Envenimation by Trimeresurus

Introduction

Trimeresurus, and especially Trimeresurus albolabris, is responsible for more than 40% of reported bite cases in Asia while Viridovipera stejnegeri accounts for nearly 70% of bite cases in Taiwan (Rojnuckarin, P., Chanthawibun, W., Noiphrom, J., Pakmanee, N., & Intragumtornchai, T. (2006), Cheng, CL, Mao, YC, Liu, PY, Chiang, LC, Liao, SC, & Yang, CC (2017)). Indeed, its proximity to humans, often tea or coffee growers increase the chances of being bitten. To this is added the weak equipment, such as the boots or the gloves of the workers. If the species does not represent the greatest danger of the continent, the fact remains that they can sometimes cause real problems of survival, especially when amputation is necessary, often marking the end of the single income. family. Nevertheless, Trimeresurus are very rarely, and wrongly, considered not dangerous to humans. In fact, the number of deaths by Trimeresurus albolabris and Trimeresurus venustus is close to 0%. Other species, such as Craspedocephalus trigonocephalus, show no death following any envenomation (Rathnayaka, R.N., Kularatne, S.A.M., & Ranathunga, P.E.N.A. (2017)). Of course, this percentage can only be applied in the case of identified envenomations and does not include bite victims who have had access, voluntarily or otherwise, to appropriate medical care.

Composition

Oral bacteriological agents, present in saliva, exogenous to venom, but present at the site of the bite, appear to be minor factors to infections, or to necrosis in species of the complex than in other species such as cobras (Naja) (Chen, CM, Wu, KG, Chen, CJ, & Wang, CM (2011), Liu, PY, Shi, ZY, Lin, CF, Huang, JA, Liu, JW, Chan, KW, & Tung, KC (2012)).

Symptoms and immunotherapies

Like all viperidae, Trimeresurus have a primarily hemotoxic venom, sometimes cytotoxic. The symptoms are generic to viperine envenomations: local pain, swelling, localized necrosis whose severity may vary according to the species, systemic signs, digestive disorders, lethargy, gastrointestinal haemorrhage and hematuria.

In a 1989 study, it was found that out of 12 patients bitten by Popeia popeiorum, one-third had lymphangitis.

Necrosis is due to cell destruction caused by cytotoxins. It is not impossible that the latter evolve into gangrenes thus requiring amputation, but these extreme cases are rare (Chan, T.Y.K., & Hung, L.K. (2010)).

A study conducted in a hospital in Guangxi Province, China, found that envenomations caused by Trimeresurus albolabris were significantly more expensive but also, and especially, longer to cure than the bites caused by Viridovipera stejnegeri.

In rare instances, pregnant women bitten by Viridovipera stejnegeri have been treated and have had normal deliveries. Follow-up of children up to 10 years of age showed no developmental delay (Chen, Y.C., Chen, M.H., Yang, C.C., Chen, Y.W., Wang, L.M., & Huang, C.I. (2007)).

The liver is the main organ used naturally in the neutralization of animal toxins by the production of coagulation inhibitors. By not being able to resynthesize correctly the coagulation factors (factors V, VII, IX, X and XI), the latter can be “supported” by the injection of serum. Although this is not always advisable and subject to debate in the medical-scientific sector, the case of a patient with cirrhosis and bitten by Viridovipera stejnegeri in Taiwan required the use of antivenomous serum thus allowing an early recovery of the disease. victim. Observation of this type of 24-hour case at the treatment center is highly recommended (Chien, C.Y., Liao, S.C., Liao, C.H., Huang, T.S., & Chen, Y.H. (2017)).

It has been found that in the water extracts of the feathers of Pavo cristatus (the blue peacock) there is a molecule able to inhibit more than 80% the enzymatic activity of PLA2, especially in Craspedocephalus malabaricus (Santos-Filho, NA, Silveira, LB, & Boldrini-França, J. (2017)).

Des extraits d'eau des plûmes de Pavot cristatus pour inhiber les PLA2 - Source: Chien, C. Y., Liao, S. C., Liao, C. H., Huang, T. S., & Chen, Y. H. (2017)
Extracts of water from the plumes of Pavot cristatus to inhibit PLA2 – Source: Chien, C. Y., Liao, S. C., Liao, C. H., Huang, T. S., & Chen, Y. H. (2017)

IgY antibody (immunoglobulin Y) is present in reptiles but also in birds. It is very concentrated in egg yolk. As a result, a 2016 study with Trimeresurus albolabris venom made it possible for the first time to highlight the possibility of producing sera from chickens, which is less expensive and less restrictive than traditional production based on chickens. horse antibody, immunoglobulin G, called IgG (Duan, HL, He, QY, Zhou, B., Wang, WW, Li, B., Zhang, YZ, … & Yu, XD (2016)) .

Studies similar to the above paragraphs demonstrated that ethanol extracted from the plant Peristrophe bivalvis was an inhibitor of the cytotoxic components of Trimeresurus albolabris venom (PHAOPONGTHAI, Jatuporn, NOIPHROM, Jureeporn, PHAOPONGTHAI, Supat, et al, 2016).

l'éthanole extrait de Peristrophe roxburghiana inhibe les effets cytologique de T. albolabris
Ethanol extracted from Peristrophe roxburghiana inhibits cytotoxic effects de T. albolabris – Source: PHAOPONGTHAI, Jatuporn, NOIPHROM, Jureeporn, PHAOPONGTHAI, Supat, et al, 2016

In 2013, a study conducted in the medical department of the “Medical College Hospital” in Chittagong (Bangladesh) confirmed the results of neighboring countries, namely, the main victims are mainly men and children, coinciding with seasonal activity of their main source of income: agriculture. The study does not report any deaths but asserts the anticoagulant and thus hemorrhagic effects of a Trimeresurus bite (Sarmin, S., Amin, MR, Al-Mamun, H., Rahman, R., & Faiz, MA (2013) ). Note that this study is also part of a major health problem: the lack of serum for the taxon, yet cited as the most common bite case.

In 2017, 3 cases of bites by Craspedocephalus trigonocephalus could demonstrate that no necrosis appeared in bitten (human) victims. Although in one of the cases, due to a pre-existing disease, the victim has suffered polyuric renal failure. Nevertheless, the venom of Craspedocephalus trigonocephalus appears to be less active than those of, for example, Trimeresurus albolabris on humans (Rathnayaka, R. N., Kularatne, S.A.M., & Ranathunga, P.E.A.N. (2017)).

A 2014 study by JYE, BOO BIING, et al. demonstrated that the destruction of red blood cells (hemolysis) caused by the venom of Craspedocephalus puniceus was influenced by the concentration of venom injected (JYE, BOO BIING, et al., 2014).

Amino acids present in the venom of Viridovipera stejnegeri have demonstrated a dose-dependent action on the HIV-1 virus (ZHANG, Yu-Jie, WANG, Jian-Hua, LEE, Wen-Hui, et al, 2003, MEENAKSHISUNDARAM, Ramachandran, SWENI, Shah, and THIRUMALAIKOLUNDUSUBRAMANIAN, Ponniah, 2009).

The venom of Trimeresurus insularis, Trimeresurus purpureomaculatus, Parias hageni and Craspedocephalus puniceus, all species that can be found in Indonesia, are neutralized by the GPVAV (Thai Green Pit Viper Antivenom) thanks to its ability to neutralize the procoagulant effects. venoms. This serum appears to be more effective than the Indonesian equivalent of the BioSave brand, but other clinical studies have yet to be established (TAN, Choo Hock, LIEW, Jia Lee, TAN, Nget Hong, et al., 2017).

In 2017, GREENE, Spencer, GALDAMEZ, Laura Ann, and TOMASHESKI, Richard described the bite of a 28-year-old breeder bitten by a juvenile Trimeresurus albolabris:

he patient complained of significant pain and swelling that had progressed across his entire hand. He also experienced nausea, lightheadedness, mild dyspnea, and a burning sensation in his lungs. After discussing the risks and benefits, we elected to treat with five vials of Thai Red Cross Green Pit Viper antivenin. The patient was also treated with intravenous fluids, parenteral opioids, and ondansetron. He received an additional five vials due to worsening hematologic laboratory values. His laboratory tests normalized and his local findings improved significantly. He was asymptomatic at discharge and at multiple follow-up visits.

Conclusion

The envenomation by Trimeresurus “sensu lato” is generally treated well thanks to the versatile antivenoms. However, in cases such as the bite of a Craspedocephalus trigonocephalus where there is no serum, it is advisable not to use a generic, under penalty of unwanted consequence.

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