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  5. Clinical entry: Naja sp., African spitting cobras

Clinic: Naja sp., African spitting cobras

Examine for venom effects

Local Effects

Bite site

  • Pain
  • Tender local (spreading) swelling
  • Blistering
  • Lymphangiopathy and lymphadenopathy
  • Necrotic skin

Eyes

  • Intense local pain
  • Blepharospasm
  • Balpebral oedema
  • Leucorrhoea
  • Photophobia
  • Clouding of vision
  • Temporary blindness

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.

   Local effects - bite site1 Local effects - eyes2
Naja katiensis    
Naja mossambica    
Naja nigricincta    
Naja nigricollis    
Naja pallida    

1Local Effects - bite site

Naja nigricollis
Tender local swelling reaching a maximum after > 1-2 days. Blistering surrounding a demarcated pale or blackened anaesthetic area of necrotic skin, regional lymphadenopathy. Putrid smell. Break down with extensive loss of skin and subcutaneous tissue appearing around the 5th day after the bite (36 h to 10 days). Skip lesions (necrotic skin separated by areas of apparently normal skin extending proximally up the limb) (Warrell 2023, Warrell et al. 1976, WHO 2010a).
Extensive local necroses, loss of the entire soft tissue covering of the affected extremity. Secondary infection. Septicaemia. If treatment is not timely or adequate amputation of digits and whole limbs is often unavoidable. In chronic recurrent ulcers risk of malignancy (Warrell et al. 1976). 

Naja mossambica
Swelling; moderate to severe local pain; necrosis (Tilbury 1982).
Development of local effects: within the first 3 h after the bite, moderate to severe local pain and progressive local swelling. 3–5 h after the bite the first signs of the necrotising process are already noticeable (dark discolouration of the skin, formation of blisters, discharge of blood-tinged serous fluid). 5–9 h after the bite the skin discolouration is more extensive, and it reaches a maximum after 9–48 h. The affected area of skin is now dark blue and demarcated. 48–72 h after the bite the swelling reaches a maximum, the skin discolouration becomes black, and blisters appear over the entire area of skin discolouration. The swelling starts to reduce from day 3. During surgical exploration or debridement, even subcutaneous tissue under epidermis that is not discoloured and destroyed has become necrotic. Pockets of necrotic tissue that extend far beyond the demarcated area can be found. After debridement, an ulcer forms with an undermined edge. In the observed cases, generally only the epidermis and subcutaneous tissue were affected, and not the musculature or other deep tissue structures (Tilbury 1982).
Loss of fluid into the sometimes massive swelling of the bitten extremity. In children in particular this is a factor that can contribute to hypovolaemia and hypovolaemic shock (Tilbury 1982).

2Local Effects - eyes

Naja nigricollis
Intense local pain, blepharospasm, palpebral oedema and leukorrhoea; corneal erosions.
Complications: Permanent opacities and blindness (secondary infection of corneal lesions). Destruction of the eye (panophthalmitis). Hypopyon and anterior uveitis (absorption of venom into the anterior chamber). Facial cranial nerve paralysis (local spread of venom) (Warrell 2023, Warrell and Ormerod 1976, Chu et al. 2010, WHO 2010a).

Naja mossambica
Accidents in which venom is sprayed into the eye: 4½ h after the accident: bilateral blepharospasm, severe conjunctivitis, dilated pupil with slow reaction to light. After 24 h the pupils were the same size, and both reacted the same to light (Tilbury 1982).

Other effects

Haemostatic effects
Spontaneous haemorrhage 3/14, subarachnoid haemorrhage 1/3 (observed 36 h after the bite), gingival bleeding 1/3 (observed 16 h after the bite), epistaxis 1/3 (observed 72 h after the bite); microhaematuria in the absence of urogenital schistosomiasis 1/14 (Warrell et al. 1976b).
Other signs & symptoms
Diminished consciousness 3/14; one of these patients had pulmonary oedema and died, another had a subarachnoid haemorrhage and also died, and the third regained full consciousness after several hours (Warrell et al. 1976b).

Clinical management

See also (Depending on the origin of the culprit)

Clinical Management: Central and Southern Africa

Clinical Management: North Africa, Near and Middle East

for advice on post-First Aid measures, diagnosis (clinical, laboratory) and treatment (supportive, antivenom).

First Aid

Any type of tourniquet follow links above.

Local treatment

Bite site

Pain control
Tetanus prophylaxis
Standard wound care
WHO (2010b) 

Eyes

Diagnostic
Intense local pain, blepharospasm, palpebral oedema and leukorrhoea.
Slit-lamp or fluorescein examination: corneal erosions
Complications: Permanent opacities and blindness (secondary infection of corneal lesions). Destruction of the eye (panophthalmitis). Hypopyon and anterior uveitis (absorption of venom into the anterior chamber). Facial cranial nerve paralysis (local spread of venom) (Warrell 2023, Chu et al. 2010, WHO 2010a).

Treatment

“1) urgent decontamination by copious irrigation 
2) analgesia by vasoconstrictors with weak mydriatic activity (e.g. epinephrine) and limited topical administration of local anaesthetics (e.g. tetracaine)
3) exclusion of corneal abrasions by fluorescein staining with a slit lamp examination and application of prophylactic topical antibiotics
4) prevention of posterior synechiae, ciliary spasm and discomfort with topical cycloplegics and 5) antihistamines in case of allergic kerato-conjunctivitis.
5) Topical or intravenous antivenom and topical corticosteroids are contraindicated.” (Chu et al. 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 african spitting cobras - specific features

see

  • 'Species-specific envenoming pattern above'.

and

Key issues:

Bite site
See footnote 1 above.

Eyes
See footnote 2 above.

Specific treatment (antivenoms)

References

  • Chu ER, Weinstein SA, White J, Warrell DA.Venom ophthalmia caused by venoms of spitting elapid and other snakes: Report of ten cases with review of epidemiology, clinical features, pathophysiology and management. Toxicon. 2010 Sep 1;56(3):259-72. Epub 2010 Mar 21. PMID: 20331993.  doi.org/10.1016/j.toxicon.2010.02.023 
  • National Snakebite Management Guidelines Kingdom of Eswatini 2021 https://eswatiniantivenom.org/newsite/wp-content/uploads/2021/12/WHO-Snake-Bite-Treatment-Protocol-Manuscript-A4.pdf 
  • 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, Ormerod LD. Snake venom ophthalmia and blindness caused by the spitting cobra (Naja nigricollis) in Nigeria. Am J Trop Med Hyg. 1976 May;25(3):525-9. PMID: 1084700.  doi:10.4269/ajtmh.1976.25.525 
  • Warrell DA, Greenwood BM, Davidson NM, Ormerod LD, Prentice CR. (1976) Necrosis, haemorrhage and complement depletion following bites by the spitting cobra (Naja nigricollis). Q J Med. Jan;45(177):1-22. PMID: 943796. https://pubmed.ncbi.nlm.nih.gov/943796/ 
  • WHO (2010a) Guidelines for the prevention and clinical management of snakebite in Africa. https://www.who.int/publications/i/item/9789290231684
  • WHO (2010b) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139
  • WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured (2018)  https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured
  • WHO ABCDE Approach  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 Snakebite Information and Data Platform  https://www.who.int/teams/control-of-neglected-tropical-diseases/snakebite-envenoming/snakebite-information-and-data-platform

Species-specific evidence

N. katiensis

Cameroon

Case reports

  • Chippaux et al (2024)
    1 patient

N. mossambica

South Africa (Natal)

Case series

  • Tilbury CR (1982)
    6 patients

Signs & symptoms

Local effects
Bite site
Swelling; moderate to severe local pain; necrosis (Tilbury 1982).
Development of local effects: within the first 3 h after the bite, moderate to severe local pain and progressive local swelling. 3–5 h after the bite the first signs of the necrotising process are already noticeable (dark discolouration of the skin, formation of blisters, discharge of blood-tinged serous fluid). 5–9 h after the bite the skin discolouration is more extensive, and it reaches a maximum after 9–48 h. The affected area of skin is now dark blue and demarcated. 48–72 h after the bite the swelling reaches a maximum, the skin discolouration becomes black, and blisters appear over the entire area of skin discolouration. The swelling starts to reduce from day 3. During surgical exploration or debridement, even subcutaneous tissue under epidermis that is not discoloured and destroyed has become necrotic. Pockets of necrotic tissue that extend far beyond the demarcated area can be found. After debridement, an ulcer forms with an undermined edge. In the observed cases, generally only the epidermis and subcutaneous tissue were affected, and not the musculature or other deep tissue structures (Tilbury 1982).
Loss of fluid into the sometimes massive swelling of the bitten extremity. In children in particular this is a factor that can contribute to hypovolaemia and hypovolaemic shock (Tilbury 1982).

Eyes 
Accidents in which venom is sprayed into the eye: 4½ h after the accident: bilateral blepharospasm, severe conjunctivitis, dilated pupil with slow reaction to light. After 24 h the pupils were the same size, and both reacted the same to light (Tilbury 1982).

Other signs & symptoms
Drowsiness (probably a non-specific symptom related to dehydration, exhaustion) (Tilbury 1982).

Morbidity
Necroses that may be extensive and can lead to loss of soft tissue, loss of function and loss of limbs. Exacerbation due to secondary effects (wound infection).
Accidents in which venom is sprayed into the eye: conjunctivitis, corneal ulceration, blindness if the injury is not treated.

N. nigricincta

Namibia

Case reports

  • Saaimanand Buys (2019)
    3 cases with bites on the head.
  • Saaiman and Buys (2022)
    1 case

Signs & symptoms

Haemolysis (secondary?) (Saaimanand Buys 2019). Necrotizing fasciitis (secondary), rhabdomyolysis (?secondary), drowsiness and convulsions (secondary) (Saaiman and Buys 2022).

N. nigricollis

Nigeria

Case series

Bite site

  • Warrell et al. (1976b) 
    14 N. nigricollis bites; identification: morphological (7/14) or immunological with ELISA (Greenwood et al. 1974) (7/14).
    Local envenoming:
    1. Extent of the swelling (grade 1–6; scale of Warrell et al. 1974):
    Grade 1 3/14
    Grade 2 1/14
    Grade 3 1/14
    Grade 4 1/14
    Grade 5 4/14
    Grade 6 4/14
    2. Intensity of the swelling (measurement method of Reid et al. 1963c): maximum difference in circumference between the bitten extremity and the healthy extremity on average 12.6 cm (4.7–18.4 cm) or 14.9% (3.8–27%).

Eyes

  • Warrell and Ormerod (1976)
    9 N. nigricollis bites; identification: patient history ("spitting" cobra was seen) and ophthalmological findings.
  • Chu et al (2010)
    3 cases

Sanke handlers (USA)

Case reports

Eyes

  • Goldman and Seefeld (2009)
    2 cases

Signs & symptoms
Local effects

Local swelling 14/14; swelling reached a maximum within 36 h after the bite (see above for degree and extent). On average it took 11 days (1–18 days) for the swelling to disappear completely (Warrell et al. 1976b). Enlarged, painful lymph nodes (10/14). Painfulness of the lymph nodes was an early sign that appeared as early as 30 min after the bite (Warrell et al. 1976b).
Blistering 8/14, beginning 4 h to 5 days after the bite. Blistering was always followed by necrosis (Warrell et al. 1976b).
Local necroses 10/14, usually appearing around the 5th day after the bite (36 h to 10 days). Necroses at times so extensive that they led to loss of the entire soft tissue covering of the affected extremity (Warrell et al. 1976b).
Accidents in which venom entered the eye: conjunctivitis 5/9, corneal ulceration 4/9, anterior uveitis, i.e. absorption of venom into the anterior chamber of the eye 1/9, permanent blindness (failure to treat symptoms, e.g. corneal ulceration) 2/9 (Warrell and Ormerod 1976).
Haemostatic effects
Spontaneous haemorrhage 3/14, subarachnoid haemorrhage 1/3 (observed 36 h after the bite), gingival bleeding 1/3 (observed 16 h after the bite), epistaxis 1/3 (observed 72 h after the bite); microhaematuria in the absence of urogenital schistosomiasis 1/14 (Warrell et al. 1976b).
Other signs & symptoms
Diminished consciousness 3/14; one of these patients had pulmonary oedema and died, another had a subarachnoid haemorrhage and also died, and the third regained full consciousness after several hours (Warrell et al. 1976b).

Morbidity
Bite site
Local necroses 10/14, at times so extensive that they led to loss of the entire soft tissue covering of the affected extremity. Untreated wounds are prone to secondary infection. If treatment is not timely or adequate (debridement, split-thickness skin grafting, antibiotic treatment), amputation of the whole limb is often unavoidable. A further problem are chronic recurrent ulcers that carry a risk of becoming malignant (Warrell et al. 1976b).
Eyes
Accidents in which venom entered the eye: conjunctivitis, corneal ulceration, anterior uveitis, permanent blindness (failure to treat symptoms, e.g. corneal ulceration) 2/9 (Warrell and Ormerod 1976).

Laboratory and physical investigations

Haemostasis
Type of haemostatic defect
Platelet dysfunction (in vitro: MacKay et al. 1969, cited in Warrell et al. 1976b); no proven effect of venom components on blood clotting in humans.
Possible activation of blood clotting and vascular impairment through activation of complement (Warrell et al. 1976b) 

Treatment (symptomatic)

1. Pain: codeine phosphate (Warrell et al. 1976b).
2. Necroses: debridement 7/14 and split-thickness skin grafting 4/14 (Warrell et al. 1976b)
3. Patients with necroses and wound incisions before hospitalisation: procaine-penicillin, anti-tetanus serum (1,500 units) (Warrell et al. 1976b).
4. Accidents in which venom enters the eye: rinse the eye immediately with water, prevention of secondary infections (local antibiotic treatment, atropine). Thorough examination of the eye (fluorescein test, split lamp: corneal ulceration, changes in the anterior chamber of the eye) in order to identify patients at risk, who must be looked after diligently until the lesions have healed (Warrell and Ormerod 1976).

Naja pallida

Kenya

Case reports
Bite site

  • Davidson RA (1970)
  • Greenham R (1978)

Signs & symptoms

Local effects
Local swelling, necrosis (Davidson 1970).
Local swelling, including swelling of the entire bitten extremity, necrosis (Greenham 1978).
Eye injuries.

Morbidity
Necroses (Davidson 1970, Greenham 1978).

Eyes

  • Handford (2018)
    1 patient

References

  • Chippaux, J.-P.; Madec, Y.; Amta, P.; Ntone, R.; Noël, G.; Clauteaux, P.; Boum, Y., II; Nkwescheu, A.S.; Taieb, F. Snakebites in Cameroon by Species Whose Effects Are Poorly Described. Trop. Med. Infect. Dis. 2024, 9, 300.  DOI:10.3390/tropicalmed9120300 
  • Chu ER, Weinstein SA, White J, Warrell DA.Venom ophthalmia caused by venoms of spitting elapid and other snakes: Report of ten cases with review of epidemiology, clinical features, pathophysiology and management. Toxicon. 2010 Sep 1;56(3):259-72. Epub 2010 Mar 21. PMID: 20331993.doi.org/10.1016/j.toxicon.2010.02.023
  • Davidson RA (1970) Case of African cobra bite. Brit. med. J. 4: 660 doi:https://doi.org/10.1136/bmj.4.5736.660

  • Goldman DR, Seefeld AW. Ocular toxicity associated with indirect exposure to African spitting cobra venom. Wilderness Environ Med. 2010 Jun;21(2):134-6. Epub 2009 Dec 22. PMID: 20591376. DOI:10.1016/j.wem.2009.12.007 

  • Greenham R (1978) Spitting cobra (Naja mossambica pallida) bite in a Kenyan child. Trans. Roy. Soc. Trop. Med. Hyg. 72: 674-675 https://doi.org/10.1016/0035-9203(78)90038-X

  • Handford C Case of venom ophthalmia following contact with Naja pallida: the red spitting cobra. BMJ Military Health 2018;164:124-126. https://doi.org/10.1136/jramc-2017-000891

  • SaaimanEL, Buys PJC. Spitting cobra (Naja nigricincta nigricincta) bites complicated by rhabdomyolysis, possible intravascular haemolysis, and coagulopathy. S Afr Med J. 2019 Sep 30;109(10):736-740. PMID:31635568.https://doi.org/10.7196/samj.2019.v109i10.14103

  • SaaimanEL, Buys PC. Fatal infective necrotising fasciitis: Complication following Naja nigricincta nigricincta bite (western barred spitting cobra/zebra snake). S Afr Med J. 2022 Dec 1;112(12):892-896. https://doi.org/10.7196/SAMJ.2022.v112i12.16689

  • Tilbury CR. Observations on the bite of the Mozambique spitting cobra (Naja mossambica mossambica). S Afr Med J. 1982 Feb 27;61(9):308-13. PMID: 7058469. https://pubmed.ncbi.nlm.nih.gov/7058469/

  • Warrell DA, Ormerod LD. Snake venom ophthalmia and blindness caused by the spitting cobra (Naja nigricollis) in Nigeria. Am J Trop Med Hyg. 1976 May;25(3):525-9. PMID: 1084700. doi:10.4269/ajtmh.1976.25.525

  • Warrell DA, Greenwood BM, Davidson NM, Ormerod LD, Prentice CR. (1976b) Necrosis, haemorrhage and complement depletion following bites by the spitting cobra (Naja nigricollis). Q J Med. Jan;45(177):1-22. PMID: 943796. https://pubmed.ncbi.nlm.nih.gov/943796/