SNAKEBITES: PHYSIOPATHOLOGY

1. SNAKEBITES: PHYSIOPATHOLOGY BENEDITO BARRAVIERA Full Professor of Tropical Diseases - Botucatu Medical School - UNESP Research from The Center for the Study of Venoms and Venomous Animals – CEVAP São Paulo State University - UNESP - Brazil

2. CONTENTS 1-The São Paulo State University history; 2-The Center for the Study of Venoms and Venomous Animals – CEVAP – facilities; 3-Main Brazilian venomous and nonvenomous snakes; 4-Classification and Epidemiology; 5-Clinical manifestations and physiopathology;

3. São Paulo State University campuses

4. São Paulo State University – UNESP Based in São Paulo city Supported by São Paulo State Government Annual Budget – U$ 750,000,000 / year (R$ 1.370.788.000,00 - 2008) UNESP has 23 University Campuses (32 Colleges, 7 Research Centers and 3 Technical schools) 168 Undergraduate courses – 34,425 students 108 Graduate courses – 12,031 students 3,354 Professors and Researchers 6,984 Employees 30 Libraries, 5 Farms, 2 Medical Hospitals, 3 Veterinary Hospitals and1,900 Research and Teaching laboratories

5. The Center for the Study of Venoms and Venomous Animals – CEVAP CEVAP was created in 1993. It is based at Lageado Experimental Farm adjoining Botucatu School of Agronomical Sciences. It is a Research Institution focusing Toxinology. The multicampus structure of UNESP allows the interaction among Learning, Research, Continuing education and Extension.

6. The Center for the Study of Venoms and Venomous Animals – CEVAP CEVAP count on the following partners: Botucatu Medical School , Botucatu School of Veterinary Medicine and Animal Husbandry, Botucatu and Rio Claro Institute of Biosciences and Araraquara School of Pharmaceutical Sciences. Total farm area – 2,000 hectares (600 hectares of native forests).

7. The Center for the Study of Venoms and Venomous Animals - CEVAP

9. CEVAP Laboratories and Serpentariums

10. Serpentariums Extension activities

11. From Public Health point of view 1-Venomous snakes (about 58 species) Viperidae family – Bothrops sp (28 species) Crotalus sp (6 sub-species) Lachesis sp (2 species) Elapidae family – Micrurus sp (22 species) 2-Nonvenomous snakes (about 250 species) Boidae family - Boaconstrictor, Eunectusmurinus, Coralluscaninus, Epicrates cenchria (11 species) Colubridae family – Cleliaclelia, Liophisfrenatus, Philodryas olfersii, Dipsasalbifrons, Spilotispullatus, Waglerophismerremii, Mastigodryasbifossatus, etc. (239 species) MAIN BRAZILIAN SNAKES

12. Viperidae family • – Bothrops sp – Bothropsjararaca, B. alternatus, B.moojeni, B.atrox (from Amazon region), B.cotiara, B.erytromelas, etc. • -Responsible for 80 to 90% of accidents in Brazil • Crotalus sp – Crotalusdurissusterrificus, C.d.collilineatus, C.d.marajoensis, C.d.cascavella, C.d.trigonicus, C.d.ruruima • -Responsible for 10 to 20% of accidents in Brazil • -Lachesis sp – Lachesismutamuta, Lachesismutarhombeata • -Responsible for 3% of accidents in the Amazon region - Brazil. MAIN BRAZILIAN VENOMOUS SNAKES

13. Bothrops sp distribution Bothrops alternatus Bothrops moojeni Bothrops jararaca

14. Bothrops moojeni

15. Crotalus sp distribution Crotalus durissus terrificus (South American rattlesnake)

16. Crotalus durissus terrificus

17. MAIN BRAZILIAN VENOMOUS SNAKES IN AMAZON REGION

18. Bothrops atrox* Bothrops brazili Bothriopsis bilineata Bothriopsis teniata Lachesis muta muta * MAIN BRAZILIAN VENOMOUS SNAKES IN THE AMAZON REGION

19. Bothrops atrox MAIN BRAZILIAN VENOMOUS SNAKES IN THE AMAZON REGION Lachesis muta muta Bothriopsis bilineata

20. Lachesis muta muta

21. Elapidae family -Micrurus sp – Micrurus frontalis, M. corallinus, M. paraensis, M. spixii, M. filiforms, etc. -Responsible for less than 1% of accidents in Brazil MAIN BRAZILIAN VENOMOUS SNAKES Micrurus corallinus

22. Micrurus sp distribution Micrurus frontalis

23. Boa constrictor Boidae family Nonvenomous snakes Corallus caninus Eunectus murinus

24. Colubridae family Nonvenomous snakes Philodryas olfersii Liophis miliaris Spilotes pullatus

25. Accidents caused by venomous animals in Brazil Snakes – 30,000/year Scorpions – 40,000/year Spiders – 19,500/year Bees and wasps – 1,500/year Catterpilars – 500/year São Paulo State – 2,000/year Botucatu – 100/year EPIDEMIOLOGY

26. Main season Summer – from December to March Patient´s characteristics Rural workers, Male (74.84%) , 15 to 49 years old, lower limbs (62.75%) Snakes characteristics 87.33% Bothrops sp envenoming 7.43% Crotalus sp envenoming 1.37% Lachesis sp envenoming 0.41% Micrurus spenvenoming The Amazon region – 3,000 cases/year 90% Bothrops sp envenoming 10% Lachesis sp and others EPIDEMIOLOGY

27. Venom activity – Bothrops sp 1-Coagulative activity – cause bleeding and clotting disturbances Bothropic envenoming Clinical aspects Bothrops alternatus Patient with severe gingival bleeding

28. Venom activity – Bothrops sp 2-Citotoxic venom activity – citotoxicity - capacity to destroy tissues Bothropic envenoming Clinical aspects Bothrops alternatus Mild bothropic envenomings

29. Venom activity – Bothrops sp 2-Citotoxic venom activity – citotoxicity - capacity to destroy tissues Bothropic envenoming Clinical aspects Bothrops alternatus Moderate bothropic envenomings

30. Venom activity – Bothrops sp 2-Citotoxic venom activity – citotoxicity - capacity to destroy tissues Bothropic envenoming Clinical aspects Bothrops alternatus Severe bothropic envenomings

31. Venom activity – Bothrops sp 3-Hemorrhaging activity – spontaneous hemorrhage by damaging vascular endothelium Bothropic envenoming Clinical aspects Bothrops alternatus Patients develop local or distant hemorrhage

32. Venom activity – Crotalus sp 1-Neurotoxic activity – neurotoxic symptoms Crotalic envenoming Clinical aspects Crotalus durissus terrificus Midriasis Local bite Ptosis, Diplopia and blurred vision

33. Venom activity – Crotalus sp 2-Systemic rhabdomyolyses – skeletal muscle Crotalic envenoming Clinical aspects Crotalus durissus terrificus Rhabdomyolysis Myoglobinuria Increase of CPK, DHL, AST and ALT enzymes

34. Venom activity – Crotalus sp 3-Renal failure Crotalic envenoming Clinical aspects Crotalus durissus terrificus Tubular necrosis causing renal failure

35. Venom activity – Crotalus sp 4-Liver toxicity Crotalic envenoming Clinical aspects Crotalus durissus terrificus Liver cells with mitochondrial edema Increase of Alanine aminotransferase enzyme Liver necrosis Liver with edema

36. Venom activities – like Bothrops sp 1-Coagulative – cause bleeding and clotting disturbances 2-Citotoxic – citotoxicity - capacity to destroy tissues 3-Hemorrhagic – spontaneous hemorrhage by damaging vascular endothelium 4-Neurotoxic – bradicardia, diarrhea and arterial hipotension including shock Lachetic envenoming Clinical aspects

37. This venom • low molecular weight neurotoxins • neurotoxic facial expression (bilateral ptosis) • respiratory muscle paralysis. • The most severe Brazilian ophidic accident! Elapidic envenoming Clinical aspects Neurotoxic facial expression Micrurus corallinus

38. Boidae family No envenomation Wash the bite area with soap and water; Inform the patient that antivenom treatment is not necessary. NONVENOMOUS SNAKE ACCIDENTS Accident with Boa constrictor

39. Colubridae family -Rare envenomation; -Rare pain and local swelling; -Rare partial defibrination; -Controversial antibotropic treatment. NONVENOMOUS SNAKE ACCIDENTS Envenomation by Philodryas olfersii

40. This lecture is available at:http://www.barraviera.med.brEmailbbviera@jvat.org.brbbviera@gnosis.com.br Thankyouverymuch!