Snakebite envenoming in Kerala, South India: clinical profile and factors involved in adverse outcomes

N Suchithra; J M Pappachan; P Sujathan

doi:10.1136/emj.2007.051136

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Snakebite envenoming in Kerala, South India: clinical profile and factors involved in adverse outcomes

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Re: Snakebite envenoming in Kerala
Joseph M Pappachan
Published on: 10 July 2008
Re: Polyvenin for snake bites
Joseph M Pappachan
Published on: 10 July 2008
Re: Ventricular tachycardia following snake bite envenoming
Joseph M Pappachan
Published on: 10 July 2008
Ventricular tachycardia following snake bite envenoming
Johnson Francis
Published on: 3 June 2008
Snakebite envenoming in Kerala
Sunil Munshi
Published on: 3 June 2008
Polyvenin for snake bites
Rayirath B Balasundaram
Published on: 3 June 2008

Published on: 10 July 2008
Re: Snakebite envenoming in Kerala
- Joseph M Pappachan
Author’s reply:
The opinion by Dr. S K Munshi and Dr. M Chauhan is very relevant, considering the low prevalence rate of snakebite envenoming in most of the developed countries including the UK. The London School of Hygiene & Tropical Medicine offers masters degree (MSc) in Tropical Medicine & International Health, but the training does not include learning about this important biohazard that is common i...
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Author’s reply:
The opinion by Dr. S K Munshi and Dr. M Chauhan is very relevant, considering the low prevalence rate of snakebite envenoming in most of the developed countries including the UK. The London School of Hygiene & Tropical Medicine offers masters degree (MSc) in Tropical Medicine & International Health, but the training does not include learning about this important biohazard that is common in the tropical countries.[1]
References:
[1] http://www.lshtm.ac.uk/prospectus/masters/mstmih.html
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Conflict of Interest:
None declared.
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Published on: 10 July 2008
Re: Polyvenin for snake bites
- Joseph M Pappachan
Author’s reply:
The use of species-specific snake antivenom is more scientific, as suggested by Prof. Balasundaram, whenever correct species identification of the offender snake is possible. But species identification may not be possible in many cases of snakebites as observed in our study (65.5%). Species-specific antivenom is not freely available in India and the majority of centers use polyvalent antivenom f...
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Author’s reply:
The use of species-specific snake antivenom is more scientific, as suggested by Prof. Balasundaram, whenever correct species identification of the offender snake is possible. But species identification may not be possible in many cases of snakebites as observed in our study (65.5%). Species-specific antivenom is not freely available in India and the majority of centers use polyvalent antivenom for treating snakebite envenoming. Even in Malaysia, polyvalent antivenom is still in use, though specific antivenom is more commonly used.[1] The incidence of allergic reactions may be less common with specific antivenom, but the reactions are not unusual and even the rate of their occurrence may be species- specific.[2]
Species identification based only on symptoms and signs of envenoming and the known prevalence of type of snakes in the locality, without observing the offender snake may not be always correct because of the similarity of some of the symptoms of envenoming by different species. Use of polyvalent antivenom may be justified in such situations and also when species-specific antivenom is unavailable.
References:
[1] Jamaiah I, Rohela M, Ng TK, et al. Retrospective prevalence of snakebites from Hospital Kuala Lumpur (HKL) (1999-2003). Southeast Asian J Trop Med Public Health. 2006; 37: 200-5.
[2] Isbister GK, Brown SG, Macdonald E, White J, Currie BJ; The Australian Snakebite Project Investigators. Current use of Australian snake antivenoms and frequency of immediate-type hypersensitivity reactions and anaphylaxis. Med J Aust. 2008;188: 473-476.
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Conflict of Interest:
None declared.
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Published on: 10 July 2008
Re: Ventricular tachycardia following snake bite envenoming
- Joseph M Pappachan
Author’s reply:
The concept of door to needle time/ medical contact to needle time in the treatment snakebite envenoming proposed by Prof. J Francis is important. All the patients who reached the emergency department of our institution directly, with clinical and laboratory evidence of envenoming at the time of arrival, received antivenom as soon as the diagnosis of envenoming was made. Hence the medical contac...
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Author’s reply:
The concept of door to needle time/ medical contact to needle time in the treatment snakebite envenoming proposed by Prof. J Francis is important. All the patients who reached the emergency department of our institution directly, with clinical and laboratory evidence of envenoming at the time of arrival, received antivenom as soon as the diagnosis of envenoming was made. Hence the medical contact to needle time could have been small and negligible. We could not estimate the medical contact to needle time in those cases referred to us from other institutions after receiving antivenom. The higher medical contact to needle time could be an important reason for the high snakebite-related complications and mortality rates in many states of India. Lack of adequate training in the management of envenoming and fears about complications related to envenoming and the high rates of allergic reactions to antivenom, prevent primary-care physicians to start antivenom even if it is available locally. [1] Attempts to lower the medical contact to needle time by proper training of the primary-care physicians and making antivenom available even in the rural settings should reduce the snakebite-related mortality rates and complications in India.
Though cardiac manifestations are not uncommon, ventricular tachycardia is rarely reported as a complication of snakebite envenoming as commented by Prof. Francis. The patient who developed ventricular tachycardia in our series had been a 32-year old male with viper envenoming. His ECG and echocardiography had been normal after the cure of envenoming. Electrophysiological studies had not been advised because of the absence of structural heart disease at baseline and the patient had been advised to follow up the cardiology clinic if he develops any cardiac symptoms later. The exact cause of ventricular tachycardia could not be found in this patient and we presume that his cardiac arrythmia had been a manifestation of envenoming. Even myocardial infarction in the absence of coronary artery disease had been reported as a complication of snakebite envenoming. [2]
Cardiac manifestations may be related to various properties of snake venom that cause damage to remote tissues and organs. Cobra cardiotoxins, a family of basic polypeptides having lipid- and heparin-binding capacities similar to the cell-penetrating peptides, had been shown to induce severe tissue necrosis and systolic heart arrest in snakebite victims. [3] Tumor necrosis factor alpha and xanthine oxidase had been proposed as potential mediators of tissue injury including cardiac damage caused by viper venom. [4] L-amino acid oxidases of snake venom had been shown to cause severe pneumorrhagia, pulmonary interstitial edema, fusion of pulmonary alveoli, cardiac interstitial edema and bleeding when injected intravenously in experimental animals. [5]
References:
[1] Simpson ID. Snakebite management in India, the first few hours: a guide for primary care physicians. J Indian Med Assoc. 2007; 105: 324, 326, 328.
[2] Saadeh AM. Case report: Acute myocardial infarction complicating a viper bite. Am J Trop Med Hyg. 2001; 64: 280-2.
[3] Wang CH, Liu JH, Lee SC, Hsiao CD, Wu WG. Glycosphingolipid- facilitated membrane insertion and internalization of cobra cardiotoxin. The sulfatide.cardiotoxin complex structure in a membrane-like environment suggests a lipid-dependent cell-penetrating mechanism for membrane binding polypeptides. J Biol Chem. 2006; 281: 656-67.
[4] Szold O, Weinbroum AA, Ben-Abraham R, Englender TE, Ovadia D, Sorkine P. Xanthine oxidase and tumor necrosis factor alpha: possible mediators of remote tissue injury after viper envenomation. Isr Med Assoc J. 2000; 2: 816-20.
[5] Wei XL, Wei JF, Li T, et al. Purification, characterization and potent lung lesion activity of an L-amino acid oxidase from Agkistrodon blomhoffii ussurensis snake venom. Toxicon. 2007; 50: 1126-39.
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Conflict of Interest:
None declared.
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Published on: 3 June 2008
Ventricular tachycardia following snake bite envenoming
- Johnson Francis, Professor of Cardiology
Dear Editor,
Read with interest the original article by Suchithra et al on "Snakebite envenoming in Kerala, South India: clinical profile and factors involved in adverse outcomes". The concept of bite to needle time is quite interesting and informative. The authors found a positive correlation between lower bite to needle time and prognosis. What about the door to needle time / medical contact to needle time? Thi...
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Dear Editor,
Read with interest the original article by Suchithra et al on "Snakebite envenoming in Kerala, South India: clinical profile and factors involved in adverse outcomes". The concept of bite to needle time is quite interesting and informative. The authors found a positive correlation between lower bite to needle time and prognosis. What about the door to needle time / medical contact to needle time? This concept will be useful in evaluating the efficacy of triage in the emergency department, as has been found to be useful in the case of thrombolysis in myocardial infarction.
The authors also report a case of ventricular tachycardia in a patient with no structural heart disease. No further details on this case could be found in the article. A case of torsades de pointes in a patient with severe panhypopituitarism and central diabetes insipidus following snake bite has been reported from our insitution [1]. A quick PubMed search has revealed just two other case reports of ventricular tachycardia following snake bite [2,3]. It will be interesting to know more about this rare occurrence of ventricular tachycardia in a person with normal heart following snake bite envenoming. Though detailed electrophysiological evaluation is out of question in the setting of snake bite envenoming, it will be worthwhile following them up for potential recurrences and if possible a full electrophysiological evaluation at a later date.
[1] Krishnan MN, Kumar S, Ramamoorthy KP. Severe panhypopituitarism and central diabetes insipidus following snake bite: unusual presentation as torsades de pointes. J Assoc Physicians India. 2001;49:923-4.
[2] Thewjitcharoen Y, Poopitaya S. Ventricular tachycardia, a rare manifestation of Russell's viper bite: case report. J Med Assoc Thai. 2005;88:1931-3
[3] Hafeez S, Majeed I. Cardiac arrhythmia as presentation of snakebite. J Coll Physicians Surg Pak. 2004;14:48-9
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Conflict of Interest:
None declared.
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Published on: 3 June 2008
Snakebite envenoming in Kerala
- Sunil Munshi, Physician
- Other Contributors:
  Sunil K Munshi, Maya Chauhan
My congratulations to N Suchithra, J M Pappachan and P Sujathan for a brilliant and highly informative article(Emerg. Med. J. 2008;25;200-204)by N Suchithra, J M Pappachan and P Sujathan on this very important topic. Physicians in the west have a very little idea of this aspect of Tropical Medicine and it is very important that institutions teaching and training people in Tropical Medicine in the UK encourage trainees to s...
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My congratulations to N Suchithra, J M Pappachan and P Sujathan for a brilliant and highly informative article(Emerg. Med. J. 2008;25;200-204)by N Suchithra, J M Pappachan and P Sujathan on this very important topic. Physicians in the west have a very little idea of this aspect of Tropical Medicine and it is very important that institutions teaching and training people in Tropical Medicine in the UK encourage trainees to spend a substantial amount of time in India and Africa side by side with local physicians such as the current authors. Well done to the authors!
Sunil K Munshi Consultant Physician
& Maya Chauhan Senior House Officer Nottingham University Hospitals
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Conflict of Interest:
None declared.
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Published on: 3 June 2008
Polyvenin for snake bites
- Rayirath B Balasundaram, Professor of Family Medicine
In my experience in treating snake bites, especially the Malaysian pit viper in the sixties in Kelantan State, it is importnat to make more use of specific anti-venins rather than polyvenins. The latter are known to cause allergic reactions to the horse serum used, delay more specific therapy and poorer outcome. Where the identification of snakes is not possible, clinical features as well as the known prevalence of type...
Show More

In my experience in treating snake bites, especially the Malaysian pit viper in the sixties in Kelantan State, it is importnat to make more use of specific anti-venins rather than polyvenins. The latter are known to cause allergic reactions to the horse serum used, delay more specific therapy and poorer outcome. Where the identification of snakes is not possible, clinical features as well as the known prevalence of type of snakes in the locality should guide the choice of a specific anti-venin. In Malaysia, we have our own specific anti-venins locally produced. Prof Dato Dr R Balasundaram
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Conflict of Interest:
None declared.
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