Acute Exposure to European Viper Bite in Children: Advocating for a Pediatric Approach

Abstract

Background: Viper bite is an uncommon but serious cause of envenoming in Europe, especially in children. Our study aim is to better describe and analyze the clinical course and treatment of viper bite envenoming in a pediatric population. Methods: We retrospectively reviewed 24 cases of pediatric viper bites that were admitted to the Pediatric Emergency Department and the Pediatric Intensive Care Unit of the Bambino Gesù Children Hospital in Rome between 2000 and 2020. Epidemiological characteristics of the children, localization of the bite, clinical and laboratory findings, and treatment approaches were evaluated. Results: The median age of the patients was 4.2 years, with male predominance. Most cases of viper bite occurred in the late summer. Most patients required admission to the ward for prolonged observation. The most common presenting signs were pain, local oedema, and swelling. Patients with a high severity score also had a significantly higher white blood cell count and an increase of INR, LDH, and CRP levels. No fatality was reported. Conclusions: Viper bite envenomation is a rare pediatric medical emergency in Italy but may sometimes be severe. A new pediatric severity score may be implemented in the screening of children with viper bites to favor a selective and prompt administration of antivenom.

Neurotoxicity and Other Clinical Manifestations of a Common European Adder (Vipera berus) Bite in Romania

“…These symptoms are similar to symptoms previously described in the literature in cases of V. berus bites in the Carpathian Basin region [ 8 ]. Antivenom indication was established after classifying the case severity as grade 2b, using the Audebert–Boels classification adapted to children by Marano et al as shown in Table 2 [ 6 ].…”

“…As stated in the literature, antibiotics in snakebite cases should only be administered if there is a positive history of infection, or clinical or biological signs of infection. [ 6 , 19 ].…”

“…Although the use of corticosteroids is controversial [ 6 , 19 ], the decision was made to administer intravenous methylprednisolone as a symptomatic treatment for its well-known anti-inflammatory effects. The outcome of methylprednisolone was favourable.…”

“…Clinical manifestations of envenomation by these adders vary and may be local or systemic. Systemic manifestations of envenomation may present as gastrointestinal, cardiac, neurological, and/or respiratory symptoms, and may also include anaphylactic reactions and coagulopathy [ 2 , 3 , 4 , 5 , 6 ]. Neurotoxic manifestations are considered unusual; in most cases published in Europe, these manifestations were attributed to V. aspis [ 4 , 6 ], and not to V. berus .…”

“…Systemic manifestations of envenomation may present as gastrointestinal, cardiac, neurological, and/or respiratory symptoms, and may also include anaphylactic reactions and coagulopathy [ 2 , 3 , 4 , 5 , 6 ]. Neurotoxic manifestations are considered unusual; in most cases published in Europe, these manifestations were attributed to V. aspis [ 4 , 6 ], and not to V. berus . Nevertheless, clinical symptoms of neurotoxicity in V. berus bites were observed as far back as 2008, when Malina et al reported a previously healthy 27-year-old man bitten by a V. berus in eastern Hungary [ 7 ] Later, in 2017, the same author also showed the possibility of neurotoxic manifestations of V. berus envenomation during an experimental study of V. berus venom of adders from the same region.…”