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Envenomation by Micrurus annellatus bolivianus (Peters, 1871) coral snake in the western Brazilian Amazon

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... In Brazilian Amazonia, 24 species of coral snakes are recorded (Silva Jr. et al., 2016b;Bernarde et al., 2018), but only seven of them known to have bitten humans ( Fig. 1 (Bucaretchi et al., 2016a;Bucaretchi et al., 2016b;Mendonça-da-Silva et al., 2018;da Silva et al., 2019). Of those, M. hemprichii, M. lemniscatus, M. spixii and M. surinamensis seem to be the main causes of bites. ...
... In Amazonia there is a lack of studies making a series of cases regarding coral snake bites. The only source of data comes from isolated case reports or personal communications (Santos et al., 1995;Pardal et al., 2010;Bucaretchi et al., 2016b;Mendonça-da-Silva et al., 2018;da Silva et al., 2019). Data coming from other countries in the region, like Colombia, suggests that the incidence could be even lower than the Brazilian average of 1% (Otero-Patiño, 2018;Gordo et al., 2016). ...
... Less severe local manifestations are mild pain, numbness and paresthesia limited to the bite site, starting few minutes after the bite (Pardal et al., 2010;Heckman et al., 2017;Cañas et al., 2017;Mendonça-da-Silva et al., 2018;da Silva et al., 2019). Bleeding, when present, is caused only by the injury inflicted by the fangs, not being long lasting or significant. ...
Article
Coral snakes constitute a relatively diverse and little known group of venomous snakes. So far, data for this kind of snakebite in the Amazon region are based only on case reports. This study takes advantage of novel data from the Brazilian Health Ministry database from 2010 to 2015 and presents a review of the cases reported in the literature regarding the Amazonian biome both from Brazil and nearby countries. Thirty-four cases reported in the database were used in the study, representing 0.05% of the snakebites in Brazilian Amazonia for that period. The incidence rate was 0.123 cases/100,000 inhabitants/year. The most affected group is that of working age men, suggesting occupational risk. Most of bites were on lower limbs. Pain, edema and paresthesia were the most common symptoms. Systemic symptoms not usually associated with coral snakes envenomings, such as coagulopathy and thrombocytopenia, have been reported in Amazonia. Five patients received less antivenom than indicated by the Health Ministry. Based on these results, we recommend the execution of educational programs to avoid such accidents and to teach both the general public and health professionals the correct treatment for the bites. We also suggest that the covering of Intensive Care Units in the region needs to be improved to avoid deaths.
... However, the residents mentioned the occurrence of adult individuals more often (surucucu) than juveniles (jararaca), perhaps because they saw larger specimens of this snake species more frequently than smaller ones. In the Alto Juruá region, five species of corals (Micrurus spp.) are found (Bernarde et al., 2017;Mota-da-Silva et al., 2019d), most of which have terrestrial habits (semi-fossorial or terrestrial) (Campbell and Lamar, 2004;Martins and Oliveira, 1998). The two coral species found on the trails in this study (M. ...
... These bio-ecological characteristics of the two corals explain why the residents reported that they encountered these snakes in aquatic environments and also because they are the species of the genus known to be found in the floodplain forests. The low frequency of accidents with corals reported by residents in this study and also recorded in the Alto Juruá region (Mota-da- Silva et al., 2019d corresponds to the pattern observed for the Amazon (Bisneto et al., 2020) and is probably related to the fact that these snakes are not aggressive, have small fangs, a mouth with a narrow opening and the small amount of venom which they produce and inoculate in the victim (Gutiérrez et al., 2016). ...
... Myotoxic manifestations are related to the increase in plasma levels of creatine kinase and myalgia Greene, 2020). Recent reports demonstrated that in some cases, thrombocytopenia, coagulopathy and electrocardiographic alterations may also be present (Manock et al., 2008;Heckman et al., 2017;Mota-Da-Silva et al., 2019). Neurotoxic manifestations include paresthesia, pain, palpebral ptosis, dizziness, ophthalmoplegia (and visual disturbances related to both, like blurred vision and diplopia), muscular weakness, dyspnea, dysarthria, dysphagia, difficulty to walk, drooling and respiratory failure, which is the main cause of death Bisneto et al., 2020;Greene, 2020). ...
... Despite the high diversity of coral snakes in Brazil, and particularly in Amazonia, most of the previous studies on the subject were performed on case reports (eg, Pardal et al., 2010;Mendonça-Da-Silva et al., 2018;Mota-Da-Silva et al., 2019). Although useful and with merits on their own, it is not possible to detect patterns about epidemiological aspects related to envenomations by coral snakes, hence the importance of addressing the problem more broadly. ...
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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.
... Motor neuron abnormalities may range from subtle myokymia to profound flaccid skeletal and respiratory muscle paralysis. Findings have included ptosis, ophthalmoplegia, hypersalivation, dysphagia, respiratory arrest, and coma [4 • , 5-7, 8 • , [16][17][18][19]. ...
... On rare occasion, profound derangements more typical of crotalid envenomation are seen. A 47-year-old male envenomated by an annellated coral snake (Micrurus annellatus bolivianus) in the western Brazilian Amazon had uncoaguable blood for 3 days, but fortunately did not have any medically significant bleeding [16]. A 27-year-old male bitten by a South American coral snake (M. ...
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Purpose of Review Snakebites are increasingly recognized as a neglected tropical disease. The purposes of this review were to determine the significance of coral snakebites in Central and South America and how best to treat these envenomations. Questions that needed to be answered included: What is the incidence of coral snake envenomation? What are the features of coral snake envenomation? What are the pharmacological and nonpharmacological ways to treat these bites? Recent Findings Multiple case reports and series describe the clinical features of coral snake envenomations, which account for fewer than 5% of all snakebites in Central and South America. Coral snake venom is a complex mixture of neurotoxins and other biologically active substances. There are multiple coral snake antivenoms available, but no single antivenom can be used for all species. Summary Coral snake envenomations are characterized by motor and sensory neurotoxicity. However, muscle damage, renal injury, hematologic toxicity, electrocardiographic abnormalities, and nonspecific signs and symptoms are also possible consequences. Supportive care and antivenom are the mainstays of therapy. Pressure immobilization may prevent systemic absorption, and neostigmine may protect against paralysis. Death is uncommon if treatment is initiated promptly. Nonspecific inhibitors of various venom components may serve as a bridge to definitive therapy.
... Some ancillary research has focused on other aspects of their venom, including observations that some coral snake venoms have anticoagulant effects on blood (Cecchini et al., 2005;Oliveira et al., 2017;Rey-Suárez et al., 2017). Additionally, some bite reports from the genus indicate mild to moderate disturbances to the victim's hemostasis (Manock et al., 2008;Strauch et al., 2018;Silva et al., 2019), though there is no direct evidence that these symptoms were caused by venom proteins rather than preexisting conditions in the patients or as a result of their ongoing treatment in the hospital. Of those patients showing these coagulopathies, all display delayed clotting times or wholly unclottable blood. ...
Article
Snakebite is a neglected tropical disease with a massive global burden of injury and death. The best current treatments, antivenoms, are plagued by a number of logistical issues that limit supply and access in remote or poor regions. We explore the anticoagulant properties of venoms from the genus Micrurus (coral snakes), which have been largely unstudied, as well as the effectiveness of antivenom and a small-molecule phospholipase inhibitor—varespladib—at counteracting these effects. Our in vitro results suggest that these venoms likely interfere with the formation or function of the prothrombinase complex. We find that the anticoagulant potency varies widely across the genus and is especially pronounced in M. laticollaris. This variation does not appear to correspond to previously described patterns regarding the relative expression of the three-finger toxin and phospholipase A2 (PLA2) toxin families within the venoms of this genus. The coral snake antivenom Coralmyn, is largely unable to ameliorate these effects except for M. ibiboboca. Varespladib on the other hand completely abolished the anticoagulant activity of every venom. This is consistent with the growing body of results showing that varespladib may be an effective treatment for a wide range of toxicity caused by PLA2 toxins from many different snake species. Varespladib is a particularly attractive candidate to help alleviate the burden of snakebite because it is an approved drug that possesses several logistical advantages over antivenom including temperature stability and oral availability.
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Background: The Alto Juruá region, located in the extreme western part of the Brazilian Amazonia, possesses an indigenous and riverine population which is involved in agricultural and forest extraction activities, and is a region that stands out for its high incidence of snakebites. Objectives: To assess the attitudes of the victims, the characteristics of the snakes and the circumstances of the snakebites which occurred in a region where human populations are highly exposed to snakes. Methods: The study was conducted at the Regional Hospital of Juruá in the Municipality of Cruzeiro do Sul (Acre), which regularly attends victims of snakebites in the Alto Juruá region. The snakes that caused the envenomations were identified from clinical and epidemiological diagnosis of the symptoms and signs that patients presented during hospital, and by enzyme immunoassay for venom detection using serum samples of the patients, or by identification of the snake responsible for the envenomation when it was taken to the hospital or photographed. People who suffered or witnessed the snakebite were interviewed to assess the circumstances of the bite, the attitude adopted after the accident and whether they recognized the species of snake that caused the envenomation. Results: There were 133 cases of snakebite (76.24 / 100.000 inhabitants), mainly involving male individuals living in the rural area and who had a low level of education. The most affected groups were farmers (48%) and children and teenagers (39%). It was observed that 8.3% of them presented a history of recurrence for bites. The lower limbs were the most affected anatomical region (84%). The Bothrops atrox snake, mainly small specimens (mostly juveniles), was the main species involved in the envenomations (83.4%). Snakebites occurred mainly in forest areas, backyards of houses in rural areas and near to aquatic environments, during activities (walking, farming, extractivism, hunting). Most of the time, the snake was on the ground and the bite occurred because of the approximation of the individual, either by trampling or by approximation of a hand. Half of the victims performed some kind of inadequate first aid (not drinking water, use of tourniquet, incision at the site of the bite, use of black stone, drinking a compound "Específico Pessoa"). Conclusions: Snakebite is an important cause of morbidity in the Alto Juruá region. Bothrops bites are mostly caused by small-sized specimens, probably due to the greater abundance of B. atrox juveniles, and also because small snakes are more difficult for people to see. People are more often bitten on the lower limbs probably due to the size of B. atrox (small and medium) and because the snakes are usually on the ground in most situations. Many victims resort to ineffective actions that can cause complications and also delay serotherapy. A low level of education is a factor that may contribute to worse outcomes in snakebites since it is associated with a lack of knowledge of preventive and first aid measures.
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A new species of elapid snake of the genus Micrurus is described herein, from the states of Rondônia and Mato Grosso, in the western Brazilian Amazon. The new species has a single anal plate, a unique characteristic shared with members of the M. hemprichii species group. It can be distinguished from the other members of this group by having a parietal reddish band in juveniles (absent in adults) and the absence of brownish or orange-yellow dorsal body bands. In addition, this species is distinguished from M. hemprichii by its lower number of body triads, and from M. ortoni by its lower numbers of ventrals and subcaudals scales. © 2018 Deutsche Gesellschaft für Herpetologie und Terrarienkunde e.V. (DGHT), Mannheim, Germany.
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Background Bites provoked by the genus Micrurus represent less than 1% of snakebite cases notified in Brazil, a tiny fraction compared with other genus such as Bothrops and Crotalus, which together represent almost 80% of accidents. In addition to their less aggressive behavior, habits and morphology of coral snakes are determinant factors for such low incidence of accidents. Although Micrurus bites are rare, victims must be rescued and hospitalized in a short period of time, because this type of envenoming may evolve to a progressive muscle weakness and acute respiratory failure. Case Presentation We report an accident caused by Micrurus corallinus involving a 28-year-old Caucasian sailor man bitten on the hand. The accident occurred in a recreational camp because people believed the snake was not venomous. The victim presented neurological symptoms 2 h after the accident and was taken to the hospital, where he received antielapidic serum 10 h after the bite. After the antivenom treatment, the patient presented clinical evolution without complications and was discharged 4 days later. Conclusions We reinforce that it is essential to have a health care structure suitable for the treatment of snakebite. Besides, the manipulation of these animals should only be carried out by a team of well-equipped and trained professionals, and even so with special attention.
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We present an updated checklist of Brazilian reptile species and, for the first time, its confirmed presence in federation units (26 states and the Federal District). Brazil has the third richest reptile fauna in the world, with 795 species: 36 Testudines, 6 Crocodylia, and 753 Squamata (72 amphisbaenians, 276 “lizards”, and 405 snakes). If subspecies are counted, these numbers increase to 842 taxa. Almost half (47%) of the Brazilian reptiles are endemic to the country, mainly amphisbaenians (76%), followed by lizards (54%), snakes (40%), and chelonians (16%). Nomenclatural changes and taxa included or excluded since the last checklist are discussed, as well as dubious or invalid state records.
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Snake envenomation is a major public health problem in Brazil. Systemic complications that may arise from snakebites are mainly related to coagulopathy. The Lee-White clotting time (LWCT) is a simple and inexpensive test and available even in remote health facilities. However, the diagnostic value of such test needs to be evaluated to accurately diagnose coagulopathy in the clinical practice. This study aimed to assess the reliability of the LWCT performed in hospital routine to diagnose venom-induced coagulopathy. We studied 186 patients admitted at the Tropical Medicine Foundation Dr. Heitor Vieira Dourado in Manaus, Amazonas, Brazil, withBothropsenvenomation diagnosis. At admission, blood samples were collected for performing LWCT and the concentration of fibrinogen. Sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, diagnostic odds ratio, and accuracy were calculated with 95% confidence intervals. From the total, 85.5% had hypofibrinogenemia. The sensitivity of the LWCT to the diagnosis of hypofibrinogenemia was 78.0% and the specificity 40.7%. The accuracy of the test was 72.6%, and patients with a prolonged LWCT had 2.4 higher odds of developing hypofibrinogenemia. In addition, the LWCT was also compared with venom antigen levels and systemic hemorrhage. The LWCT showed moderate sensitivity to detect consumption coagulopathy and constitutes a valuable tool for the diagnosis ofBothropssnake envenomation and indication of antivenom therapy.
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The Amazon region reports the highest incidence of snakebite envenomings in Brazil. We aimed to describe the epidemiology of snakebites in the state of Amazonas and to investigate factors associated with disease severity and lethality. We used a nested case-control study, in order to identify factors associated with snakebite severity and mortality using official Brazilian reporting systems, from 2007 to 2012. Patients evolving to severity or death were considered cases and those with non-severe bites were included in the control group. During the study period, 9,191 snakebites were recorded, resulting in an incidence rate of 52.8 cases per 100,000 person/years. Snakebites mostly occurred in males (79.0%) and in rural areas (70.2%). The most affected age group was between 16 and 45 years old (54.6%). Fifty five percent of the snakebites were related to work activities. Age ≤15 years [OR=1.26 (95% CI=1.03-1.52); (p=0.018)], age ≥65 years [OR=1.53 (95% CI=1.09-2.13); (p=0.012)], work related bites [OR=1.39 (95% CI=1.17-1.63); (p6 hours [OR=1.73 (95% CI=1.45-2.07); (p6 hours [OR=2.01 (95% CI=1.15-3.50); (p=0.013)] were independently associated with the risk of death. Snakebites represent an occupational health problem for rural populations in the Brazilian Amazon with a wide distribution. These results highlight the need for public health strategies aiming to reduce occupational injuries. Most cases of severe disease occurred in the extremes of age, in those with delays in medical attention and those caused by Micrurus bites. These features of victims of snakebite demand adequate management according to well-defined protocols, including prompt referral to tertiary centres when necessary, as well as an effective response from surveillance systems and policy makers for these vulnerable groups.
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Envenomation by coral snakes (Micrurus sp.) is one of the most dangerous injuries in America and it is considered as a serious medical emergency, however bites by these snakes appear to be rare. We analyzed epidemiological data, clinical signs and antivenom use in Argentina during the period between 1979-2003. During this period of study 46 non-fatal Micrurus bites were reported. The majority of cases were men from 31 to 40 years old. Bites occurred primarily in spring and summer. Most cases were reported from the northeast and northwest provinces of the country. The bites were mostly located on hands or feet and occurred mostly during agricultural activities and so mainly involved farmers. Only four cases occurred as a result of handling snakes. The median time it took for antivenom to be administrated was 60 minutes after the bite, and the median number of vials applied was 2. Local pain was mentioned and edema was reported in 41% of patients. All patients recovered without sequelae. This study showed a low incidence of Micrurus bites and low severity of envenomation. However, although no deaths have been reported during the last 30 years, given the toxicity of the venom of Micrurus snakes, the risk of severe envenomation should be considered.
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Two cases of proven coral snake bites were reported in Belém, Pará State, Brazil. The first case was a severe one caused by Micrurus surinamensis. The patient required mechanical ventilation due to acute respiratory failure. The second case showed just mild signs of envenomation caused by Micrurus filiformis. Both patients received specific Micrurus antivenom and were discharged without further complications. Coral snake bites are scarcely reported in the Amazon region and there is a broad spectrum of clinical manifestations, varying from extremely mild to those which may rapidly lead to death if the patient is not treated as soon as possible.
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A man bitten by a large coral snake (Micrurus lemniscatus helleri) in the Amazon basin of Ecuador developed persistent excruciating pain in the bitten arm. On admission to hospital less than 30 min later, he had a polymorphonuclear leucocytosis, thrombocytopenia and mildly prolonged prothrombin time/partial thromboplastin time. Not until 14 h after the bite did he develop the first signs of neurotoxicity. Despite treatment with specific antivenom 50 h after the bite, he required oxygen for respiratory failure 60 h, and 6 h of mechanical ventilation 72 h, after the bite. Over the next 38 h, he required two further intubations and periods of assisted ventilation before being airlifted to a tertiary referral hospital. Complications included bacterial pneumonia, pneumothorax, bronchial obstruction by mucus plugs and mild rhabdomyolysis. He was discharged from hospital 15 days after the bite with persistent limb weakness and urinary incontinence but eventually recovered. The interesting and unusual features of this case (severe local pain, very slow evolution of neurotoxic envenoming, persistent thrombocytopenia and mild coagulopathy) are discussed in the context of what is known of the composition of Micrurus venoms and the small clinical literature on envenoming from their bites.
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Micrurus venoms are known to induce mainly neurotoxicity in victims. However, other manifestations, including hemorrhage, edema, myotoxicity, complement activation, and hemostatic activity have been reported. In order to develop a more complete pharmacological profile of these venoms, inflammatory responses and hemostasis were evaluated in C57BL/6 mice treated with a sub-lethal dose of M. t. tener (Mtt) venom (8 μg/mouse), inoculated intraperitoneally. The venom induced moderate bleeding into the abdominal cavity and lungs, as well as infiltration of leukocytes into the liver. After 30 min, the release of pro-inflammatory mediators (TNF-α, IL-6, and NO) were observed, being most evident at 4 h. There was a decrease in hemoglobin and hematocrit levels at 72 h, a prolongation in coagulation times (PT and aPTT), a decrease in the fibrinogen concentration and an increase in fibrinolytic activity. In this animal model, it was proposed that Mtt venom induces inflammation with the release of mediators such as TNF-α, in response to the toxins. These mediators may activate hemostatic mechanisms, producing systemic fibrinolysis and hemorrhage. These findings suggest alternative treatments in Micrurus envenomations in which neurotoxic manifestations do not predominate.
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Micrurus snakes, commonly known as coral snakes, are responsible for 0.4% of the snakebites envenomings in Brazil. In this report, we describe a case of envenoming by Micrurus averyi, the black-headed coral snake, recorded in the western Brazilian Amazon. To the best of our knowledge, this is the first published case perpetrated by this species. The major complaint of the patient was an intense local pain and paresthesia. Examination of the bite site revealed edema extending from the left foot up the left leg that was accompanied by erythema involving the foot and distal third of the leg. Systemic signs at admission included nausea and drooling. The patient was treated with 100 mL of coral snake antivenom and intravenous analgesics (dipyrone) and was discharged 48 h post-admission with no complaints. The patient showed more intense local edema than that generally described in several other cases of Micrurus bites in Brazil.
Article
Objectives: Snakebite severity corresponds to size of snake because the amount of venom a snake injects is positively associated with snake size. Because fang marks are often present on snakebite patients, we tested whether the relationship between snake length and distance between fang puncture wounds can be generalized for rattlesnakes of genus Crotalus. Methods: We measured 2 interfang distances from 79 rattlesnakes of both sexes, 5 species, and varying body length: 1) distance between fang bases in anesthetized snakes, and 2) distance between fang punctures in a membrane-covered beaker bitten defensively. Results: Statistical analyses supported our 2 hypotheses, that 1) body size-related fang divergence during fang protraction (ie, anterolateral movement during fang erection), and 2) the relationship between snake length and interfang distance are similar between the sexes and among different rattlesnake species. We therefore derived a general equation to estimate snake length based on distance between fang marks, and recommended 5 snake size categories: very small (<10 mm), small (10-15 mm), medium (15-20 mm), large (20-25 mm), and very large (>25 mm). Conclusions: The distance between fang marks on a snakebite patient may be used to estimate the size or size category of the offending snake, which in some cases may have predictive value for overall clinical severity of a given envenomation. Assessing interfang distance from puncture wounds can improve snakebite research and anticipation of snakebite severity.
Article
The venom of Micrurus lemniscatus, a coral snake of wide geographical distribution in South America, was fractionated by reverse-phase HPLC and the fractions screened for phospholipase A2 (PLA2) activity. The major component of the venom, a PLA2, here referred to as ‘Lemnitoxin', was isolated and characterized biochemically and toxicologically. It induces myotoxicity upon intramuscular or intravenous injection into mice. The amino acid residues Arg15, Ala100, Asn108, and a hydrophobic residue at position 109, which are characteristic of myotoxic class I phospholipases A2, are present in Lemnitoxin. This PLA2 is antigenically related to M. nigrocinctus nigroxin, Notechis scutatus notexin, Pseudechis australis mulgotoxin, and Pseudonaja textilis textilotoxin, as demonstrated with monoclonal and polyclonal antibodies. Lemnitoxin is highly selective in its targeting of cells, being cytotoxic for differentiated myotubes in vitro and muscle fibers in vivo, but not for undifferentiated myoblasts or endothelial cells. Lemnitoxin is not lethal after intravenous injection at doses up to 2 μg/g in mice, evidencing its lack of significant neurotoxicity. Lemnitoxin displays anticoagulant effect on human plasma and proinflammatory activity also, as it induces paw edema and mast cell degranulation. Thus, the results of this work demonstrate that Lemnitoxin is a potent myotoxic and proinflammatory class I PLA2.
Article
Context: In the Americas, the main representatives of the family Elapidae are coral snakes of the genus Micrurus, of which 33 species are in Brazil. They are the smallest cause of venomous snakebite in Brazil. We analyzed literature reports of coral snake bites in Brazil from 1867 to 2014, and provide a brief review of case series and reports of coral snake bites in the Americas in general. Methods: Only reports with clinical descriptions of envenomation were included. The variables recorded included identification of the offending snake, patient's age, sex, bite site, clinical manifestations, treatment, including antivenom and anticholinesterase drugs, and general evolution of the cases. 30 published reports describing bites caused by Micrurus spp. in Brazil were identified and involved 194 distinct cases. Since no information on the clinical manifestations was available in 44 cases, the analysis was restricted to 25 reports (150 cases). Results: Most patients were from southern (61.3%; primarily Santa Catarina state, 60%) and southeastern (20%) Brazil and were male (70.7%), with a median age of 27 years (interquartile interval = 18 to 40 years). The offending snakes were described in 59 cases (M. corallinus 36, M. frontalis 12, M. lemniscatus 5, M. hemprichi 2, M. filiformis 1, M. ibiboboca 1, M. spixii 1 and M. surinamensis 1); in 22 cases only the genus (Micrurus spp.) was reported. Of the 143 cases in which the bite site was recorded, most involved the hands (46.2%) and feet (26.6%). The main clinical features were local numbness/paresthesia (52.7%), local pain (48%), palpebral ptosis (33.3%), dizziness (26.7%), blurred vision (20.7%), weakness (20%), slight local edema (16%), erythema (16%), dysphagia (14.7%), dyspnea (11.3%), inability to walk (10.7%), myalgia (9.3%), salivation (8%) and respiratory failure (4.3%). Fang marks were described in 47.3% of cases and 14% of bites were classified as asymptomatic. A slight increase in total blood creatine kinase was reported in 3 children, suggesting mild myotoxicity. Therapeutic procedures included coral snake antivenom (77.3%), anticholinesterase drugs (6%), and mechanical ventilation (3.3%). Two patients reported in 1933 developed paralysis/respiratory failure and died 6 h and 17 h post-bite. Four more deaths probably caused by coral snakes were reported (2 in 1867, 1 in 1959, 1 in 1962), but no clinical information was available. Discussion: Neuromuscular blockade was the hallmark of systemic envenomation by Micrurus spp., with signs of myasthenia such as weakness and ptosis that may evolve to paralysis and respiratory failure. Local features, mainly numbness/paresthesia and pain, were frequently reported, with the pain being intense in some cases. Although myotoxicity has been detected in experimental studies with Micrurus spp. venoms, few human reports described laboratory findings compatible with myotoxicity. Conclusion: Most coral snake bites reported in Brazil were caused by M. corallinus and M. frontalis, with several patients showing signs of acute myasthenia. Serious complications such as paralysis with respiratory failure were observed but comparatively rare. The deaths occurred where respiratory support (mechanical ventilation) was unavailable when needed.
Article
We gathered data on 39 victims of Eastern coral snake bite over a 12-year period. The most common situation resulting in snakebite was erroneous identification of the snake as the nonpoisonous scarlet king snake. While no patient died, several experienced severe envenomation, including bulbospinal respiratory paralysis. We found that neurologic symptoms may be delayed for 12 hours, and then may be precipitous. Envenomation occurs in 75% of the persons bitten by a coral snake. Antivenin is effective and should be intravenously administered early to patients who have been bitten by a positively identified coral snake, depending on the clinical presentation. (JAMA 1987;258:1615-1618)
Article
Of the numerous techniques for measuring coagulation (clotting) time (CT), the method of Lee and White1 is certainly the most frequently cited. More often than not, however, the test is not done exactly as its originators described it. Recent criticisms that the CT is unreliable and insensitive stem at least in part from this fact. Any value can be obtained, depending on how the test is done.2 Variables include the number of syringes used, whether one discards some of the blood, the degree and frequency of tilting the tubes, the diameter of the tubes, the number of tubes, the volume of blood, prerinsing the tubes with saline, and temperature. All affect the result. The test may be invalidated by a traumatic venipuncture; by delayed flow or bubbling of the blood; by a "dirty" needle, syringe, or tube; by traces of water in the syringe; by failure to remove
Article
The coral snake Micrurus tener tener (Mtt) from the Elapidae family inhabits the southwestern United States and produces severe cases of envenomations. Although the majority of Mtt venom components are neurotoxins and phospholipase A₂s, this study demonstrated, by SDS-PAGE and molecular exclusion chromatography (MEC), that these venoms also contain high-molecular-weight proteins between 50 and 150 kDa that target the hemostatic system. The biological aspects of other Micrurus venoms were also studied, such as the LD₅₀s of Micrurus isozonus (from 0.52 to 0.61 mg/kg). A pool from these venoms presented a LD₅₀ of 0.57 mg/kg, Micrurus f. fulvius (Mff) and Mtt had LD₅₀s of 0.32 and 0.78 mg/kg, respectively. These venoms contained fibrino(geno)lytic activity, they inhibited platelet aggregation, as well as factor Xa and/or plasmin-like activities. M. isozonus venoms from different Venezuelan geographical regions inhibited ADP-induced platelet aggregation (from 50 to 68%). Micrurus tener tener venom from the United States was the most active with a 95.2% inhibitory effect. This venom showed thrombin-like activity on fibrinogen and human plasma. Fractions of Mtt showed fibrino(geno)lytic activity and inhibition on plasmin amidolytic activity. Several fractions degraded the fibrinogen Aα chains, and fractions F2 and F7 completely degraded both fibrinogen Aα and Bβ chains. To our knowledge, this is the first report on thrombin-like and fibrino(geno)lytic activity and plasmin or factor Xa inhibitors described in Micrurus venoms. Further purification and characterization of these Micrurus venom components could be of therapeutic use in the treatment of hemostatic disorders.
Article
We gathered data on 39 victims of Eastern coral snake bite over a 12-year period. The most common situation resulting in snakebite was erroneous identification of the snake as the nonpoisonous scarlet king snake. While no patient died, several experienced severe envenomation, including bulbospinal respiratory paralysis. We found that neurologic symptoms may be delayed for 12 hours, and then may be precipitous. Envenomation occurs in 75% of the persons bitten by a coral snake. Antivenin is effective and should be intravenously administered early to patients who have been bitten by a positively identified coral snake, depending on the clinical presentation.
Article
Venoms from five species of Micrurus (coral snakes) from Brazil (Amazonas State) were tested for the following effects: edematogenic, myotoxic, coagulant, hemorrhagic and phospholipase A2 (PLA2) detection. None of the venoms tested presented coagulant activity. The presence of PLA2 was detected by ELISA in the venoms of M. spixii, M. averyi and M. lemniscatus. The myotoxicity was estimated by the increase in the serum creatine kinase level and by histological analysis. All venoms, except that from M. surinamensis, induced intense edematogenic and myotoxic effects. The venom of M. averyi showed hemorrhagic activity which was confirmed by histopathological analysis. This is the first evidence of such an effect by coral snake venom.
Article
Toxicities of crude venoms from 49 coral snake (Micrurus sp.) populations, representing 15 nominal taxa, were examined in both laboratory mice and in native prey animals and compared with data gathered from two non-micrurine elapids and a crotalid, which served as outgroups. These venoms were further compared on the basis of 23 enzymatic activities. Both toxicities and enzymatic activities were analyzed with respect to natural prey preferences, as determined from stomach content analyses and literature reports. Venoms of nearly all Micrurus for which prey preferences are known, are more toxic to natural prey than to non-prey species. Except for amphisbaenians, prey are more susceptible to venoms of Micrurus that feed upon them, than to venoms of those that eat other organisms. All venoms were more toxic i.v.>i.p.>i.m. Route-specific differences in toxicity are generally greatest for preferred prey species. Cluster analyses of venom enzymatic activities resulted in five clusters, with the fish-eating M. surinamensis more distant from other Micrurus than even the crotalid, Bothrops moojeni. Ophiophagous and amphisbaenian-eating Micrurus formed two close subclusters, one allied to the outgroup species Naja naja and the other to the fossorial, ophiophagous Bungarus multicinctus. Prey preference is shown to be the most important determinant of venom composition in Micrurus.
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