World Rural Health Conference
Home Print this page Email this page Small font size Default font size Increase font size
Users Online: 229
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents 
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 1386-1390  

Diagnosis of envenomation by Russell's and Echis carinatus viper: A clinical study at rural Maharashtra state of India


Department of Clinical Medicine, Bawaskar Hospital and Clinical Research Center, Mahad, Raigad, Maharashtra, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Himmatrao S Bawaskar
Bawaskar Hospital and Clinical Research Center, Mahad, Raigad, Maharashtra - 402 301
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_156_19

Rights and Permissions
  Abstract 


Background: Envenoming by vipers Russell's and Echis Carinatus are common accidents faced by farmers and labors. Both viper venom toxins alter coagulation mechanism in the victim. The dose of snake antivenin to neutralize the venom is empirical and varies. Though the clinical manifestations in both vipers bite envenoming are nearly similar but dose of antivenin required is more in Russell's viper. We studied in detail about the correlation of clinical manifestations and confirmed species of snake. Methods: Cases of vipers snake bites admitted for last two successive years were studied. Analysis by local manifestations, systemic involvement, 20 minute whole blood clotting test (20WBCT), identification of snake responsible for clinical effects are confirmed by the snake species brought by victims or bystanders, in case of where victim saw the snake bur failed to kill. The victims identified from pictures of big four poisonous snakes (Russell's viper, Echis carinatus, Cobra, and krait). Further confirmation from the species responsible is done by showing the hospital preserved specimen to identify the culprits. Findings: About 77 cases of viper bite studied of these 57 has clinical syndrome suggestive of Russell's viper (RV) bite, one has dry bite, 23 victims brought the killed specimen confirmed RV, of these 18 identified the specimen picture and 5 wrongly locate the species in pictures, 20 victims correctly identified the hospital preserved specimen while 3 failed to recognize. There were 28 patients who saw the snake while bitten but failed to kill, of these 20 patients identify correctly the species on picture while 8 failed to identify. Only 22 correctly identified the culprit by looking at the hospital preserved specimen and 6 were confused. One dry bite victim correctly identified the bitten snake species in picture and hospital preserved specimen. Interpretation: In viper bite poisoning clinical pictures and hospital specimen help to confirm the species are highly supportive for clinical diagnosis.

Keywords: Antisnake venom, echis carinatus, Russell's viper


How to cite this article:
Bawaskar HS, Bawaskar PH. Diagnosis of envenomation by Russell's and Echis carinatus viper: A clinical study at rural Maharashtra state of India. J Family Med Prim Care 2019;8:1386-90

How to cite this URL:
Bawaskar HS, Bawaskar PH. Diagnosis of envenomation by Russell's and Echis carinatus viper: A clinical study at rural Maharashtra state of India. J Family Med Prim Care [serial online] 2019 [cited 2019 May 26];8:1386-90. Available from: http://www.jfmpc.com/text.asp?2019/8/4/1386/257075




  Introduction Top


Envenoming by venomous snake evokes a acute time limiting life threatening medical emergency often faced by villagers in tropical and subtropical countries.[1] High rainfall and humid climatic condition a pleasant environment for vipers snake (Echis carinatus and Russell's viper) to flourish.[2],[3] High incidence of envenoming by Echis carinatus reported from Jammu state.[3] while envenoming by Russell's viper seen throughout south -East Asia. Maharashtra incidence of Russell viper bite is 70 per 100000 inhabitant with fatality 2.4 per 100000 per year.[4] Because of poor transport facilities and blind faith of villagers, majority of victim initially report to the Tantrik this result in delay hospitalization contribute to high morbidity and fatality.[5] Early administration of adequate antivenin arrest the progression of severe envenoming, minimum venom reach to renal tissue and help to reduce the morbidity and mortality.[5],[6] Echis carinatus and Russell's viper snake bite is 55% and 48% respectively reported from rural Maharashtra.[7],[8] Similar reports are from Jammu [3] and other part of south Asia.[9]

Total dose required to neutralize the injected venom by snake differ from species to species. The average dry weight of venom injected at strike is 13 mg in Echis carinatus and 63 mg in Russell's viper.[10] Newly posted medical officers are unaware of the signs and symptoms of venomous snake poisoning, and ignorance regarding initial dose of antivenin to be administered are varies with species of vipers. In rural India trained snake catchers are encouraged by government of Maharashtra for to protect the snakes. Venomous and non-venomous snake pictures are disposed in villages and villagers are well aware that the treatment differ, and depends upon the species hence majority of victims or bystander always accompanied with the killed specimen of culprit.

In absent of specific antigen detecting ELISA kit for to recognizes circulating venom and the species of snake involved, one has to depends upon the evolved clinical syndrome, identify the killed species or by showing the pictures of species or preserved specimen in case of victim saw the snake or did not brought the killed specimen.[11] We report here the correlation and diagnostic specificity of clinical syndrome, snake picture and hospital preserved specimen.


  Patients and Methods Top


We studied cases of suspected or confirmed viper Echis carinatus (EC) and Russell's (RV) bite poisoning during last two years. The detail demographic study, time of bite, site of bite, season of bite were analyzed. Clinical syndrome consists of fangs marks with active blood oozing from abrasions of fangs, development of edema and its extension, ecchymosed, blebs over the site of bite, regional lymphadenitis, active external bleeding may or may not be present. 20MBCT test showed no clotting of blood 2-3 ml of blood is collected in a new dry glass test tube, not washed with detergents, kept for 20 minutes. And then look for development of clot, absence of clotting of blood suggestive hypo fibrinogenemia.[7],[8],[9],[10],[12]

Killed specimen- were studied and identified by zoologist.

Pictures posters- We prepared posters of photographs of local venomous snake found in this area, and victim is shown the pictures and allowed to take their own time to identify the snake bitten to him. The rate of confirmation of snake in picture is confirmed by identifying the killed specimen. In case of snake is killed but failed to bring the specimen or only saw the snake bitten is correlated with identification of pictures and clinical syndrome. All cases were shown the preserved specimen Echis Carinatus and Russell's viper for to identify the culprit.

Details are given in [Table 1], [Table 2], [Table 3].
Table 1: Age wise distribution of snake bite cases

Click here to view
Table 2: Month wise distribution of snake bite cases

Click here to view
Table 3: Site and time of bite

Click here to view


Table confirmation of species [Table 4].
Table 4: Echis carinatus

Click here to view



  Results Top


About 76 snake bite cases studied, out of these 57 were bitten by RV, 73% are male, and 52% are from age group 21-40 years. 85% cases occurred during Manson and early winter (June to December) season. 64% had snake bite to lower extremities. 61% victim reported between 6-12 AM.

Out of 57 cases of RV bite 24 victim could manage to kill the snake of these one has dry bite, 18 victims identified the RV photograph, while 5 confused and failed to identify. While 20 victims exactly identified the RV from the hospital preserved specimen of snake. 20 victim had clinical manifestations suggestive of RV bite. All the 28 patients saw the bitten snake but did not attempt to kill it. Of these 20 recognized and localized the culprit in photographs [Figure 1], 8 were confused to identify while 22 victims identified the RV specimen. 5 did not see the snakes but they suffered and had clinical syndrome suggestive of poisoning by RV.
Figure 1: Photographs of BIG four venomous snake Echis carinatues, Russell' viper, Krait and cobra. Victim who saw the snake Russell's viper at the time of bite but did not kill snake but identified the culprit Russell's viper

Click here to view


Out of 19 cases suspected Echis carinatus bite 14 brought the specimen [Figure 2] and [Figure 3] of these 9 correctly recognized on photographs, 10 correctly identified from hospital specimen. 5 victims saw the snake of these 4 correctly identified in photographs and hospital specimen.
Figure 2: Echis carinatus or saw scaled or carpet viper

Click here to view
Figure 3: Bite fangs abrasion with clotted blood at the site of bite by Echis carinatus snake

Click here to view



  Discussion Top


We report here the correlation of clinical syndrome and possibility of species involved by studying the killed specimen brought by the victim or by showing the photographs of snake for to identify and further confirmation by recognizing the hospital preserved specimen of snakes.[5] Big four Krait, cobra, Echis Carinatus and Russell's viper are common venomous snake seen all over Maharashtra. We prepared the poster by actually taking photographs of snakes [Figure 1]. Because of the high literacy rate in Maharashtra, even villagers are more conscious regarding health. Repeated workshops regarding different snakes found in rural Maharashtra are held at Panchayat by snake rescuers. Victims are not encouraged to kill the snake. However, the villagers are aware that the treatment snake poisoning depends upon the species of snake and to avoid delay and confusion in the management at primary health center in present series 48% victim manage to killed and brought the specimen of snake.

In India polyvalent snake antivenom is available from Hakkine institute Mumbai, Serum institute Pune, and Bharat serum. 1 ml of reconstituted serum neutralizes 0.6 mg of dried Russell's viper and 0.45 mg dried Echis Carinuts venom. The average dry weight of venom injected at the time of bite is 63 mg by Russell's and 13 mg by Echis carinatus viper. Initial total dose of ASV to be administered 200 and 70 ML respectively.[10],[13] In India Russell's and Echis Carinatus included in category 1 snake poisoning.[14] Snake bite is a disease of poverty.[15],[16] moreover ASV is not free from severe reaction thus, it should be administered to only a case whom snake injected the venom and shows sign and symptoms of envenoming. ASV is always short supply. Medical officer who never treated case of snake bite before is unaware of this indication, total dose and possible specie involved resulted in un-necessary use as in dry bite [16] or avoidance of administration in indicated cases result in high morbidly and mortality.[17] In viper bite rapid diagnosis and early administration of ASV may prevent venom induced coagulopathy and subsequent vascular complication including disseminated intravascular coagulation and renal failure.[18],[19],[20],[21]

Russell's viper fangs are long curved and more than 70% stored of venom in the gland is emptied during bite in the deep tissues. The venom is rich in procoagulant and glycoprotein which activates factor x. Venom and arginine esterhydrolase which activates factor V -induced consumption coagulopathy occurred due to activation of the activators and factor x.[20] Soon after the bite victim experienced severe local pain and development of rapid swelling extending more than one segment of bitten part within few hours. Subsequently ecchymosed and blebs occur over the bitten part [Figure 4], [Figure 5], [Figure 6]. Because of rapid development of DIC at the bite site, result in continuous oozing of blood from fangs abrasions and subsequently gum and systemic bleeding and if not treated victim developed hypotension, shock and renal failure.[9],[10],[21],[22],[23],[24]
Figure 4: Russell's viper

Click here to view
Figure 5: Active oozing of blood from fangs abrasion of Russell's viper bite site

Click here to view
Figure 6: Extensive blebs

Click here to view


Echis carinatusa inject 10% of stored venom, venom is a big molecular size injected in subcutaneous tissue, and venom of Echis carinatus contains a zinc metaloprotein -ecarin which activates prothombin. Soon after envenoming by Echis carinatus species, within one 60-90 minutes there is progressive swelling over the bitten part. Fangs marks or abrasion with clotted blood seen at the site of bite [Figure 4]. Venom is big molecular size and being circulated through the lymphatic. Within 60-90 minutes victim experiences a painful lymphadenopathy at drainage area of the bitten part.[5],[7],[8],[25]

In India most of practicing doctors at rural setting have to rely on the circumstances of the bite and the clinical features of envenoming to infer the biting process. Clinical syndrome is almost similar Russell's and Echis carinatus poisoning, but dose requirement of polyvalent snake antivenom significantly differ.[5],[7],[8]

In absence of ELISA antigen detection test in India. By showing the pictures of common venomous snakes seen in particularly area, clinician can confirm the species by correlation with syndromic presentations. Rather than only depends upon the description of snake bitten by victim.[24],[26] In the present series we found majority of victim could able to localize the bitten snake in photos. Posters of venomous snakes are available in all medical text books and also at primary health centers. However preserved species are rare. We trained all the peripheral doctors in kokan region regarding clinical syndromes evoked by venomous snakes and provided them a published literature along with pictures of venomous snakes helped to early administration of required quantity of antivenin in a indicated envenomed cases.[17],[27],[28]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chippaux JP. Snake -bites: Appraisal of the global situation. Bull World Health Organ 1998;76:515-24.  Back to cited text no. 1
    
2.
Banerjee RN. Poisonous snakes and their venoms, symptomatology and treatment. In: Ahuja MMS, editor. Progress in Clinical Medicine Second Series. India: Heinemann. p. 136-79.  Back to cited text no. 2
    
3.
Bhat RN. Viperine snake bite poisoning in Jammu. J Indian Med Assoc 1974;63:383-92.  Back to cited text no. 3
    
4.
Gaitonde BB, Bhattacharya S. An epidemiological survey of snake bite cases in India. Snake 1980;12:129-33.  Back to cited text no. 4
    
5.
Bawakar HS, Bawakar PH. Profile of snake bite envenomimg in western Maharashtra, India. Trans Roy Soc Trop Med Hyg 2002;96:79-84.  Back to cited text no. 5
    
6.
Nervencar K. Correlation between timing of ASV administration and complication in snake bite. J Assoc Physician India 2006;54:717-9.  Back to cited text no. 6
    
7.
Bawaskar HS, Bawakar PH, Punde DP, Inamdar MK, Dongare RB, Bhoite RB. Profile of snake bite envenoming in Rural Maharashtra, India J Assoc Physicians India 2008;56:88-95.  Back to cited text no. 7
    
8.
Punde DP. Management of snake-bite in rural Maharashtra: A 10-year experience. Natl Med J India 2005;18:71-5.  Back to cited text no. 8
    
9.
Warrell DA. The clinical management of snake bites in the Southeast Asian region. Southeast Asian J Trop Med Public Health 1999;30:1-67.  Back to cited text no. 9
    
10.
Warrel DA. Injuries, envenoming, poisoning and allergic reactions caused by animals. In: Warrell DA, Cox TM, Firth JD, editors. Oxford Text Book of Medicine. 10th ed. Oxford University Press; 2010. p. 1324-31.  Back to cited text no. 10
    
11.
Brunda G, Sashidhar RB. Epidemiological profile of snake-bite cases from Andhra Pradesh using immunoanalytical approach. Indian J Med Res 2007;125:661-8.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Sano-Martin IS, Fan HW, Catro SC, Franca FD, Jeorge MT, Kamiguti AS, et al. Realiability of simple 20 minute blood clotting test (20WBCT) as an indicator of low plasma fibrinogen concentration in patients envenomed by botrops snake. Butan institute antivenom study group. Toxicon 1994;32:1045-50.  Back to cited text no. 12
    
13.
Duatta TK, Ghotekar LH. Rational use of anti-snake venom in API Med Update. 1998:Ch. 116;8:760-65.  Back to cited text no. 13
    
14.
Warrell DA. Guidelines for the Management of Snake-Bite. WHO library cataloguing; 2010. p. 40-1.  Back to cited text no. 14
    
15.
Harrisn RA, Hargreaves A, Wagstaff SC, Faragher B, Lalloo DG. Snake envenoming: A disease of poverty. PLoS Negl Trop Dis 2009;3:e569.  Back to cited text no. 15
    
16.
McNamee D. Tackling venomous snake bites worldwide. Lancet 2001;357:1680.  Back to cited text no. 16
    
17.
Bawaskar HS, Bawakar PH. Call for global snake -bite control and procurement funding. Lancet 2001;357:1132-3.  Back to cited text no. 17
    
18.
Bawakar HS, Bawakar PH. Aphasia in a farmer after viper bite. Lancet 2002;360:1703.  Back to cited text no. 18
    
19.
Daswani BR, Chandanwale AS, Kadam DB, Ghongane BB, Ghorpade VS, Manu HC. Comparison of different dosing protocol of anti-snake venom (ASV) in snake bite cases. J Clin Diagn Res 2017;11:FC17-21.  Back to cited text no. 19
    
20.
Vikrant S, Parashar A. Case report: Snakebite -induced acute kidney injury: Report of a successful outcome during pregnancy. Am J Trop Med Hyg 2017;96:885-6.  Back to cited text no. 20
    
21.
Isbister G, Maduwage K, Scorgle FE, Shahmy S, Mohamed F, Abeysinghe C, et al. Venom concentration and clotting factor levels in a propective cohort of Russell's viper bite with coagulopathy. PLoS Negl Trop Dis 2015:e0003968. doi: 10.137/journal.pntd. 0003968.  Back to cited text no. 21
    
22.
Isbiter GK. Snakebite doesn't cause disseminated intravascular coagulation: Coagulopathy and tyhrombotic microangiopathy in snake envenoming. Semin Thromb Hemost 2010;36:444-51.  Back to cited text no. 22
    
23.
Lwin M, Warrell DA, Phillis RE, Swe TN, Pe T, Lay MM. Bites by Russel's viper (viper russelli siamensis) in Burma: Haemostatic, vascular, and renal disturbances and response to treatment. Lancet 1985;2:1259-64.  Back to cited text no. 23
    
24.
Warrel DA. Snake bite: Seminar. Lancet 2010;375:77-90.  Back to cited text no. 24
    
25.
Udayabhaskaran V, Thombas A, Shaji B. Capillary leak syndrome following snake bite envenoimation. Indian J Crit Med 2017;21:698-702.  Back to cited text no. 25
    
26.
Bawaskar HS, Bawaskar PH. Snake bite (A clinical observations). Bombay Hosp J 1992;34:190-4.  Back to cited text no. 26
    
27.
Ariaratnam CA, Sheriff MHR, Arambepola C, Theakston RD, Warrell DA. Syndromic approach to treatment of snake bite in Sri Lanka bases on results of a prospective national hospital -based survey of patients envenomed by identified snakes. Am. J Trop Med Hyg 2009;81:725-31.  Back to cited text no. 27
    
28.
Airmol E, Sharma SK, Bawakar HS, Kuch U, Chappuis F. Snake bite in South Asia: A review. PLoS Negl Trop Dis 2010;4:e603.  Back to cited text no. 28
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
   
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Patients and Methods
  Results
  Discussion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed70    
    Printed0    
    Emailed0    
    PDF Downloaded19    
    Comments [Add]    

Recommend this journal