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  5. Clinical entry: Gloydius sp. (formerly Asian Agkistrodon sp.)

Clinic: Gloydius sp. (formerly Asian Agkistrodon 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!)

Neurological effects

  • Descending flaccid paralysis (rarely progresses to involve bulbar and respiratory muscles)
    • Ptosis (not to be mixed up with tiredness / drowsiness; test: lid retraction with upward gaze).
    • Double vision (external ophthalmoplegia)
    • Difficulties to swallow (dysphagia) (bulbar paralysis) > inhalation of vomitus!
    • Difficulties to lift the head when lying on the back (‘broken neck syndrome’)
    • Cyanosis, shallow breathing, respiratory arrest (respiratory paralysis); respiratory arrest may be precipitated by obstruction of the upper airway by the paralysed tongue or inhaled vomitus. 
    • Weakness or loss of voluntary movement; movements of digits may still be possible, allowing the patient to communicate.
    • Loss of consciousness and generalized convulsions caused by hypoxaemia in patients who have respiratory paralysis.  

Muscular effects

  • Generalized rhabdomyolysis
    • Muscles pain and tenderness, painful on passive stretching, muscle stiffness, trismus
    • Bulbar and respiratory muscle weakness.
    • Dark brown urine. 
    • Renal failure
    • Laboratory: Generalized rhabdomyolysis: defined by a serum creatine kinase level > 10,000 U/l
    • ECG: Signs of hyperkalaemia.

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.
"In Japan, the diagnosis of the snake responsible is usually made clinically, based on history and clinical symptoms and sign" (Aoki et al. 2020). 

  

Autopharma-
cological 
effects1
 

 Local
effects2		 Haematological effects Neurological effects Muscular effects
Bleeding3  Coagulopathy4    

Gloydius blomhoffii

            

Gloydius monticola

            

Gloydius tsushimaensis

            

1Autopharmacological effects

Gloydius blomhoffii

  • Nausea, vomiting, abdominal pain, diarrhoea (Hifuma et al. 2015)

2Local effects 

Gloydius sp.

  • Local pain and swelling, blistering, subcutaneous haemorrhage, lymphadenopathy.
  • necrosis (skin, subcutis, musculature, bones).  

Haematological effects 

3Bleeding
Gloydius sp.
It appears to be uncommon, even in Gloydius tsushimaensis where severe hypofibringenaemia has been described (e.g. in Yokoi et al. 2020 no case of spontaneous systemic bleeding).

4Coagulopathy
Type of haemostatic defect 

Gloydius blomhoffii

  • Thrombocytopenia (Hifuma et al. 2015). Mild coagulopathy?
Gloydius monticola
  • Severe hypofibrinogenemic coagulopathy (Qiao et al. 2025)

Gloydius tsushimaensis

  • Procoagulation by thrombin-like effect with severe hypofibrinogenemia, thrombocytopenia  (Yokoi et al. 2020).

Neurological effects 

Gloydius blomhoffii

  • Diplopia, dysphagia, dysarthria, blurred vision (Hifuma et al. 2015),

Muscular effects

Gloydius tsushimaensis

  • Rhabdomyolysis with a CK value of more than 40,000 IU/L (with renal dysfunction) (Yokoi et al. 2020).

Morbidity

  • Necrosis (skin, subcutis, musculature, bones).

Clinical management

See also (depending on the origin of the culprit)

Clinical Management: Indian Subcontinent and Southeast Asia

Clinical Management: Far East

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

First Aid

Release of any type of tourniquet follow links above.

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care
WHO (2010, 2016) 

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 Gloydius sp. - specific features

see 

  • 'Species-specific envenoming pattern' above

and

Key issues

See footnotes above.

Specific treatment (antivenoms)

References

  • Aoki Y, Yoshimura K, Sakai A, Tachikawa A, Tsukamoto Y, Takahashi K, Yamano S, Smith C, Hayakawa K, Tasaki O, Ariyoshi K, Warrell DA. Exotic (non-native) snakebite envenomation in Japan: A review of the literature between 2000 and 2022. Toxicon. 2023 Aug 15;232:107226. Epub 2023 Jul 12. PMID: 37442298. https://doi.org/10.1016/j.toxicon.2023.107226
  • Hifumi T, Sakai A, Kondo Y, Yamamoto A, Morine N, Ato M, Shibayama K, Umezawa K, Kiriu N, Kato H, Koido Y, Inoue J, Kawakita K, Kuroda Y. Venomous snake bites: clinical diagnosis and treatment. J Intensive Care. 2015 Apr 1;3(1):16.  PMID: 25866646; PMCID: PMC4393627. https://doi.org/10.1186/s40560-015-0081-8
  • 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 (2010) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139
  • WHO (2016) Guidelines for the management of snakebites. 2nd edition. https://www.who.int/publications/i/item/9789290225300
  • 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

Gloydius blomhoffii

 Japan

  • Chiba et al. (2018)
    231 patients enrolled in a retrospective hospital-based study. 

Gloydius blomhoffii, G. ussuriensis, G. intermedius 

Described as Agkistrodon blomhoffii, A. caliginosus, A. intermedius

South Korea

  • Moore (1977)
    48 Gloydius sp. bites; no identification at the species level; systemic signs of envenoming 23/48.
  • Sawai and Lah (1978) 
    82 Gloydius sp. bites; identification morphological: G. blomhoffii brevicaudis (Agkistrodon blomhoffii brevicaudis) 12/48, G. ussuriensis (described as A. caliginosus) 13/82, G. saxatilis (A. saxatilis) 3/82; 54 unidentified.
  • Moon et al. (2023)
    231 patients enrolled in a retrospective study. 

Gloydius monticola

  • Qiao et al. (2025)
    1 patient; identification: morphological.

Gloydius tsushimaensis

Japan (Tsushima Island)

  •  Yokoi et al. (2020)
    72 patients (retrospective hospital-based study); identfication: G. tsushimaensis only venomous species on the island.
  •  Yokoi et al. (2021)
    12 patients (comparative study with 72 patients (see above) before and after the entroduction of a treatment algorithm.

References

  • Chiba T, Koga H, Kimura N, Murata M, Jinnai S, Suenaga A, Kohda F, Furue M. Clinical Condition and Management of 114 Mamushi (Gloydius blomhoffii) Bites in a General Hospital in Japan. Intern Med. 2018 Apr 15;57(8):1075-1080.  Epub 2017 Dec 27. PMID: 29279485; PMCID: PMC5938495. https://doi.org/10.2169/internalmedicine.9409-17
  • Moon JM, Chun BJ, Cho YS. Clinical features of snake envenomation in South Korea. Clin Toxicol (Phila). 2023 Apr;61(4):276-282. Epub 2023 Mar 20. PMID: 36939139. https://doi.org/10.1080/15563650.2022.2160341
  • Moore, T. C. (1977) Snakebite from the Korean pit viper. Milit. Med.: 546-549
  • Qiao Z, Tang Y, Shang A, Tao Y, Fry BG. First documented cases of envenomations in mainland China by Ovophis species (mountain pitvipers): Severe coagulopathy and variable antivenom response in two patients from Yunnan Province. Toxicon. 2025 Nov;267:108583. Epub 2025 Sep 12. PMID: 40946754. https://doi.org/10.1016/j.toxicon.2025.108583
  • Sawai, Y., K. Y. Lah (1978) Snakebites in the South Korea. Snake 9: 39-47
  • Yokoi H, Sakai A, Kodama T, Magome S, Nagayasu T, Tawara M, Hasegawa T, Yasaka T, Abe T, Takeuchi I. Severe hypofibrinogenemia in patients bitten by Gloydius tsushimaensis in Tsushima Island, Nagasaki, Japan, and treatment strategy. Toxicon. 2020 Dec;188:142-149. Epub 2020 Oct 29. PMID: 33130186. https://doi.org/10.1016/j.toxicon.2020.10.027
  • Yokoi H, Sakai A, Kodama T, Magome S, Itose O, Tawara M, Yasaka T, Abe T, Takeuchi I. Evaluation of a Treatment Algorithm for Tsushima Mamushi (Gloydius tsushimaensis) Snakebites, after Its Introduction to Tsushima Island, Nagasaki, Japan. Intern Med. 2021 Oct 1;60(19):3093-3099.  Epub 2021 Jul 17. PMID: 34275980; PMCID: PMC8545649. https://doi.org/10.2169/internalmedicine.7131-21