Polyvalent Antivenom Research Articles

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.

Effect of Indian Polyvalent Antivenom in the Prevention and Reversal of Local Myotoxicity Induced by Common Cobra (Naja naja) Venom from Sri Lanka In Vitro.

Bites by many Asiatic and African cobras (Genus: Naja) cause severe local dermonecrosis and myonecrosis, resulting in permanent disabilities. We studied the time scale in which two Indian polyvalent antivenoms, VINS and Bharat, remain capable of preventing or reversing in vitro myotoxicity induced by common cobra (Naja naja) venom from Sri Lanka using the chick biventer cervicis nerve-muscle preparation. VINS fully prevented while Bharat partially prevented (both in manufacturer recommended concentrations) the myotoxicity induced by Naja naja venom (10 µg/mL) when added to the organ baths before the venom. However, both antivenoms were unable to reverse the myotoxicity when added to organ baths 5 and 20 min post-venom. In contrast, physical removal of the venom from the organ baths by washing the preparation 5 and 20 min after the venom resulted in full and partial prevention of the myotoxicity, respectively, indicating the lag period for irreversible cellular injury. This suggests that, although the antivenoms contain antibodies against cytotoxins of the Sri Lankan Naja naja venom, they are either unable to reach the target sites as efficiently as the cytotoxins, unable to bind efficiently with the toxins at the target sites, or the binding with the toxins simply fails to prevent the toxin-target interactions.

Moringa oleifera Extract Extenuates Echis ocellatus Venom-Induced Toxicities, Histopathological Impairments and Inflammation via Enhancement of Nrf2 Expression in Rats.

Echis ocellatus snakebite causes more fatalities than all other African snake species combined. Moringa oleifera reportedly possesses an antivenom property. Therefore, we evaluated the effectiveness of M. oleifera ethanol extract (MOE) against E. ocellatus venom (EOV) toxicities. Thirty male rats were grouped as follows (n = 5): Group 1 (normal control received saline), groups 2 to 6 were administered intraperitoneally, 0.22 mg/kg (LD50) of EOV. Group 2 was left untreated while group 3 to 6 were treated post-envenoming with 0.2 mL of polyvalent antivenom, 200, 400, and 600 mg/kg of MOE respectively. MOE significantly (p < 0.05) normalized the altered haematological indices and blood electrolytes profiles. MOE attenuated venom-induced cellular dysfunctions, characterized by a significant increase in NRF2, and concomitant downregulation of increased antioxidant enzymes (SOD and CAT) activities in the serum and heart of the treated rats. MOE normalized the elevated TNF-α and IL-1β in serum and heart tissues. Furthermore, the IgG titre value was significantly (p < 0.5) higher in the envenomed untreated group compared to the MOE-treated groups. Hemorrhagic, hemolytic and coagulant activities of the venom were strongly inhibited by the MOE dose, dependently. Lesions noticed on tissues of vital organs of untreated rats were abolished by MOE. Our findings substantiate the effectiveness of MOE as a potential remedy against EOV toxicities.

Evaluation on Triaging Pathway Strategy Guidelines for Cases with Elipidae Bite during COVID-19 Pandemic at Emergency Department

Introduction: Emergency departments (ED) typically practice a triage system to classify patients into priority levels. A triage system is commonly used in crowded emergency rooms to determine which patient should be seen and treated immediately.Objective: The objective of this study was to evaluate the effectiveness of triaging pathway guidelines for critical cases seen in the Emergency Department during the COVID-19 outbreak.Case Presentation: Emergency Department, Taiping Hospital is practicing a triaging system which consists of two divisions; cases with respiratory symptoms (SARI) and cases without symptoms of respiratory impairment (non-SARI). A patient with snake bite was presented at the Emergency Department, Taiping Hospital with symptoms of numbness at the site of the bite and a complaint of difficulty to open the eyes, while tachycardia was noted. However, no shortness of breath or difficulty in breathing was reported. COVID-19 rapid screening was done and the patient was treated under Red Zone (non-SARI). Luckily, the patient survived and was stable with no reaction observed after treated with Neuro Polyvalent Antivenom 50ml in 500ml normal saline over one hour.Conclusion: The available patient triaging pathway strategy guideline was effectively practiced by paramedics when managing critical cases at the Emergency Department during COVID-19 outbreak. Other emergency departments are advised to practice effective and appropriate triaging pathway strategy guidelines to save patients’ lives.International Journal of Human and Health Sciences Supplementary Issue: 2021 Page: S15

Evolution Bites — Timeworn Inefficacious Snakebite Therapy in the Era of Recombinant Vaccines

Snakebite is a neglected tropical disease that inflicts severe socioeconomic burden on developing countries by primarily affecting their rural agrarian populations. India is a major snakebite hotspot in the world, as it accounts for more than 58,000 annual snakebite mortalities and over three times that number of morbidities. The only available treatment for snakebite is a commercially marketed polyvalent antivenom, which is manufactured exclusively against the 'big four' Indian snakes. In this review, we highlight the influence of ecology and evolution in driving inter- and intra-specific venom variations in snakes. We describe the repercussions of this molecular variation on the effectiveness of the current generation Indian antivenoms in mitigating snakebite pathologies. We highlight the disturbing deficiencies of the conventional animal-derived antivenoms, and review next-generation recombinant antivenoms and other promising therapies for the efficacious treatment of this disease.

Evaluation of Allergic Reactions Following Intravenous Infusion of Polyvalent Antivenom in Snakebite Patients.

Antivenom is a gold-standard treatment for snakebite envenoming. However, adverse reactions to snake antivenom are common in many parts. The aim of this study was to evaluate the allergic reactions following intravenous administration of antivenom sera. This was retrospective study conducted on snakebites patients referred to the Rahimi Hospital in Khorramabad. The files of these patients were accessed for demographic data, snakebite-related data, treatment provided, clinical presentation and allergic reaction status as a result of antivenom treatment. 141 cases were investigated, including 73.8% male and 26.2% female patients. The mean age of the patients was 38.1±17.1 years. Age group 30-39 years accounted for the highest number of snakebite cases (24.1%). A majority of victims (89.4%) were from rural areas. Most of the patients (51.8%) were bitten in the spring and highest number of snakebite were reported in May (39.1%). The most common site of snakebite was lower extremities (50.4%) and upper extremities (44.7%). Among clinical feature of snakebite, pain was the most prevalent in 135 cases (95.7%) followed by swelling (83.7%). The mean antivenom vials used were 6.5±3.7 vials. Allergic reactions occurred in 6 patients (4.26%); reactions were mild in 5 patients and severe in 1 patient. The commonest presentation was maculopapular rash (1.4%) and the least common were headache (0.71%), nausea (0.71%), fever (0.71) and hypotension (0.71%). Snakebite is one of the significant life-threatening environmental events. Immediate antivenom treatment can reduce mortality however, patients should be carefully monitored for adverse allergic reactions.

Moringa oleifera leaf fractions attenuated Naje haje venom-induced cellular dysfunctions via modulation of Nrf2 and inflammatory signalling pathways in rats

Naja haje envenoming could activate multiple pathways linked to haematotoxic, neurological, and antioxidant systems dysfunctions. Moringa oleifera has been used in the management of different snake venom-induced toxicities, but there is no scientific information on its antivenom effects against Naja haje. This study thus, investigated the antivenom activities of different extract partitions of M. oleifera leaves against N. haje envenoming. Forty five male rats were divided into nine groups (n = 5). Groups 2 to 9 were envenomed with 0.025 mg/kg (LD50) of N. haje venom while group 1 was given saline. Group 2 was left untreated, while group 3 was treated with polyvalent antivenom, groups 4, 6 and 8 were treated with 300 mg/kg−1 of N-hexane, ethylacetate and ethanol partitions of M. oleifera, respectively. Groups 5, 7 and 9 were also treated with 600 mgkg−1of the partitions, respectively. Ethanol extract and ethyl acetate partition of M. oleifera significantly improved haematological indices following acute anaemia induced by the venom. Likewise, haemorrhagic, haemolytic and anti-coagulant activities of N. haje venom were best inhibited by ethanol partition. Envenoming significantly down-regulated Nuclear factor erythroid 2-related factor 2 (Nrf2) with the consequent elevation of antioxidant enzymes activities in the serum and brain. Treatment with extract partitions however, elevated Nrf2 levels while normalising antioxidant enzyme activities. Furthermore, there were reduction in levels of pro-inflammatory cytokines (TNF-α and interleukin-1β) in tissues of treated envenomed rats. This study concludes that ethanol partition of M. oleifera was most effective against N. haje venom and could be considered as a potential source for antivenom metabolites.

A Neurotoxic Snake Venom without Phospholipase A2: Proteomics and Cross-Neutralization of the Venom from Senegalese Cobra, Naja senegalensis (Subgenus: Uraeus).

The Senegalese cobra, Naja senegalensis, is a non-spitting cobra species newly erected from the Naja haje complex. Naja senegalensis causes neurotoxic envenomation in Western Africa but its venom properties remain underexplored. Applying a protein decomplexation proteomic approach, this study unveiled the unique complexity of the venom composition. Three-finger toxins constituted the major component, accounting for 75.91% of total venom proteins. Of these, cardiotoxin/cytotoxin (~53%) and alpha-neurotoxins (~23%) predominated in the venom proteome. Phospholipase A2, however, was not present in the venom, suggesting a unique snake venom phenotype found in this species. The venom, despite the absence of PLA2, is highly lethal with an intravenous LD50 of 0.39 µg/g in mice, consistent with the high abundance of alpha-neurotoxins (predominating long neurotoxins) in the venom. The hetero-specific VINS African Polyvalent Antivenom (VAPAV) was immunoreactive to the venom, implying conserved protein antigenicity in the venoms of N. senegalensis and N. haje. Furthermore, VAPAV was able to cross-neutralize the lethal effect of N. senegalensis venom but the potency was limited (0.59 mg venom completely neutralized per mL antivenom, or ~82 LD50 per ml of antivenom). The efficacy of antivenom should be further improved to optimize the treatment of cobra bite envenomation in Africa.

In Vitro Neurotoxicity of Chinese Krait (Bungarus multicinctus) Venom and Neutralization by Antivenoms

Bungarus multicinctus, the Chinese krait, is a highly venomous elapid snake which causes considerable morbidity and mortality in southern China. B. multicinctus venom contains pre-synaptic PLA2 neurotoxins (i.e., β-bungarotoxins) and post-synaptic neurotoxins (i.e., α-bungarotoxins). We examined the in vitro neurotoxicity of B. multicinctus venom, and the efficacy of specific monovalent Chinese B. multicinctus antivenom, and Australian polyvalent elapid snake antivenom, against venom-induced neurotoxicity. B. multicinctus venom (1–10 μg/mL) abolished indirect twitches in the chick biventer cervicis nerve-muscle preparation as well as attenuating contractile responses to exogenous ACh and CCh, but not KCl. This indicates a post-synaptic neurotoxic action but myotoxicity was not evident. Given that post-synaptic α-neurotoxins have a more rapid onset than pre-synaptic neurotoxins, the activity of the latter in the whole venom will be masked. The prior addition of Chinese B. multicinctus antivenom (12 U/mL) or Australian polyvalent snake antivenom (15 U/mL), markedly attenuated the neurotoxic actions of B. multicinctus venom (3 μg/mL) and prevented the inhibition of contractile responses to ACh and CCh. The addition of B. multicinctus antivenom (60 U/mL), or Australian polyvalent snake antivenom (50 U/mL), at the t90 time point after the addition of B. multicinctus venom (3 μg/mL), did not restore the twitch height over 180 min. The earlier addition of B. multicinctus antivenom (60 U/mL), at the t20 or t50 time points, also failed to prevent the neurotoxic effects of the venom but did delay the time to abolish twitches based on a comparison of t90 values. Repeated washing of the preparation with physiological salt solution, commencing at the t20 time point, failed to reverse the neurotoxic effects of venom or delay the time to abolish twitches. This study showed that B. multicinctus venom displays marked in vitro neurotoxicity in a skeletal muscle preparation which is not reversed by antivenom. This does not appear to be related to antivenom efficacy, but due to the irreversible/pseudo-irreversible nature of the neurotoxins.

The in vitro laboratory tests and mass spectrometry-assisted quality assessment of commercial polyvalent antivenom raised against the ‘Big Four’ venomous snakes of India

India has recorded the maximum snakebite deaths in the world. Intravenous administration of polyvalent antivenom (PAV) raised against the ‘Big Four’ venomous snakes of India (Naja naja, Daboia russelli, Echis carinatus, and Bungarus caeraleus) is the only choice of treatment. The WHO has recommended the evaluation of quality and safety of commercial antivenom by in vitro laboratory tests prior to their pre-clinical evaluation in animal model and therapeutic use. Therefore, in this study an attempt has been made to evaluate the quality of commercial polyvalent antivenom produced in India by simple, and affordable laboratory tests. Proteomic analysis revealed that PAVs contained 78.7–94.8% IgG/F(ab’)2 and small quantities of plasma proteins. The PAVs showed batch-to-batch variations with varying amounts of undigested IgG and its aggregates, and moderate complement activation. However, absence of IgE, negligible endotoxin contamination, and recommended limit of preservative (cresol) in PAVs were observed. The PAVs contain varying proportions and least amount of venom-specific antibodies against venoms of the ‘Big Four’ snakes from different locales of India, and against eastern India N. kaouthia venom, respectively. The importance of independent in vitro laboratory tests for the quality control and safety assessment for improving the quality of Indian commercial PAV is reinforced.

Hemodynamic Changes Provoked through Intravascular Injection of the Echis carinatus Venom in Rats.

Echis carinatus (E. carinatus) is known for its hematological and nephrotoxic properties in the envenomed patients. Based on the limited data upon the cardiovascular changes associated with this dangerous venomous snake in Iran, the current study purposed to evaluate the venom-induced hemodynamic manifestations in rats. Venom (120 µg/kg) was administered intravenously within one minute through the left femoral vein, and the hemodynamic parameters were continuously recorded using a pressure transducer (MLT844, ADInstruments, Australia). The venom caused prominent hypotension leading to death a few minutes after a transient uprise in blood pressure. It also induced a decrease in heart and pulmonary rates, yet it had no arrhythmogenic properties. Additionally, pre-treatment with the pepsin-derived Iranian polyvalent antivenom (30 µl/Kg) completely neutralized the hemodynamic responses but had no effect when instilled two minutes after venom injection. Heparin (300 IU/kg) and epinephrine (1.5 µg/kg) prevented dramatic hypotension when used 10 minutes before venom instillation; however, atropine (1 mg/kg), dexamethasone (1 mg/kg), and ketorolac (10 mg/ml) had no effects. All treated rats were killed post-injection. Histologically, the lung was the most vulnerable organ with mononuclear infiltration, microcystic formation, and significant capillary congestion. Prominent renal pathological deterioration also occurred, including mesangial cell infiltration and diffuse bleeding, leading to acute tubular necrosis. Modest portal inflammation and vascular congestion were observed in the hepatic tissue of the envenomed rats. The crude venom of Iranian Echis carinatus caused hypotension leading to bradycardia, a decrease in pulmonary rate, and death without significant histological changes to the heart.

Proteomics, toxicity and antivenom neutralization of Sri Lankan and Indian Russell's viper (Daboia russelii) venoms.

Background: The western Russell’s viper (Daboia russelii) is widely distributed in South Asia, and geographical venom variation is anticipated among distant populations. Antivenoms used for Russell’s viper envenomation are, however, raised typically against snakes from Southern India. The present study investigated and compared the venom proteomes of D. russelii from Sri Lanka (DrSL) and India (DrI), the immunorecognition of Indian VINS Polyvalent Antivenom (VPAV) and its efficacy in neutralizing the venom toxicity.Methods: The venoms of DrSL and DrI were decomplexed with C18 high-performance liquid chromatography and SDS-polyacrylamide gel electrophoresis under reducing conditions. The proteins fractionated were identified through nano-ESI-liquid chromatography-tandem mass spectrometry (LCMS/MS). The immunological studies were conducted with enzyme-linked immunosorbent assay. The neutralization of the venom procoagulant effect was evaluated in citrated human plasma. The neutralization of the venom lethality was assessed in vivo in mice adopting the WHO protocol.Results: DrSL and DrI venom proteomes showed comparable major protein families, with phospholipases A2 (PLA2) being the most abundant (> 60% of total venom proteins) and diverse (six protein forms identified). Both venoms were highly procoagulant and lethal (intravenous median lethal dose in mice, LD50 = 0.24 and 0.32 µg/g, for DrSL and DrI, respectively), while lacking hemorrhagic and anticoagulant activities. VPAV was immunoreactive toward DrSL and DrI venoms, indicating conserved protein antigenicity in the venoms. The high molecular weight venom proteins were, however, more effectively immunorecognized than small ones. VPAV was able to neutralize the coagulopathic and lethal effects of the venoms moderately.Conclusion: Considering that a large amount of venom can be injected by Russell’s viper during envenomation, the potency of antivenom can be further improved for optimal neutralization and effective treatment. Region-specific venoms and key toxins may be incorporated into the immunization procedure during antivenom production.

In Vitro Immunological Cross-Reactivity of Thai Polyvalent and Monovalent Antivenoms with Asian Viper Venoms.

The intravenous administration of polyclonal antibodies known as antivenom is the only effective treatment for snakebite envenomed victims, but because of inter-specific variation in the toxic components of snake venoms, these therapies have variable efficacies against different snake species and/or different populations of the same species. In this study, we sought to characterize the in vitro venom binding capability and in vitro cross-neutralizing activity of antivenom, specifically the Hemato Polyvalent antivenom (HPAV; The Queen Saovabha Memorial Institute (QSMI) of the Thai Red Cross Society, Thailand) and three monovalent antivenoms (QSMI) specific to Daboia siamensis, Calloselasma rhodostoma, and Trimeresurus albolabris venoms, against a variety of South Asian and Southeast Asian viper venoms (Calloselasma rhodostoma, Daboia russelii, Hypnale hypnale, Trimeresurus albolabris, Trimeresurus purpureomaculatus, Trimeresurus hageni, and Trimeresurus fucatus). Using ELISA and immunoblotting approaches, we find that the majority of protein components in the viper venoms were recognized and bound by the HPAV polyvalent antivenom, while the monospecific antivenom made against T. albolabris extensively recognized toxins present in the venom of related species, T. purpureomaculatus, T. hageni, and T. fucatus. In vitro coagulation assays using bovine plasma revealed similar findings, with HPAV antivenom significantly inhibiting the coagulopathic activities of all tested viper venoms and T. albolabris antivenom inhibiting the venoms from Malaysian arboreal pit vipers. We also show that the monovalent C. rhodostoma antivenom exhibits highly comparable levels of immunological binding and in vitro venom neutralization to venom from both Thailand and Malaysia, despite previous reports of considerable intraspecific venom variation. Our findings suggest that Thai antivenoms from QSMI may by useful therapeutics for managing snake envenomings caused by a number of Southeast Asian viper species and populations for which no specific antivenom currently exists and thus should be explored further to assess their clinical utility in treating snakebite victims.

Development of a Treatment Protocol for Cobra (Naja naja) Bite Envenoming in Dogs.

There is limited information on clinical profiles, treatment, and management aspects of Indian cobra (Naja naja) bite envenoming in dogs in Sri Lanka. Dogs with cobra bites presented to the Veterinary Teaching Hospital (VTH), University of Peradeniya, were prospectively studied over a period of 72 months; local and systemic clinical manifestations and hematological abnormalities were recorded. We studied 116 cobra bite envenomings in dogs. A grading system was established using a combination of anatomical site of fang marks, as well as local and systemic clinical manifestations. Accordingly, treatment strategies were established using Indian polyvalent antivenom (AVS). Pain and swelling at the bite site were major clinical signs observed, while neurotoxic manifestations (mydriasis, wheezing, and crackles) were detected in most dogs. Leukocytosis was observed in 78% of them. Statistical analysis revealed that the grading scores obtained were compatible to initiate AVS administration according to the severity. The minimum number required was 2 AVS vials (range 2–12). Almost 20% of the dogs developed wheezing, crackles, hypersalivation, restlessness, and dyspnea as adverse reactions to AVS treatment. Necrotic wounds on bitten anatomical sites developed in 19% of the dogs and 2.5% developed acute kidney injuries as a consequence of envenoming crisis. Despite treatment, 3% of dogs died. No dry bites were recorded.

In-Vitro Neutralization of the Neurotoxicity of Coastal Taipan Venom by Australian Polyvalent Antivenom: The Window of Opportunity.

Coastal taipan (Oxyuranus scutellatus) envenoming causes life-threatening neuromuscular paralysis in humans. We studied the time period during which antivenom remains effective in preventing and arresting in vitro neuromuscular block caused by taipan venom and taipoxin. Venom showed predominant pre-synaptic neurotoxicity at 3 µg/mL and post-synaptic neurotoxicity at 10 µg/mL. Pre-synaptic neurotoxicity was prevented by addition of Australian polyvalent antivenom before the venom and taipoxin and, reversed when antivenom was added 5 min after venom and taipoxin. Antivenom only partially reversed the neurotoxicity when added 15 min after venom and had no significant effect when added 30 min after venom. In contrast, post-synaptic activity was fully reversed when antivenom was added 30 min after venom. The effect of antivenom on pre-synaptic neuromuscular block was reproduced by washing the bath at similar time intervals for 3 µg/mL, but not for 10 µg/mL. We found an approximate 10–15 min time window in which antivenom can prevent pre-synaptic neuromuscular block. This time window is likely to be longer in envenomed patients due to the delay in venom absorption. Similar effectiveness of antivenom and washing with 3 µg/mL venom suggests that antivenom most likely acts by neutralizing pre-synaptic toxins before they interfere with neurotransmission inside the motor nerve terminals.

Species-specific and geographical variation in venom composition of two major cobras in Indian subcontinent: Impact on polyvalent antivenom therapy

While snakebite is a severe problem for several countries throughout the world the Indian subcontinent has witnessed the highest global incidence of snakebite which represents an occupational health hazard. Belonging to the family Elapidae, the Indian spectacled cobra (Naja naja), is one of the members of the “Big Four” venomous snakes found throughout the Indian subcontinent. Indian monocled cobra Naja kaouthia is prevalent in eastern and north-eastern India as well as in Bangladesh, Nepal, and Bhutan. Species-specific and geographical differences in venom composition of two major Indian cobras (N. naja vs. N. kaouthia) may limit the effectiveness of antivenom treatment. Therefore, exploring the venom proteomes of N. naja and N. kaouthia from different geographical locales of the Indian subcontinent, and the effect of this variation on antivenom efficacy is warranted. Proteomic analyses have demonstrated that although eastern Indian N. naja and N. kaouthia venoms have similarities, species-specific and geographical variation is evident by differences in their venom toxicity values and pathobiological effects in experimental animals. This is the major reason as to why a polyvalent antivenom against N. naja venom exhibited only partial neutralization of enzymatic activity and immunological cross-reactivity against cobra venoms from other regions of India. This suggests that addition of polyclonal antibodies against N. kaouthia venom to polyantivenom, or preparation/administration of region-specific polyantivenom will provide better treatment of cobra bites in the Indian subcontinent.

α-Gal on Crotalidae-polyvalent Fab antivenom (CroFab): Investigating the relevance to immediate hypersensitivity reactions

Crotalidae-polyvalent immune Fab [ovine] (FabAV) is a polyvalent Fab fragment antivenom that is generated by papain digestion of Crotalidae-specific antibodies derived from hyperimmunized sheep. FabAV is approved for administration in patients being treated for snake envenomation of the Crotalidae subfamily, which includes rattlesnakes, copperheads, and cottonmouths/water moccasins.1,2 The frequency of acute adverse reactions is lower with FabAV than with whole immunoglobulin IgG antivenom products, but nonetheless immediate reactions (ie, occurring within 3 hours) do occur and can be severe.

ANAVIP® interaction with western pygmy rattlesnake venom: In vitro assesment of reactivity using SE-HPLC

Every year large numbers of venomous snake bites occur around the world, especially in tropical areas. The World Health Organization classifies venomous snake bites as one of their highest priority neglected tropical diseases, one of the reasons being the short supply of antivenom compared to the number of snake envenomations. The standard of care for snake envenomation is administration of antivenom. Many antivenoms are polyvalent, which are produced using venoms from multiple species of snakes. The polyvalent antivenoms can treat envenomation from snake venoms used in the production, but also show cross-reactivity against snake venoms with similar composition. Determining cross-reactivities of antivenoms could help improve the quality of treatment and provide a better understanding of venom-antivenom binding. One antivenom only has been available in the United States for treatment of North American Crotaline envenomation, with the recent introduction of an F(ab’)2 antivenom (ANAVIP®). Size-exclusion high performance liquid chromatography (SE-HPLC) was used to assess cross-reactivity of the western pygmy rattlesnake, Sistrurus miliarius streckeri (S. m. streckeri), against ANAVIP®. Estimates of venom-antivenom reactivity was measured in reaction mixtures based on the increase in elution profile area of higher molecular weight complexes (region 1) and on the decrease in elution profile area of reactants (region 2). Reaction mixtures contained ANAVIP® (1.0 mg/ml) and S. m. streckeri venom (0.125, 0.25, 0.5, or 1.0 mg/ml). Controls were ANAVIP® and S. m. streckeri (1.0 mg/ml). Mixtures were incubated at 37 °C for 30 min, then stored at 4 °C (5 min) prior to SE-HPLC. Relative binding, estimated from the increase in region 1 (immune complexes) and decrease in region 2 (reactants) region areas, suggested saturation of reactive antivenom binding sites at 0.125 (and above) mg venom/mg antivenom. SE-HPLC data indicate that binding of ANAVIP® to S. m. streckeri venom does occur, consistent with protective effects observed clinically. Further studies are needed to compare the binding of S. m. streckeri venom to other commercially available antivenoms, and the binding of ANAVIP® to other venoms of clinical significance.

Comparison of two types of polyvalent snake antivenom used in treatment

Purpose: In this study; we aimed to compare the effectiveness of the two types of polyvalent snake antivenom and to determine the possible local and systemic reactions in patients who admitted to the emergency department with snake bite. Materials and Methods: We performed this retrospective study on 30 patients who complained of snakebite. We grouped the patients according to the antivenom type (PoliseraTM or Polivalan TM) which they received. Demographic characteristics of the patients, vital signs, local tissue findings, and laboratory parameters were recorded in the standard data form. The following data were also recorded; the number of vials of snake antivenom used in each group, additional doses of venom were administered, and whether any local or systemic reaction to antivenom has developed or not. Results: Thirty patients were included in the study. 16 patients were administered PoliseraTM (Group 1) snake antivenom and 14 patients were administered Polivalan TM (Group 2) snake antivenom. Patients in Group 1 were given an average of 9.1±7.3 vials, while patients in Group 2 were given an average of 11.6±12.7 vials. More allergic reactions-urticaria, fever, and cellulite were observed in the group receiving PolivalanTM antivenom. Conclusion: Different methodologies arising from the production of antivenom, pyrogen contamination, and differences in packaging can cause different effects and side effects even in products with the same dose and antivenom content.

An Examination of the Neutralization of In Vitro Toxicity of Chinese Cobra (Naja atra) Venom by Different Antivenoms.

The Chinese Cobra (Naja atra) is an elapid snake of major medical importance in southern China. We describe the in vitro neurotoxic, myotoxic, and cytotoxic effects of N. atra venom, as well as examining the efficacy of three Chinese monovalent antivenoms (N. atra antivenom, Gloydius brevicaudus antivenom and Deinagkistrodon acutus antivenom) and an Australian polyvalent snake antivenom. In the chick biventer cervicis nerve-muscle preparation, N. atra venom (1–10 µg/mL) abolished indirect twitches in a concentration-dependent manner, as well as abolishing contractile responses to exogenous acetylcholine chloride (ACh) and carbamylcholine chloride (CCh), indicative of post-synaptic neurotoxicity. Contractile responses to potassium chloride (KCl) were also significantly inhibited by venom indicating myotoxicity. The prior addition of Chinese N. atra antivenom (0.75 U/mL) or Australian polyvalent snake antivenom (3 U/mL), markedly attenuated the neurotoxic actions of venom (3 µg/mL) and prevented the inhibition of contractile responses to ACh, CCh, and KCl. The addition of Chinese antivenom (0.75 U/mL) or Australian polyvalent antivenom (3 U/mL) at the t90 time point after the addition of venom (3 µg/mL), partially reversed the inhibition of twitches and significantly reversed the venom-induced inhibition of responses to ACh and CCh, but had no significant effect on the response to KCl. Venom (30 µg/mL) also abolished direct twitches in the chick biventer cervicis nerve-muscle preparation and caused a significant increase in baseline tension, further indicative of myotoxicity. N. atra antivenom (4 U/mL) prevented the myotoxic effects of venom (30 µg/mL). However, G. brevicaudus antivenom (24 U/mL), D. acutus antivenom (8 U/mL) and Australian polyvalent snake antivenom (33 U/mL) were unable to prevent venom (30 µg/mL) induced myotoxicity. In the L6 rat skeletal muscle myoblast cell line, N. atra venom caused concentration-dependent inhibition of cell viability, with a half maximal inhibitory concentration (IC50) of 2.8 ± 0.48 μg/mL. N. atra antivenom significantly attenuated the cytotoxic effect of the venom, whereas Australian polyvalent snake antivenom was less effective but still attenuated the cytotoxic effects at lower venom concentrations. Neither G. brevicaudus antivenom or D. acutus antivenom were able to prevent the cytotoxicity. This study indicates that Chinese N. atra monovalent antivenom is efficacious against the neurotoxic, myotoxic and cytotoxic effects of N. atra venom but the clinical effectiveness of the antivenom is likely to be diminished, even if given early after envenoming. The use of Chinese viper antivenoms (i.e., G. brevicaudus and D. acutus antivenoms) in cases of envenoming by the Chinese cobra is not supported by the results of the current study.