Treatment of a Snakebite Injury With Secondary Bacterial Infection: A Case Study.

BACKGROUND: Pit viper snakebites are challenging as they often cause tissue injury and secondary bacterial infection that may impair full recovery of the affected limb. We describe the evolution of a snakebite injury with secondary infection and the use of specialized dressings to achieve tissue repair and complete closure of the wound. CASE: Ms E., a 45-year-old woman, was bitten by a pit viper that began as a small lesion and progressed to necrosis, cellulitis, edema, and hyperemia of the perilesional skin, local inflammation, and infection. We implemented a combination of topical hydrogel therapy with calcium alginate and hydrofiber with 1.2% silver to promote autolytic debridement, combat local infection, and provide a moist wound environment. The wound required daily local treatment for 2 months due to extensive tissue damage, combined with the proteolytic action of the bothropic venom. CONCLUSION: The care of wounds caused by snakebites is a challenge for the health care team due to tissue loss resulting from the action of the venom and secondary bacterial infection. Close follow-up with the use of systemic antibiotics and topical therapies proved effective in minimizing tissue loss in this case.

Cerebrovascular Accidents Related to Snakebites in the Amazon-Two Case Reports.

The objective of this case series was to describe 2 patients presenting with subarachnoid hemorrhage with hydrocephalus and hemoventricle after a snakebite caused by presumed Bothrops ssp. Both cases occurred in the municipality of Guajará (Amazonas state), Western Brazilian Amazon. Both cases featured delay in administration of serum therapy, which may have contributed to the emergence of complications such as stroke. Patient 1 was admitted to hospital 16 h after the snakebite occurred. Before receiving antivenom, testing showed the patient as having unclottable blood. She developed hemorrhagic stroke (a subarachnoid hemorrhage with hydrocephalus and hemoventricle). On the seventh day, she was discharged from hospital. Patient 2 arrived at the hospital 3 d after the snakebite occurred and presented with unclottable blood. He had a stroke (right frontoparietal hemorrhage, intraparenchymal hemorrhage already open to the ventricle) and died on the eighth day after the snakebite. Delay in seeking health care after snake envenomation can result in worse outcome.

Bothrops atrox Snakebite: How a Bad Decision May Lead to a Chronic Disability: A Case Report.

Snakebites are a neglected and underestimated global health hazard. In the Brazilian Amazon, Bothrops snakebites are the most prevalent and may lead to severe complications. Here we describe a severe case of Bothrops atrox snakebite that, owing to delayed medical assistance, presented with renal and respiratory failure, compartment syndrome, and tissue necrosis. After several fasciotomy surgeries, the patient survived; however, he showed significant functional disability. Prompt management of snake envenomation would aid in the early diagnosis of local and systemic complications and, consequently, would result in a better functional outcome with improved quality of life.

Envenomation by a common green racer (Chlorosoma viridissimum) in the Brazilian Amazon: A report of three cases.

Envenomations by the common green racer (Chlorosoma viridissimum) are seldom reported in the literature. Herein, we report three cases caused by the same specimen of C. viridissimum in three different victims in the Brazilian Amazon. In all cases, the victims were either a biologist or biology students that were handling the animal and were bitten in their upper limbs. The victims showed only local symptoms, such as edema, tooth marks, pain, erythema, ecchymoses and bleeding. One of the patients presented extensive ecchymosis. Two patients sought medical care, but were only treated for local manifestations and evolved without complications. Chlorosoma viridissimum is capable of provoking mild to moderate signs and symptoms.

Long-term disability after cerebral ischemic stroke following a Bothrops atrox snakebite in the Brazilian Amazon.

Bothrops atrox envenomations in the Brazilian Amazon are responsible for a number of local and systemic effects. Among these, stroke presents the worst prognosis for the patient since it may evolve into disabilities and/or premature death. This complication is caused by coagulation disorders and generates hemorrhagic and thrombotic conditions. This study presents a case report of a 54-year-old female patient who presented extensive cerebral ischemia after a B. atrox envenomation that occurred in the state of Amazonas, Brazil. The patient was hospitalized for 102 days, which included a stay in the intensive care unit. Clinical and laboratory findings indicated a thrombogenic coagulopathy. On discharge, the patient had no verbal response, partial motor response, and right hemiplegia. The assessment carried out four years after discharge evidenced incapacitation, global aphasia and bilateral lower and upper limbs showed hypotrophy with a global decrease in strength. Ischemic stroke is a possible complication of B. atrox snakebites even after antivenom treatment, with the potential to cause debilitating long-term consequences.

Understanding the complexity of Tityus serrulatus venom: A focus on high molecular weight components.

Tityus serrulatus scorpion is responsible for a significant number of envenomings in Brazil, ranging from mild to severe, and in some cases, leading to fatalities. While supportive care is the primary treatment modality, moderate and severe cases require antivenom administration despite potential limitations and adverse effects. The remarkable proliferation of T. serrulatus scorpions, attributed to their biology and asexual reproduction, contributes to a high incidence of envenomation. T. serrulatus scorpion venom predominantly consists of short proteins acting as neurotoxins (α and ß), that primarily target ion channels. Nevertheless, high molecular weight compounds, including metalloproteases, serine proteases, phospholipases, and hyaluronidases, are also present in the venom. These compounds play a crucial role in envenomation, influencing the severity of symptoms and the spread of venom. This review endeavors to comprehensively understand the T. serrulatus scorpion venom by elucidating the primary high molecular weight compounds and exploring their potential contributions to envenomation. Understanding these compounds' mechanisms of action can aid in developing more effective treatments and prevention strategies, ultimately mitigating the impact of scorpion envenomation on public health in Brazil.

Long-term hospital care needs after Bothrops atrox envenomation with hemorrhagic stroke in the Brazilian Amazon: 'From social to physical death' - A case report.

Hemorrhagic stroke is a severe complication reported in cases of Bothrops atrox snakebite envenomation. We report an unusual case of a patient who evolved with an intracranial hemorrhagic stroke and was in a coma for more than five years in a tertiary hospital located in Manaus, Amazonas. 52-year-old man, carpenter, resident in the rural area of the municipality of Tabatinga, located 1106 km from Manaus, capital of Amazonas, Brazil, victim of an accident involving Bothrops atrox evolution with cardiorespiratory arrest, acute kidney injury and hemorrhagic stroke. After 43 days of hospitalization in the ICU, he was transferred to the ward, without contact with the environment and family, sent for home treatment, however, without acceptance by family members. During a long hospital stay for a period of 6 years, totally dependent on special care, in a flexed position, using a tracheostomy and mechanical ventilation, diagnosed and treated for hospital infections throughout his hospitalization, he died due to bacterial pneumonia. Losses of autonomy can result in an individual being completely disconnected from social life - a "social death before physical death".

Photobiomodulation Therapy to Treat Snakebites Caused by Bothrops atrox: A Randomized Clinical Trial.

Importance: Bothrops venom acts almost immediately at the bite site and causes tissue damage. Objective: To investigate the feasibility and explore the safety and efficacy of low-level laser therapy (LLLT) in reducing the local manifestations of B atrox envenomations. Design, Setting, and Participants: This was a double-blind randomized clinical trial conducted at Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, Brazil. A total of 60 adult participants were included from November 2020 to March 2022, with 30 in each group. Baseline characteristics on admission were similarly distributed between groups. Data analysis was performed from August to December 2022. Intervention: The intervention group received LLLT combined with regular antivenom treatment. The laser used was a gallium arsenide laser with 4 infrared laser emitters and 4 red laser emitters, 4 J/cm2 for 40 seconds at each application point. Main Outcomes and Measures: Feasibility was assessed by eligibility, recruitment, and retention rates; protocol fidelity; and patients' acceptability. The primary efficacy outcome of this study was myolysis estimated by the value of creatine kinase (U/L) on the third day of follow-up. Secondary efficacy outcomes were (1) pain intensity, (2) circumference measurement ratio, (3) extent of edema, (4) difference between the bite site temperature and that of the contralateral limb, (5) need for the use of analgesics, (6) frequency of secondary infections, and (7) necrosis. These outcomes were measured 48 hours after admission. Disability assessment was carried out from 4 to 6 months after patients' discharge. P values for outcomes were adjusted with Bonferroni correction. Results: A total of 60 patients (mean [SD] age, 43.2 [15.3] years; 8 female individuals [13%] and 52 male individuals [87%]) were included. The study was feasible, and patient retention and acceptability were high. Creatine kinase was significantly lower in the LLLT group (mean [SD], 163.7 [160.0] U/L) 48 hours after admission in relation to the comparator (412.4 [441.3] U/L) (P = .03). Mean (SD) pain intensity (2.9 [2.7] vs 5.0 [2.4]; P = .004), circumference measurement ratio (6.6% [6.6%] vs 17.1% [11.6%]; P < .001), and edema extent (25.8 [15.0] vs 40.1 [22.7] cm; P = .002) were significantly lower in the LLLT group in relation to the comparator. No difference was observed between the groups regarding the mean difference between the bite site temperature and the contralateral limb. Secondary infections, necrosis, disability outcomes, and the frequency of need for analgesics were similar in both groups. No adverse event was observed. Conclusions and Relevance: The data from this randomized clinical trial suggest that the use of LLLT was feasible and safe in a hospital setting and effective in reducing muscle damage and the local inflammatory process caused by B atrox envenomations. Trial Registration: Brazilian Registry of Clinical Trials Identifier: RBR-4qw4vf.

Perceptions of nurses regarding the management of snakebite envenomations: Limits and possibilities.

Snakebites can be caused by harmless or venomous snakes and, according to their severity and frequency, can be considered events of medical importance. In health facilities in remote areas, nurses work in the first line of care of patients that are victims of these envenomations. The aim was to discover the perception of nurses regarding the management of snakebites, its limitations and possibilities, with a view to professional empowerment in the context of primary health care. This is exploratory and descriptive research, with a qualitative approach, developed at FMT-HVD in Manaus, Amazonas state, Brazil, in the year 2021. The participants were nurses who work in basic health units in the municipalities of Careiro da Várzea, Ipixuna and Boa Vista do Ramos in the state of Amazonas. For data collection, the focus group strategy was adopted. Thematic content analysis was employed, which was carried out in the stages of pre-analysis; exploration or coding of the material; treatment of the results, inference and interpretation. After processing the data obtained, four topics emerged from the coding: Topic 1 - limitations in the primary care. Topic 2 - the need for infrastructure and personnel. Topic 3 - the need for continuing education. Topic 4 - the perception of training regarding the management of snakebite envenomations. The results showed a lack of antivenom in the healthcare units where nurses work. Another aspect highlighted by the nurses is the absence of a doctor in situ to perform the primary care or out of hours care in the units. The nurses' perceptions regarding the management of snakebite envenomations revealed the existence of failures in relation to the subject, such as the lack of antivenom, poor infrastructure in the units and the lack of a doctor, which must be solved, since the nurses are the most active professionals in primary health care, in addition to the high incidence of snakebite envenomations in the Brazilian Amazon.

Experience report of the contributions of telehealth in riverside communities of Amazonas in the pandemic.

OBJECTIVE: to report on the creation and implementation of telehealth activities developed by the Forest Health Program in communities in conservation areas, in the state of Amazonas, during the COVID-19 pandemic. METHODS: this is an experience report on the creation and implementation of the program. RESULTS: the project began in June 2021 with medical and nursing services and currently has 63 points of connectivity installed. Dermatology was the most requested specialty (30.1%), with dermatitis being the main grievance diagnosed. For nursing, the most requested specialty was obstetrics, followed by pediatrics. Rio Madeira and the Catuá-Ipixema Extractive Reserve requested more than half of all consultations. CONCLUSION: this project showed a differentiated performance of telehealth in riverside communities in Amazonas, especially in the pandemic context, expanding health care in remote areas, such as these.

When to think about a Lachesis muta envenomation in the Western Brazilian Amazon: Lessons from a case report.

In the Brazilian Amazon, envenomations by lancehead pit vipers prevail across the region, while bushmaster (Lachesis muta) envenomations are rarely confirmed. Here, we described a moderate snakebite, diagnosed as a lancehead pit viper envenomation upon admission and treated with four vials of Bothrops antivenom. Blood remained unclottable for 4 days of hospitalization. On day 4, after admission, the patient presented pictures of the perpetrating snake to the hospital staff, which was identified as a Lachesis muta specimen. After administering 10 vials of Lachesis antivenom, blood became clottable 12 hours after treatment. The patient was discharged without complaints.

Secondary infection profile after snakebite treated at a tertiary referral center in the Brazilian Amazon.

BACKGROUND: Bothrops envenomations can often lead to complications, such as secondary infections. METHODS: This cross-sectional study analyzed the medical records of all patients diagnosed with snakebite. RESULTS: A total of 127 patients were included. Clindamycin was the most commonly prescribed antibiotic, with 105 patients (82.7%) receiving it as the primary antibiotic regimen. In 31 (24.4%) individuals, the first-choice antibiotic did not cease the infection. CONCLUSIONS: Secondary infection is an important complication resulting from snakebites, and evidence-based management of this complication can contribute to better clinical outcomes.

Envenomations by coral snakes in an Amazonian metropolis: Ecological, epidemiological and clinical aspects.

Envenomation by coral snakes represents a little known burden in Brazilian Amazonia. So far, details on clinical and epidemiological aspects remain obscure in the region. We gathered data from medical charts and from the scientific collection of snakes from Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, finding 26 cases of envenomation by five species of Micrurus in Manaus region, between 1987 and 2018. They represent 0.7% of the snakebites treated in the hospital since the records began, in 1979. Micrurus lemniscatus was responsible for most of the bites (10), followed by M. hemprichii (five), M. spixii (three), M. surinamensis (three) and M. averyi (one). There was no difference between the sexes of the snakes that caused bites. Patients were mostly males, and most of the cases were reported in urban areas. Bites predominated in dry season, and there was a clear geographical segregation among species. We describe seven cases of envenomation, three mild and four severe, all of which evolved to cure. Paresthesia (six), pain (five) and edema (four) were the most common local symptoms. Systemic features such as dyspnea/shallow breath (four), palpebral ptosis (four), blurred vision (three), dysarthria (three) and difficulty to walk (three) were also detected. Two patients bitten by Micrurus sp. and M. hemprichii, showed slight increased serum levels of creatine kinase (reference level <190 U/L), 1184 U/L and 1229 U/L, respectively, indicative of mild systemic myotoxicity. This is the first report of myotoxic manifestation in the envenomation by M. hemprichii. No patient developed respiratory failure, though one bitten by an adult M. spixii required intubation and mechanical ventilation due to decreased level of consciousness during evolution, probably related to induced sedation caused by concurrent alcohol intoxication. All patients were treated with Brazilian Micrurus antivenom (soro antielapídico, median = 10 vials). Six patients were pretreated intravenously with H1 and H2 antagonists and steroids, with two patients developing early adverse reactions. The median length of hospital stay was four days. Envenomations by coral snakes in Manaus region are clinically severe, but rare and sparsely distributed over time, making the detection of epidemiological and clinical patterns a challenge for public health.

Snakebites in Rio Branco and surrounding region, Acre, Western Brazilian Amazon.

INTRODUCTION: Snakebites are considered a neglected tropical disease in many countries in Latin America, including Brazil. As few studies have assessed snakebites in the Amazon region and especially in the state of Acre, epidemiological studies are of great importance. The present study aimed to describe the epidemiological characteristics of snakebites in the Rio Branco region, observing their characteristics in rural and urban areas and their correlation with rainfall and river outflow. METHODS: This retrospective, descriptive study analyzed epidemiological information obtained from snakebite notifications registered on the Information System for Notifiable Diseases that occurred from March, 2018 to February, 2019. The cases of snakebite were correlated with rainfall and flow. RESULTS: A total of 165 cases of snakebite were registered in the period. Most cases were caused by Bothrops and affected mainly individuals of the male sex who were between 21 and 30 years old. Most of the snakebites occurred in Rio Branco (71.52%; 29 cases per 100,000 inhabitants). Of these, 60.2% occurred in the urban area and 39.8% in the rural area and the majority occurred during the rainy season. CONCLUSIONS: Although studies have shown that a majority of cases occur in rural areas, in this study, urbanization of snakebites was observed. The Bothrops genus was responsible for the highest number of snakebites and, during the rainy season, bites occurred more frequently. Educational prevention campaigns, population advice, and first aid in case of snakebites for the population are thus suggested.

Understanding the complexity of Tityus serrulatus venom: A focus on high molecular weight components

Tityus serrulatus scorpion is responsible for a significant number of envenomings in Brazil, ranging from mild to severe, and in some cases, leading to fatalities. While supportive care is the primary treatment modality, moderate and severe cases require antivenom administration despite potential limitations and adverse effects. The remarkable proliferation of T. serrulatus scorpions, attributed to their biology and asexual reproduction, contributes to a high incidence of envenomation. T. serrulatus scorpion venom predominantly consists of short proteins acting as neurotoxins (α and ß), that primarily target ion channels. Nevertheless, high molecular weight compounds, including metalloproteases, serine proteases, phospholipases, and hyaluronidases, are also present in the venom. These compounds play a crucial role in envenomation, influencing the severity of symptoms and the spread of venom. This review endeavors to comprehensively understand the T. serrulatus scorpion venom by elucidating the primary high molecular weight compounds and exploring their potential contributions to envenomation. Understanding these compounds' mechanisms of action can aid in developing more effective treatments and prevention strategies, ultimately mitigating the impact of scorpion envenomation on public health in Brazil.

Delayed healthcare and secondary infections following freshwater stingray injuries: risk factors for a poorly understood health issue in the Amazon.

INTRODUCTION: This study aimed to describe the profile of freshwater stingray injuries in the State of Amazonas, Brazilian Amazon, and to identify the associated risk factors for secondary infections. METHODS: This cross-sectional study used surveillance data from 2007 to 2014 to identify factors associated with secondary infections from stingray injuries. RESULTS: A total of 476 freshwater stingray injuries were recorded, with an incidence rate of 1.7 cases/100,000 person/year. The majority of injuries were reported from rural areas (73.8%) and 26.1% were related to work activities. A total of 74.5% of patients received medical assistance within the first 3 hours of injury. Secondary infections and necrosis were observed in 8.9% and 3.8%, respectively. Work-related injuries [odds ratio (OR) 4.1, confidence interval (CI); 1.87-9.13] and >24 hours from a sting until receiving medical care (OR; 15.5, CI; 6.77-35.40) were independently associated with the risk of secondary bacterial infection. CONCLUSIONS: In this study, work-related injuries and >24 hours from being stung until receiving medical care were independently and significantly associated with the risk of secondary infection. The frequency of infection following sting injuries was 9%. The major factor associated with the risk of secondary bacterial infection was a time period of >24 hours from being stung until receiving medical care.

Snakebite by Micrurus averyi (Schmidt, 1939) in the Brazilian Amazon basin: Case report.

Micrurus snakes, commonly known as coral snakes, are responsible for 0.4% of the snakebites envenomings in Brazil. In this report, we describe a case of envenoming by Micrurus averyi, the black-headed coral snake, recorded in the western Brazilian Amazon. To the best of our knowledge, this is the first published case perpetrated by this species. The major complaint of the patient was an intense local pain and paresthesia. Examination of the bite site revealed edema extending from the left foot up the left leg that was accompanied by erythema involving the foot and distal third of the leg. Systemic signs at admission included nausea and drooling. The patient was treated with 100 mL of coral snake antivenom and intravenous analgesics (dipyrone) and was discharged 48 h post-admission with no complaints. The patient showed more intense local edema than that generally described in several other cases of Micrurus bites in Brazil.

Predicting acute renal failure in Bothrops snakebite patients in a tertiary reference center, Western Brazilian Amazon.

Acute Kidney Injury (AKI) is the main systemic complication and cause of death in viperid envenomation. Although there are hypotheses for the development of AKI, the mechanisms involved are still not established. The aim of this study was to evaluate the clinical-laboratorial-epidemiological factors associated with AKI in victims of Bothrops sp envenomation. This is an observational study carried out at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado. AKI was defined according to the guidelines of the Acute Kidney Injury Network (AKIN). Among the 186 patients evaluated, AKI was observed in 24 (12.9%) after 48 hours of admission. Stage I was present in 17 (70.8%) patients, II in 3 (12.5%) and III in 4 (16.7%). Epidemiological characterization showed predominance of men, occurrence in rural areas, aged between 16-60 years, feet as the most affected anatomical region, and time to medical assistance less than 3 hours. Hypertension and diabetes were the comorbidities identified. Most of the accidents were classified as moderate, and clinical manifestations included severe pain, mild edema, local bleeding and headache. Laboratory results showed blood uncoagulability, hypofibrinogenemia, leukocytosis, increase of creatine kinase, and high lactate dehydrogenase levels. Multivariate analysis showed an association with high LDH levels [AOR = 1.01 (95% CI = 1.01-1.01, p<0.002)], local bleeding [AOR = 0.13 (95%CI = 0.027-0.59, p<0.009)], and the presence of comorbidities [AOR = 60.96 (95%CI = 9.69-383.30; p<0.000)]. Herein, laboratory markers such as high LDH levels along with local bleeding and comorbidities may aid in the diagnosis of AKI.

Experience report of the contributions of telehealth in riverside communities of Amazonas in the pandemic / Relato de experiencia de las contribuciones de la telesalud en comunidades ribereñas de Amazonas en la pandemia / Relato de experiência das contribuições da telessaúde em comunidades ribeirinhas do Amazonas na pandemia

ABSTRACT Objective: to report on the creation and implementation of telehealth activities developed by the Forest Health Program in communities in conservation areas, in the state of Amazonas, during the COVID-19 pandemic. Methods: this is an experience report on the creation and implementation of the program. Results: the project began in June 2021 with medical and nursing services and currently has 63 points of connectivity installed. Dermatology was the most requested specialty (30.1%), with dermatitis being the main grievance diagnosed. For nursing, the most requested specialty was obstetrics, followed by pediatrics. Rio Madeira and the Catuá-Ipixema Extractive Reserve requested more than half of all consultations. Conclusion: this project showed a differentiated performance of telehealth in riverside communities in Amazonas, especially in the pandemic context, expanding health care in remote areas, such as these.

RESUMEN Objetivo: Relatar la creación e implementación de actividades de telesalud desarrolladas por Programa Salud en la Floresta en comunidades de áreas de conservación, en el estado de Amazonas, durante la pandemia de COVID-19. Métodos: Relato de experiencia sobre la creación e implementación del programa. Resultados: El proyecto tubo inicio en junio de 2021 con atenciones en el área de medicina y enfermería y actualmente cuenta con 63 puntos de conectividad instalados. La dermatología fue la especialidad más requerida (30,1%), con las dermatitis siendo el principal agravio diagnosticado. En enfermería, la especialidad más solicitada fue en el área de obstetricia, seguida por pediatría. Río Madeira y la Reserva Extractivista Catuá-Ipixema solicitaron más de la mitad de todas las atenciones. Conclusión: Este proyecto mostró una actuación diferenciada de telesalud en comunidades ribereñas de Amazonas, especialmente en el contexto pandémico, ampliando el cuidado a salud en áreas remotas, como estas en cuestión.

RESUMO Objetivo: Relatar a criação e implementação das atividades de telessaúde desenvolvidas pelo Programa Saúde na Floresta em comunidades de áreas de conservação, no estado do Amazonas, durante a pandemia de COVID-19. Métodos: Trata-se de um relato de experiência sobre a criação e implementação do programa. Resultados: O projeto teve início em junho de 2021 com atendimentos na área de medicina e enfermagem e atualmente conta com 63 pontos de conectividade instalados. A dermatologia foi a especialidade mais requerida (30,1%), com as dermatites sendo o principal agravo diagnosticado. Para a enfermagem, a especialidade mais solicitada foi na área de obstetrícia, seguida pela pediatria. Rio Madeira e a Reserva extrativista Catuá-Ipixema solicitaram mais da metade de todos os atendimentos. Conclusão: Este projeto mostrou uma atuação diferenciada da telessaúde em comunidades ribeirinhas do Amazonas, especialmente no contexto pandêmico, ampliando o cuidado à saúde em áreas remotas, como estas em questão.

When to think about a Lachesis muta envenomation in the Western Brazilian Amazon: Lessons from a case report

ABSTRACT In the Brazilian Amazon, envenomations by lancehead pit vipers prevail across the region, while bushmaster (Lachesis muta) envenomations are rarely confirmed. Here, we described a moderate snakebite, diagnosed as a lancehead pit viper envenomation upon admission and treated with four vials of Bothrops antivenom. Blood remained unclottable for 4 days of hospitalization. On day 4, after admission, the patient presented pictures of the perpetrating snake to the hospital staff, which was identified as a Lachesis muta specimen. After administering 10 vials of Lachesis antivenom, blood became clottable 12 hours after treatment. The patient was discharged without complaints.