Prospective, consecutive case series of 158 snakebite patients treated at Savannakhet provincial hospital, Lao People's Democratic Republic with high incidence of anaphylactic shock to horse derived F(ab')2 antivenom

Vongphoumy, Inthanomchanh; Chanthilat, Phankham; Vilayvong, Phongmany; Blessmann, Joerg

doi:10.1016/j.toxicon.2016.03.011

Cited by 24 publications

(44 citation statements)

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“…A previous report in Laos showed a higher incidence of antivenom allergy (53%) but did not mention specific snake type of antivenom contributing to the allergy. 18 We believe that the allergic reactions are primarily non-IgE mediated, 19 , 20 so the current guideline allows reinstitution of antivenoms (by slowing rate of infusion/giving premedication) if the symptoms subsided. However, data regarding the patient’s previous exposure to horse or sheep-derived products, which might induce IgE-mediated reactions, are limited in our study.…”

Section: Discussionmentioning

confidence: 99%

<p>Hematotoxic Manifestations and Management of Green Pit Viper Bites in Thailand</p>

Thumtecho¹,

Tangtrongchitr²,

Srisuma³

et al. 2020

TCRM

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Introduction: Green pit vipers (GPV) are widely distributed throughout Thailand and are responsible for significant morbidity. The primary objective of this study was to characterize clinical presentations and treatment methods for GPV bites. The secondary objective was to demonstrate the earliest and latest onset of hematotoxicity. Methods: GPV bites reported to the Ramathibodi Poison Center between July 1, 2016, and June 30, 2018, were analyzed. Results: There were 288 GPV cases within the study period. Patients were predominantly male (62.8%), and the median age was 40 years (interquartile range (IQR) 22.8-58). Median time from envenomation to hospital presentation was 1 hour (IQR 0.5-2). Patients were primarily bitten on the finger (27.4%). Most patients reported swelling (90.3%). Necrosis and compartment syndrome occurred in 13 and 9 cases, respectively. Systemic effects occurred in 190 cases (65.9%), with median onset 15 hours (IQR 6-28.3) post-bite. Venous clotting time (VCT) showed the highest percentage of abnormalities. Systemic bleeding occurred in 13 cases (4.5%). Monitoring patients for 24, 48, and 72 hours after bites detected 62.7%, 85.9%, and 96.5% of cases with systemic effects, respectively. In total, 184 patients (62.5%) were treated, sometimes repeatedly, with antivenoms (285 courses, 949 vials). The most common indication was prolonged VCT (144 courses, 50.5%). Recurrent systemic effects after antivenom occurred in 11 cases (6.1% of patients received antivenom). No recurrence presented as systemic bleeding. Adverse reactions to antivenom were reported in 44 courses (15.4% of 285 courses), being anaphylaxis in 19 courses (6.7%). Other treatments included antibiotics (192 cases, 66.7%), surgical intervention (10, 34.7%), and blood components (4, 1.4%). Conclusion: Most GPV bites result in envenomation. The most frequent local effect is mild swelling. Systemic bleeding is uncommon. The current recommendation of a 3-day followup can detect up to 96% of patients who may require antivenom. No severe morbidity or mortality is reported. Antivenoms are primarily indicated by prolonged VCT. Side effects of antivenom are minimal.

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Section: Discussionmentioning

confidence: 99%

<p>Hematotoxic Manifestations and Management of Green Pit Viper Bites in Thailand</p>

Thumtecho¹,

Tangtrongchitr²,

Srisuma³

et al. 2020

TCRM

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“…Adverse reactions to antivenom may be early or late developing due to the involvement of different pathological pathways, including early developing IgE anaphylaxis, early developing non-IgE-mediated anaphylactoid reactions, and the IgG and IgM mediated late developing adverse reaction of serum sickness [ 49 , 145 , 189 , 190 , 191 , 192 , 193 , 194 , 195 , 196 , 197 , 198 ]. However, premedication with adrenalin has been shown to significantly reduce the incidence of early adverse reactions [ 193 , 199 , 200 , 201 , 202 , 203 ].…”

Section: Issues and Controversies In Modern Medical Carementioning

confidence: 99%

Snakebite: When the Human Touch Becomes a Bad Touch

Fry

2018

Toxins

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Many issues and complications in treating snakebite are a result of poor human social, economic and clinical intervention and management. As such, there is scope for significant improvements for reducing incidence and increasing patient outcomes. Snakes do not target humans as prey, but as our dwellings and farms expand ever farther and climate change increases snake activity periods, accidental encounters with snakes seeking water and prey increase drastically. Despite its long history, the snakebite crisis is neglected, ignored, underestimated and fundamentally misunderstood. Tens of thousands of lives are lost to snakebites each year and hundreds of thousands of people will survive with some form of permanent damage and reduced work capacity. These numbers are well recognized as being gross underestimations due to poor to non-existent record keeping in some of the most affected areas. These underestimations complicate achieving the proper recognition of snakebite’s socioeconomic impact and thus securing foreign aid to help alleviate this global crisis. Antivenoms are expensive and hospitals are few and far between, leaving people to seek help from traditional healers or use other forms of ineffective treatment. In some cases, cheaper, inappropriately manufactured antivenom from other regions is used despite no evidence for their efficacy, with often robust data demonstrating they are woefully ineffective in neutralizing many venoms for which they are marketed for. Inappropriate first-aid and treatments include cutting the wound, tourniquets, electrical shock, immersion in ice water, and use of ineffective herbal remedies by traditional healers. Even in the developed world, there are fundamental controversies including fasciotomy, pressure bandages, antivenom dosage, premedication such as adrenalin, and lack of antivenom for exotic snakebites in the pet trade. This review explores the myriad of human-origin factors that influence the trajectory of global snakebite causes and treatment failures and illustrate that snakebite is as much a sociological and economic problem as it is a medical one. Reducing the incidence and frequency of such controllable factors are therefore realistic targets to help alleviate the global snakebite burden as incremental improvements across several areas will have a strong cumulative effect.

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“…The rate of these early anaphylactic reactions (EARs) against snake antivenom varies depending on the product and region between 3% and 88% and usually poor physicochemical quality is blamed for it ( De Silva HA et al, 2015 ; Prabhakar et al, 2014 ). However, the rate of EARs against the same horse-derived F(ab’) 2 antivenom from Queen Saovabha Memorial Institute (QSMI), Bangkok, Thailand was much higher (53%) in a rural population in Savannakhet province in Lao People's Democratic Republic (Lao PDR) studied between 2013 and 2015 than in an urban population (3.5%) in Bangkok, Thailand, investigated between 1997 and 2006, indicating that host factors may play a role as well ( Vongphoumy et al, 2016 ; Thiansookon and Rojnuckarin, 2008 ). However, the comparability of the studies is rather limited.…”

Section: Introductionmentioning

confidence: 99%

Serum IgE against galactose-alpha-1,3-galactose is common in Laotian patients with snakebite envenoming but not the major trigger for early anaphylactic reactions to antivenom

et al. 2020

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Snake antivenom is the only specific treatment for snakebite envenoming, but life-threatening anaphylaxis is a severe side effect and drawback for the use of these typically mammalian serum products. The present study investigates the hypotheses whether serum IgE antibodies against the epitope galactose-alpha-1,3-galactose (α-gal) located on the heavy chain of non-primate mammalian antibodies are a possible cause for hypersensitivity reactions to snake antivenom. Serum samples from 55 patients with snakebite envenoming were obtained before administration of snake antivenom and tested for serum IgE (sIgE) against α-gal and total IgE. Early anaphylactic reactions (EARs) during the first 3 h after antivenom administration were classified into mild, moderate or severe and correlated with the presence of sIgE against α-gal. Fifteen (27%) out of 55 patients (37 male, 18 female, median 34 years, range 9–90 years) developed EARs after antivenom administration. Eleven, three and one patients had mild, moderate and severe EARs, respectively. Serum IgE against α-gal was detected in 17 patients (31%); in five (33%) out of 15 patients with EARs and in 12 (30%) out of 40 patients without EAR (Odds Ratio = 1.2; 95%-confidence interval: 0.3–4.2) with no correlation to severity. Although the prevalence of serum IgE against α-gal was high in the study population, very high levels of total IgE in the majority of patients question their clinical relevance and rather indicate unspecific sIgE binding instead of allergy. Lack of correlation between α-gal sIgE and EARs together with significantly increased total IgE levels suggest that sIgE against α-gal is not the major trigger for hypersensitivity reactions against snake antivenom.

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Prospective, consecutive case series of 158 snakebite patients treated at Savannakhet provincial hospital, Lao People's Democratic Republic with high incidence of anaphylactic shock to horse derived F(ab')2 antivenom

Cited by 24 publications

References 24 publications

<p>Hematotoxic Manifestations and Management of Green Pit Viper Bites in Thailand</p>

<p>Hematotoxic Manifestations and Management of Green Pit Viper Bites in Thailand</p>

Snakebite: When the Human Touch Becomes a Bad Touch

Serum IgE against galactose-alpha-1,3-galactose is common in Laotian patients with snakebite envenoming but not the major trigger for early anaphylactic reactions to antivenom

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