Department of Emergency Medicine & Center for Research in Emergency Medicine Universiti Kebangsaan Malaysia Medical Centre
Centre for Research in Emergency Medicine, Department of Emergency Medicine, UKMMC, Malaysia 2009
09A-131 “BITTEN BY A RARE BEAUTY” A CASE OF SYSTEMIC ENVENOMATION BY THE TWIN BARRED TREE SNAKE CHRYSOPELEA PELIAS Ahmad Khaldun Ismail, Dazlin Masdiana Sabardin, Shahridan Mohd Fathil, Teodoro Herbosa, Ismail Mohd Saiboon
Snakes & bites in Malaysia
• Approximately ≥ 154 species
Snake families and species in West Malaysia 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
File Snakes Dwarf Pipe Snakes Pythons Colubrids Asian Pipe Snakes Elapids See Snakes Blind Snakes Pit Vipers Sun Beam Snakes Spine-jawed Snakes
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Acrochordidae Anomochelidae Pythonidae Colubridae Cylindrophiidae Elapidae Hydrophiidae Typhlopidae Crotalidae Xenopeltidae Xenophidiidae
> 2 >1 >4 > 102 >1 > 10 > 20 >4 >9 >1 >1
Venomous snakes are not poisonous!
“A study of snake bites in Peninsular Malaysia with special reference to Perlis & Kedah from 1979-1983” Stephen Ambu & Lim Boo Liat. Trop Biomed 1998
– 5077 - 5492 bites per year – > 50% in Perlis & Kedah. Johor the lowest – Commonest by Calloselama rhodostoma – Males > Females; Age group 11-30 y/o – Lower limb in paddy fields – Death rate 1.6%(1958-59) to 0.13%(1977-83)
“Retrospective prevalence of snakebites from HKL (1999-2003)” Jamaiah et. all. SEA Trop Med 2006 – 126 snakebite cases. 79% admitted for ≤ 3 days – 11-30 years age group (52%). male:female ratio 3:1 – Malaysians (80%, 101 cases). non-Malaysians (20%,25 cases), Indonesians (56%, 14 cases) – lower limbs (49%), upper limbs (45%) and others (6%). None fatal. pain and swelling 92% (116 cases) – 60% (70 cases) snake unidentified. Cobra (both suspected and confirmed) (25%), viper (10%), python (4%) and sea snake (1%) – 48% (61 cases) treated with cloxacillin, 25% (32 cases) given polyvalent antivenom
Snake identification & Management of bites • A local issue – familiarization/experts • Utilizations of technology and sharing of information – local, national, regional, international. • Guidelines – updated • Research
The incident • Evening of 23rd June 2008 • a 19 years old female arrived to the ED six hours after being bitten by an unidentified snake • Location: a picnic area by a stream at 100m to 200m elevation • Snake killed and picture taken with mobile phone
Clinical presentation • Triaged P2 and assess in the “Red Box”. • The airway, breathing, circulation, neurological functions were normal at presentation. • There was mild pyrexia of 37.5˚C. • The pain score (VNRS) was 5/10. • She had headache and sleepiness less than one hour post bite which resolved on arrival.
ED Management • • • • • •
First aid treatment Immobilization Primary survey and resuscitation Secondary survey and snake identification Investigations Treatment – Polyvalent antivenom 20cc after test dose • Observation - Progress after specialized treatment
Blood & urine investigations • Urine analysis showed red cells 4+ but no myoglobinuria. • The full blood count showed neutrophil leucocytosis with white blood cell count of 11.2x109.
TABLE I. Blood and urine investigation results Date
23/06/2008 Day 1
24/06/2008 Day 2
04/07/2008 Day 10
RBC 4+↑
negative
negative
negative
negative
11.2↑
12.2↑
9.3
9.1
8.0↑ (71.4%)
11.2↑ (91.4%)
Hb (g/dL)
13.7
13.9
12.9
13.3
Platelet (x109/L)
381
335
446↑
313
PT (sec)
13.7
13.8
INR (ratio)
1.10
1.10
APTT (ratio)
1.25
1.59↑
Investigation Urine hemoglobin Urine myoglobin
Full Blood Count
White Cell count (x109/L) Neutrophils (x109/L)
Coagulation profile
17/07/2008 Day 24
TABLE I. Blood investigation results Investigation ABG
RP
LFT
24/6/2008 Day 2
04/7/08 Day 10
17/7/2008 Day 24
PH
7.378
pO2
90.7
pCO2
38.9
HCO3
22.8
Urea (mmol/L)
2.3
3.3
2.9
Creatinine(μmol/ L)
48
52
48
Sodium(mmol/L)
137
141
136
Potassium (mmol/L)
3.6
3.9
4.0
ALT (U/L)
12
12
12
Creatinine Kinase (U/L) LDH (U/L)
Date 23/6/2008 Day 1
133
99
118
454↑
366
370
Clinical Progress • There was minimal numbness over the dorsum of the right foot and discomforting sensation radiating up the thigh which persisted for several days.
• Warded (medical) for observation for 48 hours and discharged with ED follow up as necessary.
Introduction to the Beauty • Chrysopelea pelias belongs to the Collubridae family, a unique tree snake species that is able to glide. • Not much is known about the effects from its bite nor the type of venom C. pelias has. • This report is probably the first documented observation of systemic envenomation by this rarely seen species
Chrysopelea pelias • . • It has rear fangs and believed to be mildly venomous. • It inhabits various lowland forests, shrubs and bushes and has been sighted in southern Thailand, Malaysia, Singapore, Sumatra, Java, Riau and Borneo at altitudes up to 600 meters. • It is diurnal and arboreal. It laid eggs and feed on small vertebrates such as lizards and frogs. • It can grow up to 74 cm in length, although mature adults were commonly found below 65cm in the wild
Conclusion • There was little known about the effects of envenomation by C. pelias. Need more research. • Possible presence of neurotoxin, haemolysin and myotoxin effects . No antivenom available. • First aid, reduced mobility, 24 hours observation in a medical facility and analgesia is recommended. • Need of a system to expedite accurate management and improve care for animal bites and stings cases. • With technology, unnecessary killings of harmless, protected and rare animal species can be avoided. • Continuous awareness programs encouraged – healthcare givers and public alike.
This experience also demonstrated the need for a more up to date research on snakes and snake bites in Malaysia
Potential for Collaborative Research Projects
[email protected]
Thank You
