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  2. Central and Southern Africa
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  4. Vipers
  5. Clinical entry: Atheris sp.

Clinic: Atheris sp.

Examine for venom effects

Autopharmacological effects

  • Nausea, vomiting
  • Sweating
  • Urticaria, angiooedema
  • Arterial hypotension / hypovolaemic shock (transient, recurrent; immediate; delayed (CLS))
  • Diarrhoea
  • Bronchospasm 

Local Effects

  • Pain
  • Tender local (spreading) swelling
  • Blistering
  • Lymphangiopathy and lymphadenopathy
  • Necrotic skin

Haematological effects 

  • Clotting disturbances:
    • Bleeding from the fang marks and from injuries, in particular ones that are not located in the region in which venom application occurred.
    • Bleeding into the skin (ecchymosis, petechiae)
    • Gingival bleeding, bleeding from the nose, conjunctiva, haematemeis, bleeding per rectum, including melaena, haematuria, haemoptysis.
    • Oliguria, anuria (VICC / AKI)
  • Bleeding and/or haemolytic anaemia:
    • Arterial hypotension (haemorrhagic shock)
    • Acute abdomen (intra-abdominal bleeding!)
    • Loin pain/renal bed sensitive to percussion (ischaemia, renal haemorrhage!)
    • Local neurological signs, meningism, coma (intracranial bleeding!)
    • Pale sclera (bleeding, haemolysis!)
    • Oliguria, anuria (arterial hypotension / AKI!)

Species-specific envenoming pattern

The assessment of the envenoming pattern is based on the data from publication in which the identification of the snakes is clearly specified and in accordance with accepted criteria.

  

Autopharma-
cological effects1

 Local effects2 Haematological effects
Bleeding3  Coagulopathy4
Atheris sp.         

1Autopharmacological effects
Nausea, vomiting, sweating (Hatten et al 2013, Knoepffler 1965).

2Local effects
Local pain, local swelling, regional lymphadenopathy (Knoepffler 1965).

Haematological effects

3Bleeding 
Atheris chlorechis
Systemic bleeding (Top et al 2006).

Atheris nitschei
Systemic bleeding (Hatten et al. 2013).

Atheris squamigera
Systemic bleeding (Chippaux et al. 2024).

4Coagulopathy

Type of haemostatic defect 
Atheris squamigera
Fibrinogen-converting activity, platelet-aggregating activity (in vitro; Mebs et al 1998). 

Clinical management

See also Clinical Management: Central and Southern Africa

for advice on post-First Aid measures, diagnosis (clinical, laboratory) and treatment (supportive, antivenom).

First Aid

Any type of tourniquet follow link above.

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care
WHO (2010a,b) 

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

Follow SAMPLE & ABCDE ApproAch

Obey Atheris sp. - specific features

see

  • 'Species-specific envenoming pattern above'.

and

Specific treatment (antivenoms)

References

see also references in section 'species specific evidence' (below). 

  • WHO-ICRC Basic Emergency Care: approach tothe acutely ill and injured (2018)
    https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured
  • WHO ABCDE Approach
    https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
  • WHO (2010a) Guidelines for the prevention and clinical management of snakebite in Africa. https://www.who.int/publications/i/item/9789290231684
  • WHO (2010b) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139
  • WHO Snakebite Information and Data Platform
    https://www.who.int/teams/control-of-neglected-tropical-diseases/snakebite-envenoming/snakebite-information-and-data-platform
  • Warrell DA. Venomous and poisonous animals. In: Farrar J, Garcia PJ, Hotez T, Junghanss T, Kang G, Laloo D (eds.). Manson’s tropical diseases. 24th ed. Elsevier; 2023.
  •  Warrell DA, Williams DJ. Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet. 2023 Apr 22;401(10385):1382-1398. PMID: 36931290. https://doi.org/10.1016/s0140-6736(23)00002-8 

Species-specific evidence

Atheris chlorechis

Captive snake

Top et al. (2006)
1 case; identification: morphological.

Atheris nitschei

Captive snake

  • Hatten et al. (2013)
    1 case; identification: morphological.

 Atheris squamigera

Cameroon

  • Chippaux et al. (2024)
    2 patients; identification: foto (1), not mentioned (1)
  • Mebs et al. (1998)
    1 case; identification: morphological.

Captive snake

  • Imperato et al. (2022)
    1 case; identification: morphological.

 Atheris sp.

  • Knoepffler (1965)
    1 case; identification: morphological.

References

  • Chippaux JP, Madec Y, Amta P, Ntone R, Noël G, Clauteaux P, Boum Y 2nd, Nkwescheu AS, Taieb F. Snakebites in Cameroon by Species Whose Effects Are Poorly Described. Trop Med Infect Dis. 2024 Dec 6;9(12):300.  PMID: 39728827; PMCID: PMC11679889. https://doi.org/10.3390/tropicalmed9120300
  • Hatten BW, Bueso A, French LK, Hendrickson RG, Horowitz BZ. Envenomation by the Great Lakes Bush Viper (Atheris nitschei). Clin Toxicol (Phila). 2013 Feb;51(2):114-6. Epub 2013 Jan 18. PMID: 23327286. https://doi.org/10.3109/15563650.2012.763134
  • Imperato NS, Amaducci AM, Abo BN, Koons AL, Fikse DJ, Katz KD. African Bush Viper Envenomation: A Case Report. Cureus. 2022 Aug 15;14(8):e28040. doi: 10.7759/cureus.28040. PMID: 36120258; PMCID: PMC9473672.
  • Knoepffler, L. P. (1965) Autoobservation d’envenimation par morsure d’Atheris sp. Toxicon 2: 275-276
  • Mebs D, Holada K, Kornalík F, Simák J, Vanková H, Müller D, Schoenemann H, Lange H, Herrmann HW. Severe coagulopathy after a bite of a green bush viper (Atheris squamiger): case report and biochemical analysis of the venom. Toxicon. 1998 Oct;36(10):1333-40. PMID: 9723832. https://doi.org/10.1016/s0041-0101(98)00008-7
  • Top LJ, Tulleken JE, Ligtenberg JJ, Meertens JH, van der Werf TS, Zijlstra JG. Serious envenomation after a snakebite by a Western bush viper (Atheris chlorechis) in the Netherlands: a case report. Neth J Med. 2006 May;64(5):153-6. PMID: 16702615.