Snake Bite Envenomation in Riyadh Province of Saudi Arabia Over the Period (2005–2010)

Saudi Journal of Biological Sciences (2015) 22, 198–203

King Saud University Saudi Journal of Biological Sciences

www.ksu.edu.sa www.sciencedirect.com

ORIGINAL ARTICLE Snake bite envenomation in Riyadh province of Saudi Arabia over the period (2005–2010)

Mohammed K. Al-Sadoon *

Department of Zoology, College of Science, King Saud University, P.O. Box 2455, Riyadh 11451, Saudi Arabia

Received 27 August 2014; revised 14 September 2014; accepted 15 September 2014 Available online 22 September 2014

KEYWORDS Abstract The present investigation is a retrospective review of snake bites in Riyadh province over Snake bites; the period (2005–2010). A total of 1019 cases of bites admitted to the Ministry of Health medical Antivenom; centers in Riyadh province were analyzed on the basis of age, sex, time of bite and its site on the Cerastes cerastes gasperettii body, outcome of treatment, antiserum dose and type of snake. Bites occurred throughout the six years with the highest frequency in 2005 and least in 2006 where most of the bite cases were mild and all evolved to cure except four patients who died following the administration of antivenom during 24 h after snake bite. Most of the patients were males (81.7%) and the most attacked age was within the range of 11–30 years (51.5%). All the bites were mainly in the exposed limbs and the most frequently bitten anatomical regions were the lower limbs (427 cases, 41.9%), principally the feet. The study incriminates Cerastes cerastes gasperettii in most of the bites indicating it as the snake of medical importance in Riyadh province. Also, the study indicates low degree of threat in spite of high rate of snake bites as a result of the availability of the medical facilities and the antivenin use in medical centers in Riyadh province. ª 2014 King Saud University. Production and hosting by Elsevier B.V. All rights reserved.

1. Introduction and 3000 poisonous bites in the U.S.A. and Australia respectively. Considerable studies on snake bites have been under- Snake bite envenomation is a world problem that represents a taken in several countries such as South-East Asia (Sawai threat to many countries including Saudi Arabia. It is et al.,1972), Nigeria (Pugh and Theakston, 1980; Paramonte, estimated that globally at least 421,000 envenomation’s and 2007), Papua New Guinea (Currie et al., 1991), South East 20,000 deaths occur each year due to snake bites of the Arabian Peninsula (Alkaabi et al., 2011), Central Iran (Kasturiratne et al., 2008). Each year there are over 8000 (Dehghani et al., 2012, 2014a,b) Senegal (Trape et al., 2001), Brazil (Franco et al., 2001), India (Mohapatra et al., 2011), * Tel.: +966 01 4675755; fax: +966 01 4675781. Nepal (Sharma et al., 2004), Malaysia (Chew et al., E-mail address: [email protected] 2011) and Morocco (Arfaoui et al., 2009). Approximately Peer review under responsibility of King Saud University. 30% of the 3000 snakes across the globe are venomous and considered dangerous to humans (Hider et al., 1991). Fifty- one species of snakes have been recorded in Saudi Arabia, nine of these are venomous with four (Walterinnesia aegyptia, Production and hosting by Elsevier Atractaspis microlepidota, Cerastes cerastes gasperettii, and http://dx.doi.org/10.1016/j.sjbs.2014.09.008 1319-562X ª 2014 King Saud University. Production and hosting by Elsevier B.V. All rights reserved. Snake bite envenomation in Riyadh province 199

Echis coloratus) of which have been recorded in Riyadh prov- As seen in Table 1, the highest rate (P < 0.05) of snake bites ince (Al-Sadoon, 1989; Gasperetti, 1988). The information was in 2005 with 183 cases (17.90%) while 160 cases concerning snake bites in Saudi Arabia is scarce and fragmen- (15.70%) were recorded in 2006. tary (Kingston,1981; Tilbury et al., 1987; Al-Sadoon and Abdo, 1990; Al-Sadoon and Jarrar, 1994; Al-Mohareb and 3.2. Distribution of bites according to age Al-Sadoon, 1994; Al-Durihim et al., 2010; Malik, 1995) with no reliable statistical studies on this issue and very little is As seen in Table 2, ninety-eight bite cases (9.6%) were known about the rate of snake bites in Riyadh province (Al- recorded with age category below 10 years. 13 bite cases were Sadoon and Jarrar, 1994). Snake bite envenomation leads to over 61 years old (1.2%) while most patients were males in various clinical features, depending on the involved snake spe- their twenties (282.5 cases, 27.7%). cies. Hematological toxicity caused by family Viperidae (C. c. gasperettii and E. coloratus) can be manifested through bleed- 3.3. Distribution of bites according to sex ing that may develop into disseminated intravascular coagu- lopathy. The neurotoxicity caused by family Elapidae (W. Male–female biting rate was 833 and 186 cases with a percent- aegyptia) and family Atractaspididae (A. microlepidota) may age of 81.70% and 18.20% respectively and males exceeded develop respiratory distress (Pantanowitz and Andrzejewski, that of the females (P < 0.05) in all years of the study period. 2006). The highest rate of bites among males was recorded in 2005 The present study is an attempt to evaluate the snake (148 cases) while the lowest rate was recorded in 2006 (131 envenoming in Riyadh province over a six year period extend- cases). The highest and lowest female rates were recorded in ing from 2005 to 2010. 2005 and 2006 (35 and 29 cases), respectively (Fig. 1). 2. Materials and methods 3.4. Distribution of bites through the year

The incidence and frequency of snake bites in Riyadh province No snake bites were recorded in December, January and Feb- were reviewed for a 6-year period beginning from 2005. This ruary in any year of the study period. Monthly incidence of study was based on 1019 cases of snake bites submitted to bites showed peak incidence from March to November. The the emergency department at the hospitals and Medical centers majority of the envenoming occurred during the hotter months of Riyadh province, Saudi Arabia. Data were extracted from of the year. The highest rate of snake bites was in August while the records of the Ministry of Health medical centers in the lowest rate was in March (P < 0.05). As it is seen in Fig. 2 Riyadh province and analyzed according to the following and Table 5, March, April, October and November showed bases: age, sex, time of bite and submission (month and time relatively low rate of snake bites while May through Septem- of day), bite details including anatomic site, clinical ﬁnding ber account a high rate of snake bites. at the site noted during hospitalization, laboratory results, pre- senting complaint, systemic symptoms, details of antivenom 3.5. Time of bites use including type and doses given, period of observation, outcome of each bite and snake species (if known) (Ministry of Health Riyadh, Saudi Arabia). Identiﬁcation of the incrimi- The highest rate of bite cases occurred at night during all the nated snakes was generally reported by patient report with years. The nocturnal bites counted 505.9 cases (49.60%) and assistance of Zoological photographs of Saudi Arabian ven- the diurnal ones were 284 cases (27.80%) while the undecided omous snakes which were available in some medical centers time cases counted 229 (22.49%). The analysis of the data of Riyadh province. Data were analyzed by using ANOVA showed that the highest nocturnal bites (P < 0.05) were for each individual character. recorded in 2005 (Fig. 3).

3. Results 3.6. Bite site on the body

3.1. Rate and distribution of bites All bites occurred on the exposed areas of the limbs. The number of bites on the lower limbs was 427 cases (41.90%) and that on the upper limbs was 313 cases (30.70%). The bites on the The total number of snake bites in Riyadh province over the lower extremities were 427 cases of which 230 (22.59%) were period (2005–2010) was 1019 with an average of 169.8/year. on the right foot and 197 (19.50%) on the left foot. No bites were recorded on the neck, head or rest of the body. The inci- Table 1 Rate and relative frequency of snake bites in Riyadh dence of bites on different parts of the hand were as follows: province over the period (2005–2010). Thumb 56.20 cases (6.30%), index finger 107 cases (10.50%), Years Number of cases Relative frequency (%) middle finger 59.10 cases (5.70%), and little finger 47.3 cases 2005 183 17.90 (4.60%) while no bites were recorded in the ring finger 2006 160 15.70 (Table 3). 2007 168 16.40 2008 172 16.80 3.7. Treatment outcome 2009 170 16.60 2010 166 16.20 The number of deaths caused by snake bites in the current Total 1019 100 study was 4 out of the total of 1019, which makes 0.3%. Other 200 M.K. Al-Sadoon

Table 2 Distribution of snake bites according to age in Riyadh province over the period (2005–2010). Years <10 years 11–20 years 21–30 years 31–40 years 41–50 years 51–60 years >61 years 2005 18.3 44.8 47 37.7 21.3 12.2 2 2006 15.2 37.7 41.7 31.5 18.4 12.5 3 2007 16.3 39.7 47.8 32.6 19.3 10.3 2 2008 16.3 39.5 52 33 19.4 10 2 2009 16.2 42 47 32.6 18.4 9.8 2 2010 16.2 39.7 47 32.6 18.3 10.2 2 Total 98.5 288.2 282.5 200 115.1 65 13 % 9.67 28.28 27.72 19.63 11.29 6.38 1.27

160

140

120

100

80 Female Male 60 number of cases 40

0 2005 2006 2007 2008 2009 2010

years (2005-2010)

Figure 1 Distribution of snake bites according to sex in Riyadh province over the period (2005–2010).

300 and Naja haje). Most of the patients (606 cases) received less than 5 ml of antiserum dose while 203.5 patients received more 250 than 5 ml. Antivenin was administered intravenously to patients (Table 4). 201.5 patients received undecided dose of 200 Antivenom.

150 3.9. Snake species 100 Most of the medical records of the bitten patients described the 50 C. c. gasperettii number of cases incriminated snake as the horned snake, (86.90%). Few undecided venomous snake species were 0 JFMAMJJASOND recorded. months 4. Discussion Figure 2 Distribution of snakebites through the year in Riyadh Province Over the period (2005–2010). Venomous snakes are widely distributed in the Saudi Arabia and Arabian peninsula in general. Fifty-one species of snakes have been identified in Saudi Arabia, nine of these are venom- bitten patients evolved to cure after being hospitalized. No ous sea snakes and the remaining 42 species are terrestrial, of cases were discharged against doctor advice. which 9 are venomous (Gasperetti, 1988; Al-Sadoon, 1989; Al- Sadoon and Al-Faraj, 1992). The results of the present study 3.8. Antiserum dose indicate that there were 1019 snake bites in Riyadh province during the period of six years extending between 2005 and Patients were given equine polyvalent ASV (The Antivenom 2010 with an average of 169.8 per year. The higher incidence and vaccine production center, National Guard Health Affairs, of snake bites in this province could be explained by its large Riyadh, Saudi Arabia). Each vial contained 10 ml of purified population. Also, the climate in this province, that varies from immunoglobulin fractions against five types of snakes (Bitis semiarid to arid, may play an important role in diverse fauna aritanus, Cerastes cerastes, Echis carinatus, Echis coloratus of venomous snakes and snake bites. The result of present Snake bite envenomation in Riyadh province 201

Figure 3 Time of snake bites in Riyadh province over the period (2005–2010).

Table 3 Distribution of snake bites according to bite body site in Riyadh province over the period (2005–2010). Years Right foot Left foot Right arm Left arm Thumb Index finger Middle finger Ring finger Little finger 2005 40 36 35 24 9.2 21.3 10.3 – 7.2 2006 36 30 27 23 9 20.5 8.8 – 5.7 2007 38 32 27 25 10 20.6 9 – 6.4 2008 40 31 28 24 12 18 11 – 8 2009 35 34 30 20 13 17 10 – 11.4 2010 41 34 29 21 12 10 10 – 9

investigation is in agreement with a previous study on the incidence of snake bites of the same province during the period Table 4 Distribution of snake bitten cases treated with 1986–1988 (Al-Sadoon and Jarrar, 1994). The present results antiserum dose in Riyadh province over the period (2005– are similar to those found in different regions of Saudi Arabia 2010). such as Asir and Hail which showed that snake bite is a med- Years >5 ml dose <5 ml dose Undecided dose ical problem (Al-Mohareb and Al-Sadoon,1994; Malik, 1995; 2005 108 35.3 39.7 Mahaba, 2000; Al-Durihim et al., 2010). 2006 95.7 34.8 29.5 The low fatality rate (0.3%) was reported in spite of the 2007 101.8 31.5 34.6 high rate of snake bites in Riyadh province as shown by the 2008 101.9 35.6 34.5 present study and all victims were transferred to hospital 2009 98.9 34.6 34.6 within a reasonable time frame. This finding differs from other 2010 98.8 31.6 36.6 result that reported death following snake bites in Saudi Ara- bia. Death cases due to snake bite were reported in Riyadh city by previous work (Al-Sadoon and Jarrar, 1994; Al-Durihim et al., 2010) and in other areas of Saudi Arabia (Al-Sadoon and Abdo, 1990; Al-Mohareb and Al-Sadoon, 1994). These Table 5 Rate and frequency of snake bites throughout the studies reported that mortality rate of snake bites in Riyadh year in Riyadh province over the period (2005–2010). city, Hail region and Al-baha was reported by previous studies Months Number of cases Relative frequency (%) as 2.3%, 4.8%, 2.9% and 1.2% respectively (Al-Sadoon and January 0 0.0 Jarrar, 1994; Al-Durihim et al., 2010; Mahaba, 2000; Al- February 0 0.0 Mohareb and Al-Sadoon, 1994). In other countries, the snake March 29.2 2.8 bite envenomation is considered as a real public health issue. April 45.2 4.4 The rate of snake bites has been reported as 8.5% in Philip- May 122.5 12.0 pines, 5.1% in Taiwan, 0.33% in Malaysia, 5.1% in Nigeria June 135 13.2 (Chapman, 1968: Sawai et al., 1972; Pugh and Theakston, July 150 14.7 1980) and 5.6% in Morocco (Arfaoui et al., 2009). Twenty- August 277 27.1 six deaths were caused by snake bites during the period September 131 12.8 October 88.6 8.6 1976–1999 in 42 villages of south-eastern Senegal (Trape November 40.5 3.9 et al., 2001). The low rate of death due to snake bites in Riyadh December 0 0 province as demonstrated in the present study and in compar- ison with previous reports indicates that this syndrome does 202 M.K. Al-Sadoon not carry the degree of a real medical threat that has been et al., 2010; Kingston, 1981; Al-Sadoon and Abdo, 1990; reported in the past. This may be due to the excellent medical AL-Sadoon and Jarrar, 1994). C. c. gasperettii has an hemo- facilities and supportive care that developed in recent years in toxic venom and is also one of the most common species in different regions of Saudi Arabia including Riyadh province. human bites throughout the Middle East. Other deadly snake In addition, the present results indicate the success of the Saudi species have been reported in other regions of Saudi Arabia national strategy against snake bite envenomation as a conse- such as Naja haje arabicus, E. coloratus and W. aegyptia quence of the establishment of national records and moreover, (Tilbury et al.1987; Al-Mohareb and Al-Sadoon, 1994; manufacturing specific and poly antivenom targeting the spec- Malik, 1995). In other countries, snake bites are incriminated trum of the local venomous snakes. by Naja nigricollis (in Nigeria), the saw-scaled viper Echis The present investigation showed that the majority of snake ocellatus (in Senegal) (Pugh and Theakston, 1980; Trape bite victims in Riyadh province were males (81.70%). This et al., 2001) and Bitis arietans, Naja h. legionis, Coluber hip- finding is in agreement with previous results carried on snake pocrepis, and Vipera mauritanica (in Morocco) (Arfaoui bites in Saudi Arabia (Al-Sadoon and Jarrar,1994; Al- et al., 2009). Durihim et al., 2010; Mahaba, 2000; Al-Mohareb and Al- Main symptoms of C. c. gasperettii envenomation were Sadoon, 1994) and with other studies in different countries local pain, shock, swelling, edema and tenderness in most of such as Brazil where 89.5% of the patients were males the patients. This finding is in agreement with other results (Franco et al., 2001); southeast of Arabian peninsula where (Al-Durihim et al., 2010; Al-Kaabi et al., 2011; Al-Mohareb the majority (87%) were male farmers (Al-Kaabi et al., and Al-Sadoon, 1994). 2011); Morocco where 53% were males (Arfaoui et al., 2009) In conclusion, from this study, we found that among those and the snake bite patients were males (96%) in Isfahan prov- identified snakes, the most common venomous snake bite was ince, Iran (Dehghani et al., 2014a,b). Snake bites in males out- of the horned viper, C. c. gasperettii. These bites result in numbered females in the present investigation. This may reflect envenomation needing antivenom administration but with no the fact that women in Riyadh province as other districts of serious clinical complication. Although the rate of snake bite Saudi Arabia in contrary to men spend most of their times is high in Al-Riyadh province most of the bitten patients indoors with their families whereas males are involved in farm- recovered. This does not imply a real medical threat. This ing activities or young camper or Bedouins’ who spend most of may be due to the excellent medical facilities and having the their life in the desert. antivenom available in the health centers in recent years in dif- The present result demonstrated that young adults and ado- ferent regions of Saudi Arabia. It is very important to educate lescents (51.5%) are more affected by snake bites. The high the native people to increase awareness about the possibility of rate of snake bites among victims younger than 30 years may venomous snakes and the risk of snake bites is greater during be explained on the basis where this age category is associated the hot months of the year. General awareness for those who with most outdoor activities. intend to hike or camp in areas known to be inhabited by ven- According to the data from this study, no snake bites were omous snakes is important. Education of the emergency med- reported in the winter months (December through February). ical staff for identification of venomous snakes is an essential This may be due to the fact that snakes hibernate and become step in the treatment. totally inactive due to lowered ambient temperatures. The highest incidence of snake bites was more frequent during Acknowledgement the summer months (May through September) with a maxi- mum frequency in August. 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