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Di Nicola MR, Crevani M, Avella I, Cerullo A, Dorne JLCM, Paolino G, Zattera C. A Guide to the Clinical Management of Vipera Snakebite in Italy. Toxins (Basel) 2024; 16:255. [PMID: 38922149 PMCID: PMC11209566 DOI: 10.3390/toxins16060255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/22/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024] Open
Abstract
The genus Vipera encompasses most species of medically significant venomous snakes of Europe, with Italy harbouring four of them. Envenomation by European vipers can result in severe consequences, but underreporting and the absence of standardised clinical protocols hinder effective snakebite management. This study provides an updated, detailed set of guidelines for the management and treatment of Vipera snakebite tailored for Italian clinicians. It includes taxonomic keys for snake identification, insights into viper venom composition, and recommendations for clinical management. Emphasis is placed on quick and reliable identification of medically relevant snake species, along with appropriate first aid measures. Criteria for antivenom administration are outlined, as well as indications on managing potential side effects. While the protocol is specific to Italy, its methodology can potentially be adapted for other European countries, depending on local resources. The promotion of comprehensive data collection and collaboration among Poison Control Centres is advocated to optimise envenomation management protocols and improve the reporting of epidemiological data concerning snakebite at the country level.
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Affiliation(s)
- Matteo Riccardo Di Nicola
- Unit of Dermatology and Cosmetology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
- Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Wildlife Health Ghent, Ghent University, 9820 Merelbeke, Belgium
- Asociación Herpetológica Española, Apartado de correos 191, 28911 Leganés, Spain
| | - Marta Crevani
- Poison Control Centre, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Ignazio Avella
- Landes-Offensive zur Entwicklung Wissenschaftlich-ökonomischer Exzellenz-Centre for Translational Biodiversity Genomics, Senckenberganlage 25, 60325 Frankfurt Am Main, Germany
- Institute for Insect Biotechnology, Justus-Liebig University Giessen, Heinrich-Buff-Ring 26-32, 35392 Giessen, Germany
| | - Anna Cerullo
- Department of Veterinary Sciences, University of Turin, L.go Braccini 2, 10095 Grugliasco, Italy
| | - Jean-Lou C. M. Dorne
- Methodological and Scientific Support Unit, European Food Safety Authority, Via Carlo Magno 1A, 43100 Parma, Italy
| | - Giovanni Paolino
- Unit of Dermatology and Cosmetology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Caterina Zattera
- Unit of Emergency Medicine, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo University Hospital, University of Pavia, P.Le Golgi, 19, 27100 Pavia, Italy
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Septelici D, Carbone G, Cipri A, Esposito S. Management Strategies for Common Animal Bites in Pediatrics: A Narrative Review on the Latest Progress. Microorganisms 2024; 12:924. [PMID: 38792754 PMCID: PMC11124134 DOI: 10.3390/microorganisms12050924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/28/2024] [Accepted: 04/30/2024] [Indexed: 05/26/2024] Open
Abstract
Animal bites are a common reason for children to visit primary care and emergency departments. Dog bites are the most prevalent, followed by cat bites at 20-30%. Other animals such as bats, monkeys, snakes, and rats collectively contribute less than 1% of cases. Hospitalization is necessary in only 4% of animal bite incidents. The main aim of this narrative review is to summarize the main protocols currently followed in pediatrics in cases involving the most common bites from different animal species. Analysis of the literature showed that the management of common animal bites in children presents a multifaceted challenge requiring a comprehensive understanding of the epidemiology, clinical presentation, and treatment modalities associated with each specific species. Effective wound management is paramount in reducing the risk of infection and promoting optimal healing outcomes. Additionally, tetanus vaccination status should be assessed and updated as necessary, and prophylactic antibiotics may be indicated in certain cases to prevent secondary infections. Furthermore, the role of rabies prophylaxis cannot be overstated, particularly in regions where rabies is endemic or following bites from high-risk animals. In addition to medical management, psychosocial support for both the child and their caregivers is integral to the overall care continuum. Future studies exploring the efficacy of novel treatment modalities, such as topical antimicrobial agents or advanced wound dressings, may offer new insights into optimizing wound healing and reducing the risk of complications.
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Affiliation(s)
| | | | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.S.); (G.C.); (A.C.)
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Sassoè-Pognetto M, Cavalcante R, Paonessa M. Acute compartment syndrome and fasciotomy after a viper bite in Italy: a case report. Ital J Pediatr 2024; 50:70. [PMID: 38627836 PMCID: PMC11020867 DOI: 10.1186/s13052-024-01638-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/28/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Bites caused by European vipers are rare medical emergencies but can occasionally cause life-threatening complications. Viper venom causes local symptoms, which can be accompanied by systemic manifestations in severe cases. The local effects of snakebites include edema and, more rarely, necrosis and compartment syndrome. The consequences of envenomation are often more pronounced in children due to their smaller body size. CASE PRESENTATION We present the case of a 6-year-old girl who experienced multiple viper bites in the lower limb in northwest Italy. The girl received supportive care but progressed to develop compartment syndrome that required emergency fasciotomy. The patient's condition improved promptly after surgical decompression and administration of antivenom, but full recovery required prolonged hospitalization and rehabilitation. CONCLUSIONS This case highlights the importance of obtaining a timely assessment of the severity of viper envenomation without delaying the administration of antivenom in most serious cases. The presence of multiple bite marks on the patient is one factor that may help to predict the clinical severity of snakebites and anticipate symptom progression.
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Affiliation(s)
- Marco Sassoè-Pognetto
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, C.so Massimo d'Azeglio, 52, 10126, Torino, Italy.
| | - Riccardo Cavalcante
- Centro Emys Piemonte, ELEADE Società Cooperativa a.r.l, Chiaverano, TO, Italy
| | - Matteo Paonessa
- Pediatric Orthopedic Surgery Department, "Regina Margherita" Children's Hospital, Torino, Italy
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Li Q, Huang Y, Zhang Y, Zeng L, Liang Q, Luo J. Venomous snakebites in children: a 10 year experience in South China. Clin Toxicol (Phila) 2024; 62:229-236. [PMID: 38668745 DOI: 10.1080/15563650.2024.2341124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 03/20/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Many studies have focused on snakebites in adults, but very few have described snakebites in children. METHODS We reviewed the clinical characteristics and outcomes of children with venomous snakebites aged less than 15 years who presented to a regional medical centre in South China from January 2013 to December 2022. RESULTS A total of 69 envenomed patients were analyzed in our study; 42 (60.9 per cent) patients were male, and 59 (85.5 per cent) reported lower limb bites. Most bites (89.8 per cent) occurred between April and October. Twenty-seven patients received first aid management, and 47 required admission to the general ward. Antivenom was administered to 58 patients, glucocorticoids to 43 patients, antibiotics to 48 patients, and tetanus antitoxin to 40 patients. No fatalities were reported. The most common snake identified was Trimeresurus albolabris. Four were classified as dry bites, 15 as mild, 43 as moderate, and seven as severe. The most common local signs were pain and swelling, while the most common systemic effects were haematological complications. Patients with high severity scores had significantly higher lactate dehydrogenase activities, creatine kinase isoenzyme activities, aspartate aminotransferase activities, D-dimer concentrations, prothrombin times and lower fibrinogen concentrations. In a receiver operating characteristic curve analysis of the values with the highest Youden index, the following cut-offs proved significant: lactate dehydrogenase activity > 248.1 U/L, creatine kinase isoenzyme activities > 17.5 U/L, fibrinogen concentration < 1,455 mg/L, D-dimer concentration > 437.0 µg/L, aspartate aminotransferase activity > 26.1 U/L, and prothrombin time > 15.2 seconds. DISCUSSION This study provides insight into the epidemiology, clinical profile, and management of snakebites in children. Data from the present study were compared with those from our previous adult study. Limitations include that 50.7 per cent of our snakebites were attributed to Trimeresurus albolabris. Therefore, the results of our study may not be generalizable to all snakebites. CONCLUSION The clinical symptoms were more severe in children than in adults in our previous study. Even though there were no fatalities, close monitoring should be performed to detect haematological and other potentially fatal complications promptly.
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Affiliation(s)
- Qianqin Li
- Department of Emergency Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yan Huang
- Department of Emergency Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Youhong Zhang
- Department of Internal Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Liangbo Zeng
- Department of Emergency Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qing Liang
- Department of Emergency Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jiangfu Luo
- Department of Emergency Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Pandit K, Rawal A, Maskey HMS, Nepal G. Neurological and neuro-ophthalmological manifestations of snake bite: a systematic review. Ann Med Surg (Lond) 2024; 86:392-400. [PMID: 38222724 PMCID: PMC10783398 DOI: 10.1097/ms9.0000000000001523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/09/2023] [Indexed: 01/16/2024] Open
Abstract
Objective Snakebites, a major health concern in developing countries, affect rural farming communities. Venom, primarily neurotoxin, injected during a snake bite disrupts the nervous system, causing symptoms like muscle weakness, paralysis, altered sensation, and coordination issues. This review focuses on evaluating neurological and neuro-ophthalmological manifestations associated with snakebites. Methods A database search was conducted in EMBASE and PubMed for studies published from 2000 to 2023. The investigation centered on examining neurological and neuro-ophthalmological symptoms and signs, treatment approaches, treatment outcomes, and long-term complications of snake bites. Results Neurological and neuro-ophthalmological symptoms were common in both neurotoxic and hemotoxic snake bites, especially in neurotoxic cases. Ptosis was a prevalent manifestation across various snake bites, along with respiratory paralysis, limb weakness, dysphasia, and visual disturbances in some instances. However, most patients improved without residual neurological symptoms after treatment. Conclusions Understanding patterns of neurological manifestations contributes valuable insights for the comprehensive management of snakebite.
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Affiliation(s)
- Kamal Pandit
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Aastha Rawal
- Department of Pharmacy, Manmohan Memorial Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Himang Man Singh Maskey
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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Sassoè M. Envenomation by Vipera aspis in Piedmont (Italy): A report of three cases, including one case with neurological symptoms. Toxicon 2023; 230:107154. [PMID: 37169267 DOI: 10.1016/j.toxicon.2023.107154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 05/13/2023]
Abstract
This report describes three cases of human envenomation by the asp viper (Vipera aspis) in Piedmont, north-west Italy. A woman was bitten on the ankle while she was hiking and two herpetologists received bites on the hand while they were manipulating the animals. In the first case, the victim presented severe systemic symptoms (abdominal pain, vomiting, diarrhea) that required treatment with two vials of antivenom and hospitalization for one week. In the second case, the patient manifested neurological symptoms (blepharoptosis, ophtalmoplegia); he was treated with antivenom and discharged after five days. In the third case, the patient was bitten by a juvenile viper and showed only local symptoms (edema and bruising). All patients reported prolonged functional impairment after discharge from hospital. Although uncommon, envenomation by Vipera aspis can cause severe consequences that require immediate management and antivenom administration. These cases highlight the importance of obtaining better knowledge of the intraspecific variability of venoms and its clinical significance, as well as of the factors that determine the severity of snakebite injuries.
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Affiliation(s)
- Marco Sassoè
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, C.so Massimo d'Azeglio, 52, 10126, Torino, Italy.
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Neurotoxicity and Other Clinical Manifestations of a Common European Adder (Vipera berus) Bite in Romania. Toxins (Basel) 2022; 14:toxins14070500. [PMID: 35878238 PMCID: PMC9318827 DOI: 10.3390/toxins14070500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/07/2022] [Accepted: 07/13/2022] [Indexed: 11/26/2022] Open
Abstract
Most cases of envenomation by common European vipers (Vipera berus) have not been reported to have neurotoxic manifestations. However, these manifestations have been demonstrated in some cases of envenomation by subspecies of V. berus, found in the Carpathian Basin region of south-eastern Europe. Here, we report the case of a 5-year-old girl from the south of Romania who presented symptoms of neurotoxicity, as well as other systemic and local symptoms, after being bitten by an adder of the V. berus subspecies. Treatment consisted of monovalent antivenom, a corticosteroid, and prophylactic enoxaparin. Neurotoxic manifestations of envenomation as well as other local and systemic symptoms improved within 5 days of treatment. The presented case shows that venom from V. berus subspecies found in the Carpathian Basin can have neurotoxic effects. This case also confirmed the efficacy of monospecific antivenom treatment in bringing about rapid and complete remission, following envenomation.
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