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QJM 2004 97(11):717-727; doi:10.1093/qjmed/hch118
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QJM vol. 97 no. 11 © Association of Physicians 2004; all rights reserved.

Life-threatening envenoming by the Saharan horned viper (Cerastes cerastes) causing micro-angiopathic haemolysis, coagulopathy and acute renal failure: clinical cases and review

M. Schneemann1, R. Cathomas1, S.T. Laidlaw2, A.M. El Nahas2, R.D.G. Theakston3 and D.A. Warrell3,4

From the 1Department of Medicine, University Hospital, Zürich, Switzerland, 2 Sheffield Kidney Institute, Northern General Hospital, Sheffield, UK, 3 Alistair Reid Venom Unit, Liverpool School of Tropical Medicine, Liverpool, UK, and 4 Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK

Received 4 May 2004 and in revised form 12 August 2004

Background: The desert horned vipers (Cerastes cerastes and C. gasperettii) are the most familiar snakes of the great deserts of North Africa and the Middle East, including the plains of Iraq. They are responsible for many human snake bites. In Western countries, they are popular among exotic-snake keepers.

Aim: To investigate mechanisms of life-threatening envenoming and treatment.

Design: Clinical investigation.

Methods: Clinical and laboratory studies with measurement of serum venom antigen concentrations by enzyme immunoassay.

Results: Two men bitten while handling captive Saharan horned vipers (Cerastes cerastes) in Europe developed extensive local swelling and life-threatening systemic envenoming, characterized by coagulopathy, increased fibrinolysis, thrombocytopenia, micro-angiopathic haemolytic anaemia and acute renal failure. The clinical picture is explicable by the presence in C. cerastes venom of several thrombin-like, Factor-X-activating, platelet-aggregating, haemorrhagic and nephrotoxic components. In one case, prophylactic use of subcutaneous epinephrine may have contributed to intracranial haemorrhage. The roles in treatment of heparin (rejected) and specific antivenom (recommended) are discussed.

Discussion: Cerastes cerastes is capable of life-threatening envenoming in humans. Optimal treatment of envenoming is by early administration of specific antivenom, and avoidance of ineffective and potentially-dangerous ancillary methods.

Address correspondence to Professor D.A. Warrell, Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK. e-mail: david.warrell{at}ndm.ox.ac.uk


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Related articles in QJMed:

The Saharan Horned Viper (Cerastes cerastes)

QJMed 2004 97: 705. [Extract] [FREE Full Text]  





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