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Treatment of scorpion envenomation in Brazil
Report
153
and Abstracts
We confirmed the good tolerance and the efficiency of the AV. No variation in biochemical constants was observed; however, some haematological parameters were systematically disturbed, soon after the bite, even in the absence of haemorrhage. The prothrombin rate (PR) decreased, activated cephalin time (ACT) lengthened, and later, the fibrinogen collapsed then the fibrin degradation products (FDP) increased. The diminution of platelets appeared clearly later. Finally, the haemoglobin declined according to the intensity of the haemorrhages. All of these parameters returned to the normal at the same time that the patient recovered. The PR appeared as a simple, reliable and cheap test. It is useful for earlier identification of viper envenomation and follow-up of efficiency of the treatment. The coagulation test on dry tube agreed with the haematological parameters measured in laboratory. In a rural infirmary where the majority of snakebites are received, this test would have to be done systematically to institute or confirm diagnosis and to appreciate recovery of patient. the confirmation of which is given when coagulation returns to normal. Pathogen&T of severe bites by certain pit vipers in Asia, and antivenom therapy. Y. Sawai, Kawamura (Japan Snake Institute, Yabuzuka-Honmachi, Nittagun, Gunma 379-23, Japan).
A. Sakai
and Y.
In Japan, two species of pit viper of habu (Trimeresurus flavoviridis) and mamushi (Agkistrodon blomh@ blomhqffii), and a colubrid snake (Rhabdophis tigrinus) are responsible for severe bites. The cause of fatality after a bite by T. flavoviridis is acute shock (AS) occurring within 24 hr of the bite, whereas AS or acute renal failure (ARF) occurs within 339 days of bites by A. blomhofii. Bites by R. tigrinus as well as Rhaodophis subminiatus elsewhere in Asia induce systemic haemorrhage and coagulopathy of blood, and ARF, in which the venom contained prothrombin-activator. Bites by the Chinese mamushi (Agkistrodon blomhojii brevicaudus) are common in Jiangsu and Zhejiang Prefectures of China, and the Korean peninsular. The cause of death of the bite is AS, acute respiratory paralysis (ARP), and ARF. It is suggested that postsynaptic and presynaptic neurotoxins contained in the venom are responsible for the ARP. High mortality rates are recorded due to Russell’s viper (Vipera russelli) bites in Myanmar and Sri Lanka. The cause of death is AS and ARF. Medical treatments of the bites are discussed. Life-supporting measures in intensive care units: an alternative to antiserum in snakebites. P. Salib,‘.* J. F. Baud* and M. Goyffon3 (‘Service d’Anesthesie A, Hopital Rent- Dubos, 95301 Pontoise, France; *Reanimation Toxicologique, Hopital Fernand Widal, 75010 Paris, France; and ‘L.E.R.A.I., Museum National d’Histoire Naturelle and C.R.S.S.A., 70005 Paris, France). Snakebite is a potentially lethal hazard wherever the path of humans crosses that of a poisonous snake. This is not a major medical problem in Europe, but can be considered one on all other continents. Even so, European vipers may cause a certain number of deaths every year and the risk is even greater concerning pet owners or certain professionals who handle exotic poisonous snakes. For these cases and wherever intensive care medicine is at hand, the knowledge of which syndromes to expect and how to treat them, be it specifically or symptomatically, is essential. Specific antiserum is not always available when the snake responsible for the bite originates from another continent; in these cases in particular, a well-adapted symptomatic treatment may save lives or at least maintain vital functions long enough for the specific treatment to be applied. We therefore present a review of the different syndromes to expect in snakebite with their symptomatic treatment in intensive care units. Electric shock therapy and snake extractors: alternative devices in the treatment qfvenomous snakebites. B. S. Gold (Johns Hopkins University, School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205-2196, U.S.A.). The use of electric shock for the treatment of venomous snakebites is not an innovative medical breakthrough. Since the 1920s it has been promoted as a successful alternative treatment for snake envenomations. This demonstrates another example of anecdotal experiences that have not been subjected to controlled and reproducible studies. Electric shock therapy is a potentially hazardous treatment and merely serves to forestall the only currently accepted standard of treatment for snakebite envenomation: the prompt administration of specific antivenom. The use of snake venom extractors in the U.S.A. as a first aid device in the first 5 min following poisonous snakebite may mitigate the effects of the venom. This has been demonstrated in the field treatment of rattlesnake bites in both rabbits and humans, Physicians who venture into snake endemic areas should be advised to carry an extractor which may reduce the severity of envenomation and the need for higher doses of antivenom. Treatment of scorpion envenomation in Brazil. L. Freire-Maia,’ J. A. Campos’ and C. F. S. Amara13 (‘Departamento de Farmacologia, ICB-UFMG, Belo Horizonte, Brazil; ‘Departamento de Pediatria, Fat. Medicina UFMG, Belo Horizonte, Brazil; and ‘Departamento de Clinica Medica, Fat. Medicina UFMG, Belo Horizonte, Brazil). In Brazil, about 8000 scorpion stings are reported each year. At the Federal University of Minas Gerais our group has treated humans stung by Tityus serrulatus scorpions for two decades (Campos et a/., 1980; Amaral et al., 1993; Freire-Maia et al., 1994). The patients at high risk or with major physiological system instability
154
Report and Abstracts
were admitted to the intensive care unit and subjected to constant clinical evaluation, continuous electrocardiographic monitoring and treatment. The treatment consisted of symptomatic measures, support of vital functions and serotherapy (iv. injection of l&20 ml of Fabs fragment, FUNED, Belo Horizonte, Brazil). Recently, an immunodiagnostic assay (ELISA) was described for the identification and quantification of antigens in the sera of patients stung by i”. serrulatus scorpions (Chaves-Olbrtegui el al., 1994) and Rezende et al. (1995) showed increased levels of circulating venom antigen before antivenom injection, which were not detected I hr after the start of serotherapy. Over a I6 year period, we treated 3860 patients stung by T. serrulatus, with a very low mortality rate (0.28%). Financial support: CNPq and FAPEMIG (Brazil).
Scorpion stings in Mexico and their treatment. E. S. Calderon-Aranda,‘,’ M. Dehesa-Davila,2 A. Chavez-Haro3 and L. Possani’ (‘Institute de Biotecnologia/UNAM, Av. Universidad 2001, Cuernavaca, Mexico; 2Centro de Investigation en Biotecnologia/UAEM, Cuernavaca, Mexico; and ‘Hospital General de Zona 21, IMSS, Leon, Guanajuato, Mexico). Several species of scorpions from the genus Centruroides (C.) are medically important in Mexico: C. limpidus limpidus, C. 1. tecomanus, C. infamatus, C. noxius, C. suflusus, C. sculpturatw and C. elegans. Recently, 215,825 cases of human stings were reported from the hospitals of the Mexican Institute of Social Security (IMSS), during the years 199&1993 (Maraboto, J.A.M., Bol Epid. IMSS - Mex.). During the same period only in the hospital of the Red Cross of the city of Leon Guanajuato we have registered 35,928 cases of accidents. These documented cases (partial statistics of the entire country) already give a figure close’ to 63,000 stings per year. The mortality rate registered by the Ministry of Health for the decade 1981-1990 is in the order of 310 per year (Dehesa-Davila and Possani, 1994). This figure would certainly be greater if horse antisera were not used. The serum is prepared by the Instituto National de Higiene (Ministry of Health) and by a private company (Bioclon S.A.). Usually, one vial containing freeze-dried serum (neutralizing capacity: I50 mice LD~,,)is dissolved in 5 ml water, and injected iv. with an antihistamine (v.g., chlorpheniramine). In the majority of cases this treatment is sutlicient to prevent severe complications, such as circulatory shock, heart failure and respiratory failure. More frequent general symptoms of envenomation are: pain, cough, hyperaesthesia, hyperexcitability, excessive salivation and vomiting. The serum is not administered to all patients, but the clinical symptoms dictate the cases deserving treatment, usually when two or more of the above-mentioned symptoms are present.
Dehesa-Davila and Possani (1994) Toxicon 32, 1015-1018. Supported in part by a grant from the Howard Hughes Medical Institute (no. 75191-527104, DGAPA/ UNAMM no. IN205893 and IN206994 to LDP).
Clinical manifestations do not disappear promptly after circulating venom neutralization by specific serotherapy in patients envenomed by Tityus serrulatus scorpions. N. A. Rezende,’ C. R. Diniz,2 D. Campolina,’ M. B. Dias, C.
Chavez-010rtegui2 and C. F. S. Amaral’ (‘Faculdade de Medicina da UFMG, Belo Horizon@ Brazil; 2Funda9ao Ezequiel Dias (FUNED), Belo Horizonte, Brazil; and ‘Hospital Jolo XXIII, (FHEMIG), Belo Horizonte, Brazil). More than 7000 cases of scorpion stings are reported annually in Brazil, with a mortality rate of about 1% in patients treated with antivenom. Despite long-term experience with scorpion antivenom therapy, no clinical studies have been carried out to detect circulating venom and to define the role of antivenom in the treatment of envenomed patients. This study reports the kinetics of circulating venom and antivenom assessed by ELISA and the evolution of the clinical and laboratory features after antivenom therapy in I9 patients envenomed by Tityus serrulatus. The medical history and physical examinations were recorded in standard forms and, after informed consent, venous blood was sampled for biochemical and haematological analysis and for venom and antivenom ELISAs before treatment and 1, 6, 12 and 24 hr after i.v. infusion of 5-30 ml of scorpion antivenom (FUNED, Brazil). High levels of venom were detected in I7 out of 19 patients before antivenom (15.07 k 2.67 ng/ml, mean + S.E.M.). Venom was no longer detected I hr after serotherapy. All patients showed high titres of antivenom I hr after serotherapy, which persisted for at least 24 hr. Vomiting and local pain decreased within I hr and hyperglycaemia was no longer detected I2 hr after serotherapy. The cardiorespiratory manifestations disappeared 6-24 hr after neutralization of circulating venom and all patients recovered completely. Data from this study support the prompt administration of antivenom to neutralize circulating venom, but adjunctive therapy and support of vital functions should also be provided since some manifestations of envenoming persisted despite circulating venom neutralization. Financial support and fellowships from EEC and Brazilian agencies FAPEMIG and CNPq.
153
and Abstracts
We confirmed the good tolerance and the efficiency of the AV. No variation in biochemical constants was observed; however, some haematological parameters were systematically disturbed, soon after the bite, even in the absence of haemorrhage. The prothrombin rate (PR) decreased, activated cephalin time (ACT) lengthened, and later, the fibrinogen collapsed then the fibrin degradation products (FDP) increased. The diminution of platelets appeared clearly later. Finally, the haemoglobin declined according to the intensity of the haemorrhages. All of these parameters returned to the normal at the same time that the patient recovered. The PR appeared as a simple, reliable and cheap test. It is useful for earlier identification of viper envenomation and follow-up of efficiency of the treatment. The coagulation test on dry tube agreed with the haematological parameters measured in laboratory. In a rural infirmary where the majority of snakebites are received, this test would have to be done systematically to institute or confirm diagnosis and to appreciate recovery of patient. the confirmation of which is given when coagulation returns to normal. Pathogen&T of severe bites by certain pit vipers in Asia, and antivenom therapy. Y. Sawai, Kawamura (Japan Snake Institute, Yabuzuka-Honmachi, Nittagun, Gunma 379-23, Japan).
A. Sakai
and Y.
In Japan, two species of pit viper of habu (Trimeresurus flavoviridis) and mamushi (Agkistrodon blomh@ blomhqffii), and a colubrid snake (Rhabdophis tigrinus) are responsible for severe bites. The cause of fatality after a bite by T. flavoviridis is acute shock (AS) occurring within 24 hr of the bite, whereas AS or acute renal failure (ARF) occurs within 339 days of bites by A. blomhofii. Bites by R. tigrinus as well as Rhaodophis subminiatus elsewhere in Asia induce systemic haemorrhage and coagulopathy of blood, and ARF, in which the venom contained prothrombin-activator. Bites by the Chinese mamushi (Agkistrodon blomhojii brevicaudus) are common in Jiangsu and Zhejiang Prefectures of China, and the Korean peninsular. The cause of death of the bite is AS, acute respiratory paralysis (ARP), and ARF. It is suggested that postsynaptic and presynaptic neurotoxins contained in the venom are responsible for the ARP. High mortality rates are recorded due to Russell’s viper (Vipera russelli) bites in Myanmar and Sri Lanka. The cause of death is AS and ARF. Medical treatments of the bites are discussed. Life-supporting measures in intensive care units: an alternative to antiserum in snakebites. P. Salib,‘.* J. F. Baud* and M. Goyffon3 (‘Service d’Anesthesie A, Hopital Rent- Dubos, 95301 Pontoise, France; *Reanimation Toxicologique, Hopital Fernand Widal, 75010 Paris, France; and ‘L.E.R.A.I., Museum National d’Histoire Naturelle and C.R.S.S.A., 70005 Paris, France). Snakebite is a potentially lethal hazard wherever the path of humans crosses that of a poisonous snake. This is not a major medical problem in Europe, but can be considered one on all other continents. Even so, European vipers may cause a certain number of deaths every year and the risk is even greater concerning pet owners or certain professionals who handle exotic poisonous snakes. For these cases and wherever intensive care medicine is at hand, the knowledge of which syndromes to expect and how to treat them, be it specifically or symptomatically, is essential. Specific antiserum is not always available when the snake responsible for the bite originates from another continent; in these cases in particular, a well-adapted symptomatic treatment may save lives or at least maintain vital functions long enough for the specific treatment to be applied. We therefore present a review of the different syndromes to expect in snakebite with their symptomatic treatment in intensive care units. Electric shock therapy and snake extractors: alternative devices in the treatment qfvenomous snakebites. B. S. Gold (Johns Hopkins University, School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205-2196, U.S.A.). The use of electric shock for the treatment of venomous snakebites is not an innovative medical breakthrough. Since the 1920s it has been promoted as a successful alternative treatment for snake envenomations. This demonstrates another example of anecdotal experiences that have not been subjected to controlled and reproducible studies. Electric shock therapy is a potentially hazardous treatment and merely serves to forestall the only currently accepted standard of treatment for snakebite envenomation: the prompt administration of specific antivenom. The use of snake venom extractors in the U.S.A. as a first aid device in the first 5 min following poisonous snakebite may mitigate the effects of the venom. This has been demonstrated in the field treatment of rattlesnake bites in both rabbits and humans, Physicians who venture into snake endemic areas should be advised to carry an extractor which may reduce the severity of envenomation and the need for higher doses of antivenom. Treatment of scorpion envenomation in Brazil. L. Freire-Maia,’ J. A. Campos’ and C. F. S. Amara13 (‘Departamento de Farmacologia, ICB-UFMG, Belo Horizonte, Brazil; ‘Departamento de Pediatria, Fat. Medicina UFMG, Belo Horizonte, Brazil; and ‘Departamento de Clinica Medica, Fat. Medicina UFMG, Belo Horizonte, Brazil). In Brazil, about 8000 scorpion stings are reported each year. At the Federal University of Minas Gerais our group has treated humans stung by Tityus serrulatus scorpions for two decades (Campos et a/., 1980; Amaral et al., 1993; Freire-Maia et al., 1994). The patients at high risk or with major physiological system instability
154
Report and Abstracts
were admitted to the intensive care unit and subjected to constant clinical evaluation, continuous electrocardiographic monitoring and treatment. The treatment consisted of symptomatic measures, support of vital functions and serotherapy (iv. injection of l&20 ml of Fabs fragment, FUNED, Belo Horizonte, Brazil). Recently, an immunodiagnostic assay (ELISA) was described for the identification and quantification of antigens in the sera of patients stung by i”. serrulatus scorpions (Chaves-Olbrtegui el al., 1994) and Rezende et al. (1995) showed increased levels of circulating venom antigen before antivenom injection, which were not detected I hr after the start of serotherapy. Over a I6 year period, we treated 3860 patients stung by T. serrulatus, with a very low mortality rate (0.28%). Financial support: CNPq and FAPEMIG (Brazil).
Scorpion stings in Mexico and their treatment. E. S. Calderon-Aranda,‘,’ M. Dehesa-Davila,2 A. Chavez-Haro3 and L. Possani’ (‘Institute de Biotecnologia/UNAM, Av. Universidad 2001, Cuernavaca, Mexico; 2Centro de Investigation en Biotecnologia/UAEM, Cuernavaca, Mexico; and ‘Hospital General de Zona 21, IMSS, Leon, Guanajuato, Mexico). Several species of scorpions from the genus Centruroides (C.) are medically important in Mexico: C. limpidus limpidus, C. 1. tecomanus, C. infamatus, C. noxius, C. suflusus, C. sculpturatw and C. elegans. Recently, 215,825 cases of human stings were reported from the hospitals of the Mexican Institute of Social Security (IMSS), during the years 199&1993 (Maraboto, J.A.M., Bol Epid. IMSS - Mex.). During the same period only in the hospital of the Red Cross of the city of Leon Guanajuato we have registered 35,928 cases of accidents. These documented cases (partial statistics of the entire country) already give a figure close’ to 63,000 stings per year. The mortality rate registered by the Ministry of Health for the decade 1981-1990 is in the order of 310 per year (Dehesa-Davila and Possani, 1994). This figure would certainly be greater if horse antisera were not used. The serum is prepared by the Instituto National de Higiene (Ministry of Health) and by a private company (Bioclon S.A.). Usually, one vial containing freeze-dried serum (neutralizing capacity: I50 mice LD~,,)is dissolved in 5 ml water, and injected iv. with an antihistamine (v.g., chlorpheniramine). In the majority of cases this treatment is sutlicient to prevent severe complications, such as circulatory shock, heart failure and respiratory failure. More frequent general symptoms of envenomation are: pain, cough, hyperaesthesia, hyperexcitability, excessive salivation and vomiting. The serum is not administered to all patients, but the clinical symptoms dictate the cases deserving treatment, usually when two or more of the above-mentioned symptoms are present.
Dehesa-Davila and Possani (1994) Toxicon 32, 1015-1018. Supported in part by a grant from the Howard Hughes Medical Institute (no. 75191-527104, DGAPA/ UNAMM no. IN205893 and IN206994 to LDP).
Clinical manifestations do not disappear promptly after circulating venom neutralization by specific serotherapy in patients envenomed by Tityus serrulatus scorpions. N. A. Rezende,’ C. R. Diniz,2 D. Campolina,’ M. B. Dias, C.
Chavez-010rtegui2 and C. F. S. Amaral’ (‘Faculdade de Medicina da UFMG, Belo Horizon@ Brazil; 2Funda9ao Ezequiel Dias (FUNED), Belo Horizonte, Brazil; and ‘Hospital Jolo XXIII, (FHEMIG), Belo Horizonte, Brazil). More than 7000 cases of scorpion stings are reported annually in Brazil, with a mortality rate of about 1% in patients treated with antivenom. Despite long-term experience with scorpion antivenom therapy, no clinical studies have been carried out to detect circulating venom and to define the role of antivenom in the treatment of envenomed patients. This study reports the kinetics of circulating venom and antivenom assessed by ELISA and the evolution of the clinical and laboratory features after antivenom therapy in I9 patients envenomed by Tityus serrulatus. The medical history and physical examinations were recorded in standard forms and, after informed consent, venous blood was sampled for biochemical and haematological analysis and for venom and antivenom ELISAs before treatment and 1, 6, 12 and 24 hr after i.v. infusion of 5-30 ml of scorpion antivenom (FUNED, Brazil). High levels of venom were detected in I7 out of 19 patients before antivenom (15.07 k 2.67 ng/ml, mean + S.E.M.). Venom was no longer detected I hr after serotherapy. All patients showed high titres of antivenom I hr after serotherapy, which persisted for at least 24 hr. Vomiting and local pain decreased within I hr and hyperglycaemia was no longer detected I2 hr after serotherapy. The cardiorespiratory manifestations disappeared 6-24 hr after neutralization of circulating venom and all patients recovered completely. Data from this study support the prompt administration of antivenom to neutralize circulating venom, but adjunctive therapy and support of vital functions should also be provided since some manifestations of envenoming persisted despite circulating venom neutralization. Financial support and fellowships from EEC and Brazilian agencies FAPEMIG and CNPq.