LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY FACULTY OF MEDICINE DEPARTMENT OF DISASTER MEDICINE TZABAR GUR CLINICAL MANIFESTATION AND MANAGEMENT OF SNAKEBITES IN LITHUANIA (Vipera berus) AND IN ISRAEL (Vipera palaestinae) A LITERATURE REVIEW MASTER THESIS Supervisor: prof. Dinas Vaitkaitis KAUNAS 2020 TABLE OF CONTENTS 1 SUMMARY........................................................................................................................................... 3 2 CONFLICTS OF INTEREST ............................................................................................................. 4 3 PERMISSION ISSUED BY THE ETHICS COMMITTEE ............................................................ 5 4 ABBREVIATIONS .............................................................................................................................. 6 5 INTRODUCTION ................................................................................................................................ 7 6 AIM AND OBJECTIVES .................................................................................................................... 8 7 RESEARCH METHODOLOGY AND METHODS ........................................................................ 9 8 RESULTS AND THEIR DISCUSSION ........................................................................................... 11 8.1 Epidemiology of snake bites ............................................................................................................................. 11 8.1.1 Epidemiology of snake bites by V. berus in Lithuania ........................................................................................... 11 8.1.2 Epidemiology of snake bites by V. palaestinae in Israel ......................................................................................... 11 8.2 Symptoms, signs and complications after snake bite ......................................................................................... 12 8.2.1 Clinical manifestation due to V. berus envenomation ............................................................................................ 12 8.2.2 Clinical manifestation due to V. palaestinae envenomation .................................................................................. 13 8.3 Vipera berus and Vipera palaestinae snake bite management ............................................................................ 15 8.3.1 First aid after snake bite ........................................................................................................................................... 15 8.3.2 Supportive treatment after snake bite envenomation ............................................................................................ 16 8.3.3 Specific treatment after snake bite envenomation in Lithuania (Vipera berus) and in Israel (Vipera palaestinae) ............................................................................................................................................................................... 16 8.4 Causes of death and mortality rate due to snake bite envenomation ................................................................. 18 8.4.1 Causes of death due to Vipera berus and Vipera palaestinae envenomation ........................................................ 18 8.4.2 Mortality rate after Vipera berus and Vipera palaestinae envenomation ............................................................. 19 9 CONCLUSIONS................................................................................................................................. 20 10 REFERENCES ............................................................................................................................... 21 2 1 SUMMARY Master thesis by Tzabar Gur Title – Clinical manifestation and management of snakebites in Lithuania (Vipera berus) and in Israel (Vipera palastinae). The aim of the theses To review epidemiology, clinical manifestation, treatment and most common causes of death of patients who were bitten by snakes Vipera palaestinae (in Israel) and Vipera berus (in Lithuania). Objectives of the study 1.To determine the epidemiology of snakebite by Vipera palaestinae in Israel and Vipera berus in Lithuania. 2. To find the symptoms, signs and complications of snakebites caused by Vipera palaestinae and Vipera berus. 3. Antivenom and supportive treatment of patients who were bitten by Vipera palaestinae in Israel and Vipera berus in Lithuania. 4. To determine mortality rate and causes of death due to snakebites caused by Vipera palaestinae in Israel and Vipera berus in Lithuania. Methodology a literature review was conducted using the electronic medical database PubMed and Google Scholar selecting publications which were relevant to the topic. Combination of the keywords: “snakebite”, ”snake bite”, ”viper”, ”Vipera berus”, ”Vipera palaestinae”, ”envenomation”, ”antivenom”, “antivenin”, ”European adder”, “middle east”, “Lithuania”, “Israel’ were used. As well as filters were applied: language “English”, “Lithuanian”, “Hebrew”; species “human” in order to select the articles and researches for this literature review. Results and conclusions: In Lithuania the average V. berus snakebites is 34 cases per year. In Israel there are 150-200 snakebites per year, most of them are caused by V. palaestinae. The main local sings of the snakebite are fangs marks, severe pain and edema. Most common systemic signs are CVS manifestation, vomiting, abdominal pain, anaphylactoid reaction. The most common complications are necrosis, compartment syndrome, limb amputation and renal failure. The only specific treatment is antivenin. In Lithuania there is no standardized protocol. In Israel the treatment protocol is 50mL i/v of V. palaestinae antivenom. In Israel there is 1 death after V. palaestinae envenomation every 5 years. In Lithuania there was no death after V. berus envenomation during 2001-2009 period. 3 2 CONFLICTS OF INTEREST The author reports no conflicts of interest. 4 3 PERMISSION ISSUED BY THE ETHICS COMMITTEE No clearance issued by the Ethics Committee is needed in this study. 5 4 ABBREVIATIONS AIDS- acquired immunodeficiency syndrome ALT- alanine transaminase APTT- activated partial thromboplastin time AST- aspartate transaminase atm- standard atmosphere unit C- Celsius C. cerastes- Cerastes cerastes C. purpureomaculatus- Cryptelytrops purpureomaculatus Cm- centimeters CVS- cardio vascular system ECG- electrocardiogram EMA- European Medicines Agency h - hours HIV- human immunodeficiency virus HSR- hypersensitivity reaction H1A-histamine H1-receptor antagonist H2A-histamine H2-receptor antagonist IM- intramuscular IgE- immunoglobulin E IV- intravenous Mg/kg- milligram per kilogram mL- milliliters Mm- millimeters Mm Hg- millimeter of mercury NSAIDs- non-steroidal anti-inflammatory drugs PLA2- phospholipase A2 PM- post meridiem PSS- Poisoning Severity Score PT- prothrombin time Rh- rhesus SC- subcutaneous Sol.- solution spp.- species V. berus- Vipera berus (common European viper, common European adder) V. palaestinae- Vipera palaestinae (Daboia palaestinae) VXP- Vipera xanthine palaestinae WHO- World Health Organization 6 5 INTRODUCTION There are 5,400,000 events of snakebite every year. Snakebite can be caused by nonvenomous and venomous snakes. Venomous snakebites can be classified into “dry” bite and envenomation. “Dry” bite means that no venom enter the victim’s body after the venomous snakebite. Envenomation is the process in which the venom enters the body during venomous snakebite. Envenomation due to snakebite considered as health threatening condition in the whole world, especially in the rustic regions of developing countries. Every year 2,500,000 cases of the snakebites are envenomated, approximately 125,000 result in death, mostly in Asia; 100,000 suffer from severe outcomes [1–3]. Snakebite envenomation is a neglected global health problem, responsible for substantial mortality, disability, anxiety and other psychological morbidity, particularly in rural tropical areas [3]. Venomous snakebite is a medical emergency impacting the site of the bite and potentially can affect the whole body systems [4]. The Viperidae is a family of venomous snakes, which are known in the society as vipers. Vipers are found in most geographical areas of the globe, for instance in Europe - Vipera berus (V. berus), in America - American crotalus durissus, in Africa - Cerastes cerastes (C. cerastes), in Asia - Cryptelytrops purpureomaculatus (C. purpureomaculatus) [5]. In Lithuania the only venomous snake is V. berus, as well as one of the most common venomous snake in Europe. V. berus is also known as common European viper, common European adder. In Israel the most common venomous snake is Vipera palaestinae (V. palaestinae), which is endemic viper found in Middle East. V. palaestinae in the literature is also known as Daboia palaestinae, Vipera xanthina palaestinae [6,7]. Vipers bites can be lethal, therefore they required attention and immediate medical care [8]. The only specific treatment is antivenin. Thus, it is limited by high price, cold storage, snakebite diagnosis and political issues [3]. The purpose of this literature review is to provide summarized information from the newest articles and studies about the most common venomous snakes in Lithuania and Israel. The aim of this master thesis: to review epidemiology, clinical manifestation, treatment and most common causes of death of patients who were bitten by snakes