Abstract
BackgroundVenom recurrence or persistence in the circulation after antivenom treatment has been documented many times in viper envenoming. However, it has not been associated with clinical recurrence for many snakes, including Russell's viper (Daboia spp.). We compare the recovery of coagulopathy to the recurrence or persistence of venom in patients with Russell's viper envenoming.Methodology/Principal FindingsThe study included patients with Russell's viper (D. russelii) envenoming presenting over a 30 month period who had Russell's viper venom detected by enzyme immunoassay. Demographics, information on the snake bite, and clinical effects were collected for all patients. All patients had serum collected for venom specific enzyme immunoassay and citrate plasma to measure fibrinogen levels and prothrombin time (international normalised ratio; INR). Patients with venom recurrence/persistence were compared to those with no detectable recurrence of venom. There were 55 patients with confirmed Russell's viper envenoming and coagulopathy with low fibrinogen concentrations: 31 with venom recurrence/persistence, and 24 with no venom detected post-antivenom. Fibrinogen concentrations increased and INR decreased after antivenom in both the recurrence and non-recurrence patients. Clinical features, laboratory parameters, antivenom dose and length of hospital were similar for both groups. Pre-antivenom venom concentrations were higher in patients with venom recurrence/persistence with a median venom concentration of 385 ng/mL (16–1521 ng/mL) compared to 128 ng/mL (14–1492 ng/mL; p = 0.008).ConclusionRecurrence of Russell's viper venom was not associated with a recurrence of coagulopathy and length of hospital stay. Further work is required to determine if the detection of venom recurrence is due to the venom specific enzyme immunoassay detecting both venom-antivenom complexes as well as free venom.
Highlights
Snake envenoming is a major public health issue in many resource poor countries in the rural tropics [1]
Further work is required to determine if the detection of venom recurrence is due to the venom specific enzyme immunoassay detecting both venom-antivenom complexes as well as free venom
Pre-antivenom venom concentrations were significantly higher in patients with venom recurrence or persistence with a median venom concentration of 385 ng/mL (16 to 1521 ng/mL) compared to patients without recurrence/persistence with a median venom concentration of 128 ng/mL (14 to 1492 ng/ mL; p = 0.008; Fig. 2)
Summary
Snake envenoming is a major public health issue in many resource poor countries in the rural tropics [1]. Venom concentrations are measured before and after antivenom and the absence of venom in blood post-antivenom has been interpreted to mean that sufficient antivenom has been administered and envenoming will resolve. This has been used as an important end-point in recent studies in Australia showing that one vial of antivenom is sufficient for the treatment of all Australian elapids [2]. Venom recurrence or persistence in the circulation after antivenom treatment has been documented many times in viper envenoming. We compare the recovery of coagulopathy to the recurrence or persistence of venom in patients with Russell’s viper envenoming
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