Vipera snakebite in Europe: a systematic review of a neglected disease

Abstract

In 2009, snakebites were included in the list of the World Health Organization (WHO) neglected diseases. Dermatological literature lacks current and up-to-date articles about snakebites and their management, despite the fact that dermatologists, especially from rural hospitals, can be called into the emergency room to consult the management of suspected snakebites. In this systematic review, we highlighted the main clinical and laboratory aspects of snakebites from Vipera spp. in Europe, by reviewing 3574 studies initially retrieved from PubMed, Embase and Cochrane CENTRAL databases. Of these, 78 were finally included in the systematic review. We found that the most involved taxon was V. berus in 63.3% and the most involved anatomic site of the bite was the upper limbs 53.1% with fang marks reported in 90.5%. The mean age of the patients was 32.9 years, and bites were slightly more common among males (58.2%). A wound washing was performed in 86.9% of cases before the hospitalization. The most frequently reported grade of envenomation was G2 (42.2%). In addition to local dermatological symptoms (extended erythema, oedema, cutaneous necrosis, hives, purpura, petechiae, acute compartment syndrome), numerous systemic symptoms have also been reported, including fatigue (14.4%), pain (75.3%), fever (49.2%), direct anaphylactoid reaction (5.3%), anxiety (60.8%), cranial nerve neurotoxicity (14.8%), dysesthesia/paraesthesia (7.9%), vomiting (33.7%), abdominal pain (23.3%), diarrhoea (15.4%), dyspnoea (6.3%), proteinuria (10.6%) and haematuria (9.3%). Secondary infections were present in 3.5% and disseminated intravascular coagulation in 3.1% of cases, and fasciotomy was performed in 4.2% cases, while an amputation in 6.9%. Only 0.9% of patients died. Antivenom was administered in 3053 cases. In conclusion, there is a pressing need for robust multi-centre randomized control trials, standardized protocol for snakebite management and antivenom administration across Europe and a National snakebite register for each European country.

Analysis of the venomous snakebite patients treated in the Uzice General Hospital (Western Serbia) between 2006 and 2018

“…In the last several years, venomous snakebites and their treatment, as well as the respective education/training of both the general population and medical workers, are gaining global attention, and actions have been announced/undertaken to reduce their impact [6,7,18,24]. Although mortality due to European Vipera spp.…”

“…Europe started recently. However, at the time of this manuscript preparation, the data regarding Serbia was not available [7,21]. Therefore, our intention was not only to present the information from a single hospital but also to inspire medical workers in other parts of Serbia to collect, analyze and publicize the data they have an insight into.…”

“…Also, medical workers could expand their knowledge of the distribution of vipers in Serbia and novel approaches in the treatment of venomous snakebites so they could standardize and improve the procedures not only of therapy but also of data gathering, severity score grading, etc. [6,7].…”

“…Venoms of Vipera species are combinations of proteins, polypeptides and enzymes with specific chemical and biological activities, primarily used to subdue prey. Oxidases, proteases, esterases, hemolysins, neurotoxins, cardiotoxins, myotoxins and factors that modify the coagulation system act on muscles, cardiovascular and neural systems, blood cells, leading to various damages of organs and organ systems [2][3][4][5][6][7][8]. Clinical manifestations of envenomation range from negligible to fatal; however, the latter are very rare and often occur in particular cases of bites e.g.…”

“…Clinical manifestations of envenomation range from negligible to fatal; however, the latter are very rare and often occur in particular cases of bites e.g. to the neck or directly to blood vessels, in very young patients or as a complication of some chronic disease in the elderly [6][7][8][9][10][11][12]. In high contrast to the popular belief, European vipers "are not considered fatal" because the lethal doses for average humans are higher than the amounts of venom the vipers can produce [12].…”