Snakebite envenomings in the Republic of Korea from the 1970s to the 2020s: A review

Clinical characteristics of snake envenomation-related acute kidney injury in South Korea

Acute kidney injury (AKI) is a common complication of bites by Viperidae snakes. The main venomous snakes in South Korea are members of the Viperidae family, but there is limited information on snake-bite induced AKI in South Korea. Therefore, we investigated snake envenomation-related AKI and the performance of surrogate baseline creatinine to diagnose true AKI. This retrospective, case-control study divided 71 patients with baseline serum creatinine into two groups according to the development of envenomation-related AKI determined based on Kidney Disease Improving Global Outcome Classification. The incidence of AKI was 14.1% with 10% having stage-3 AKI. During hospitalization, the AKI group did not develop venom-induced consumption coagulopathy more frequently than did the non-AKI group. Only one patient needed renal replacement therapy, and no patients died. The serum creatinine concentration at presentation underestimated the incidence of AKI, while the lowest creatinine concentration during hospitalization overestimated the incidence of AKI. After discharge, the incidence of chronic kidney disease did not increase in the AKI group. Snake envenomation-related AKI is characterized by a relatively lower incidence and severity, has no correlation with coagulation disturbance, and has favorable short- and long-term outcomes in South Korea. Based on this study, it is recommended that future envenomation-related AKI studies would utilize the baseline creatinine for diagnosing AKI. If not, envenomation-related AKI studies should include the definition of baseline creatinine used to diagnose AKI and report bias if a baseline creatinine surrogate is used.

Snakebite Management: The Need of Reassessment, International Relations, and Effective Economic Measures to Reduce the Considerable SBE Burden

The sole treatment for snakebite envenomation (SBE), the anti-snake venom (ASV), suffers from considerable drawbacks, including side effects and limited species specificity. Additionally, despite its existence for more than a century, uniform availability of good quality ASV does not yet exist. The present review describes the journey of a SBE victim and highlights the global crisis of SBE management. A detailed analysis of the current ASV market has also been presented along with the worldwide snake distribution. The current production of country specific licensed ASV throughout the globe along with their manufacturers has been examined at the snake species level. Furthermore, a detailed analysis of on-ground situation of SBE management in antivenom manufacturing countries has been done using the most recent literature. Additionally, the export and import of different ASVs have been discussed in terms of procurement policies of individual countries, their shortcomings, along with the possible solution at the species level. It is interesting to note that in most countries, the existence of ASV is really either neglected or overstated, implying that it is there but unsuitable for use, or that it is not present but can be obtained from other countries. This highlights the urgent need of significant reassessment and international collaborations not just for development and production, but also for procurement, distribution, availability, and awareness. A PROMISE (Practical ROutes for Managing Indigenous Snakebite Envenoming) approach has also been introduced, offering simple, economical, and easy to adopt steps to efficiently alleviate the worldwide SBE burden.

The association between the neutrophil lymphocyte ratio and local edema after viper snake envenomation in South Korea

The role of the inflammatory process in the pathogenesis of local edema-related envenomation has not been explored with endemic venomous snakebites in Korea. Gloydius species are responsible for most snakebites in South Korea. In this study we aimed to investigate whether the neutrophil-lymphocyte ratio is relevant to snake envenomation-induced local edema in South Korea. This retrospective study divided 126 patients into two groups according to local edema severity at presentation. Logistic regression models were used to investigate the association between the neutrophil-lymphocyte ratio and local edema. Sixty-one (48.4%) patients had grade 2 or higher local edema at presentation despite 21 of them being given antivenom before presentation. During hospitalization, local edema progressed in 61 patients 48 (11.5-48) hours after presentation, and 54 patients demonstrated grade 3 or higher local edema. A higher neutrophil-lymphocyte ratio at presentation after adjustment for factors related to envenomation and antivenom administration and factors influencing the neutrophil-lymphocyte ratio were associated with both a higher grade of local edema at presentation and a higher peak local edema grade during hospitalization. The delta neutrophil-lymphocyte ratio during the first 24 h after presentation was related to the local edema progression after presentation. The neutrophil-lymphocyte ratio at presentation is associated with the severity of local edema-related envenomation. Furthermore, the change in the neutrophil-lymphocyte ratio during the first 24 h is related to the risk of local edema progression. Further clinical and experimental research aimed at investigating the role of inflammation on the pathogenesis of local edema should be conducted. This study may suggest the introduction of short-term anti-inflammatory agents considering the failure of antivenom to curb local edema.

Thromboelastographic evaluation in dogs with Asian pit viper (Gloydius) envenomation

The objective of this study was to investigate the thromboelastography (TEG) variables and platelet count after Asian pit viper (Gloydius) envenomation in dogs compared with healthy control dogs. Ten dogs with snake envenomation and twenty healthy dogs were included. There was a significant decrease in G (P=0.017), maximum amplitude (MA) (P=0.012), angle value (P=0.041), platelet count (P<0.001, as well as an increase in K value (P=0.034) and R value (P=0.007) in dogs with snake envenomation. The results of this study revealed that dogs with Asian pit viper (Gloydius) envenomation showed a hypocoagulable state compared with healthy dogs. Our findings may support the use of TEG for diagnosing and monitoring coagulopathy after Asian pit viper (Gloydius) envenomation in dogs.

Snakebite epidemiology, outcomes and multi-cluster risk modelling in Eswatini

BACKGROUND

Halving snakebite morbidity and mortality by 2030 requires countries to develop both prevention and treatment strategies. The paucity of data on the global incidence and severity of snakebite envenoming causes challenges in prioritizing and mobilising resources for snakebite prevention and treatment. In line with the World Health Organisation's 2019 Snakebite Strategy, this study sought to investigate Eswatini's snakebite epidemiology and outcomes, and identify the socio-geographical factors associated with snakebite risk.

METHODOLOGY

Programmatic data from the Ministry of Health, Government of Eswatini 2019-2021, was used to assess the epidemiology and outcomes of snakebite in Eswatini. We developed a snake species richness map from the occurrence data of all venomous snakes of medical importance in Eswatini that was subjected to niche modelling. We formulated four risk indices using snake species richness, various geospatial datasets and reported snakebites. A multivariate cluster modelling approach using these indices was developed to estimate risk of snakebite and the outcomes of snakebite in Eswatini.

PRINCIPAL FINDINGS

An average of 466 snakebites was recorded annually in Eswatini. Bites were recorded across the entire country and peaked in the evening during summer months. Two cluster risk maps indicated areas of the country with a high probability of snakebite and a high probability of poor snakebite outcomes. The areas with the highest rate of snakebite risk were primarily in the rural and agricultural regions of the country.

SIGNIFICANCE

These models can be used to inform better snakebite prevention and treatment measures to enable Eswatini to meet the global goal of reducing snakebite morbidity and mortality by 50% by 2030. The supply chain challenges of antivenom affecting southern Africa and the high rates of snakebite identified in our study highlight the need for improved snakebite prevention and treatment tools that can be employed by health care workers stationed at rural, community clinics.

Snake envenomation in three cats in South Korea

Case series summary

Three cats in South Korea were diagnosed with snake envenomation based on the appearance and location of bite wounds. Two cats were envenomed by the Gloydius species and one by an unidentified species. Clinical signs were detected, including local bite-site swelling, haemorrhagic discharge and necrosis. All three cats were given supportive treatment. An antivenom was administered to one cat, and the cat showed no adverse reactions. All cats survived, but skin necrosis remained a complication of the snake envenomation. This was observed during the 1-year follow-up period.

Relevance and novel information

Cats with snake envenomation are extremely rare in South Korea, and information regarding clinical details are limited. This study is the first to describe the clinical details and prognosis of feline snake envenomation in South Korea.

Identification of Risk Areas for Gloydius Snakebites in South Korea

Snakebites can pose a significant threat to human health as the destruction of natural habitats and increased human intrusion into ecosystems result in more frequent encounters with snakes. Mitigation measures for snakebites are particularly crucial for hiking trails where transportation of snakebite victims to medical facilities is challenging due to limited emergency resources and difficult access. This study employed a random forest-based species distribution model approach to investigate the potential habitats of Gloydius spp., specifically Gloydius saxatilis, Gloydius brevicaudus, and Gloydius ussuriensis, in South Korea and to assess the snakebite risk in national parks. Potential habitats of Gloydius spp. were identified and visualized by overlaying binary maps derived from species distribution models (SDMs) of each Gloydius spp. that corresponded to high-risk snakebite areas. In addition, hiking trails with high snakebite risk in the national parks were identified after demonstrating the statistical correlation between the potential habitat distribution of Gloydius spp. and the actual snakebite incidents in major regions of South Korea. The primary environmental variables determining Gloydius spp. habitat were the topographic position index, slope, and the annual average of the maximum and minimum temperatures. The potential habitat of G. saxatilis generally appeared in high-altitude mountainous areas, mostly in the eastern part of the study area. Favorable habitats for G. brevicaudus and G. ussuriensis were predominantly located in mountainous areas throughout the study area, with the exception of some high-altitude mountainous terrain in the east. The number of snakebite incidents per 10,000 people was significantly correlated with the area ratio of Gloydius spp. potential habitat (Spearman's rho = 0.638, p < 0.01). The proportion of snakebite risk areas among national parks in South Korea ranged from 18% to 57%. This study can support practical solutions to prevent injuries and fatalities among hikers due to snakebites by identifying areas with a high risk of snakebite accidents at the hiking-trail level.

Snakebite envenoming in Brazilian children: clinical aspects, management and outcomes

Snakebite envenoming is currently considered a neglected tropical disease, which affects over 5 million people worldwide, and causes almost 150 000 deaths every year, as well as severe injuries, amputations and other sequelae. Snakebite envenoming in children, although proportionally less frequent, is generally more severe, and represents an important challenge for pediatric medicine, since they often result in worse outcomes. In Brazil, given its ecological, geographic and socioeconomic characteristics, snakebites are considered an important health problem, presenting approximately 30 000 victims per year, approximately 15% of them in children. Even with low snakebite incidence, children tend to have higher snakebite severity and complications due to the small body mass and same venom volume inoculated in comparison to adults, even though, due to the lack of epidemiological information about pediatric snakebites and induced injuries, it is difficult to measure the treatment effectiveness, outcomes and quality of emergency medical services for snakebites in children. In this review, we report how Brazilian children are affected by snakebites, describing the characteristics of this affected population, clinical aspects, management, outcomes and main challenges.

A Retrospective Evaluation of Snake Envenomation in Dogs in South Korea (2004-2021)

Snake envenomation is a medical emergency capable of causing local and systemic complications. However, information on venomous snakebite in dogs in South Korea is scarce. In this study, fifty-nine dogs treated at a private veterinary clinic from 2004 to 2021 were retrospectively studied. The aim was to characterize the demographics, elapsed time between snakebite and veterinary clinic presentation, laboratory findings, clinical signs, treatments, adverse reactions to antivenom, and prognosis of venomous snakebite. Snakebite was mostly observed between 12 p.m. and 5 p.m. from April to October. On the days of envenomation, the weather conditions were mostly cloudy, followed by rain/precipitation, and least frequently fair weather. Grassland was the most common incident location, and leashed dog walking was the most frequent activity when snakebite occurred. The main local symptoms were edema, hemorrhagic discharge, cutaneous erythema, ulceration, and necrosis. Major systemic clinical signs were tachypnea, tachycardia, altered mentation, ptyalism, and hypotension. Based on the time interval between snakebite and presentation at the veterinary clinic, two groups were defined: <4 h (Group 1, 49.2%) and ≥4 h (Group 2, 50.8%). Systemic inflammation was more frequently observed in Group 2. The level of C-reactive protein at presentation (p = 0.036) and the highest-level during hospitalization (p = 0.023) were significantly elevated in Group 2 (≥4 h). The dogs in Group 2 displayed more frequent muscle damage (increased creatine kinase) than the dogs in Group 1, and a higher level of creatine kinase was associated with delayed (≥4 h) presentation after snakebite (p = 0.003). All of the dogs were treated symptomatically, and 34 dogs (58%) received antivenom. Treatment with antivenom showed no adverse reactions in this study. All of the treated dogs recovered. One dog was euthanized without any treatment due to respiratory distress, hypotension, and cost constraints. In conclusion, this study provides baseline information on venomous snakebite in dogs in South Korea. The prognosis was excellent, especially when the dogs were treated within 4 h.