Envenomation by Trimeresurus stejnegeri stejnegeri: clinical manifestations, treatment and associated factors for wound necrosis

Abstract

Background: Trimeresurus stejnegeri stejnegeri bite induces tissue swelling, pain, thrombocytopenia, rhabdomyolysis, and acute renal failure. However, the incidence of coagulopathy, factors associated with wound necrosis, and the appropriate management of this condition have not been well characterized yet. Materials: This study included patients bitten by T . s . stejnegeri that were admitted to the study hospitals from 2001 to 2016. Patient characteristics, laboratory data, and management approaches were compared in victims with and without wound necrosis. Results: A total of 185 patients were evaluated: three patients (1.6%) were asymptomatic; whereas tissue swelling and pain, local ecchymosis, wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and renal impairment were present in 182, 53, 13, 15, 10, 1, and 3 patients, respectively. One patient died from coagulopathy and hemorrhagic shock. Antivenom was administered to all envenomed patients at a median time of 1.8 h after the bite. The median total dose of antivenom was five vials. Chi-square analysis showed that bitten fingers, using cold packs during first aid, presence of bullae or blisters, lymphangitis or lymphadenitis, local numbness and suspected infection to be significantly associated with wound necrosis. After adjustment using a multivariate logistic regression model, only cold packs as first aid, bulla or blister formation, and wound infection remained significant. Conclusions: The main effects of T . s . stejnegeri envenomation are tissue swelling, pain, and local ecchymosis. We do not recommend the use of cold packs during first aid to reduce wound pain, as this may be a risk factor for wound necrosis. In addition, patients with bulla or blister formation should be carefully examined for subsequent wound necrosis. Antiplatelet use may worsen systemic bleeding. No severe rhabdomyolysis or renal failure was observed in this large case series, we therefore considered that they were not prominent effects of T . s . stejnegeri bite.

An investigation of conventional microbial culture for the Naja atra bite wound, and the comparison between culture-based 16S Sanger sequencing and 16S metagenomics of the snake oropharyngeal bacterial microbiota

“…morganii are frequently present in the infected bite wound [ 21 ]. Mao et al and Chiang et al suggested that first-generation cephalosporin with aminoglycoside or sulfamethoxazole/trimethoprim is the preferable antibiotics in the management of infected Protobothrops mucrosquamatus and Trimeresurus stejnegeri stejnegeri bites [ 22 , 23 ]. These suggestions are based on conventional wound microbial culture without prior determination of antibiotic administration before obtaining cultures, thus rendering these suggestions biased.…”

The development of surgical risk score and evaluation of necrotizing soft tissue infection in 161 Naja atra envenomed patients

“…s . stejnegeri bites; both studies were analyzed using multivariate logistic regression [ 25 ]. Another study has found risk factors of ecchymosis and cyanosis in rattlesnake bites in North America, analyzed as relative risk assessment [ 28 ].…”

“…atra has distinct biological features that makes visual identification relatively easy [6,24]. The clinical manifestations caused by N. atra envenoming, however, overlap with those of the common crotaline snakebites [11,14,25]. Therefore, in this study we only included patients with a definite diagnosis and those who saw the culprit snake to construct the surgical risk score and excluded those with snakebites for which the culprit snake could not be identified (i.e., clinical diagnosis [4]).…”

“…The risk factors for wound necrosis and, therefore, possible surgical intervention were finger or toe as the bite site, bullae or blister formation, and PLOS NEGLECTED TROPICAL DISEASES PLOS NEGLECTED TROPICAL DISEASES venom-induced coagulopathy in green pit viper (Trimeresurus spp.) bites in Thailand [27] and cold packing as the first aid, bullae and blister formation, and suspected wound infection in T. s. stejnegeri bites; both studies were analyzed using multivariate logistic regression [25].…”

“…GI effects were reported only in N. atra bites, in contrast to the other common crotaline snakebites (i.e., T. s. stejnegeri and P. mucrosquamatus) in Taiwan [4,14,25]. Typically, patients presented with repeated vomiting and diarrhea in the first few hours post-bite before treatment and promptly responded to the administration of specific antivenom and/or anti-emetics [4].…”