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Bites by the Colubrid Snake Philodryas Patagoniensis: a Clinical and Epidemiological Study of 297 Cases

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Bites by the Colubrid Snake Philodryas Patagoniensis: a Clinical and Epidemiological Study of 297 Cases Toxicon 56 (2010) 1018–1024 Contents lists available at ScienceDirect Toxicon journal homepage: www.elsevier.com/locate/toxicon Bites by the colubrid snake Philodryas patagoniensis: A clinical and epidemiological study of 297 cases Carlos R. de Medeiros a,b,*, Priscila L. Hess c, Alessandra F. Nicoleti d, Leticia R. Sueiro e, Marcelo R. Duarte f, Selma M. de Almeida-Santos e, Francisco O.S. França a,d a Hospital Vital Brazil, Instituto Butantan, Av. Vital Brazil 1500, 05503-900, São Paulo, SP, Brazil b Serviço de Imunologia Clínica e Alergia, Departamento de Clínica Médica, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil c Laboratório de Imunoquímica, Instituto Butantan, São Paulo, SP, Brazil d Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil e Laboratório de Ecologia e Evolução, Instituto Butantan, São Paulo, SP, Brazil f Laboratório de Herpetologia, Instituto Butantan, São Paulo, SP, Brazil article info abstract Article history: We retrospectively analyzed 297 proven cases of Philodryas patagoniensis bites admitted to Received 9 November 2009 Hospital Vital Brazil (HVB), Butantan Institute, São Paulo, Brazil, between 1959 and 2008. Received in revised form 4 July 2010 Only cases in which the causative animal was brought and identified were included. Part of Accepted 9 July 2010 the snakes brought by the patients was still preserved in the collection maintained by the Available online 17 July 2010 Laboratory of Herpetology. Of the 297 cases, in 199 it was possible to describe the gender of the snake, and seventy three (61.3%) of them were female. The length of snakes (snout- Keywords: vent length) ranged from 160 to 1080 mm. In 117 snakes their state of preservation Philodryas patagoniensis Colubridae enabled the dissection and examination of their stomach contents. The stomach was Snakebite empty in 106 snakes (89.1%). Most bites occurred in the seasons of spring and summer Envenomation (n ¼ 196, 66.0%) and during warmer periods of the day. The mean age of the victims was 24.1 Æ 15.1 years old and 206 (69.4%) patients were men. Around 92% of the patients sought medical care within 6 h after the bite. Both lower (n ¼ 188, 63.3%) and upper limbs (n ¼ 102, 34.3%) were most frequently bitten, especially the feet and hands (n ¼ 205, 69.0%). The local clinical manifestations were pain (n ¼ 151, 50.8%), transitory bleeding (n ¼ 106, 35.7%), erythema (n ¼ 47, 15.8%) and edema (n ¼ 39, 13.1%). Ecchymosis was not observed. Only 7 (2.4%) patients reported systemic symptoms characterized by mild dizziness and 88 patients (29.6%) showed no evidence of envenoming. The whole blood clotting time was performed in 76 (25.6%) patients on admission and all of them had coagulable blood. Supportive treatment was offered to only 13.4% of patients, namely administration of antihistamines (n ¼ 19, 6.4%) and analgesics (n ¼ 12, 4.1%). Eight patients (2.7%) were mistreated with Bothrops antivenom before their admission to HVB. No sequels or relevant complications were observed in patients, and the prognostic was benign. Therefore, although P. patagoniensis accidents can cause mild local symptomatology, it is very important that health professionals know how to make the correct diagnosis to avoid unnecessary use of antivenom. Ó 2010 Elsevier Ltd. All rights reserved. * Corresponding author at: Hospital Vital Brazil, Instituto Butantan, Av. Vital Brazil 1500, 05503-900, São Paulo, SP, Brazil. Tel./fax: þ55 11 37267962. E-mail address: [email protected] (C.R. de Medeiros). 0041-0101/$ – see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.toxicon.2010.07.006 C.R. de Medeiros et al. / Toxicon 56 (2010) 1018–1024 1019 1. Introduction described in the literature. Therefore, we decided to study the epidemiological and clinical aspects of the In Brazil, approximately 26,000 snakebites were repor- P. patagoniensis accidents. ted in 2008 and most of these (w73%) were caused by Bothrops-like species and only 3% caused by non-venomous 2. Material and methods snakes (SINAN, 2009), including colubrids. Since in many cases the offending species was not identified and the 2.1. Study design and population diagnosis was established by clinical findings, it is possible that some of these unidentified bites have been caused by A retrospective study was conducted by reviewing the colubrids (Nishioka and Silveira, 1994; Ribeiro et al., 1994; records of patients admitted to Hospital Vital Brazil (HVB), Prado-Francheschi and Hyslop, 2002; Salomão et al., 2003). Butantan Institute, São Paulo, Brazil, between January, 1959 Despite the biological relevance and abundance of and December, 2008, with diagnosis of snakebite by P. colubrid snakes in the world, little information is known patagoniensis. Only proven cases, in which the causative about the composition and biological activities of their animal was brought and identified, were included. The venoms. The Philodryas genus, belonging to the Dipsadidae taxonomical identification of the snakes involved in enve- family (Zaher et al., 2009), is widespread in all South nomations was carried out at the Herpetology Laboratory America with 17 species, 10 of which can be found in Brazil. of Butantan Institute, which still preserves most of the These are considered of minor clinical significance to snakes brought since 1959. P. patagoniensis preserved in humans and, therefore, have received little attention from this collection were dissected and the following data was the clinical point of view. However, they are able to produce collected: reproductive status, gender, genital tract, secretions from Duvernoy’s gland, currently synonymized stomach or intestine contents, and snout-vent-length by Fry et al. (2003) as the venom glands, which are toxic (SVL). The critical values of SVL between immature and enough to produce lesions at the bite’s site. Several species adult P. patagoniensis males and females are 42 cm and of Philodryas cause accidents with clinical significance 47 cm respectively (Fowler and Salomão, 1995). Physicians (Prado-Francheschi and Hyslop, 2002): Philodryas aestivus through the use of a standardized form reviewed the (Fowler and Salomão, 1994), Philodryas baroni (Kuch and records. The following variables were analyzed: gender and Jesberger, 1993), Philodryas chamissonis (Otero et al., age of patients, month and time of the accident, circum- 2007), Philodryas olfersii (Nickerson and Henderson, 1976; stance and site of the bite, use of tourniquet, variables Silva and Buononato, 1983/84, Fowler and Salomão, 1994; related to the snake, clinical manifestations, whole blood Ribeiro et al., 1999) and P. patagoniensis (Martins, clotting time (WBCT), when carried out, and treatments. 1916; Fowler and Salomão, 1994; Nishioka and Silveira, The study maintained the privacy of the patients’ data, with 1994; Araújo and Santos, 1997). approval of the Ethics Committee (Protocol number: 5502). P. patagoniensis is an opistoglyphous snake that has diurnal habits, being semi-arboreal, predominantly 2.2. Statistical analysis terrestrial (Marques et al., 2001; Sazima and Haddad, 1992; Fowler and Salomão, 1994; Hartmann and Marques, 2005), To ascertain whether the values were normally distrib- occupying open environments such as fields and savannas uted, the Kolmogorov–Smirnov test was used. The chi- (Lema, 1973; Thomas, 1976). Fig. 1 shows the species square test was applied for the analysis of the significance distribution in South America. They are 0.5 to approxi- of data obtained. When at least one cell of the 2 Â 2 mately 1 m long, weighing between 100 and 250 g (Fig. 2). contingency tables presented an expected frequency of less In the few cases of human accidents described in the than 5, Fisher’s exact test was used. Mann–Whitney test for literature, only local symptoms, such as edema, pain, itch- independent samples was used to study the association ing, and slight increase in temperature at the site of the between clinical manifestations and time between the bite bite, have been described (Martins, 1916; Nishioka and and the admittance to the hospital, and the association Silveira, 1994; Araújo and Santos, 1997). In all these cases between clinical manifestations and the length of snakes. no systemic symptoms or coagulopathy were reported. Values of p < 0.05 were considered statistically significant. In 1916, Naur Martins conducted the first studies with All statistical analyses were performed using the this venom, noting proteolytic and hemolytic actions Statistical Package for Social Sciences (SPSS) for Windows without coagulant activity, pain, swelling and hemorrhage (version 15.0, 2006; Statistical Products and Service Solu- in animal models (Martins, 1916). Over eighty years later, tions Inc., Chicago, IL, USA). neuromuscular activity of this venom in mice was demonstrated (Souza-Filho et al., 2000). Recently, 3. Results biochemical and biological characterization of this venom and the study of the mechanisms of local action such as Two hundred ninety seven medical records were pain and edema have been reported (Acosta et al., 2003; analyzed, with 5.9 accidents per year. All cases occurred in Peichoto et al., 2004, 2005, 2006, 2007, 2009; Rocha and the city of São Paulo and surrounding areas with predom- Furtado, 2007; Zelanis et al., 2010). inance of accidents in rural areas. Of the 297 patients, 206 While these experimental studies suggest a potential were men (69.4%) and 91 were women (30.6%) distributed severity of these bites (and the possibility misidentification according to age as shown in Table 1. The mean age of the of P. patagoniensis bites as Bothrops bites), there is, appar- patients was 24.1 Æ 15.1 years old, and the median age was ently, an absence of significant symptoms in the few cases 22.0 years old (interquartile range 11.0–36.0). Although 1020 C.R.
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