A retrospective study of 40 victims of Crotalus snake bites: analysis of the hepatic necrosis observed in one patient

Forty patients with a diagnosis of snake bite were studied at the Infectious and Parasitic Disease Service of the Faculty of Medicine of Botucatu. Thirty were males and 10 females, ranging in age from 16 to 70 years. All were farm laborers and 35 of them were bitten in the lower limbs. Two of the 9 patients seen more than 6 hours after the bite died. The low mortality rate (5%) observed could be explained by the early care provided, by the use of appropriate doses of anti-crotalus serum, parenteral hydration, urine alkalinization with sodium bicarbonate and induction of osmotic diuresis with a mannitol solution. Anatomopathological examination of one of the patients who died revealed extensive hepatic necrosis. The authors discuss the possibility of the effect of a factor of snake venom in the genesis of hepatic necrosis and in the increased transaminase levels.

Atherogenesis and atherosclerosis in primary antiphospholipid syndrome

ABSTRACT: In the late seventies the term “Haematological Stress Syndrome” defined some haematological abnormalities appearing in the course of acute and chronic disorders, such as raised plasma levels of fibrinogen (FNG) and factor VIII, reduced fibrinolytic activity and hyperviscosity. In the early nineties the “Membrane stress syndrome hypothesis” proposed the unification of the concepts of haematological stress syndrome with those of oxidation, inflammation and immune activation to explain the pathogenesis of the antiphospholipid syndrome (APS) Antiphospholipid antibodies, coagulation, fibrinolysis and thrombosis. This chapter investigated the occurrence of the “Haematological Stress Syndrome” and thrombosis in 144 participants positive for aPL detected by clotting and immune tests. Among the clotting assays for the detection of lupus anticoagulant, dilute Russell's viper venom time better correlated with a history of venous thrombosis than activated partial thromboplastin time (p<0.0002 vs p<0.009) and was the only test correlated with a history of arterial thrombosis (p<0.01). By regression analysis, serum levels of IgG anticardiolipin antibodies (aCL) associated with the number of venous occlusions (p<0.001). With regards to FNG and von Willebrand factor (vWF), the former rose by 36% (95% CI; 21%, 53%) and the latter by 50% (95% CI; 29%, 75%) at the first venous occlusion and remained unchanged after subsequent occlusions. At variance FNG rose by 45% (95% CI; 31%, 60%) per arterial occlusion and vWF by 27% (95% CI; 10%, 47%) per arterial occlusion throughout. The coagulation/fibrinolytic balance was cross-sectionally evaluated on 18 thrombotic PAPS patients, 18 subjects with persistence of idiopathic aPL and in healthy controls. Markers of thrombin generation prothrombin fragment 1+2 (F1+2), thrombin-antithrombin complex (TAT) and of fibrin turnover D-Dimer (D-D) were higher in thrombotic (p=0.006)and non-thrombotic subjects (p=0.0001) than in controls as were those of D-D (p<0.0001 and p=0.003 respectively). TAT levels did not differ. Gender analysed data revealed blunted tPA release (hence a negative venous occlusion test) in thrombotic females but neither in thrombotic males (p=0.01) nor in asymptomatic subjects of either sex. Also, in both patient groups females had higher mean PAI than males (p<0.0002) and control females (p<0.02). The activity of factor XIII (FXIIIa) was evaluated was evaluated in 29 patients with PAPS, 14 persistent carriers of aPL without thrombosis, 24 thrombotic patients with inherited thrombophilia, 28 healthy controls and 32 patients with mitral and aortic valve prosthesis as controls for FXIII only. FXIIIa was highest in PAPS (p=0.001), particularly in patients with multiple (n=12) than single occlusion (p=0.02) and in correlation with PAI (p=0.003) and FNG (p=0.005). Moreover FXIIIa was strongly associated with IgG aCL and IgG anti-2GPI (p=0.005 for both) in the PAPS group and to a lesser degree in the aPL group (FXIIIa with IgG aCL, p=0.02, with IgG anti-2GPI, p=0.04). Altogether these results indicate: 1) a differential relationship of aPL, vWF and FNG with venous and arterial thrombosis; 2) heightened thrombin generation, accelerated fibrin turnover and fibrinolysis abnormalities also in asymptomatic carriers of aPLs; 3) enhanced FXIIIa that may contribute to atherothrombosis via increased fibrin/fibrinogen cross-linking. Lipid profile, lipid peroxidation and anti-lipoprotein antibodies in thrombotic primary antiphospholipid syndrome. Given the atherogenic lipid profile of SLE, the same possibility was explored in PAPS by comparing high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol (CHO), apolipoprotein AI (ApoAI), apolipoprotein B (ApoB), triglycerides (TG), anti-lipoprotein antibodies, beta-2-glycoprotein I complexed to oxidized low-density lipoprotein (oxLDL-2GPI) and C-reactive protein (CRP) in 34 thrombotic PAPS patients compared to 36 thrombotic patients with inherited thrombophilia (IT), to 18 subjects persistently positive for antiphospholipid antibodies (aPL) with no underlying autoimmune or non-autoimmune disorders and to 28 healthy controls. Average concentrations of HDL (p<0.0001), LDL (p<0.0001), CHO (p=0.0002), ApoAI (p=0.002) were lower in PAPS whereas average TRY was higher (p=0.01) than other groups. Moreover PAPS showed higher IgG anti-HDL (p=0.01) and IgG anti-ApoAI (p<0.0001) as well as greater average oxLDL-2GPI (p=0.001) and CRP (p=0.003). Within PAPS, IgG anti-HDL correlated negatively to HDL (p=0.004) and was an independent predictor of oxLDL-2GPI (p=0.009). HDL and ApoAI correlated negatively with CRP (p=0.001 and p=0.007, respectively). IgG anti-HDL may hamper the antioxidant and anti-inflammatory effect of HDL favouring low-grade inflammation and enhanced oxidation in thrombotic PAPS. Indeed plasma 8-epi-prostaglandin F2α (a very specific marker of lipid peroxidation) was significantly higher in 10 patients with PAPS than 10 age and sex matched healthy subjects (p=0.0002) and strongly related to the titre of plasma IgG aCL (r=0.89, p=0.0004). Hence oxidative stress, a major player in atherogenesis, also characterises PAPS. Nitric oxide and nitrative stress in thrombotic primary antiphosholipid syndrome. Oxidative stress goes hand in hand with nitrative stress and to address the latter plasma nitrotyrosine (NT, marker of nitrative stress), nitrite (NO2-) and nitrate (NO3-) were measured in 46 thrombotic PAPS patients, 21 asymptomatic but persistent carriers of antiphospholipid antibodies (PCaPL), 38 patients with inherited thrombophilia (IT), 33 patients with systemic lupus erythematosus (SLE) and 29 healthy controls (CTR). Average crude NT was higher in PAPS and SLE (p=0.01) whereas average plasma NO2- was lower in PAPS and average NO3- highest in SLE (p<0.0001). In PAPS, IgG aCL titer and number of vascular occlusions negatively predicted NO2-, (p=0.03 and p=0.001, respectively) whereas arterial occlusions and smoking positively predicted NO3- (p=0.05 and p=0.005). Moreover CRP (an inflammatory marker) positively predicted NT (p=0.004). Nitric oxide metabolites relates to type and number of vascular occlusions and to aPL titers, whereas nitrative stress relates to low grade marker) positively predicted NT (p=0.004). Nitric oxide metabolites relates to type and number of vascular occlusions and to aPL titers, whereas nitrative stress relates to low grade inflammation and both phenomena may have implications for thrombosis and atherosclerosis in PAPS Inflammation and immune activation in thrombotic primary antiphospholipid syndrome. To investigate inflammation and immune activation in thrombotic PAPS high-sensitivity CRP (hs-CRP), serum amyloid A (SAA), oxLDL-2GPI, CRP bound to oxLDL-2GPI (CRP-oxLDL-2GPI) (as inflammatory markers) neopterin (NPT) and soluble CD14 (sCD14) (as immune activation markers) were measured by ELISA in 41 PAPS patients, in 44 patients with inherited thrombophilia (IT) and 39 controls (CTR). Compared to other groups, PAPS presented with higher plasma concentrations of inflammatory, hs-CRP (p=0.0004), SAA (p<0.01), CRP-oxLDL-2GPI (p=0.0004) and immune activation markers, NPT (p<0.0001) and sCD14 (p=0.007). By regression analysis SAA independently predicted thrombosis number (p=0.003) and NPT independently predicted thrombosis type (arterial, p=0.03) and number (p=0.04). These data confirm that low-grade inflammation and immune activation occur and relate to vascular features of PAPS. Antiphosholipid antibodies, haemostatic variables and atherosclerosis in thrombotic primary antiphospholipid syndrome To evaluate whether IgG aCL titre, haemostatic variables and the lipid profile bore any relationship to the intima media thickness (IMT) of carotid arteries high-resolution sonography was applied to the common carotid (CC), carotid bifurcation (CB) and internal carotid (IC) of 42 aPL subjects, 29 with primary thrombotic antiphospholipid syndrome and 13 with persistence of aPL in the absence of any underlying disorder. The following were measured: plasma FNG, vWF, PAI, homocysteine (HC), CHO, TG, HDL, LDL, platelet numbers and aCL of IgG and IgM isotype. By multiple regression analysis, IgG aCL titre independently predicted IMT at all carotid segments examined (p always <0.005). Plasma FNG and HC independently predicted IMT at the CB (p=0.001 and p<0.0001, respectively) and IC (p=0.03 and p<0.0001, respectively). These data strongly support an atherogenic role for IgG aCL in patients with aPL in addition to traditional risk factors. The atherosclerosis hypothesis was investigated in an age and sex-matched case-double-control study including 49 thrombotic PAPS patients (18 M, 31 F, mean age 37 ± 11), 49 thrombotic patients for IT and 49 healthy subjects. Average IMT was always greater in PAPS than control patients (CC: p=0.004, CB: p=0.013, IC: p=0.001). By dividing participants into age tertiles the IMT was greater in the second (CC: p=0.003, CB: p=0.023, IC: p=0.003) and third tertiles (CC: p=0.03, CB: p=0.004, IC: p=0.007). Conclusion: Coagulation activation, fibrinolysis depression, hightened fibrin turnover, oxidative and nitrative stress in parallel with low grade inflammation and immune activation characterise thrombotic PAPS: all these are early atherogenic processes and contribute to the demonstrated premature atherosclerosis that should be considered a clinical feature of PAPS.

Epidemiologia dos acidentes por serpentes peçonhentas no Estado do Ceará - Brasil

Foram notificados à Secretaria de Saúde do Estado do Ceará, no período de 1992 a 1995, 688 acidentes causados por serpentes peçonhentas (média anual de 172 casos), com coeficiente de incidência variando entre 0,9 e 5,8 por 100.000 habitantes. Dentre 473 casos em que houve referência ao gênero da serpente 88,3% foram por Bothrops, 10,6% por Crotalus, 0,8% por Micrurus e 0,2% por Lachesis. Os meses de abril a setembro apresentaram maior incidência. Houve predominância de pacientes do sexo masculino (75,6%) e com idades entre 10 a 49 anos (72,3%). As regiões anatômicas mais freqüentemente picadas foram os membros inferiores (81,9%) e superiores (14,7%). O atendimento na unidade de saúde que notificou o acidente ocorreu dentro de seis horas em 66,9% dos casos. A letalidade foi de 0,7%. Os acidentados foram sobretudo agricultores (62,7%), a maioria dos casos ocorreu no próprio local de trabalho. Os autores reforçam que os acidentes ofídicos no Estado do Ceará podem ser considerados acidentes de trabalho, acometem principalmente os trabalhadores rurais e constituem causa de óbito.

Cases of human envenoming caused by Philodryas olfersii and Philodryas patagoniensis (serpentes: Colubridae)

The present paper reports two cases of human envenoming by colubrid snakes of Philodryas, considered as not poisonous, showing evidence of the clinical aspects and the evolution of the symptoms of envenoming. The similarity of these cases with those caused by Bothrops suggests a more careful evaluation on the victims considering the medical treatment to be adopted.

South American rattlesnake bite and soft-tissue infection: report of a case

The case of a man bitten by a South American rattlesnake (Crotalus durissus) and who developed an abscess at the site of the bite is reported. Abcesses are a rare complication of this type of envenoming, possibly due to the lack of a strong cytotoxic action of Crotalus durissus venom.

Influenza em animais heterotérmicos

O objetivo foi pesquisar Ortomyxovirus em animais heterotérmicos. Coletou-se sangue de serpentes dos gêneros Bothrops e Crotalus e de sapo e rãs dos gêneros Bufo e Rana, para a detecção dos receptores de hemácias e anticorpos específicos, ao vírus influenza, pelos testes de hemaglutinação e inibição da hemaglutinação, respectivamente. Pelo teste de hemaglutinação, verificou-se que serpentes e sapos em cativeiro apresentaram receptores em suas hemácias para o vírus influenza, humano e eqüino do tipo A e tipo B. O mesmo ocorreu com serpentes recém chegadas. Quanto ao teste de inibição da hemaglutinação dos soros dos répteis observou-se títulos protetores de anticorpos aos vírus influenza tipo A (origens humana e eqüina) e tipo B. Com soro de sapo não se observou reação de inibição da hemaglutinação porém, 83,3% das rãs obtiveram médias de 40UIH para algumas cepas. Conclui-se que animais heterotérmicos podem oferecer condições de hospedeiros aos vírus influenza, assim como susceptibilidade à infecção.

Características clínicoepidemiológicas dos acidentes ofídicos em Rio Branco, Acre

Com o objetivo de determinar o perfil clínico-epidemiológico dos acidentes ofídicos, em hospital do Estado do Acre, foram estudados prospectivamente 144 pacientes admitidos no período de janeiro a dezembro de 2002. Desses, 113 (78,5%) foram classificados como vítimas de acidente com envenenamento. Os gêneros Bothrops, Lachesis e Micrurus foram responsáveis por, respectivamente, 75,7%, 2,1% e 0,7% dos casos. Os acidentes predominaram em pessoas do sexo masculino (78,5%), trabalhadores rurais (51,4%) e com idades entre 10 e 29 anos (43,8%). Nos acidentes botrópicos, os envenenamentos considerados moderados (48,6%) prevaleceram sobre os leves (31,2%) e graves (20,2%). Dois casos envolvendo o gênero Bothrops não receberam terapia antipeçonha. Entretanto, soro heterólogo foi administrado em 23 vítimas de acidente sem envenenamento. Concluindo, os resultados obtidos neste estudo diferiram dos observados por outros autores quanto à gravidade dos casos e adequação do tratamento, indicando a necessidade de treinamento da equipe.

Perfil epidemiológico de acidentes ofídicos do Estado do Amapá

O presente trabalho apresenta o perfil epidemiológico dos acidentes ofídicos notificados junto à Secretaria do Estado de Saúde do Estado do Amapá. Para isso, foram analisadas 909 fichas durante o período de 2003 a 2006. A maior freqüência de picadas foi no ano de 2004 com registro de 255 casos, seguido pelo ano de 2006 com 246 casos. Os números mais expressivos de pacientes encontram-se nas faixas etárias compreendidas entre 20 e 34 anos (30%). Os gêneros Bothrops e Crotalus foram responsáveis por 67,5% e 0,7% dos acidentes, respectivamente. Serpentes consideradas não peçonhentas causaram 0,2% dos acidentes e em 31,2% dos casos não foi possível a identificação da espécie. Indivíduos do sexo masculino (80,6%) foram os mais atingidos. A maior incidência de picadas foi nos membros inferiores (68%). Os acidentes ocorreram, em sua maioria, na área rural (62,7%), em circunstâncias equilibradas de trabalho (60%) e lazer (15,6%). O tempo decorrido entre a picada e o atendimento ao paciente foi de 12 horas (29%). Dos acidentes ofídicos, 263 foram classificados como leves, 193 graves e 187 moderados.

First report of an accident with the speckled forest pit viper (Bothriopsis taeniata) in Brazil

The first reported case of an accident with Bothriopsis taeniata in Brazil is described. The victim, a 43-year-old man, was bitten just above his right heel and presented a clinical condition compatible with mild Bothrops poisoning: local edema with hemorrhage at the bite site and pain, although without coagulopathy.

Perfil dos acidentes ofídicos no norte do Estado de Minas Gerais, Brasil

O objetivo deste estudo foi descrever o perfil epidemiológico dos acidentes ofídicos da macrorregião de saúde do Norte do Estado de Minas Gerais, Brasil. Foram analisadas informações sobre os acidentes ofídicos relativos ao período compreendido entre janeiro de 2002 a dezembro de 2006, por meio de bancos de dados. Os resultados demonstraram 10.553 casos notificados, com ênfase para a maior casuística em meses de tempo quente e chuvoso, em áreas urbanas (54,1%), faixa etária menor de 20 anos (39,7%), acometendo mais homens e estudantes (53,1% e 29,1%) respectivamente. Os membros inferiores (pé, dedo do pé, perna e coxa) foram os locais mais afetados (35,9%), as serpentes prevalentes foram do gênero Bothrops (82,9%) e a gravidade da maioria dos acidentes foi leve (66,2%). Observou-se nesse estudo um importante impacto da sazonalidade, urbanização, subnotificação das espécies envolvidas nesses acidentes e busca rápida pelo pronto atendimento. Espera-se que os dados inéditos da casuística obtida possam servir de substrato para o planejamento e execução de medidas voltadas para vigilância em saúde e atendimento.

Comparison of Bothropoides jararaca bites with and without envenoming treated at the Vital Brazil Hospital of the Butantan Institute, State of São Paulo, Brazil

INTRODUCTION: This study analyses the cases of all bites (including dry bites) caused by Bothropoides jararaca attended at the Vital Brazil Hospital of the Butantan Institute, State of São Paulo, Brazil. METHODS: A retrospective study was conducted of patients bitten by Bothropoides jararaca (n=792) from January 1990 to December 2004. The characteristics of the snake specimen, data related to the accident and clinical manifestations on admission were obtained from patient medical records. RESULTS: The majority of the cases in this study were caused by female and juvenile snakes. No stomach contents were found in 93.4% of the snake specimens after dissection. No statistical difference was observed between the occurrence of dry bites and the maturity or sex of the snake. The median SVL of snakes in mild and moderate cases was 40.5cm and in severe cases, SVL increased to 99cm. Necrosis was more common in the digits of the feet and hands (4.8%) compared to the other body regions (1.8%). A significant difference was verified between severity and a time interval greater than six hours from the bite to hospital admission. A significant association was verified between gingival bleeding and abnormal blood coagulability. In accidents caused by adult snakes, necrosis was more frequent (7.2%) compared to accidents caused by juvenile snakes (1%). CONCLUSIONS: In this work, the association between certain epidemiological data and the evolution of biological parameters in the clinical course of Bothrops sensu latu accidents were highlighted, contributing to the improvement of snake bite assistance.

Bilateral posterior circulation stroke secondary to a crotalid envenomation: case report

Snake bite envenoming is a disease with potential serious neurological complications. We report a case of an adolescent who was bitten by a rattlesnake and developed bilateral posterior circulation stroke. The rattlesnake was later identified as being Crotalus durissus terrificus. Stroke was probably due to toxic vasculitis or toxin-induced vascular spasm and endothelial damage.

Snakebite cases in the municipalities of the State of Paraiba, Brazil

Introduction This study investigated the epidemiological and clinical profile of snakebite cases reported from 2007 to 2012 in the municipalities of the Curimataú region, State of Paraíba, in northeastern Brazil. Methods Data were collected from the Health Department of the State of Paraíba using the Injury Notification Information System data banks of the Health Ministry. Results A total of 304 snakebite cases were studied. The cases occurred most frequently from April to June. The genera Bothrops, Crotalus, and Micrurus were responsible for 74.6%, 6.2%, and 1.3% of cases, respectively. Snakebite cases predominated in males living in rural areas and between 10 and 19 years old. The highest incidence of bites occurred on the feet. The majority of the victims received medical assistance within 1 to 3h after being bitten. With regard to severity, 48% of the cases were classified as mild, 26% as moderate, and 2.6% as severe. Successful cures predominated, and no deaths were reported. The average antivenom ampoule dose used for the treatment in some snakebite cases was lower than that recommended by the Health Ministry. Conclusions Although our results show that Paraíba has a good level of medical care, there are serious deficiencies in recording snakebite information. These data indicate the need to improve the recording process for snakebite cases. Further training for health professionals seems to be necessary to optimize their skills in treating snakebite victims.

An outbreak of Portuguese man-of-war (Physalia physalis - Linnaeus, 1758) envenoming in Southeastern Brazil

Introduction Portuguese man-of-war, Physalia physalis (Linnaeus, 1758), are cnidarians capable of discharging intracellular organelles filled with venom, resulting in severe envenomation in humans. Methods We report the clinical and therapeutic aspects of 331 accidents involving Portuguese man-of-war in an outbreak on the coast of the State of São Paulo, Brazil. Results The clinical manifestations of envenomation were rare and mild and mostly local, systemic reactions; there was a low rate of late complications. Conclusions The consequences of envenomation were of moderate severity, and first aid measures were effective in controlling the pain. Outbreaks of accidents involving Portuguese man-of-war occur periodically in the area without a clear explanation.

Skin lesions simulating blue toe syndrome caused by prolonged contact with a millipede

Venomous animals are those that, by means of a hunting and defense mechanism, are able to inject their prey with a toxic substance produced in their bodies, directly from specialized glands (e.g., tooth, sting, spur) through which the poison passes. Millipedes are poisonous animals; they can be harmful to humans, and their effects usually manifest as erythematous, purpuric, and cyanotic lesions; local pain; and paresthesia. Here, we report a case of skin contact with a millipede for 6h resulting in skin lesions similar to blue toe syndrome.