Letters to the Editor
199
First reported case of African Viper bite treated with Indian Polyvalent Anti Snake Venom Dear Editor,
T
he compositional differences between venoms among different geographic regions may be due to evolutionary environmental pressure acting on isolated populations. The polyvalent variety of anti snake venom (ASV) with local specificity remains the mainstay of therapy in most countries. ASV against the venom of one species occasionally may have partial cross neutralizing activity against other venoms, usually from closely related species, known as paraspecific activity. We managed a case of an African viper bite successfully using Indian polyvalent ASV as the specific African variety was not available to us. A 25 year old serving soldier of a foreign army contingent in UN mission in the Democratic Republic of Congo, was brought on 29 Sep 07 at 0025 hours, with a history of a mildly painful snake bite of about two hours duration on the left foot. There was no history suggestive of neurological involvement. Clinical examination revealed normal vital parameters and a normal general examination. Local exam revealed swelling and tenderness of left foot extending beyond the ankle to the distal leg. Two fang marks 1.5 cm apart were visible on dorsum of left foot along with a small patch of ecchymosis (Fig. 1). A bed side whole blood clotting time revealed no clotting at 30 minutes, with a clotting time of 35 minutes by capillary method. Bleeding time was in normal range. Since specific ASV for the regional area was not available, a decision to give Indian polyvalent ASV (which was available) was taken as an emergency life saving measure. A total of 150 ml of reconstituted ASV (15 vials of polyvalent Indian variety) was administered as per standard protocol over next nine hours in view of progressively increasing swelling in the leg and deranged clotting time in range of 15 to 21 minutes. The progression of the swelling of the limb halted and clotting parameters started improving (Fig. 2). Antibiotics and other supportive therapy were given. The patient had a haemoglobin drop from 16.3 to 13.6 gm per dl and mild thrombocytopenia in range of 1,20,000 to 1,40,000/mm2 during the initial few days which subsequently recovered. He also developed an uncomplicated resolving small abdominal wall hematoma (confirmed by ultrasound). He was discharged at three weeks with a complete and uneventful recovery.
terrificus is said to have been up to 70 %, but this has been reduced to less than 12% by ASV treatment and in African varieties like Atractaspis and bush vipers (like those found in the Congo basin) the mortality ranges from 8-43% [1,2]. “Specific” antivenom, implies that the antivenom has been raised against the venom of a particular snake that has bitten the patient (Monovalent or monospecific antivenom). Polyvalent antivenom neutralises the venoms of several different species of snakes. FAV AFRICA is the polyvalent equine ASV recommended for Sub-Saharan African snakes. The Indian ASV contains sera against the saw scaled viper, Russel’s viper. Indian Cobra (Naja naja) and the banded krait. Analysis of Indian cobra (Naja naja) venom samples from eastern, western and southern India revealed differences in composition, biochemical, and pharmacological properties emphasizing regional variation: continents will logically be different [3]. There are only a handful of documented cases of snake bites managed with ASV pertaining to different geographical locations. Use of Tiger Snake ASV in Stephen’s Banded Snake envenomation in Australia, pit viper envenomation (South American) treated with nonspecific ASV and two North American coral snake venoms treated with Mexican ASV have been described [4-6]. A study was performed to assess the ability of polyvalent anti snake venom VACSERA (produced by Egypt), to neutralize venoms of snakes not only from Egypt but also African and Middle Eastern habitats showed encouraging results [7]. There is a description of a severe systemic envenomation of a African bush viper managed successfully with Near Middle East ASV [8]. Ours is possibly the first reported case of an African viper bite successfully managed with Indian polyvalent ASV given in the backdrop of unavailability of specific antisera. We recommend that more studies be carried out on this paraspecific activity of the Indian ASV .
The mortality after untreated viper bites like Crotalus durissus
Fig. 1 : Fang marks with swelling of foot. MJAFI, Vol. 66, No. 2, 2010
Fig. 2 : Reduction of swelling of the limb by day three.
200
Letters to the Editor
References 1. Chifundera Kusamba. Snakes of Zaire and Their Bites. In: African Study Monographs. The Center for African Area Studies, Kyoto University, Kyoto, Japan 1990; 3: 137-70. 2. Sanofi Pasteur. Application for inclusion of Equine fab 2 antivenoms in the WHO Model list for essential medcines. Available from http:// archives.who.int/ eml/expcom/expcom15/ applications/ newmed/equine/antivenoms.pdf./2007. 3. Shashidharamurthy R, Kemparaju K. Region-specific neutralization of Indian cobra (Naja naja) venom by polyclonal antibody raised against the eastern regional venom: A comparative study of the venoms from three different geographical distributions. Int Immunopharmacol 2007; 7: 619. 4. Hession M. Stephen’s Banded Snake envenomation treated with tiger snake antivenom. Emerg Med Australas 2007; 19:4768. 5. Rudnicki DS, Debien B, Leclerc T, et al. Paraspecific antivenins
and exotic bites of snakes: about two case reports. Ann Fr Anesth Reanim 2008; 27:326-9. 6. Sánchez EE, Lopez-Johnston JC, Rodríguez-Acosta A, Pérez JC. Neutralization of two North American coral snake venoms with United States and Mexican antivenoms. Toxicon 2008; 51:297-303. 7. Seddik SS, Wanas S, Helmy MH, Hashem M. Cross neutralization of dangerous snake venoms from Africa and the Middle East using the VACSERA polyvalent antivenom. Egyptian Organization for Biological Products and Vaccines. J Nat Toxins 2002; 11:329-35. 8. Robinson RF, Baker RS, Martin S, Casavant MC. Use of “Near Middle East Antivenom” to treat African bush viper envenomation. Vet Hum Toxicol 2004; 46:264-5. Contributed by Lt Col A Sagar*, Col DC Joshi+ Classified Specialist (Medicine), Military Hospital, Shillong, Meghalaya-793001. +Project Officer, Command Hospital (SC), Pune 411040.
*
Book Review Maxillofacial Imaging: Larheim TA, Westesson PL. First Edition 2006, Reprint 2008, Chapters XVI, Pages 440, Illustrations 1450 (87 in colour), soft cover. Publisher: Springer, ISBN: 978-3-540-78685-6. Cost: 99.95 Euros
M
axillofacial imaging has evolved dramatically over the past two decades with development of new cross sectional imaging techniques. Traditional maxillofacial imaging was based on plain films and dental imaging. However, advanced imaging techniques like CT and MRI have only been partially implemented for maxillofiacial questions. This book bridges the gap between traditional maxillofacial imaging and advanced medical imaging. The authors have applied CT and MRI to a variety of maxillofacial
cases and these are illustrated with high quality images and multiple planes. A comprehensive chapter on imaging anatomy is also included. This book is useful for oral and maxillofacial radiologists, oral and maxillofacial surgeons, dentists, radiologists, plastic surgeons, head and neck surgeons and others who work with severe maxillofacial disorders. This book is also useful for clinicians who are dealing with maxillofacial region. Contributed by Maj R Sharma*, Brig R Sinha+, Col PS Menon (Retd)# * Graded Specialist (Surgery), MDC Jalandhar Cantt. +Deputy DG (P), O/o DGDS, 'L' Block, New Delhi. #Associate Professor, Vydehi Dental College, Bangalore
Answers to MCQs 1. (b)
2. (a)
3. (d)
4. (a)
5. (b)
6. (b)
7. (c)
8. (d)
9. (b)
10. (a)
MJAFI, Vol. 66, No. 2, 2010
199
First reported case of African Viper bite treated with Indian Polyvalent Anti Snake Venom Dear Editor,
T
he compositional differences between venoms among different geographic regions may be due to evolutionary environmental pressure acting on isolated populations. The polyvalent variety of anti snake venom (ASV) with local specificity remains the mainstay of therapy in most countries. ASV against the venom of one species occasionally may have partial cross neutralizing activity against other venoms, usually from closely related species, known as paraspecific activity. We managed a case of an African viper bite successfully using Indian polyvalent ASV as the specific African variety was not available to us. A 25 year old serving soldier of a foreign army contingent in UN mission in the Democratic Republic of Congo, was brought on 29 Sep 07 at 0025 hours, with a history of a mildly painful snake bite of about two hours duration on the left foot. There was no history suggestive of neurological involvement. Clinical examination revealed normal vital parameters and a normal general examination. Local exam revealed swelling and tenderness of left foot extending beyond the ankle to the distal leg. Two fang marks 1.5 cm apart were visible on dorsum of left foot along with a small patch of ecchymosis (Fig. 1). A bed side whole blood clotting time revealed no clotting at 30 minutes, with a clotting time of 35 minutes by capillary method. Bleeding time was in normal range. Since specific ASV for the regional area was not available, a decision to give Indian polyvalent ASV (which was available) was taken as an emergency life saving measure. A total of 150 ml of reconstituted ASV (15 vials of polyvalent Indian variety) was administered as per standard protocol over next nine hours in view of progressively increasing swelling in the leg and deranged clotting time in range of 15 to 21 minutes. The progression of the swelling of the limb halted and clotting parameters started improving (Fig. 2). Antibiotics and other supportive therapy were given. The patient had a haemoglobin drop from 16.3 to 13.6 gm per dl and mild thrombocytopenia in range of 1,20,000 to 1,40,000/mm2 during the initial few days which subsequently recovered. He also developed an uncomplicated resolving small abdominal wall hematoma (confirmed by ultrasound). He was discharged at three weeks with a complete and uneventful recovery.
terrificus is said to have been up to 70 %, but this has been reduced to less than 12% by ASV treatment and in African varieties like Atractaspis and bush vipers (like those found in the Congo basin) the mortality ranges from 8-43% [1,2]. “Specific” antivenom, implies that the antivenom has been raised against the venom of a particular snake that has bitten the patient (Monovalent or monospecific antivenom). Polyvalent antivenom neutralises the venoms of several different species of snakes. FAV AFRICA is the polyvalent equine ASV recommended for Sub-Saharan African snakes. The Indian ASV contains sera against the saw scaled viper, Russel’s viper. Indian Cobra (Naja naja) and the banded krait. Analysis of Indian cobra (Naja naja) venom samples from eastern, western and southern India revealed differences in composition, biochemical, and pharmacological properties emphasizing regional variation: continents will logically be different [3]. There are only a handful of documented cases of snake bites managed with ASV pertaining to different geographical locations. Use of Tiger Snake ASV in Stephen’s Banded Snake envenomation in Australia, pit viper envenomation (South American) treated with nonspecific ASV and two North American coral snake venoms treated with Mexican ASV have been described [4-6]. A study was performed to assess the ability of polyvalent anti snake venom VACSERA (produced by Egypt), to neutralize venoms of snakes not only from Egypt but also African and Middle Eastern habitats showed encouraging results [7]. There is a description of a severe systemic envenomation of a African bush viper managed successfully with Near Middle East ASV [8]. Ours is possibly the first reported case of an African viper bite successfully managed with Indian polyvalent ASV given in the backdrop of unavailability of specific antisera. We recommend that more studies be carried out on this paraspecific activity of the Indian ASV .
The mortality after untreated viper bites like Crotalus durissus
Fig. 1 : Fang marks with swelling of foot. MJAFI, Vol. 66, No. 2, 2010
Fig. 2 : Reduction of swelling of the limb by day three.
200
Letters to the Editor
References 1. Chifundera Kusamba. Snakes of Zaire and Their Bites. In: African Study Monographs. The Center for African Area Studies, Kyoto University, Kyoto, Japan 1990; 3: 137-70. 2. Sanofi Pasteur. Application for inclusion of Equine fab 2 antivenoms in the WHO Model list for essential medcines. Available from http:// archives.who.int/ eml/expcom/expcom15/ applications/ newmed/equine/antivenoms.pdf./2007. 3. Shashidharamurthy R, Kemparaju K. Region-specific neutralization of Indian cobra (Naja naja) venom by polyclonal antibody raised against the eastern regional venom: A comparative study of the venoms from three different geographical distributions. Int Immunopharmacol 2007; 7: 619. 4. Hession M. Stephen’s Banded Snake envenomation treated with tiger snake antivenom. Emerg Med Australas 2007; 19:4768. 5. Rudnicki DS, Debien B, Leclerc T, et al. Paraspecific antivenins
and exotic bites of snakes: about two case reports. Ann Fr Anesth Reanim 2008; 27:326-9. 6. Sánchez EE, Lopez-Johnston JC, Rodríguez-Acosta A, Pérez JC. Neutralization of two North American coral snake venoms with United States and Mexican antivenoms. Toxicon 2008; 51:297-303. 7. Seddik SS, Wanas S, Helmy MH, Hashem M. Cross neutralization of dangerous snake venoms from Africa and the Middle East using the VACSERA polyvalent antivenom. Egyptian Organization for Biological Products and Vaccines. J Nat Toxins 2002; 11:329-35. 8. Robinson RF, Baker RS, Martin S, Casavant MC. Use of “Near Middle East Antivenom” to treat African bush viper envenomation. Vet Hum Toxicol 2004; 46:264-5. Contributed by Lt Col A Sagar*, Col DC Joshi+ Classified Specialist (Medicine), Military Hospital, Shillong, Meghalaya-793001. +Project Officer, Command Hospital (SC), Pune 411040.
*
Book Review Maxillofacial Imaging: Larheim TA, Westesson PL. First Edition 2006, Reprint 2008, Chapters XVI, Pages 440, Illustrations 1450 (87 in colour), soft cover. Publisher: Springer, ISBN: 978-3-540-78685-6. Cost: 99.95 Euros
M
axillofacial imaging has evolved dramatically over the past two decades with development of new cross sectional imaging techniques. Traditional maxillofacial imaging was based on plain films and dental imaging. However, advanced imaging techniques like CT and MRI have only been partially implemented for maxillofiacial questions. This book bridges the gap between traditional maxillofacial imaging and advanced medical imaging. The authors have applied CT and MRI to a variety of maxillofacial
cases and these are illustrated with high quality images and multiple planes. A comprehensive chapter on imaging anatomy is also included. This book is useful for oral and maxillofacial radiologists, oral and maxillofacial surgeons, dentists, radiologists, plastic surgeons, head and neck surgeons and others who work with severe maxillofacial disorders. This book is also useful for clinicians who are dealing with maxillofacial region. Contributed by Maj R Sharma*, Brig R Sinha+, Col PS Menon (Retd)# * Graded Specialist (Surgery), MDC Jalandhar Cantt. +Deputy DG (P), O/o DGDS, 'L' Block, New Delhi. #Associate Professor, Vydehi Dental College, Bangalore
Answers to MCQs 1. (b)
2. (a)
3. (d)
4. (a)
5. (b)
6. (b)
7. (c)
8. (d)
9. (b)
10. (a)
MJAFI, Vol. 66, No. 2, 2010
