Crotalus Oreganus Concolor: Envenomation Case with Venom Analysis and a Diagnostic Conundrum of Myoneurologic Symptoms

WILDERNESS & ENVIRONMENTAL MEDICINE XXXX; XXX(XXX): 1e6

CASE REPORT

Crotalus oreganus concolor: Envenomation Case with Venom Analysis and a Diagnostic Conundrum of Myoneurologic Symptoms

Daniel E. Keyler, PharmD 1; Vinay Saini, MD 2;MarkO’Shea, Prof. 3;JeffGee,EMT4; Cara F. Smith, MS 5; Stephen P. Mackessy, PhD 5

1Department of Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis, MN; 2Mimbres Memorial Hospital, Deming, New Mexico; 3Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK; 4Portal Rescue, Portal, AZ; 5School of Biological Sciences, University of Northern Colorado, Greeley, CO

A case of midget-faded rattlesnake (Crotalus oreganus concolor) envenomation of an adult male professional herpetologist occurred in a rural setting and resulted in an array of venom induced myoneurologic symptoms. The patient experienced blurry vision, total body paresthesia, dyspnea, chest tightness, and waves of spastic muscle movements of the hands and feet that resembled tetany. It was not apparent whether these symptoms were potentially venom induced or were related to stress-induced physiologic responses. Local envenomation effects were minimal, and coagulation parameters remained within normal limits. Anti- venom was not administered per patient concerns related to a history of acute allergic reactions to antivenom. Venom was collected from the Crotalus oreganus concolor responsible for the bite, and analysis revealed the presence of high levels of myotoxins (SR calcium pump antagonists) and concolor toxin, a presynaptic neurotoxin that can have myotoxic effects and cause respiratory paralysis; several serine proteinases associated with coagulopathies were also present in the venom proﬁle. Keywords: rattlesnake, snakebite, hyperventilation, carpopedal, alkalemia, hypocalcemia

Introduction Crotalus oreganus concolor venom studies have revealed the presence of a potent lethal toxin, antigenically The midget-faded rattlesnake (Crotalus oreganus conco- similar to Mojave toxin.6,7 Ithasbeendeterminedtobeone lor) is an uncommon, small (50e65 cm total body length) of the most lethal crotaline venoms, nearly equal in toxicity subspecies originally assigned to the Crotalus viridis com- to Crotalus durissus terrificus and Crotalus scutulatus scu- plex and currently recognized as a subspecies in the Crota- tulatus venoms based on murine lethality experiments.8 In lus oreganus clade.1,2 It is indigenous to a restricted addition, Crotalus oreganus concolor venom lethality is geographic range of the Colorado Plateau that includes reported to range from 10- to 30-fold greater than multiple west central Colorado, the Colorado and Green River other crotaline species.8,9 A presynaptic phospholipase basins, eastern Utah, southwestern Wyoming, and extreme A2-ß-neurotoxin (concolor toxin) and nonenzymatic pep- northern Arizona.3-5 tide myotoxins have been identified as major venom components.9-12 Envenomation of humans by Crotalus oreganus conco- Platform presentation by Daniel E Keyler at the Venom Week VI lor is rare, and the case reported here illustrates what Meeting, March 14, 2018; Texas A&M University, Kingsville, Texas, USA. clinically appeared to be possible venom-induced myoneur- Corresponding author: Daniel E. Keyler, PharmD, Department of ologic symptoms that were confounded in interpretation by & Experimental Clinical Pharmacology, 7-115 Weaver-Densford Hall, 308 physiologic stresses. Analysis of venom from the Crotalus Harvard St. S.E., University of Minnesota, Minneapolis, Minnesota, 55455; e-mail: [email protected]. oreganus concolor responsible in this case suggested a pos- Submitted for publication May 2019. sible correlation between specific venom components and Accepted for publication December 2019. several observed clinical symptoms. 2 Keyler et al

Figure 1. A, The midget faded rattlesnake (Crotalus oreganus concolor) responsible for the bite, in its housing drawer enclosure from which it struck, imparting a single fang puncture to the patient. B, Single fang puncture into the distal phalangeal region of the right thumb.

Case Presentation spastic muscle movement (Figure 2A). The patient was alert and oriented; blood pressure was normal by sphygmo- A healthy 61-y-old male professional herpetologist sus- manometer/cuff (113/72 mm Hg), and pulse was normal by tained a bite from a captive (wild caught) adult male Crota- palpitation (69 beats$min-1)(Figure 2B). lus oreganus concolor (Figure 1A). Patient history included Approximately 2.5 h postbite the patient arrived to the prior crotaline envenomation from Crotalus horridus, Cro- emergency department, and the myoneurologic symptoms talus horridus atricaudatus (subspecies recognized at the had abated. Examination revealed a single fang puncture time of the bite), and Crotalus durissus ruruima. Treat- in the distal phalangeal region of the right thumb and swel- ments involved Wyeth anticrotalic antivenoms and Instituto ling that extended proximally to the thenar eminence. Butantan anticrotalico, with anaphylactic reactions having Chemistry panel, complete blood count, electrolytes, coagu- occurred. Patient medication history included migraine lation, and hematologic parameters were within normal headache prescriptions (rizatriptan, atenolol, and limits, excepting a slightly elevated D-dimer (566 ng$mL-1 amitriptyline). FEU; reference laboratory range 190e490 ng$mL-1 FEU) The incident took place in a remote facility, and the bite and elevated creatine kinase (CK) 3394 U$L-1 (reference occurred as the snake was being removed from a drawer- laboratory range 22e198 U$L-1). type housing unit, resulting in a single fang puncture into Over the following 24 h, there was a small decline the right thumb (Figure 1B). The patient immediately in total serum calcium from 8.8 mg$dL-1 (3 h) to 7.7 experienced generalized “pins and needles” sensations in mg$dL-1 (22 h) (reference laboratory range 8.5e10.1 the bitten thumb that rapidly progressed to pain, followed mg$dL-1) and a corresponding slight decline in serum albu- by tingling of the lips and a feeling of chest tightness. min from 4.2 g$dL-1 (3 h) to 3.5 g$dL-1 (22 h) (reference Within 15 min the patient reported total body tingling. laboratory range 3.4e5.0 g$dL-1). There was no evidence The first responder found the patient resting supine on the of bleeding at any time. Swelling spread proximally to mid- floor and reported the patient did not appear anxious or agi- forearm over the first 3 h, but local pain had lessened. Med- tated, with no obvious signs of hyperventilation (20 ical staff observed weak patient total body strength with breaths$min-1). The patient described feeling like he was poor coordination, requiring walking frame assistance. “wearing a clay mask and a hat with hat band one size too There was no evidence of compartment syndrome. Despite small constricting around my forehead.” The affected indications for antivenom, its administration was declined limb was splinted for immobilization during a 1-h ground by the patient because of anaphylactic reactions from pre- ambulance transport to the helispot and subsequent 45- vious antivenom treatments. min helicopter flight to a rural hospital. During ground The patient was observed for another 6 h and discharged transport, the patient reported breathing difficulty, and sup- at 25 h postbite (22 h post admission) in stable condition. At plemental oxygen was provided via nasal cannula. Tighten- 24 h after discharge, the patient remained weak but could ing of the tongue, blurred vision, and difficulty speaking walk without assistance. Myalgia in the right arm and gen- were also experienced. Three distinct waves of transient eralized weakness persisted for several days. At 3-wk fol- neuromuscular spasms associated with inspirational weak- low-up, the bitten thumb skin had sloughed and thumb ness ensued. Spastic simultaneous contractures of first the numbness persisted, but other local symptoms had resolved left hand and then to a lesser degree the right (bitten) hand completely and all laboratory studies were unremarkable. and foot/toes occurred, followed by a third wave that Venom from the responsible Crotalus oreganus concolor involved the left forearm, lower leg, and foot. The first was collected for assay and analysis of venom components responder described these waves as severe, tetany-like, and their potential correlation to observed symptoms. Crotalus oreganus concolor Envenomation 3

Figure 2. A, Tetany-like spasms showing ﬂexion of the hands and extension of the feet (carpopedal spasms) that began 30 min after the bite. Three waves of approximately 10 min each, 20 min apart, were observed. B, Blood pressure and pulse were normal to low as measured by palpitation and the sphygmomanometer/cuff placed on the contralateral arm.

METHODS patient, the tetany-like carpopedal spasms may not have been venom induced, but instead from patient anxiety- Venom was extracted manually from the Crotalus orega- induced hyperventilation or sphygmomanometer cuff nus concolor responsible for the bite approximately 4 d inflation.18,19 Crotalus oreganus concolor venom contains after the bite and centrifuged to pellet the cell debris, and myotoxic and neurotoxic components capable of eliciting fl m z the supernatant was lyophilized ( uid yield 120 L; 27 neurotoxic symptoms.9,10,12 Purified Crotalus oreganus mg dry venom). Lyophilized venom was solubilized in concolor venom toxins injected into mice elicit myotoxic $ -1 m phosphate-buffered saline (8.0 mg mL ), and 200 L effects of rapid ataxia, hind limb extension, and respiratory (1.6 mg) was subjected to reversed-phase high-performance distress.7,20 Collectively, symptoms in the present case liquid chromatography (RP-HPLC) as reported previously; 13 combined with the interpretation of the venom analysis 1-min fractions were collected and lyophilized. Toxins for the inflicting snake provide for interesting discussion. fi fi fi were identi ed from the known elution pro les of puri ed Venomous snakebite can trigger significant anxiety, fi toxins and quanti ed via peak area integration (percentage leading to an autonomic response of hyperventilation- total area). induced alkalemia with consequent precipitation of hypo- HPLC fractions were also subjected to polyacrylamide calcemia, resulting in symptoms of breathlessness and gel electrophoresis (SDS-PAGE) under reducing condi- 13 paresthesia of the face and hands, although blood pressure tions to identify chromatogram peaks. Crude venom remains normal.18 Tetany-like symptoms of painful sharp was assayed for protein content via Pierce BCA assay and fl 10,14 involuntary exion of the wrist and ankle joints (carpopedal for 6 enzyme activities common to rattlesnake venoms. spasms), cramps, and muscle twitching may be clinically These data were used in conjunction with HPLC chromato- misleading. These physiologic responses are due to gram data to identify the protein families present and their decreased extracellular ionized calcium, resulting in hyper- relative abundance in the venom. excitability of muscles and nerves.18 Ionized serum calcium DISCUSSION was not measured in our patient; however, the patient was not observed to be tachypnic, although hyperventilation Our patient’s symptoms illustrate a potential diagnostic may occur via slow deep breathing. Hypocalcemic tetany conundrum clinicians may face in cases of snakebite enve- of the lower extremities has been reported in a case of nomation: What symptoms might be venom-induced Crotalus scutulatus envenomation with minimal coagulo- effects, and what symptoms might be related to stress- pathy, but this was thought to have been subsequent to induced physiologic responses? Our patient experienced rhabdomyolysis.21 Our patient had normal blood pressure generalized paresthesia, blurred vision, waves of spastic, and may have deeply hyperventilated to the point of respira- tetany-like symptoms of the hands and feet (carpopedal tory alkalosis followed by hypocalcemic tetany. The carpo- spasms), breathing difficulties, numbness, and generalized pedal symptoms fit the profile of stress-related physiologic weakness that persisted for days, all symptoms consistent responses, which were considered a contributing root with venom-induced effects reported in other cases of cause. North American rattlesnake envenomation, including by Blood pressure measurement via sphygmomanometer Crotalus oreganus concolor.9,15-17 However, in our with an inflatable cuff was used to monitor our patient’s 4 Keyler et al

Figure 3. Reversed-phase high-performance liquid chromatography chromatogram of Crotalus oreganus concolor venom, 1.6 mg in 200 mL phosphate- buffered saline. Identification of peaks are based on SDS-PAGE and enzyme activity assays. Inset: reducing SDS-PAGE of indicated high-performance liquid chromatography fractions. CRiSP, cysteine-rich secretory protein. blood pressure during ambulance transport. Cuff inflation, maximum dose; this is a potential reason for the reduced in conjunction with hyperventilation-induced hypocalce- severity and duration of symptoms. Neurotoxic effect dura- mia, likely triggered a classic Trousseau sign.19 Cuff inflation after snake envenomation is highly variable.25 The tion to greater than the mean arterial pressure can result in short duration of myoneurologic actions in our patient the hand adopting a posture of metacarpophalangeal joint may have been related to dose-dependent pharmacokinetics flexion with the interphalangeal joints of the fingers and or pharmacokinetic metabolic actions on a responsible thumb extended so that the thumb is in an opposing posture, toxin. as observed in our patient (Figure 2B). This phenomenon Myokymia has been reported after envenomation by has been reported in 1 to 4% of healthy individuals but Crotalus oreganus concolor and other North American has not been reported to be associated with cases of snake- rattlesnakes.15,26,27 In our patient, the periodic episodes bite envenomation.19 Although Crotalus oreganus conco- of tetany-like carpopedal spasms were distinctly different lor myotoxic venom components can induce muscle from myokymia or fasciculations.15,27 contractile activity, causing rapid tetany-like hind limb Crotaline envenomation can result in hematologic hyperextension in mice (a symptom somewhat similar to effects ranging from mild to severe coagulopathy and neu- the extension of the ankles, feet, and toes observed in our rologic effects ranging from paresthesia to seizures and patient), this symptom was likely a stress-induced response rather than venom induced 20,22 Our patient’s other myoneurologic symptoms of par- Table 1. Composition of Crotalus oreganus concolor venom esthesia, respiratory distress, and total body weakness may based on percent area of reversed-phase high-performance liquid have been related to the high myotoxin content and concolor chromatography peaks and SDS-PAGE toxin in the Crotalus oreganus concolor’s venom (Figure 3, Protein family Percent Table 1). Studies in mice injected with Crotalus oreganus Myotoxin I and II 60 concolor venom showed they died from rapid respiratory Concolor toxin subunit B 15 failure, suggesting that venom may have contributed to Snake venom serine proteinases 9 our patient’s respiratory difficulty, as has been reported to Concolor toxin subunit A 6 occur after C scutulatus, C cerastes, C oreganus helleri, Phospholipase A2 (acidic) 6 and C horridus envenomation.16,17,23,24 Unidentified 3 Venom was delivered to our patient via a single fang Snake venom metalloproteinase (PeIII) 1 puncture, and it is reasonable to assume it was not a Note that myotoxins I and II comprise the majority of venom proteins. Crotalus oreganus concolor Envenomation 5

Table 2. Assays of Crotalus oreganus concolor venom for enzyme activities common to rattlesnake venoms Enzyme assayed Specific activity Relative activity -1 -1 Phospholipase A2 (nmol product$min $mg ) 25.4 Y Azocasein metalloproteinase (Abs 342 nm$min-1$mg-1) 0.01 YY Kallikrein-like (nmol product$min-1$mg-1) 970.9 [[ Thrombin-like (nmol product$min-1$mg-1) 1388.8 [[ Phosphodiesterase (Abs 400 nm$min-1$mg-1)1 [ L-amino acid oxidase (nmol product$min-1$mg-1) 9.7 Y Y, venom activity lower than average; [, venom activity higher than average Activity levels in the responsible venom relative to averages of 22 taxa of rattlesnakes (Mackessy33) are also indicated. coma. Consequently, patients can exhibit multiple combi- these high activity levels, coagulopathies including nations of clinical manifestations varying in severity.28 hypofibrinogenemia would have been expected; how- Thus, the absence of hematologic effects in our patient, in ever, laboratory blood panels did not indicate any form the presence of neurologic symptoms, was not uncharacter- of coagulopathy. Phospholipase A2 levels were moderate istic of rattlesnake envenomation. Neurologic symptoms but not noteworthy compared to other species; PLA2 after C cerastes and C concolor envenomation, without activity is sometimes associated with severe inflamma- hematologic effects, have been reported.9,15-17 tion, myotoxicity, and occasionally renal damage/failure. Local wound complications in our patient were The lack of these symptoms indicates that this acidic modest, including ecchymosis, swelling, pain, and skin PLA2 was not particularly toxic, consistent with similar sloughing. Elevated CK, a routinely used marker for tissue enzymatic PLA2s from other species. damage and myonecrosis, has been reported in 2 cases of RP-HPLC analysis of the venom (Figure 3) indicated Crotalus oreganus concolor envenomation (range the presence of myotoxins I and II, small peptide compo- 1800e17,000 IU$L-1) and in the absence of coagulopathic nents common to the venoms of numerous species of complications.15,29 rattlesnakes.31 In humans, they may be responsible for fasci- Our patient’s elevated CK value (3394 U$L-1)at22h culations (possibly muscle weakness, both acute and after envenomation was indicative of venom-induced prolonged).25 The myotoxin content of this venom was local tissue/muscle damage to the bitten thumb. extremely high and comprised >59% of the total venom Medications may influence snake envenomation symp- proteins; concolor toxin made up >21% of the venom total toms, and our patient’s medications (atenolol, rizatriptan, protein content (Figure 3, Table 1). The combined actions and amitriptyline) have reported adverse effects of blurred of these 2 protein families, comprising >80% of venom pro- vision, numbness, chest tightness, paresthesia, and weak- teins, possibly contributed to the rapid paraesthesias and ness similar to our patient’s symptoms.30,31 Our patient other tetany-like symptoms observed in the patient. reported having no adverse effects to these medications before the bite, suggesting drug/venom interactions were Conclusions noncontributory to observed symptoms. Venom analyses of the responsible snake revealed The case reported here is an interesting academic case in abundant PLA2-based ß neurotoxin (concolor toxin) that certain symptoms, similar to previously reported and nonenzymatic peptide myotoxins.9,12,32 Enzyme cases of Crotalus oreganus concolor envenomation, may analyses revealed the presence of 6 enzymes common have been a hybridization of anxiety- and stress-induced to rattlesnake venoms (Table 2); however, their levels symptoms combined with venom-induced symptoms. Ana- varied significantly from averaged values based on 22 lyses of ionized calcium and arterial blood gases and a for- taxa of rattlesnakes.33 Notably, snake venom metallopro- mal neurologic evaluation would have provided for a more teinase activity (azocasein metalloproteinase) was barely comprehensive assessment to confirm or rule out the source detectable, and this likely was responsible for the lack of of some symptoms. Although the venom profile of the hemorrhage, rhabdomyolysis, or inflammation. These snake involved showed a high myotoxin content, this is very low levels of snake venom metalloproteinase are unlikely to have played a role in the myoneurologic (carpo- characteristic of type II venoms, including that of Crota- pedal spasms) symptoms. Thus, the presented case illus- lusoreganusconcolor.10 Thrombin-like and kallikrein- trates a diagnostic conundrum, and medical personnel like serine proteinase activities in the venom were quite should be cognizant of the potential for confounding symp- high, and thrombin-like activity was nearly twice the toms associated with rattlesnake envenomation and inter- average value of many rattlesnake venoms. Because of pretation as to their cause. 6 Keyler et al

Acknowledgments: Appreciation is extended to Professor David Warrell 16. Bosak AR, Ruha AM, Graeme KA. A case of neurotoxicity for insightful comments regarding the clinical case. following envenomation by the sidewinder rattlesnake, Cro- Author Contributions: Acquisition of case data and analysis of case data talus cerastes. J Med Toxicol. 2014;10(2):229e31. (DEK, MO, VS, JG); photo credits: Figure 1 (DEK), Figure 2 (JG); drafting 17. Bush SP, Siedelburg E. Neurotoxicity associated with of case and overall manuscript (DEK); acquisition of venom data and analysis suspected Southern Pacific rattlesnake (Crotalus viridis helleri) of venom data (SPM, CFS); drafting venom analysis portion of manuscript envenomation. Wilderness Environ Med. 1999;10(4):247e9. fi (SPM, CFS); critical revision and approval of nal manuscript (DEK, SPM). 18. Mrunalini P, Shaik MS, Nagendra NV. Cramps and tingling: a Financial/Material Support: None. diagnostic conundrum. Anesth Essays Res. 2014;8(2):247e9. Disclosures: None. 19. Rehman HU, Wunder S. Trouseau sign in hypocalcemia. CMAJ. 2011;183(8):E498. References 20. Ownby CL, Aird SD, Kaiser II . Physiological and immunolo- gical properties of small myotoxins from the venom of the 1. Ashton KG, de Queiroz A. Molecular systematics of the wes- midget faded rattlesnake (Crotalus viridis concolor). Toxicon. tern rattlesnake, Crotalus viridis (Viperidae), with comments 1988;26(3):319e23. on the utility of the D-loop in phylogenetic studies of snakes. 21. Bush SP, Jansen PW. Severe rattlesnake evenomation with Mol Phylogenet Evol. 2001;21(2):176e89. anaphylaxis and rhabdomyolysis. Ann Emerg Med. 2. Parker JM, Anderson SH. Ecology and behavior of the midget 1995;25(6):845e8. faded rattlesnake (Crotalus oreganus concolor)inWyoming. 22. Hayes CE, Bieber AL. The effects of myotoxin from midget J Herpetol. 2007;41(1):41e51. faded rattlesnake (Crotalus viridis concolor) venom on neona- 3. Woodbury AM. A new rattlesnake from Utah. Bull Unit Utah. tal rat myotubes in cell culture. Toxicon. 1986;24(2):169e73. 1929;20:1. 23. Clark RF, Williams SR, Nordt SP, Boyer-Hassen LV. Suc- 4. Woodbury AM. The name Crotalus viridis concolor Wood- cessful treatment of Crotalid-induced neurotoxicity with a bury. Copeia. 1958;2:151. new polyspecific Crotalid Fab antivenom. Ann Emerg Med. 5. Brennan TC, Holycross AT. Crotalus oreganus concolor geo- 1997;30(1):54e7. graphic distribution. Herpetol Rev. 2004;35:190e1. 24. Madey JJ, Price AB, Dobson JV, Stickler DE, McSwain SD. 6. Pool WR, Bieber AL. Characterization of some components Facial diplegia, pharyngeal paralysis, and ophthalmoplegia of venom from Crotalus viridis concolor). FedProcFed after a timber rattlesnake envenomation. Pediatr Emerg Am Soc Exp Biol. 1980;39(4):1646. Care. 2013;29(11):1213e6. 7. Weinstein SA, Minton SA, Wilde CE. The distribution among 25. Ranawaka UK, Lalloo DG, de Silva HJ. Neurotoxicity in sna- ophidian venoms of a toxin isolated from the venom of the kebite e the limits of our knowledge. PLoS Negl Trop Dis. Mojave rattlesnake (Crotalus scutulatus scutulatus). Toxicon. 2013;7(10):e2302. 1985;23(5):825e44. 26. Brick JF, Gutmann L, Brick J, Apelgren KN, Riggs JE. Tim- 8. Glenn JL, Straight R. The midget faded rattlesnake (Crotalus ber rattlesnake venom-induced myokymia: evidence for per- viridis concolor) venom: lethal toxicity and individual varia- ipheral nerve origin. Neurology.1987;37(9):1545e6. bility. Toxicon. 1977;15(2):129e33. 27. Vohra R, Cantrell FL, Williams SR. Fasciculations after 9. Mackessy SP, Williams K, Ashton KG. Ontogenetic variation rattlesnake envenomations: a retrospective statewide poison in venom composition and diet of Crotalus oreganus concolor: control system study. Clin Toxicol (Phila). 2008;46(2):117e21. a case of venom paedomorphosis? Copeia. 2003;4:769e82. 28. Dart RC, Hurlbut KM, Garcia R, Boren J. Validation of a 10. Mackessy SP. Evolutionary trends in venom composition in severity score for the assessment of crotalid envenomation. the western rattlesnakes (Crotalus viridis sensu lato): toxicity Ann Emerg Med. 1996;27(3):321e6. vs. tenderizers. Toxicon. 2010;55(8):1463e74. 29. Mebs D, Ehernfeld M, Samejima Y. Local necrotizing effect 11. Modahl CM, Mackessy SP. Full-length venom protein cDNA of snake venoms on skin and muscle: relationship to serum sequences from venom-derived mRNA: exploring composi- creatine kinase. Toxicon. 1983;21(3):393e404. tional variation and adaptive multigene evolution. PLoS 30. Schulte J, Kleinschmidt KC, Domanski K, Smith EA, Negl Trop Dis. 2016;10(6), e0004587. Haynes A, Roth B. Differences between snakebites with con- 12. Pool WR, Bieber AL. Fractionation of midget faded rattle- comitant use of alcohol or drugs and single snakebites. South snake (Crotalus viridis concolor) venom: lethal fractions Med J. 2018;111(2):113e7. and enzymatic activities. Toxicon. 1981;19(4):517e27. 31. US Food & Drug Administration. Drugs. Available at: 13. Smith CF, Mackessy SP. The effects of hybridization on https://www.fda.gov/Drugs/default.htm.AccessedNovember divergent venom phenotypes: characterization of venom 18, 2018. from Crotalus scutulatus scutulatus x Crotalus oreganus hel- 32. Bieber AL, McParland RH, Becker RR. Amino acid leri hybrids. Toxicon. 2016;120:110e23. sequences of myotoxins from Crotalus viridis concolor 14. Smith PK, Krohn RI, Hermanson GT, Mallia AK, venom. Toxicon. 1987;25(6):677e80. Gartner FH, Provenzano MD, et al. Measurement of protein 33. Mackessy SP. Venom composition in rattlesnakes: trends and using bicinchoninic acid. Anal Biochem. 1985;150(1):76e85. biological significance. In: Hayes WK, Beaman KR, 15. LoVecchio F, Pizon AF, Wallace KL, Kunkel DB. Myokymia Cardwell MD, Bush SP, eds. The Biology of Rattlesnakes. after snake envenomation in Arizona. Wilderness Environ Loma Linda, CA: Loma Linda University Press; 2008: Med. 2005;16(2):116e7. 495e509.