Efficacy and safety of two Antivenoms in the treatment of eastern copperhead (Agkistrodon contortrix) envenomations in Southeast Texas.

Background: There are two Food and Drug Administration-approved antivenoms for the treatment of North American pitviper envenomations: Crotalidae polyvalent immune fab (ovine) (CroFab, henceforth FabAV) and Crotalidae immune F(ab')2 (equine) (Anavip, henceforth Fab2AV). This study compared the effectiveness and safety of the two products in eastern copperhead envenomations. Methods: We retrospectively reviewed eastern copperhead bites on which our toxicology service consulted between January 1, 2021 and November 1, 2023. Collected data included patient demographics, bite location, clinical features, antivenom use, response to treatment, and adverse reactions to antivenom. Results: There were 134 patients with confirmed copperhead envenomations. We administered antivenom to 89 patients, of which 36 (40%) were female. The median age was 42 years old (range: 2-89 years). Fifty-nine patients received Fab2AV and 30 were treated with FabAV. Initial control was achieved in 30 (100%) patients treated with FabAV. In the Fab2AV group, 53 (89.8%) achieved control; six patients with acute adverse reactions declined further treatment despite persistent symptoms. The median FabAV dose required for initial control was six vials (range: 4-6). A median dose of 10 vials (range: 10-30) was used in the Fab2AV group. Repeat doses of Fab2AV were required in 15 (25.4%) cases. There were no acute adverse reactions to FabAV. Acute adverse reactions were seen in seven (11.9%) of patients treated with Fab2AV. Conclusion: Fewer patients treated with FabAV required repeat antivenom dosing to attain initial control following eastern copperhead envenomation. A higher percentage of patients treated with Fab2AV developed acute adverse reactions.

A review of bites by non-front-fanged snakes (NFFS) of Europe.

Non-front-fanged snakes (NFFS) have long been overlooked by snake venom research, likely due to most of them being considered non-medically relevant for humans. The paucity of information about composition and activities of NFFS venoms and oral secretions makes it difficult to assess whether a given species can inflict medically significant bites. Here, we provide a review of the information currently available about the symptoms/signs elicited by bites from European NFFS, aiming to offer a foundation for understanding the threat they pose in terms of snakebite. Despite an overall limited amount of available data for most of the considered taxa, the genus Malpolon is notable for its capacity to cause local and systemic envenoming, including neurotoxic symptoms. Bites by other genera like, Hemorrhois, Hierophis, Natrix, Platyceps, Telescopus, and Zamenis are mainly associated with local symptoms, but the extent of their medical significance remains unclear. Our findings suggest that, although bites from European NFFS generally cause only mild effects, the potential occurrence of systemic effects from some species cannot be ruled out. Considering the above, any bite by European NFFS should receive professional medical evaluation in order to ensure patient safety and appropriate management, as well as detailed documentation facilitating construction of an accurate medical risk profile for the species.

Deciphering toxico-proteomics of Asiatic medically significant venomous snake species: A systematic review and interactive data dashboard.

Snakebite envenomation (SBE) is a neglected tropical disease (NTD) with an approximate 1.8 million cases annually. The tremendous figure is concerning, and the currently available treatment for snakebite envenomation is antivenom. However, the current antivenom has limited cross-neutralisation activity due to the variations in snake venom composition across species and geographical locations. The proteomics of medically important venomous species is essential as they study the venom compositions within and among different species. The advancement of sophisticated proteomic approaches allows intensive investigation of snake venoms. Nevertheless, there is a need to consolidate the venom proteomics profiles and distribution analysis to examine their variability patterns. This review systematically analysed the proteomics and toxicity profiles of medically important venomous species from Asia across different geographical locations. An interactive dashboard - Asiatic Proteomics Interactive Datasets was curated to consolidate the distribution patterns of the venom compositions, serve as a comprehensive directory for large-scale comparative meta-analyses. The population proteomics demonstrate higher diversities in the predominant venom toxins. Besides, inter-regional differences were also observed in Bungarus sp., Naja sp., Calliophis sp., and Ophiophagus hannah venoms. The elapid venoms are predominated with three-finger toxins (3FTXs) and phospholipase A2 (PLA2). Intra-regional variation is only significantly observed in Naja naja venoms. Proteomics diversity is more prominent in viper venoms, with widespread dominance observed in snake venom metalloproteinase (SVMP) and snake venom serine protease (SVSP). Correlations exist between the proteomics profiles and the toxicity (LD50) of the medically important venomous species. Additionally, the predominant toxins, alongside their pathophysiological effects, were highlighted and discussed as well. The insights of interactive toxico-proteomics datasets provide comprehensive frameworks of venom dynamics and contribute to developing antivenoms for snakebite envenomation. This could reduce misdiagnosis of SBE and accelerate the researchers' data mining process.

Viber Snakebite Presenting with Cerebral Venous Thrombosis: A Very Rare Case Report from Somalia.

Cerebral sinus venous thrombosis (CSVT) is an uncommon and potentially life-threatening neurological disorder that is often missed because its clinical and radiological symptoms are not specific. Snake bites are a rare cause of cerebral venous sinus thrombosis that must be recognized and treated promptly to improve survival. Here, we present a case of a 30-year-old male patient who had cerebral venous thrombosis after snake bite in the rural area of southern Somalia. After close monitoring with anticoagulation, the condition of the patient improved and discharged from the hospital with full of consciousness. There are only a few cases reported in the literature of snake bites causing cerebral venous thrombosis.

The impact of the door-to-antivenom time on the resolution of coagulopathy caused by green pit viper bite-a retrospective cohort study.

Trimeresurus albolabris (green pit viper) accounts for 95% of human venomous snakebites in Hong Kong and the Green Pit Viper antivenin has become the only antivenom available. Little is known about the impact of early antivenom administration on the duration of venom-induced coagulopathy. This retrospective study aimed to evaluate the impact of the door-to-antivenom time (DTAT) on the duration of such coagulopathy. Consecutive patients with green pit viper bite reported to the Hong Kong Poison Control Centre between 1 January 2012 and 31 December 2022 were included. Electronic medical records were reviewed, and the time and dose of antivenom administration were examined. The level of coagulopathy before and after antivenom was graded using the modified Snakebite Severity Scale. The primary outcome was the duration of venom-induced coagulopathy. Univariate and multivariable generalized linear regression analyses were used to evaluate the association between DTAT and the duration of coagulopathy. In total, 82 adult cases (median age 56 years, 51.2% men) were analyzed. The median DTAT was 4.2 h. DTAT was correlated with the duration of coagulopathy (Spearman r 0.426, p < 0.001), which was correlated with the hospital length of stay (Spearman r 0.357, p = 0.001). However, DTAT was not correlated with the hospital length of stay (Spearman r 0.105, p = 0.346). After adjusting for confounding factors, DTAT (adjusted regression coefficient [ß] 1.73, 95% confidence interval [CI] 0.38 to 3.08, p = 0.012), pre-antivenom level of coagulopathy (adjusted ß 17.08, 95% CI 3.00 to 31.16, p = 0.017), platelet transfusion (adjusted ß 217.11, 95% CI 70.43 to 363.80, p = 0.004), and transfusion of fresh frozen plasma (adjusted ß -175.34, 95% CI 330.90 to -19.77, p = 0.027) were significantly associated with the duration of coagulopathy. These findings suggest that prompt administration of antivenom may shorten the duration of coagulopathy.

The Toxin Diversity, Cytotoxicity, and Enzymatic Activity of Cape Cobra (Naja nivea) Venom.

"True" cobras (genus Naja) are among the venomous snakes most frequently involved in snakebite accidents in Africa and Asia. The Cape cobra (Naja nivea) is one of the African cobras of highest medical importance, but much remains to be learned about its venom. Here, we used a shotgun proteomics approach to better understand the qualitative composition of N. nivea venom and tested its cytotoxicity and protease activity as well as its effect on intracellular Ca2+ release and NO synthesis. We identified 156 venom components representing 17 protein families, with the dominant ones being three-finger toxins, mostly of the short-chain type. Two-thirds of the three-finger toxin entries identified were assigned as cytotoxins, while the remainder were categorized as neurotoxins, including short-chain, long-chain, and ancestral three-finger toxins. We also identified snake venom metalloproteinases and members of CRISP, l-amino acid oxidase, and other families. Protease activity and its effect on intracellular Ca2+ release and NO synthesis were low. Phospholipase A2 activity was surprisingly high, despite this toxin family being marginally recovered in the analyzed venom. Cytotoxicity was relevant only at higher venom concentrations, with macrophage and neuroblastoma cell lines showing the lowest viability. These results are in line with the predominantly neurotoxic envenomation symptoms caused by Cape cobra bites. The present overview of the qualitatively complex and functionally intriguing venom of N. nivea may provide insights into the pathobiochemistry of this species' venom.

Frequency, Clinical Characteristics, and Management of Snakebite Patients Admitted at the Envenomation Treatment Center of the Applied Biology Research Institute of Guinea.

The aim of this study was to describe the frequency, clinical signs, management, and outcomes of snakebite patients admitted to the envenomation treatment center of the Institut de Recherche en Biologie Appliquée de Guinée (IRBAG). This was a retrospective review combining aggregated annual statistics (2011-2015) and routine data (from January to October 2021) from the IRBAG treatment center. There were 1345 (57.2%) snakebite victims out of a total of 2352 consultations at the center during the study period. Males (67.7%), persons aged ≥45 years (29%) and ≤14 years (27.7%), farmers/housewives (44.5%), workers (23.9%), and those residing in the Kindia Prefecture (53.5%) were the most commonly affected. The majority of victims (84.5%) were admitted three hours after snakebite, with bites mainly occurring in rural areas (86.5%) and during the rainy season (83.2%). Pain (100%), edema (76.8%), and bleeding (65.2%) were the most common clinical presentations. Almost all victims received antivenom serum (98%), antibiotics (87.7%), and analgesics or anti-inflammatory drugs (88.4%). Six out of the one hundred and fifty-five patients died. Snakebites are a frequent public health problem in rural Guinea. The majority of victims seek medical attention too late. There is an urgent need to include snakebite in the country's list of priority NTDs in order to promote access to antivenom serum.

Single-Batch Expression of an Experimental Recombinant Snakebite Antivenom Based on an Oligoclonal Mixture of Human Monoclonal Antibodies.

Oligoclonal antibodies, which are carefully defined mixtures of monoclonal antibodies, are valuable for the treatment of complex diseases, such as infectionss and cancer. In addition to these areas of medicine, they could be utilized for the treatment of snakebite envenoming, where recombinantly produced monoclonal human antibodies could overcome many of the drawbacks accompanying traditional antivenoms. However, producing multiple individual batches of monoclonal antibodies in an industrial setting is associated with significant costs. Therefore, it is attractive to produce oligoclonal antibodies by mixing multiple antibody-producing cell lines in a single batch to have only one upstream and downstream process. In this study, we selected four antibodies that target different toxins found in the venoms of various elapid snake species, such as mambas and cobras, and generated stable antibody-producing cell lines. Upon co-cultivation, we found the cell line ratios to be stable over 7 days. The purified oligoclonal antibody cocktail contained the anticipated antibody concentrations and bound to the target toxins as expected. These results thus provide a proof of concept for the strategy of mixing multiple cell lines in a single batch to manufacture tailored antivenoms recombinantly, which could be utilized for the treatment of snakebite envenoming and in other fields where oligoclonal antibody mixtures could find utility.

Supplementation of polyclonal antibodies, developed against epitope-string toxin-specific peptide immunogens, to commercial polyvalent antivenom, shows improved neutralization of Indian Big Four and Naja kaouthia snake venoms.

Snakebites profoundly impact the rural population of tropical nations, leading to significant socio-economic repercussions. Polyvalent antivenom (PAV) therapy faces several limitations, including intra-specific variations and poor efficacy against some major toxins and low molecular mass, poorly immunogenic toxins, which contribute to increased mortality and morbidity rates. Innovative strategies for developing novel antivenoms are continuously explored to address these challenges. The present study focuses on designing of 17 epitope-string toxin-specific peptide immunogens from pharmacologically active major and/or poorly immunogenic toxins (snake venom metalloprotease, Kunitz-type serine protease inhibitor, phospholipase A2, three-finger toxin) from the venom of the 'Big Four' venomous snakes and Naja kaouthia (NK) in India. These custom peptide antibodies demonstrated robust immuno-reactivity against the venoms 'Big Four' and NK. When these antibodies were supplemented with commercial PAV at a defined ratio (formulated polyvalent antivenom or FPAV), it significantly enhanced the neutralization of snake venom enzymes and in vivo neutralization of lethality and pharmacological activities such as haemorrhage, necrosis, pro-coagulant, defibrinogenation, and myotoxicity of 'Big Four' and NK venoms compared to PAV in mice. The present study highlights a promising strategy for developing next-generation antivenoms using synthetic peptide-based immunogens, offering a targeted approach to address the limitations of current antivenom therapy.

Treatment response and clinical features of snakebite envenomation in Alborz province, Iran: A cross-sectional study.

Background: Snakebite envenomation is a significant yet neglected public health burden. Our aim was to investigate the clinical and demographic factors of snakebite envenomation, as well as the factors associated with its severity and response to treatment, in Alborz province, northern Iran. Methods: In this cross-sectional study, we included 50 patients diagnosed with snakebite envenomation, referring to the Poison Control Centre of Alborz University of Medical Sciences. The presenting signs and symptoms, demographic data, treatment dose, response to treatment, complications, laboratory findings, and snakebite severity scale (SSS) were collected. Results: Forty-six patients (92%) were men, the total mean age was 31.7 ± 12.06 years, and mean SSS was 6.54 ± 3.39. The patients were admitted for a median of 2 days, and 11 patients needed ICU admissions. The majority of snakebites were in upper extremities (60%) and they mainly occurred in summer (56%). SSS was significantly associated with response to treatment, ICU admission, gastrointestinal adverse events, thrombocytopenia, and length of stay. Similarly, response to treatment was significantly related to the history of snakebite, ICU admission, gastrointestinal adverse events, thrombocytopenia, length of stay, and SSS. Conclusion: Gastrointestinal symptoms, higher severity scores, and longer hospital stays were associated with poor treatment response. Importantly, no mortality was observed in this cohort. Further research is needed to confirm these findings and optimize treatment strategies for snakebite management.

Characterization of patients with a snakebite presenting to healthcare facilities and reported to poison and drug information centers-Arizona, 2017-2021.

INTRODUCTION: Envenomation after a North American rattlesnake (Crotalus spp. and Sistrusus spp.) bite is associated with substantial morbidity. Arizona reports the highest number of rattlesnake envenomations annually in the United States. We evaluated the performance of poison and drug information centers for snakebite surveillance, compared with the hospital and emergency department discharge database. We used both datasets to improve the characterization of epidemiology, healthcare costs, and clinical effects of snakebite envenomations in Arizona. METHODS: We identified patients with a snakebite during 2017-2021 using Arizona hospital and emergency department discharge data and snakebite consults with two regional Arizona poison centers. Patients were matched using name and birthdate. The performance of poison center data for snakebite surveillance was evaluated using the percentage of snakebite patients in hospital and emergency department discharge data that consulted with poison centers. Patient demographics, healthcare characteristics, clinical effects, and context of snakebite events were described using both datasets. RESULTS: In total, 1,288 patients with a snakebite were identified using the Arizona hospital and emergency department discharge data, which resulted in 953 (74%) consultations with poison centers. The median age of patients was 48 years (IQR 28-62 years), and they were predominantly male (66%), White (90%), and non-Hispanic (84%). The median billed charges were US$ 84,880 (IQR US$ 13,286-US$ 168,043); the median duration of a healthcare stay was 34 h (IQR 13-48 h), and 29% of patients were transferred between healthcare facilities. Among 953 consulted poison center calls for a snakebite, a median of 14 vials of antivenom was administered per patient; 375 (60%) bites occurred near the home, and 345 (43%) patients were bitten on a lower extremity. One death was identified. DISCUSSION: Snakebites in Arizona can cause severe morbidity and require extensive healthcare resources for treatment. Poison centers are valuable for monitoring venomous snakebites in Arizona. CONCLUSIONS: Using hospital and emergency department discharge data with poison center records can improve public health surveillance data regarding snakebite epidemiology and human-snake interaction information and be used to tailor interventions to increase awareness of snake encounters and prevent snakebites.

The bridge relationships of PTSD and depression symptoms among snakebite victims: a cross-sectional community-based survey.

BACKGROUND: The incidence of comorbid depression and post-traumatic stress disorder (PTSD) symptoms is higher in snakebite victims. However, the present state and contributing factors of depression and PTSD among Chinese snakebite victims remain unclear. METHODS: A representative sample of 6837 snakebite victims were assessed with the Post-traumatic Stress Disorder Checklist (Civilian Version) and The Center for Epidemiologic Studies Depression Scale. Multivariate analyses, including network analysis, evaluated the contributing factors of PTSD and depression symptoms caused by snake bites, as well as the bridge symptoms of comorbidity networks. RESULTS: Among 6,837 snakebite victims, 79.5% reported PTSD symptoms and 81.4% reported depression symptoms. Comorbidity of PTSD and depression symptoms was found in 75.1%. Key factors included the presence sequelae after snakebite (ORPTSD = 2.31, ORDepression = 1.89), time to medical facilities (6-8 h: ORPTSD = 3.17, ORDepression = 2.46), and marital status (divorced/widowed: ORPTSD = 1.78, ORDepression = 1.76). Symptoms I1 ("Repeated disturbing memories") and D1 ("Bothered by things that don't usually bother me") bridged PTSD and depression networks. CONCLUSION: The primary psychological challenges for snakebite victims in China are PTSD and depression symptoms, which is concerning. Standardized diagnosis and treatments, timely medical care, and stable marital relationships can reduce risks. Additional psychological support and management of negative memories, especially for those with severe bridge symptoms, can be beneficial. Further research should concentrate on understanding victims' psychological states and developing effective interventions.

Understanding pediatric snakebites: Clinical and epidemiological insights from a healthcare center in Bihar, India.

Background: Snakebites are a common medical emergency and occupational hazard for children in India, particularly in rural areas where poverty is prevalent. However, there is limited data on the epidemiology of snakebites on the Indian subcontinent. Objective: This cross-sectional, observational study aims to investigate the epidemiology, major clinical manifestations, and outcomes of snakebites in children under the age of 15 who were admitted to a tertiary care center in Bihar, a state in East India, and draw attention to this public health concern. Methods: A cross-sectional observational study was conducted at the Department of Paediatrics, Patna Medical College and Hospital, Patna. The study included all cases of snakebites with features of envenomation involving patients less than 15 years of age who were brought to the department over a 2-year period. Data were collected using a data collection form and analyzed using the Statistical Package for the Social Sciences, version 11.0 (SPSS Inc., Chicago, IL, USA). Results: A total of 59 cases were recorded, with 62.71% (n = 37) being male and 37.28% (n = 22) being female. Kraits were responsible for 38.9% (n = 23) of cases, vipers for 42.3% (n = 25), and cobras for 5% (n = 3). Fang marks were present in 67.7% (n = 40) of cases, and the majority of bites (84.7%, n = 50) occurred on a lower limb during the day. The age distribution showed that 16.9% (n = 10) were below 5 years old, 44% (n = 26) were between 5 and 10 years old, and 22% (n = 13) were above 10 years old. Traditional treatment was used in 44.7% (n = 22) of cases, with the most common treatments being local incision + tourniquet (22%, n = 13) and no traditional treatment (55.9%, n = 33). The highest number of cases occurred during July-September (35.5%, n = 21). Conclusion: Snakebites are a significant public health issue in Bihar, India, with the majority of cases occurring in rural areas. The study highlights the importance of increased awareness and preparedness among healthcare providers and the general public, particularly during the monsoon season. Early hospital transfer, prehospital management, and prevention should be promoted through regular public health initiatives.

Strikes and stripes of the Saw-scaled Viper in the Western Ghats-A case series.

We describe 5 cases of envenomation and complications related to saw scaled viper (Echis carinatus) bites from the Western Ghats region of Karnataka over a period of 5 years (December 2019-May 2023). Although the smallest member of the Big Four, Saw Scaled viper envenomation is associated with significant morbidity. In our region, envenomation appears to be rare. The careful review of all these cases has suggested VICC with one patient having persistent coagulopathy despite adequate ASV administration, and three patients developing anaphylaxis. It needs to be brought to notice that the complications due to envenoming run high, despite timely administration of ASV. Through these cases, we want to contribute evidence suggesting variable efficacy of Indian polyvalent ASV for Echis carinatus bites and the need for updating protocols for the same.

The Chinese guideline for management of snakebites.

In 2009, the World Health Organization included snakebite on the list of neglected tropical diseases, acknowledging it as a common occupational hazard for farmers, plantation workers, and others, causing tens of thousands of deaths and chronic physical disabilities every year. This guideline aims to provide practical information to help clinical professionals evaluate and treat snakebite victims. These recommendations are based on clinical experience and clinical research evidence. This guideline focuses on the following topics: snake venom, clinical manifestations, auxiliary examination, diagnosis, treatments, and prevention.

Design, development and preclinical assessment of MENAVip-ICP, a new snake antivenom with potential coverage of species in the Middle East and North Africa regions.

Snakebite in the Middle East and North Africa (MENA) is a public health problem whose magnitude is not fully known. Several antivenoms are available in these regions, but these formulations are designed for restricted geographical settings. Many countries do not have local production of antivenoms and must access products whose clinical performance has not been demonstrated. We hypothesize that it is possible to unify the treatment for viperid snakebites of MENA in a single antivenom formulation. Hereby we describe the design, development and preclinical evaluation of an antivenom of broad geographical coverage for this region (MENAVip-ICP). We produced this antivenom from the plasma of horses immunized with eight medically important venoms of viperid snake species from MENA. For this, we used a strategy based on two stages: first, immunization of horses with North African (NA) venoms, followed by a second immunization stage, on the same horses, with MENA venoms. We purified antivenoms from both stages: the Anti-NA and the final product Anti-MENA (MENAVip-ICP). Anti-NA was considered as intermediate formulation and was purified with the intention to study the progression of the immunoglobulin immune response of the horses. Antivenoms from both stages neutralized lethal, hemorrhagic, and procoagulant activities of homologous venoms. Compared to Anti-NA, MENAVip-ICP improved the neutralization profile of intravenous lethality and in vitro procoagulant activities of venoms. A notable finding was the difference in the neutralization of lethality when MENAVip-ICP was assessed intraperitoneally versus intravenously in the murine model. Intraperitoneally, MENAVip-ICP appears more effective in neutralizing the lethality of all venoms. Furthermore, MENAVip-ICP neutralized the lethal activity of venoms of species from other regions of MENA, Central/East Asia, and Sub-Saharan Africa that were not included in the immunization protocol. Our results showed that MENAVip-ICP neutralizes the main toxic activities induced by viperid MENA venoms at the preclinical level. Consequently, it is a promising product that could be clinically assessed for the treatment of snakebite envenomings in this region.

Bites and Stings: Exotic Causes of Stroke in Asia.

BACKGROUND: Many unusual and fascinating causes of stroke are seen in Asia. Although rarely encountered in the Western world, such cases are seen not so infrequently by neurologists, physicians, and other healthcare workers in Asian countries. This article highlights some of these intriguing causes of stroke such as snakebite, scorpion stings, and bee and wasp stings. SUMMARY: Snakebite is a neglected tropical disease of global importance affecting over 5 million people each year, and scorpion stings and bee and wasp stings affect over a million people worldwide every year. Strokes due to these uncommon causes predominantly affect young males in their most productive years, and many victims die or remain with residual disability with significant socioeconomic consequences to the affected families and society. Both ischaemic and haemorrhagic strokes are seen, with ischaemic strokes being more common. Many unanswered questions remain regarding the pathophysiological mechanisms, clinical spectrum, and the natural history of stroke due to these causes. Antivenom is effective in snake envenoming, antivenom and prazosin are effective in scorpion envenoming, and treatment of anaphylaxis and allergy is recommended in systemic reactions due to bee or wasp stings. However, there are no treatment guidelines or expert recommendations to guide the management of stroke in these patients, and there are no data on the safety and efficacy of stroke-specific treatments such as antiplatelet therapy, thrombolysis or endovascular treatment. KEY MESSAGES: More research is clearly needed to unravel the complexities related to stroke following snakebite, scorpion envenoming, and bee and wasp stings, and to guide the development of optimal stroke treatment strategies in these unusual situations. Awareness of these exotic stroke aetiologies is important in early recognition and appropriate management of patients presenting with stroke symptoms in Asian countries, and in global travellers from the region. International collaborations would go a long way in improving our understanding of these rare but fascinating causes of stroke.

Predicting the drivers of Bothrops snakebite incidence across Brazil: A Spatial Analysis.

Snakebite envenoming poses a significant public health challenge on a global basis, affecting millions of people annually and leading to complications that may result in fatalities. Brazil stands as one of the countries most impacted by snakebite envenoming, with snakes of the Bothrops genus being responsible for most bites. The current study aimed to identify the determinants of Bothrops snakebite incidence across different regions of Brazil. An ecological study was conducted using municipality-aggregated data, with snakebite incidence as the dependent variable. The study period comprised the years 2015-2021. We constructed Species Distribution Models (SDMs) for Bothrops species, and information was collected on precipitation, runoff, maximum and minimum temperatures, native forest, historical forest loss, agriculture, and pasture in each Brazilian municipality. These data were employed to assess the association between snakebite incidence and biotic, climatic, and landscape factors. The data were analyzed using Generalized Least Squares (GLS) regression. The SDMs demonstrated good performance. The average annual snakebite incidence during the study period ranged from zero to 428.89 per 100,000 inhabitants, depending on the municipality. Higher incidence rates were concentrated primarily in municipalities in the northern region of the country. In this study, we found that nationwide, areas with extensive native forests and those that have historically experienced significant loss of forest cover exhibited higher snakebite incidence rates. Additionally, areas with higher temperatures and precipitation levels, as well as greater climatic suitability for the species B. jararaca, showed significantly higher snakebite incidence rates in the South and Southeast of Brazil, respectively. These associations may be linked to increased snake abundance and active behavior, as well as to engagement in activities favoring human-snake contact in these areas. The findings of this study can contribute to the improvement of prevention and control strategies for this public health issue in Brazil.

Multiple ventricular premature complexes following equatorial spitting cobra (Naja sumatrana) envenomation.

Naja species bite is the commonest cause for consultation to Remote Envenomation Consultancy Services in Malaysia. Envenomation by Naja species may result in neuroparalysis and cardiotoxic effects including arrhythmias, hypertension, tachycardia, atrioventricular blocks, ventricular tachycardia, and ventricular fibrillation. We report a case of cardiotoxicity as an early manifestation following an equatorial spitting cobra, Naja sumatrana bite, preceding early paralytic envenomation manifestation. A 14-year-old boy presented to an emergency department with mild local envenomation. ECG showed multiple ventricular premature complexes. Subsequently patient developed ptosis. Complete resolution of ptosis and resumption of normal sinus rhythm occurred following administration of the appropriate antivenom. The patient was discharged well after two days of hospitalization. The patient's ECG findings and neurotoxic manifestation suggested acute systemic envenomation. High index of suspicion for cardiotoxicity with close serial monitoring is recommended to ensure timely administration of antivenom.