1. Snake venom toxicity: Usefulness and limitations of antivenom Dr Aniruddha Ghose Chittagong Medical College

2. Overview Composition of snake venom Actions of components Phenotypic expressions Actions of anti venom Limitations of anti venom Clinical implication

3. Snake venom: composition Snake venoms are the most complex of all natural venoms and poisons – mixture of more than 100 different components Mostly protein – enzymes, polypeptide toxins and non-toxic proteins Non protein components – carbohydrates, metals, lipids, free amino acids, nucleosides and biogenic amines (serotonin and acetylcholine)

4. Evolutionary pressures have selected venom toxins that are specific for many targets in animal tissues The toxins of most importance in human envenoming include those that affect the nervous, cardiovascular, and haemostatic systems, and cause tissue necrosis

5. Venom enzymes These include digestive hydrolases, hyaluronidase, kininogenase. Most venoms contain l-amino acid oxidase, phosphomono- and diesterases, 5’-nucleotidase, DNAase, NAD-nucleosidase, phospholipase A2 and peptidases. Zinc metalloproteinase haemorrhagins: Damage vascular endothelium, causing bleeding Serine proteases and other procoagulant enzymes

6. Venom enzymes Phospholipase A2 (lecithinase) Acetylcholinesterase Hyaluronidase Proteolytic enzymes (metalloproteinases, endopeptidases or hydrolases) and polypetide cytotoxins (“cardiotoxins”) Samson A.O., Scherf. T., Eisenstein M., Chill J., and Anglister J., “The mechanism for acetylcholine receptor inhibition by alpha- neurotoxins and species-specific resistance to alpha-bungarotoxin revealed by NMR”, 2002, Neuron, 35, 319-332.

7. Neurotoxicity Neuromuscular junction showing ion channels and sites of action of presynaptic and postsynaptic snake venom neurotoxins, and three neurotoxins specifi c to mamba (Dendroaspis) venoms—ie, dendrotoxins, fasciculins, and calciseptine

8. Venom polypeptide toxins (“neurotoxins”) Postsynaptic (α) neurotoxins: α-bungarotoxin and cobrotoxin: bind to acetylcholine receptors at the motor endplate. Presynaptic (β) neurotoxins: β-bungarotoxin, crotoxin, and taipoxin, contain a phospholipase A subunit – These release acetylcholine at the nerve endings at neuromuscular junctions and then damage the endings, preventing further release of transmitter Samson A.O., Scherf. T., Eisenstein M., Chill J., and Anglister J., “The mechanism for acetylcholine receptor inhibition by alpha- neurotoxins and species-specific resistance to alpha-bungarotoxin revealed by NMR”, 2002, Neuron, 35, 319-332.

10. Faiz et al. Brain 2010: 133; 3181–3193 Synaptic vesicles labelled with anti-synaptophysin IgG (green) Acth receptors labelled with TRITC-conjugated a- bungarotoxin (red). Combined images

11. Neurotoxicity Neurotoxins bind to their receptors with high affinity, making reversal of paralysis by antivenom implausible. Rapid improvement in neurotoxicity has been noted when postsynaptic toxins were implicated—eg, Asian cobras and Australasian death adders (Acanthophis spp). Anticholinesterases sometimes reverse postsynaptic neurotoxicity in envenomed patients.

12. Naja kaouthia bite: neurotoxic effects

13. Paralysis in envenomed people starts with ptosis, external ophthalmoplegia, and mydriasis, descending to involve muscles innervated by the other cranial and spinal nerves and leading to bulbar and respiratory paralysis and, if ventilation is supported, eventually to total flaccid paralysis

14. Necrotoxicity A range of venom myotoxic and cytolytic factors – zinc-dependent metalloproteinases and myotoxic phospholipases A2. Digestive hydrolases, hyaluronidase, polypeptide cytotoxins (Elapidae) Secondary effects of inflammation Ischaemia, resulting from thrombosis, intracompartmental syndrome, or application of a tight tourniquet, contributes to tissue loss.

15. Naja kaouthia bite: local necrosis © DA Warrell

16. Myotoxicity Myotoxic phospholipases A2 in venoms of some species of Viperidae and Elapidae, especially sea snakes, cause generalised rhabdomyolysis that is often complicated by acute renal failure (B Niger)

17. Haemotoxicity Serine proteases, metalloproteinases, C-type lectins, disintegrins, and phospholipases: by activating or inhibiting coagulant factors or platelets, and disrupting vascular endothelium. Viperidae contain thrombinlike fibrinogenases and activators of prothrombin, factors V, X, and XIII, and endogenous plasminogen.

18. Haemotoxicity Toxins bind to a range of platelet receptors, inducing or inhibiting aggregation. Phospholipases A2 hydrolyse or bind to procoagulant phospholipids and inhibit the prothrombinase complex. Haemorrhagins (metalloproteinases) damage vascular endothelium: Spontaneous systemic bleeding

19. Haemotoxicity The combination of consumption coagulopathy, anticoagulant activity, impaired and few platelets, and vessel wall damage can result in severe bleeding, a common cause of death after bites by Viperidae, Australian Elapidae, and some Colubridae.

20. Cryptelytrops erythrusus

21. Cadiotoxicity Hypotension after snake bite – permeability factors that cause hypovolaemia from extravasation of plasma – toxins acting directly or indirectly on cardiac muscle, vascular smooth muscle, and on other tissues. Sarafotoxins potently vasoconstrict coronary and other arteries, and delay atrioventricular conduction

22. Clinical effects of venom action Neurotoxicity Myotoxicity Haemotoxicity Necrotoxicity Cardiotoxicity

23. Role of antivenom The only specific antidote to the toxins in snake venom Hyperimmune globulin from an animal that has been immunised with the appropriate venom Albert Calmette: “Serum antivenimeuse”: 1895: quickly accepted

24. Immunoglobulin antivenoms are accepted as essential drugs Reappraisal is needed The limitations of antivenom treatment should be recognized

25. Limitations of Anti Venom Patients with respiratory, circulatory, and renal failure need urgent resuscitation as well as antivenom.

26. Role of AV in neurotoxicity Pre synaptic neuro toxicity: can not be reversed especially in Krait bite Entubation is essential – Respiaratory failure – Impending resp failure Neostigmine: no effect

27. Low-cost, rechargeable, portable, disposable ventilator $300: typical ventilators $8,000-$60,000 Post-synaptic paralysis: (clinical evidence confirming experimental studies) indicating AV can reverse this paralysis in at least some cases. – Naja kaouthia

28. SOP should be First ensure adequate respiratory effort – Entubation – Amboo Neostigmine Antivenom Simultaneous approach

29. Role of AV in reversing coagulopathy Controversial – for most species there is good clinical evidence AV can help control or reverse coagulopathy The caveat is that if it is a consumptive coagulopathy the response time will be longer – While AV can neutralize venom, it cannot speed replacement of consumed coagulation factors or fibrinogen

30. Role of AV in reversing coagulopathy Controversial – for most species there is good clinical evidence AV can help control or reverse coagulopathy The caveat is that if it is a consumptive coagulopathy the response time will be longer – While AV can neutralize venom, it cannot speed replacement of consumed coagulation factors or fibrinogen No anti venom for Pit vipers

31. Role of AV in myolysis Also uncertain Theoretically it could be argued it won't help much if major myolysis is already established. Clinical experience shows cases where use of AV was associated with a marked improvement in both symptoms and CK levels within a short time (a few hours only).

32. Role of AV in local tissue necrosis Treating local tissue injury: difficult Evidence for using AV is muddy Probably helps to at least some extent, particularly if given early

33. Venom injection Inflammatory reaction to envenomation Further tissue damage In situ injection of toxin inhibitors or antibody fragments iv administration of antivenom Necrosis Hemorrhage ECM degradation Blockade of deleterious effects of inflammation Tissue repair and regeneration Stimulus for tissue regeneration   Ancillary interventions Local effects Local tissue destruction © José María Gutiérrez

34. Role of AV in Nephrotoxicity Possible causes: – Hypotension – DIC – Direct nephrotoxic action AV even given early failed to prevent development of renal failure (Myanmar)

35. Treating renal failure

36. AV hypersensitivity Dependent on the dose, route, and speed of administration, and the quality of refinement, the risk of any early reaction varies from about 3% to more than 80% Only about 5–10% of reactions are associated with severe symptoms such as bronchospasm, angiooedema, or hypotension May be life threatening

37. Treating physicians should actively look for early features like restlessness, urticaria Prompt intervention React at the first sign e,g, single urticaria –Adrenalin, steroid, H1 blocker: Repeat as necessary “Pre medication”!!!

38. So Don’t be disappointed if you don’t have anti venom Don’t be content when you have it Remain vigilant

39. Conclusion Snake venom is a complex mixture of different component Phenotypic presentation depends on action of these compounds on victims body Anti venom is the mainstay of treatment Anti venom can not neutralize all effects of venom Supportive treatment is crucial Attending physician has an important role in determining outcome

40. Acknowledgement Prof David A Warrell Prof Jullian White

41. Thank You