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Scorpion sting is a medical burden globally but especially frequent hotspots of scorpion biodiversity. In Iran, one of those hotspot countries, many fatalities occur in the South as well as the Southwest and are thought to be caused by Hemiscorpius lepturus. Accordingly, those are used for antivenom production. However, recent surveys revealed that indeed a different species Hemiscorpius acanthocercus is responsible for most accidents in the South, while H. lepturus is primarily causing the fatalities in the Southwest and thus Iranian scorpion antivenom needs to be refined in that respect. Such a refined antivenom would need to cover both species of Hemiscorpius. In response, the Iranian Ministry of Health requested the adjustment of the production line from local antivenom suppliers but until today no action has been taken., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

When patients present with an unknown puncture wound, emergency physicians need to consider regional hazards, in addition to standard mechanical injury etiologies. In the Southwestern United States, one such hazard is the rattlesnake. In this report, we present a case in which a rattlesnake envenomation was not considered as a possible cause for a puncture wound of unknown origin, which resulted in an envenomation left untreated for 7 days. A full dry bite observation period of 12 h with serial physical exams and laboratory analysis with guidance from the region poison control center might have led to earlier recognition of an envenomation and antivenom administration. A male patient in his late 70's felt a painon his right ankle while in his backyard in southern Arizona. He did not see the cause and assumed he had sustained an insect bite. He went to the ED that day with minor pain and swelling and was discharged home. One week later, he re-presented severely anemic with edema and ecchymosis to the entire right lower extremity that developed over several days after his first ED visit. He was admitted for antivenom and blood transfusion and discharged on hospital day three. For as long as humans continue to interact with the natural world, venomous creature encounters are going to continue to happen. Rattlesnake envenomation should be included in a physician's differential diagnosis even if one is not witnessed, especially in regions with high rattlesnake activity. In addition to assessing for other potential causes of undifferentiated puncture wounds, serial physical examinations and laboratory testing (with guidance of the regional poison center) are necessary to rule out rattlesnake envenomation., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

The eastern small eyed snake (Cryptophis nigrescens; CN) is an uncommon cause of snakebite in Australia despite the widespread distribution of the snake along the east coast of Australia. Diagnosis of envenomation relies on identification of the snake which is often not possible with animal snakebite cases. This study examined the immunoreactivity profile of CN venom towards specific rabbit IgG made against the medically relevant snake venom immunotypes found in Australia (tiger, brown, black, death adder and taipan). A simultaneous sandwich ELISA format was used to quantify CN venom binding to venom specific Protein A purified rabbit IgG. The binding profiles demonstrated weak binding of CN venom to rabbit IgG made against both tiger (N. scutatus) and black snake (P. australis) venoms with approximately 0.19% and 0.069% cross reactivity, respectively. However, the concentration of venom likely to be present in the urine of CN envenomed patients and the low cross reactivity suggest that envenomed veterinary patients are unlikely to be detected in the commercial snake venom detection kit. It is possible that CN envenomation is more common but may be underdiagnosed where snake venom antigen detection is relied upon solely. Serum biochemical abnormalities also overlap with other snake species found in the same geographical area. In respect of antivenom therapy, administration of tiger snake antivenom is supported by the binding data, but due to the low cross reactivity multiple vials may be required. Limited clinical evidence also supports the efficacy of tiger snake antivenom for envenomation by CN., (© 2024 The Author(s). Australian Veterinary Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Veterinary Association.)

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., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Vipera berus berus is the only venomous snake present in the Nordic countries and cases of envenomation in horses are reported during the warmer months. Little is known about the presentation, treatment and survival of horses with common European adder envenomation. Clinical and laboratory findings, treatment and outcome are reported for 28 horses admitted to Helsinki University Equine Hospital in 2008-2023 due to suspicion of snake bite. Eleven of these horses received antivenom treatment. Other common treatments included non-steroidal anti-inflammatories (22/28), antimicrobials (19/28), intravenous fluid therapy (11/28), corticosteroids (9/28) and local treatment (11/28). All horses survived until discharge. No difference was detected in the length of hospital stay between horses with moderate envenomation that had or had not received antivenom treatment. Horses with moderate envenomation are more likely to receive antivenom treatment and require longer hospital stay than horses with mild envenomation. Antivenom treatment is not associated with shorter hospital stay. Little evidence supports the use of corticosteroids and antibiotics in treatment of envenomation. Studies with larger numbers of animals are warranted to evaluate the effect of treatment, including administration of antivenom, on long-term outcome and survival from envenomation., Competing Interests: Declaration of competing interest None of the authors has any financial or personal relationships that could inappropriately influence or bias the content of the paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Snakebites in unusual anatomical locations may lead to life-threatening consequences. Merrem's hump-nosed viper ( Hypnale hypnale ) is a medically important snake in Sri Lanka and India that causes many bites and envenomings. Their bites occur almost exclusively on upper and lower limbs and commonly result in local effects, with some patients developing systemic envenoming. No antivenom is available for treating envenoming by H. hypnale . We report an unusual case of H. hypnale bite on the tongue of a 10-month-old infant resulting in rapid local swelling of the tongue and floor of the mouth, requiring prompt intervention to prevent life-threatening upper airway obstruction. Early tracheostomy prevented upper airway obstruction and, along with supportive steroid therapy and antibiotics, led to a complete resolution of the local effects of the infant without permanent disability, despite the unavailability of antivenom.

We present a case of neurotoxic effects in a pediatric patient after envenomation by a timber rattlesnake ( Crotalus horridus ) in the Appalachian upstate of South Carolina. Though some members of this species are capable of primarily neurotoxic envenomation, there is heterogeneity in venom composition, and neurotoxic timber rattlesnakes are not endemic to the Appalachian region. However, neurotoxic effects caused by C horridus species lacking typical neurotoxins have been suspected, though not previously confirmed in the medical literature. This case presents a patient who was envenomated by a genotypically confirmed non-neurotoxic C horridus but who nevertheless presented with symptoms consistent with primary neurotoxicity. Neurotoxic effects can be variable in their response to traditional antivenom, though this patient demonstrated rapid response to treatment, representing a novel case in the literature of neurotoxic effects from a snake lacking typical neurotoxins with documented improvement with traditional antivenom.

Snakebite envenoming is a high-priority neglected tropical disease and antivenom is the cornerstone of treatment. Antivenom is listed among essential medicines and its access must be considered as a human right. Despite resolutions from various international organizations including the WHO, antivenom remains unavailable, unaffordable, and sometimes not targeted against the specific snake involved. Also, despite an expanding global antivenom market, some manufacturers have stopped production due to a lack of profits. However, justice and equitable access to care according to medical needs are among the four pillars of medical ethics. Overall, snakebite envenoming is a typical example of social and ethnic inequity in medicine. It is imperative that this issue be addressed from an ethical standpoint and that government laboratories take the lead in antivenom production., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Severe Lonomia caterpillar envenoming is an increasing hazard in South America. It can trigger severe coagulation disorders that can progress to systemic complications and death. We report the first documented case of severe Lonomia caterpillar envenoming in Guyana. It was managed using antivenom provided by the Brazilian Ministry of Health as part of humanitarian support. This case describes a successful international collaboration driving a favorable outcome for the envenomed patient., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Poecilotheria spiders are considered theraphosids of underestimated clinical importance, with bites from these species inducing symptoms such as severe pain and intense muscle cramps. However, there is no specific treatment for the envenomation caused by these species, which, while native to India and Sri Lanka, are widely distributed worldwide. The present study reports the case of a 31-year-old man bitten by a Poecilotheria regalis specimen. The patient's clinical presentation was similar to Latrodectus envenomation, and patient was treated with an L. mactans antivenom. Most of patient's symptoms improved (fasciculations, pain, erythema, and local swelling), except muscle cramps. A toxicological study conducted on mice did not show that L. mactans antivenom has a neutralizing effect on the toxicity of P. regalis. The present report discusses the envenoming process of Poecilotheria species and the possible neutralizing effect exerted by L. mactans antivenom., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Viper bites pose a significant public health issue in Armenia, even within urban areas, often resulting in clotting disorders, hypofibrinogenemia, and tissue necrosis in humans. This study investigates histopathological changes in various tissues during mice envenomation by West-Asian blunt-nosed viper (Macrovipera lebetina obtusa) venom, as well as the recovery process aided by experimental antivenom derived from sheep. The high venom dose caused substantial damage to the heart, lungs, liver, and kidneys in mice, indicating systemic harm. While antivenom administration can prevent mortality in mice envenomation, it may not fully mitigate histological damage in affected organs. Additionally, the study highlights the importance of timing antivenom administration, as the severity of tissue alterations can vary depending on the duration of envenomation. These findings shed light on antivenom's effects on viper envenomation and stress the need for further research to optimize its timing and dosage for minimizing histological damage and enhancing clinical outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Snakebite is a significant health concern in Africa, particularly due to neurotoxic envenomation which can lead to neuromuscular paralysis and respiratory failure. In Nigeria, snakes from the Elapidae family are a notable cause of envenomation cases, though these incidents are underreported. This review examined case reports of neurotoxic envenomation in Africa, highlighting the clinical impacts and the efficacy of available antivenoms. Preclinical studies showed that the polyvalent antivenom from the South African Institute for Medical Research (SAIMR) was highly effective against neurotoxicity with a protective efficacy (R) of 1346.80 mg/mL, while clinical assessment emphasized the need for high-dose antivenom therapy along with supportive measures like mechanical ventilation. Unlike hemorrhagic envenomation, where antivenom promptly resolves bleeding, neurotoxic cases often require additional interventions. The review underscores the necessity for tailored approaches in antivenom therapy to address the complexities of neurotoxic snakebites and reduce their public health burden in Africa., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Snakebite envenoming (SBE) is a potentially life-threatening event that can lead to severe physical, mental, and economic hardships, particularly in under-resourced regions like sub-Saharan Africa. In Rwanda, there have been no epidemiological assessments of SBE to guide the Ministry of Health in its efforts to reduce the burden. This study had two main objectives: first, to estimate the incidence of snakebites across districts, and second, to describe formal versus informal healthcare seeking behaviors among snakebite victims in Eastern Province, Rwanda in 2020., Methodology: This cross-sectional study utilized a cluster sampling approach, involving Community Health Workers (CHWs) who recorded snakebite cases across seven districts. The descriptive analysis considered sampling weights, and healthcare seeking behavior was assessed based on the type of care sought as the first point of treatment., Findings: The study surveyed 390,546 individuals across 763 villages and estimated a provincial annual incidence rate of 4.3 cases per 1,000 individuals. Incidence estimates ranged from 1.1 cases per 1,000 in Nyagatare to 9.1 cases per 1,000 individuals in Bugesera and Ngoma districts. Among the 2,545 cases recorded by CHWs, three resulted in deaths. Regarding healthcare-seeking behavior, 13% of snakebite victims (143 out of 1,098) initially consulted formal care providers (CHWs, health post/center, or hospital), while 87% sought informal care (family/friends, pharmacist, or traditional healer). Approximately half of the victims (583, 53.1%) reported severe symptoms. Unsafe practices included skin cutting/burning, tourniquet application, use of black stones, and venom extraction; only 24 cases (2.2%) received anti-venom., Conclusions: This large-scale community-based assessment highlights variations in snakebite incidence between districts and confirms frequent involvement of traditional healers in management. Improving access to anti-venom and community education on the risks of ineffective practices, along with timely use of formal healthcare, are crucial. Collaboration between healthcare providers, traditional healers, community leaders, and policymakers is essential to implement targeted interventions for enhancing snakebite prevention and management strategies., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Hakizimana et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Introduction: Limited access to antivenoms is a global challenge in treating snakebite envenoming. In emergency situations where non-expired antivenoms are not readily available, expired antivenoms may be used to save lives with the risk of deteriorating quality, efficacy and safety. Therefore, we aimed to systematically review and summarise the sparse preclinical evidence of neutralising efficacy of expired antivenoms and real-world experience of using expired antivenoms in humans., Methods: We searched for articles published until 1 March 2023 in PubMed, Scopus, Web of Science and Embase. Studies demonstrating the preclinical studies evaluating expired antivenoms or studies describing the real-world experience of using expired antivenoms were included. Narrative synthesis was applied to summarise the evidence of expired antivenoms., Results: Fifteen studies were included. Ten were preclinical studies and five were real-world experiences of using expired antivenoms in humans. The expired duration of antivenoms in the included studies ranged from 2 months to 20 years. The quality of expired antivenoms was evaluated in one study, and they met the standard quality tests. Five studies demonstrated that the expired antivenoms' immunological concentration and venom-binding activity were comparable to non-expired ones but could gradually deteriorate after expiration. Studies consistently exhibited that expired antivenoms, compared with non-expired antivenoms, were effective when stored in proper storage conditions. The safety profile of using expired antivenoms was reported in two included studies. However, it was inconclusive due to limited information., Conclusion: Even though the quality and efficacy of expired antivenoms are comparable to non-expired antivenoms in preclinical studies, the information is limited in terms of real-world experiences of using expired antivenoms and their safety. Therefore, the use of expired antivenoms may be generally inconclusive due to scarce data. Further investigations may be needed to support the extension of antivenoms' expiration date according to their potential efficacy after expiration., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Snakebite is a global environmental and occupational hazard and a significant public health threat. In rural areas, snakebite cases often go unreported and undocumented due to the lack of access to well-structured healthcare facilities/infrastructure. In some cases, the need for antisnake venom (ASV) far outstrips supply, negatively affecting treatment outcomes. This study, therefore, assessed the epidemiological characteristics of snakebite cases, their management, and how antivenoms are utilised at the selected hospital in the Jasikan District Hospital. Methods: A 6-year retrospective study using secondary data from antivenom return forms (pharmacy records), clinical records (patient folders), the District Health Information Management System-2 (DHIMS-2) database, and consulting room registers was carried out in selected hospitals in the Jasikan District, Oti, Ghana. Results: The predominant symptom of snakebite was localised pain (71.4%). The snakebite commonly occurred at home (19%) and on farms (18%). Of the 98 snakebite cases, ASV was administered to 73 (74.5%) cases. Supportive treatment applied included prophylactic antitetanus immunoglobulin (ATS) (80.6%), prophylactic antibiotics (63%), corticosteroids (80.6%), and analgesics (63%). 95% ( n = 94) of complete recoveries were recorded; three were discharged against medical advice, and one was mortality. The supply and use of antivenom were erratic throughout the months of high incidence, partly due to inconsistent availability at the Regional Medical Stores. The average ASV vials and hospital stay duration were 1.23 ± 0.86 vials and 2.67 ± 1.97 days, respectively. Although the peak of snakebites occurs in April, May, and June, the demand for antivenom in April and May exceeded supply. Conclusion: The outcome of most snakebite case management was appropriate, irrespective of inadequate ASV supply in certain months. The erratic antivenom supply should be aligned with seasonal and facility-use patterns to enhance regional snakebite management., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Courage Edem Ketor et al.)

Envenomations are the 23rd most common reason for calls to US poison control centers, with over 35,000 incidents reported annually. Snake bites account for over 20% of those calls, while marine envenomations are likely underreported at 3% to 4%. 1 While these types of envenomations may not be encountered on a daily basis for many physicians, the different types of envenomations warrant unique management strategies based on the offending creature and symptom presentation. This text serves as a review of the epidemiology, clinical presentations, and management of endemic North American species of snakes and marine vertebrate and invertebrate envenomations., Competing Interests: Disclosure The authors declare that they do not have a current financial relationship with any non-eligible entities (commercial interests) that may have a direct interest in the subject matter of the continuing medical education program., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This report details the case of a 51-year-old man with a Tiger snake bite who developed systemic envenomation, coagulopathy and thrombotic microangiopathy (TMA) requiring renal replacement therapy. He received plasma exchange as additional therapy while awaiting confirmation of the cause of the TMA. We discuss clinical decision making in detection of systemic envenomation and management of the rare complication of TMA, as well as current Australian guidelines around antivenom administration. This is the fourth known documented case of TMA from a Tiger snake bite in Australia., (© 2024 Asian Pacific Society of Nephrology.)

Background: Snake bites cause considerable morbidity and mortality worldwide, yet evidence from low- and middle-income countries remains fragmented. This is particularly the case in Eastern Mediterranean Region where available data on snake bites is relatively weak. Without reliable data, it is difficult to make the case for greater visibility and investment to address the snakebite burden in this Region. A scoping review was therefore conducted to summarize evidence on snake bites in countries of the Eastern Mediterranean., Methodology/principal Findings: The review employed manual and electronic searching methods of four databases plus Google Scholar, ultimately including 196 records from 20 countries published between 2000 and 2023. More than half originated from Iran, Morocco, and Pakistan. Many records lacked information on permanent sequalae, disability, snake species, and types and sources of antivenoms. When identified, offending snakes belonged to 30 species. Use of more than 12 types of antivenoms were described across the Region, and some were not specific to indigenous species., Conclusion/significance: Despite the relatively large number of publications identified, the data were concentrated in just a few countries in the Region, and there was little or no information available for the remainder. As is the case worldwide, disability associated with snake bites was poorly characterized and quantified across the Region. There is an urgent need for concrete action at national and regional levels to enhance epidemiological surveillance, research, and the collection of clinical, disability and outcomes data to inform policy and public health investment. Greater regional cooperation and collaboration is also crucial for addressing this neglected disease throughout the Region., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 World Health Organization. Licensee Public Library of Science. This is an open access article distributed under the Creative Commons Attribution IGO License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://creativecommons.org/licenses/by/3.0/igo/. In any use of this article, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL.)

Snakebite envenomation remains an important, yet a neglected public health issue in most tropical and subtropical countries. Underdeveloped medical infrastructure, suboptimal medical services, poor documentation and failure to make snake-related injury a mandatory notifiable disease are important contributing factors. The King Cobra (Ophiophagus hannah) is a medically significant species encountered in Malaysia however, there have been few publications from the clinical perspective. The objectives of this study were to determine the frequency of King Cobra related injuries, geographical distribution, clinical presentation, type and frequency of antivenom utilization and the management outcome. This is a cross-sectional study of confirmed King Cobra related injuries consulted to Remote Envenomation Consultation Services (RECS) from 2015 to 2020. Data were extracted from the RECS database and descriptively analyzed. A total of 32 cases of King Cobra bite were identified. Most cases were from Peninsular Malaysia with the most frequent from the state of Pahang (n = 9, 28.1%). Most patients got bitten while attempting to catch or play with the snake (68.8%). Signs and symptoms of envenomation were documented in 24 (75.0%) cases and the most frequent systemic manifestation was ptosis (n = 13, 40.6%). Tracheal intubation and ventilatory support were required in 13 (40.6%) patients. Antivenom was administered to 22 (68.8%) patients with most (25.0%) receiving 10 vials (1 dose). The commonest antivenom used was monospecific King Cobra antivenom (50.0%) from Thai Red Cross. There was one death documented due to complications from necrotizing fasciitis and septicemia. Public awareness of the dangers and proper handling of King Cobras needs to be emphasised. Timely administration of the appropriate antivenom is the definitive treatment and leads to favorable outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Renault et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Access to antivenoms in cases of snakebite continues to be an important public health issue around the world, especially in rural areas with poorly developed health care systems. This study aims to evaluate therapeutic itineraries and antivenom accessibility following snakebites in the states of Oaxaca and Chiapas in southern Mexico. Employing an intercultural health approach that seeks to understand and bridge allopathic and traditional medical perceptions and practices, we conducted field interviews with 47 snakebite victims, documenting the therapeutic itineraries of 54 separate snakebite incidents that occurred between 1977 and 2023. Most victims used traditional remedies as a first line of treatment, often to withstand the rigors of a long journey to find antivenoms. The main obstacles to antivenom access were distance, poor antivenom availability, and cost. Standard antivenom treatment is highly valued and sought after, even as traditional beliefs and practices persist within a cultural framework known as the "hot-cold" system. The findings are crucial for informing future enhancements to antivenom distribution systems, health education initiatives, and other interventions aimed at mitigating the impact of snakebites in the region., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Vasquez et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: A 39-year-old healthy patient accidentally stepped barefoot on an adder and was then bitten into the foot. After initially only local complaints, severe systemic symptoms developed within 10-15 minutes with swelling of the lips and soft palate, recurrent vomiting, bradycardia, weakly palpable peripheral pulse, hypotension, dyspnea and intermittent somnolence. The potentially life-threatening consequences of this severe poisoning could be avoided by using adequate emergency measures and immediate intravenous administration of antivenin., Competing Interests: Die Autoren haben keine Interessenkonflikte im Zusammenhang mit diesem Artikel deklariert, (© 2024 Aerzteverlag medinfo AG.)

Snakebites are a major cause of morbidity and mortality worldwide. Snake envenomation can cause acute local and systemic effects leading to severe complications, even death. Neurological complications such as intracranial hemorrhage, subarachnoid bleed, ischemic strokes, acute disseminated encephalomyelitis, and leukoencephalopathy have been reported. Anti-snake venom which forms the mainstay of therapy also has its own set of early and delayed complications. This report describes a rare case of snakebite resulting in leukoencephalopathy and parkinsonian features., (Copyright © 2024 Copyright: © 2024 Annals of African Medicine.)

Introduction: Local tissue destruction following envenomation from North American snakes, particularly those within the Crotalinae subfamily, has the potential to progress to compartment syndrome. The pathophysiology of venom-induced compartment syndrome (VICS) is a debated topic and is distinct from trauma/reperfusion-induced compartment syndrome. Heterogeneity exists in the treatment practices of VICS, particularly regarding the decision to progress to fasciotomy. Associations with functional outcomes and evolution in clinical practice since the introduction of Crotalidae polyvalent immune Fab (FabAV) have not been well defined. Our goal was to identify the potential gaps in the literature regarding this phenomenon, as well as illuminate salient themes in the clinical characteristics and treatment practices of VICS., Methods: We conducted this systematic scoping-style review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Records were included if they contained data surrounding the envenomation and hospital course of one or more patients who were envenomated by a snake species native to North America and were diagnosed with compartment syndrome from 1980-2020., Results: We included 19 papers: 10 single- or two-patient case reports encompassing 12 patients, and nine chart reviews providing summary statistics of the included patients. In case reports, the median compartment pressure when reported was 60 millimeters of mercury (interquartile range 55-68), 66% underwent fasciotomy, and functional outcomes varied. Use of antivenom appeared to be more liberal with FabAV than the earlier antivenin Crotalidae polyvalent. Rapid progression of swelling was the most commonly reported symptom. Among the included retrospective chart reviews, important data such as compartment pressures, consistent laboratory values, and snake species was inconsistently reported., Conclusions: Venom-induced compartment syndrome is relatively rare. Existing papers generally describe good outcomes even in the absence of surgical management. Significant gaps in the literature regarding antivenom dosing practices, serial compartment pressure measurements, and functional outcomes highlight the need for prospective studies and consistent standardized reporting., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

African cobras (Naja species) represent one of the most encountered medically important snakes in Africa. They are classified as African spitting (Afronaja subgenus) and non-spitting cobras (Uraeus and Boulengerina subgenera) with similar and different characteristics. Snake venom toxins including three-finger toxin (3FTx), phospholipase A2 (PLA 2 ), and snake venom metalloproteinase (SVMP) cause snakebite envenomation leading to morbidity and mortality. The profile of the proteome of African cobra venoms will help to develop safer and more effective antivenoms. The approval of Captopril by the US Food and Drug Administration (FDA) for the treatment of cardiovascular diseases, has led to intensified research towards possible use of venom toxins as therapeutics. In this review, we compare the venom proteome profile of 3 African Naja subgenera. In both Afronaja and Boulengerina subgenera, 3FTx (Afronaja-69.79%; Boulengerina-60.56%) followed by PLA 2 (Afronaja-21.15%; Boulengerina-20.21%) dominated the venoms compared to the Uraeus subgenus dominated by 3FTx (84.55%) with little to no PLA 2 abundance (0.8%). The venom of subgenus Uraeus was distinct from the other two subgenera by the almost total absence of PLA 2 , thus indicating little or no contribution of PLA 2 in the envenomation caused by Uraeus compared to Afronaja and Boulengerina. Furthermore, we report studies on the experimental testing of African cobra venoms and toxins against diseases including anti-cancer properties., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Benedict C Offor reports financial support was provided by National Research Foundation South Africa. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To analyze the vulnerability factors of snakebite patients in China., Methods: Multi-stage random sampling was used as the main sampling method and snowball sampling as the auxiliary sampling method. The knowledge, attitude and behavior of snakebite among Chinese residents were investigated. Non-parametric test was used to compare the percentage differences in residents' knowledge, attitude and behavior of snakebite, and generalized linear regression analysis was used to analyze the influencing factors, and the vulnerability factors of snakebite patients were comprehensively analyzed., Results: A total of 6338 subjects were included in this study, of which 68.4% were males, and 58.6% were farmers, workers and service personnel. The median total score of knowledge, attitude, and behavior was 26 (22,36). The patients who were improperly treated after injury were ligation proximal to the affected area (23.43%), squeezing (21.82%), and oral and suction wounds (8.74%). Did not go to hospital due to poverty (1351 cases) and did not receive antivenom (2068 cases). There were 21.32% and 32.63%, respectively. Among 4270 patients injected with antivenom 30.7% were vaccinated within 2 h. Among the patients who went to the hospital for treatment (4987), 75.0% arrived at the hospital within 6 h; Among the 4,761 patients who made emergency calls, 37.4% were treated within 0.5 h., Conclusions: Snakebite patients in China have weak knowledge about snakebite, low awareness of medical treatment, lack of correct prevention and emergency treatment measures, dependence on folk remedies, poor housing and so on. In addition, there are low availability of antivenoms and unreasonable distribution of medical resources in some areas of China. Multisectoral and multidisciplinary cooperation should be developed to prevent and control snakebites in order to reduce the burden caused by snakebites., (© 2024. The Author(s).)

Camelid single-domain antibodies (VHH) represent a promising class of immunobiologicals for therapeutic applications due to their remarkable stability, specificity, and therapeutic potential. To enhance the effectiveness of antivenoms for snakebites, various methods have been explored to address limitations associated with serum therapy, particularly focusing on mitigating local damage and ensuring sustainable production. Our study aimed to characterize the pharmacological profile and neutralization capacity of anti-Phospholipase A 2 (PLA 2 ) monomeric VHH (Genbank accessions: KC329718). Using a post-envenoming mouse model, we used intravital microscopy to assess leukocyte influx, measured CK and LDH levels, and conducted a histopathology analysis to evaluate VHH KC329718's ability to neutralize myotoxic activity. Our findings demonstrated that VHH KC329718 exhibited heterogeneous distribution in muscle tissue. Treatment with VHH KC329718 reduced leukocyte influx caused by BthTX-I (a Lys-49 PLA2) by 28 %, as observed through intravital microscopy. When administered at a 1:10 ratio [venom or toxin:VHH (w/w)], VHH KC329718 significantly decreased myotoxicity, resulting in a 35-40 % reduction in CK levels from BthTX-I and BthTX-II (an Asp-49 PLA 2 ) and a 60 % decrease in CK levels from B. jararacussu venom. LDH levels also showed reductions of 60%, 80%, and 60% induced by BthTX-I, BthTX-II, and B. jararacussu venom, respectively. Histological analysis confirmed the neutralization potential, displaying a significant reduction in tissue damage and inflammatory cell count in mice treated with VHH KC329718 post B. jararacussu venom inoculation. This study underscores the potential of monomeric anti-PLA 2 VHH in mitigating myotoxic effects, suggesting a promising avenue for the development of new generation antivenoms to address current therapeutic limitations., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: Antivenom is first line treatment for snake envenomation worldwide, despite few placebo controlled clinical trials demonstrating effectiveness. We aimed to investigate whether early antivenom in red-bellied black snake ( Pseudechis porphyriacus ) bites would prevent systemic myotoxicity., Methods: We undertook a multicentre randomized placebo-controlled trial of antivenom for red-bellied black snake bites with patients recruited from the Australian Snakebite Project (July 2014 to June 2020). In addition, we report all patients with red-bellied black snake bites during the same period, comparing the same outcomes. Patients over 2 years of age with definite red-bellied black snake bites and early systemic effects were randomized to receive 50 per cent glucose (placebo) or tiger snake antivenom within 6 hours post-bite, or in the cohort group received antivenom determined by the treating clinician. The primary outcome was the proportion of patients with myotoxicity (peak creatine kinase activity >1,000 U/L). Secondary outcomes were: area under the curve of total creatine kinase elevation over 48 hours, presence of venom post-antivenom, and adverse reactions. We analyzed both the randomized control trial patients and the combination of randomized control trial and cohort patients., Results: Fifteen patients were recruited to the randomized controlled trial, and a cohort of 68 patients who were not randomized were included in the analysis. After treatment, two of seven patients given placebo had a peak creatine kinase activity >1,000 U/L versus none of the eight given antivenom (difference in favour of antivenom; 29 per cent; 95 per cent confidence interval:-18 per cent to +70 per cent; P  = 0.2). The median area under the curve of total creatine kinase elevation over 48 hours in patients given placebo was 0 U/L*h (interquartile range: 0-124 U/L*h), which was not significantly different to those given antivenom: 197 U/L*h (interquartile range: 0-66,353 U/L*h; P  = 0.26). Venom was not detected post-antivenom in six patients with measured venom concentrations given antivenom. Two patients given antivenom had immediate hypersensitivity reactions, one severe anaphylaxis, and another had serum sickness. Combining randomized and not randomized patients, three of 36 (8 per cent) administered antivenom less than 6 hours post-bite had a peak creatine kinase activity >1,000 U/L versus 17/47 (36 per cent) patients not receiving antivenom less than 6 hours post-bite (difference in favour of antivenom 29 per cent; 95 per cent confidence interval: 8 per cent to 44 per cent; P  < 0.004). Overall, 13/36 (36 per cent) patients administered antivenom within 6 hours had hypersensitivity reactions, six severe anaphylaxis (17 per cent)., Discussion: We found that early antivenom was effective in red-bellied black snake bites, and only three patients need to be given antivenom within 6 hours to prevent myotoxicity in one (number needed to treat = 3). However, one in three patients administered antivenom developed a hypersensitivity reaction, and one in six had severe anaphylaxis. The major limitation of this study was the small number of patients recruited to the randomized controlled trial., Conclusion: Administration of antivenom in red-bellied black snake envenomation within 6 hours post-bite appeared to decrease the proportion of patients with myotoxicity, but a third of patients had adverse reactions.

Background: The Western diamondback rattlesnake ( Crotalus atrox ) is a medically important venomous snake in the Southwestern United States, injuring humans, and their companion animals. The goals of this investigation were to utilize a rabbit model of subcutaneous envenomation to assess Crotalus atrox venom coagulopathy and determine the efficacy of a ruthenium-containing antivenom (RA) in attenuating it., Methods: Sedated New Zealand White rabbits had viscoelastic measurements of whole blood coagulation kinetics obtained from ear artery samples. Crotalus atrox venom (4 mg/kg) was injected subcutaneously and changes in coagulation determined over three hours and compared to samples obtained prior to envenomation. Other rabbits had site-directed RA injected 5 min after venom injection., Results: A significant decrease in the velocity of clot growth and thrombus strength was observed in animals injected with venom alone. Site-directed administration of RA resulted in no change in coagulation over the 3 h following venom injection. The interaction of antivenom administration and time was significantly different in the cases of clot growth velocity and strength., Conclusions: A novel rabbit model was used to define the toxicodynamic profile of coagulopathy of Crotalus atrox venom and demonstrate the efficacy of RA. Future investigation is planned involving other medically important venoms and RA administration., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Snakebite envenomation is a significant life-threatening public health problem in Southeast Asia (SEA). In this region, India reported the largest number of snakebite deaths from 2000 to 2019 (1.2 million), with an average of 58,000 deaths yearly., Methods: This prospective observational study was carried out among snakebite victims at the emergency department (ED) of a tertiary care public sector hospital in eastern India., Results: A total of 145 cases of venomous snakebite were investigated. More than half ( n  = 81, 56%) of the snakebite victims were between 17 to 45 years. Most of the snakebite victims were male (68%) and were farmers (53%) by occupation. The majority of snakebites occurred during the daytime (76%) and while outdoors (67%). Most victims sustained a bite on the lower extremity (71%). The peak incidence of snakebites occurred from June to September (69%). Three-quarters of all patients were unaware of the required first aid measures following a snakebite. Among the 145 venomous snakebites, 48 were presumptively identified as the Indian cobra, 32 by the Indian krait, 56 by the Russel's viper, and 9 by saw-scaled viper. The mean duration from the snakebite to the onset of systemic effects in the Indian cobra was 52 ± 14.28 min, 66 ± 18.35 min in the Indian krait, 42 ± 13.47 min in Russel's viper, and 48 ± 16.38 min in saw-scaled viper. Respiratory failure was the commonly observed complication following an elapid envenomation. The mortality rate was 2.1% among the patients treated with antivenom., Conclusions: Snakebite is considered an occupational hazard in India, commonly affecting the young population in their productive period. The peak incidence was during monsoon season, and the majority had neurotoxic envenomation following an elapid bite (55%) that contributed to the increased mortality and morbidity among young adults. Of the 145 patients, the majority (84%) recovered fully with treatment; 16% of the victims developed morbidity viz cellulitis, respiratory failure, acute renal failure, compartment syndrome, local tissue necrosis, intracerebral hemorrhage, and disseminated intravascular coagulation. Appropriate first aid measures and timely medical intervention can significantly improve the treatment outcome following snakebites., Competing Interests: Declaration of Conflicting InterestsThe authors have no potential conflicts of interest to disclose.

Many snakebite deaths in India may remain unreported as these patients still seek treatment from traditional healers or quacks. Though local and systemic toxicity due to snake envenomation is quite common, the clinical presentation as disseminated extensive tissue damage and ulceration is not seen. We present a lady who presented with extensive skin erosions with tissue necrosis in all four limbs and the trunk. The case was successfully managed with antisnake venom, wound debridement, and split skin grafting. Early antisnake venom halts the progression of tissue damage effects of snake venom. The future treatment of these extensive ulcerations may be the use of drugs that can inhibit the hydrolyzing enzymes of snake venom. The case also stresses the need for excellent wound care after the management of systemic envenomation with antivenom treatment., (© Journal of the Association of Physicians of India 2024.)

This report details a documented case of fatal King cobra (Ophiophagus hannah) envenomation in the Philippines. A 46-year-old woman from a mountainous town in Leyte was bitten on her left thigh by a snake. Despite receiving prompt medical attention, including administration of fluids and oxygen, she went into arrest and succumbed within 2.5 hours of the bite. Inadequate pre-hospital care, including endotracheal intubation and assisted ventilation, highlights a notable gap in emergency medical services. Photographic evidence, verified by a herpetologist, confirmed the involvement of a King cobra, with venom presenting with a swift and lethal systemic effect that led to the patient's demise, despite minimal local manifestations. This incident accentuates the urgent need for accessible, effective antivenom and improved snakebite management protocols in the Philippines. It also calls for heightened awareness and preparedness among pre-hospital healthcare providers and the public, alongside advocating for more research into snakebite envenomation., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

The genus Vipera encompasses most species of medically significant venomous snakes of Europe, with Italy harbouring four of them. Envenomation by European vipers can result in severe consequences, but underreporting and the absence of standardised clinical protocols hinder effective snakebite management. This study provides an updated, detailed set of guidelines for the management and treatment of Vipera snakebite tailored for Italian clinicians. It includes taxonomic keys for snake identification, insights into viper venom composition, and recommendations for clinical management. Emphasis is placed on quick and reliable identification of medically relevant snake species, along with appropriate first aid measures. Criteria for antivenom administration are outlined, as well as indications on managing potential side effects. While the protocol is specific to Italy, its methodology can potentially be adapted for other European countries, depending on local resources. The promotion of comprehensive data collection and collaboration among Poison Control Centres is advocated to optimise envenomation management protocols and improve the reporting of epidemiological data concerning snakebite at the country level.

African spitting cobra, Naja nigricincta nigricincta (Zebra snake), envenomation is an important cause of snakebite morbidity and mortality in Namibia. The snake is endemic to central and northern Namibia as well as southern Angola. The venom is mainly cytotoxic, resulting in aggressive dermo-necrosis and often accompanied by severe systemic complications. No specific antivenom exists. Rhabdomyolysis, systemic inflammatory response, haemostatic abnormalities, infective necrotising fasciitis as well as acute kidney failure have been documented. Based on murine models, this study assessed SAVP/SAIMR - and EchiTAb-Plus-ICP polyvalent antivenom neutralisation as well as subdermal necrosis. Additional muscle, cardiac, kidney and lung histology, creatine kinase measurements and post-mortems were performed. An intravenous median lethal dose (LD50) of Naja nigricincta nigricincta venom was determined at 18.4 (CI: 16.3; 20.52) μg and a subdermal lethal dose at 15.3(CI: 12.96; 17.74)μg. The SAIMR/SAVP polyvalent antivenom median effective dose (ED50) was 1.2 ml antivenom/1 mg venom equating to a potency (WHO) of 1 ml antivenom neutralising 0.63 mg venom and approximately 240 ml (24 vials) needed for initial treatment. The ED50 of the EchiTAb-Plus-ICP was 1 ml antivenom/1 mg venom and a potency of 65 mg venom/ml antivenom (3.3 x LD 50 ), estimating 230 ml (23 vials) for treatment. Histology and serology (creatine kinase) evidenced venom induced skeletal myotoxicity, which was not prevented by the antivenoms tested. Cardiac myonecrosis, an inflammatory response, direct venom kidney tubular necrosis and cardio-pulmonary failure were documented., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Esta Saaiman reports financial support was provided by Lady Pohamba Private Hospital, Windhoek, Namibia. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This retrospective, observational study describes the clinical findings, case management trends, and outcomes of 83 dogs and nine cats exposed to eastern coral snakes in a university teaching hospital setting. The medical records of dogs and cats that received antivenom following coral snake exposure were reviewed. Data collected included signalment, time to antivenom administration, physical and laboratory characteristics at presentation, clinical course during hospitalization, length of hospitalization, and survival to discharge. The mean time from presentation to coral snake antivenom administration was 2.26 ± 1.46 h. Excluding cases where the owner declined in-hospital care, the mean hospitalization time for dogs and cats was 50.8 h and 34 h, respectively. The mean number of antivenom vials was 1.29 (1-4). Gastrointestinal signs (vomiting and ptyalism) occurred in 42.2% (35/83) of dogs and 33.3% (3/9) of cats. Peripheral neurologic system deficits (ataxia, paresis to plegia, absent reflexes, and hypoventilation) were noted in 19.6% (18/92) of dogs and cats. Hemolysis was also common in 37.9% (25/66) of dogs but was not observed in cats. Mechanical ventilation (MV) was indicated in 12% (10/83) of dogs but no cats. Acute kidney injury (AKI), while rare, was a common cause of euthanasia at 20% (2/5) and was the most common complication during MV at 44.4% (4/9). Pigmenturia/hemolysis occurred in 88.9% (8/9) of MV cases and in all cases with AKI. Despite delays in antivenom administration by several hours, dogs and cats with coral snake exposure have low mortality rates (6% of dogs (5/83) and 0% of cats). Gastrointestinal signs were common but were not predictive of progression to neurological signs. Thus, differentiating between coral snake exposure and envenomation before the onset of neurological signs remains challenging.

Certain snake envenomation patients with consumptive coagulopathy, termed venom-induced consumption coagulopathy, develop thrombotic microangiopathy (TMA). Due to predominant renal involvement, TMA is said to resemble haemolytic uraemic syndrome and is treated with haemodialysis. We present a case of a young male who presented to the emergency department after being bitten by a white-lipped pit viper ( Trimeresurus albolabris ). He developed heart failure in addition to acute kidney injury secondary to TMA. He was treated with 30 vials of anti-snake venom according to national guidelines and underwent haemodialysis. Despite haemodialysis, the patient's ventilatory parameters continued to worsen, necessitating invasive mechanical ventilation. Thus, he was initiated on plasma exchange therapy, to which the patient responded well. TMA has not been reported in Trimeresurus envenomations yet, to the best of our knowledge. Additionally, plasma exchange therapy can be considered an adjunctive therapy for snakebite patients who develop TMA., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

In cases of severe envenomation due to snakebites, patients require antivenom, intensive care management, including respiratory support, haemodynamic monitoring and renal replacement therapy. Early recognition and treatment of complications such as acute kidney injury, rhabdomyolysis and coagulopathy are important to improve outcomes.Tele-ICU models can play a critical role in providing access to critical care expertise and nuanced support to remote healthcare facilities that may not have the necessary resources or expertise to manage complex cases of envenomation. With the help of telemedicine technology, remote intensivists can provide timely guidance on diagnosis and ongoing management, improving the quality of care and outcomes for patients. We discuss two patients in resource-constrained regions of India with severe envenomation who were managed with tele-ICU support., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Snakebite envenoming and its resulting complications are serious threats to the health of vulnerable people living in rural areas of developing countries. The knowledge of the heterogeneity of symptoms associated with snakebite envenoming and their management strategies is vital to treat such life-threatening complications to save lives. Russell's viper envenomation induces a diverse range of clinical manifestations from commonly recognised haemotoxic and local effects to several rare conditions that are often not reported. The lack of awareness about these unusual manifestations can affect prompt diagnosis, appropriate therapeutic approaches, and positive outcomes for patients. Here, we report pulmonary thromboembolism that developed in three patients following Russell's viper envenomation and demonstrate their common clinical features and diagnostic and therapeutic approaches used. All patients showed clinical signs of local (oedema) and systemic (blood coagulation disturbances) envenomation, which were treated using polyvalent antivenom. They exhibited elevated heart rates, breathlessness, and reduced oxygen saturation, which are non-specific but core parameters in the diagnosis of pulmonary embolism. The recognition of pulmonary embolism was also achieved by an electrocardiogram, which showed sinus tachycardia and computed tomography and echocardiogram scans further confirmed this condition. Anti-coagulant treatment using low-molecular-weight heparin offered clinical benefits in these patients. In summary, this report reinforces the broad spectrum of previously unreported consequences of Russell's viper envenomation. The constant updating of healthcare professionals and the dissemination of major lessons learned in the clinical management of snakebite envenoming through scientific documentation and educational programs are necessary to mitigate the adverse impacts of venomous snakebites in vulnerable communities.

Snakebite envenomation remains a neglected tropical public health issue claiming thousands of lives every year. It is a common medical emergency and a threat to the impoverished populations of low-income and middle-income countries including India. A combination of ischaemic stroke and deep vein thrombosis is a devastating duo complication of snake bite, with no literature report to date. Here, the authors report an unusual case of a young woman developing ischaemic stroke and deep vein thrombosis following snakebite even after the use of antivenom. MRI brain showed right thalamic infarct with haemorrhagic transformation and, ultrasound Doppler revealed right lower limb deep vein thrombosis. The pathophysiology of deep vein thrombosis and ischaemic stroke is complex. It is believed that the activation of the coagulation cascade, complement system together with endothelial injury and immune activation leads to inflammation, thrombosis and occlusion of smaller and even larger vessels., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

In Taiwan, six medically important venomous snakes, Trimeresurus stejnegeri stejnegeri, Protobothrops mucrosquamatus, Deinagkistrodon acutus, Daboia siamensis, Naja atra, and Bungarus multicinctus, are found. However, comprehensive research on the complications and associated healthcare costs of snakebite envenomation (SBE) is lacking. We retrospectively analyzed pertinent information from the Taiwan National Health Insurance Research Database dated January 2002 to December 2014. We investigated the risk factors for complications and their impact on healthcare costs. Among the 12,542 patients with SBE, those from N. atra or B. multicinctus were more likely to experience wound infections and neurological complications than were those from T. s. stejnegeri or P. mucrosquamatus. In addition, being female, being elderly, and having a Charlson Comorbidity Index equal to or greater than 3 points were associated with an increased likelihood of wound infections and psychological complications. The annual national economic burden averaged US$1,083,624, with an average healthcare cost of US$1,129 per SBE. Snakebite envenomations from N. atra or B. multicinctus, as well as various complications, resulted in significantly higher costs. It is crucial to comprehend the risk factors for complications and their role in increasing expenses to provide insight for tailored healthcare interventions, mitigate complications, and reduce the economic burdens associated with SBEs.

Members of the genus Protobothrops are amongst the more than twenty-eight range-restricted Indian pit viper species. Their bites and envenomings are rarely documented from India. Pit viper envenomings can be challenging to treat in the Indian setting, since available antivenoms do not satisfactorily neutralize their venoms. Herein, we present the first Indian reports on bites and envenoming by Protobothrops jerdonii and Protobothrops himalayanus resulting in local effects, coagulopathy and acute kidney injury in the case of the former and possible mild, isolated coagulopathy in the case of the latter; and discuss management-related challenges in the context of absent specific antivenoms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Green pit vipers are one of the most widely distributed group of venomous snakes in south-east Asia. In Indian, green pit vipers are found in the Northern and North-eastern states spreading across eastern and central India and one of the lesser studied venoms. High morphological similarity among them has been a long-established challenge for species identification, however, a total of six species of Indian green pit viper belonging to genus Trimeresurus, Popeia and Viridovipera has been reported from North-east India. Biochemical and biological studies have revealed that venom exhibits substantial variation in protein expression level along with functional variability. The symptoms of envenomation are painful swelling at bite site, bleeding, necrosis along with systemic toxicity such as prolonged coagulopathy. Clinical data of green pit viper envenomated patients from Demow community health centre, Assam advocated against the use of Indian polyvalent antivenom pressing the need for a suitable antivenom for the treatment of green pit viper envenomation. To design effective and specific antivenom for green pit vipers, unveiling the proteome profile of these snakes is needed. In this study, a comparative venomic of green pit vipers of Northern and North-eastern India, their clinical manifestation as well as treatment protocol has been reviewed., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Scorpion envenomation poses a global public health issue, with an estimated 1,500,000 cases worldwide annually resulting in 2600 deaths. North Africa, particularly Morocco, experiences severe envenomations, mainly attributed to Androctonus mauretanicus and Buthus occitanus in Morocco, and Buthus occitanus and Androctonus australis hector in Algeria and Tunisia, with case numbers often underestimated. Current treatment relies mainly on symptomatic approaches, except in Morocco, where management is limited to symptomatic treatment due to controversies regarding specific treatment. In Morocco, between 30,000 and 50,000 scorpion envenomation cases are reported annually, leading to hundreds of deaths, mainly among children. Controversies among clinicians persist regarding the appropriate course of action, often limiting treatments to symptomatic measures. The absence of a specific antivenom for the venoms of the most lethal scorpions further exacerbates the situation. This study aims to address this gap by developing a monovalent antivenom against the endemic and most dangerous scorpion, Androctonus mauretanicus . The antivenom was produced by immunizing albino rabbits with a mixture of Androctonus mauretanicus venom collected from high-risk areas in Morocco. Immunizations were performed by subcutaneous injections at multiple sites near the lymphatic system, following an immunization schedule. Production control of neutralizing antibody titers was conducted through immunodiffusion. Once a sufficient antibody titer was achieved, blood collection was performed, and the recovered plasma underwent affinity chromatography. The efficacy of purified IgG was evaluated by determining the ED 50 in mice, complemented by histological and immunohistochemical studies on its ability to neutralize venom-induced tissue alterations and the neutralization of toxins bound to receptors in the studied organs. The monovalent antivenom demonstrated specificity against Androctonus mauretanicus venom and effective cross-protection against the venom of the scorpions Buthus occitanus and Androctonus australis hector , highly implicated in lethal envenomations in the Maghreb. This study shows that the developed monovalent antivenom exhibits notable efficacy against local scorpions and a surprising ability to neutralize the most lethal envenomations in North Africa. These results pave the way for a new, more specific, and promising therapeutic approach to countering severe scorpion envenomations, especially in Morocco, where specific treatment is lacking.

Envenomation of humans by snakes, a global health challenge, is poorly studied in liver transplant recipients. We report a case of rattlesnake envenomation in a 52-year-old female patient who had previously received a liver transplant to treat nonalcoholic steatohepatitis cirrhosis. Despite stable graft function since her transplant, she exhibited elevated liver enzymes on admission, with a mixed hepatocellular and cholestatic pattern. Treatment included CroFab Crotalidae polyvalent immune Fab (ovine) antivenom and close monitoring, with continuation of her standard immunosuppression regimen. Inpatient observation showed reduced swelling and pain but persistently elevated enzymes. Imaging indicated fatty infiltration with patent hepatic vasculature. Her liver enzymes improved spontaneously, and she was discharged after 5 days, with complete normalization of herliver enzyme levels as shown by repeated laboratory test results 1 month later. Our case emphasizes the risk of graftinjury in liver transplant recipients, as well as the need for vigilant monitoring and early antivenom administration. We urge furtherresearch to establish guidelines for optimal care in this unique population.

Snake envenomation is relatively common in small animals, particularly in endemic areas. Effects and outcomes of envenomation during pregnancy are poorly described in humans and more so in veterinary patients. Two young pregnant female dogs presented to a university teaching hospital with a history of acute soft tissue swelling and bleeding. History, physical examination findings, and diagnostics were consistent with envenomation by crotalid snakes. Medical management of one of the dogs included administration of antivenin. Both dogs survived envenomation with minimal complications and went on to whelp without complications, and all fetuses survived. This is the first description of the management of pit viper envenomation in pregnant dogs., (© 2024 by American Animal Hospital Association.)

Background: A minority of snake envenomations in the United States involve non-native snakes. In this report, we describe what we believe is the first documented human envenoming from an emerald horned pitviper, Ophryacus smaragdinus., Case Report: A previously healthy 36-year-old woman was bitten on her left index finger by a captive emerald horned pitviper she was medicating at work. Swelling to the entire hand was present on emergency department arrival. She had no systemic symptoms and her initial laboratory studies were unremarkable. The affected limb was elevated. We administered five vials of Antivipmyn TRI Ⓡ (Bioclon), which specifically lists Ophryacus among the envenomations for which it is indicated. She developed pruritus and was treated with IV diphenhydramine and famotidine. Her swelling improved, but her repeat laboratory studies were notable for a platelet count of 102 K/µL and a fibrinogen level of 116 mg/dL. She declined additional antivenom because of the previous allergic reaction. She was admitted for further monitoring and pain control. Subsequent laboratory tests were better, but a small hemorrhagic bleb developed at the bite site. She was discharged the next day and followed up as an outpatient. Her swelling had resolved, her bleb had healed, and her laboratory studies continued to improve. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians may be required to treat bites from non-native snakes. Many of these bites will warrant treatment with non-U.S. Food and Drug Administration-approved antivenoms. Consultation with a regional poison center or medical toxicologist may be necessary to procure the proper antivenom., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)