Determinants of snakebite mortality in Asia: A systematic review

PURPOSE

This systemic review summarizes the evidence exploring the determinants of mortality due to snakebite envenomation in Asia.

MATERIALS AND METHODS

The database PubMed, Web of Science and Science Direct were searched to identify the relevant literatures concerning mortality due to snakebites mortality in Asia. All the articles chosen were critically appraised for its quality using a mixed-method assessment tool by two independent reviewers with discrepancies sorted by a third person.

RESULTS

A total of 7 studies were included in the final analysis which was 3 cross-sectional studies, 2 case reports, 1 observation prospective study and 1 randomized control trial study. Two studies were conducted in India and two studies in Sri Lanka while one study was conducted in Taiwan, Vietnam and Nepal respectively. The cases of snakebite victims were retrieved from the year of 1987 until 2017. In total, there were 762 cases of snakebite victims recorded, with 61 of those victims succumbed to death. From the final total of 7 studies, 4 of the studies showed snakebites mortality were related to delayed treatment access and 3 studies due to suboptimal care.

CONCLUSION

Mortality and morbidity can be reduced if there is a quick access for victims to emergency medical care, rapid transfer time to hospital and receiving immediate optimal medical treatment from trained medical staff once in the hospital or dispensary.

Unusually prolonged neuromuscular weakness caused by krait (Bungarus caeruleus) bite: Two case reports

Snakebites are common in India and the most common neurotoxic snakebites in India are due to Common krait (Bungarus caeruleus) and cobra (Naja naja). Severe envenomation may mimic brain death or a locked-in state with flaccid paralysis in a descending manner and total ophthalmoplegia. Usually, patients who receive timely antivenom and ventilator support recover completely without any sequalae. We are reporting two cases of krait bite with an unusually long period of flaccid paralysis, which required prolong ventilation. While case 1 required 10 days of mechanical ventilation followed by 5 days of non-invasive ventilation, case 2 required 11 days of mechanical ventilation followed by 5 days of non-invasive ventilation. Both the cases had delayed recovery and residual weakness at 3-month follow up. These case reports suggest that krait bite may cause prolong neuromuscular weakness in children, which has implications for both acute and chronic management.

Protein decomplexation and proteomics: A complementary assessment method of the physicochemical purity of antivenom

The quality of antivenom is governed by its safety and efficacy profiles. These quality characteristics are much influenced by the purity of antivenom content. Rigorous assessment and meticulous monitoring of antivenom purity at the preclinical setting is hence crucial. This study aimed to explore an integrative proteomic method to assess the physicochemical purity of four commercially available antivenoms in the region. The antivenoms were subjected to Superdex 200 HR 10/30 size-exclusion fast-protein liquid chromatography (SE-FPLC). The proteins in each fraction were trypsin-digested and analyzed by nano-ESI-liquid chromatography-tandem mass spectrometry (LC-MS/MS). SE-FPLC resolved the antivenom proteins into three major protein components of very high (>200 kDa), high (100-120 kDa) and medium (<60 kDa) molecular weights. The major components (80-95% of total proteins) in the antivenoms were proteins of 100-120 kDa consisting of mainly the light and partially digested heavy immunoglobulin chains, consistent with F(ab')₂ as the active principle of the antivenoms. However, LC-MS/MS also detected substantial quantity of large proteins (e.g. alpha-2-macroglobulins), immunoglobulin aggregates and impurities e.g. albumins in some products. The method is practical and able to unveil the quantitative and qualitative aspects of antivenom protein compositions. It is therefore a potentially useful preclinical assessment tool of antivenom purity.

Care-seeking behaviour of suspected snakebite cases admitted in a medical college of West Bengal: A pathway analysis

BACKGROUND

Snakebite is a time decisive medical emergency requiring contact with health facility at the earliest. Many snakebite victims yet seek care from traditional healers (THs) or village quacks (VQs) before reaching an appropriate facility, which leads to adverse consequences. This study was conducted to assess care-seeking behaviour and pathways followed in reaching appropriate facilities among suspected snakebite cases and to identify associated factors.

METHODS

A hospital-based cross-sectional study was conducted at a medical college in West Bengal. All suspected snakebite cases admitted during a reference period of two months were studied. Study subjects and/or accompanying persons were interviewed for care-seeking behaviours and pathways followed.

RESULTS

Among the 393 study participants, most were ≤30 years of age, men, agricultural workers, of lower middle and lower socioeconomic class and only 69.5% had formal schooling. The commonest place of occurrence was the agricultural field (40.7%), and the commonest biting site was the lower extremity (77.6%). Only half of participants (55.2%) used immediate correct measures at the biting site. Incorrect practices included tourniquet application (29.5%), use of herbal preparation (7.1%), blade shaving at site (2.8%) etc. As first care-seeking points, 15% and 24.9% of cases visited THs and VQs, respectively. Pathway analysis revealed that unfavourable pathway was followed by 39.9% participants. Two unfavourable points were consulted by 3.8% of participants. The care-seeking pathway was significantly associated with religion, caste, education and socioeconomic class.

CONCLUSIONS

Findings of this study highlight the urgent need for behaviour change interventions addressing the myths and misconceptions of people regarding snakebite.

Chronic kidney failure following lancehead bite envenoming: a clinical report from the Amazon region

Background:

Snakebite envenoming can be a life-threatening condition, for which emergency care is essential. The Bothrops (lancehead) genus is responsible for most snakebite-related deaths and permanent loss of function in human victims in Latin America. Bothrops spp. venom is a complex mixture of different proteins that are known to cause local necrosis, coagulopathy, and acute kidney injury. However, the long-term effects of these viper envenomings have remained largely understudied.

Case presentation:

Here, we present a case report of a 46-years old female patient from Las Claritas, Venezuela, who was envenomed by a snake from the Bothrops genus. The patient was followed for a 10-year period, during which she presented oliguric renal failure, culminating in kidney failure 60 months after the envenoming.

Conclusion:

In Latin America, especially in Brazil, where there is a high prevalence of Bothrops envenoming, it may be relevant to establish long-term outpatient programs. This would reduce late adverse events, such as chronic kidney disease, and optimize public financial resources by avoiding hemodialysis and consequently kidney transplantation.

Acute kidney failure following severe viper envenomation: clinical, biological and ultrasonographic aspects

Background:

Acute kidney injury (AKI) is a frequent complication of snakebite envenomation, which is still little known in sub-Saharan Africa. This study aims to describe the clinical, biological and ultrasonographic aspects of AKI following severe snakebite envenomation managed in the intensive care unit.

Method:

A prospective observational survey was performed in Benin over a period of 18 months. All patients suffering severe snakebite envenomation (SBE) were included. The diagnosis of AKI was made using the KDIGO criteria. Kidney ultrasound exam was performed in all patients to assess internal bleeding and morphological and structural abnormalities of the kidneys.

Results:

Fifty-one cases of severe SBE were included. All patients presented inflammatory syndrome and showed abnormal WBCT whereas bleeding was found in 46 of them (90%). The median time to hospital presentation was three days. The majority of patients were male (M/F sex ratio = 1.55) and the median age was 26. Sixteen patients (31%) showed AKI according to the KDIGO criteria. Severe AKI (KDIGO stage 2 and 3) was observed in three patients, including one stage 2 and two stage 3. Kidney ultrasound revealed three cases of kidney capsular hematoma (6%), two cases of kidney hypertrophy (3%), three cases of kidney injury (4%), two stage 1 KDIGO and one stage 2 KDIGO. Only one patient benefited from hemodialysis. All patients showing AKI recovered without sequels. The median duration of hospital stays was four days. Seven patients died (14%) including four among the 16 AKI patients. Antivenom has been administered to 41 patients (80%). The comparison between patients without and with AKI did not show any significant difference except gender (p = 10^-2).

Conclusion:

AKI is a common complication of severe snakebite envenomation. Resulting from inflammatory and hemorrhagic disorders, AKI may prove to be a short-term life-threatening factor.

Cryotherapy as a coadjuvant in crotaline snakebite management with F(ab')2 antivenom: A randomized pilot study

INTRODUCTION

Local cryotherapy induces vasoconstriction, which leads to a reduction in the inflammatory process. However, the effectiveness of local cryotherapy as a coadjuvant in the treatment of snakebite with F(ab')₂ antivenom is unknown.

OBJECTIVE

To describe the clinical effectiveness of local cryotherapy as a coadjuvant in patients with snakebite treated with F(ab')₂ antivenom therapy at the Hospital Juárez de Mexico.

MATERIAL AND METHODS

Patients with grade II snakebite envenomation according to the Christopher-Rodning classification system were enrolled from the Clinical Toxicology Service of the Hospital Juárez de México. One group of patients received F(ab')₂ antivenom therapy (Antivipmyn®) plus local cryotherapy, and the other group received only F(ab')₂ antivenom therapy.

RESULTS

Thirty-eight patients were included, of whom 86.8 % were male (n = 33). Approximately 81.5 % of the subjects were injured in an upper extremity, while 18.5 % were injured in a lower extremities; 47.3 % of the subjects reported treatment of the snakebite prior to hospitalization (suction, the application of a tourniquet, incision of the bite site, or the application of traditional medicine). No differences were found concerning edema, swelling, and pain between the groups. The group that received local cryotherapy as a coadjuvant to F(ab')₂ antivenom therapy had a shorter hospital stay (Cohen's d = 1.33; 95 % confidence interval [95 % CI] = 0.74-1.62; p < 0.01) and received fewer doses of F(ab')₂ antivenom therapy (Cohen's d = 0.69; 95 % CI = 0.19-3.80; p = 0.03).

CONCLUSIONS

The use of adequate local cryotherapy as a coadjuvant to F(ab')₂ antivenom therapy reduces the length of hospital stay and the number of doses of F(ab')₂ antivenom therapy used.

Severe hypofibrinogenemia in patients bitten by Gloydius tsushimaensis in Tsushima Island, Nagasaki, Japan, and treatment strategy

Gloydius tsushimaensis is an endemic species inhabiting only Tsushima, a remote Japanese island, and is a distinct species from Gloydius blomhoffii widely distributed throughout mainland Japan and Gloydius brevicaudus and Gloydius ussuriensis which are geographically distributed in South Korea. This is the first multicenter retrospective study of G. tsushimaensis bites in Japan. A study of seventy-two patients who visited the former Izuhara Hospital, the former Naka Tsushima Hospital, Tsushima Hospital, and Kamitsushima Hospital during the fourteen years from January 1, 2005, to December 31, 2018, revealed the typical clinical characteristics of G. tsushimaensis bites. Five out of seventy-two cases (6.9%) showed severe hypofibrinogenemia, in which fibrinogen levels were below 100 mg/dl, which is an unreported clinical finding for G. blomhoffii bites. Generally, when fibrinogen levels are lower than 100 mg/dl, the bleeding risk increases, and it is perilous. Severe hypofibrinogenemia cases did not improve after G. blomhoffii antivenom administration. Additionally, all five cases had disseminated intravascular coagulation, and there were two cases of acute kidney injury and one death. five cases had a median maximum creatine kinase level of 5171 IU/l (Interquartile range: 4992-41,310). Although the mechanism is not precise, coagulation tests showed that the G. tsushimaensis venom contains a thrombin-like enzyme. Based on this research, we created an algorithm for the treatment of G. tsushimaensis bites and unified the treatment methods used on the island.

Envenomation by opisthoglyphous snake Thamnodynastes hypoconia (Cope, 1860) (Dipsadinae: Tachymenini) in southern Brazil

We report here a case of human envenoming by Thamnodynastes hypoconia, a common and abundant non-front-fanged snake belonging to the subfamily Dipsadinae. The case was registered in the municipality of Tapes, Rio Grande do Sul state, Brazil, in a 27-year-old female. The snakebite was on the wrist of the left arm while handling the snake in a field outing. No pain sensation was noted during the bite, and after 20 minutes edema developed along the hand and forearm with a slight sensation of numbness and mild pain when moving the fingers. After 15 hours, the victim began to develop erythema, paraesthesia, and a sensation of warmth at the bite site. After 30 hours, ecchymosis occurred on the fingers and forearms, and the edema began to decrease. After 70 hours from the time of the bite, ecchymosis along with pruritus and mild pain were still evident. The patient was treated with prescribed medications, and after 7 days no further symptoms were observed. This is the first reported case of envenoming by T. hypoconia.

Second case report of slender coral snake (Calliophis melanurus sinhaleyus) envenomation of Sri Lanka

Bite and envenomation by the slender coral snake (Calliophis melanurus sinhaleyus) is rare in Sri Lanka. This case report describes an authenticated slender coral snake envenomation that occurred in a 32-year-old male. The bite to the middle phalanx of the left index finger was allowed to persist for 10 minutes. The victim developed pain, swelling and paresthesia without signs of systemic neurotoxicity.

Clinical and Therapeutic Aspects of Brazilian Native Bothrops Envenomation in Nine Horses

In this retrospective study, clinical records of nine horses with a diagnosis of Bothrops envenomation were investigated. The accidents were classified as severe (5/9), moderate (2/9), or mild (2/9) according to the adapted bothropic snakebite severity score (BSSS). All snakebites were on the head region. The main clinical signs were local edema, blood coagulation disorders, and respiratory distress. The whole-blood clotting time (WBCT) was prolonged in all horses, and five horses presented with uncoagulable blood. All horses received specific snake antivenom according to the BSSS (six vials for severe, four vials for moderate, and two vials for mild accidents), and emergency tracheotomy was required in six horses because of respiratory distress. One horse died after eight days of hospitalization, whereas the others were discharged after nine days of hospitalization. The BSSS plus the WBCT were useful in determining the prognosis and the amount and frequency of antivenom therapy. Snakebite accidents are emergency cases; therefore, rapid and efficient therapeutic intervention will reflect positively on the prognosis.

Cerastes cerastes snakebite complicated by coagulopathy and cardiotoxicity with electrocardiographic changes

Snakebites occur worldwide with varying frequency. Outcomes associated with snakebite are varied and depend on the type of snake and the general health of the patient. We report a case of snakebite by Cerastes cerastes or desert horned viper. Consumptive coagulopathy and cardiotoxicity with electrocardiographic changes complicated the clinical course of the patient. To the best of our knowledge, this is the first reported case in the state of Qatar.

Neutralising effects of small molecule toxin inhibitors on nanofractionated coagulopathic Crotalinae snake venoms

Repurposing small molecule drugs and drug candidates is considered as a promising approach to revolutionise the treatment of snakebite envenoming. In this study, we investigated the inhibiting effects of the small molecules varespladib (nonspecific phospholipase A2 inhibitor), marimastat (broad spectrum matrix metalloprotease inhibitor) and dimercaprol (metal ion chelator) against coagulopathic toxins found in Crotalinae (pit vipers) snake venoms. Venoms from Bothrops asper, Bothrops jararaca, Calloselasma rhodostoma and Deinagkistrodon acutus were separated by liquid chromatography, followed by nanofractionation and mass spectrometry identification undertaken in parallel. Nanofractions of the venom toxins were then subjected to a high-throughput coagulation assay in the presence of different concentrations of the small molecules under study. Anticoagulant venom toxins were mostly identified as phospholipases A2, while procoagulant venom activities were mainly associated with snake venom metalloproteinases and snake venom serine proteases. Varespladib was found to effectively inhibit most anticoagulant venom effects, and also showed some inhibition against procoagulant toxins. Contrastingly, marimastat and dimercaprol were both effective inhibitors of procoagulant venom activities but showed little inhibitory capability against anticoagulant toxins. The information obtained from this study aids our understanding of the mechanisms of action of toxin inhibitor drug candidates, and highlights their potential as future snakebite treatments.

Pets in peril: The relative susceptibility of cats and dogs to procoagulant snake venoms

Snakebite is a common occurrence for pet cats and dogs worldwide and can be fatal. In Australia the eastern brown snake (Pseudonaja textilis) is responsible for an estimated 76% of reported snakebite cases to domestic pets nationally each year, with the primary pathology being venom-induced consumptive coagulopathy. While only 31% of dogs survive P. textilis bites without antivenom, cats are twice as likely to survive bites (66%). Even with antivenom treatment, cats have a significantly higher survival rate. The reason behind this disparity is unclear. Using a coagulation analyser (Stago STA R Max), we tested the relative procoagulant effects of P. textilis venom-as well as 10 additional procoagulant venoms found around the world-on cat and dog plasma in vitro, as well as on human plasma for comparison. All venoms acted faster upon dog plasma than cat or human, indicating that dogs would likely enter coagulopathic states sooner, and are thus more vulnerable to procoagulant snake venoms. The spontaneous clotting time (recalcified plasma with no venom added) was also substantially faster in dogs than in cats, suggesting that the naturally faster clotting blood of dogs predisposes them to being more vulnerable to procoagulant snake venoms. This is consistent with clinical records showing more rapid onset of symptoms and lethal effects in dogs than cats. Several behavioural differences between cats and dogs are also highly likely to disproportionately negatively affect prognosis in dogs. Thus, compared to cats, dogs require earlier snakebite first-aid and antivenom to prevent the onset of lethal venom effects.

Snakebite outbreak and associated risk factors in Donga, Taraba State, Nigeria, June, 2016

Snakebite envenoming is a public health problem among rural communities in Nigeria. In June, 2016, an outbreak of snakebites in Donga Local Government Area, Taraba State, north-east Nigeria, was reported. We investigated the outbreak to identify risk factors for snakebites and to institute appropriate control measures. We conducted an unmatched case control study to identify risk factors for snakebite in the communities involved. We conducted key informant interviews and Focus Group Discussions with stakeholders in the communities to obtain information on the community´s perspective of the outbreak. There were Sixty-one (61) snakebite cases with Fifteen (15) deaths [CFR 24.6%]. Majority of the mortalities [37(60.3%)] were males. Median age was 27 years (Range: 5-58). Kadarko ward had the highest [26 (42.6%)] number of cases. Most snakebites 12 (44.4%) occurred in the farm, 27 (96.4%) vipers Echis spp were responsible for most of the bite and most [26 (92.9%)] victims sought care from traditional healers. Residing in Kadarko ward and having a history of snakebite in the past were risk factors [Odds ratio of 2.9 (95% CI 1.1-7.4) and 5.9 (95% CI 1.1-32.5)] respectively. Abandonment of homes for two years due to communal clashes has been thought to have allowed snake populations to grow. The snakebite outbreak in Donga, Taraba State affected predominantly male farmers in the rural wards. Residing in Kadarko ward and having a previous history of snakebite were risk factors.

Ketamine for pain control of snake envenomation in Guinea: A case series

Snakebite envenomation is a global health crisis and is classified as a Category A neglected tropical disease by the World Health Organization (WHO). Snakebite envenomations account for a significant amount of morbidity and morbidity in tropical and subtropical regions. Recently, publications have illustrated the potential for snake envenomations causing post-traumatic stress disorder (PTSD) in a significant number of patients. Ketamine is on the WHO's list of essential medications and is used for a variety of pharmacologic applications including anesthesia and acute pain management. To date it has not been assessed for pain control in snakebite envenomations. Twelve patients who presented with severe pain secondary to Bitis, Causus, and Atractaspis envenomations were treated with low-dose intravenous ketamine. The patients included 7 males and 5 females with a median age of 37.5 (range 14-64) and a median presentation time of 5.75 h (range 5 min-96 h) after the initial bite occurred. Ten envenomations were presumed to have been caused by Bitis species resulting in extensive swelling and blistering of the affected extremities. One envenomation was presumedC. maculatus causing local swelling and pain. One envenomation was a presumed Atractaspis species causing significant local pain with minimal swelling. All patients expressed having significant pain but could not express the degree of their pain using an analogue pain scale. An initial median dose of 5 mg of ketamine (range 2.5-15 mg) was administered intravenously for pain control. Every patient expressed decreased pain and felt more comfortable within 1 min after administration of ketamine. Nine of the twelve patients only required a single dose. There were no adverse side effects. Ketamine appears to be an effective means of pain control for those suffering from painful envenomations. With minimal risk of significant side effects at acute pain management doses and the average cost per effective dose averaging between US$0.03-0.06, this may provide a cheap, safe, and effective solution for Sub-saharan Africa and other resource-limited settings. Controlled studies need to be done to critically assess our observations.

Epidemiology of fatal snakebites in the United States 1989-2018

BACKGROUND

There are 5000-10,000 snake envenomations annually in the United States. Fortunately, few are fatal. In this study we review the epidemiology of fatal snakebites.

METHODS

Native snakebite cases from the American Association of Poison Control Centers (AAPCC) National Poison Data System from 1989 to 2018 were reviewed. Additional cases that were not reported to the AAPCC were identified by reviewing Wikipedia and by searching PubMed and online news outlets using various combinations of relevant keywords.

RESULTS

We identified 101 fatal bites from native snakes. Rattlesnakes accounted for 74 (90.2%) of the 82 deaths for which the species was known or which occurred where rattlesnakes are the only native crotalids. There were five fatalities attributed to copperheads, two due to cottonmouths, and one caused by an eastern coral snake. Males were disproportionately affected. The median age for victims was 40 years old. In cases for which data were available, many of the snake interactions were intentional, e.g. religious services, animal husbandry, and attempting to kill the snake.

CONCLUSIONS

Death following envenomation from a native U.S. snake is unlikely, particularly if medical attention is sought promptly. Rattlesnake envenomations are more likely to be fatal than bites from other species. Intentionally engaging with a venomous snake raises the risk of incurring a fatal bite, as does concurrent alcohol or drug use. Age less than 12 years old does not appear to be a risk factor for a fatal outcome, while elderly patients may have a slightly increased risk of death.

Preparation and detection of sea snake antisera raised in rabbits

Antivenoms are currently the most effective medication used in the treatment of snakebites. However, there were relatively few studies on preparation of antivenoms targeting sea snakes, especially common sea snakes in China. In this study, we sought to prepare and detect mono- and bispecific antisera raised in rabbits against venoms of two sea snakes, Hydrophis cyanocinctus and H. curtus. The results of enzyme-linked immunosorbent assay showed that the rabbit antisera generally showed clearly detectable immunological cross-reactions after the third immunization and indicated that the strength of cross-reactions increased with an increase in the immunizing dose. Proteins within the H. cyanocinctus and H. curtus venoms showed similar profiles and were mainly concentrated in the low-molecular-weight region (8-25 kDa). Western blotting results revealed that the bands of these low-molecular weight proteins were dense and showed strong immunogenicity. Although we detected comparatively few bands of the high-molecular-weight proteins, these also showed strong immunogenicity. Our results indicate that both mono- and bispecific antisera both can neutralize H. cyanocinctus and H. curtus venoms, and in this regard, the monospecific H. curtus and bispecific antiserum were found to be superior to the H. cyanocinctus antiserum. Given the increasing frequency of snakebites worldwide, we believe that the findings of this study will have high practical applicability.

Epidemiology, Clinical Features, and Management of Texas Coral Snake (Micrurus tener) Envenomations Reported to the North American Snakebite Registry

INTRODUCTION

Few of the 5000-8000 snakebites reported to poison control centers annually in the USA are attributed to coral snakes. This study describes Texas coral snake envenomations reported to the North American Snakebite Registry.

METHODS

All Texas coral snake envenomation cases reported to the registry were identified for the period from January 1, 2015, through December 31, 2019. Data reviewed for this study included details regarding the snake encounter, patient demographics, signs and symptoms, treatment, and outcomes. Descriptive statistics were used to report results.

RESULTS

Ten men and four nonpregnant women reported coral snake bites. The median patient age was 15.5 (range 5-72 years). There were 12 upper extremity bites and two bites to the lower extremity. The most common symptoms reported were paresthesias and pain. All subjects had paresthesias, often described as an "electric" sensation. Seven patients described them as painful. The most common clinical findings were erythema and swelling. No patient developed tissue damage, hematotoxicity, rhabdomyolysis, hypotension, weakness, or respiratory symptoms. Thirteen subjects were treated with opioids. Six patients were treated with antiemetics: three prophylactically and two for opioid-induced nausea. One patient developed nausea and non-bloody, nonbilious emesis within 1 hour of the bite, prior to receiving opioids. No patients were treated with antivenom. Antibiotics were not administered to any patient, and no infections were reported.

CONCLUSIONS

Envenomations from M. tener in Southeast Texas are characterized by painful paresthesias. Mild swelling and erythema are common. Neurotoxicity necessitating antivenom or mechanical ventilation did not occur.

Serum IgE against galactose-alpha-1,3-galactose is common in Laotian patients with snakebite envenoming but not the major trigger for early anaphylactic reactions to antivenom

Snake antivenom is the only specific treatment for snakebite envenoming, but life-threatening anaphylaxis is a severe side effect and drawback for the use of these typically mammalian serum products. The present study investigates the hypotheses whether serum IgE antibodies against the epitope galactose-alpha-1,3-galactose (α-gal) located on the heavy chain of non-primate mammalian antibodies are a possible cause for hypersensitivity reactions to snake antivenom. Serum samples from 55 patients with snakebite envenoming were obtained before administration of snake antivenom and tested for serum IgE (sIgE) against α-gal and total IgE. Early anaphylactic reactions (EARs) during the first 3 h after antivenom administration were classified into mild, moderate or severe and correlated with the presence of sIgE against α-gal. Fifteen (27%) out of 55 patients (37 male, 18 female, median 34 years, range 9-90 years) developed EARs after antivenom administration. Eleven, three and one patients had mild, moderate and severe EARs, respectively. Serum IgE against α-gal was detected in 17 patients (31%); in five (33%) out of 15 patients with EARs and in 12 (30%) out of 40 patients without EAR (Odds Ratio = 1.2; 95%-confidence interval: 0.3-4.2) with no correlation to severity. Although the prevalence of serum IgE against α-gal was high in the study population, very high levels of total IgE in the majority of patients question their clinical relevance and rather indicate unspecific sIgE binding instead of allergy. Lack of correlation between α-gal sIgE and EARs together with significantly increased total IgE levels suggest that sIgE against α-gal is not the major trigger for hypersensitivity reactions against snake antivenom.

Clinical assessment and pathophysiology of Bothrops venom-related acute kidney injury: a scoping review

Bothrops are one of the most common medically important snakes found in Latin America. Its venom is predominantly hemotoxic and proteolytic, which means that local lesion (edema and redness) and hemorrhagic symptoms are recurrent in envenoming by this snake. Although hemorrhage is usually the major cause of death, snakebite-related acute kidney injury is another potentially fatal clinical complication that may lead to chronic kidney disease. The present review highlights the main studies on Bothrops venom-related acute kidney injury, including observational, cross-sectional, case-control and cohort human studies available up to December 2019. The following descriptors were used according to Medical Subject Headings (MeSH): on Medline/Pubmed and Google Scholar "acute kidney injury" or "kidney disease" and "Bothrops"; on Lilacs and SciELO "kidney disease" or "acute kidney injury" and "Bothrops". Newcastle-Ottawa quality assessment scale was used to appraise the quality of the cross-sectional and cohort studies included. The selection of more severe patients who looked for health care units and tertiary centers is a risk of bias. Due to the methodological heterogeneity of the studies, a critical analysis of the results was performed based on the hypothesis that the design of the included studies influences the incidence of acute kidney injury. Fifteen human studies (total participants 4624) were included according to stablished criteria. The coagulation abnormalities (hemorrhagic symptoms, abnormal fibrinogen and activated partial thromboplastin time) were associated with acute kidney injury in the most recent studies reported. The findings observed in this review provide up-to-date evidence about the acute kidney injury pathogenesis following Bothrops syndrome. Studies pointed out that coagulation abnormalities comprise the major pathway for acute kidney injury development. This review may improve patient management by primary healthcare providers, allowing earlier diagnosis and treatment of Bothrops venom-related acute kidney injury.

Failure of a Mexican antivenom on recovery from snakebite-related coagulopathy in French Guiana

INTRODUCTION

In French Guiana, most snakebites are caused by crotalids, with the main signs being tissue damage and bleeding due to venom-induced coagulopathy. Since December 2014 the Western Guiana Hospital (WGH) has used Antivipmyn Tri ^TM, a Mexican polyvalent antivenom. The aim of the study was to assess its benefit on the correction of snakebite-related coagulopathy.

METHODS

This retrospective study included patients hospitalized at the WGH with snakebite and a coagulopathy defined by: a prothrombin rate (PR) lower than 45%, an activated partial thromboplastin time ratio (aPTTr) greater than 2 or a fibrinogen lower than 100 mg.dL^-1. The antivenom group included patients receiving Antivipmyn Tri ^TM from December 2014 to September 2017. The control group included patients admitted between January 2013 and November 2014 (when antivenom was unavailable) or admitted between December 2014 and September 2017 during times of antivenom shortage. We graphically compared the time courses of PR, aPTTr and fibrinogen between groups. Other endpoints were the length of hospital stay and the need for surgery or dialysis.

RESULTS

84 patients were included: 42 in the antivenom group, 42 in the control group. Both groups were similar for age, sex-ratio, proportion of bleedings, necrosis, and severity. Most patients in the antivenom group received 3 vials. There were no significant differences in recovery of PR, aPTTr and fibrinogen through the first 24 h. Fibrinogen declined again in the control group at 30 h and showed a slower rise to normal concentration. There were no significant differences in any secondary endpoint.

CONCLUSION

Antivipmyn Tri ^TM as currently used did not show any benefit in recovery from coagulopathy.

Medicinal plants species used by herbalists in the treatment of snakebite envenomation in Uganda

Background

There are high mortality and morbidity rates due to poisonous snakebites globally with sub-Saharan Africa having some of the highest cases. However, traditional medicine practitioners (TMP) have been treating snakebites in Uganda for long despite the fact that few studies have been conducted to document such vital and rich indigenous traditional knowledge before it is lost. This study aimed to document the medicinal plant species used by experienced TMP in treating snakebite envenomation in selected post-conflict parts of Uganda. An ethnopharmacological survey was conducted in Kitgum, Serere, Kaberamaido and Kaabong districts in Uganda. Twenty-seven TMP with expertise in treating snakebites were purposively identified using the snowball technique and interviewed using semi-structured questionnaires. Data were analysed using simple descriptive statistics.

Results

Sixty plant species from 28 families were documented with high consensus among the isolated indigenous Ik tribe of Kaabong district. Most of the plant species used were from the Asteraceae and Fabaceae families with eight species each. The genus Echinops was the most well-represented with three species. The most commonly used plant species were of citation were Steganotaenia araliaceae (16), Microglossa pyrifolia (Lam.), Gladiolus dalenii Van Geel (13), Aframomum mildbraedii Loes. (11), Jasminum schimperi Vatke and Cyathula uncinulata (Schrad) Schinz (10) and Crinum macowanii Baker and Cyphostemma cyphopetalum (Fresen.) Desc. ex Wild & R.B. Drumm (10). S. araliaceae which was mentioned by all the TMP in the Ik community was used for first aid. Most of the plant species were harvested from the wild (68.75%) and were herbs (65.0%) followed by trees (23.3%). The most commonly used plant parts were roots (42.6%) and leaves (25.0%). Thirteen different methods of preparation and administration were used. Most of the medicines were administered orally (61.2%) and topically (37.6%). The commonest methods of oral application were cold water infusions (32.5%) and decoctions (21.7%).

Conclusions

TMP widely use several medicinal plant species for treating snakebite envenomation in the selected post-conflict regions of Uganda

Antibiotic susceptibility of cultivable aerobic microbiota from the oral cavity of Echis carinatus from Odisha (India)

During a snake bite, the microbes may get transferred to the bite site and may cause secondary infection along with envenomation. The knowledge on the oral bacterial flora of snakes constitutes information important for snake bite management. The inadequately studied oral microflora of snakes differ geographically, temporally and among the members of the same species. The objective of this study is to determine the pattern of oral bacterial flora of Saw-scaled viper (Echis carinatus) and their susceptibility to antibiotics. Oral swabs were collected from nine healthy Saw-scaled vipers, subjected to microbiological, biochemical and molecular characterization. Additionally, these isolates were subjected to antimicrobial susceptibility testing using ICOSA-20-Plus and ICOSA-20-Minus. A wide range of pathogenic bacteria such as Salmonella arizonae, Pseudomonas stutzeri, Proteus penneri, Alcaligenes faecalis; Citrobacter diversus, C. freundii, Enterococcus faecalis, Bacillus anthracis, Staphylococcus sciuri and Achromobacter xylosoxidans were isolated as new additions to the floral diversity of saw scale viper. Most of the isolates were sensitive towards amikacin, azithromycin, imipenem, ciprofloxacin, gentamicin, ofloxacin, sparfloxacin, tobramycin, levofloxacin, kanamycin, tetracycline, and chloramphenicol while resistant to amoxyclav, cephalothin, cefpodoxime, Co-Trimoxazole, oxacillin and penicillin. The present study revealed that the bacterial flora of the oral cavity of Saw-scaled viper is resistant to many common antibiotics, which are often used for the treatment of snake-bite victims.