpion (1.8% v. 9.2%), hymenoptera (bee, wasp, or hornet) (12.4% v. 37.1%), black widow spider (2.8% v. 8.1%), and caterpillar (10.4% v. 37.7%) exposures. There was an increased likelihood of antivenom use during pregnancy with rattlesnake envenomations (85.0% v. 58.9%) and black widow spider bites (4.8% v. 2.2%). There were no maternal deaths, and most maternal outcomes were coded as having no (1.0%) or minor (87.6%) effects. Three fetal deaths occurred, all following snakebites and all before 20 weeks gestation. Two were attributed as related, and one as of uncertain relationship to the exposure, by the managing poison centers. Most envenomations caused no or minor effects to pregnant women.

Atypical systemic and dermatologic loxoscelism in a non-endemic region of the USA

Introduction Loxosceles reclusa (LR), commonly known as the brown recluse spider, is endemic to the south central United States. We present a case of LR envenomation in a healthy adult male outside the usual geographic range, with atypical dermatologic and delayed, prolonged systemic loxoscelism (LX). This case demonstrates the importance of expanding the depth of knowledge of LR envenomations. Case report A previously healthy 27 year-old male presented to an emergency department (ED) in central Virginia two hours after a LR envenomation to his left proximal arm. He was treated with diphenhydramine and discharged on oral methylprednisolone for a 5-day taper. On post-bite Days 1 and 2, the patient developed subjective fevers, chills, arthralgias, and myalgias, followed by a blanching, pruritic, morbilliform rash throughout his trunk and lower extremities. Post-bite Day 3, the patient presented to the ED again because of marked erythema of face and the right lateral thigh, and posterior and anterior trunk. Vital signs and laboratory analysis were generally unremarkable. The patient was observed overnight, and discharged with a prescription for prednisone 60 mg per day. On post-bite Day 7, the patient noted a petechial rash on the palms and soles and returned to the ED with a fever of 102.6 °F, a heart rate of 130 beats per minutes, and systolic blood pressure ranging 80–90 mmHg. After considering this may be an atypical presentation of LX, corticosteroids were increased to methylprednisolone 1 mg/kg IV every 6 h. The patient’s condition slowly improved and he was discharged on post-bite Day 10. On post-bite Day 24, he had nearly complete resolution of skin findings. Conclusions LR envenomation can cause a variety of dermatological and systemic manifestations of toxicity. It is critical for toxicologists to be aware of the variety of presentations and findings to appropriately assess and treat LX.

SnakeMap: four years of experience with a national small animal snake envenomation registry.

SnakeMap is a national cloud-based, veterinary snakebite registry. It was designed to prospectively collect data of the clinical circumstances and temporospatial information on cases of snake envenomation in dogs and cats. We herein introduce the project and summarise the data from the first 4 years of SnakeMap. The registry is a veterinary community-based online database allowing case entry from veterinary hospitals across Australia. Registry data comprise hospital characteristics, patient characteristics, envenoming snake type, treatment and outcome variables, including time and geolocation of the snake bite. We present summative information on select key variables from the SnakeMap registry (1 July 2015 to 30 June 2019). Twenty-eight hospitals from 6 states/territories entered 624 cases into the registry, including 419 dogs (67%) and 205 cats (33%). Bite time was available in 216 animals of which 90 (42%) were reported to be bitten in the 3 hours between 03:00 pm and 05:59 pm; median bite to presentation interval was 60 (interquartile range [IQR] 30, 211) minutes in dogs and 95 (IQR 41, 238) minutes in cats. Bites occurred in the owner's yard in 356 dogs (85%) and 53 cats (26%). A snake venom detection kit was used in 172 cases (28%) and antivenom was administered in 523 cases (85%). Most animals (n = 534, 88%) survived to discharge (median hospitalisation of 25 [IQR 16, 62] hours). SnakeMap effectively collects relevant clinical data from dogs and cats with presumed snake bite and provides locally specific information on the epidemiology of snake envenomation in small animals.

Envenomations by coral snakes in an Amazonian metropolis: Ecological, epidemiological and clinical aspects

Envenomation by coral snakes represents a little known burden in Brazilian Amazonia. So far, details on clinical and epidemiological aspects remain obscure in the region. We gathered data from medical charts and from the scientific collection of snakes from Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, finding 26 cases of envenomation by five species of Micrurus in Manaus region, between 1987 and 2018. They represent 0.7% of the snakebites treated in the hospital since the records began, in 1979. Micrurus lemniscatus was responsible for most of the bites (10), followed by M. hemprichii (five), M. spixii (three), M. surinamensis (three) and M. averyi (one). There was no difference between the sexes of the snakes that caused bites. Patients were mostly males, and most of the cases were reported in urban areas. Bites predominated in dry season, and there was a clear geographical segregation among species. We describe seven cases of envenomation, three mild and four severe, all of which evolved to cure. Paresthesia (six), pain (five) and edema (four) were the most common local symptoms. Systemic features such as dyspnea/shallow breath (four), palpebral ptosis (four), blurred vision (three), dysarthria (three) and difficulty to walk (three) were also detected. Two patients bitten by Micrurus sp. and M. hemprichii, showed slight increased serum levels of creatine kinase (reference level <190 U/L), 1184 U/L and 1229 U/L, respectively, indicative of mild systemic myotoxicity. This is the first report of myotoxic manifestation in the envenomation by M. hemprichii. No patient developed respiratory failure, though one bitten by an adult M. spixii required intubation and mechanical ventilation due to decreased level of consciousness during evolution, probably related to induced sedation caused by concurrent alcohol intoxication. All patients were treated with Brazilian Micrurus antivenom (soro antielapídico, median = 10 vials). Six patients were pretreated intravenously with H1 and H2 antagonists and steroids, with two patients developing early adverse reactions. The median length of hospital stay was four days. Envenomations by coral snakes in Manaus region are clinically severe, but rare and sparsely distributed over time, making the detection of epidemiological and clinical patterns a challenge for public health.

Basal ganglia hemorrhage secondary to scorpion sting: a fatal presentation

IntroductionCerebrovascular manifestations are uncommon presentations of scorpion sting in the Indian subcontinent. Encephalopathy, cerebral edema, subarachnoid hemorrhage, non-hemorrhagic strokes, and cortical necrosis are a few CNS complications described in the medical literature due to scorpion envenomation.Case descriptionWe report a rare case of scorpion envenomation in a 40-year old, non-hypertensive farmer, who presented in an unconscious state. Non-contrast CT head revealed intracerebral hemorrhages in left temporoparietal lobe extending into left basal ganglia with intraventricular extension.Discussion and evaluationToxin-induced autonomic storm is mostly responsible for the acute hypertensive crisis in affected individuals leading to stroke (commonly cerebral infarct) as a CNS complication.ConclusionBasal ganglia bleed following scorpion sting is an extremely rare scenario which is usually fatal as was in our case. Early suspicion and prompt institution of treatment (prazosin) is crucial in the management of intracranial bleed secondary to scorpion sting.

Cytotoxic and genotoxic effects on human keratinocytes triggered by sphingomyelinase D from Loxosceles venom.

The spiders of the Loxosceles genus (called brown or violin spiders) are of medical relevance in several countries due to the many human envenomation cases reported. The main component of Loxosceles venom is the enzyme sphingomyelinase D (SMase D), which is responsible for the local and systemic effects induced by the whole venom. Here, we investigated the cytotoxic and genotoxic effects caused by Loxosceles laeta venom and SMase D on human keratinocytes to better understand the dermonecrosis development mechanism. Our findings indicate that whole venom, as well as SMase D, increases intracellular superoxide levels, leading to DNA damage. These effects appear to be dependent on the binding of SMase D to the cell surface, although the complete pathway triggered as a result of the binding still needs to be elucidated. Moreover, after SMase D treatment, we observed the presence of histone γH2AX, suggesting that the cells are undergoing DNA repair. Moreover, when ATR kinase was inhibited, the cell viability of human keratinocytes was decreased. Together, our findings strongly suggest that L. laeta venom, as well as SMase D, increases intracellular superoxide levels, leading to DNA damage in human keratinocytes. Additionally, the induced DNA damage is repaired through the activation of an apparent ATR-mediated DNA-damage response. This knowledge may contribute to a better understanding of the behaviour of human keratinocytes during cutaneous loxoscelism, a condition that affects thousands of people around the world.

A case of severe systemic copperhead envenomation with delayed diagnosis

A case of severe systemic copperhead envenomation with delayed diagnosis