Abstract
Snakebite is classified by the WHO as a neglected tropical disease. Envenoming is a significant public health problem in tropical and subtropical regions. Neurotoxicity is a key feature of some envenomings, and there are many unanswered questions regarding this manifestation. Acute neuromuscular weakness with respiratory involvement is the most clinically important neurotoxic effect. Data is limited on the many other acute neurotoxic manifestations, and especially delayed neurotoxicity. Symptom evolution and recovery, patterns of weakness, respiratory involvement, and response to antivenom and acetyl cholinesterase inhibitors are variable, and seem to depend on the snake species, type of neurotoxicity, and geographical variations. Recent data have challenged the traditional concepts of neurotoxicity in snake envenoming, and highlight the rich diversity of snake neurotoxins. A uniform system of classification of the pattern of neuromuscular weakness and models for predicting type of toxicity and development of respiratory weakness are still lacking, and would greatly aid clinical decision making and future research. This review attempts to update the reader on the current state of knowledge regarding this important issue.
Highlights
Snakebite is a neglected tropical disease of global importance [1]
While the pathological significance of these toxic effects in humans is not clear, these findings clearly demonstrate the possibility of neurotoxins affecting the central nervous system
The clinical manifestations of acute neuromuscular weakness with respiratory involvement are well recognised, it is surprising how many questions remain unanswered regarding neurotoxicity. This lack of clarity may at least partly be explained by the emerging evidence that has led to an increased understanding of neuromuscular transmission
Summary
Snakebite is a neglected tropical disease of global importance [1]. Kasturiratne et al (2008) estimated that annually at least 1.2 million snakebites, 421,000 envenomings, and 20,000 deaths occur due to snakebite worldwide [2]. Several other acute neurological features are reported after snake envenomation, which are likely to be due to direct neurotoxicity These have not been well studied, with available data being mostly confined to case reports, and their potential pathophysiological mechanisms remain unclear. Accurate case definition is the key to meaningful interpretation of available data and comparison between studies This is hampered by the difficulties in identifying envenoming snakes, which have been previously highlighted [88,89,90,91]. Immunodiagnosis of snake venom antigen is the most reliable way of identifying the biting species, but cost and availability issues preclude its use in the resource-poor settings where snakebite is common [88,89,90,91]. Use of a clinical scoring system [89] or a syndromic classification [90] has been suggested to improve snake identification in the community setting, but these approaches have their own drawbacks
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