Winter 2019, Volume 9, Number 1 Research Paper: Snake Envenomation in North-West Iran: A Three-Year Clinical Study Rahim Nejadrahim1 , Mehrdad Sahranavard2 , Anita Aminizadeh3 , Mohammad Delirrad4* 1. Department of Infectious Disease, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran. 2. Student Research Committee, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran. 3. School of Medicine, Urmia University of Medical Sciences, Urmia, Iran. 4. Department of Forensic Medicine and Toxicology, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran. Use your device to scan and read the article online Citation Nejadrahim R, Sahranavard M, Aminizadeh A, Delirrad M. Snake Envenomation in North-West Iran: A Three-Year Clinical Study. International Journal of Medical Toxicology and Forensic Medicine. 2019; 9(1):31-38. https://doi.org/10.22037/ ijmtfm.v9i1(Winter).24072 : https://doi.org/10.22037/ijmtfm.v9i1(Winter).24072 A B S T R A C T Background: Snakebite is a medical emergency and must receive high-priority assessment Article info: and treatment, even in patients who initially appear well. A few reports have been published Received: 25 May 2018 regarding snakebite in Iran. This study aimed to assess the snakebite cases in a tertiary teaching First Revision: 29 Jun 2018 hospital in the northwest of Iran. Accepted: 23 Oct 2018 Methods: We assessed demographic and clinical characteristics of adult patients who were Published: 01 Jan 2019 admitted because of snakebite into Ayatollah Taleghani Teaching Hospital, Urmia, West Azerbaijan, Iran, between January 1, 2012, and December 31, 2014. After institutional Ethics Committee approval, the required data were extracted, analyzed, and reported. Results: Totally, 60 snakebite cases were recorded during three years study period, of them 63.3% were male. The patients’ Mean±SD age was 37.8±15.8 years. The majority of snake envenomations occurred in the farms and mountains (71.4%), frequently in the afternoons of spring and summer seasons, and mostly affected inhabitants or visitors of the rural areas. The Mean±SD time interval between snake envenomation and admission to the first health center was 15.3±28.6 hours. The anatomic sites of the snakebite were lower and upper extremities in most instances (96.6%). Only 5 (8.3%) patients had severe toxicity, and 2 patients underwent surgical fasciotomy. The patients were treated using antihistamines (n=45), corticosteroids (n=35), antibiotics (n=54), polyvalent snake antivenins (n=50), wound care and tetanus immunization (n=39). The Mean±SD number of polyvalent snake antivenins used for each patient was 3.3±1.9 (range, 1-8) vials. There was no in-hospital fatality. Keywords: Conclusion: Most snakebites victims in the northwest of Iran were men in their productive Snake bites, Epidemiology, age. Early diagnosis and proper use of snake antivenins could be life-saving and should Therapy, Antivenins, Iran be encouraged. * Corresponding Author: Mohammad Delirrad, PhD. Address: Department of Forensic Medicine and Toxicology, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran. Tel: +98 (44) 33444591 E-mail: [email protected] 31 Winter 2019, Volume 9, Number 1 1. Introduction 2. Materials and Methods nakes belong to a widespread group of In this observational clinical study, we gathered regis- reptiles that are found in almost every part tered data of all adult patients (≥14 years) with a history of the world, except small areas such as of a snakebite who were referred to Ayatollah Taleghani Antarctica or some isolated islands [1-3]. Teaching Hospital in Urmia, West Azerbaijan Province, S There are around 3500 species of snakes Iran, from January 1, 2012, to December 31, 2014. around the world from which less than 10% are poi- sonous [1, 4, 5]. Venomous snakes have a pair of teeth The shape of Iran on the world map resembles a cat, (fangs) that works like an enlarged needle to inject their and West Azerbaijan Province is located at the right side venom deeply, especially subcutaneously or intramuscu- of its face (Figure 1 A). The province is one of the 31 larly into the tissues of the victims and humans [1, 6, 7]. provinces of the country bordering Turkey, Iraq, and the The injection of the toxin causes a variety of symptoms Nakhchivan Autonomous Republic, as well as the prov- from mild toxicity to critical systemic response depend- inces of East Azerbaijan, Zanjan, and Kurdistan. Urmia ing on the type of snake, venom volume, season, vic- is the capital city and largest county of the province. tim’s age and physical status. Clinical presentations of There are also 16 other counties in the province (Figure 1 the snakebites may differ from almost none, dry bite, to B). According to the last national census (2016), the pop- severe systemic complications such as shock, infection, ulation of West Azerbaijan Province and Urmia County coagulopathies, neuropathies, cardiomyopathy, renal was 3,265,219 and 1,040,565 people, respectively [20, failure, rhabdomyolysis, and even death [6, 8-10]. 21]. Ayatollah Taleghani Teaching Hospital is the second largest public hospital in Urmia which has Clinical Toxi- Snakebite is a significant health emergency, especially cology, Infectious Diseases, Dermatology, Cardiology, in rural areas of developing countries. Hence, the World and Internal Medicine Wards. The first three wards are Health Organization (WHO) mentioned snakebite man- the only academic referral wards in the province. agement as one of its priorities [6, 11, 12]. It is estimated that every year around 2.1 to 5.5 million people were bit- The snake envenomation was confirmed by either a ten by snakes in the world from which 20000 to 125000 clinical toxicologist or an infectious disease special- die and thousands of them develop chronic disabilities, ist. The required demographic and clinical data such including 400000 amputations [2, 13, 14]. Only in Asia, as gender, age, address, marital status, occupation, date the reported annual number of snake envenomations and of admission, time of discharge, the anatomic site of resulting deaths are approximately 2 million and 100000 snakebite, presence of fang mark(s), clinical symptoms cases, respectively [2]. and signs, the prescribed treatments (antihistamines, corticosteroids, antibiotics, antivenins, wound care, Iran is also a country with high reported cases of ani- and tetanus immunization), surgical interventions (in- mal bites as well as snake envenomation. It is estimated cluding fasciotomy), and complications of snake en- that Iran has a variety of 69 species of snakes with 9 venomation (including patient’s death) were extracted semi-venomous and 25 venomous (including The Per- from the hospital documents. sian Gulf water snakes) species [1, 15]. The number of snakebites in 8 years from 2002 to 2009 was reported to The conduction of this study was according to the Hel- be around 5 to 7 thousand cases, with 3 to 9 deaths per sinki Declaration and approved by the Ethics Committee year [4, 5]. Another study reported the number of snake- of Deputy of Research and Technology, Urmia Univer- bites in a decade from 2002 to 2011 to be more than sity of Medical Sciences, Urmia, Iran. All the gathered 50000 cases with an incidence rate of 4.5 to 9 cases per data were analyzed in SPSS for Windows version 16 100000 population and 67 fatalities in a whole decade software (SPSS Inc., Chicago, IL, USA). We expressed [16]. Isolated epidemiologic studies concerning snake- quantitative data as Mean±SD and qualitative data as bite are available from only some parts of the country frequency and percentage. such as Ardabil [17], Kashan [5], Queshm [18], and Ta- briz [19]. This study aimed to assess snakebite cases in a 3. Results tertiary teaching hospital in the northwest of Iran. Overall, 60 cases of snakebite were included in the study that happened during the three years. Out of them, 63.3% were male, and 36.7% were female. The Mean±SD age of the patients was 37.8±15.8 (range: 15 Nejadrahim R, et al. Snake Envenomation in North-West Iran. IJMTFM. 2019; 9(1):31-38. 32 Winter 2019, Volume 9, Number 1 Figure 1. West Azerbaijan Province [37] A. Location of the province on the country map (Coordinates: 37.5528°N 45.0759°E); B. Counties of the province to 72 y) years. This was 34.3±14.8 years (range: 15 to The highest number of snakebites occurred in 2013 61 y) for men (n=38) and 43.7±16.1 (range: 22 to 72 (n=25), followed by 2012 (n=22) and 2014 (n=13). En- y) years for women (n=22). Assessment of marital sta- venomations only happened from April to October (first tus showed that 76.7% of the patients (25 males and 21 seven months of the solar calendar); mostly in summer females) were married, and 18.3% (1 male and 10 fe- and spring seasons (Figure 2). The majority of snake- males) were single. For 5% of the patients (3 males), the bites occurred during day times (afternoon: 19, noon: marriage status was unknown. 12, and morning: 12 cases) and the lowest was at night with 2 cases; however, the time of 15 snakebite cases Regarding occupation and career, the status of 24 was unknown. (40%) cases was unknown, and among remaining 36 patients, 11 (18.3%) were self-employed, 13 (21.7%) Most of the patients (n=42, 70%) were from Urmia house wive, 5 (8.3%) farmer, 5 (8.3%) student, and 2 County followed by other cities of the province, includ- (3.3%) worker. Eleven (18.3%) patients mostly men ing Oshnavieh (n=6, 10%), Piranshahr (n=3, 5%), Sar- (n=9) and 49 (81.7%) patients also mostly men (n=29) dasht (n=3, 5%), Salmas (n=2, 3.3%) as well as Khoy, were inhabitants of urban and rural areas, respectively.