Immune response to snake envenoming and treatment with antivenom; complement activation, cytokine production and mast cell degranulation

Abstract

Background: Snake bite is one of the most neglected public health issues in poor rural communities worldwide. In addition to the clinical effects of envenoming, treatment with antivenom frequently causes serious adverse reactions, including hypersensitivity reactions (including anaphylaxis) and pyrogenic reactions. We aimed to investigate the immune responses to Sri Lankan snake envenoming (predominantly by Russell's viper) and antivenom treatment.

Methodology/principal findings: Plasma concentrations of Interleukin (IL)-6, IL-10, tumor necrosis factor α (TNFα), soluble TNF receptor I (sTNFRI), anaphylatoxins (C3a, C4a, C5a; markers of complement activation), mast cell tryptase (MCT), and histamine were measured in 120 Sri Lankan snakebite victims, both before and after treatment with antivenom. Immune mediator concentrations were correlated with envenoming features and the severity of antivenom-induced reactions including anaphylaxis. Envenoming was associated with complement activation and increased cytokine concentrations prior to antivenom administration, which correlated with non-specific systemic symptoms of envenoming but not with coagulopathy or neurotoxicity. Typical hypersensitivity reactions to antivenom occurred in 77/120 patients (64%), satisfying criteria for a diagnosis of anaphylaxis in 57/120 (48%). Pyrogenic reactions were observed in 32/120 patients (27%). All patients had further elevations in cytokine concentrations, but not complement activation, after the administration of antivenom, whether a reaction was noted to occur or not. Patients with anaphylaxis had significantly elevated concentrations of MCT and histamine.

Conclusions/significance: We have demonstrated that Sri Lankan snake envenoming is characterized by significant complement activation and release of inflammatory mediators. Antivenom treatment further enhances the release of inflammatory mediators in all patients, with anaphylactic reactions characterised by high levels of mast cell degranulation but not further complement activation. Anaphylaxis is probably triggered by non allergen-specific activation of mast cells and may be related to the quality of available antivenom preparations, as well as a priming effect from the immune response to the venom itself.

Figure 1. Changes in MCT and histamine concentrations during treatment with antivenom.

Lowess curve (thick dash-dot line). Upper limit (99^th centile healthy control values from our laboratory) (thin dashed line). Normal limit defined by assay (MCT only) (thin dotted line). * p-value for difference between pre-antivenom concentration and peak concentration during the first four hours post-antivenom (Wilcoxon Signed Rank Test).

Figure 2. Changes in IL-6, IL-10, TNFα and sTNFRI concentrations during treatment with antivenom.

Lowess curve (thick dash-dot line). Upper limit (99^th centile healthy control values from our laboratory) (thin dashed line). * p-value for difference between pre-antivenom concentration and peak concentration during the first four hours post-antivenom (Wilcoxon Signed Rank Test).

Figure 3. Changes in anaphylatoxin (C3a, C4a and C5a) concentrations during treatment with antivenom.

Lowess curve (thick dash-dot line). Upper limit (99^th centile healthy control values from our laboratory) (thin dashed line). There were no significant differences between pre-antivenom concentrations and peak concentrations during the first four hours post-antivenom for C3a, C4a or C5a (p>0.13 for all comparisons, Wilcoxon Signed Rank Test).