Bisneto Pedro Ferreira, Araújo Bruno Dos Santos, Pereira Handerson da Silva, Mendonça da Silva Iran, Sachett Jacqueline de Almeida Gonçalves, Bernarde Paulo Sérgio, Monteiro Wuelton Marcelo, Kaefer Igor Luis
Universidade Federal do Amazonas - UFAM, Instituto de Ciências Biológicas, Programa de Pós-Graduação em Zoologia, Av. General Rodrigo Octavio, 1200, Coroado I, 69067-005, Manaus, Amazonas, Brazil.
Faculdade Estácio do Amazonas, Av. Constantino Nery, 3693, Chapada, 69050-001, Manaus, Amazonas, Brazil.
Toxicon. 2020 Oct 15;185:193-202. doi: 10.1016/j.toxicon.2020.07.009. Epub 2020 Jul 22.
Envenomation by coral snakes represents a little known burden in Brazilian Amazonia. So far, details on clinical and epidemiological aspects remain obscure in the region. We gathered data from medical charts and from the scientific collection of snakes from Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, finding 26 cases of envenomation by five species of Micrurus in Manaus region, between 1987 and 2018. They represent 0.7% of the snakebites treated in the hospital since the records began, in 1979. Micrurus lemniscatus was responsible for most of the bites (10), followed by M. hemprichii (five), M. spixii (three), M. surinamensis (three) and M. averyi (one). There was no difference between the sexes of the snakes that caused bites. Patients were mostly males, and most of the cases were reported in urban areas. Bites predominated in dry season, and there was a clear geographical segregation among species. We describe seven cases of envenomation, three mild and four severe, all of which evolved to cure. Paresthesia (six), pain (five) and edema (four) were the most common local symptoms. Systemic features such as dyspnea/shallow breath (four), palpebral ptosis (four), blurred vision (three), dysarthria (three) and difficulty to walk (three) were also detected. Two patients bitten by Micrurus sp. and M. hemprichii, showed slight increased serum levels of creatine kinase (reference level <190 U/L), 1184 U/L and 1229 U/L, respectively, indicative of mild systemic myotoxicity. This is the first report of myotoxic manifestation in the envenomation by M. hemprichii. No patient developed respiratory failure, though one bitten by an adult M. spixii required intubation and mechanical ventilation due to decreased level of consciousness during evolution, probably related to induced sedation caused by concurrent alcohol intoxication. All patients were treated with Brazilian Micrurus antivenom (soro antielapídico, median = 10 vials). Six patients were pretreated intravenously with H1 and H2 antagonists and steroids, with two patients developing early adverse reactions. The median length of hospital stay was four days. Envenomations by coral snakes in Manaus region are clinically severe, but rare and sparsely distributed over time, making the detection of epidemiological and clinical patterns a challenge for public health.
珊瑚蛇咬伤在巴西亚马逊地区是一个鲜为人知的负担。到目前为止，该地区临床和流行病学方面的细节仍不清楚。我们从热带医学基金会多托·埃托尔·维埃拉·多拉多医生的医学图表和蛇类科学收藏中收集数据，发现在1987年至2018年期间，玛瑙斯地区有26例被五种珊瑚蛇属蛇咬伤的病例。自1979年有记录以来，这些病例占医院治疗蛇咬伤病例的0.7%。咬伤大多由宽带珊瑚蛇（10例）所致，其次是亨氏珊瑚蛇（5例）、斯氏珊瑚蛇（3例）、苏里南珊瑚蛇（3例）和艾氏珊瑚蛇（1例）。致伤蛇的性别无差异。患者多为男性，大多数病例报告于城市地区。咬伤在旱季居多，且不同蛇种之间存在明显的地理隔离。我们描述了7例咬伤病例，3例轻度，4例重度，所有病例均治愈。感觉异常（6例）、疼痛（5例）和水肿（4例）是最常见的局部症状。还发现了一些全身症状，如呼吸困难/呼吸浅促（4例）、上睑下垂（4例）、视力模糊（3例）、构音障碍（3例）和行走困难（3例）。两名分别被斯氏珊瑚蛇属和亨氏珊瑚蛇咬伤的患者，血清肌酸激酶水平略有升高（参考水平<190 U/L），分别为1184 U/L和1229 U/L，提示轻度全身肌毒性。这是亨氏珊瑚蛇咬伤致肌毒性表现的首次报告。尽管有一名被成年斯氏珊瑚蛇咬伤的患者在病情发展过程中因意识水平下降需要插管和机械通气，这可能与同时存在的酒精中毒引起的诱导镇静有关，但没有患者发生呼吸衰竭。所有患者均接受了巴西珊瑚蛇抗蛇毒血清治疗（抗蛇毒血清，中位数=10瓶）。6例患者静脉注射H1和H2拮抗剂及类固醇进行预处理，2例患者出现早期不良反应。住院时间中位数为4天。玛瑙斯地区珊瑚蛇咬伤在临床上较为严重，但罕见且随时间分布稀疏，这使得检测流行病学和临床模式成为公共卫生面临的一项挑战。
