Australian taipan (Oxyuranus spp.) envenoming: clinical effects and potential benefits of early antivenom therapy – Australian Snakebite Project (ASP-25)

Abstract Context: Taipans (Oxyuranus spp.) are medically important venomous snakes from Australia and Papua New Guinea. The objective of this study was to describe taipan envenoming in Australian and its response to antivenom. Methods: Confirmed taipan bites were recruited from the Australian Snakebite Project. Data were collected prospectively on all snakebites, including patient demographics, bite circumstances, clinical effects, laboratory results, complications and treatment. Blood samples were taken and analysed by venom specific immunoassay to confirm snake species and measure venom concentration pre- and post-antivenom. Results: There were 40 confirmed taipan bites: median age 41 years (2–85 years), 34 were males and 21 were snake handlers. Systemic envenoming occurred in 33 patients with neurotoxicity (26), complete venom induced consumption coagulopathy (VICC) (16), partial VICC (15), acute kidney injury (13), myotoxicity (11) and thrombocytopenia (7). Venom allergy occurred in seven patients, three of which had no evidence of envenoming and one died. Antivenom was given to 34 patients with a median initial dose of one vial (range 1–4), and a median total dose of two vials (range 1–9). A greater total antivenom dose was associated with VICC, neurotoxicity and acute kidney injury. Early antivenom administration was associated with a decreased frequency of neurotoxicity, acute kidney injury, myotoxicity and intubation. There was a shorter median time to discharge of 51 h (19–432 h) in patients given antivenom <4 h post-bite, compared to 175 h (27–1104 h) in those given antivenom >4 h. Median peak venom concentration in 25 patients with systemic envenoming and a sample available was 8.4 ng/L (1–3212 ng/L). No venom was detected in post-antivenom samples, including 20 patients given one vial initially and five patients bitten by inland taipans. Discussion: Australian taipan envenoming is characterised by neurotoxicity, myotoxicity, coagulopathy, acute kidney injury and thrombocytopenia. One vial of antivenom binds all measurable venom and early antivenom was associated with a favourable outcome.

[1]  K. Maduwage,et al.  Detection of Snake Venom in Post-Antivenom Samples by Dissociation Treatment Followed by Enzyme Immunoassay , 2016, Toxins.

[2]  Sisira Siribaddana,et al.  Neuromuscular Effects of Common Krait (Bungarus caeruleus) Envenoming in Sri Lanka , 2016, PLoS neglected tropical diseases.

[3]  N. Buckley,et al.  Snakebite in Australia: a practical approach to diagnosis and treatment , 2013, The Medical journal of Australia.

[4]  Nicholas A. Buckley,et al.  Clinical Effects and Antivenom Dosing in Brown Snake (Pseudonaja spp.) Envenoming — Australian Snakebite Project (ASP-14) , 2012, PloS one.

[5]  H. Parkington,et al.  In vivo and in vitro cardiovascular effects of Papuan taipan (Oxyuranus scutellatus) venom: Exploring "sudden collapse". , 2012, Toxicology letters.

[6]  B. Currie,et al.  Death Adder Envenoming Causes Neurotoxicity Not Reversed by Antivenom - Australian Snakebite Project (ASP-16) , 2012, PLoS neglected tropical diseases.

[7]  G. Isbister,et al.  Tiger snake (Notechis spp) envenoming: Australian Snakebite Project (ASP‐13) , 2012, The Medical journal of Australia.

[8]  W. Hodgson,et al.  Solving the 'Brown snake paradox': in vitro characterisation of Australasian snake presynaptic neurotoxin activity. , 2012, Toxicology letters.

[9]  David J. Williams,et al.  Comparative proteomic analysis of the venom of the taipan snake, Oxyuranus scutellatus, from Papua New Guinea and Australia: role of neurotoxic and procoagulant effects in venom toxicity. , 2012, Journal of proteomics.

[10]  B. Currie,et al.  Clinical effects and treatment of envenoming by Hoplocephalus spp. snakes in Australia: Australian Snakebite Project (ASP-12). , 2011, Toxicon : official journal of the International Society on Toxinology.

[11]  N. Buckley,et al.  Changes in serial laboratory test results in snakebite patients: when can we safely exclude envenoming? , 2010, The Medical journal of Australia.

[12]  W. Hodgson,et al.  Development of a sensitive enzyme immunoassay for measuring taipan venom in serum. , 2010, Toxicon : official journal of the International Society on Toxinology.

[13]  B. Fry,et al.  Variations in the pharmacological profile of post-synaptic neurotoxins isolated from the venoms of the Papuan (Oxyuranus scutellatus canni) and coastal (Oxyuranus scutellatus scutellatus) taipans. , 2010, Neurotoxicology.

[14]  G. Isbister,et al.  Commercial monovalent antivenoms in Australia are polyvalent. , 2009, Toxicon : official journal of the International Society on Toxinology.

[15]  B. Currie,et al.  Current use of Australian snake antivenoms and frequency of immediate‐type hypersensitivity reactions and anaphylaxis , 2008, The Medical journal of Australia.

[16]  W. Hodgson,et al.  The neuromuscular activity of paradoxin: A presynaptic neurotoxin from the venom of the inland taipan (Oxyuranus microlepidotus) , 2007, Neuropharmacology.

[17]  S. Donnellan,et al.  A new species of taipan (Elapidae: Oxyuranus) from central Australia , 2007 .

[18]  D. Hepner,et al.  Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. , 2006, The Journal of allergy and clinical immunology.

[19]  D. Hepner,et al.  Symposium on the definition and management of anaphylaxis: summary report. , 2005, The Journal of allergy and clinical immunology.

[20]  B. Currie,et al.  Snakebite in tropical Australia: a prospective study in the “Top End” of the Northern Territory , 2004, The Medical journal of Australia.

[21]  S. Brown.  Clinical features and severity grading of anaphylaxis. , 2004, The Journal of allergy and clinical immunology.

[22]  R. Bellomo,et al.  Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group , 2004, Critical care.

[23]  W. Hodgson,et al.  The effects of antivenom on the in vitro neurotoxicity of venoms from the taipans Oxyuranus scutellatus, Oxyuranus microlepidotus and Oxyuranus scutellatus canni. , 1999, Toxicon : official journal of the International Society on Toxinology.

[24]  D. Lalloo,et al.  Electrophysiological findings in patients envenomed following the bite of a Papuan taipan (Oxyuranus scutellatus canni). , 1995, Transactions of the Royal Society of Tropical Medicine and Hygiene.

[25]  D. Lalloo,et al.  Snake bites by the Papuan taipan (Oxyuranus scutellatus canni): paralysis, hemostatic and electrocardiographic abnormalities, and effects of antivenom. , 1995, The American journal of tropical medicine and hygiene.

[26]  D. Lalloo,et al.  The efficacy of antivenom in the treatment of bites by the Papuan taipan (Oxyuranus scutellatus canni). , 1995, Transactions of the Royal Society of Tropical Medicine and Hygiene.

[27]  C. Maltin,et al.  MYOTOXIC ACTIVITY OF THE CRUDE VENOM AND THE PRINCIPAL NEUROTOXIN, TAIPOXIN, OF THE AUSTRALIAN TAIPAN, Oxyuranus scutellatus , 1982, British journal of pharmacology.

[28]  C. Campbell.  THE TAIPAN (OXYURANUS SCUTELLATUS) AND THE EFFECT OF ITS BITE , 1967 .

[29]  David J. Williams,et al.  Hemolytic uremic syndrome following taipan envenomation with response to plasmapheresis , 1997, Pathology.

[30]  S. Sutherland,et al.  The lethality in mice of dangerous Australian and other snake venom. , 1979, Toxicon : official journal of the International Society on Toxinology.