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  5. Clinical entry: Daboia palaestinae

Clinic: Daboia palaestinae

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!)

Renal effects

  • Acute kidney injury:
    • Loin pain (lower back pain)
    • Renal bed sensitive to percussion
    • Haematuria, haemoglobinuria, myoglobinuria
    • Oliguria (< 400 ml of urine / 24 h), anuria
    • Uraemia (nausea, acidotic breathing, hiccups, pleuritic chest pain, encephalopathy) 

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 Renal
effects6
 Bleeding3  Coagulopathy4  Thrombotic
microangiopathy5

Daboia palaestinae
(formerly Vipera palaestinae)

                

1Autopharmacological effects
“Acute profound hypotension with or without other features of anaphylaxis is part of the autopharmacological syndrome which may occur within minutes of bites by Daboia species. It may be caused by release of endogenous vasoactive compounds such as nitric oxide, kinins, histamine, serotonin and endothelins” (Warrell 2023).
"Early, repeated, usually transient but sometimes persistent and fatal, syncopal attacks with features of anaphylaxis may develop in patients not previously exposed to venom who have been bitten by some Viperidae, notably also Daboia palaestinae" (Warrell 2023).
Amr et al. (2020) describe “Within 15–20 min after the initial pain of the bite, victims report a sudden sense of weakness, and restlessness, and begin to vomit and sweat. Abdominal pain is associated with diarrhoea which may be watery and blood-stained. There is an anaphylactic syndrome: angioedema affects lips and face, the tongue, which may swell to “several times its normal size”, the glottis (requiring tracheostomy in one case); urticaria; tachycardia; hypotension and shock causing collapse and unconsciousness.”

2Local effects
Amr et al. (2020) describe “Tender, erythematous swelling extends up the bitten limb and onto the trunk. There is local serous or sanguinous blistering, bruising, lymphangitic lines and regional lymphadenopathy. Superficial necrosis may occur at the site of the bite and roofs of blisters exfoliate. Hypovolaemic shock may supervene within a few days in untreated cases.”

3,4Haematological effects
3Bleeding
Bleeding seems to vary considerably across the geographical distribution of D. palaestinae. It seems to be a common clinical feature e.g. in Jordan and much less so in Israel.
“Spontaneous bleeding affects the skin, soft tissues, muscle, brain, heart muscle, lungs, kidneys and gastrointestinal tract. Rare neurological abnormalities are attributed to cerebral oedema or focal intracranial haemorrhages.” (Amr et al. 2020). No bleeding in 57 patients reported from Israel (Pivko-Levy et al. 2017).

4Coagulopathy
Type of haemostatic defec
Venom-induced coagulopathy - predominantly anticoagulant (net-anticoagulant), thombocytopenia.
The difference in the occurence of bleeding is reflected in the coagulopahy: The blood usually remains coagulable, although with increased fibrinolysis, thrombocytopenia (Amr et al. 2020). Mild coagulopathy and thrombocytopenia rare in 3/57 children (Pivko-Levy et al. 2017). See also Op den Brouw et al. (2021). 

5Thrombotic microangiopathy (TMA)
Microangiopathic haemolysis 5/19 (Abu Baker et al. 2022).
“TMA include disseminated intravascular coagulation, microangiopathic haemolytic anaemia diagnosed by finding schistocytes in peripheral blood films, thrombocytopenia, and acute kidney injury associated with arteriolar and capillary microthrombi. TMA with acute kidney injury is increasingly recognised in patients envenomed by Russell’s vipers and a variety of other species.” (Warrell and Williams 2023).

6Renal effects
AKI 9/19, persisted as chronic renal failure in 1/9 (Abu Baker et al. 2022).
A wide variety of causes contribute to acute kidney injury (AKI). ). In D. palaestinae envenoming, the most likely causes to various degrees are direct venom nephrotoxicity, renal ischaemia secondary to shock, disseminated intravascular coagulation with thrombotic microangiopathy (TMA).

Clinical Management

See also Clinical Management: North Africa, Near and Middle East

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
Necroses: debridement; split-thickness skin grafting
Systemic antibiotics: standard indications
WHO (2010) 

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 Daboia palaestinae - specific features

see

  • 'Species-specific envenoming pattern above'.

and


 Key issues

Early hypotensive collapse and shock - autopharmacological, (anaphylactic)

see footnote 1 above

Bleeding

see footnote 3,4 above

Acute kidney injury (AKI)

see footnote 6 above

Specific treatment (antivenoms)

References

  • Abu Baker MA, Al-Saraireh M, Amr Z, Amr SS, Warrell DA.Snakebites in Jordan: A clinical and epidemiological study. Toxicon. 2022 Mar;208:18-30. Epub 2022 Jan 10. PMID: 35026216. https://doi.org/10.1016/j.toxicon.2022.01.005
  • Amr ZS, Abu Baker MA, Warrell DA.Terrestrial venomous snakes and snakebites in the Arab countries of the Middle East. Toxicon. 2020 Apr 15;177:1-15. Epub 2020 Jan 27. PMID: 32001320. https://doi.org/10.1016/j.toxicon.2020.01.012
  • Efrati, P. (1979) Symptomatology, pathology and treatment of the bites of viperid snakes. In Lee, C. Y.: Snake venoms. Springer, Berlin: 956-977
  • Efrati P, Reif L.Clinical and pathological observations of sixty-five cases of viper bite in Israel. Am J Trop Med Hyg. 1953 Nov;2(6):1085-1108. PMID: 13104817. https://doi.org/10.4269/ajtmh.1953.2.1085
  • Jenkins TP, Ahmadi S, Bittenbinder MA, Stewart TK, Akgun DE, Hale M, Nasrabadi NN, Wolff DS, Vonk FJ, Kool J, Laustsen AH. Terrestrial venomous animals, the envenomings they cause, and treatment perspectives in the Middle East and North Africa.PLoS Negl Trop Dis. 2021 Dec 2;15(12):e0009880. PMID: 34855751; PMCID: PMC8638997. https://doi.org/10.1371/journal.pntd.0009880
  • Op den Brouw B, Coimbra FCP, Casewell NR, Ali SA, Vonk FJ, Fry BG. A Genus-Wide Bioactivity Analysis of Daboia (Viperinae: Viperidae) Viper Venoms Reveals Widespread Variation in Haemotoxic Properties. Int J Mol Sci. 2021 Dec 15;22(24):13486. PMID: 34948283; PMCID: PMC8706385. https://doi.org/10.3390/ijms222413486
  • Pivko-LevyD, Munchnak I, Rimon A, Balla U, Scolnik D, Hoyte C, Voliovitch Y, Glatstein M. Evaluation of antivenom therapy for Vipera palaestinae bites in children: experience of two large, tertiary care pediatric hospitals. Clin Toxicol (Phila). 2017 Apr;55(4):235-240. Epub 2017 Jan 20. PMID: 28103732. https://doi.org/10.1080/15563650.2016.1277233
  • 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 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

Daboia palaestinae (formerly Vipera palaestinae)

Case reports and review
Jordan

  • Abu Baker et al. (2022)
    19 confirmed cases

Case reports and case series (exemplary)
Israel

  • Efrati and Reif (1953)
    65 patients bitten by V. palaestinae. Identification: geographical distribution (Vipera palaestinae is mostly found in the centre and north of Israel) and 33 of 65 snakes were identified as Vipera palaestinae (morphological?, by the patients themselves?).
  • Pivko-Levy et al. (2017)
    57 cases. A retrospective chart review was performed for all children admitted with definite or probable signs of V. palaestinae envenomation to Chaim Sheba Medical Center and Kaplan Medical Center.

Review

  • Amr et al. 2020

For further country-specific assessment see Amr et al. 2020 and Jenkins et al. 2021.

Signs & symptoms

Autopharmacological effects
Vomiting, perspiration, abdominal pain, diarrhoea. Angioneurotic oedema (face, lips, tongue), tachycardia, arterial hypotension (hypovolaemic shock, anaphylactic/anaphylactoid shock) (Efrati 1979).
Angioedema of the face, abdomen and larynx was observed in a single case before antivenom treatment 1/19 (Abu Baker et al. 2022).
“Within 15–20 min after the initial pain of the bite, victims report a sudden sense of weakness, and restlessness, and begin to vomit and sweat. Abdominal pain is associated with diarrhea which may be watery and blood-stained. There is an anaphylactic syndrome: angioedema affects lips and face, the tongue, which may swell to “several times its normal size”, the glottis (requiring tracheostomy in one case); urticaria; tachycardia; hypotension and shock causing collapse and unconsciousness.” (Amr et al. 2020).

Local effects
Pain, onset 15–20 min after the bite. Local swelling that may extend over the entire bitten extremity and may even involve the trunk. Several hours after the onset of local swelling, lymphangitis and lymphadenitis. After several days, blistering. The swelling subsides completely within 1–2 weeks (Efrati 1979).
17/19 including necrosis (Abu Baker et al 2022).
“Tender, erythematous swelling extends up the bitten limb and onto the trunk. There is local serous or sanguinous blistering, bruising, lymphangitic lines and regional lymphadenopathy. Superficial necrosis may occur at the site of the bite and roofs of blisters exfoliate. Hypovolaemic shock may supervene within a few days in untreated cases.” (Amr et al. 2020).

Haematological effects
Systemic bleeding: including soft tissue haemorrhage, bloody diarrhoea (Efrati 1979).
Bleeding from the bite site and spontaneous systemic bleeding from gums, nose, haematuria, etc. 9/19. Ecchymoses 12/19 (Abu Baker et al. 2022).
“Spontaneous bleeding affects the skin, soft tissues, muscle, brain, heart muscle, lungs, kidneys and gastrointestinal tract. Rare neurological abnormalities are attributed to cerebral oedema or focal intracranial haemorrhages.” (Amr et al. 2020).

Renal effects
AKI 9/19, persisted as chronic renal failurein 1/9 (Abu Baker et al. 2022).

Laboratory physical investigations 
Haemostasis

Coagulopathy [increased bleeding time, prothrombin time (PT) and partial thromboplastin time (PTT) 15/19 cases; hypofibrinogenemia confirmed in 1/15. Thrombocytopenia 9/19 (Abu Baker et al. 2022).
Thrombocytopenia. The blood usually remains coagulable, although with increased fibrinolysis (Amr et al. 2020).
Thrombocytopenia and mild coagulopathy rare in 57 children (Pivko-Levy et al. 2017)
Thrombotic microangiopathy (TMA)
Microangiopathic haemolysis 5/19 (Abu Baker et al. 2022).

Clinical management of main toxic effects

Treatment (specific)
Antivenoms and their availability in the arab countries of the Middle East are discussed in Amr et al 2020 and Jenkins et 2021.

References

  • Abu Baker MA, Al-Saraireh M, Amr Z, Amr SS, Warrell DA.Snakebites in Jordan: A clinical and epidemiological study. Toxicon. 2022 Mar;208:18-30. Epub 2022 Jan 10. PMID: 35026216. https://doi.org/10.1016/j.toxicon.2022.01.005
  • Amr ZS, Abu Baker MA, Warrell DA.Terrestrial venomous snakes and snakebites in the Arab countries of the Middle East. Toxicon. 2020 Apr 15;177:1-15. Epub 2020 Jan 27. PMID: 32001320. https://doi.org/10.1016/j.toxicon.2020.01.012
  • Efrati, P. (1979) Symptomatology, pathology and treatment of the bites of viperid snakes. In Lee, C. Y.: Snake venoms. Springer, Berlin: 956-977
  • Efrati P, Reif L.Clinical and pathological observations of sixty-five cases of viper bite in Israel. Am J Trop Med Hyg. 1953 Nov;2(6):1085-1108. PMID: 13104817. https://doi.org/10.4269/ajtmh.1953.2.1085
  • Jenkins TP, Ahmadi S, Bittenbinder MA, Stewart TK, Akgun DE, Hale M, Nasrabadi NN, Wolff DS, Vonk FJ, Kool J, Laustsen AH. Terrestrial venomous animals, the envenomings they cause, and treatment perspectives in the Middle East and North Africa.PLoS Negl Trop Dis. 2021 Dec 2;15(12):e0009880. PMID: 34855751; PMCID: PMC8638997. https://doi.org/10.1371/journal.pntd.0009880
  • Pivko-LevyD, Munchnak I, Rimon A, Balla U, Scolnik D, Hoyte C, Voliovitch Y, Glatstein M. Evaluation of antivenom therapy for Vipera palaestinae bites in children: experience of two large, tertiary care pediatric hospitals. Clin Toxicol (Phila). 2017 Apr;55(4):235-240. Epub 2017 Jan 20. PMID: 28103732. https://doi.org/10.1080/15563650.2016.1277233