Rattlesnake Bites in Europe—Experiences from Southeastern France and Northern Germany

Bites by exotic snakes reported to the UK National Poisons Information Service 2009-2020

Introduction: Snakebite is recognised as a neglected tropical disease and a cause of substantial morbidity and mortality. Whilst the most medically important snakes are typically native of Asia, Africa, Latin America and Oceania, the possibility of encountering these snakes is no longer limited by geography due to an increasing number of exotic (non-native) snakes being held in captivity.Methods: A retrospective review of snakebite enquiries to the UK National Poisons Information Service (NPIS) between 2009 and 2020. Enquiries about the European adder (Vipera berus) or where the identity of the snake was unknown were excluded.Results: There were 321 exotic snakebites in 300 patients involving 68 different species during this period. Ten patients were bitten on more than one occasion. The majority of patients (64.5%) were male. Most bites were inflicted by snakes of the family Colubridae (184/321, 57.3%); seventeen bites resulted in moderate symptoms (predominantly swelling of the bitten limb). There were 30 (9.3%) bites by Viperidae and 14 (4.3%) bites by Elapidae. All severe cases (n = 15) resulted from bites by either Viperidae (n = 10) or Elapidae (n = 5). Antivenom was given in 17 cases. One fatality was recorded.Conclusions: Despite their low incidence, exotic snakebites present a substantial challenge for UK healthcare professionals. Although rare, these bites typically occur in individuals (usually male) who keep snakes as part of their occupation or hobby and are therefore at risk of multiple bites. Bites can result in venom hypersensitisation and the risk of venom-induced anaphylaxis. Rapid access to expert clinical advice is available in the UK on a 24-hour basis through the National Poisons Information Service and is strongly recommended in all cases of exotic snakebite.

Snakebite Envenoming Diagnosis and Diagnostics

Snakebite envenoming is predominantly an occupational disease of the rural tropics, causing death or permanent disability to hundreds of thousands of victims annually. The diagnosis of snakebite envenoming is commonly based on a combination of patient history and a syndromic approach. However, the availability of auxiliary diagnostic tests at the disposal of the clinicians vary from country to country, and the level of experience within snakebite diagnosis and intervention may be quite different for clinicians from different hospitals. As such, achieving timely diagnosis, and thus treatment, is a challenge faced by treating personnel around the globe. For years, much effort has gone into developing novel diagnostics to support diagnosis of snakebite victims, especially in rural areas of the tropics. Gaining access to affordable and rapid diagnostics could potentially facilitate more favorable patient outcomes due to early and appropriate treatment. This review aims to highlight regional differences in epidemiology and clinical snakebite management on a global scale, including an overview of the past and ongoing research efforts within snakebite diagnostics. Finally, the review is rounded off with a discussion on design considerations and potential benefits of novel snakebite diagnostics.

Increase in reptile-associated human salmonellosis and shift toward adulthood in the age groups at risk, the Netherlands, 1985 to 2014

While the contribution of the main food-related sources to human salmonellosis is well documented, knowledge on the contribution of reptiles is limited. We quantified and examined trends in reptile-associated salmonellosis in the Netherlands during a 30-year period, from 1985 to 2014. Using source attribution analysis, we estimated that 2% (95% confidence interval: 1.3–2.8) of all sporadic/domestic human salmonellosis cases reported in the Netherlands during the study period (n = 63,718) originated from reptiles. The estimated annual fraction of reptile-associated salmonellosis cases ranged from a minimum of 0.3% (corresponding to 11 cases) in 1988 to a maximum of 9.3% (93 cases) in 2013. There was a significant increasing trend in reptile-associated salmonellosis cases (+ 19% annually) and a shift towards adulthood in the age groups at highest risk, while the proportion of reptile-associated salmonellosis cases among those up to four years-old decreased by 4% annually and the proportion of cases aged 45 to 74 years increased by 20% annually. We hypothesise that these findings may be the effect of the increased number and variety of reptiles that are kept as pets, calling for further attention to the issue of safe reptile–human interaction and for reinforced hygiene recommendations for reptile owners.

Should We Be Using the Poisoning Severity Score?

INTRODUCTION

Despite the existence of a number of severity-of-illness classifications for other areas of medicine, toxicology research lacks a well-accepted method for assessing the severity of poisoning. The Poisoning Severity Score (PSS) was developed in the 1990s in Europe as a scoring system for poisonings reported to a poison center in order to describe a patient's most severe symptomatology. We reviewed the literature to describe how the PSS is utilized and describe its limitations.

DISCUSSION

We searched the medical literature in all languages using PUBMED, EMBASE, and SCOPUS from inception through August 2013 using predefined search terms. Out of 204 eligible publications, 40 met our criteria for inclusion in this review. There has been a paucity of published studies from North America that used the PSS. In some cases,  the PSS was misapplied or modified from standard scoring, making a bottom line appraisal of the validity or reliability of the original version of the instrument challenging. The PSS has several subjective criteria, is time consuming to score, and is likely to be of little use with some types of poisonings, limiting its clinical utility.

CONCLUSION

The PSS was developed as a tool to document encounters with poisoned patients. However, it is used infrequently and, when applied, has been misused or modified from its original form. In its current form, it has limited clinical utility and likely cannot be broadly applied to many exposures due to their unique clinical circumstances. With better global collaboration among medical toxicologists, it is possible that a modified score could be developed for use clinically or as a research instrument.

Establishment and first experiences of the National Serum Depot in the Netherlands

Since 2008, a National Serum Depot is operational in the Netherlands, guaranteeing antivenom supply, 24 h per day, during medical emergencies. In this article the organisation structure, choice of antivenoms, problems encountered during the establishment, and the results from establishment in 2008 till December 2011 are discussed. The Serum Depot is organised by the National Institute for Public Health and the Environment in cooperation with the Dutch National Poisons Information Center. During establishing and maintaining of the Serum Depot several antivenom purchase difficulties were encountered. Some antivenom producers did not respond upon (initial) contact and some antivenoms were (temporarily) unavailable. Good contacts with professional herpetologists are necessary in order to keep the content of the depot up-to-date. At the same time, it is important to remain well informed concerning the safety and efficacy of the currently available antivenoms and development of new antivenoms. During the first four years of the National Serum Depot, the Dutch National Poisons Information Center was consulted on average 10 times a year about exotic venomous bites and stings in which antivenom treatment might play a role. Almost half of these consultations were related to bites by venomous exotic snakes, the other half to scorpion and fish stings. Antivenom was delivered in five cases, all after a bite by an exotic venomous snake, and actually administered twice because of the severity of local effects. To reduce costs and extend coverage of the Serum Depot of antivenoms for more unfamiliar snake species, international cooperation between the various owners of the antivenom Serum Depots in Europe is recommended.

Management of snakebites in France

Although not a major health problem in Europe, snakebite in the old continent was the focus of recent studies to evaluate their overall incidence and define management techniques. The purpose of this three-part report is to present the experience of the Marseille Poison Centre with snakebite in France. The first section deals with viper envenomation that now benefits from a validated therapeutic protocol using of purified antivenom of proven efficacy and tolerance in patients showing grade 2 and 3 symptoms. The second section describes the highly variable snakebite situation in French overseas territories that include areas where local species require specialized management, e.g. Martinique and French Guiana. The third section involves the emerging problems associated with the keeping of exotic snakes as pets with problems related to the use of antivenoms from foreign countries. The exotic-snake pets fashion was at the origin of the creation of a national antivenom bank by two French poison centers (Angers and Marseille) to ensure prompt delivery of antivenoms for exotic snake envenomation anywhere in mainland France.

Bites and stings by exotic pets in Europe: an 11 year analysis of 404 cases from Northeastern Germany and Southeastern France

INTRODUCTION

The presence of exotic, and sometimes venomous, pets in European homes is becoming more common. This phenomenon is the basis of a French-German cooperative evaluation of the species causing the injuries and the circumstances, severity, and treatment of the envenomations

METHODS

A retrospective, descriptive, cross-sectional, case series of data from 1996 to 2006. The study sample consists of all cases of bites and stings by exotic pets that were registered at four poisons European poisons centers. The inclusion criteria were bites and stings of human beings.

RESULTS

From 1996 to 2006 four poisons centers in Europe were consulted on 404 bites and stings by exotic pets. The average age of the patients was 36 (2 to 75) years and 73% of the patients were male. The severity of the envenomations, according to the Poisoning Severity Score, was as follows: 29 severe (7.1%), 55 moderate (14.2%) and 320 minor (78.7%). There were no fatalities in this case series. Exotic snakebites from rattlesnakes, cobras, mambas, and other venomous snakes caused 39% of envenomations, aquatic animals (mostly lionfish of the Pterois genus and stingrays) caused 30% of envenomations and arthropods (tarantulas and scorpions) caused 27% of envenomations. All severe envenomations were caused by venomous snakes.

CONCLUSIONS

European healthcare professionals may encounter patients bitten or stung by exotic pets. Poisons center consultation can help manage these unusual presentations and help obtain rarely used antivenoms.