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“Dry Bite” in Venomous Snakes: a Review Toxicon

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“Dry Bite” in Venomous Snakes: a Review Toxicon Toxicon 133 (2017) 63e67 Contents lists available at ScienceDirect Toxicon journal homepage: www.elsevier.com/locate/toxicon Review “Dry bite” in venomous snakes: A review DR. B. Sadananda Naik, M.D. Senior Physician Alva's Health Centre, Moodabidri 574227, Karnataka, India article info abstract Article history: It is quite interesting that when a venomous snake bites a person and the victim does not suffer from any Received 3 February 2017 signs or symptoms of envenomation. A good percentage of venomous snake bites in humans do occur Received in revised form without venom injection. This phenomenon is termed as “Dry” bite in clinical medicine. Though this was 21 April 2017 not very uncommon in toxicological practice but, our awareness of this problem has increased. In this Accepted 23 April 2017 article an effort has been made to provide an insight into the incidence, pathophysiology and patho- Available online 27 April 2017 mechanics of this unique medical enigma. © 2017 Elsevier Ltd. All rights reserved. Keywords: Envenomation Venomous snake bite Dry bite Non-envenomation Contents 1. Introduction . ................................................. 63 1.1. Inclusion of ‘dry bite’ in the grading of clinical features of snake bite envenomation . .......................64 1.2. Historical perspectives and the epidemiology of “dry bite” ....................................... ..................................64 1.3. Etiopathogenesis and pathomechanics of ‘dry bite’ .......................................... .....................................64 1.4. Possible reasons for the total absence of venom inoculation or injection of very minute quantity of venom which is insufficient to produce clinical or laboratory features of toxicity (de Rezende et al., 1998; Silveira and Nishioka Sde, 1995; Warrell, 2004) . .............64 1.5. Snake species and the morphology of the fangs . ........................65 1.6. Venom metering . ........................65 1.7. “Dry bite” by the venomous snakes in relation to lunar cycle . ........................65 1.8. Faulty delivery of the venom . ........................65 1.9. Victim's dress material . ........................65 2. Diagnosis of “dry bite” ........................................................... ................................................... 66 3. Management of “dry bite” .......................................................... ................................................. 66 4. Conclusions . ................................................. 66 Competing interests . ................................................. 66 Conflicts of interest . ................................................. 66 Ethical statement . ................................................. 66 Acknowledgements . ........................66 References................................................................. ................................ ........................66 1. Introduction threatening medical problem seen not only in the tropics but also in the rest of the world as well. More than 5 million people are Venomous snake bite is considered as a serious and life- bitten by venomous snakes in a year and nearly 100,000 of them succumb to it (Adukauskiene_ et al., 2011; Warrell, 2010). Similarly, a national mortality survey done in India has shown an estimated 46,000 people dying of snake bite in 2005 (Mohapatra et al., 2011). E-mail address: [email protected]. http://dx.doi.org/10.1016/j.toxicon.2017.04.015 0041-0101/© 2017 Elsevier Ltd. All rights reserved. 64 B.S. Naik / Toxicon 133 (2017) 63e67 Venomous snake bite could result in varying degree of toxicity, poisoning”. Later on, several other studies showed that, around from mild local symptoms to features of serious systemic toxicity 20e60% of the venomous snake bites could fall into the category of like severe coagulopathy, neuroparalysis, multi organ failure, shock ‘dry-bite’ (Russell, 1980). and finally death. But, when the poisonous snake bites and the Over here in Table 2, few important studies have been discussed, victims have no local or systemic or laboratory features of enven- with special emphasis on the venomous snake bites without fea- omation, it is termed a “Dry Bite”. This accounts for a sizable pro- tures of envenomation. However, as we see here, the incidence of portion of venomous snake bites all over the world (Tibballs, 1992; “dry-bites” varies with species of venomous snakes and from place Silveira and Nishioka Sde, 1995; Mead and Jelinek, 1996; Warrell, to place and also to some extent clinician's criteria and judgement 2010; Russell et al., 1997; Johnson, 1991). The incidence of “dry to differentiate between very mild oedema and no local signs. bites” has often been reported in any given study on venomous Kitchens and Van Mierop (1987), Barry S. Gold et al. (2002) in snake bites, but just as a statistical figure without much emphasis their study have left some cautions that some of the patients who on its implications. Dry bite is not unique to any one species of have activation of the sympathetic system due to extreme fear venomous snake and is seen in all the types venomous snake bites could mimic systemic manifestation of the venom. Extreme panic, but, with varying frequencies. In this article an attempt has been fear could result in nausea, vomiting, diarrhoea, syncope, tachy- made to highlight the incidence of “dry bite” by the venomous cardia, cold and clammy skin akin to snake envenomation. Hifumi snakes and to list out the reasons and the causes for this surprise et al. (2015) attributed the high incidence of dry bite in their and lucky escape for the victims of venomous snake bite. It should study on the pit vipers, known in Japan as “habu” (Protobothrops be the duty of every clinician to suspect dry bite whenever the local flavoviridis) as compared to the other snakes to their unique fangs. and systemic signs of snake envenomation are not evident with In the W.H.O. guidelines on the management of snake bites, Pro- clear cut evidence of snake bite either with the presence of fang fessor David Warrell, has made special mention on the incidence of marks or the snake being brought to the hospital either alive or dry bites in various snakes (Warrell, 2010). It is very fascinating to dead. know that 80% of bites by the sea snakes, one of the deadliest venomous snakes show either mild or no envenomation (Reid, 1.1. Inclusion of ‘dry bite’ in the grading of clinical features of snake 1975). Highest rate of dry bite is thought to be 70e80%, from bite envenomation brown snake bites(Pseudonaja sp.) in Australia (White, 2010). Bites by venomous snakes without envenomation [dry bite] 1.3. Etiopathogenesis and pathomechanics of ‘dry bite’ were not recognized until recent years. Clinicians all over the world used to be very sceptical about the very idea of a venomous snake It is not possible to pin point the exact reasons for the occur- bite whenever there was absence of features of envenomation. The rence of this phenomenon known as ‘dry bite’. However, there are tendency of clinicians was used to be, to brush aside such snake many possible explanations for the absence of envenomation in the bites as non-venomous ones or the theory that the venom gland victim. The incidence of ‘dry bite’ varies among the species of was empty used to be a popular explanation (Russell et al., 1997). venomous snakes, and the circumstances under which they bite. But, now it is no longer a miracle but a well-accepted clinical entity. The amount of venom injected differs when the snake strikes a prey Dry bite has been included as an important clinical manifestation in or it bites in defence as always been seen in human victims where the grading of envenomation by poisonous snakes (Adukauskiene_ the amount of venom injected would be quite small (Reid, 1968). It et al., 2011). Depending on the severity of envenoming, which is also depends on the structure of the fangs, namely the length and obviously differ depending on the species of snakes, the cases can location in the mouth, the location of opening in the fangs to deliver be classified as given in Table 1. the venom, hollow structure like the hypodermic needle or the presence groove in the fangs. 1.2. Historical perspectives and the epidemiology of “dry bite” Many biologists, herpetologists and snake handlers did observe 1.4. Possible reasons for the total absence of venom inoculation or this phenomenon for centuries but they knew very little about the injection of very minute quantity of venom which is insufficient to reasons behind it and they did nothing to document it (Russell, produce clinical or laboratory features of toxicity (de Rezende et al., 1980). It was Sir Joseph Fayrer, who probably published the first 1998; Silveira and Nishioka Sde, 1995; Warrell, 2004) case report where the an account of accidental insertion of one of the fangs of a pet rattle snake while feeding the mouse. Though he Natural or acquired immunity of the victim against the snake did not use the word “dry bite”, he did discuss the reasons for not poison showing the signs of envenomation in a venomous snake bite Absence of venom in the glands at the time of strike (Fayrer, 1892). One could find similar instances of venomous snakes Diseased venom glands wounding humans without envenoming in his “Thanatopidia” a Fangs (venom duct) of the snakes getting obstructed due to legendary book on snakes in India (Fayrer, 1872). Later on H.M. calcifications impairing the smooth and swift delivery of the Parrish
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