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  5. Clinical entry: Echis sp. – Africa and Arabian Peninsula

Clinic: Echis sp. – Africa and Arabian Peninsula

Examine for venom effects

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
    • 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
microangiopathy (TMA)5

Echis ocellatus

            

Echis romaniA

  ?       ?  

Echis coloratus

            

Echis leucogasterB

            

Echis omanensisC

            

Echis pyramidumD

            

AThe species E. romani was recently described (Trape 2018). As the distributions of Echis ocellatus and E. romani overlap, clinical reports prior to and also after 2018 may contain cases of E. romani bites.
BNo case descriptions found. Venom effects not based on suffient data.
COnly one published case with mild envenoming found. Venom effects not based on suffient data.
DOnly two published cases found. Venom effects not based on suffient data.

1Early vomiting is reported in E. occelatus envenoming; facial and laryngeal oedema causing obstruction of the airway before antivenom treatment in E. coloratus envenoming.

2Pain, local swelling maximum of grade 3, i.e. involving the segment affected by the bite and the neighbouring segment, blisters. Necroses which appeared on average on the 6th (1st–13th) day after the bite and involved the skin, hypodermis and musculature (E. ocellatus; Warrell et al. 1977).
In E. coloratus envenoming, swelling extends from the bitten limb to the trunk (Abu Baker et al. 2022).

3Spontaneous bleeding beyond the region of the bite wound, from the bite mark and incisions (!). Bleeding into the subcutaneous tissue and intramuscularly. Gingival bleeding, epistaxis, haemoptysis, haematemesis, melaena, bloody stools, haematuria, subconjunctival bleeding. Intracarnial haemorrhage, haemorrhagic shock. Severe (fatal) haemorrhaging occurs 1(2)–12 days after the bite (E. ocellatus; Warrell et al. 1977).

4Venom-induced consumptive coagulopathy

5Features of 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” (Noutsos et al. 2020, 2022; Warrell and Willimas 2023).
TMA (numerous schizooytes and poikilocytes and thrombocytopenia) has been observed in one severely envenomed patient in a cohort of 115 patients (E. ocellatus; Warrell et al. 1977).

6Acute kidney injury due to a wide range of causes: direct venom nephrotoxicity, renal ischaemia secondary to shock, disseminated intravascular coagulation with thrombotic microangiopathy (TMA), haemoglobinuria, myoglobinuria, and hyperkalaemia contribute to acute tubular necrosis). Acute renal failure has been observed in a cohort of 115 patients in one patient who has been hypotensive for a long time (E. ocellatus; Warrell et al. 1977). Thus, there is no indication of primary nephrotoxicity.
In E. coloratus envenoming, AKI was frequently observed necessitating haemodialysis and leading to chronic renal failure (Abu Baker et al. 2022). Intertstingly, in E. coloratus envenoming swelling extends from the bitten limb to the trunk implicating that hypovolaemia is the most likely cause for AKI.

For study-based evidence, see Section ‘Species-specific evidence’ below.

Clinical management

See also (Depending on the origin of the culprit)

Clinical Management: Central and Southern Africa

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 links above.

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care
Necroses: debridement; split-thickness skin grafting
Systemic antibiotics: standard indications
WHO (2010a, 2010b) 

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 ECHIS SP. - specific features

see

  • 'Species-specific envenoming pattern above'.

and

Key issues

Early nausea, vomiting and other autopharmacological features

Appear to be rare: see footnote 1 above

Local pain, swelling, necrosis

see footnote 2 above

Bleeding

see footnote 3 and 4 above.

“The 20WBCT is a simple, cheap, and easily accessible bedside test with a high sensitivity for the detection of patients with venom induced consumptive coagulopathy (VICC) following envenoming by E. ocellatus / E. romani, although false positives do occur. Repeated 20WBCTs can identify patients with new, persistent, and rebound coagulopathy.” (Tianyi et al. 2023).

Haemolytic anaemia

see footnote 5 above.

Acute kidney injury (AKI), chronic kidney disease

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

  • Noutsos T, Currie BJ, Lek RA, Isbister GK. Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis. PLoS Negl Trop Dis. 2020 Dec 8;14(12):e0008936. PMID: 33290400; PMCID: PMC7748274. https://doi.org/10.1371/journal.pntd.0008936

  • Noutsos T, Currie BJ, Wijewickrama ES, Isbister GK. Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice. Toxins (Basel). 2022 Jan 14;14(1):57. PMID: 35051033; PMCID: PMC8778654. https://doi.org/10.3390/toxins14010057 

  • Tianyi FL, Hamza M, Abubakar SB, Al Solaiss J, Trelfa A, Abdullahi HL, Iliyasu G, Mohammed N, Mohammed SA, Casewell NR, Harrison RA, Lalloo DG, Stienstra Y, Habib AG. Diagnostic characteristics of the 20-minute whole blood clotting test in detecting venom-induced consumptive coagulopathy following carpet viper envenoming.PLoS Negl Trop Dis. 2023 Jun 26;17(6):e0011442. PMID: 37363905; PMCID: PMC10328339. https://doi.org/10.1371/journal.pntd.0011442

  • Trape, J. F. (2018) Partition d’Echis ocellatus Stemmler, 1970 (Squamata, Viperidae), avec la description d’une espèce nouvelle. Bull. Soc. Herp. Fr. 167: 13-34

  • 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 

  • Warrell DA, Davidson NMcD, Greenwood BM, Ormerod LD, Pope HM, Watkins BJ, Prentice CR. Poisoning by bites of the saw-scaled or carpet viper (Echis carinatus) in Nigeria. Q JMed. 1977 Jan;46(181):33-62. PMID: 866568.

  • 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/9789290225300

  • 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

Species-specific evidence

Echis ocellatus

Nigeria

Case series

  • Warrell et al. (1977)
    115 Echis ocellatus bites; identification: morphological 47/115, immunological (Greenwood et al. 1974) 15/115 or other indirect criteria: description of the snake by the patient plus incoagulable blood at the time of hospitalisation (inclusion criterion, as at that time no case of incoagulability of the blood caused by other species of snakes had been observed) 53/115.
  • Pugh and Theakston(1987):
    26 Echis ocellatus bites; identification: morphological 8/26; on the basis of the criteria of spontaneous bleeding and incoagulable blood (inclusion criterion, see above) 14/26; clinical, supported by immunological findings 4/26.

Case reports 

  • Reid (1977)
    1 Echis ocellatus bite; identification: morphological.
  • Habib et al. (2008)
    10 Echis ocellatus bites (in pregnant women); identification: killed snakes or “incoagulable blood using the WBCT20 which is diagnostic of carpet viper in this part of Nigeria.”

Signs & symptoms

Autopharmacological effects
Vomiting within the first 30 min after the bite 2/13 (Pugh and Theakston 1987a).
Local effects
Pain 114/115, onset within 10 min after the bite at the site of the bite in 80% of patients.
Swelling (study inclusion criterion) 115/115, onset within 30 min after the bite at the site of the bite in 60% of patients. Local swelling maximum of grade 3, i.e. involving the segment affected by the bite and the neighbouring segment. No difference between patients with and without bleeding. Therefore, it is not an indicator of the severity of systemic envenoming.
Blisters 15/115; blister contents: Echis venom in 5/7 of the studied patients. This finding supports the notion of ongoing absorption of venom from the region around the site at which the venom entered the body.
Painful regional lymph nodes 88/115, in 23% within 30 min after the bite; painful enlargement of the regional lymph nodes 57/115.
Necroses 13/115, which appeared on average on the 6th (1st–13th) day after the bite and involved the skin, hypodermis and musculature. Osteomyelitis 1/115 (Warrell et al. 1977).
Haemological effects
Spontaneous bleeding beyond the region of the bite wound 66/115. Bleeding from the bite mark/incision 92/115, duration of less than 10 min in 80% of patients. Subcutaneous and intramuscular haematomas. Gingival bleeding 40/115, bloody saliva 25/115, haematemesis 5/115, melaena 1/115, bloody stool 1/115. Epistaxis 10/115, haemoptysis (in the absence of another source of bleeding in the nose-throat region) 1/115, sublingual haematoma. Haematuria 32/115 (in 7/32 also S. haematobium eggs). Subconjunctival haemorrhage. Subarachnoid haemorrhage 3/115, of these 1/3 diagnosed postmortem, 1/3 clinical suspicion, 1/3 xanthochromic fluid (Warrell et al. 1977).
5 fatalities from amongst the 115 patients who were bitten by Echis ocellatus; intracranial haemorrhage 2/5, of which 1/2 subarachnoid haemorrhage, 1/2 intracerebral haemorrhage; haemorrhagic shock 3/5, of which 1/3 gastrointestinal haemorrhage (Warrell et al. 1977).
Mortality 2/26, of which 1/2 subarachnoid haemorrhage, 1/2 complications of a tourniquet that was applied too tightly (Pugh and Theakston 1987a).
Severe (fatal) haemorrhaging occurs 1(2)–12 days after the bite (Warrell et al. 1977).
Renal effects
Acute renal failure 1/115, this patient had been hypotensive for a long time (Warrell et al. 1977). Thus, there is no indication of primary nephrotoxicity.

Laboratory investigations (selected problems)
Haemostasis
Studies

  • Warrell et al. (1977)
  • Edgar et al. (1980)

Type of haemostatic defect

Venom-induced consumptive coagolopathy (VICC)
(Disseminated intravascular coagulation induced by direct activation of prothrombin and reactive (secondary) hyperfibrinolysis. Thrombopaenia (although this seemed to occur mainly in patients with severe envenoming). Little intravascular fibrin deposition (this is reflected in the low incidence of renal function impairment and microangiopathic haemolysis). Fibrin clearance appears to be very efficient. Haemorrhagic activity is present, which together with the coagulation defect is responsible for the systemic bleeding (Warrell et al. 1977, Edgar et al. 1980)).
Haemostatic parameters
20WBCT
“The 20WBCT is a simple, cheap, and easily accessible bedside test with a high sensitivity for the detection of patients with venom induced consumptive coagulopathy (VICC) following envenoming by E. ocellatus, although false positives do occur. Repeated 20WBCTs can identify patients with new, persistent, and rebound coagulopathy.” (Tianyi et al. 2023).
Microangiopathic haemolysis (MAH)
In 1 (severely envenomed)/115 “numerous schizooytes and poikilocytes and thrombocytopenia” (Warrell et al. 1977).

Treatment (specific)

Antivenom effectiveness and strategies for delivery (Abubakar et al. 2010; Habib and Warrell 2013). 

Echis romani

The species E. romani was recently described (Trape 2018). As the distributions of Echis ocellatus and E. romani overlap, clinical reports prior to and also after 2018 may contain cases of E. romani bites.

Nigeria

Studies

  • Hamza et al. (2023) (study on 20WBCT; see also ‘Laboratory investigations’ below; description of clinical signs and symptoms of envenoming limited)
  • Hamman et al. (2024) (on antivenom)

Signs & symptoms

Local effects
Pain 1433/1541; swelling 1442/1541; blisters 41/1541 (Hamza et al. 2023).
Haematological effects
Bleeding 238/1541 (at bite site 123/238, 68/238 systemic, 48/238 local and systemic); shock 50/1541(Hamza et al. 2023).
Renal effects
? (Hamza et al. 2023).

Laboratory  investigations (selected problems) 

Type of haemostatic defect

Venom-induced consumption coagulopathy (VICC)
Haemostatic parameters
Study

  • Hamza et al. (2023)
    20WBCT
    Positive 20WBCT or incoagulable blood at T0 (time when antivenom was administered) 1259/1541.
    “The 20WBCT is a rapid, cheap, simple, widely available point-of-care test that is very useful in detecting, monitoring and managing snakebite envenoming in resource-constrained settings where alternative laboratory investigations are unavailable.” (Hamza et al. 2023)

Echis coloratus

Jordan

Case reports and review
  • Abu Baker et al. (2022)
    68 cases (50 had sufficient clinical history); identification: mostly specimens brought to the hospital and photographs.
  • Obeidatet al. (2021)
    1 case; identification: morphological.

Israel

Case reports and case series

  • Glatsteinet al. (2021)
    11 cases (children)
  • Porathet al (1992)
    68 cases; identification: snake had been identified by an expert, or (b) envenomation occurred in the geographic habitat of the snake, and if impaired clotting function followed the envenomation.

Saudi Arabia

Case reports and case series

  • Abdeldayem et al. (2021)
    1 case; identification: morphological.
    Anobil (1993)

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

Signs & symptoms

Autopharmacological effects
Facial and laryngeal oedema causing obstruction of the airway before antivenom treatment 2/50 (Abu Baker et al. 2022).
Local effects
43/50; pain (up to severe); swelling (up to extended; bitten limb and trunk); necrosis (Abu Baker et al. 2022).
Haematological effects
Spontaneous bleeding 20/50. Ecchymoses 39/50. Fatal intracranial and pulmonary haemorrhage (Abu Baker et al. 2022).
Renal effects
AKI 33/50; haemodialysis 9/50; chronic renal failure 3/50 (Abu Baker et al. 2022).

Laboratory investigations

Haemostasis
Coagulopathy 45/50 (prolonged prothrombin time and/or activated partial thromboplastin time with decrease in fibrinogen levels), sometimes associated with microangiopathic haemolytic anaemia (MAHA) 42/50. Thrombocytopenia 22/50 (Abu Baker et al. 2022).
Hypofibrinogenaemia and elevated fibrin(ogen) degradation products (Amr et al. 2020).
Type of haemostatic defect
Venom-induced consumption coagulopathy (VICC)
Thrombotic microangiopathy (TMA)
Anaemia, schistocytes and elevated lactate dehydrogenase (LDH) (microangiopathic haemolytic anaemia (MAHA)); thrombocythemia; renal impairment (see above) (Abu Baker et al. 2022, Noutsos et al. 2020, 2022).

Clinical management

Antivenom
Abu Baker et al (2022) make the point that “serious consequences of E. coloratus envenoming in Jordan, including fatalities, may evolve in the absence of effective specific antivenom treatment. Results of un-neutralized envenoming include extensive local swelling prompting fasciotomy, persisting coagulopathy, fatal intracranial and pulmonary hemorrhage, and, in two-thirds of cases, AKI”. In contrast, fatalities and local tissue reaction are rare in countries where antivenom is available and being used (Abdeldayem et al. 2021, Anobil 1993, Glatstein et al. 2021, Obeidat et al. 2020, Porath et al. 1993)

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

Echis leucogaster

 No case description found

Echis omanensis

Oman

  • Al Hatali et al. (2015)
Signs & symptoms

Local effects
Severe pain, moderate swelling (Al Hatali et al. 2015)

Echis pyramidum

Captive snakes

  • Gillissen et al. (1994) (Snake of Tunisian origin)
  • Valenta et al. (2014)

Signs & symptoms

Local effects
Swelling (Gillissen et al. 1994; Valenta et al. 2014)
Haematological effects
Spontaneous bleeding (Gillissen et al 1994)
Neurological effects
Transient bilateral ptosis (attributed to envenoming) (Gillissen et al 1994)
Renal effects
AKI (anuria after several hours) (Valenta et al 2014)

Laboratory investigations

Haemostasis
Type of haemostatic defect
Venom-induced consumption coagulopathy (VICC)
(Disseminated intravascular coagulation and fibrinolysis (Gillissen et al 1994))
Haemostatic parameters
Prothrombin time (INR) 10, aPTT 180 s, fibrinogen immeasurable, D-dimer 6400 μg/L, antithrombin III 65%, and platelets 22.109/L (Valenta et al 2014).

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

References

  • Abdeldayem A, Alanazi AA, Aljabri JN, Abid I. Challenges in the Management of an Echis coloratus Adult Snakebite Victim at a Tertiary Care Hospital: A Case Report. Am J Case Rep. 2021 Jun 9;22:e931532. PMID: 34103465; PMCID: PMC8197442. https://doi.org/10.12659/ajcr.931532
  • Abubakar IS, Abubakar SB, Habib AG, Nasidi A, Durfa N, Yusuf PO, Larnyang S, Garnvwa J, Sokomba E, Salako L, Theakston RD, Juszczak E, Alder N, Warrell DA; Nigeria-UK EchiTab Study Group. Randomised controlled double-blind non-inferiority trial of two antivenoms for saw-scaled or carpet viper (Echis ocellatus) envenoming in Nigeria. PLoS Negl Trop Dis. 2010 Jul 27;4(7):e767. PMID: 20668549; PMCID: PMC2910709. https://doi.org/10.1371/journal.pntd.0000767
  • 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

  • Al Hatali BA, Al Mazroui SA, Alreesi AS, Geller RJ, Morgan BW, Kazzi ZN.Report of a Bite from a New Species of the Echis Genus--Echis omanensis. J Med Toxicol. 2015 Jun;11(2):242-4. PMID: 25403810; PMCID: PMC4469716. https://doi.org/10.1007/s13181-014-0444-x

  • 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
  • Annobil SH. Complications of Echis colorata snake bites in the Asir region of Saudi Arabia. Ann Trop Paediatr. 1993;13(1):39-44. PMID: 7681644. https://doi.org/10.1080/02724936.1993.11747623
  • Edgar W, Warrell MJ, Warrell DA, Prentice CR. The structure of soluble fibrin complexes and fibrin degradation products after Echis carinatus bite. Br J Haematol. 1980 Mar;44(3):471-81. PMID: 7378311. https://doi.org/10.1111/j.1365-2141.1980.tb05917.x
  • Gillissen A, Theakston RD, Barth J, May B, Krieg M, Warrell DA. Neurotoxicity, haemostatic disturbances and haemolytic anaemia after a bite by a Tunisian saw-scaled or carpet viper (Echis 'pyramidum'-complex): failure of antivenom treatment. Toxicon. 1994 Aug;32(8):937-44. PMID: 7985198. https://doi.org/10.1016/0041-0101(94)90372-7
  • Glatstein M, Lerman L, Gatt D, Scolnik D, Rimon A, Hoyte C, Iazar I. Echis coloratus envenomation in children: a retrospective case series. Clin Toxicol (Phila). 2022 Mar;60(3):293-297. Epub 2021 Jul 28. PMID: 34319210. https://doi.org/10.1080/15563650.2021.1959604
  • Habib AG, Abubakar SB, Abubakar IS, Larnyang S, Durfa N, Nasidi A, Yusuf PO, Garnvwa J, Theakston RD, Salako L, Warrell DA; EchiTab Study Group (Nigeria & UK). Envenoming after carpet viper (Echis ocellatus) bite during pregnancy: timely use of effective antivenom improves maternal and foetal outcomes. Trop Med Int Health. 2008 Sep;13(9):1172-5. Epub 2008 Jul 8. PMID: 18631310; PMCID: PMC2857546. https://doi.org/10.1111/j.1365-3156.2008.02122.x
  • Habib AG, Warrell DA.Antivenom therapy of carpet viper (Echis ocellatus) envenoming: effectiveness and strategies for delivery in West Africa. Toxicon. 2013 Jul;69:82-9. Epub 2013 Jan 20. PMID: 23339853. https://doi.org/10.1016/j.toxicon.2013.01.002
  • Hamman NA, Ibrahim AD, Hamza M, Jahun MG, Micah M, Lawal HA, Abubakar SB, Iliyasu G, Chedi BAZ, Mohammed I, Harrison RA, Gutiérrez JM, Habib AG. A Randomized Controlled Trial to Optimize Antivenom Therapy for Carpet Viper (Echis romani)-Envenomed Children in Nigeria. Am J Trop Med Hyg. 2024 Aug 6;111(4):904-910. PMID: 39106853; PMCID: PMC11448515. https://doi.org/10.4269/ajtmh.24-0222
  • Hamza M, Dajel TB, Abubakar SB, Hamza AS, Abdullahi HL, Iliyasu G, Habib AG. Performance of the 20 minutes Whole Blood Clotting Test in detection, monitoring and antivenom therapy of West African Carpet viper (Echis romani) envenoming in resource constrained settings in Nigeria. Toxicon. 2023 Mar 1;224:107025. Epub 2023 Jan 11. PMID: 36640811. https://doi.org/10.1016/j.toxicon.2023.107025
  • 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
  • Noutsos T, Currie BJ, Lek RA, Isbister GK.Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis.PLoS Negl Trop Dis. 2020 Dec 8;14(12):e0008936. PMID: 33290400; PMCID: PMC7748274. https://doi.org/10.1371/journal.pntd.0008936
  • Noutsos T, Currie BJ, Wijewickrama ES, Isbister GK.Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice. Toxins (Basel). 2022 Jan 14;14(1):57. PMID: 35051033; PMCID: PMC8778654. https://doi.org/10.3390/toxins14010057
  • Obeidat MB, Al-Swailmeen AM, Al-Sarayreh MM, Rahahleh KM.Thrombotic Microangiopathy Following Arabian Saw-Scaled Viper (Echis coloratus) Bite: Case Report. Am J Case Rep. 2020 Apr 15;21:e922000. PMID: 32291384; PMCID: PMC7176588. https://doi.org/10.12659/ajcr.922000
  • A Porath, D Gilon, H Schulchynska-Castel, O Shalev, A Keynan, J Benbassat Risk indicators after envenomation in humans by Echis coloratus (mid-east saw scaled viper) Toxicon, 30 (1992), pp. 25-32 https://doi.org/10.1016/0041-0101(92)90498-t
  • Tianyi FL, Hamza M, Abubakar SB, Al Solaiss J, Trelfa A, Abdullahi HL, Iliyasu G, Mohammed N, Mohammed SA, Casewell NR, Harrison RA, Lalloo DG, Stienstra Y, Habib AG. Diagnostic characteristics of the 20-minute whole blood clotting test in detecting venom-induced consumptive coagulopathy following carpet viper envenoming.PLoS Negl Trop Dis. 2023 Jun 26;17(6):e0011442. PMID: 37363905; PMCID: PMC10328339. https://doi.org/10.1371/journal.pntd.0011442
  • Pugh RN, Theakston RD. A clinical study of viper bite poisoning. Ann Trop Med Parasitol. 1987 Apr;81(2):135-49. PMID: 3689023. https://doi.org/10.1080/00034983.1987.11812106
  • Reid HA. Prolonged defibrination syndrome after bite by the carpet viper Echis carinatus. Br Med J. 1977 Nov 19;2(6098):1326. PMID: 589168; PMCID: PMC1632516. https://doi.org/10.1136/bmj.2.6098.1326
  • Valenta J, Stach Z, Michalek P. Exotic snake bites in the Czech Republic--Epidemiological and clinical aspects during 15-year period (1999-2013). Clin Toxicol (Phila). 2014 Apr;52(4):258-64. Epub 2014 Mar 26. PMID: 24666339. https://doi.org/10.3109/15563650.2014.902066 
  • Warrell DA, Davidson NMcD, Greenwood BM, Ormerod LD, Pope HM, Watkins BJ, Prentice CR. Poisoning by bites of the saw-scaled or carpet viper (Echis carinatus) in Nigeria. Q JMed. 1977 Jan;46(181):33-62. PMID: 866568.