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Snake bite is a major cause of mortality in the Indian subcontinent. The condition is fraught with the problem of under reporting. Most bites in India are caused by the "Big 4 species," based on this, the anti–snake venom (ASV) is also sourced from these species only. It has been observed that the venom of snakes from different regions respond differently to it, as is sourced mainly from snakes of southern region of India. We present a case of a saw-scaled viper (SSV) bite, where the patient had unusual presentation of thrombotic microangiopathy (TMA) along with venom-induced consumption coagulopathy (VICC). The patient was resistant to ASV and finally succumbed. The snake was identified as Echis carinatus sochureki (a subspecies of SSV). This case highlights that VICC is the commonest presentation in a SSV bite, rather than disseminated intravascular coagulation (DIC). The organ failure in such bites is due to rare coexistence of TMA (especially in an E carinatus sochureki bite) and should not be attributed to DIC. It also identifies that the polyvalent ASV produced in India is not effective against E carinatus sochureki bite. [ABSTRACT FROM AUTHOR]

Snake bites are an important cause of illness and deaths in the rural population in tropical, subtropical and southeast Asian countries. There are more than 3000 species of snakes found all over the world of which around 300 species are found in India. In India, most of snake bite deaths occur due to delayed arrival to treatment centers. The purpose of the present review article is to explore the various species of snakes, their toxicology, clinical manifestations, and management. In addition, various ways to avoid snake bites and early approaches to government centers rather than private centers for the availability of Anti-snake venom have been discussed in this article. Rapid diagnostic test for the identification of species is available in selective centers only and treatment mainly depends on the administration of anti-snake venom. In addition, proper community education and strong health-care policy will reduce the morbidity and mortality due to snake bites. [ABSTRACT FROM AUTHOR]

Ingestion of snake venom is a rare occurrence. The manner varies from a direct snake bite on the tongue or other body parts or used as a venom pill at rave parties. Very few cases have been described in the literature. An alcoholic male with a history of psychiatric illness presented with anxiety due to ingestion of snake venom the previous day. The patient's vital signs were within the normal range. The patient was admitted in the Medicine intensive care unit for observation. Multivitamins, thiamine, antiemetic were given; however anti snake venom was not administered. He was discharged after 24 hours. Drinking snake venom can have devastating consequences if the venom is not properly broken down in the gut and is absorbed as such. Treatment is based on the patient's presenting characteristics. Monitoring is important to detect any late complications. Categories: Emergency Medicine, Internal medicine. [ABSTRACT FROM AUTHOR]

Background: Snake bites are a common cause of morbidity and mortality, especially in tropical countries. Snake bites in any community are managed based on the clinical features and intravenous administration of antisnake venom (ASV). The administration of ASV is either deficient or given in excess based on clinical decisions and whole blood clotting test results. The present study is designed to analyze the level of snake venom component in the blood of snake bite in association with the clinical features. Patients and methods: Blood samples were collected from the patients admitted to Karnataka Institute of Medical (KIMS) hospital with a history of snakebite considering the inclusion criteria. Serum was collected from the blood of snakebite patients before and after ASV and used to assess the level of venom-specific phospholipase A2 (PLA2) enzyme using the enzyme-linked immunosorbent assay (ELISA) method. Results: Quantitative ELISA results revealed that the snake venom-specific PLA2 in the victim's blood was in the range of 0.3-1.27 mg/mL before the administration of ASV. However, the concentration of PLA2 after 24 hours of ASV administration was decreased in most of the patients. Further, it was observed that envenomation complications were directly proportional to the amount of snake venom-specific PLA2 found in the blood of the snakebite patient. Conclusions: The study concludes that snake venom-specific PLA2 in the blood of snakebite patients could be used as a reliable venom marker, which helps in determination of appropriate ASV dosage in snakebite patients. [ABSTRACT FROM AUTHOR]

Envenoming and deaths resulting from snake bite are a particularly important public health problem in the tropical world, with the highest burden in rural areas of South East Asia and Africa. Snake bite is one of the most severe "Neglected Tropical Diseases" in the world and more importantly in this part of India. We present a case of hemotoxic snake bite where the coagulation parameters remained deranged for a longer time without any active bleeding manifestations, despite treatment with Anti-Snake Venom (ASV) as per the National Treatment Guidelines. Indian Snake Bite Management Protocol emphasizes on the Role of Whole Blood Clotting Time (WBCT) as a bedside, accessible and feasible test for assessment of coagulopathy even in rural settings. Certain scenarios where the patients present late to our hospital with Snake Bite and Venom Induced Consumption Coagulopathy (VICC), the decision regarding ASV prescription in such patients is quite tricky, and needs to be individualized. [ABSTRACT FROM AUTHOR]

Venom from a snake is extremely uncommonly consumed by humans. It can be administered in a variety of ways, including a direct bite on the tongue or other parts of the body, or it can be taken as a venom pill at rave parties. The belief is that upon consumption, it provides virility, a sense of elation, and excitement, among other effects. However, it is more often dangerous to the human body and can even be fatal. Only a very small number of cases have been described in publications. In the present case report, a 36-year-old male patient who was an alcoholic and had a history of psychiatric disease initially arrived with anxiety as a result of having consumed snake venom the day before. As for the patient's vital signs, they were acceptable. For observation, the patient was admitted to the intensive care unit reserved for medicine. However, antisnake venom was not administered. After 24 hours, he was released from the hospital. This is an unusual case where the patient was relatively unharmed after the consumption and didn't show any obvious lasting effects on the neurological or haematological systems. If the venom is not effectively broken down in the intestines and is absorbed as such, drinking snake venom can have deadly repercussions. The treatment is determined by the features that the patient presents. In the present case, antivenom was not administered, as the need was not justified. However, there may arise situations in other cases where it should be administered sparingly. [ABSTRACT FROM AUTHOR]

Snakebites have been reported to induce hematological complications. Thrombocytopenia usually occurs secondary to disseminated intravascular coagulation (DIC) and coagulopathy induced by the snake bite. However, thrombocytopenia can develop after the snake bite, even in the absence of significant coagulopathy. We reported the case of a 36-year-old Jordanian male patient who was bitten by Arabian Macrovipera Lebetina Obtusa (Levantine viper), which developed venom-induced severe thrombocytopenia without coagulopathy. A progressive drop in platelet count was observed during his admission. His condition improved after anti-venom therapy, and he was discharged after 4 weeks of treatment for a full recovery. This case supports that snake venom can produce severe thrombocytopenia without significant coagulopathy, which can be treated successfully with anti-venom and the best supportive care. [ABSTRACT FROM AUTHOR]

The most common venomous snake in Israel, both in geographic spread and in number of snakebite incidents, is Daboia (Vipera) palaestinae. The clinical presentation of D. palaestinae envenomation varies and includes both local and systemic symptoms. Studies conducted on D. palaestinae revealed different amounts of venom in the snakes' glands in different seasons, however little is known regarding the potential impact of this finding on the clinical presentation after D. palaestinae bites during different seasons. To evaluate whether there is a difference in the severity of the clinical presentation of D. palaetinae bites in different seasons. A retrospective chart review study including all patients diagnosed with D. palaestinae bites treated at Shamir Medical Center from 2006 through 2020. Patients were divided into two groups: early bite season – spring and early summer, and late bite season – late summer and autumn. Variables examined included demographic features, admission details and treatment administrated. One hundred and seven D. palaestinae bite victims were included, forty-five were bitten during the early season and sixty-two during the late season. Four patients in the early season (8.9%) and one patient (1.6%) in the late season presented with decreased level of consciousness, and four patients, all from the early season group, required mechanical ventilation (p < 0.05) Vasopressors were used in six patients (13.3%) during the early season and two (3.2%) during the late season; (p = 0.06). There were no other differences between the groups, except for a lowest platelet count during hospitalization (mean 161.5 ± 51 K/μl during early season and 196.9 ± 77 K/μl during late season (p < 0.01). D. palaestinae bite victims more often present as critically ill patients during the spring and early summer compared to late summer and autumn. Hospitals should be prepared with appropriate staff training and medications for treating such patients, especially during the early season. However, in general, D. palaestinae bites are as dangerous during the late season as they are during the early season, and all snake bite victims should be treated with a high index of suspicion regardless of the season. [Display omitted] • This study compares clinical and laboratory values of D. palaestinae bite victims at different seasons. • Bites shortly following brumation may present with more severe manifestations compared with those incurred prior to brumation. • All D. palaestinae bites may be severe regardless of season of envenomation and should be treated accordingly. [ABSTRACT FROM AUTHOR]

The boomslang (Dipholidus typus) has a predominantly haemotoxic venom. Because of the consumptive nature of the coagulopathy, signs and symptoms are usually delayed by up to 72 h after the bite. Traditional laboratory coagulation assays have a long turnaround time, by which time the patient's bleeding and clotting profile has changed. A 25-year-old male patient was bitten by a boomslang. Despite two normal laboratory coagulation assay results, a pointof- care rotational thromboelastometry showed low fibrinogen levels, leading to the administration of monovalent antivenom. This report highlights the value of point-of-care thromboelastometry in the care of patients with subclinical boomslang envenomation. [ABSTRACT FROM AUTHOR]

A significant problem faced in rural India is snake bite. India’s high mortality rate is due to climatic conditions, population predominance in rural areas, and agricultural dependency. In order to research the epidemiology and outcome of snake bite cases, this retrospective study was done at B.K.L Walawalkar Rural Medical College and Hospital, Sawarde. During the study period, 58 snake bite cases were reported.30 of the bites were poisonous. Male preponderance has been noted.Maximum number of cases were seen during rainy season and more during day time.The lower limbs were most frequently involved.42 cases were recovered out of 58 cases and 16 patients left the hospital againstthe medical advice.As a specific treatment, polyvalent Anti Snake Venom (ASV) vials were used. The improvement in mortality may be the consequence of timely hospitalization and specific care and subsequent first aid steps. [ABSTRACT FROM AUTHOR]

Introduction: Snake bite is considered as an occupational hazard, especially in rural and semi-urban regions where agriculture is the major source of occupation. According to the National Crime Records Bureau, there were 8,660 deaths due to snake bite reported in the year 2015, but this does not reflect the actual data because of the traditional methods and healers opt by the people. Materials and Methods: An autopsy based prospective study was conducted on fatal cases of snakebite reported at the Mortuary of JIPMER, Puducherry over 2 years from January 2017 to December 2018. Epidemiological and demographic data were collected and analysed. Results: The cases studied about 2.7% (38) of the total 1407 medico-legal autopsies conducted during the study period. Most of the cases were male with the age group of 41-60 (36.9%) was affected the most. Most of the incidents occur in the agricultural fields (52.6%) and the people working there become more vulnerable to the bite. There was a marked increase in the number of cases in the summer season (50%). Snakes were unidentified in 25 cases (65.8%) and among the identified cases the most common culprit was Viper amounting to 12 (31.6%) cases. The lower extremity was the most frequently involved site of the bite (81.6%). Majority victims (78.9%) had been applied a tourniquet or native traditional methods before hospitalization. Conclusions: These results urge in educating the rural population about the preventive measures of snakebite and the importance of early hospitalization to save the golden period engulfed by the traditional healers. [ABSTRACT FROM AUTHOR]

To elucidate the toxic mechanism of snake venom at the protein level, proteomics technology was applied to investigate the effect of venom on circulation in the mammalian body. Temporal proteomic analysis was performed to profile the dynamic changes in the sera of Sprague–Dawley rats administered with Chinese cobra venom or saline. Using 8-plex iTRAQ analysis, 392 and 636 serum proteins were identified to be linearly upregulated or downregulated over time in the low-dose group and high-dose group, respectively. These proteins were mainly associated with the acute phase response pathway, complement system, and liver X receptor (LXR)/retinoid X receptor (RXR) and farnesoid X receptor (FXR)/RXR activation pathways. Compared with the low-dose group, the immune response and integrin pathways were inhibited in the high-dose group, although no obvious effect was observed. With consistently higher or lower expression in the high-dose group compared to the low-dose group throughout the whole process of venom poisoning, two proteins, Kininogen-1 (KNG1) and orosomucoid 1 (ORM1), which are involved in metabolism and immune response, occupied a core position in the pathway network and are considered venom dose-dependent biomarker candidates. [ABSTRACT FROM AUTHOR]

Introduction: Poisoning is a global public health problem causing significant morbidity and mortality. It is important to know the pattern and outcome of acute poisoning cases for proper planning, prevention and management of these cases. Aims and Objective: To find out the pattern of poisoning reported in Geetanjali Medical College, Udaipur. Material and Methodology: The present prospective study had been conducted in the Department of Forensic Medicine, Geetanjali Medical College & Hospital, Udaipur, Rajasthan during the period of Two year from 1st Jan 2017 to 31th Dec 2018. Result and Observation: In our study majority of poisoning case [101 cases (35.69%)] were observed in the age group of 21-30 years followed by the age group of 11-20 years. Male person [153 cases (54.06%)] most commonly affected by poison and majority of patients [184 cases (65.02%)] belongs to Rural area. In our study majority numbers of cases [128 cases (43.82%)] found in rainy season. In our studyhigher number of poisoning cases were due to Aluminium phosphide poisoning [106 cases (37.47%)] followed by snakebite poisoning [62 cases (21.91 %)]. Among insecticides, maximum 40 cases (14.13 %) were due to Organophosphorus compounds. Conclusion:Awareness and education about the potential toxicity of commonly used pesticides and drugs may help in reducing the burden of poisoning [ABSTRACT FROM AUTHOR]

A dog was presented with history of frothy salivation, dull, depressed and bloody diarrhea with recumbent position. Dog was diagnosed with snake bite based on history and physical examination. The haematological parameters showed reduced values of hemoglobin, packed cell volume and increased total leukocyte count. The biochemical values showed elevated levels of Alanine Aminotransferase and creatinine. The successful treatment was undertaken with Anti-snake venom, Dextrose, Dexamethasone phosphate, Normal saline, Tetanus toxoid and Broad-spectrum antibiotic. [ABSTRACT FROM AUTHOR]

Acute disseminated encephalomyelitis (ADEM) occurs in children commonly following infections and vaccination. Central demyelinating disorder such as ADEM following snake bite is rarely reported. We present a case of an 11-year-old boy who developed altered sensorium and quadriparesis suggestive of ADEM following a cobra bite. The role of early diagnosis with a high index of clinical suspicion and optimum neuroimaging modality in recovery is highlighted. [ABSTRACT FROM AUTHOR]

Abstract Snakebite is an important toxicologic emergency with the potential of triggering local and systemic inflammation. Antivenom has remained the mainstay of treatment for snakebite envenomation. In this study we sought to investigate the effectiveness of Iranian antivenom in a series of 44 viper envenomed patients through analysis of changes in clinical severity and the levels of inflammatory markers. Clinical envenomation severity assessed by snakebite severity score (SSS) and laboratory exams of the patients were recorded before (baseline visit) and after antivenom therapy. During 12-h antivenom therapy, the median (range) score of SSS significantly decreased from 3.5 (2–10) on admission to 1 (0–5) in the last visit (P < 0.001). Moreover, a significant decrease in prothrombin time and international normalized ratio was found (P = 0.006 and 0.008; respectively). Plasma concentrations of interleukin (IL) 1-β, IL-6, IL-8, tumor necrosis factor α (TNF-α), complement hemolytic activity (CH50) were also measured in 10 severely Echis carinatus sochureki envenomed victims and 10 age and gender-matched healthy controls. Except IL-8, the baseline levels of IL-1β, IL-6 and TNF-α in victims were significantly higher than healthy controls (P = 0.005, <0.001 and < 0.001, respectively). Moreover, the baseline level of CH50 was significantly lower in the patients compared to healthy controls (P < 0.001). After 12-h antivenom therapy, the plasma levels of IL-1β, IL-6 and TNF-α significantly decreased (P = 0.032, 0.006 and 0.003, respectively), the levels of IL-8 remained relatively unchanged and the CH50 significantly increased (P = 0.011). Iranian snake antivenom was effective in treating viper bite envenomation as it reversed clinical venom effects and restored near normal underlying inflammatory status. This study is the first to ascertain and report the effectiveness of this antivenom in human subjects. Highlights • Clinical effects of viper bite envenomation are reversed following treatment with Iranian snake antivenom. • Echis carinatus sochureki bite envenomation causes acute-phase response with increased levels of pro-inflammatory cytokines. • E. c. sochureki bite envenomation can activate complement system. • Pro-inflammatory cytokines and complement activity of E. sochureki victims return to baseline after Iranian antivenom therapy. • Iranian snake antivenom is clinically effective. [ABSTRACT FROM AUTHOR]

Background: Snake bites are a neglected public health problem in all tropical countries, and particularly in Malabar region of Kerala, India. Demographic characteristics and clinical parameters vary in this part of the world, and studies based on them are scarce. Increased incidence of capillary leak syndrome (CLS) in hemotoxic snake bites and emergence of cases of hump-nosed pit viper (HNPV, Hypnale hypnale) envenomation are some notable features seen here. Objectives: The study was conducted to assess the epidemiological profile and clinical features to identify factors contributing to outcome in patients with venomous snakebites. Materials and methods: An observational cross-sectional study was done among patients with snakebite envenomation, admitted to Government Medical College, Kozhikode, Kerala, from January 2012 to October 2016. Results: There were 1,500 cases of toxic snake bites, of which 65% of these cases were males. Forty eight percent of them were aged between 21 and 40 years. Hemotoxic snake bites predominated, accounting for 912 cases. Viperine bite was the most commonly observed snakebite, and 70% of this was due to Russell’s viper and 25% due to HNPV. Among the neurotoxic bites, common krait bites predominated. Overall mortality was 8.8%. CLS was the major cause of death (80%). The mean dose of antivenom given for neuroparalytic snakebite was 10.25 vials, and 18.5 vials for hemotoxic bites. Albuminuria, neutrophilic leucocytosis, thrombocytopenia, acute kidney injury (AKI), and early onset of symptoms were associated with poor outcome. Conclusion: This study emphasizes the importance of snakebite as a significant threat to the community in the tropics. CLS in hemotoxic snake bites is the leading cause of mortality and is often refractory to any treatment measures. This study also brings to light the graveness of complications caused by HNPV envenomation. Anti-snake venom with activity against HNPV venom needs to be manufactured. Lack of awareness, delayed presentation to the hospital, and treatment by nonmedical personnel also add to the risk of mortality. [ABSTRACT FROM AUTHOR]

Snake envenomations have been a serious yet often overlooked public health threat especially in tropical and subtropical countries, including Southeast Asia. The medically important venomous land snakes in Southeast Asia include snakes from the Elapidae and Crotalidae families. Among the elapids, there are only 12 species that are considered of medical importance, represented by the kraits (Bungarus caeruleus, B. candidus, B. fasciatus, B. flaviceps and B. multicinctus). The incidence of snakebite is high in India. Apart from mortality, the morbidity is due to various complications. The common krait (Bungarus caeruleus) is the most toxic snake found commonly in the plains of throughout the India and the number of snakebites in the rural areas of India was recorded by this snake. The present article highlights the prevalence and the clinical complications of Indian common krait envenomation among the rural populations of India. [ABSTRACT FROM AUTHOR]

Cobra bites are quite rare in European countries as these snakes are not native there. Toxins are devastating for tissue resulting in massive necrosis, thus plastic surgery might play a role in reconstruction of the lost tissue. A case of a male patient bitten by a thai cobra in the left index finger is presented. Antitoxin administration was delayed due to secondary patient admission. Progressive tissue necrosis made radical debridement necessary, resulting in the need for plastic surgical defect coverage with a flap. While a radical debridement to prevent toxic necrosis due to lytic enzymes in cobra venom has been favoured beforehand, large case studies led to a more restrained initial surgical intervention. However, antitoxin administration should be first line therapy in management of these cases. If severe necrosis is present as it might occur in delayed admission, a plastic surgical management of the patient might be advantageous.

Background:Western Pygmy Rattlesnake (WPR) envenomation reportedly causes refractory and persistent coagulopathy when treated with CroFab®(Crotalidae Polyvalent Immune Fab). We report two cases where polyvalent equine anti-viper serum (AntivipmynTRI®) was used to treat recurrent coagulopathy in children. Case details:The first patient was a 16-month-old male who was bitten by a confirmed WPR. The patient received a total of 18 vials of CroFab®. His labs normalized, swelling gradually improved, and the child was discharged to home. On day 5, the child returned to the emergency department with a great deal of inguinal tenderness. Labs were obtained and the child’s INR was >13.1, while the fibrinogen was <60 mg/dL and the d-dimer was 11.72 mg/L. A decision was made to administer Antivipmyn TRI®, and the child received a total of 10 vials. Lab values significantly improved: INR 1.2, fibrinogen 93 mg/dL, and d-dimer 4.21 mg/L. The second patient was a 20-month-old male who presented following snake envenomation. The child was administered a total of 22 vials of CroFab®over approximately 70 h following envenomation. Physical exam continued to improve, however, lab results showed an increasing INR 1.98, decreasing platelet count 124 × 103per μL, fibrinogen <60 mg/dL, and d-dimer >20 ug/mL. A total of 15 vials of Antivipmyn TRI®were administered to this patient. Following this administration, labs and clinical exam both significantly improved. Labs revealed INR 1.16, fibrinogen 110 mg/dL, d-dimer 3.2 mg/L and platelet count 215 × 103/μL. Discussion:CroFab®is still the first-line treatment for children bitten by a WPR, but in some cases patients develop a recurrent coagulopathy. The rapid response demonstrated by Antivipmyn TRI®leads us to conclude that this is a potential therapy for this clinical situation. [ABSTRACT FROM PUBLISHER]

Naja kaouthia (monocled cobra) venom contains many isoforms of secreted phospholipase A2 (sPLA2). The PLA2 exerts several pharmacologic and toxic effects in the snake bitten subject, dependent or independent on the enzymatic activity. N. kaouthia venom appeared in two protein profiles, P3 and P5, after fractionating the venom by ion exchange column chromatography. In this study, phage clones displaying humanized-camel single domain antibodies (VH/VHH) that bound specifically to the P3 and P5 were selected from a humanized-camel VH/VHH phage display library. Two phagemid transfected E. coli clones (P3-1 and P3-3) produced humanized-VHH, while another clone (P3-7) produced humanized-VH. At the optimal venom:antibody ratio, the VH/VHH purified from the E. coli homogenates neutralized PLA2 enzyme activity comparable to the horse immune serum against the N. kaouthia holo-venom. Homology modeling and molecular docking revealed that the VH/VHH covered the areas around the PLA2 catalytic groove and inserted their Complementarity Determining Regions (CDRs) into the enzymatic cleft. It is envisaged that the VH/VHH would ameliorate/abrogate the principal toxicity of the venom PLA2 (membrane phospholipid catabolism leading to cellular and subcellular membrane damage which consequently causes hemolysis, hemorrhage, and dermo-/myo-necrosis), if they were used for passive immunotherapy of the cobra bitten victim. The speculation needs further investigations.

Background & objectives: The optimal anti-snake venom (ASV) dose required to treat neurotoxic snake envenomation is not known. Low-dose ASV (national protocol: maximum dose 200 ml) may be as efficacious as the conventional regimen (100 ml six hourly till all symptoms disappear), but a direct comparison of the regimens is not available. The aim of this study was to test the efficacy of low-dose ASV regimen against the conventional high-dose regimen. Methods: The clinical profile of 51 patients with neurotoxic snake envenomation was studied. Patients were treated with either the national protocol or the conventional protocol for ASV administration. The time to complete recovery of symptoms, duration of mechanical ventilation and total dose of ASV were compared. Results: More patients were females (28 vs. 23) bitten in the early morning hours (2400-0600 h). Thirty nine of 51 (76.4%) patients required mechanical ventilation. In terms of progression of neuroparalysis, time to complete resolution of ptosis and occurrence of VAP and ASV reactions, there was no difference. Duration of mechanical ventilation was less with the national protocol (24 vs. 43.5 h). Significantly less amount of ASV was used with the national protocol (224 vs. 982 ml) per patient. There were no mortality or permanent neurological sequelae with either regimen. Interpretation & conclusions: In this preliminary study, it was found that the national ASV protocol was as effective as the conventional regimen for neurotoxic snake bites. However, the findings need to be tested in a larger randomized controlled trial for definitive conclusions. [ABSTRACT FROM AUTHOR]

Introduction: In the developing world, occupation has been identified as a risk factor for snake bite. Such an association has not been described in the USA. The objective of this study was to describe the epidemiology and clinical manifestations of occupational snake bite in patients reported to the ToxIC North American Snakebite Registry (NASBR). Methods: This was a prospective case series of patients reported to the ToxIC NASBR between January 1, 2014 and November 5, 2015. Variables collected included snake species, patient demographics, date and location of exposure, occupation, bite location, clinical manifestations, and management. Results: Of 180 adult snake bites reported, 25 (13.9 %; 95 % CI 9.2-19.8 %) were occupational in nature. Rattlesnake envenomations were common (80 %). Most snake bites (96 %) occurred in men. Occupations most associated with snake bite were landscaping (28 %) and working directly with snakes (24 %). Fifty-six percent of bites occurred in an outdoor work environment. Seventy-six percent of envenomations were to the upper extremities. Intentional interaction occurred in 40 % of cases, all of which sustained finger envenomations. No cases presented with apparent acute ethanol intoxication. Conclusions: The majority of occupational snake bites occurred in men working outdoors and were unintentional injuries. Bites involving the upper extremity tended to result from intentional interactions. Acute ethanol intoxication did not appear to be involved with occupational envenomations. [ABSTRACT FROM AUTHOR]

A patient suffered from an envenomation that, at his hospitalization, was judged severe: Grade 3 out of 3, as defined in clinical studies for CroFab™ antidote [Crotalidae Polyvalent Immune Fab (Ovine)]. In addition to the usual antivenom treatment we applied adjunctive hyperbaric oxygen (HBO2) therapy. Our aim was to facilitate better control of the lesions, already presenting as problematic wounds and at high risk of necrotizing soft tissue infection with compartment aspects. The regimen consisted of six treatments, one daily at 2.4 atmospheres absolute at 25 minutes x3 (75 minutes) at FiO2=1, with two five-minute air breaks interposed. The therapy was well tolerated in spite of the patient's declared trait of claustrophobia. Our findings at a long-term follow up suggest that HBO2 therapy may be reasonably and effectively administered at least in the post-acute phase of such occurences. [ABSTRACT FROM AUTHOR]

Background: A snake bite is an injury caused by a bite from a snake, often resulting in puncture wounds, amputations and sometimes envenomation. Envenoming resulting from snake bite is a particularly important public health problem in rural areas of tropical and sub-tropical countries in Africa. This paper reports the incidence of snake bites and its associated mortality in the Western Region of Ghana. Method: The study was a descriptive cross-sectional review of 2006-2010 snake bite secondary data generated by the Western Regional Health Information Office in Ghana. Data was extracted from the District Health Information Management System (DHIMS) database. Data was managed and analyzed using SPSS Version 16.0. Univariate analyses were expressed as percentages and graphs. Results: The year 2009 recorded the highest incidence of Snake bites in the Western Region with Juabeso district recording the highest incidence of snake bites over the study period. Over the period about 55% of the incidence was between 50 - 100 per 100,000 population. The total number of snake bites recorded in the region for the period was 7,275, of which 52% (3,776) were males. About 60% of the patients were of the age group 15-49 years. A total of 12 reported snake bite deaths were recorded, of which 67% were men. This study recommends to the Districts Health Directorates in the Western Region to regularly organize community education on snake bite and the use of protective clothing by the farmers. [ABSTRACT FROM AUTHOR]

Rattlesnake envenomation incidence and its severity remain largely misunderstood in Europe. The evolution of cases reported in the few countries, where these accidents are correctly reported, proves to be unpredictable. Rattlesnake venom is mainly hemotoxic, affecting mainly the blood vessels, blood cells and the heart. The venom contains zinc metalloproteinases, cytotoxins and myotoxins. As an additional effect, the necrosis of skeleton muscles is produced by the venom through secondary ischemia and reduced perfusion. We will present the case of a 30-year-old lady, snake and tarantula breeder from Bucharest, presented at the emergency department on the 15Th of March 2015 after one of her pets, a diamondback rattlesnake had bitten her wrist. [ABSTRACT FROM AUTHOR]

Snake bite is a common neglected emergency in children. Due to lack of adequate epidemiological data its incidence is underestimated. This study analyses the clinical profile of neurotoxic snake bites in children. Retrospective analysis of 37 children with features of neurotoxicity with or without history of snake bite was done. 37 cases of neurotoxic envenomation had a median age of 8 years. 30 were males. Majority of bites occurred during night hours and in upper limbs. Among the 17 who were bitten during night 12 were sleeping on floor. The most common systemic presentation was ptosis (94.59%) followed by difficulty in breathing (78.37%), pain abdomen (64.86%) blurring of vision and diplopia (54.04%), decreasing level of consciousness (45.94%) and vomiting (29.72%). 13 patients (35.13%) with clinical features of neurotoxic envenoming but without any history of snake bite were brought with history of early morning sudden onset of abdominal pain. All patients were given Anti Snake Venom (ASV) with medial dose of 600 units. Twenty patients received ventilator support. Ten (27%) patients died all of whom received ASV after a delay of at least 5 hours. [ABSTRACT FROM AUTHOR]

Snake bite is a common problem faced by healthcare professionals in almost every part of India. Few professions are relatively at high risk for the same particularly field workers. Due to rapidity of action of snake venom, immediate analysis of presenting symptoms & administration of treatment as per protocols greatly improves mortality as well as morbidity. Any variation of symptoms & signs being reported greatly enhances the knowledge & thereby helps in planning the therapy. We report an unusual presentation of snake bite where the manifestations were in variation with usual & this had significant treatment repercussions. [ABSTRACT FROM AUTHOR]

Background: Even though snakebite associated coagulopathy is a common cause of mortality and morbidity in India, the severity assessment and management protocols are poorly defined. Our study aims at identifying - a) Clinical spectrum of bleeding B) Hematological markers of severe coagulopathy C) Optimize the dose of Anti Snake Venom (ASV) in patients with severe coagulopathy Method : Case records of 59 patients with systemic bleeding following snakebite were studied and their clinical presentation and coagulation parameters were noted. They were grouped depending on total ASV received: <100ml-group A & >100ml-group B. Statistical analysis was done to find out correlation between different coagulation parameters with the total dose of ASV required at endpoint in each group. Results : Patients in Group-B had severe coagulopathy featured by significantly prolonged CT, and APTT (p<0.05); prolonged PT and low fibrinogen (p <0.01). All these tests have shown strong association with mean higher doses of ASV. Group-B patients presented much later and the mean doses of ASV required in groups A and B were 81.48 ±21.6 ml and 206 ± 73 ml respectively. Conclusion : A combination of PT and fibrinogen correlated well with severety of coagulopathy in patients with systemic bleeding due to snake bite. These patients may require up to 206 ± 73 ml of ASV. Patients with delayed presentation had more severe coagulopathy and required higher doses of ASV. [ABSTRACT FROM AUTHOR]

Venomous snakes with hematotoxin—Russell’s viper ( Daboia spp), Malayan pit viper ( Calloselasma rhodostoma ), and green pit viper ( Cryptelytrops albolabris and C macrops , previously named Trimeresurus spp) are commonly found in Thailand. Coagulation factor activation, thrombocytopenia, hyperfibrinolysis, and disseminated intravascular coagulation are the main mechanisms of hemorrhaging from these snake bites. The neurological involvement and hepatocellular injury after Russell’s viper bites were reported in Sri Lanka, but there is no report from Southeast Asia. This case was a 12-year-old hill tribe boy who had ptosis and exotropia of the left eye, respiratory distress, and prolonged venous clotting time, prothrombin time, and activated partial thromboplastin time; low fibrinogen and platelet count; and transaminitis after being bitten by a darkish-colored snake. He did not respond to antivenom for cobra, Malayan pit viper, or Russell’s viper. However, his neurological abnormalities, respiratory failure, and hepatocellular injury improved, and coagulopathy was finally corrected after receiving antivenom for green pit viper. The unidentified snake with hematotoxin was alleged for all manifestations in this patient. [ABSTRACT FROM AUTHOR]

In vitroinhibitory activity ofCarissa spinarumleaf extracts againstBungarus caeruleusandVipera russellitoxic snake venom enzymes was determined. The leaf extracts in non-polar and polar solvents were concentrated and were used for inhibitory activity determination. Methanol extracts (100 μg.mL−1) inhibited acetylcholinesterase, phospholipase A2, hyaluronidase, phosphomonoesterase, phosphodiesterase,5′ nucleotidase enzymes of B. caeruleus and V. russelli venoms. [ABSTRACT FROM AUTHOR]

In Australia each year there are approximately 3000 incidents of snake bite, resulting in 1 to 4 deaths. Of Australian snakebite fatalities, 60% are caused by brown snake envenomation. The most common effect brown snake venom has on the human body is venom-induced consumptive coagulopathy, which can lead to secondary conditions such as haemorrhage, microangiopathic haemolytic anaemia and acute kidney injury. The venom can also cause neurotoxicity, systemic symptoms, collapse and cardiac arrest. The purpose of this case study is to describe and investigate the acute kidney injury that occurred as a consequence of a bite from an Eastern Brown snake. The patient developed anuric acute kidney injury secondary to microangiopathic haemolytic anaemia and required haemodialysis (HD) for three weeks. This case study will describe the clinical events in detail, discuss the pathophysiology underlying the venom-induced consumptive coagulopathy and acute kidney injury that developed, and also reflect on the treatment of the patient including HD, antivenom and first aid. It is intended that this case study will contribute to the limited amount of evidence currently available, and help build the knowledge and preparedness of health professionals for similar situations. [ABSTRACT FROM AUTHOR]

Aims: Envenomation with poisonous snakes is associated with considerable morbidity and mortality. The present study was undertaken with the objectives of assessing anti-snake venom (ASV) use, early adverse reactions to ASV, premedication and clinical outcomes in snake bite patients. Association of various risk factors (age, gender, dose of ASV, time gap between snake bite and ASV administration, use of mechanical ventilation and type of snake bite) with mortality was also assessed. Settings and Design: This retrospective study was conducted at two Tertiary Care Teaching Hospitals. Subjects and Methods: The medical records of 176 patients of snake bite with documented use of ASV were retrospectively analyzed to retrieve relevant data. Statistical Analysis: Descriptive statistics was used to express results about ASV use, early adverse reactions to ASV, premedication and clinical outcomes. Univariate and multivariate analysis was performed to find out significant risk factors associated with mortality. Results: The main indication for ASV was vasculotoxic snake bite (75%) followed by neurotoxic snake bite (16%). Mean dose of ASV was 18.63 ± 14.52 vials. Prophylactic premedication with corticosteroids alone or in combination with antihistaminic was used in more than 70% patients. Early adverse reactions to ASV were seen in 4% patients. Neurotoxic snake bite was a significant risk factor associated with mortality in multivariate analysis. Conclusions: Neurotoxic snake bite is an independent predictor of mortality in snake bite patients. Currently used polyvalent ASV may be less effective in treating neurotoxic snake bite. [ABSTRACT FROM AUTHOR]

Background: To determine the optimal dose of antisnake venom required to treat hemotoxic snake bite more effectively. Methods: In this interventional study, out of 52 patients 46 patients with the features of systemic envenomation .i.e. deranged coagulation profile, nephrotoxic or neurotoxic features were assessed clinically and through laboratory tests, while 06 patients had no feature of envenomation. Patients with systemic envenomation were given Antisnake venom. Results: Hemotoxicity was the most common clinical manifestation of snake bite i.e. 39 patients of hemotoxic envenomation, 4 with neurotoxic features while 03 patients had mixed toxicity i.e. hemotoxic, neurotoxic and nephrotoxic. 12 patients responded to single dose of 06 vials (10 ml each vial; total dose of 60 ml), 28 patients required further dose of anti snake venom after initial dose of 6 vials while 06 patients received even higher dose of anti snake venom i.e. 18 vial (180 ml) with blood transfusion. Of these 06 patients, 02 required mechanical ventilation, 02 with nephrotoxicity were referred to dialysis unit, and 02 mortalities were encountered, one with intracranial bleed and other with mixed toxicity and delayed presentation of patient. Conclusion: Most patients with envenomation require higher dose of anti snake venom . An increase in morbidity and mortality is mainly due to delayed presentation after snake bite and under dosage of ASV.

Aim: Snake bite is a common medical emergency faced mainly by the rural populations in tropical and subtropical countries with heavy rainfall and humid climate. Although India is a single largest contributor of snake bite cases, reporting is very poor. There is hardly any publication of the same from Gujarat state that is developing at a good pace. Hence, we aimed to study the snake bite cases with particular attention to demography, epidemiology, and clinical profile. Settings and Design: The present descriptive, observational study was carried out at the Emergency Medicine Department of a tertiary care center in Ahmedabad, Gujarat. This department is one if the firsts to get recognized by the Medical Council of India. Materials and Methods: This is a cross-sectional single-center study. Cases were entered into the prescribed form, and detailed information regarding demographic, epidemiologic, and clinical parameters was entered. Statistical Method: Data were analyzed using Epi2000. Means and frequencies for each variable were calculated. Results: Majority (67.4%) of the snake bite victims were in the age group between 15 and 45 years. Majority were male victims (74.2%). 71% victims of snake bite lived in rural areas. Farmers and laborers were the main victims. 61.2% incidents took place at night time or early morning (before 6 a.m.). 64% patients had bite mark on the lower limb. 40% victims had seen the snake. Eight patients had snake bite, but were asymptomatic. 52% had neuroparalytic manifestation, 34% were asymptomatic, and 9.6% had hemorrhagic manifestation. 14% cases received treatment within 1 h of the bite and 64.84% within 1-6 h after the bite. First aid given was in the form of application of tourniquet (16.2%), local application of lime, chillies, herbal medicine, etc., (1%). 2.20% cases were sensitive to anti-snake venom. Only three patients died. Conclusion: In this region (Gujarat), neuroparalytic manifestation of snake bite is more prevalent. Cobra and krait are the commonest types of poisonous snakes. The time of seeking treatment has reduced because of awareness about snake bite treatment and better transport and ambulance facility. Mortality is very less in well-equipped hospitals due to early initiation of treatment with anti-snake venom. [ABSTRACT FROM AUTHOR]

Naja kaouthia (monocled cobra) venom contains many isoforms of secreted phospholipase A2 (sPLA2). The PLA2 exerts several pharmacologic and toxic effects in the snake bitten subject, dependent or independent on the enzymatic activity. N. kaouthia venom appeared in two protein profiles, P3 and P5, after fractionating the venom by ion exchange column chromatography. In this study, phage clones displaying humanized-camel single domain antibodies (VH/VHH) that bound specifically to the P3 and P5 were selected from a humanized-camel VH/VHH phage display library. Two phagemid transfected E. coli clones (P3-1 and P3-3) produced humanized-VHH, while another clone (P3-7) produced humanized-VH. At the optimal venom:antibody ratio, the VH/VHH purified from the E. coli homogenates neutralized PLA2 enzyme activity comparable to the horse immune serum against the N. kaouthia holo-venom. Homology modeling and molecular docking revealed that the VH/VHH covered the areas around the PLA2 catalytic groove and inserted their Complementarity Determining Regions (CDRs) into the enzymatic cleft. It is envisaged that the VH/VHH would ameliorate/abrogate the principal toxicity of the venom PLA2 (membrane phospholipid catabolism leading to cellular and subcellular membrane damage which consequently causes hemolysis, hemorrhage, and dermo-/myo-necrosis), if they were used for passive immunotherapy of the cobra bitten victim. The speculation needs further investigations. [ABSTRACT FROM AUTHOR]

Abstract: Snake envenomation and its treatment cause the entry of two kind of foreign antigens into the human body: snake toxins and antivenom from animal origin. Samples of patients bitten by snakes in Uruguay were assayed to determine levels of human antibodies against venom and antivenom. The ELISA results showed that most of the patients presented an important increase of IgG and IgM antibodies against antivenom at day 15 post accident. Antibodies were reactive against both equine immunoglobulin chains by western blot assay. In the case of the response against the venom, increase in titre at day 15 was of a minor degree as compared with the antivenom by ELISA. Only one of the patients showed an important increase of IgG and IgM levels against Bothropoides pubescens and only of IgG level against Rhinocerophis alternatus. This patient also showed an extensive reactivity against B. pubescens by western blot. [Copyright &y& Elsevier]

Snake venom may be hemotoxic, neurotoxic or local tissue toxic. Due to local toxins tissue necrosis occurs and progressive edema proximally compartment syndrome is expected. The present article presents favorable result of fasciotomy in two pediatric cases of snake bite and concluded that early signs of compartment syndrome and/ or direct measurement of compartment pressure are indications of fasciotomy to prevent/limit extent of tissue necrosis. Scarring, hypertrophy and contractures were noted as long term complications of fasciotomy. [ABSTRACT FROM AUTHOR]

Introduction: Russell’s viper is a commonly encountered venomous snake in India. Morbidity and mortality following envenomation and the treatment thereof are frequent. We report a rarely seen complication after a treated Russell’s viper bite. Case Report: A 36-year-old male farmer received 30 vials polyvalent anti-snake venom after a viper bite to his right leg. Improvement in initial hematemesis and circulatory shock was followed by acute renal failure managed with regular hemodialysis. He displayed no abnormalities on neurological examination at admission. Fourth day onwards his neurologic status started deteriorating with development of behavioral abnormalities, hemi-spatial neglect of left upper limb, paralysis of left facial nerve, left upper limb, and right lower limb. Acute disseminated encephalomyelitis was confirmed on magnetic resonance imaging (MRI) of brain with typical spectroscopic characteristics. High dose methyl prednisolone was administered and a rapid recovery followed. Conclusion: Russels viper bite followed by treatment with antivenom may be complicated by the development of immune complex mediated demyelination and development of acute disseminated encephalomyelitis. MRI spectroscopy helps in early identification of demyelination and in a definite diagnosis. Treatment with corticosteroids was associated with resolution of symptoms in this case. [ABSTRACT FROM AUTHOR]

Abstract: The aim of this study was to evaluate the burden of snake bite in Ecuador and to identify the difficulties of snake bite management in Ecuadorian health facilities. A survey based on national health statistics was carried out in Ecuador to estimate the overall incidence and mortality due to snake bites. During the period 1998–2007, the average annual incidence and mortality was respectively 11 and 0.5 per 100 000 inhabitants. The at-risk population was represented mainly by males aged 10–54 years. Snake bite incidence increased during the rainy season and El Niño. According to one data source, the majority of snake bites occurred in the coastal region (56%) compared with the Amazonian rainforest (11%) and the highlands (33%). This geographical variation in snake bite incidence may reflect the distribution of venomous snakes and human population densities and activities. This preliminary national survey on the incidence of the envenomings due to snake bite in Ecuador showed a stable incidence over the time period studied but was heterogeneous in the three geographical regions of Ecuador. The incidence and mortality were higher in the lowland humid regions where Bothrops species are abundant. [ABSTRACT FROM AUTHOR]

Nearly all prior studies to delay onset of systemic toxicity and death after snake bite use a model of distal extremity envenomation. In the first of a series of planned studies using snake venoms with different toxicity profiles, the application of a novel device in a new model of torso envenomation in the setting of Eastern Coral Snake ( Micrurus fulvius) venom (a potent neurotoxin) envenomation showed promise by delaying systemic intoxication. In this pilot study, we investigated this novel localizing circumferential compression (LoCC) device’s ability to delay onset of life threatening systemic toxicity after Eastern Diamondback Rattlesnake ( Crotalus adamanteus) envenomation, a potent hemotoxic and myotoxic venom. With university approval, four juvenile female pigs (22–25 kg) were anesthetized, sedated, and intubated but not paralyzed to allow for spontaneous respirations. Each animal was injected subcutaneously with 50 mg of C. adamanteus venom in identical preselected areas of the trunk. After 1 min, two treatment animals had the LoCC device applied; two control animals had no intervention. Vital signs were recorded every 10 min for the first 2 h and every 30 min thereafter. Endpoints included cardiovascular collapse (fatal arrhythmia, loss of mean arterial pressure, or pulse) or respiratory arrest (<3 breaths/min, saturation < 80%) or survival to 7 h. The pigs in the treatment group reached an endpoint at an average time of 355 (±65) min compared with control 32 (±3.5) min ( p < 0.04). In this pilot study, the LoCC device significantly delayed onset of systemic symptoms and death after torso envenomation with Eastern Diamondback Rattlesnake venom in this model. [ABSTRACT FROM AUTHOR]

Abstract: Snake bite causes significant morbidity and mortality in Sri Lanka. Snake venoms contain neurotoxins that block neuromuscular junction transmission. Presynaptic neurotoxicity most commonly causes destruction of nerve terminals with recovery by regrowth, whilst postsynaptic neurotoxicity usually involves competition at the acetylcholine receptor. The aim of this study was to investigate whether there were long-term clinical or neurophysiological changes in snake bite survivors 1 year after their envenoming. Detailed neurophysiological tests and clinical examinations were performed on 26 snake bite victims who had presented with neurotoxicity 12 months previously, and their results were compared with controls recruited from the same communities. Significant differences were observed in some nerve conduction parameters in some snake bite victims compared with controls, predominantly in those thought to have elapid bites, including prolongation of sensory, motor and F-wave latencies and reduction of conduction velocities. There was no evidence of any residual deficits in neuromuscular junction transmission. These results suggest a possible demyelinating type polyneuropathy. None of the cases or controls had abnormalities on clinical examination. This is one of the few studies to report possible long-term neurological damage following systemic neurotoxicity after snake bite. The clinical significance of these neurophysiological abnormalities is uncertain and further studies are required to investigate whether the abnormalities persist and to see whether clinical consequences develop. [Copyright &y& Elsevier]

Snake bites are common in many regions of the world. Snake envenomation is relatively uncommon in Egypt; such unfortunate events usually attract much publicity. Snake bite is almost only accidental, occurring in urban areas and desert. Few cases were reported to commit suicide by snake. Homicidal snake poisoning is so rare. It was known in ancient world by executing capital punishment by throwing the victim into a pit full of snakes. Another way was to ask the victim to put his hand inside a small basket harboring a deadly snake. Killing a victim by direct snake bite is so rare. There was one reported case where an old couple was killed by snake bite. Here is the first reported case of killing three children by snake bite. It appeared that the diagnosis of such cases is so difficult and depended mainly on the circumstantial evidences. [ABSTRACT FROM AUTHOR]

Abstract: Monovalent antivenoms have a lower volume of specific antibodies that may reduce reactions but require accurate snake identification to be used. Polyvalent antivenoms are larger volume and may have a higher reaction rate. However, they avoid the problem of snake identification and may be more cost-effective to manufacture. We have previously shown cross-neutralisation of two Australian elapid venoms, tiger snake (Notechis scutatus) and brown snake (Pseudonaja textilis) venoms, by their respective monovalent antivenoms. In this study enzyme immunoassays were used to quantify the amount of monovalent antivenom (quantity of monovalent antibodies to a specific snake venom) in vials of commercially produced antivenom in Australia. All antivenoms tested appeared to be polyvalent and contain varying amounts of all five terrestrial snake monovalent antibodies based on their binding to the five representative venoms. Redback spider antivenom did not have any measurable binding affinity for any of the five snake venoms, showing that the observed binding is not due to non-specific interactions with equine protein. The antivenoms had expiry dates over a 15year period, suggesting that the antivenoms have been mixtures for at least this time. This study cannot be used to rationalise hospital stocks of antivenom in Australia because there is no guarantee that the antivenoms will remain as mixtures. However, it would be possible for the manufacturer to reduce the number of types of snake antivenoms available in Australia to two polyvalent antivenoms which would simplify treatment of snakebite. [Copyright &y& Elsevier]