László Krecsák

Snakebites in Hungary--epidemiological and clinical aspects over the past 36 years.

Epidemiological and clinical aspects of snakebites in Hungary between 1970 and 2006 were surveyed. A total of 97 cases were recorded from 21 species, including the two native vipers, Vipera berus and Vipera ursinii, and various exotic species represented by Viperidae, Elapidae, and Colubridae. Bites by native species on laymen are uncommon (17 cases) and present trivial clinical manifestations. Compared with the consequences of native Vipera cases, bites by exotic species often resulted in severe or life-threatening envenomations. These cases were treated with antivenom administration, plasmapheresis, fasciotomy, and amputation. There were two fatalities caused by V. berus and Agkistrodon contortrix. Both of these cases were inflicted in snake-handlers with a previous history of Viperidae bites and the cause of deaths are attributed to anaphylactic reactions as a consequence of hypersensitivity to the venom. Snake-handlers and their physicians face a major challenge due to the diversity and severity of signs and symptoms following exotic venomous snakebites, and the risk of anaphylaxis or anaphylactoid reactions in patients with repeated exposure to snake venom and antivenom. Highly dangerous venomous snake species continue to appear in collections of Hungarian snake-handlers.

First clinical experiences about the neurotoxic envenomings inflicted by lowland populations of the Balkan adder, Vipera berus bosniensis

The first overall clinical description of envenomings by the lowland populations of the Balkan adder (Vipera berus bosniensis) is provided by this study. Fifty-four incidents have been collected retrospectively from the south-western Hungarian and the northern Croatian distribution area of the taxon. There were five (9%) asymptomatic, 24 (44%) mild, 12 (22%) moderate, 12 (22%) severe, and one fatal (2%) case according to the Poisoning Severity Score. The single death is a 60-year-old Hungarian case that was caused by V.b. bosniensis. Average hospitalisation was 2.75 days. The most common systemic symptoms were gastrointestinal disorders, ECG changes, persisting hypotension and neurological disorders. The initial phase of neurotoxic manifestations was always expressed in cranial nerve disturbances: ptosis, external ophthalmoplegia, diplopia, reduced focusing capability and blurred vision. Neuromuscular paralysis progressed to dyspnoea and lower limb paralysis in the most severe cases. Unusual symptoms were fluctuating arterial hypertension, drowsiness, and hypokalaemia. Laboratory results reveal leucocytosis, while deviation in the other laboratory values is not common. Envenomings by V.b. bosniensis significantly differ from those by the European adder (Vipera berus berus) in lower manifestation rate of extensive oedema, anaemia, CNS depression, and haematuria but the development of neuromuscular paralysis is high (20%). Their bites rather resulted in mild and moderate local symptoms in envenomed patients than those inflicted by the nominate form. This study presents the evidence of the frequent neurotoxic manifestations in Balkan adder-bitten patients for the first time, which strongly suggests that the venom of the lowland populations of V.b. bosniensis has neurotoxic activity.

Clinical picture of envenoming with the Meadow Viper (Vipera (Acridophaga) ursinii)

Objective. The vipers in the Vipera (Acridophaga) ursinii complex are small-sized insectivorous snakes found in parts of central and southern Europe. Subspecies include Vipera ursinii ursinii, Vipera ursinii moldavica, Vipera ursinii macrops, Vipera ursinii rakosiensis, and Vipera ursinii graeca and are commonly known as the meadow vipers. These are the least known European Vipera from a clinical point of view. Methods. We identified cases of V. ursinii envenomations through three methods, including literature search in PubMed, ISI web of Knowldge, JSTOR, Biological Abstracts, Zoological Record, using the various combination of the following terms: snakebite, envenoming, bite, venom, ursinii, meadow viper, steppe viper (in English, French, Italian, Hungarian, Croatian, Serbian, Romanian), review of paper-based medical case records of hospitals in Hungary (four) and Romania (one) covering the 1970–July 2010 period, and personal communications of professional and amateur herpetologists studying V. ursinii and snake-handlers bitten by these snakes. Results. We identified 64 cases from subspecies: V. u. ursinii (14), V. u. moldavica (8), V. u. macrops (5), and V. u. rakosiensis (37). Forty-five bites were collected from the literature, 5 from hospitals, 10 cases were communicated by seven herpetologists and four cases by two snake keepers. Bites were mostly asymptomatic. Forty-five envenomings (70%) resulted in mild and moderate local symptoms, involving pain with low-intensity, pruritus, numbness, swelling with or without erythema and/or local hematoma. Bullae (n = 3, 5%), mild superficial necrosis (n = 4, 6%), cellulitis (n = 1, 2%), and moderately extended edema (n = 8, 13%) of the bitten extremity rarely develop. Massive limb edema was recorded in eight (13%) cases. The most common systemic symptoms were dizziness caused by transient hypotension and tachycardia. Gastrointestinal disorders (i.e. nausea, vomiting) were rare (n = 2, 3%) compared to other Vipera, and probably triggered only by anxiety. Symptomatic and supportive therapy was applied in the relatively severe envenomings and antivenom therapy in six cases. Complete recovery ranged from 12 h to 2 weeks. Moderate and severe envenomings required significantly longer recovery. Application of first aid was associated with significantly longer recovery times. Neither the age (i.e. juvenile or adult) of the culprit specimen, nor the anatomical location of the bite determined the severity of symptoms. Conclusion. Professional and amateur herpetologists, and snake keepers are mainly at risk. Most V. ursinii bites do not require first aid or medical intervention, since only local symptoms develop and resolve spontaneously. The rare hospitalized cases require symptomatic and supportive treatment only. Antivenom therapy is not indicated.

[An overview on envenomings inflicted by the Common adder (Vipera berus) and their treatment in Hungary. Facts and beliefs -- part I].

Consequences of bites by the Common adder (Vipera berus) were reviewed in this study. Patients bitten by snakes from different populations may develop variable symptoms due to geographical venom variation. The correct diagnosis of snake bites and the knowledge of the distribution of venomous snake taxa have a crucial impact on snake bite therapy. The characteristic symptoms of patients bitten by V. berus in Hungary are highlighted. The habitat characteristics, seasonal activity and the Hungarian distribution of the adder are described based on literature data, museum specimens and field observations. However, envenomings are uncommon in Hungary, the annual 3 to 4 incidents have to be taken seriously, regardless of the age and actual health condition of the patients. Contrary to beliefs persisting both among laymen and professionals, the venom of V. berus is powerful. Medical observation of the patients is necessary in the first 5 to 6 hours. Any systemic symptom or progression of the edema requires hospital admission.

A survey of the Linnaean type material of Coluber berus, Coluber chersea and Coluber prester (Serpentes, Viperidae)

Carl Linnaeus (1707–1778) described three taxa that are currently in the synonymy of Vipera berus: Coluber Berus, Coluber Chersea and Coluber Prester. We survey the existing preserved specimens of Vipera berus in the collections at Uppsala University Museum of Evolution and the Swedish Museum of Natural History, Stockholm. We give a short account of the Linnaean collections of snakes, describe the manuscript and printed catalogues on the holdings of the two museums and present the current disposition of the Linnaean collections. We review the type status of five specimens that we located and draw conclusions based on the catalogues and literary works that Linnaeus referred to. We designate a neotype for Coluber berus and restrict the type locality to Berthåga, Uppsala, and designate lectotypes for Coluber chersea and Coluber prester and restrict the type localities to Angelstad, Småland and Småland, southern Sweden respectively.