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  2. South America and the West Indies
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  4. Pit Vipers
  5. Clinical entry: Lachesis sp.

Clinic: Lachesis sp.

Examine for venom effects

Autopharmacological effects

  • Nausea, vomiting
  • Sweating
  • Urticaria, angiooedema
  • Generalized oedema
  • Arterial hypotension / hypovolaemic shock (transient, recurrent)
  • 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
    • Oliguria, anuria (acute kidney injury - AKI)

Neurological effects

Autonomic neurotoxicity

  • Sweating
  • repeated bilious vomiting
  • severe abdominal colic
  • profuse diarrhoea
  • hypotension
  • sinus bradycardia
  • shock 

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 Neurological
effects
(autonomic)5  		 Other
effects6
 Bleeding3  Coagulopathy4
Lachesis acrochorda            
Lachesis muta          
Lachesis stenophrys          

Envenoming by snakes of the genus Lachsis can be indistinguishable from Bothrops envenoming. Autonomic effects (see footnote 5) can support the diagnosis Lachesis envenoming. The absence, however, does not rule it out (Malaque and Gutiérrez 2017). 

1Autopharmacological effects

Autopharmacological vs autonomic see footnote 5. 

2Local effects

Pain, swelling which can be extensive, bleeding, bruising and blisters. Necrosis (Malaque and Gutiérrez 2017, Warrell 2004). 

Haematological effects

3Bleeding

Systemic bleeding

(Malaque and Gutiérrez 2017, Warrell 2004). 

4Coagulopathy

Type of haemostatic defect

Venom-induced consumption coagulopathy (VICC) (Jorge et al. 1997). 

5Neurological effects

“Bushmaster (Lachesis sp.) envenoming causes a distinctive autonomic syndrome of sweating, repeated bilious vomiting, severe abdominal colic, profuse diarrhoea, hypotension, sinus bradycardia, and shock that can develop as early as 15 min after the bite.” (Warrell and Williams 2023; cit. Bolaños et al. 1982, Jorge et al. 1997).

“A review of reports of 20 cases of bites in humans reliably attributed to this snake in Costa Rica, French Guiana, Brazil, Colombia and Venezuela confirms a syndrome of nausea, vomiting, abdominal colic, diarrhoea, sweating, hypotension, bradycardia and shock, possibly autopharmacological or autonomic in origin, not seen in victims of other American crotaline snakes” (Jorge et al. 1997). 

7Other effects

Renal effects

AKI results from a combination of factors (Malaque and Gutiérrez 2017; Warrell 2023). 

Clinical management

See also (depending on the origin of the culprit)

Clinical Management: South America and the West Indies

Clinical Management: Mexico and Central America

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
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 Lachesis sp. - specific features

see 'Species-specific envenoming pattern' above.

Key issues

see footnotes above.

Specific treatment (antivenoms)

Species-specific evidence

Lachesis acrochorda

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61.

Colombia

  • Cañas CA, Castaño-Valencia S, Castro-Herrera F. The Colombian bushmasters Lachesis acrochorda (García, 1896) and Lachesis muta (Linnaeus, 1766): Snake species, venoms, envenomation, and its management. Toxicon. 2023 Jul;230:107152. Epub 2023 May 11. PMID: 37178796. https://doi.org/10.1016/j.toxicon.2023.107152

Lachesis mealnocepha

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61.

Lachesis muta

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61.

Brazil

  • Bard R, de Lima JC, de Sa Neto RP, de Oliveira SG, dos Santos MC.Ineficácia do antiveneno botrópico na neutralização da atividade coagulante do veneno de Lachesis muta muta.Relato de caso e comprovação experimental [Inefficacy of bothropic antivenin in the neutralization of the coagulation activity of Lachesis muta muta venom. Report of a case and experimental confirmation]. Rev Inst Med Trop Sao Paulo.1994 Jan-Feb;36(1):77-81. Portuguese. PMID: 7997778.
  • Haad, J. S. (1980/81) Accidents humanos por las serpientes de los generos Bothrops y Lachesis. Mem. Inst. Butantan 44/45: 403-423
  • Jorge, M. T., I. S. Sano-Martins, R. S. Ferrari, L. A. Ribeiro, S. C. Tomy, S. C. B. Castro (1993) Envenomation by Lachesis muta muta in Brazil: a case report. Abstracts. IVth Pan American symposium on animal, plant and microbial toxins (IST) and IInd symposium of the Brazilian society on toxinology (SBTX), in honour of vital Brazil.Toxicon 31: 140-141
  •  Jorge MT, Sano-Martins IS, Tomy SC, Castro SC, Ferrari RA, Ribeiro LA, Warrell DA.Snakebite by the bushmaster (Lachesis muta) in Brazil: case report and review of the literature.Toxicon. 1997 Apr;35(4):545-54. PMID: 9133709. https://doi.org/10.1016/s0041-0101(96)00142-0
  • Pardal PP, Souza SM, Monteiro MR, Fan HW, Cardoso JL, França FO, Tomy SC, Sano-Martins IS, de Sousa-e-Silva MC, Colombini M, Kodera NF, Moura-da-Silva AM, Cardoso DF, Velarde DT, Kamiguti AS, Theakston RD, Warrell DA.Clinical trial of two antivenoms for the treatment of Bothrops and Lachesis bites in the north eastern Amazon region of Brazil. Trans R Soc Trop Med Hyg. 2004 Jan;98(1):28-42. PMID: 14702836. https://doi.org/10.1016/s0035-9203(03)00005-1
  • Sachett JAG, Marinho APS, Santos MMO, Fan HW, Bernarde PS, Monteiro WM. When to think about a Lachesis muta envenomation in the Western Brazilian Amazon: Lessons from a case report. Rev Soc Bras Med Trop. 2022 Sep 19;55:e0027. PMID: 36134857; PMCID: PMC9549943.

Colombia

  • Patino, R. O., G. S. T. Jaramillo, L. F. G. Gomez, R. G. O. Gutiérrez, R. V. Hernandez (1993) Bite from the bushmaster (Lachesis muta) in Antioquia and Choco, Columbia, report of five accidents. Abstracts. IVth Pan American symposium on animal, plant and microbial toxins (IST) and IInd symposium of the Brazilian society on toxinology (SBTX), in honour of vital Brazil. Toxicon 31: 158-159

 French Guiana
  • Hulin, A., Ochoa, J. M. Desbordes (1982) Envenimations par des crotalidés en Guyane Française. Méd. Afr. noire 29: 249-255

Lachesis stenophrys

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61.

Costa Rica

  • Bolaños R, Rojas O, Ulloa Flores CE. Aspectos biomédicos de cuatro casos de mordedura de serpiente por Lachesis muta (Ophidia: Viperidae) en Costa Rica [Biomedical aspects of 4 cases of snake bites by Lachesis muta (Ophidia: Viperidae) in Costa Rica]. Rev Biol Trop. 1982 Jul;30(1):53-8. Spanish. PMID: 7156428.
  • Rosenthal R, Meier J, Koelz A, Müller C, Wegmann W, Vogelbach P. Intestinal ischemia after bushmaster (Lachesis muta) snakebite--a case report. Toxicon. 2002 Feb;40(2):217-20. PMID: 11689244. https://doi.org/10.1016/s0041-0101(01)00203-3

Panama

  • Clark, H. C. (1928) Abstracts of snake-bite cases, Central American divisions-United Fruit Company. United Fruit Comp., Med. Dept., 7th ann. report: 271-287

1 case of Lachesis muta (=Lachesis stenophrys or L. acrochordata) bite; identification: morphological.

References

Publications reporting broadly on Lachesis sp. envenoming

Diniz-Sousa et al. (2020), Malaque and Gutiérrez (2017), Warrell (2004).

All references

  • Bard R, de Lima JC, de Sa Neto RP, de Oliveira SG, dos Santos MC.Ineficácia do antiveneno botrópico na neutralização da atividade coagulante do veneno de Lachesis muta muta.Relato de caso e comprovação experimental [Inefficacy of bothropic antivenin in the neutralization of the coagulation activity of Lachesis muta muta venom. Report of a case and experimental confirmation]. Rev Inst Med Trop Sao Paulo.1994 Jan-Feb;36(1):77-81. Portuguese. PMID: 7997778.
  • Bolaños R, Rojas O, Ulloa Flores CE. Aspectos biomédicos de cuatro casos de mordedura de serpiente por Lachesis muta (Ophidia: Viperidae) en Costa Rica [Biomedical aspects of 4 cases of snake bites by Lachesis muta (Ophidia: Viperidae) in Costa Rica]. Rev Biol Trop. 1982 Jul;30(1):53-8. Spanish. PMID: 7156428.
  • Cañas CA, Castaño-Valencia S, Castro-Herrera F. The Colombian bushmasters Lachesis acrochorda (García, 1896) and Lachesis muta (Linnaeus, 1766): Snake species, venoms, envenomation, and its management.Toxicon. 2023 Jul;230:107152. Epub 2023 May 11. PMID: 37178796.https://doi.org/10.1016/j.toxicon.2023.107152
  • Clark, H. C. (1928) Abstracts of snake-bite cases, Central American divisions-United Fruit Company. United Fruit Comp., Med. Dept., 7th ann. report: 271-287
  • Diniz-Sousa R, Moraes JDN, Rodrigues-da-Silva TM, Oliveira CS, Caldeira CADS. A brief review on the natural history, venomics and the medical importance of bushmaster (Lachesis) pit viper snakes. Toxicon X. 2020 Jul 25;7:100053. PMID: 32793880; PMCID: PMC7408722.https://doi.org/10.1016/j.toxcx.2020.100053
  • Haad, J. S. (1980/81) Accidents humanos por las serpientes de los generos Bothrops y Lachesis. Mem. Inst. Butantan 44/45: 403-423
  • Hulin, A., Ochoa, J. M. Desbordes (1982) Envenimations par des crotalidés en Guyane Française. Méd. Afr. noire 29: 249-255
  • Jorge MT, Sano-Martins IS, Tomy SC, Castro SC, Ferrari RA, Ribeiro LA, Warrell DA. Snakebite by the bushmaster (Lachesis muta) in Brazil: case report and review of the literature. Toxicon. 1997 Apr;35(4):545-54. PMID: 9133709.https://doi.org/10.1016/s0041-0101(96)00142-0
  • Malaque, C.M., Gutiérrez, J.M. (2017). South and Central American Snakes. In: Brent, J., et al. Critical Care Toxicology. Springer, Cham.https://doi.org/10.1007/978-3-319-17900-1_146
  • Pardal PP, Souza SM, Monteiro MR, Fan HW, Cardoso JL, França FO, Tomy SC, Sano-Martins IS, de Sousa-e-Silva MC, Colombini M, Kodera NF, Moura-da-Silva AM, Cardoso DF, Velarde DT, Kamiguti AS, Theakston RD, Warrell DA.Clinical trial of two antivenoms for the treatment of Bothrops and Lachesis bites in the north eastern Amazon region of Brazil. Trans R Soc Trop Med Hyg. 2004 Jan;98(1):28-42. PMID: 14702836.https://doi.org/10.1016/s0035-9203(03)00005-1
  • Patino, R. O., G. S. T. Jaramillo, L. F. G. Gomez, R. G. O. Gutiérrez, R. V. Hernandez (1993) Bite from the bushmaster (Lachesis muta) in Antioquia and Choco, Columbia, report of five accidents. Abstracts. IVth Pan American symposium on animal, plant and microbial toxins (IST) and IInd symposium of the Brazilian society on toxinology (SBTX), in honour of vital Brazil. Toxicon 31: 158-159
  • Sachett JAG, Marinho APS, Santos MMO, Fan HW, Bernarde PS, Monteiro WM. When to think about a Lachesis muta envenomation in the Western Brazilian Amazon: Lessons from a case report. Rev Soc Bras Med Trop. 2022 Sep 19;55:e0027. PMID: 36134857; PMCID: PMC9549943.
  • Rosenthal R, Meier J, Koelz A, Müller C, Wegmann W, Vogelbach P. Intestinal ischemia after bushmaster (Lachesis muta) snakebite--a case report. Toxicon. 2002 Feb;40(2):217-20. PMID: 11689244.https://doi.org/10.1016/s0041-0101(01)00203-3
  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61.
  •  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
  • WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured; 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.