Fig 1 - uploaded by Matteo Riccardo Di Nicola
Content may be subject to copyright.
Heads of the six snake families present in Europe: Colubridae (A), Natricidae (B), Psammophiidae (C), Viperidae (D), Erycidae (E), Typhlopidae (F). The species portrayed in the pictures are: Zamenis lineatus (A), Natrix maura (B), Malpolon insignitus (C), Vipera ursinii (D), Eryx jaculus (E), Indotyphlops braminus (F). Photo credits: Matteo R. Di Nicola.
Source publication
Snakebites in Europe are mostly due to bites from Viperidae species of the genus Vipera. This represents a neglected public health hazard with poorly defined incidence, morbidity and mortality. In Europe, fourteen species of “true vipers” (subfamily Viperinae) are present, eleven of which belong to the genus Vipera. Amongst these, the main medicall...
Contexts in source publication
Context 1
... important first step in the management of snakebites is the identification of the species involved in the bite. According to the recent taxonomic updates and including the main alien taxa, 57 species of snakes live in Europe, belonging to six different families: Colubridae, Erycidae, Natricidae, Psammophiidae, Typhlopidae and Viperidae ( Fig. 1) Speybroeck et al., 2020;Zaher et al., ...
Context 2
... can be easily identified in comparison with the other European snakes using a series of morphological characteristics as well as the symptomatology associated with their bite. Excluding Erycyidae and Typhlopidae families, which include snakes morphologically (and ecologically) very different from other European species ( Fig. 1), the remaining non-viperid snakes are all colubrids sensu lato (Colubridae, Natricidae and Psammophiidae) ( Uetz et al., 2020;Zaher et al., ...
Context 3
... body of vipers ( Fig. 2A1) is proportionally shorter and stockier than that of the colubrids (Fig. 2B1), with a lower length/width ratio. In addition, European vipers usually reach an average size of 50 70 cm and do not exceed the meter (only Montivipera xanthina, limited to Greek Thrace and some Greek islands off the Turkish West coast, can exceed 100 cm). ...
Context 4
... body of vipers ( Fig. 2A1) is proportionally shorter and stockier than that of the colubrids (Fig. 2B1), with a lower length/width ratio. In addition, European vipers usually reach an average size of 50 70 cm and do not exceed the meter (only Montivipera xanthina, limited to Greek Thrace and some Greek islands off the Turkish West coast, can exceed 100 cm). Various species of colubrids, on the other hand, abundantly exceed one meter in ...
Context 5
... the skin ulcer has healed, an annual dermatological follow-up should be performed in the patient to prevent a possible scar-related cutaneous degeneration which can also occur in other dermatological conditions (WHO, 2010a;Mercuri et al., 2018Mercuri et al., , 2020). In extremely rare cases, a compartment syndrome may arise, it is characterised by an excessive pressure inside an enclosed muscle space in the body reducing blood flow to the tissues; it may induce a massive and rapid necrosis as a potential life threatening situation ( Supplementary Fig. 1). In physiological conditions, pressure within the compartments is between 0 mmHg-8 mmHg ( Torlincasi et al., 2020). ...
Context 6
... Pulselessness, Paraesthesia, Paralysis and Pallor, indicates a compartment syndrome and a need for fasciotomy ( Kim et al., 2019;Torlincasi et al., 2020). In children, compartment pressure cannot be easily measured at the bedside and in this case, fasciotomy should not be performed without adequate diagnosis of the compartment syndrome (Laohawiriyakamol et al., 2011). The fasciotomy should be performed ideally within six hours after the diagnosis of a snakebite but it is not recommended after 36 h ( Torlincasi et al., 2020). ...
Context 7
... main treatment for snake-bite related rhabdomyolysis is antivenom therapy. Symptomatic treatment of rhabdomyolysis is limited to an adequate parenteral supply of liquids to prevent a decrease in perfusion pressure in the glomeruli and facilitate production of a sufficient quantity of primary urine (Nelson et al., 2019). Besides, the fluid supplements are also important to prevent hypotension which is often common in Vipera envenomation (Valenta, 2010). ...
Context 8
... et al. (2016) highlighted that hyperglycaemia is a potential risk factor for high-grade envenomation after European Vipera bites in children (Claudet et al., 2016). The presence of hyperglycaemia in association with other factors that may increase the progression of symptoms to high-grade envenomation, may represent an indication to transfer paediatric patients to a tertiary level hospital where the antivenom is available (Claudet et al., 2012). ...
Similar publications
Objective: To define the microbiological characteristics of animal bites in tropical Australia and the appropriateness of current Australian antimicrobial guidelines for their management.
Methods: This retrospective audit examined hospitalisations in tropical Australia following an animal bite or animal-associated penetrating injury, between 2013...
Citations
... It has a burden of approximately 8000 SBE annually and the medically relevant venomous snakes belong to the Viperinae family [46,47]. There is a long history of ASV production in Europe and almost 13 laboratories produced it in early 1980s. ...
... Nevertheless, trust in immunotherapy, has recently increased with availability of purified and well tolerated ASVs. There are several ASVs for vipers in Europe [47,48]. Recently, a new polyvalent ASV has been shown to be effective against European vipers [49]. ...
The sole treatment for snakebite envenomation (SBE), the anti-snake venom (ASV), suffers from considerable drawbacks, including side effects and limited species specificity. Additionally, despite its existence for more than a century, uniform availability of good quality ASV does not yet exist. The present review describes the journey of a SBE victim and highlights the global crisis of SBE management. A detailed analysis of the current ASV market has also been presented along with the worldwide snake distribution. The current production of country specific licensed ASV throughout the globe along with their manufacturers has been examined at the snake species level. Furthermore, a detailed analysis of on-ground situation of SBE management in antivenom manufacturing countries has been done using the most recent literature. Additionally, the export and import of different ASVs have been discussed in terms of procurement policies of individual countries, their shortcomings, along with the possible solution at the species level. It is interesting to note that in most countries, the existence of ASV is really either neglected or overstated, implying that it is there but unsuitable for use, or that it is not present but can be obtained from other countries. This highlights the urgent need of significant reassessment and international collaborations not just for development and production, but also for procurement, distribution, availability, and awareness. A PROMISE (Practical ROutes for Managing Indigenous Snakebite Envenoming) approach has also been introduced, offering simple, economical, and easy to adopt steps to efficiently alleviate the worldwide SBE burden.
... While a protocol for the management and treatment of viper bites at the European level has been proposed [14], differences in venomous snake species and available resources, including antivenoms, in each country highlight the need for nation-specific protocols to optimise snakebite treatment locally. In this scenario, Italian clinicians need tools to aid in the management of Vipera envenomations. ...
The genus Vipera encompasses most species of medically significant venomous snakes of Europe, with Italy harbouring four of them. Envenomation by European vipers can result in severe consequences, but underreporting and the absence of standardised clinical protocols hinder effective snakebite management. This study provides an updated, detailed set of guidelines for the management and treatment of Vipera snakebite tailored for Italian clinicians. It includes taxonomic keys for snake identification, insights into viper venom composition, and recommendations for clinical management. Emphasis is placed on quick and reliable identification of medically relevant snake species, along with appropriate first aid measures. Criteria for antivenom administration are outlined, as well as indications on managing potential side effects. While the protocol is specific to Italy, its methodology can potentially be adapted for other European countries, depending on local resources. The promotion of comprehensive data collection and collaboration among Poison Control Centres is advocated to optimise envenomation management protocols and improve the reporting of epidemiological data concerning snakebite at the country level.
... Vipers are the only medically significant snakes in Europe. Envenomation by European vipers is rare [4] but can result in symptoms of varying severity, which may require treatment with antivenom and prolonged hospitalization [6,8,12,23,27]. The clinical manifestations of envenomation vary depending on the anatomical site of the bite, the amount and characteristics of the venom, and the general condition of the victim. Children are usually considered to be at greater risk due to their smaller body size [5,16,20,24], although some studies have not identified significant differences in the severity of envenomation between adults and children [12,22]. ...
Background
Bites caused by European vipers are rare medical emergencies but can occasionally cause life-threatening complications. Viper venom causes local symptoms, which can be accompanied by systemic manifestations in severe cases. The local effects of snakebites include edema and, more rarely, necrosis and compartment syndrome. The consequences of envenomation are often more pronounced in children due to their smaller body size.
Case presentation
We present the case of a 6-year-old girl who experienced multiple viper bites in the lower limb in northwest Italy. The girl received supportive care but progressed to develop compartment syndrome that required emergency fasciotomy. The patient’s condition improved promptly after surgical decompression and administration of antivenom, but full recovery required prolonged hospitalization and rehabilitation.
Conclusions
This case highlights the importance of obtaining a timely assessment of the severity of viper envenomation without delaying the administration of antivenom in most serious cases. The presence of multiple bite marks on the patient is one factor that may help to predict the clinical severity of snakebites and anticipate symptom progression.
... Possibly due to the pre-set eligibility criteria, records from European territory are totally missing (data from Turkey come only from the Southeastern Anatolia Region, Asia). This aspect could emphasize the neglect of snake bites in children in an area such as Europe where this condition is usually underestimated, also in non-pediatric subjects (see Paolino et al., 2020;Di Nicola et al., 2021). Considering that Europe has a relatively high number of medically relevant venomous species, with relevant medical aspects, the underestimation confirms that snakebite in Europe is a disease with neglected incidence, morbidity and mortality. ...
... The timeline diagram of keyword clustering revealed that recent studies have paid more attention to the exploration of other snake species, the toxicological testing of snake venoms, clinical long-term evaluations, the preparation of broad-spectrum antivenoms, and paediatrics; the trends for these keywords serve as a reference for future snakebite research. A secondary search of keywords with strong emergence further revealed that the diagnosis, treatment and prevention and control of snakebite are the current hot topics of interest, for example, studies of the evidence-based diagnosis and treatment of snakebite [18,19], enzyme inhibitors [20,21], snake venom proteomics [15], recombinant venom serum antibodies [16], broad-spectrum antivenom [22], clinical effects of antivenom [23], and macroeconomic and social factors [24]. Research on snakebite diagnosis, treatment and prevention and control is in line with the WHO's overall 2021-2030 approach to neglected tropical diseases. ...
Objective: To conduct a bibliometric analysis of the global snakebite literature to provide a reference for the future development of snakebite research.
Methods: The Web of Science citation analysis tools, VOSviewer and CiteSpace V were used to carry out the bibliometric analysis of the literature and generate visualization maps.
Results: The number of publications has increased at a considerably accelerated rate in the past 8 years. Nine distinct cooperation clusters were formed between institutions and countries. Keyword clustering yielded nine well-structured clusters covering two major topics, i.e., snakebite envenoming and antivenom. Burstiness detection revealed eight keywords with strong emergence, including neglected tropical diseases, Elapidae, Viperidae, and Russell’s viper, which have sustained popularity up to the present.
Conclusion: Current research on snakebites has gradually garnered attention from the academic community. Cooperation papers between nations severely affected by snakebite and those with higher economic status received more attention. The continued exploration of therapeutic mechanisms, the development of antivenoms or alternative medicines, and primary prevention of snakebites to ensure the safety of populations in impoverished regions should be prioritized by international scholars. The epidemiological evidence and the timely translation of research findings should be valued by policymakers.
... Collectively, these species possess proteolytic, hemolytic, and cytotoxic properties, and their envenomations are known to result in various disorders, including local and systemic bleeding, as well as tissue damage It is noteworthy that, owing to their medical significance (Organization, 2010), Viperidae species, particularly Ml, Vaa, and Vbb, have been extensively characterized using an MS-based proteomics approach, leading to a substantial representation of their protein sequences in the UniProt database. In contrast, the Montivipera genus remains one of the less explored genera in this context (Damm et al., 2021;Di Nicola et al., 2021). ...
... Several studies have shown that the chemicals contained in some cosmetics and some naturally occurring toxic ingredients, such as snake venom, may pose a threat to the health of people with allergies. [5][6][7][8][9][10] Some cosmetic products would interact with the skin microbiota and cause certain degree of disruption of the skin barrier. 11 Mild symptoms include only mild allergic reactions, such as local itching and erythema, etc, while severe cases may even have physical symptoms such as headache and nausea. ...
Background
There are still some gaps in the summary and generalization of cosmetic-related adverse reaction reports.
Objective
The aim of this study is to summarize and analyze the occurrence of cosmetic adverse reactions in Shanghai Han population by using available survey data.
Materials and Methods
Collection, statistics and analysis of patients with cosmetic adverse reactions in Shanghai Huashan Hospital from 2017 to 2021.
Results
Among the 1004 patients, most of them (96.71%) were diagnosed as cosmetic contact dermatitis, which often occurred within 3 days of using cosmetics (51.79%). A total of 260 patients were tested with patch test, but the compliance rate was only 18.08%. Among them, 240 patients underwent additional European standard allergen tests, and positive allergens were detected in 210 cases (87.5%). Univariate analysis revealed that dosage form (emulsion and cream), age (≤25 years) and the allergic ingredients triethanolamine, rose oil, propylene glycol, thiomersal and musk ambrette are associated with the occurrence of cosmetic adverse reactions within seven days. A logit prediction model was also successfully constructed: Logit (P) = 1.710–0.796×1 + 1.185×2 −3.650X3-1.335X4.
Conclusion
This study complements the data reported on cosmetic adverse reactions in the Chinese Han population and suggests that in future clinical diagnosis and data collection, emphasis should be placed on patch testing, combining the patch test with cosmetic protoplast with the European standard allergen test to improve the detection rate.
... On the one hand, this interest is due to the fact that cases of poisoning by their toxins are extremely common and belong to unsolved health problems worldwide, as they cause numerous fatal consequences. According to WHO estimates, 81,000 to 138,000 people die from snake bites every year, and another 400,000 victims have severe complications or even disability [8,9,10]. However, despite this, snake toxins are also considered valuable sources for the production of various medicines [2,12]. ...
Among all poisonous animals, snakes attract the special attention of mankind. Cases of poisoning by their toxins are extremely common and are an unsolved public health problem worldwide. It has been established that among a number of complications due to snakebites, an important role is played by disturbances in the normal functioning of the organs of the cardiovascular system. The aim of the research is to study the features of histological changes in the heart tissue of rats under conditions of acute intoxication with Vipera berus berus venom. Experimental studies were carried out on white non-linear male rats. The animals were conditionally divided into two groups – a control and an experimental group of 10 individuals each. Experimental rats were injected intraperitoneally with a semi-lethal dose (LD50) (1.576 mg/g-1) of Vipera berus berus venom in saline solution. Animals of the control group were injected intraperitoneally with only saline solution. Rats were removed from the experiment 24 hours after exposure to the venom, anesthetized by cervical dislocation. Heart samples were taken for microscopic examination. Fixation of the material and preparation of paraffin blocks were carried out according to generally accepted methods. Histological heart preparations were stained with Picro Sirius Red/Fast Green. Histological preparations were studied using a SEO SСAN light microscope. Thus, under the conditions of acute intoxication with Vipera berus berus venom in experimental rats, microscopic examination of the heart tissue revealed pathological shifts in the structural organization of all layers of the organ. In the epicardium, an increase in the volume of collagen fibers and thickening of vessel walls were characteristic. The most pronounced histological changes were observed in the myocardium. Swelling, disorganization of muscle fibers, their fragmentation, lysis, destruction, loss of characteristic transverse striations, necrosis were detected in it. In addition, an increase in the number of fibroblasts, their activation and, as a result, the growth of connective tissue components, including collagen fibers, in the myocardial tissue were revealed. The endocardium of experimental rats was distinguished by desquamation of the endothelial lining and an increase in the number of active fibroblasts in the outer connective tissue layer.
... Consequently, venom components exhibit different toxicokinetic profiles [62]. On the other hand, antivenoms with a uniform composition, which involves only large molecules, if given by the same route, reach the central compartment by slow diffusion into the initial lymphatics [62,72]. In addition, there is proof that the lymphatic system not only plays a role in venom distribution and bioavailability [73] but also serves as a compartment where antivenom, extravasated from the blood after i.v. ...
Envenomations induced by animal bites and stings constitute a significant public health burden. Even though a standardized protocol does not exist, parenterally administered polyclonal antivenoms remain the mainstay in snakebite therapy. There is a prevailing opinion that their application by the i.m. route has poor efficacy and that i.v. administration should preferentially be chosen in order to achieve better accomplishment of the antivenom therapeutic activity. Recently, it has been demonstrated that neutralization not only in the systemic circulation but also in the lymphatic system might be of great importance for the clinical outcome since it represents another relevant body compartment through which the absorption of the venom components occurs. In this review, the present-day and summarized knowledge of the laboratory and clinical findings on the i.v. and i.m. routes of antivenom administration is provided, with a special emphasis on the contribution of the lymphatic system to the process of venom elimination. Until now, antivenom-mediated neutralization has not yet been discussed in the context of the synergistic action of both blood and lymph. A current viewpoint might help to improve the comprehension of the venom/antivenom pharmacokinetics and the optimal approach for drug application. There is a great need for additional dependable, practical, well-designed studies, as well as more practice-related experience reports. As a result, opportunities for resolving long-standing disputes over choosing one therapeutic principle over another might be created, improving the safety and effectiveness of snakebite management.
... In particular, such variation corresponds to the occurrence of profound clinical differences between geographically close populations of species such as Vipera aspis and Vipera berus [38,39]. However, several Vipera species remain inadequately studied, especially in terms of the presence of intraspecific venom variation, which represents a significant knowledge gap given the medical importance of the genus [40][41][42]. ...
... The Iberian adder is recognised as medically important by the World Health Organization [42] and is considered one of the venomous snake species of major clinical relevance in Europe [40,41]. An early study [56] aiming at investigating the toxicity of V. seoanei venom across its Spanish distribution suggested the presence of a West-East gradient, with venoms from the western populations presenting higher lethal potencies than those collected from eastern populations (e.g., Galicia (W Spain): LD 50 = 6.9-9.9 µg per 20 g mouse; Basque Country (E Spain): LD 50 = 23.1-23.6 µg per 20 g mouse). ...
European vipers (genus Vipera) are medically important snakes displaying considerable venom variation, occurring at different levels in this group. The presence of intraspecific venom variation, however, remains understudied in several Vipera species. Vipera seoanei is a venomous snake endemic to the northern Iberian Peninsula and south-western France, presenting notable phenotypic variation and inhabiting several diverse habitats across its range. We analysed the venoms of 49 adult specimens of V. seoanei from 20 localities across the species’ Iberian distribution. We used a pool of all individual venoms to generate a V. seoanei venom reference proteome, produced SDS-PAGE profiles of all venom samples, and visualised patterns of variation using NMDS. By applying linear regression, we then assessed presence and nature of venom variation between localities, and investigated the effect of 14 predictors (biological, eco-geographic, genetic) on its occurrence. The venom comprised at least 12 different toxin families, of which five (i.e., PLA2, svSP, DI, snaclec, svMP) accounted for about 75% of the whole proteome. The comparative analyses of the SDS-PAGE venom profiles showed them to be remarkably similar across the sampled localities, suggesting low geographic variability. The regression analyses suggested significant effects of biological and habitat predictors on the little variation we detected across the analysed V. seoanei venoms. Other factors were also significantly associated with the presence/absence of individual bands in the SDS-PAGE profiles. The low levels of venom variability we detected within V. seoanei might be the result of a recent population expansion, or of processes other than directional positive selection.
