PRIMEVIEW

SNAKEBITE ENVENOMING
For the Primer, visit doi:10.1038/nrdp.2017.63

Snakebite DIAGNOSIS
Snakebite envenoming is a neglected EPIDEMIOLOGY
tropical disease that affects envenoming
1.8–2.7 million people worldwide per year is an
occupational and Identifying the snake species responsible for the
and causes 81,000–138,000 deaths.
environmental bite is important for antivenom administration
and depends on the description of the snake
disease The global
by the individual bitten or bystanders, clinical
MECHANISMS Snakebites are burden
manifestations, geographical location and the
most common in of snakebite
envenoming is detection of venom antigens or DNA. Clinical
Owing to the high variability of venoms of impoverished areas assessment of vital signs and laboratory tests help
of the warmer tropics estimated at 6 million
different snake species, clinical manifestations disability-adjusted to assess local and systemic envenoming, which is
and subtropics,
of envenoming vary from local tissue damage life years globally characterized by extensive swelling or necrosis,
such as sub-Saharan
to potentially life-threatening systemic effects. hypovolaemic shock, spontaneous systemic
Africa, South to
Some toxins present in venom provoke local bleeding, incoagulable blood, neurotoxicity,
Southeast Asia, Papua
tissue damage, such as myonecrosis, skin damage systemic muscle damage and kidney failure.
New Guinea and
(blisters and necrosis), local inflammation and Latin America
pain, often resulting in permanent sequelae.
Other toxins induce systemic effects, including MANAGEMENT
Snakebite
neurotoxicity (leading to, for example,
The most envenoming
respiratory paralysis), cardiotoxicity,
dangerous leads to chronic
haemostatic disturbances (resulting in, disability Immediate first aid includes immobilization to
species belong to
for example, haemorrhage), acute including reduce the spread of the venom, removal of tight
the family Viperidae
kidney injury and rhabdomyolysis amputations, objects around the bitten limb (such as rings) and
(for example, pit vipers)
(generalized breakdown of and the family Elapidae post-traumatic application of pressure bandages for neurotoxic
muscle fibres). (for example, cobras, stress disorder envenomings. Intravenous administration of
kraits and mambas) and blindness antivenom is the only specific treatment for
systemic envenoming, but is only partially effective
against local effects. General measures include
analgesics, ventilator support, fluid therapy,
haemodialysis and antibiotic therapy.

OUTLOOK
The WHO recommends an
integrated global strategy to
reduce the burden of snakebite
• Phospholipases A2 • Snake venom serine envenoming, including
• Snake venom proteinases educational programmes
metalloproteinases • Vasoactive peptides that detail safe methods for
• Three-finger toxins • Sarafotoxins high-risk tasks, better first
• Hyaluronidases • Dendrotoxins aid strategies, training of
health professionals, research
in diagnostics and new
management options, data
collection, and improved access
and distribution of antivenoms.
The current crisis in antivenom
availability has created an
important, life-threatening
therapeutic gap, especially in
Africa. Increased antivenom
production is needed, and
novel therapeutic alternatives
for conventional antivenom
based on recombinant antibody
technologies and new toxin
inhibitors are being explored.
Antivenom comprises
concentrated and often
modified immunoglobulins
derived from animals immunized with
the venom of one or more snake species.
Disadvantages of conventional antivenom
are that only ~15% of the immunoglobulins
are specific to the toxins, that they are
specific to the species (or closely related
species) they were raised against, and
that early and late adverse events
can occur.

Written by Liesbet Lieben; designed by Laura Marshall Article number: 17064; doi:10.1038/nrdp.2017.64; published online 14 Sep 2017
©
2
0
1
7
M
a
c
m
i
l
l
a
n
P
u
b
l
i
s
h
e
r
s
L
i
m
i
t
e
d
,
p
a
r
t
o
f
S
p
r
i
n
g
e
r
N
a
t
u
r
e
.
A
l
l
r
i
g
h
t
s
r
e
s
e
r
v
e
d
.