Dear editor
We congratulate Kumar et al for their relevant study “Clinical and epidemiologic profile and predictors of outcome of poisonous snake bites – an analysis of 1,500 cases from a tertiary care center in Malabar, North Kerala, India” published in June 2018 in the International Journal of General Medicine.Citation1 The study is noteworthy in being one of the largest series addressing snake bites from the subcontinent. The study has succeeded in highlighting several important findings related to snake envenomation, which is a serious and neglected problem in India and other tropical countries.
An important finding that has surfaced from this study is the emergence of hump-nosed pit viper (Hypnale hypnae) - accounting for nearly 25% of envenomations. This is a cause for serious concern as the widely used Indian polyvalent antivenom does not neutralize Hypnale venom.Citation2 Thus, there is an urgent need to reassess and address the adequacy of the Indian polyvalent antivenom in light of these findings.
Other interesting findings reported are pituitary apoplexy and acute angle closure glaucoma, which have been encountered in Russell’s viper envenomation patients from Southern India.Citation3,Citation4 However, it is surprising that none of the patients with Russell’s viper envenomation exhibited neurotoxic symptoms. This finding is usually associated with venom induced capillary leak syndrome. Neurologic manifestations have also been reported to occur in over 50% of Russell’s viper envenomation patients from Srilanka.Citation5 It is unclear whether this difference is as a result of regional intraspecific variations in the Russell’s viper venom or if the authors have not reported the number of patients who had both hemotoxic and neurotoxic manifestations.
From our clinical experience, we agree that patients with features of increased capillary permeability often have poor outcomes. In this regard, it would also be useful to know how many patients with features of increased capillary permeability developed early refractory hypotension and how many succumbed to other causes in the late phase.
We note that the mean antivenom use in viper envenomation is 18.5 vials with a maximum of 20 vials. This suggests that most patients required higher doses of anti-venom. It would be of use to know the transfusion requirements of patients, especially those with hump-nosed pit viper envenomation.
We suggest that the authors consider adjusting the risk factors for mortality by using a multivariable logistic regression model that will help to identify independent predictors.
This will prove useful for clinicians involved in the management of snake bite victims.
Disclosure
The authors report no conflicts of interest in this communication.
References
- KumarKSNarayananSUdayabhaskaranVThulaseedharanNKClinical and epidemiologic profile and predictors of outcome of poisonous snake bites - an analysis of 1,500 cases from a tertiary care center in Malabar, North Kerala, IndiaInt J Gen Med20181120921629892202
- World Health OrganizationGuidelines for the management of snakebites2nd edWHO Regional Office for South-East Asia Available from: http://www.who.int/snakebites/resources/9789290225300/en/Accessed September 02, 2018
- SrinivasanRKaliaperumalSDuttaTKBilateral angle closure glaucoma following snake biteJ Assoc Physicians India200553464815857013
- RajagopalaSThabahMMArigaKKGopalakrishnanMAcute hypopituitarism complicating Russell’s viper envenomation: case series and systematic reviewQJM2015108971972825630907
- SilvaAMaduwageKSedgwickMNeurotoxicity in Russell’s viper (Daboia russelii) envenoming in Sri Lanka: a clinical and neurophysiological studyClin Toxicol2016545411419