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NEWSLETTER
MALAYSIAN SOCIETY ON
TOXINOLOGY (MST)
ISSUE 2021-2022
HIGHLIGHTS
The Relevance of
Clinical Toxinology in
Wilderness Medicine
Recent Progress in
Toxinology Research
for Two Spitting Cobras
of The Philippines
A Small Yet Life-Saving
Impact
Point-of-Care Testing
for Snakebite
Envenoming: How
Prepared are We?
CONTENT
❖ Message from the President
❖ Message from the Editorial Team
❖ Newsletter Editorial Board
2021/2022
❖ Society Update
❖ Society Activities
❖ Highight Stories
Current Opinion on the
Role of CSL Box Jellyfish
Antivenom for Jellyfish
Sting Envenomation in
Malaysia
Widows in the House: A
Tale of Venomous
Spider
Toxic Shellfish Poisoning,
Old Problem with Potential
New Solution to Handle
the Case Exposure?
MST NEWSLETTER | ISSUE 2021/2022
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Message from the President|
Assalamualaikum and greetings to all,
Dear respected readers,
I am truly glad that the Malaysian Society on Toxinology E-Newsletter Duo-Edition (2021/2022) could
finally be published. Amidst the very hectic working environment that we all had been facing from
the Covid endemic until it becoming pandemic and dealing with the repercussion of the other non-
communicable diseases, we however are able to survive the situation. Some of our dear comrades
may be affected more compared to us, therefore we should always be very grateful. So, I welcome
all of you to enjoy reading what we have prepared.
Throughout 2021/2022, MST with our few other excellent collaborators had been working hand-in-
hand to conduct a few online webinars and programs. Towards the second half of 2022, when the
Covid cases becoming lesser and with the relaxation of the restriction announced, a few face-to-
face courses also had been conducted. Kudos to the team. As always, you guys are the best. MST
had also successfully involved in the development of the College of Emergency Physician Special
Interest Group (CEP SIG) in Clinical Toxinology presented during the special meeting held way back
in January 2022. I believe that this CEP SIG in Clinical Toxinology group can be one of the platforms
for further advancement in the Clinical Toxinology field, particularly from the academic point of
view.
RECS ASEAN consultants and majority of the MST members also have been very active in
participating on online webinars, courses and became expert panels and presenters in local and
international conferences. For this, my hats off for all of you. What I aspire in 2023 is so that we can
conduct the ASEAN Marine and Snake Envenomation/Poisoning Management Conference (AMSEM
2023) in Malaysia, and to make ASEAN Fellowship on Clinical Toxinology (AFCT) a reality. A few
studies in many aspects in Clinical Toxinology had been published during this two-year period, and a
few of them are still ongoing. We aim to get them published in a timely manner. I believe we can be
more active in educating and engaging the publics and civilians with regards to increase the
awareness and knowledge of the Appropriate Safe Seeking Behaviour (ASSB) and Appropriate
Health Seeking Behaviour (AHSB). However, this is still a long way to go for all of us.
Finally, I would like to thank my dedicated and hardworking editorial team for this E-Newsletter Duo
Edition (2021/2022), the MST EXCOs (2021/2023) and all the MST members for your continuous support
to our society. May MST continue to always be relevant in the field of clinical toxinology and beyond.
Dr Ruth Sabrina Safferi
MST President (2021/2023)
MST NEWSLETTER | ISSUE 2021/2022
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Message from the Editorial Team|
On behalf of the MST Editorial Team, I would like to thank all members for your support and faith in
the Malaysian Society on Toxinology.
Over the past two years, we have witnessed remarkable scientific advances and human
adaptability in dealing with an unprecedented global crisis in health, economics and various social
issues. The pandemic, which begin about three years ago, challenged the practice of healthcare
and education as well as activities conducted by societies like ours in the community. A crisis like this
requires a nimble approach that incorporates effective and inclusive practices with priority. Perhaps,
living through the time of prolonged uncertainties has been transformative for most of us; it is not just
about what we have learned, but rather how we learn to cope, and for what end.
In those situations of hardship, if you remember, MST, just like the community at large, comes
forth to do its part in moving knowledge and service forward. The Society’s activities, in fact, never
discontinued but instead carried on with whatever measures deemed appropriate from time to time.
Virtual meetings, online discussions and consultations, new and modified SOPs to keep safe.... We
survive, we adapt, and we deliver what we believe is good for ourselves and the community. In this
issue of newsletter, you will see the growing activities engaged by our members and friends from
2021 to 2022 while carrying the MST’s flag. As it is, the situation turns up and down from time to time.
We are continuously confronted with creating and adapting to new norms, while embracing the
values of resilience, creativity, self-reflection, and gratitude. We hope for the best to come.
As the year 2022 draws to an end, the borders are re-opening, people are moving, and lives
seem to return to normal – or I should say, adapting to the new norm. We are anticipating more
exciting and holistic activities for our members in the coming years. Before that, let us entice you
with some of the best and memorable moments of MST activities featured in this issue of newsletter.
As usual, we also provide some useful information, including several articles highlighting knowledge
and research development in toxinology relevant to this part of the world.
We hope you enjoy reading, and we wish you a happy and productive new year ahead.
With warm regards to everyone.
Assoc. Prof. Dr. Tan Choo Hock
Chief Editor, MST Newsletter
Hon. Secretary, MST 2021-2023
MST NEWSLETTER | ISSUE 2021/2022
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Newsletter Editorial Board 2021/2022|
Dr. Ruth Sabrina is an Emergency Physician and Clinical Toxicologist by
profession, and currently working in in The Emergency and Trauma Department,
Raja Permaisuri Bainun Hospital Ipoh, Malaysia. She is the current President of the
Malaysian Society on Toxinology for Year 2021-2023. She can be contacted
through email : sabrinasafferi@gmail.com.
Dr. Tan Kae Yi is a senior lecturer at the Protein and Interactomics Laboratory,
Department of Molecular Medicine, Faculty of Medicine, Universiti Malaya. He
has been actively engaged in the comparative studies of –omics and
antigenicity of diverse snake venoms and their toxins, applying molecular,
pharmacological and bioinformatic approaches. He can be contacted via
email: kytan_kae@um.edu.my.
Dr. Tan Choo Hock is an associate professor of pharmacology from the
Department of Pharmacology, Faculty of Medicine, Universiti Malaya
(www.vetoxlab.com). He is based at the Venom Research & Toxicology Lab
(Vetox Lab), and his research broadly encompasses snake toxins, venom
proteins and antivenoms. He can be contacted via email: tanch@um.edu.my.
Dr. Muhamad Na’im Bin Ab Razak or better known as Dr Jacknaim is a prolific
writer, poet, outdoor activities enthusiast, coffee lover and a medical doctor
whom currently serve at the Emergency and Trauma Department, Hospital Lahad
Datu. He is an active member of the Malaysian Society on Toxinology since 2014.
He can be contacted via email: jacknaim@gmail.com.
Dr. Zainalabidin is a Consultant Emergency Physician in Hospital Tengku
Ampuan Afzan, Kuantan, Pahang, Malaysia. He is also the state head of
service for Emergency and Trauma Services in Pahang, Malaysia. He is currently
the Vice President of Malaysian Society on Toxinology (MST) and Consultant for
Remote Envenomation Consultancy Services (RECS). He has special interest in
Emergency Medicine, Clinical Toxinology, Prehospital Care and Disaster
Medicine. He has conducted several educational programs and life support
courses for students, healthcare providers and the public.
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Dr. Noredelina Mohd Noor is an emergency physician who loves outdoor
activities and has special interest in Clinical Toxinology and Wilderness
Medicine. She is currently working at the Emergency & Trauma Department,
Hospital Selayang and can be contacted via email at edlin_mn@yahoo.com.
Dr. Praneetha Palasuberniam, known to colleagues and students as Dr
Neetha or Dr Pala, is a Senior Lecturer at the Department of Biomedical
Sciences, Universiti Malaysia Sabah, under the Pharmacology division. Her
professional interests focus on Pharmacology and Toxinology, and her most
recent research involves the investigation of snake venoms and antivenoms.
In addition, she is currently sitting on a board of external consultants with the
World Health Organization to understand other treatment modalities besides
the century-old antivenom.
Dr. Anas Amri is the Emergency Physician of Emergency & Trauma
Department Hospital Sultan Abdul Halim, Sungai Petani, Kedah. Previously he
worked in East Malaysia from January 2017 until August 2022. He is actively
involved as instructor for several life-support courses and he regularly conducts
programmes to educate healthcare workers and the public. He is also active
in voluntary works and sports activities, particularly football and futsal.
Dr. Mohd Shukruddeen Salleh is a Consultant Emergency Physician and
the Head of Emergency Department, Hospital Sultan Ismail Petra, Kuala Krai,
Kelantan. He is involved with the Remote Envenomation Consultancy
Services (RECS) since 2013. He has special interest in Clinical Toxinology and
Point of Care Ultrasound. He can be contacted via email :
drskru@gmail.com.
MST NEWSLETTER | ISSUE 2021/2022
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MST Executive Committee and Internal Auditor|
MST NEWSLETTER | ISSUE 2021/2022
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Society Update|
MST offers four categories of membership since 2013:
I. Malaysian Ordinary Member (Academician, Scientists & Clinician)
II. Malaysian Associate Member (Non-academician/Non-clinician)
III. International Associate Member
IV. Malaysian Student
Membership status:
Registered members who renew annual membership with up-to-date payment of membership fee
are considered financially active. Active financial status is required to enjoy the various benefits
offered by the Society from time to time, which includes entitlement for a discount on the registration
fee of some courses/activities, complimentary Hi-Tea for year-end gathering, a token of membership
appreciation for supporting the Society and other activities.
Malaysian Ordinary Member with current financially active membership status is eligible to vote in
AGM, and to hold ExCo position.
Existing Life Members enjoy the privileges as provided in the previous Constitution of the Society
before the year 2013.
At present, there are 48 members registered with MST. The majority of the members are of the
Ordinary Membership category.
Information about registration and renewal for membership is available at:
http://mstoxinology.blogspot.my/p/membership.html
MST NEWSLETTER | ISSUE 2021/2022
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Society Activities|
MST ACTIVITIES FOR 2021
13 March - Wilderness Medicine 2021 Webinar:
Animal Bites, Stings, and Envenomation. Organiser:
USM, Wilderness Medicine Society Malaysia. (RECS:
Dr Edel).
21 March - Webinar on Snakes and Snakebites in
Pets. Organiser: FRIM. Collaborators : MST and
RECS. (Prof Dr Indraneil Das, Dr Tan Choo Hock, Dr
Melissa Aw, Assoc Prof Dr Scott Weinstein).
25 March - FB Live@AsasiUiTM: Appropriate Safe
Practices and First Aid Management for Land and
Marine Animal Bites and Stings. Organiser: Unit
Kesihatan Pusat Asasi UiTM. (RECS: Dr Khaldun).
15 April - 3rd Emergency Medicine Seminar Series
2021 (Part 1). Organiser: Department of
Emergency Medicine, UKMMC. Collaborators:
MST, RECS and MYSOT. (RECS and MST).
22 April - 3rd Emergency Medicine Seminar Series
2021 (Part 2). Organiser: Department of
Emergency Medicine, UKMMC. Collaborators:
MST, RECS and MYSOT. (RECS and MST).
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26 - 27 April - Philippine College of Emergency
Medicine Virtual Convention 2021: Current
Emerging Trends in EM Practice: Clinical Toxinology
- Marine Envenomation
Management. Organiser: Philippine College of
Emergency Medicine. (RECS: Dr Khaldun).
7 May - First Aid for Venomous Bites/Stings in
Dental Clinic @ Institut Perubatan dan Pergigian
Termaju (IPPT), USM Pulau Pinang. Organiser: IPPT
USM Pulau Pinang. (MST : Mr Kumaradevan)
29 May - MST AGM 2021. (MST: All members).
15 June - Latrodectus
geometricus Envenomation in Malaysia
Webinar. Organiser: Department of Parasitology,
University of Malaya. (RECS: Dr Khaldun).
19 June - Dangerous Creature
Underwater Webinar. Organiser: VGO Dive
Centre. (MST: Dr Naim).
10 July - AFCT Progress Meeting. (RECS: All).
8 September - AFCT Program and Curriculum
presentation to the Department of Emergency
Medicine, Faculty of Medicine, Universiti
Kebangsaan Malaysia. (RECS: All).
11 September - 1st UKM Emergency Medicine
Housemenship Academic Project Competition
2021: Topic of Rate of Proximal Progression (RPP)
Virtual Judging Session. Organiser: Department of
Emergency Medicine, HCTM Cheras. (RECS: Dr
Khaldun, Dr Sabrina, Dr Francis Bonn, Dr Aida, Dr
Shukruddeen).
21 October - Webinar Hari Reptilia
Sedunia. Organiser: Econinja.my (MST: Dr
Khaldun).
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31 October - Taichung Veterans General Hospital
International Medical Conference 2021: The
Current Practices & Recommendations for Snake
Related Injuries Organiser: Taichung Veterans
General Hospital (MST: Dr Khaldun & Dr Choo
Hock).
31 October - "Herps": Their Science &
Conservation Webinar. Organiser : Herpetological
Society of Singapore, John Beaufoy
Publishing.(MST: Prof Indraneil Das).
3 November - International Society on Toxinology
Hybrid Conference 2021: Day 3 Session 7 (
Envenomation). Topic: The Strategies in Preventing
and Treating Envenoming in the Asia - Pacific
Region: A Perspective from Malaysia &
ASEAN. Organiser: IST. (RECS: Dr Khaldun).
19 November - International Symposium for Poison
Control & Research Development 2021: Unusual
Challenge in Clinical Toxicology. Topic: Health
Seeking Behaviour following Snake Related Injuries
Consulted to Remote Envenomation Consultancy
Services, Malaysia. Organiser: Taiwan Poison
Control Centre (RECS: Dr Khaldun).
9 December - Hospital Serdang Hospital CME :
Snakebite (Myths and Reality) by Dr Lim Eu Jack,
EP H Serdang. Organiser: Hospital
Serdang. (RECS: Dr Khaldun, Dr Shuk, Dr Sabrina).
9 December - E- CME Snakebite Envenomation
Management. Organiser: Hospital Haji Sultan
Ahmad Shah Temerloh, Pahang. (RECS: Dr Zainal,
Dr Aida, Dr Anas, Dr Sabrina).
10 December - Hospital Kuala Lumpur Toxicology
Week : Appropriate Health and Safety Seeking
Behaviour (AHSB). Organiser: Department of
Emergency Medicine, HKL. (RECS: Dr Khaldun & KL
Exopetz Team).
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14 December - Snakebite Envenomation and
Marine Envenomation and Poisoning
Lectures. Organiser: Tohoku University Graduate
School of Medicine. (RECS: Dr Khaldun).
16 December - WHO SBE Community
Engagement Stakeholder Forum
Discussion. Organiser: SBE WHO. (MST: All).
18 December - 11th Asian Conference on
Emergency Medicine 2021. Toxicology Track 2:
Snake-related Injuries: Strategies for Optimal
Care. Organiser: Hong Kong College of
Emergency Medicine. (RECS: Dr Khaldun).
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MST ACTIVITIES FOR 2022
8 January - Instructional Video Competition:
Animal Bites and Stings. Zoom Online. Organiser:
Department of Emergency Medicine HCTM, RECS,
MST & EMSA. (RECS).
10 - 12 January - RECS Standardisation Workshop
2022. Zoom Online Course. Organiser: RECS &
MST (RECS).
8 January - Onsite Official Launch Ceremony of
the 3rd Edition of Land Snakes of Medical
Significance in Malaysia 2022. Organiser: Ministry
of Energy and Natural Resources (KeTSA). (MST &
RECS).
28 January - Presentation on the Formation of
Special Interest Group in Clinical Toxinology,
College of Emergency Physician, Academy of
Medicine Malaysia. Webex Meeting. Organiser:
CEP Malaysia (RECS).
29 January - Early expert and representative
meeting for final draft report for burden of
snakebite and access to antivenom in ASEAN,
Funded by Wellcome Trust. Zoom Online
Meeting. Organiser: Researcher teams (RECS &
MST).
30 January - World Neglected Tropical Disease
Day.
16 February - Appropriate Snake Antivenom for
Malaysia Webinar. Zoom Online
Course. Organiser: Department of Emergency
Medicine HCTM, RECS & MST (RECS).
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24 February - Morbidity and Mortality Review on
Snakebite Related Death - Hospital Putrajaya.
Zoom Online Course. Organiser: Department of
Emergency Medicine H Putrajaya. (RECS).
17 - 18 March - CREPSUM / IOC-WESTPAC Online
Workshop on Jellyfish Identification. Zoom Online
Course. Organiser: JPJS, CREPSUM, CEMACS, USM.
24 March - Clinical Toxinology: Is It relevant to
Medical Students. Zoom Online Course. Organiser:
Department of Emergency Medicine HCTM,
RECS & MST (RECS).
29 March - National Stroke Grand Round Case
Discussion. Zoom Online Course. Organiser:
Department of Emergency Medicine H Putrajaya,
MSC, UPM, Docquity, RECS, CEP SIG NeuroEM and
ClinToxino (RECS : Dr Khaldun).
30 March - Tumbuhan dengan Khasiat Perubatan,
Manfaat atau Mudarat. Zoom Online
Course. Organiser: National Poison Centre, USM,
RECS & MST (RECS: Dr Aida).
31 March - 2 April - Wilderness Emergency First
Aider and Training of Trainers for Wilderness
Emergency First Aider Course 2022. Organiser:
Wilderness EMS Sabah Team, KRK ETD HLD, WAMS,
RECS & MST @ Hospital Lahad datu, Sabah. (MST:
Dr Naim).
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5 April - National Biodiversity Database:
Pengurusan Maklumat Toksinologi di dalam MyBIS:
Impact on MyBIS-RECS Toxinology Module
Collaborations from 2017 - 2022. Zoom Online
Course. Organiser: MyBIS, RECS & MST (RECS: Dr
Khaldun).
20 April - Clinical Toxinology: Marine Envenoming
and Poisoning. Zoom Online Course. Organiser:
Department of Emergency Medicine HCTM,
RECS & MST (RECS).
23 April - Herp Talks: Health and Safety Measure for
Snake-Related Injuries in Malaysia, Zoom Online
Course. Organiser: Malaysian Nature
Society (RECS: Dr Khaldun).
27 April - Prevention in EM Webinar 3/2022 -
Rawatan Awal Gigitan Haiwan Berbisa. Zoom
Online Course. Organiser: CEP AMM. (MST: Dr
Naim).
26-28 May - Annual Snakebite Conference 2022,
Indian Society for Toxinology and Snakebite
Mitigation (ISTSM), India. Snake venomics: recent
progress and implications in Southeast Asia. (MST:
Dr Choo Hock)
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2 June - Clinical Toxinology: Is It Relevant for
Medical Students? Zoom Online
Course. Organiser: Department of Emergency
Medicine HCTM, RECS & MST (RECS).
3 June - Aquatic Life Support: Topic: Marine
Envenomation. Organiser: Department of
Emergency Medicine HUSM@Auditorium ETD
HUSM. (RECS: Dr Zainal).
5 June - Kursus Wilderness Medicine Pasukan
Bergerak Orang Asli. Topik : Animal Bites, Stings
and Envenomations. Organiser: Department of
Emergency Medicine H Selayang & HBOA
Gombak, Selangor. (RECS: Dr Edel).
25 June - Snake Awareness, Safety and First Aid for
Snakebites Seminar. Organiser: Akademi
Bombadan Penyelamat Malaysia Wilayah Timur,
Terengganu @ Auditorium Akademi Bomba, UUM,
KKM. (RECS: Dr Zaki).
8 July - Clinical Tox2 Awareness (Toxicology and
Toxinology) Day 2 SEM H Selayang. Organiser:
Department of Emergency Medicine H Selayang,
RECS & MST. (RECS: Dr Edel, Dr Zainal, Dr Anas
Amri, Dr Aida).
14 July - CME Snake Related Injuries: What Primary
Care Physicians Should Know. Zoom Online
Course. Organiser: Department of Family Medicine
HCTM. (RECS: Dr Khaldun).
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16 July - First Aid on Venomous Bites Awareness
Talk. Organiser: Malaysian Nature Society
Kedah. (MST: Mr Kumar).
16 July - One-Day National Symposium on Snake
and Scorpion Envenomation and Therapy:
National and International Perspectives, Institute
of Advanced Study in Science and Technology,
India. Unveiling venom variability of kraits
(Bungarus species) through venomics: Impacts on
snakebite envenoming and treatment. (MST: Dr
Choo Hock)
28 July - Clinical Toxinology: Is It Relevant for
Medical Students? Zoom Online
Course. Organiser: Department of Emergency
Medicine HCTM, RECS & MST (RECS).
7 August - Kursus Pertolongan Cemas Untuk
Gigitan/Sengatan/Patukan Haiwan-Haiwan
Berbisa/Berbahaya. Organiser: SMK (Persendirian)
Sin Min, Sungai Petani, Kedah, MST, St John
Ambulance Malaysia Kedah. (MST: Mr Kumar).
23 - 24 August - 7th National Clinical Toxicology
Course. Organiser: Department of Emergency
Medicine SGH Sarawak, CEP SIG Clinical
Toxicology & Clinical Toxinology @UNIMAS. (RECS:
Dr Sabrina, Dr Anisah).
1 September - 4th Emergency Medicine Seminar
Series 2021 (Part 1) - Clinical and Analytical
Toxicology Theme. Zoom Online
Course. Organiser: Department of Emergency
Medicine HCTM, RECS & MST, SIG ClinToxino, et al.
7 September - Site Visit to Klinik Kesihatan Pangkor
and Pangkor Beaches, Perak. (RECS: Dr Sabrina).
8 September - 4th Emergency Medicine Seminar
Series 2021 (Part 2) - Marine Organism
Envenomation and Poisoning Theme. Zoom Online
Course. Organiser: Department of Emergency
Medicine HCTM, RECS & MST, SIG ClinToxino, et al.
11 September - Kursus Pertolongan Cemas Untuk
Gigitan/Sengatan/Patukan Haiwan-Haiwan
Berbisa/Berbahaya. Organiser: MST, St John
Ambulance Malaysia Pulau Pinang. (MST: Mr
Kumar).
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15 September - 4th Emergency Medicine Seminar
Series 2021 (Part 3) - Land Organism Envenomation
and Poisoning Theme. Zoom Online
Course. Organiser: Department of Emergency
Medicine HCTM, RECS & MST, SIG ClinToxino, et al.
22 September - 4th Emergency Medicine Seminar
Series 2021 (Part 4) - Environment and Wilderness
Medicine Theme. Zoom Online Course. Organiser:
Department of Emergency Medicine HCTM,
RECS & MST, SIG ClinToxino, et al.
24 - 25 September - National Emergency Critical
Care Symposium 2022: 5 Most Difficult Poisoning to
Treat. Organiser: Ipoh Emergency Critical Care
Society @ Auditorium HRPB Ipoh, Perak. (Dr
Sabrina).
1 October - MST AGM (without Election) @
Cinnamon Coffee House, One World Hotel,
Petaling Jaya, Selangor.
8 October - Snakebite/Venomous Animals
Bites/Stings First Aid Course Organiser: MST, St John
Ambulance Malaysia Kedah. (MST : Mr Kumar).
9 October - Snake and Envenomation. Organiser:
Malaysian Conservation Alliance for Tigers
(MyCAT) @ Private Lounge Kiara Bay Sales Gallery,
Kuala Lumpur. (RECS; Dr Khaldun).
16 - 20 October - 21st World Congress of the
International Society on Toxinology Organiser:
IST@Conrad Abu Dhabi Etihad Towers, UAE. (MST:
Dr Choo Hock, Dr Kae Yi, Prof Iekhsan, Dr Maha, Dr
Praneetha).
17 October - Snake Related Injuries: What Primary
Care Professional Should Know. Organiser:
Toxicology Unit, Emergency Department, Saitama
Medical University Moroyama Campus,
Japan. (RECS: Dr Khaldun).
17 - 18 October - Emergency Medicine Annual
Symposium Meeting (EMAS-SUCCES-EMS ASIA)
Toxinology Track Topics: Mass Poisoning involving
Toxins: Philippines Experience, Geographical
Distributions of Pit Vipers Spp in Malaysia Identified
via RECS, Clinical Presentation and Outcome of
Naja Spp Injuries Consulted to RECS
Malaysia. Organiser: CEP AMM. (RECS&MST&CEP
SIG ClinToxino- Dr John David, Dr Reza, Dr Anuar).
19 October – Bengkel Kesedaran Terhadap
Ancaman Keselamatan Berhubung Sengatan
Obor-obor Merbahaya. Topic: Medical Approach
to Jellyfish Sting. Organiser: CEMACS, USM &
Jabatan Perikanan Negeri Pahang. (Dr Sabrina).
29 October - First Aid Course for
Snakebite. Organiser: RECS, MST, Universiti Sultan
Azlan Shah Perak, KL Exopetz (RECS & MST).
16 - 17 November - 4th Malaysia Congress of
Toxicology (MyCOT 2022). Topic: Clinical
Toxicology and Its Development in
Malaysia. Organiser: MySOT, UIAM @ UIAM (MST: Dr
Sabrina).
18 - 19 November - 2022 International Symposium
for Poison Control and research Development:
Novel Aspect in Clinical Toxinology. Topic : Clinical
Presentation and Outcome of Naja Spp Injuries
Consulted to RECS Malaysia. Organiser: Taipei
Veterans General Hospital, Taiwan. (RECS & MST).
28 - 29 November - 8th National Clinical
Toxicology Course. Organiser: Department of
Emergency Medicine HTAR Klang, CEP SIG Clinical
Toxicology & Clinical Toxinology @ NIH Setia Alam,
Selangor. (RECS: Dr Sabrina, Dr Anisah).
17 December - Emergency Medicine Clinical
Toxinology Webinar. Organiser: Department of
Emergency Medicine HCTM, CEP SIG Clinical
Toxinology, RECS, MST, EMSA, PERSIAP, PPPM, PRN.
(Dr Emelia, Dr Aida Nur Sharini, Dr Anas Amri, Dr
Khaldun, Dr Zainal, Dr Sabrina)
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Highlight | The Relevance of Clinical Toxinology in
Wilderness Medicine
Dr. Muhamad Na’im Bin Ab Razak (MD, MRCEM, FEWM)
Emergency and Trauma Department, Hospital Lahad Datu, Sabah
The Wilderness Medical Society (WMS) defines wilderness medicine (WM) as caring for a
patient who is an hour away from a hospital that can provide definitive care. Unfortunately, the
journey can take days to weeks. WM is also about the interaction between people and their
environment and the richness of biodiversity. However, there is a grey area in defining patients who
are hospitalized after being injured in their environment, such as from an envenomation occurring in
the city. For the sake of discussion, such injuries are grouped under the WM.
Imagine you are in the middle of an expedition in a remote area where it was impossible to
reach hospital within the golden hour after an accident. You are the wilderness doctor in charge of
the expedition when one of the participants is bitten by a snake. What should you do? One of the
most difficult questions to answer is: should we stop the expedition or continue? This is a very complex
decision-making process, as both options have implications for the expedition.
“Continue with the expedition, and the victim dies from neurotoxic snake envenomation – the
blame is on you!” Abort the expedition and it turns out the patient only bitten by a non-venomous
snake after a very difficult and expensive evacuation - the organization may blame you for the false
alarm.
While a wilderness expedition is costly and requires extensive preparation, it is also adventurous
and can lead to a groundbreaking discovery. Unfortunately, a medical mishap can occur, resulting
in cardiac arrest. Unlike inpatient settings, victims have a poor prognosis if definitive care cannot be
provided in a timely manner. Of all patients with cardiac arrest in the wild, envenomation cases are
reversible and have better prognosis than other causes, such as myocardial infarction. Therefore,
early first aid treatment and identification of patients for early evacuation are extremely important.
To do this with excellence, you must have adequate knowledge and experience in clinical
toxinology.
There are several international organizations that teach WM. The curriculum is extensive, but
when it comes to clinical toxinology, it is less relevant to our local setting because of the different
endemic venomous animals, envenomation syndrome, and treatment protocol.
In Malaysia, with the establishment of the Wilderness and Austere Medicine Society Malaysia
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(WAMS Malaysia) in 2019 and the Wilderness Medicine Special Interest Group, College of Emergency
Physicians Malaysia, in 2022, WM is a new fraternity that heralds the new era of the specialty in
Malaysia. Previously, the Malaysian Society on Toxinology (MST) had been collaborating with the
Wilderness EMS Team, Jabatan Kecemasan dan Trauma Hospital Lahad Datu (which was later
involved in the establishment of WAMS Malaysia) on the clinical toxinology curriculum since 2015,
focusing on problems caused by locally endemic venomous animals. The collaboration focuses not
only on education, but also on sharing clinical experiences and local research in clinical toxinology.
In Sabah, it has been determined that the Malayan Pit Viper is not endemic there and
envenomation by other pit vipers can be treated with QSMI Green Pit Viper Antivenom or QSMI
Haemato Polyvalent Snake Antivenom. Therefore, QSMI Malayan Pit Viper Antivenom is no longer
stocked in most hospitals in Sabah. Although there is no Monocled Cobra in Sabah, QSMI Monocled
Cobra Antivenom was found to be able to neutralize envenomation by the locally endemic
Equatorial Spitting Cobra. The knowledge is very important as we can plan a suitable strategy for
obtaining the appropriate antivenom.
There are many unconfirmed reports of children from different states of Sabah who were stung
by unidentified jellyfish and died. Between 2006 and 2022, six deaths were recorded in children under
the age of 10. The MST has worked with several institutions on this issue. As recently as 2019, the killer
responsible was identified as Chironex yamaguchii. In 2022, a patient with Irukandji-like syndrome
presented to Tawau Hospital after being stung by an unidentified jellyfish. The syndrome, usually
associated with the sting of smaller carybdeid box jellyfish, had never been reported as the
causative organism and is not endemic here. A field survey was conducted and a carybdeid box
jellyfish was retrieved. This specimen was believed to be a Morbakka sp. (exact identification is
pending). These events are good examples of how sknowledge of clinical toxinology can be helpful
in the field of WM while future scientific expedition may discover other venomous animals.
Clinical toxinology is also important in determining risk and mitigation strategies prior to a
wilderness expedition. A prior knowledge of endemic venomous animals, the number of cases of
sting- bite-envenomation, the available hospital nearby that provides antivenom, and the presence
of intensive care unit will help a wilderness and expedition physician properly plan their expedition.
Although carrying antivenom and administering antivenom in the field is not currently practiced, it
could be considered in the future for an expedition where there is a high risk of envenomation cases
and it would take days to evacuate the patient to the hospital.
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Highlight | Recent Progress in Toxinology Research for Two
Spitting Cobras of the Philippines: Naja philippinensis and
Naja samarensis
Assoc. Prof. Dr. Tan Choo Hock (PhD, MD, MBBS)
Venom Research & Toxicology (Vetox) Lab
Department of Pharmacology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur
In Asia, there are at least ten different species of cobra (ular tedung). Virtually all cobras are
considered medically important, as their bites can result in fatal and debilitating envenomation
(toxicity caused by the venom injected into the victim). The Philippine Cobra (Naja philippinensis)
and Samar Cobra (Naja samarensis, also known as Peter’s cobra) are two medically important
venomous snakes (Category 1) endemic to the Philippines. Naja philippinensis distributes in the
northern Philippines (the islands of Luzon, Mindoro, Catanduanes, Azria and Masbate), while N.
samarensis is found in the southern regions, specifically the Visayas and Mindanao island groups
(Figure). Both species cause severe neurotoxic envenoming, and are capable of spraying venom
into the eyes of victims, causing venom ophthalmia. Research is needed to understand how the
venom of individual species works, and how their envenomation can be best treated.
Recent proteomic studies undertaken at the Vetox Lab in Universiti Malaya successfully
decoded the secret of the two cobras: both the species produce venoms that are very unique from
other known cobra species throughout Asia and Africa. The venoms of these Philippine cobras
contain very high abundance of three-finger toxins (66–91% of total venom proteins) in which short
alpha-neurotoxins predominate exclusively (45–66%) without long alpha-neurotoxins (1,2). The high
abundances of alpha-neurotoxins correlate with the venoms’ high lethality (i.v. LD50 < 2 µg/g in
mice). LD50 (median lethal dose) is the dose of venom that kills half of the mice tested; hence, the
smaller the number is, the more lethal the venom is. This explains the development of severe
neurological paralysis with rapid onset seen in clinical envenomation caused by these cobras.
Clinically, the treatment must be able to prevent respiratory failure (due to systemic paralysis)
either with assisted ventilation, or more definitively, reversal of the paralysis using antivenom. The
Philippine Cobra Antivenom (PCAV, locally known as Purified Cobra Antivenin) is the only available
species-specific ‘antidote’ to N. philippinensis envenomation in the country. PCAV is a monovalent
antivenom raised against N. philippinensis, and is produced by the Research Institute for Tropical
Medicine (RITM) in the country. The Vetox team has investigated the composition purity,
immunoreactivity and neutralization efficacy of PCAV in order to appreciate its utility in the region3,4.
Biochemical profiling (applying gel electrophoresis and size-exclusion chromatography) and
proteomics (applying LCMS/MS) of PCAV revealed a favourable content of equine immunoglobulins
(constituting ~80% of total antivenom proteins) in the form of F(ab’)2, which represents the key
therapeutic component of this biologic (3). The antivenom, however, also contained some protein
impurities (mainly non-immunoglobulin plasma proteins). This finding reveals a concern for
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hypersensitivity reactions.
Using a venom-binding ELISA (enzyme-linked immunosorbent assay) system established in the
lab, the Vetox team further showed that PCAV could immunologically bind to the venom proteins of
both N. philipinensis and N. samarensis (4). Its immunorective reactions toward both venoms were
comparable, indicating conserved antigenicity in the toxins of both venoms. In the evaluation of its
efficacy, the WHO-recommended gold standard protocol for lethality neutralization was adopted. In
in vivo experiment, PCAV was only moderately effective in neutralizing the toxicity of both venoms.
Its neutralization potency was even lower against the hetero-specific N. samarensis venom by half as
compared with its potency against N. philippinensis venom4. The para-specific cross-neutralization
activity of PCAV suggested the antivenom can be used to treat N. samarensis envenomation but
likely requires a higher dose. This may be another concern of increased risk of hypersensitivity, and
worsening of antivenom shortage in the field, as PCAV production and supply are limited. Currently,
the team aims to improve the purification processes for antivenom production, and to develop a
low-dose, high-efficacy antivenom product that is effective against the venoms of various cobra
species. Research partnership is important to achieve a greater impact, and the Vetox team warmly
welcome collaboration from researchers and industry in the region. (Contact:
tanchoohock@gmail.com)
References:
1. Tan, C. H., Wong, K. Y., Chong, H. P., Tan, N. H., Tan, K. Y. (2019) Proteomic insights into short neurotoxin-driven, highly neurotoxic
venom of Philippine cobra (Naja philippinensis) and toxicity correlation of cobra envenomation in Asia. Journal of Proteomics,
206, 103418. DOI: 10.1016/j.jprot.2019.103418
2. Palasuberniam, P., Chan, Y. W., Tan, K. Y., Tan, C. H. (2021). Snake venom proteomics of Samar Cobra (Naja samarensis) from the
Southern Philippines: Short alpha-neurotoxins as the dominant lethal component weakly cross-neutralized by the Philippine Cobra
Antivenom, Frontiers in Pharmacology, 12, 727756. DOI: 10.3389/fphar.2021.727756
3. Tan, C. H., Palasuberniam, P., Blanco, F. B., Tan, K. Y. (2021). Immunoreactivity and neutralization capacity of Philippine Cobra
Antivenom against Naja philippinensis and Naja samarensis venoms. Transactions of the Royal Society of Tropical Medicine and
Hygiene, 115, 78-84. DOI: 10.1093/trstmh/traa087
4. Palasuberniam, P., Tan, K. Y., Chan, Y. W., Blanco, F. B., Tan, C. H. (2022) Decomplexation proteomic analysis and purity
assessment of a biologic for snakebite envenoming: Philippine Cobra Antivenom. Transactions of the Royal Society of Tropical
Medicine and Hygiene, in press.
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Highlight | A Small Yet Life-Saving Impact
Dr. Praneetha Palasuberniam (MD, PhD)
Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, University Malaysia
Sabah, Sabah
Why the sudden urge to find new therapeutic options for snakebite envenoming? Are small
molecule therapeutics next in line, replacing the century-old treatment modality of animal-derived
antivenoms? The answers to such questions lie within the complex pathophysiology of snakebite
envenoming. Many features contribute to the global problem of snakebite envenoming; poverty,
lack of medical infrastructure and ineffective treatments (1). There are some 1.8 – 2.7 million
snakebite cases annually, with far too many being killed or permanently disabled (2).
Snake venoms contain complex mixtures of toxins that have now been well-described in
many species, and specific toxin families from medically important venomous snakes exert their toxic
effects in multiple ways, including paralytic neurotoxicity and bleeding disorders amongst a wide
array of clinical syndromes.
Here lies the key. High-quality conventional antivenoms can abrogate most or all toxin effects.
However, this is not always the case. Thus, the search for better alternatives. Between a snake bite
and hospital-level care, several medications may be repurposed to fill the therapeutic and temporal
gaps. These toxin inhibitors have been proposed for in-field use, in hospitals (as adjuncts to
antivenom therapy) and in post-hospital uses, reducing morbidities and perhaps even mortalities.
There is a number of drugs that have
been repurposed and are in the in vitro and in
vivo explorative stages. Amongst these
inhibitors, varespladib and unithiol,
phospholipase A2 and snake venom
metalloproteinase inhibitors, respectively, are
the very first drugs to be repurposed for treating
snakebite envenoming. Both are currently in the
clinical trial pipeline for safety and tolerability
for short-term usage and varespladib to assess
efficacy (ClinicalTrials.gov Identifier:
NCT04996264 and Pan African Clinical Trial
Registry ID: PACTR202103718625048). These are
the first two candidates to enter trials for many
decades. What is missing is an overarching
guidance on what a repurposed drug should
look like to help position such drugs (if they are
successful in trials) in the market—hence the
need to develop Target Product Profiles (TPPs)
for using small molecule inhibitors. A team at
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the World Health Organization, of which I am part, is creating a landscape analysis and TPP for the
development of small molecule inhibitors, due for publication in 2023.
These inhibitors, which target lethal
proteins, recognize the active catalytic sites,
bind, and suppress the catalytic processes,
transforming them into a therapeutic possibility
by suppressing enzymatic activities.
Accordingly, inhibition of a single group of
toxins or multiple toxin components is worthy of
exploration as they have been shown to inhibit
toxicities and/or prolong survival in mice
models (3,4). Returning to the questions posed
at the beginning, the answer is yes,
repurposed drugs against known toxins offer
new potential therapeutic options for
snakebite envenoming; however, it will act as
an adjunctive therapy, not completely
replacing the current treatment, antivenom.
We thank Wellcome for funding this work.
References:
1. Albulescu, L.-O., Hale, M. S., Ainsworth, S., Alsolaiss, J., Crittenden, E., Calvete, J. J., Evans, C., Wilkinson, M. C., Harrison, R. A., Kool,
J., & Casewell, N. R. (2020). Preclinical validation of a repurposed metal chelator as an early-intervention therapeutic for
hemotoxic snakebite. Science translational medicine, 12(542), eaay8314. https://doi.org/10.1126/scitranslmed.aay8314
2. Gutiérrez, J. M., Calvete, J. J., Habib, A. G., Harrison, R. A., Williams, D. J., & Warrell, D. A. (2017). Snakebite envenoming. Nature
Reviews Disease Primers, 3(1), 17063. https://doi.org/10.1038/nrdp.2017.63
3. Lewin, M., Samuel, S., Merkel, J., & Bickler, P. (2016). Varespladib (LY315920) appears to be a potent, broad-spectrum, inhibitor of
snake venom phospholipase A2 and a possible pre-referral treatment for envenomation. Toxins (Basel), 8(9).
https://doi.org/10.3390/toxins8090248
4. Longbottom, J., Shearer, F. M., Devine, M., Alcoba, G., Chappuis, F., Weiss, D. J., Ray, S. E., Ray, N., Warrell, D. A., Ruiz de
Castañeda, R., Williams, D. J., Hay, S. I., & Pigott, D. M. (2018). Vulnerability to snakebite envenoming: a global mapping of
hotspots. The Lancet, 392(10148), 673-684. https://doi.org/10.1016/S0140-6736(18)31224-8
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Highlight | Point-of-Care Testing for Snakebite
Envenoming: How Prepared are We?
Dr. Tan Kae Yi (Ph.D.)
Department of Molecular Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur
Assoc. Prof. Dr. Tan Choo Hock (Ph.D., MD)
Department of Pharmacology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur
Point-of-care (POC) testing is medical diagnostic testing at the time and place of medical care
to determine the underlying issue that brought a patient to the doctor. This handy medical test
performed at the bedside can provide an accurate and timely diagnosis for appropriate
management, disease surveillance and effective public health responses. Despite this, the
significance of access to timely diagnosis remains underappreciated, especially in low- and middle-
income countries (1). This problem is particularly worse in snakebite envenoming (SBE), a top priority
neglected tropical disease declared by the World Health Organization (WHO) in 2017 (2).
Every year, SBE costs the lives of countless people and leaves behind enormous numbers of
permanent disabilities worldwide (3). SBE victims are fundamentally powerless and voiceless people
of impoverished populations living in poverty. Unfortunately, this tragic situation remains unresolved
today, partly due to inadequate global efforts in tackling various SBE-related issues. While the supply
of safe and effective antivenom is limited globally, a reliable POC test to aid in the appropriate
selection of the “right” treatment is virtually non-existent in most of the affected regions. This is
another major issue that impedes the progression of improved management of snakebites.
Without POC testing, doctors usually decide on the treatment based on patient’s description of
the snake, captured snake specimen (if brought in and in good shape), or toxic signs and symptoms
developed in the patient. Although these methods may be useful, they can be rather non-specific
and time-consuming, causing a delay in the treatment or even misidentification of the snake
species. Furthermore, diagnosis based solely on clinical observation of signs and symptoms can be
difficult to discriminate between species which cause similar envenoming effects clinically.
Misidentification of snake may result in the administration of non-specific or inappropriate antivenom
to the patient (4).
As everything happens for a reason, the unavailability of the snakebite POC test is mainly due to
various technical difficulties. Snake venoms are intrinsically complex, containing different toxins of
varying amounts and toxic activity. This is further complicated by the huge diversity of venomous
snake species and their geographical distribution in different regions, where snake venoms can vary
greatly in composition, toxicity and antigenicity not only between different species but also within a
same one. The diversity of snake venom, in general, has hindered the progression of snakebite
diagnostic development. Therefore, even though there is an unmet market need for snakebite
diagnostic, it fails to entice profit-seeking industries to invest in the development of an accurate and
sensitive POC test while ensuring its affordability and sustainability.
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Where there’s a will, there’s a way. Taking small steps, the venom research group in Universiti
Malaya built on their venomic findings (-OMICs research on snake venoms) to discover unique
toxin(s) that can be utilized as a target analyte for snakebite diagnostic (5). Through proteomics,
venom purification and animal immunization techniques established by the team, it is shown that
novel antibodies produced from a unique toxin have the potential utility of diagnostic for cobra bite
(5). These antibodies also serve the purpose of clinical monitoring of envenomation in addition to
rapid diagnosis of cobra bites. The discovery has also inspired the team to further develop a new
immunodiagnostic test by harnessing antibodies from the antivenom production pipeline. It is
envisaged that this approach will pave way for the development of a more economic and
sustainable POC test in the region.
With this evidence supporting the
development of snakebite POC, naturally
the next question is how prepared are we
to adopt the test in clinical settings?
Admittedly, there are many challenges
that must be overcome prior to its
implementation at the bedside. For
instance, the design of an effective POC
test requires a comprehensive
understanding of the snake species
distribution and their venom
characteristics pertaining to individual
species as well as venom variation that
may arise within the same species. This
knowledge gap can be gradually filled in
by high-throughput venomics, as shown
by series of comparative venom profiling
for close to a hundred snake species in Asia and Africa. From the patient’s perspective, treatment
efficacy and safety must be prioritized; thus, the concurrent development of reliable diagnostics and
high quality antivenoms is the way to go. Research has proven the feasibility of snakebite POC
testing, and the field now needs genuine collaborative efforts from various parties involved in
snakebite management to ensure that the anticipated outcome is successfully translated. We
therefore believe that the POC test will progressively gain prominence as part of the WHO’s strategic
plan in ensuring a safe and effective treatment of SBE (6). For more details, please contact
kytan_kae@um.edu.my or tanch@um.edu.my. For more information, please visit www.vetoxlab.com.
References:
1. Fleming, K. A., Horton, S., Wilson, M. L., Atun, R., DeStigter, K., Flanigan, J., ... & Walia, K. (2021). The Lancet Commission on
diagnostics: Transforming access to diagnostics. The Lancet, 398(10315), 1997-2050.
2. Chippaux, J. P. (2017). Snakebite envenomation turns again into a neglected tropical disease! Journal of Venomous Animals and
Toxins including Tropical Diseases, 23(1), 1-2.
3. Gutiérrez, et al. (2017). Snakebite envenoming. Nature reviews Disease primers, 3(1), 1-21.
4. Knudsen, C., Jürgensen, J. A., Føns, S., Haack, A. M., Friis, R. U., Dam, S. H., ... & Laustsen, A. H. (2021). Snakebite envenoming
diagnosis and diagnostics. Frontiers in Immunology, 12, 661457.
5. Ong, H. L., Tan, C. H., Lee, L. P., Khor, S. M., & Tan, K. Y. (2022). An immunodetection assay developed using cobra cytotoxin-
specific antibodies: Potential diagnostics for cobra envenoming. Toxicon, 216, 157-168.
6. Williams, et al. (2019). Strategy for a globally coordinated response to a priority neglected tropical disease: Snakebite
envenoming. PLoS neglected tropical diseases, 13(2), e0007059.
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Highlight|Current Opinion on the Role of CSL Box Jellyfish
Antivenom For Jellyfish Sting Envenomation In Malaysia
Dr. Muhamad Na’im Bin Ab Razak (MD, MRCEM, FEWM)
Emergency and Trauma Department, Hospital Lahad Datu, Sabah
Research on jellyfish and jellyfish antivenoms is still in its infancy in Malaysia, although they are a
significant problem in coastal areas of Malaysia. They cause morbidity and mortality, especially in
children. Based on observational data, at least 8 patients died from box-jellyfish stings in Langkawi,
Pangkor Island, and various states of Sabah between 2006 and 2022. These data may be inaccurate
and underestimating the true number of deaths because jellyfish stings are not a reportable disease
in Malaysia. Anecdotal reports have also shown that many of the victims are not taken to a hospital.
Until now, there is only one jellyfish antivenom available worldwide since 1970s to treat
envenomation by box jellyfish which is being produced by the Commonwealth Serum
Laboratories™ (CSL). The use of this antivenom is controversial due to paucity of evidence and
conflicting result.
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Current stands
Given the paucity of evidence, box jellyfish antivenom may not be a superior treatment modality.
Evidence-based first-line treatment and clinical management should be initiated. However, further
studies including in vitro and clinical data are needed to determine the benefit of box jellyfish
antivenom. Until these are available, we believe it is unethical to withhold the antivenom when it is
clinically indicated. Therefore, the antivenom should be retained in a region with confirmed
chirodropid box jellyfish. Mobilization of box jellyfish antivenom should be coordinated if the jellyfish
sting occurs in the hospital that has not stored the antivenom. Remote Envenoming Consultation
Services (RECS) and MST can continue the coordination that is already in place for the use of jellyfish
antivenom and proceed with data collection as well as auditing the use of antivenom.
Reference:
1. Cegolon L, Heymann WC, Lange JH, Mastrangelo G. Jellyfish stings and their management: a review. Mar Drugs. 2013 Feb
22;11(2):523-50. doi: 10.3390/md11020523. PMID: 23434796; PMCID: PMC3640396.
2. Winkel, Kenneth D., Hawdon, Gabrielle M., Fenner, Peter J., Gershwin, Lisa-Ann, Collins, Allen Gilbert, and Tibballs, James. 2003.
"Jellyfish antivenom: Past, Present and Future." Toxin Reviews. 22 (1):115–127.
3. Currie, B. (1994). Clinical implications of research on the box jellyfishChironex fleckeri. Toxicon 32:1305 – 1313
4. E.H.Baxter A.G.M.Marr, "Sea wasp (Chironex fleckeri) antivenene: Neutralizing potency against the venom of three other jellyfish
species" Toxicon Volume 12, Issue 3, May 1974, Pages 223-229
5. Gershwin, L. (2006). Comments on Chiropsalmus (Cnidaria: Cubozoa: Chirodropida): a preliminary revision of the Chiropsalmidae,
with descriptions of two new genera and two new species. Zootaxa. 1231: 1–42.
6. Lewis, Cheryl, Bentlage, Bastian (2009): Clarifying the identity of the Japanese Habu-kurage, Chironex yamaguchii, sp. nov.
(Cnidaria: Cubozoa: Chirodropida). Zootaxa 2030: 59-65, DOI: 10.5281/zenodo.186248
7. Chuan, C.H.; Venmathi Maran, B.A.; Yap, T.K.; Cheong, K.C; Syed Hussein, M.A.; Saleh,E. New Records of Cubozoan and
Scyphozoan Jellyfish from Sabah Waters, Malaysia. Diversity 2021, 13,420.
8. Kitatani R, Yamada M, Kamio M, Nagai H (2015) Length Is Associated with Pain: Jellyfish with Painful Sting Have Longer
Nematocyst Tubules than Harmless Jellyfish. PLoS ONE 10(8)
9. Lau, MT., Manion, J., Littleboy, J.B. et al. Molecular dissection of box jellyfish venom cytotoxicity highlights an effective venom
antidote. Nat Commun 10, 1655 (2019). https://doi.org/10.1038/s41467-019-09681-1
10. Andreosso et al.: Dose and time dependence of box jellyfish antivenom. Journal of Venomous Animals and Toxins including
Tropical Diseases 2014 20:34.
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Highlight|Widows in the House: A Tale of Venomous Spider
Amir Ridhwan Mohd Ghazali
Founding member of the Asian Society of Arachnologr
Some time in 2012 I received a call from my colleague at the Arthropod Research Laboratory in the
Faculty of Medicine in the University of Malaya asking me to check my email. There were some
photos of tangled spider webs and white spiky balls which were egg sacs. There was also a blurry
photo of a dead spider in such an unhelpful angle which could be anything from probably 20
families and a few hundred genera. In the phone call I was told that a lady in Bukit Mertajam found
several of these spiders while cleaning her new house and she was afraid that it was a black widow.
The carcass looked similar but it was impossible to distinguish conclusively as a black widow based
on a photo taken using an early generation smartphone. Furthermore, of the 32 widow spiders
known to science, none has ever been recorded in Malaysia. Just how people can imagine a lot of
things from watching TV and reading chained email.
However a scientist is a natural detective who ought not to dismiss possibilities should there is
even a sliver of hint to arouse suspicion. Whenever there is something we haven’t yet fully
understand being present in the picture, an investigation should be in order. What piqued me was
the odd shape of the spiky egg sacs which, at a glance, were similar to that of spiders from the
family Uloboridae, which totally lacks venom gland, but whose sacs are oblong instead of spherical.
After closer examination and consult from a friend in the Netherlands, I had a strong suspicion that
we were looking at the first sighting in Malaysia of Latrodectus geometricus, also commonly known
as brown widow, a relative of the infamous black widow. Our lab immediately dispatched an overly
excited team to Bukit Mertajam to collect specimens which later progressed into a study of its global
distribution.
Despite being depicted as agents of evil in many folklore, spiders are reclusive animals that will
retreat quickly when being confronted by a larger animal such as a curious bipedal primate. Most
spider venoms are particularly potent against arthropods and their fangs are too small or weak to
administer venom through the human skin. Some, however, are of medical interest such as those
from the genus Latrodectus, also infamously known as the widow spiders. They have lanky legs, a
sexy yet ridiculously high waist-to-hips ratio and you can easily tell one by the hourglass mark at the
ventral part of the abdomen. Their venom glands carry latrotoxin, a cocktail of several neurotoxins
that are target-specific. One of these is the alpha-latrotoxin that is a pure stimulatory neurotoxin
particularly active on vertebrate synapse. In human, a bite can cause intense muscle pain, cramp
and nausea. This is what granted the widow spiders their celebrity status, apart from their renowned
sexual cannibalism habit that gave rise to the deserving moniker.
While writing the paper on the new record of brown widow in Bukit Mertajam, members of the
lab, now fully aware of its existence, began to find them in the oddest places such as in a car and at
a bicycle wheel. I found a colony underneath the table I was having lunch in a mamak restaurant,
which caused some worried looks among the staff when they saw a customer crouching under the
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table appearing to collect cobwebs. This observation triggered another suspicious- how did they
spread under our nose?
The brown widow is a cosmopolitan species, making our home theirs. They take free rides on
freight ships to faraway ports, then make nests in warehouses and disperse by air like dandelion
seeds into the countryside by weaving silk parachutes. We have recorded non-fatal envenomation
cases in Tawau and Paka, both with the culprits taking up residence in motorcycle helmets that have
been left unused for some time. The bites were described as intense pain, numbness and a burning
sensation which compare well to the symptoms of latrodectism. It seems reasonable to assume that
more incidents went unreported during the Covid-19 pandemic as people avoid visiting hospitals
and tend to self-treat benign bites from seemingly harmless tiny critters.
Creating awareness is what scientists always longed for but often denied. We believe that
knowledge can often prevent a mishap from escalating into a calamity if only we can get it across
to as many people as possible. With knowledge comes the ability to act wisely and timely,
sometimes saving lives. My wish is that this article can make a small contribution to the awareness on
the widows in the house.
Uniques shape of the egg sacs
Adult female Latrodectus geometricus at the site of first
record in Malaysia in Bukit Mertajam.
Observed predation of adult L. geometricus by jumping
spider Plexippus paykulli.
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Young L. geometricus Adult female guarding the egg sacs
References
1. Muslimin, M., Wilson, J.-J., Ghazali, A.-R. M., Braima, K. A., Jeffery, J., Wan-Nor, F., Alaa-Eldin, M. E., Mohd-Zin, S.-W., Wan-Yusoff, W.
S., Norma-Rashid, Y., Lau, Y. L., Rohela, M., & Abdul-Aziz, N. M. (2015). First report of brown widow spider sightings in Peninsular
Malaysia and notes on its global distribution. The Journal of Venomous Animals and Toxins Including Tropical Diseases, 21.
https://doi.org/10.1186/s40409-015-0010-2
2. Ushkaryov, Y. A., Volynski, K. E., & Ashton, A. C. (2004). The multiple actions of black widow spider toxins and their selective use in
neurosecretion studies. Toxicon, 43(5), 527–542. https://doi.org/10.1016/j.toxicon.2004.02.008
3. Bennett, Kacy M., "α-Latrotoxin Genes are Highly Divergent Between Species of Widow Spiders (Genus Latrodectus)" (2014).
Honors College Theses. 28.
4. Rosenthal, L., & Meldolesi, J. (1989). α-latrotoxin and related toxins. Pharmacology & Therapeutics, 42(1), 115–134.
doi:10.1016/0163-7258(89)90024-7
5. Mowery, M. A., Lubin, Y., & Segoli, M. (2022). Invasive brown widow spiders disperse aerially under a broad range of environmental
conditions. Ethology, 128(8), 564–571. https://doi.org/10.1111/eth.13314
6. A.S., M. (2021). Bite envenomation by Latrodectus geometricus (Araneae: Theridiidae) spiders in Malaysia. Tropical Biomedicine,
38(4), 568–577. https://doi.org/10.47665/tb.38.4.100
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Highlight|Toxic Shellfish Poisoning, Old Problem with
Potential New Solution to Handle the Case Exposure?
Dr. Zainalabidin bin Mohamed @ Ismail
Hospital Tengku Ampuan Afzan, Pahang
Toxic shellfish poisoning is a foodborne illness that develop typically after consumption of
shellfish contaminated with biotoxins. These toxins are heat stable and not destroyed by cooking. The
toxins are originated from toxic algae or plankton which is the food source for the shellfish. The toxins
accumulated in the shellfish without giving significant effect to it. When people consume
contaminated shellfish, the symptoms may develop from 15 minutes to 48 hours and last up to five
days or months in severe cases. Example of shellfish that implicated in the outbreak of toxicity
include mussels, oysters, cockles, clams and scallops. Almost all the incidences involved non-
commercial / self-collect shellfish.
There are four major syndromes of toxic shellfish poisoning: Paralytic Shellfish Poisoning (PSP),
Neurotoxic Shellfish Poisoning (NSP), Diarrhetic Shellfish poisoning (DSP) and Amnestic Shellfish
poisoning (ASP) (Table 1). In 1995 Azaspiracid posisoning (AZP) was described that may also be part
of DSP.
Table 1: Toxic shellfish poisoning syndrome, toxins and symptoms.
Toxic Syndrome
Biotoxins
Source (examples)
Symptoms
Onset and
duration
Paralytic Shellfish
Poisoning (PSP)
Saxitoxins &
gonyautoxins
(Block
nerve/muscle Na+
channel)
dinoflagellates &
algae e.g
Alexandrium
tamarense, A.
catenella,
A. minutum
Numbness of the mouth, lips
and throat, followed by
instability then weakness of
the arms and legs, ataxia,
nausea and vomiting. May
develop frank paralysis and
respiratory failure
Onset 30 mins
to few hours
and lasted for
2 to 5 days
Neurotoxic
Shellfish Poisoning
(NSP)
Brevetoxins A & B
(Stimulate Na+
channels –
parasympathetic
nerve)
Ptychodiscus
dinoflagellate e.g
Karenia brevis
Nausea, abdominal pain,
diarrhoea, numbness,
ataxia, vertigo,
bradycardia,
bronchospasm and
convulsions.
Onset 15 mins
to 3 hours and
lasted for 2 to 3
days
Diarrhetic
Shellfish Poisoning
(DSP)
Derivatives of
okadaiac acid
(binds to intestinal
epithelial cells and
increases their
permeability)
Dinophysis spp.,
Prorocentrum spp
Nausea, abdominal pain
and severe diarrhoea. May
cause hypovolaemic shock
Onset 30 mins
to 5 hours and
last up to 3
days.
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Azaspiracid
poisoning (AZP)
Azaspiracid
dinoflagellates
of the genera
Azadinium and
Amphidoma
Diarrhea, nausea, vomiting,
and abdominal cramps
Onset 3 hours
and last for 15
hours
Amnestic shellfish
Poisoning (ASP)
Domoic Acid
(Excitatory
neuronal
degeneration –
necrosis of
hippocampus,
amygdaloid)
Diatoms e.g
Nitzschia pungens.
Nausea, vomiting,
diarrhoea,
ophthalmoplegia, cognitive
impairment, hemiparesis,
coma and convulsion. May
cause permanent memory
lost
Onset 15 mins
to 48 hours
and can
persist for
several months
in severe
cases.
The clinical descriptions suggestive of paralytic shellfish poisoning have been documented for
centuries but it was first reported in 1927 near San Francisco. In 1987 ASP was first described in
Canada. Later, other syndromes of toxic shellfish poisoning had been described and reported. The
first case of paralytic shellfish poisoning reported in Malaysia was in 1976 from Sabah. The incident
recurred in Sabah in 1980, 1983 & 1984 with a few deaths. Later, other states also reporting PSP cases
such as Melaka, Kelantan and Pahang. So far, only PSP had been documented and no cases of
NSP, DSP, ASP or AZP had been reported in Malaysia. It is believed that it is just a tip of the iceberg
and possibly under diagnosed or under reported.
Fig. 1: Water sampling for HABs in
Kuantan Port during PSP
outbreak in 2013.
Detection of the biotoxins
is mainly from the affected
shellfish. Samples from leftover
contaminated meal or
remaining shellfish from the
source of harvesting may detect
the amount of toxins. A few
laboratories in Malaysia
especially from the fishery
department and universities are
capable of analysing the
biotoxins but the results will take
some time. The fishery
department is doing active
surveillance for PSP and a
special survey program for
others. The water samples also
can be tested to identify the present of harmful alga blooms (HABs). It is done when there is any
outbreak and regularly as a monitoring and R&D programme. Quantification of saxitoxin in patients’
blood or urine can be done but is very limited. Due to this limitation, diagnosis is made mainly by
clinical assessment.
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Fig. 2: A. Contaminated green mussels with saxitoxin in Kuantan Port 2013 and B. Contaminated
oyster with saxitoxin in Kuantan Port 2014.
Even though the illness has been
already described for almost 100 years,
the treatment of toxic shellfish
poisoning remains supportive. There is
no antidote or specific medication to
be used to reverse the effect of the
toxin. If the ingestion of shellfish
occurred within an hour, gastric
lavage may be performed and if it
happens within 4 hours, activated
charcoal may be given. Those patients
who develop respiratory paralysis need
to be intubated and mechanicay
ventilated. Studies in rats and guinea
pigs have shown that 4-aminopyridine
can reverse the flaccid paralysis and
respiratory failure caused by saxitoxin,
however, no studies have been
documented in humans. The use of
neostigmine and edrophonium has not
been studied.
In conclusion, prevention is the
most effective measure to tackle toxic
shellfish poisoning incidences. Effective
food safety surveillance and
regulations and HABs monitoring will
help to prevent any outbreak.
Effective coordinated action among
the agencies are needed to prevent
more people from being affected or
death during the outbreak. Serum or
Fig. 3: One of the posters by Kuantan Health Office
during the outbreak of PSP in 2013 & 2014
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urine biotoxin level is potentially and should be made available to help in early confirmatory
diagnosis. The use of 4-amynopyridine, neostigmine and edrophonium can be further studied for the
treatment of PSP.
Reference:
1. Alexander A. Jothy; Status of Shellfish Toxicity and Related Problems in Malaysia; Marine Fisheries Research Department, Southeast
Asian Fisheries Development Center; 1st January 1984
2. Bates SS, Bird CJ, de Freitas AS, et al. Pennate diatom Nitzschia pungens as the primary source of domoic acid, a toxin in shellfish
from eastern Prince Edward Island, Canada. Can J Fish Aquat Sci 1989;46:1203-15
3. Dauglas J Lanska, Shellfish poisoning; Medlink Neurology; https://www.medlink.com/articles/shellfish-poisoning
4. Meyer KF, Sommer H, Schoenholz P. Mussel poisoning. Am J Prev Med 1928;2:365-94.
5. Rodrigues SM, de Carvalho M, Mestre T, et al. Paralytic shellfish poisoning due to ingestion of Gymnodinium catenatum
contaminated cockles – application f the AOAC HPLC official method. Toxicon. 2012;59(5):558-566.
6. Wan Norhana Md Noordin et al. Marine Biotoxins in Malaysia: Occurrence, Toxicity Cases, Analytical Capabilities and Regulatory
Limits; Malaysia Fisheries Journal 21: 26-42 (2022)
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Malaysian Society on Toxinology
Newsletter 2021/2022
