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The genus Latrodectus (Araneae: Theridiidae) consists of 35 widow spider species with global distribution. Envenoming by medically important species, latrodectism, commonly features bite site erythema and diaphoresis, variably severe pain that may be persistent, myalgia/cramping and/or myoclonus, autonomic symptoms, abdominal distress; severe envenoming can be prolonged and include serious effects such as oliguria, hypertension and, rarely, myocarditis/myocardial injury. Red-back spiders (Latrodectus hasselti) are the most common cause of envenoming in Australia and can cause the spectrum of effects noted for other medically important widow spiders. A 34-yr-old woman with a history of previous L. hasselti envenoming and treatment with antivenom was envenomed in her left ankle by a verified L. hasselti (hiding in her boot) while attending an appointment with her primary care physician. She reported some of the common effects of latrodectism including severe, prolonged pain, bite site diaphoresis, and malaise; however, she also developed marked edema that involved the entire left foot. She also exhibited mild hypertension and autonomic/non-specific effects limited to nausea, headache, and anxiety. She was effectively treated with red-back spider antivenom (a total of 4 ampoules) and supportive care; full resolution of the edema required almost 5 days. The uncommon clinical evolution of L. hasselti local envenoming observed in this patient may have been caused by a mixed picture of venom-induced effects and Type I hypersensitivity, but alternatively could be a rare, solely venom-induced manifestation. While provision of patient-centred care for anyone envenomed by Latrodectus spp. requires careful history collection and assessment of comorbidities, differentiation of atopic and direct venom effects may be challenging in some envenomed patients with established complex allergy history.
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For more than a century, concerns about the medical significance of Montpellier snakes, Malpolon spp. (Psammophiidae) have been expressed by herpetologists and toxinologists. Although some of the opinions have suggested that the most familiar species, the Western Montpellier snake, Malpolon monspessulanus, poses a significant medical risk, only a few detailed, formally documented reports have been published that describe effects in humans. Two reports support a rare risk of systemic envenoming (cranial nerve palsies) after prolonged bites by M. monspessulanus. Relevantly, there has been only one previous report describing a bite by the Eastern Montpellier snake, Malpolon insignitus. Reported here are the effects of a bite inflicted by a 1.1-m female Malpolon insignitus fuscus in Alborz Province, Iran. The 40-yr-old male victim was handling the snake while preparing to photograph it when he was bitten on the right wrist. The snake remained attached for approximately 40-s during which it repeatedly advanced its jaws. The bite caused moderate local envenoming that featured moderate but reportedly notably uncomfortable sharp pain, moderate edema, erythema and pruritis; wound site bleeding was transient and proportional. Full resolution required 5-days; there were no sequelae. The clinical evolution included signs/symptoms consistent with Type I hypersensitivity and subtype Type IV hypersensitivity. Detailed reports of medically significant bites by Malpolon spp. are briefly reviewed and the evidence for medical significance of the genus is evaluated. Management of envenoming by Malpolon spp. is supportive only; almost all victims with qualified medical review have developed only local envenoming that is often mild-moderate. Notably rare systemic effects, e.g., neurotoxicity so far limited to non-progressive cranial nerve palsies, should prompt airway protection, ICU admission, and consultation as indicated. Future study of Malpolon venoms and formal documentation of their bites should increase the evidence quality for the medical risk profile of the genus.
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Mordeduras de Serpentes , Adulto , Animais , Humanos , Masculino , Antivenenos/uso terapêutico , Irã (Geográfico)/epidemiologiaRESUMO
We describe species richness patterns of venomous snakes in Iran in order to produce snakebite risk prediction maps and identify gaps in regional health care centers capable of managing snakebites. We digitized distribution maps from the literature, Global Biodiversity Information Facility (GBIF), and the results of our own field studies of 24 terrestrial venomous snake species (including 4 endemic to Iran). Species richness patterns were associated with eight environmental factors. The variables have been extracted from the WorldClim dataset (bio12 = annual precipitation, bio15 = precipitation seasonality, bio17 = precipitation of the driest quarter, bio2 = mean diurnal range, bio3 = isothermality (bio2/bio7), bio4 = temperature seasonality, bio9 = mean temperature of the driest quarter and slope). Based on spatial analyses, species richness in Iran is highly affected by three environmental variables (bio12, 15, and 17) associated with precipitation. The relationship patterns among these predictors and species richness were strong and linear. The hotspot regions for venomous snakes species are concentrated on the western to southwestern and north to northeastern regions of Iran, which is partially consistent with the known Irano-Anatolian biodiversity hotspot. Because of the high number of endemic species and climatic conditions on the Iranian Plateau, the venoms of snakes distributed in those areas may contain novel properties and components.
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Mordeduras de Serpentes , Animais , Mordeduras de Serpentes/epidemiologia , Irã (Geográfico)/epidemiologia , Serpentes , Biodiversidade , TemperaturaRESUMO
In Iran, there are approximately 4500-6500 snakebites per year, but fortunately only 3-9 of these are fatal. However, in some population centers such as Kashan city (Isfahan Province, central Iran), approximately 80% of snakebites are attributed to "non-venomous" snakes that are often comprised of several species of non-front-fanged snakes (NFFS). NFFS comprise a diverse group that constitute approximately 2900 species belonging to an estimated 15 families. We report here two cases of local envenoming from H. ravergieri, and one from H. nummifer that occurred in Iran. The clinical effects consisted of local erythema, mild pain, transient bleeding and edema. Two victims experienced progressive local edema that distressed the victims. The medical team's unfamiliarity with snakebites contributed to the incorrect clinical management of one victim including the contraindicated, ineffective provision of antivenom. These cases provide further documentation about local envenoming caused by these species, and also emphasize the need for regional medical personnel to receive increased training in order to improve familiarity with the local snake fauna and evidence-based snakebite management.
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Colubridae , Mordeduras de Serpentes , Animais , Mordeduras de Serpentes/tratamento farmacológico , Mordeduras de Serpentes/epidemiologia , Irã (Geográfico) , Antivenenos/uso terapêutico , EdemaRESUMO
The mixed quality evidence about non-front-fanged snake bites has included unsupported speculation and presumption; the possible role of atopy and/or primary hypersensitivity have often been prematurely discounted. Described is a medically insignificant bite by a captive African emerald snake, Hapsidophrys smaragdinus Schlegel, 1837 (Colubridae, Colubrinae) that caused the development of moderate Type IV hypersensitivity; the 44-year-old male victim experienced persistent pruritis and an erythematous bite site maculopapular dermatitis that slowly resolved and required 6 days for full resolution. The victim had received several previous medically insignificant bites from non-front-fanged snakes. Brief comparison is made with a previously reported case consistent with a mixed clinical picture of local mild envenoming and hypersensitivity from a bite by another colubrine, the coin snake (Hemmorhois nummifer). This case highlights slowly accumulating evidence supporting the risk of acquired and primary hypersensitivity to some snakebites in susceptible individuals. In order to provide accurate medical risk profiles for less-known snake species it is essential that the case of any patient developing acute or delayed effects from bites by these species is formally documented. The need for further attention to atopic risks, especially in private collectors, is emphasised with consideration of venom/other ophidian product-induced anaphylaxis.
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Colubridae , Dermatite Atópica , Mordeduras de Serpentes , Adulto , Animais , Documentação , Humanos , Masculino , Mordeduras de Serpentes/veterinária , Venenos de SerpentesRESUMO
INTRODUCTION: The first meeting of the Integration of Continuous Glucose Monitor Data into the Electronic Health Record (iCoDE) project, organized by Diabetes Technology Society, took place virtually on January 27, 2022. METHODS: Clinicians, government officials, data aggregators, attorneys, and standards experts spoke in panels and breakout groups. Three themes were covered: 1) why digital health data integration into the electronic health record (EHR) is needed, 2) what integrated continuously monitored glucose data will look like, and 3) how this process can be achieved in a way that will satisfy clinicians, healthcare organizations, and regulatory experts. RESULTS: The meeting themes were addressed within eight sessions: 1) What Do Inpatient Clinicians Want to See With Integration of CGM Data into the EHR?, 2) What Do Outpatient Clinicians Want to See With Integration of CGM Data into the EHR?, 3) Why Are Data Standards and Guidances Useful?, 4) What Value Can Data Integration Services Add?, 5) What Are Examples of Successful Integration?, 6) Which Privacy, Security, and Regulatory Issues Must Be Addressed to Integrate CGM Data into the EHR?, 7) Breakout Group Discussions, and 8) Presentation of Breakout Group Ideas. CONCLUSIONS: Creation of data standards and workflow guidance are necessary components of the Integration of Continuous Glucose Monitor Data into the Electronic Health Record (iCoDE) standard project. This meeting, which launched iCoDE, will be followed by a set of working group meetings intended to create the needed standard.
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Diabetes Mellitus , Registros Eletrônicos de Saúde , Glicemia , Diabetes Mellitus/terapia , Humanos , Fluxo de TrabalhoRESUMO
Snakebite is an important problem in Myanmar. Regionally, bites by Eastern Russell's vipers, Daboia siamensis (Viperidae, Viperinae), and monocled cobras, Naja kaouthia are considered medically important, but those categorised as "green snake" bites are not. However, these may include bites by green pit vipers, Trimeresurus spp. (Viperidae, Crotalinae) for which no antivenom is available in Myanmar. Elsewhere in Southeast Asia, these snakes are reported to cause local and systemic envenoming. As part of the Myanmar Snakebite Project, prospective case data were collected over 3 years from five hospitals in the Mandalay region. These included 3803 snakebite cases reported from Mandalay region. Of these, 355 were listed as bites by a witnessed green-coloured snake. In 22 cases, the snakes responsible were retained and preserved, then expertly identified; 21 were medically important white-lipped pit vipers (Trimeresurus albolabris), and one as an Asian vine snake, Ahaetulla prasina (Colubridae, Ahaetuliinae) which is not of medical importance. Among confirmed Trimeresurus albolabris bites, 15/21 developed swelling of the bitten limb, and 3/21 coagulopathy, defined as a positive 20-min whole blood clotting test (20WBCT). None developed necrosis, blistering, thrombocytopenia or acute kidney injury (AKI). Of the remaining 333 patients bitten by green snakes that were not specifically identified, 241 (72%) developed swelling of the bitten limb, and 62 (19%) coagulopathy. AKI occurred in 21/333 patients, but only one required dialysis. At least 10/21 of the cases with AKI in this study were more likely to represent bites from Trimeresurus spp. than D. siamensis because the snake responsible was brought into the hospital, examined and described by the treating physician as "green-coloured". This study describes a previously unpublished case of AKI from envenoming by T. erythrurus in Yangon, and reviews cases of AKI following bites by this species and T. albolabris in Myanmar. This confirms that, at least on rare occasions, Trimeresurus spp. envenoming can cause AKI. This has important implications for snakebite management in Myanmar as the finding of local swelling, coagulopathy and AKI is generally considered pathognomonic of D. siamensis envenoming. Further collection of confirmed Trimeresurus spp. bites is required in Myanmar in order better to define the syndrome of envenoming and to assess the possible need for antivenom against Trimeresurus spp. in this country.
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Colubridae , Crotalinae , Mordeduras de Serpentes , Trimeresurus , Animais , Humanos , Mianmar , Mordeduras de Serpentes/tratamento farmacológico , Mordeduras de Serpentes/epidemiologiaRESUMO
The first reported snakebite by an African snake-eater, Polemon spp. (Atractaspididae, Aparallactinae); Local envenoming by Reinhardt's snake-eater, Polemon acanthias (Reinhardt, 1860). Toxicon XX, xxx. A 51-yr-old male herpetologist was bitten on the left index finger by a captive male Polemon acanthias while manually removing fragments of incompletely shed skin from the specimen. The snake sustained its bite for approximately 2 mins, advancing its jaws several times. The victim rapidly developed moderate pain, erythema, progressive edema that ultimately extended to the left wrist; a blister later developed in the wound site, as well as joint stiffness in the bitten and adjacent two fingers that limited flexion and extension. These effects regressed during the week following the bite, but recurred thereafter and were similar to the effects that developed immediately post-envenoming. There were no systemic signs or symptoms. The victim sought medical advice and was treated with broad-spectrum antibiotics, antihistamines and wound care; no laboratory investigations were conducted. He improved during the subsequent month with complete resolution in 5 and one-half weeks. This is the first documented bite by a Polemon spp. and the victim's clinical course suggests the development of local effects from venom components. The phylogenetic relationship of Polemon spp. with the burrowing asps (Atractaspis spp.) and the similarity of some of the features of this local envenoming by P. acanthias with mild/moderate envenoming by some Atractaspis spp., suggests that none of these snakes should be handled; they should be considered capable of inflicting potentially serious envenoming.
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Mordeduras de Serpentes , Animais , Antivenenos/uso terapêutico , Venenos Elapídicos , Elapidae , Masculino , Filogenia , Mordeduras de Serpentes/tratamento farmacológicoRESUMO
Two cases of bites by a South African psammophiid snake, Psammophylax rhombeatus, are described and analyzed. These are the first detailed reports of local envenoming by a Psammophylax spp. While handling a wild-collected 1 m P. rhombeatus, the snake inflicted a protracted bite proximal to the metacarpophalangeal joint of digit #5, left hand of a 24-year-old male amateur herpetologist. Local edema persisted for three days, but no pain or other signs or symptoms including non-specific autonomic effects (e.g. headache, nausea) occurred. In a second case, a 28-year-old male herpetologist-photographer was repositioning a 0.58 m female P. rhombeatus in order to photograph the snake and her egg clutch, when the snake bit the metacarpophalangeal joint of digit #5, left hand, and briefly advanced its jaws. The bite caused mild local pain, progressive edema of the left hand, and arthralgia; resolution required almost 1 week. Bites from non-front-fanged snakes such as these by P. rhombeatus are uncommonly reported in comparison with those described for front-fanged snakes (e.g. Viperidae, Elapidae). Therefore, documentation of bites even with minimal effects provides information essential for the construction of an accurate medical risk profile for these less-known species.
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Colubridae , Mordeduras de Serpentes , Adulto , Animais , Antivenenos , Edema/induzido quimicamente , Elapidae , Feminino , Humanos , Masculino , Dor , Mordeduras de Serpentes/tratamento farmacológico , Adulto JovemRESUMO
A recent case of a bite by a psammophiid snake, Psammophis schokari, is described and analyzed. This is the first report of local envenoming by this species. The 1 m long P. schokari inflicted a protracted bite on the third digit, right hand of the male 59 year-old victim who developed mild, but locally progressive edema and persistent pain; full resolution required almost three months. All documented cases of bites by snakes of the genus Psammophis are briefly reviewed and discussed. Finally, we encourage the use of a standardized method to describe the observed symptoms of bites by non-front-fanged colubroid snakes (NFFCs). Such bites are rare compared to those described for front-fanged snakes (e.g. Viperidae, Elapidae). Published data are still often comprised of anecdote or second-hand information. Whenever possible, formal medical evaluation of victims bitten by NFFCs should be performed in order to establish a medical risk and management profile for each species.
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Mordeduras de Serpentes , Serpentes , Animais , Edema , Humanos , Masculino , Pessoa de Meia-Idade , DorRESUMO
Mushroom poisoning is a significant and increasing form of toxin-induced-disease. Existing classifications of mushroom poisoning do not include more recently described new syndromes of mushroom poisoning and this can impede the diagnostic process. We reviewed the literature on mushroom poisoning, concentrating on the period since the current major classification published in 1994, to identify all new syndromes of poisoning and organise them into a new integrated classification, supported by a new diagnostic algorithm. New syndromes were eligible for inclusion if there was sufficient detail about both causation and clinical descriptions. Criteria included: identity of mushrooms, clinical profile, epidemiology, and the distinctive features of poisoning in comparison with previously documented syndromes. We propose 6 major groups based on key clinical features relevant in distinguishing between poisoning syndromes. Some clinical features, notably gastrointestinal symptoms, are common to many mushroom poisoning syndromes. Group 1 - Cytotoxic mushroom poisoning. Syndromes with specific major internal organ pathology: (Subgroup 1.1; Primary hepatotoxicity); 1A, primary hepatotoxicity (amatoxins); (Subgroup 1.2; Primary nephrotoxicity); 1B, early primary nephrotoxicity (amino hexadienoic acid; AHDA); 1C, delayed primary nephrotoxicity (orellanines). Group 2 - Neurotoxic mushroom poisoning. Syndromes with primary neurotoxicity: 2A, hallucinogenic mushrooms (psilocybins and related toxins); 2B, autonomic-toxicity mushrooms (muscarines); 2C, CNS-toxicity mushrooms (ibotenic acid/muscimol); 2D, morel neurologic syndrome (Morchella spp.). Group 3 - Myotoxic mushroom poisoning. Syndromes with rhabdomyolysis as the primary feature: 3A, rapid onset (Russula spp.); 3B, delayed onset (Tricholoma spp.). Group 4 - Metabolic, endocrine and related toxicity mushroom poisoning. Syndromes with a variety of clinical presentations affecting metabolic and/or endocrine processes: 4A, GABA-blocking mushroom poisoning (gyromitrins); 4B, disulfiram-like (coprines); 4C, polyporic mushroom poisoning (polyporic acid); 4D, trichothecene mushroom poisoning (Podostroma spp.); 4E, hypoglycaemic mushroom poisoning (Trogia venenata); 4F, hyperprocalcitoninemia mushroom poisoning (Boletus satanas); 4G, pancytopenic mushroom poisoning (Ganoderma neojaponicum). Group 5 - Gastrointestinal irritant mushroom poisoning. This group includes a wide variety of mushrooms that cause gastrointestinal effects without causing other clinically significant effects. Group 6 - Miscellaneous adverse reactions to mushrooms. Syndromes which do not fit within the previous 5 groups: 6A, Shiitake mushroom dermatitis; 6B, erythromelagic mushrooms (Clitocybe acromelagia); 6C, Paxillus syndrome (Paxillus involutus); 6D, encephalopathy syndrome (Pleurocybella porrigens).
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Agaricales/classificação , Intoxicação Alimentar por Cogumelos/classificação , Intoxicação Alimentar por Cogumelos/diagnóstico , Agaricales/química , Algoritmos , Humanos , Intoxicação Alimentar por Cogumelos/terapiaRESUMO
The red-bellied black snake (Pseudechis porphyriacus, Elapidae) is one of several species of venomous snakes most commonly implicated in human and domestic animal envenoming in Australia. Human systemic envenoming can present with myotoxicity that may include myoglobinuria; hemoglobinuria and intravascular hemolysis; thrombocytopenia, anticoagulant coagulopathy, and, rarely, mild cranial nerve palsies. Pseudechis porphyriacus envenoming can also feature significant local morbidity such as ecchymoses, bleeding, pain and necrosis. Some envenomed patients may develop progressive thickness necrosis independent of secondary infection, and occasionally require surgical debridement. Uncommonly, some digital envenoming may cause more severe deeper tissue pathology that justifies dermotomy and/or distal phalangeal amputation. Presented are two patients with significant local morbidity from P. porphyriacus envenoming. An 18-month old girl received a protracted envenoming on her right foot, while a 38-year old male professional zoologist was envenomed on the third digit of his right hand. Each patient experienced myotoxicity, one had anticoagulant coagulopathy, and both developed clinically significant local morbidity including persistent bleeding, ecchymoses, local necrosis and pain; each required extensive treatment and variably prolonged admission. Noted also were transiently elevated D-dimer with low-normal or normal fibrinogen levels. The progressive necrosis and subsequent chronic pathologic changes with ischemia of the latter patient's digit eventually required a dermotomy and amputation of the distal phalanx. The pediatric patient did not require extensive wound debridement, but experienced prolonged difficulty in ambulation because of slowly resolving wound discomfort. Factors that may contribute to the severity of local morbidity of P. porphyriacus envenoming are considered, and management of envenoming by this taxon is briefly reviewed.
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Venenos Elapídicos/intoxicação , Elapidae , Mordeduras de Serpentes/terapia , Adulto , Animais , Antivenenos/uso terapêutico , Austrália/epidemiologia , Feminino , Humanos , Lactente , Masculino , Morbidade , Mordeduras de Serpentes/epidemiologia , Mordeduras de Serpentes/patologiaRESUMO
INTRODUCTION: A case of life threatening envenoming by a wild specimen of the inland taipan, Oxyuranus microlepidotus, is described. There have been 11 previously well-documented envenomings by O. microlepidotus, but only 2 were inflicted by wild snakes. Envenomed patients have presented predominantly with defibrinating coagulopathy and neurotoxicity. CASE REPORT: The victim was seeking to observe members of an isolated population of this species and was envenomed while attempting to photograph an approximately 1.5 m specimen. He reported feeling "drowsiness" and blurred vision that progressed to ptosis; he later developed dysphagia and dysarthria. The patient was treated with 1 vial of polyvalent antivenom, which was later followed with an additional two vials of taipan monovalent. He was intubated during retrieval, and recovered after 3 days of intensive care. He had a right ophthalmoplegia that persisted for approximately 1 week post-envenoming. Despite a positive 20-min whole blood clotting test, defibrination coagulopathy was absent, and there was no myotoxicity, or acute kidney injury. DISCUSSION: Physicians presented with a patient envenomed by O. microlepidotus should remain cognizant of the possible variability of medically important venom toxins in some populations of this species. Some patients seriously envenomed by this species may develop persistent cranial nerve palsies. When clinically indicated, prompt provision of adequate antivenom is the cornerstone of managing O. microlepidotus envenoming. Rapid application of pressure-bandage immobilization and efficient retrieval of victims envenomed in remote locales, preferably by medically well-equipped aircraft, probably improves the likelihood of a positive outcome.