First report of a confirmed case of Montivipera latifii (Latifi's viper) envenoming and a literature review of envenoming by Montivipera species.

Latifi's viper (Montivipera latifii), also known as Lar Valley or Damavandi viper, is endemic to Iran. It has rarely been recorded, as it occurs in a highly-protected national park. In this first clinical report of a confirmed bite by this species, a teenage girl was bitten on the chin, causing rapidly-progressive swelling of the face and oropharyngeal mucosa. At a local hospital, a misleading history given by the patient's relatives of a wasp sting and inadequate inspection of the bite wound misled the physicians from making the correct diagnosis, resulting in a considerable delay in the administration of antivenom. This allowed the development of partial obstruction of the upper airway causing respiratory distress. After transfer to a tertiary hospital, attempts at endotracheal intubation failed, necessitating tracheostomy, but this was not implemented early enough to prevent her developing respiratory failure and losing consciousness. After she was stabilized, snakebite envenoming was diagnosed by a clinical toxicologist who observed two fang puncture marks on her chin. This was later confirmed when a snake, identified as M. latifii, was discovered at the room where the bite had occurred. Her facial swelling and ecchymosis, attributable to envenoming, were effectively controlled by high-dose antivenom therapy. However, she did not recover consciousness, remaining in a vegetative state. About three weeks after the bite, she died as an indirect result of hypoxic brain damage complicated by septicemia. Prompt diagnosis, relief of upper airway obstruction and timely antivenom therapy might have prevented this tragic fatal outcome.

Urinary microRNAs as non-invasive biomarkers for toxic acute kidney injury in humans.

MicroRNAs in biofluids are potential biomarkers for detecting kidney and other organ injuries. We profiled microRNAs in urine samples from patients with Russell's viper envenoming or acute self-poisoning following paraquat, glyphosate, or oxalic acid [with and without acute kidney injury (AKI)] and on healthy controls. Discovery analysis profiled for 754 microRNAs using TaqMan OpenArray qPCR with three patients per group (12 samples in each toxic agent). From these, 53 microRNAs were selected and validated in a larger cohort of patients (Russell's viper envenoming = 53, paraquat = 51, glyphosate = 51, oxalic acid = 40) and 27 healthy controls. Urinary microRNAs had significantly higher expression in patients poisoned/envenomed by different nephrotoxic agents in both discovery and validation cohorts. Seven microRNAs discriminated severe AKI patients from no AKI for all four nephrotoxic agents. Four microRNAs (miR-30a-3p, miR-30a-5p, miR-92a, and miR-204) had > 17 fold change (p < 0.0001) and receiver operator characteristics area-under-curve (ROC-AUC) > 0.72. Pathway analysis of target mRNAs of these differentially expressed microRNAs showed association with the regulation of different nephrotoxic signaling pathways. In conclusion, human urinary microRNAs could identify toxic AKI early after acute injury. These urinary microRNAs have potential clinical application as early non-invasive diagnostic AKI biomarkers.

Extensive spontaneous cerebral haemorrhage after Russell's viper bite.

A 30-year-old man presented with altered sensorium following Russell's viper bite, which was found to be secondary to intracranial hemorrhage secondary to venom-induced consumptive coagulopathy. He was managed conservatively with blood component transfusion and antivenom injection, and successfully discharged.

Thrombotic Microangiopathy Following Arabian Saw-Scaled Viper (Echis coloratus) Bite: Case Report.

BACKGROUND Consumption coagulopathy post envenomation is one the most common complications after a snakebite. It occurs secondary to activation of a coagulation cascade by snake venom and could be followed by a syndrome consistent with thrombotic microangiopathy. The efficacy of plasma exchange for the treatment of thrombotic microangiopathy post envenomation is a matter of debate. CASE REPORT We reported the case of a 50-year-old male who had Arabian saw-scaled viper envenomation. He developed venom induced coagulopathy that improved within 24 hours of antivenom therapy. He subsequently developed micro-angiopathic hemolytic anemia, thrombocytopenia, and renal failure that was consistent with thrombotic microangiopathy. The patient was treated by plasma exchange and hemodialysis. He made a full recovery and was discharged after 4 weeks. CONCLUSIONS This case report supports plasmapheresis as an option for management of a patient who develops thrombotic microangiopathy secondary to snake bite, especially those who do not improve with antivenom and supportive therapy.

Status epilepticus and bilateral middle cerebral artery infarction: A rare presentation after viper bite.

Owing to the antihemostatic property of viper venom, hemorrhagic complications including intracerebral hemorrhage are the most commonly encountered after viper bite. Ischemic strokes have been rarely reported after viper envenomation, and its occurrence has been attributed to multiple mechanisms. Postsnakebite seizures are known to occur after neurotoxic bite. Here, we report the case of a viper bite victim who developed status epilepticus within 3 h after viper bite. He had only mild signs of local envenomation, and prolonged whole blood clotting time was the only manifestation of systemic envenomation. Subsequently, he was found to have developed right hemiparesis and global aphasia. Brain imaging revealed large infarcts in bilateral middle cerebral artery (MCA) territories. We report this as a unique case of viper bite which presented to the emergency room with status epilepticus. Moreover, bilateral MCA infarct, as was found in this case, is genuinely rare in scientific literature. Finally, the absence of overt features of envenomation makes this case stand out from other similar reported occurrences.

Résumé En raison de la propriété antihémostatique du venin de vipère, les complications hémorragiques, y compris l'hémorragie intracérébrale, sont les plus courantes. rencontré après morsure de vipère. Des AVC ischémiques ont rarement été signalés après une envenimation par vipère, et son apparition a été attribuée à mécanismes multiples Les crises d'épilepsie postnakebite se produisent après une piqûre neurotoxique. Ici, nous rapportons le cas d'une victime de morsure de vipère qui état de mal épileptique dans les trois heures suivant la piqûre des vipères. Il ne présentait que de légers signes d'envenimation locale et un temps de coagulation du sang total prolongé était la seule manifestation de l'envenimation systémique. Par la suite, il s'est avéré avoir développé une hémiparésie droite et une aphasie globale. L'imagerie cérébrale a révélé de grands infarctus dans les territoires bilatéraux de l'artère cérébrale moyenne (ACM). Nous rapportons cela comme un cas unique de morsure de vipère présenté à la salle d'urgence avec le statut épileptique. De plus, l'infarctus bilatéral à MCA, comme on l'a constaté dans ce cas, est vraiment rare dans littérature scientifique. Enfin, l'absence de caractéristiques évidentes d'envenimation fait que ce cas se distingue des autres cas similaires.

Snakebite Mitigation Project of the Madras Crocodile Bank/Centre for Herpetology, India: background and a brief summary of activities.

Snakebite is a serious problem in rural India where several highly venomous species are commonly found in and around agricultural areas where prey such as rodents and amphibians are abundant. Four snake species, referred to as the Big Four, are responsible for the most serious and fatal bites: spectacled cobra (Naja naja), Russell's viper (Daboia russelii), common krait (Bungarus caeruleus) and saw-scaled viper (Echis carinatus). A polyvalent antivenom is made to treat these bites but public awareness and distribution of this life-saving drug is inadequate. The Madras Crocodile Bank and its partners are conducting a snakebite project which includes venom sampling and research, snake and snakebite treatment centre mapping, and a nationwide awareness campaign for snakebite mitigation.

Analysis of effectiveness of Iranian snake antivenom on Viper venom induced effects including analysis of immunologic biomarkers in the Echis carinatus sochureki envenomed victims.

Snakebite is an important toxicologic emergency with the potential of triggering local and systemic inflammation. Antivenom has remained the mainstay of treatment for snakebite envenomation. In this study we sought to investigate the effectiveness of Iranian antivenom in a series of 44 viper envenomed patients through analysis of changes in clinical severity and the levels of inflammatory markers. Clinical envenomation severity assessed by snakebite severity score (SSS) and laboratory exams of the patients were recorded before (baseline visit) and after antivenom therapy. During 12-h antivenom therapy, the median (range) score of SSS significantly decreased from 3.5 (2-10) on admission to 1 (0-5) in the last visit (P < 0.001). Moreover, a significant decrease in prothrombin time and international normalized ratio was found (P = 0.006 and 0.008; respectively). Plasma concentrations of interleukin (IL) 1-ß, IL-6, IL-8, tumor necrosis factor α (TNF-α), complement hemolytic activity (CH50) were also measured in 10 severely Echis carinatus sochureki envenomed victims and 10 age and gender-matched healthy controls. Except IL-8, the baseline levels of IL-1ß, IL-6 and TNF-α in victims were significantly higher than healthy controls (P = 0.005, <0.001 and < 0.001, respectively). Moreover, the baseline level of CH50 was significantly lower in the patients compared to healthy controls (P < 0.001). After 12-h antivenom therapy, the plasma levels of IL-1ß, IL-6 and TNF-α significantly decreased (P = 0.032, 0.006 and 0.003, respectively), the levels of IL-8 remained relatively unchanged and the CH50 significantly increased (P = 0.011). Iranian snake antivenom was effective in treating viper bite envenomation as it reversed clinical venom effects and restored near normal underlying inflammatory status. This study is the first to ascertain and report the effectiveness of this antivenom in human subjects.

Russell's Viper Envenomation-Associated Addisonian Crisis.

Snakebite envenomation is an important public health problem in tropical countries. We report a case of bilateral adrenal hemorrhage in a 28-y-old man with Russell's viper bite that occurred in the Sathyamangalam forest range in the Indian state of Tamil Nadu. In this case, a combination of early bite recognition, hospital-based supportive care, corticosteroid therapy, and timely administration of polyvalent antivenom resulted in a favorable clinical outcome.

Extending knowledge of the clinical picture of Balkan adder (Vipera berus bosniensis) envenoming: The first photographically-documented neurotoxic case from South-Western Hungary.

We report a severe envenoming associated with minimal local symptoms following a Balkan adder (Vipera berus bosniensis) bite in South-Western Hungary. A 63-year-old male with a history of hypertension and sinus bradycardia (45/min) was bitten by a sub-adult specimen of V. b. bosniensis in Somogy County on 04 May 2017. The patient was transported to and treated at the Emergency Department of "Moritz Kaposi" General Hospital, Kaposvár. Locally only pain and minimal swelling with a small haematoma developed on the bitten finger. The abdominal muscles were very tender and guarding was detected upon palpation on the way to hospital. The patient, who had taken his telmisartan (80 mg) tablet in that morning, complained of nausea and dizziness during the first medical examination. The systemic signs included fluctuations in blood pressure (115/85-165/105 mmHg), ECG changes (transient horizontal ST depression in V5-6, and sinus tachycardia (90/min)), severe diarrhoea and vomiting (in 7 episodes). Descending neuromuscular paralysis appeared in the next morning, including complete bilateral ptosis with external ophthalmoplegia, and binocular diplopia. Single-fiber electromyography confirmed the neuromuscular block in the frontalis muscle innervated by the facial nerve. Intense dizziness with uncoordinated movement emerged on the 3rd day. The laboratory findings were mild, including anaemia, hypokalaemia, elevated glutamic-pyruvic transaminase and C-reactive protein levels. The absolute neutrophil count remained almost completely normal. Supportive care and monovalent antivenom (Viper Venom Antitoxin®, Biomed, Warsaw) were applied. The patient was discharged from hospital on the 4th day, although recovery was not complete until 9 days after the bite. This is the first photographically-documented case of neurotoxic envenoming from the South-Western Hungarian distribution range of V. b. bosniensis.

Daboia (Vipera) palaestinae envenomation in horses: Clinical and hematological signs, risk factors for mortality and construction of a novel severity scoring system.

Daboia palaestinae is the most common venomous snake in Israel and an important cause of envenomations in humans and animals. Although specific antivenom is produced from horses, little documentation exists regarding the characteristics of envenomed horses. This survey was constructed to describe the clinical, hematological and biochemical characteristics of D. palaestinae envenomation in horses, to identify risk factors for fatality and to construct a prognostic snakebite severity scale (SSS) to be used by veterinarians in the field. Data regarding 123 equine snakebite cases were collected over four years. Clinical signs most frequently described were local swelling (100%), tachycardia (67%), increased respiratory effort (62%), bite marks (44%) and reduced appetite (50%). Blood samples were collected at initial presentation from 23 of these horses. Hematological and biochemical abnormalities described in the majority of the sampled cases included leukocytosis (52%), neutrophilia (78%), increased creatine phosphokinase (77%), hypoproteinemia (50%), decreased total carbon dioxide (54%), and hyperphosphatemia (54%). The overall case fatality rate was 20.3% (25/123 horses). Risk factors associated with increased mortality (P < 0.05) were body weight below 200 kg, hind limb envenomation, severity of local swelling, mental status, respiratory effort, bleeding disorders, dehydration, basophilia, monocytosis, bilirubinemia, hypocalcemia and hyperphosphatemia. These risk factors were used to construct an SSS adapted for the assessment of envenomed horses in the field, consisting of seven dichotomous parameters. A cutoff value of 1.5 predicted mortality with 95% sensitivity and 68% specificity. In the future, this tool could assist clinicians with case management and communication with owners.

Ischemic brain infarcts and intracranial haemorrhages following Russell's viper (Daboia russelii) bite in Sri Lanka.

Snakebite is an important medical problem in Sri Lanka. Of the deadly venomous snakes, Russell's viper (Daboia russelii) is widely distributed and responsible for most of the fatalities of snakebite in the country. It is not uncommon to see atypical manifestations in Russell's viper bite. We report the events of intracranial haemorrhages and multiple ischemic brain infarcts following Russell's viper (Daboia russelii) bite of a previously healthy 43-years-old male who succumbed to envenoming.

Snake-bite-induced Acute Kidney Injury.

OBJECTIVE: To describe the clinical spectrum and outcome of patients presenting to a tertiary care kidney center, developing acute kidney injury (AKI) after snake-bite. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Nephrology Department, Sindh Institute of Urology and Transplantation (SIUT), Karachi, from January 1990 to December 2014. METHODOLOGY: All patients coming to SIUTidentified as having AKI after snake-bite during the study period were included. AKI was defined according to RIFLE criteria with sudden rise in creatinine or decline in urine output or both. Demographics, clinical presentation, laboratory profile, and final outcome was noted. RESULTS: During the studied period, 115 cases of AKI, secondary to snake-bite, were registered at this institution. Median age of patients was 35.92 ±15.04 (range: 6 - 70) years and male to female ratio was 1.6:1. Time from bite and referral to this hospital ranged from 2 to 28 days (mean: 8.77 ±5.58 days). Oligo-anuria was the most common presentation, being found in 98 (93.90%) patients. Bleeding diathesis was reported in 75 (65.21%) patients on presentation. All patients had normal sized, non-obstructed kidneys on ultrasonography, with no previous comorbids. Renal replacement therapy (RRT) was required in 106 (92.17%) patients. Complete recovery was seen in 59 (51.30%), while 15 (13.04%) patients expired during acute phase of illness, 4 (3.47%) developed CKD, 11 (9.56%) required dialysis beyond 90 days, and 26 (22.60%) were lost to long-term follow-up. CONCLUSION: Snake-bite, leading to multiple complications including renal failure and death, is a major health issue in tropical countries. Late referral of these patients to specialized centres results in undesirable outcome.

Mordedura por víbora hocicuda (Vipera latastei) / Vipera latastei (Hocicuda viper) bite

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Novedades en el envenenamiento por mordedura de víbora / Changes in viper bite poisonings

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[Adder bites].

Correct treatment of adder bites can reduce morbidity. We aim at creating an evidence-based guideline on pre- and in-hospital treatment of bites by the European adder (Vipera berus). Pre-hospital treatment consists of reassurance, immobilisation, elevation and paracetamol for pain. Icepacks, oral suction and tourniquets should be avoided. In-hospital treatment includes tetanus prophylaxis, paracetamol or opioids, antiemetics and the monovalent ovine immunoglobulin Fab fragment ViperaTAb. We strongly advise emergency departments to carry up-to-date guidelines regarding bites from the European adder.