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  2. Mexico and Central America
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  5. Clinical entry: Crotalus durissus ssp.

Clinic: Crotalus durissus ssp.

Examine for venom effects

Autopharmacological effects

  • Nausea, vomiting
  • Sweating
  • Urticaria, angiooedema
  • Generalized oedema
  • Arterial hypotension / hypovolaemic shock (transient, recurrent)
  • Diarrhoea
  • Bronchospasm 

Local Effects

  • Pain
  • Tender local (spreading) swelling
  • Blistering
  • Lymphangiopathy and lymphadenopathy
  • Necrotic skin; can include muscle locally.

Haematological effects 

  • Clotting disturbances
    • Bleeding from the fang marks and from injuries, in particular ones that are not located in the region in which venom application occurred.
    • Bleeding into the skin (ecchymosis, petechiae)
    • Gingival bleeding, bleeding from the nose, conjunctiva, haematemeis, bleeding per rectum, including melaena, haematuria, haemoptysis.
    • Oliguria, anuria (VICC / AKI)
  • Bleeding and/or haemolytic anaemia
    • Arterial hypotension (haemorrhagic shock)
    • Acute abdomen (intra-abdominal bleeding!)
    • Loin pain/renal bed sensitive to percussion (ischaemia, renal haemorrhage!)
    • Local neurological signs, meningism, coma (intracranial bleeding!)
    • Pale sclera
    • Oliguria, anuria (acute kidney injury - AKI)

Neurological effects

  • Descending flaccid paralysis
    • Ptosis (not to be mixed up with tiredness / drowsiness; test: lid retraction with upward gaze).
    • Double vision (external ophthalmoplegia)
    • Difficulties to swallow (dysphagia) (bulbar paralysis) > inhalation of vomitus!
    • Difficulties to lift the head when lying on the back (‘broken neck syndrome’)
    • Cyanosis, shallow breathing, respiratory arrest (respiratory paralysis); respiratory arrest may be precipitated by obstruction of the upper airway by the paralysed tongue or inhaled vomitus. 
    • Weakness or loss of voluntary movement; movements of digits may still be possible, allowing the patient to communicate.
    • Loss of consciousness and generalized convulsions caused by hypoxaemia in patients who have respiratory paralysis.  

Muscular effects

  • Generalized rhabdomyolysis
    • Muscles pain and tenderness, painful on passive stretching, muscle stiffness, trismus
    • Bulbar and respiratory muscle weakness.
    • Dark brown urine. 
    • Renal failure (AKI)
    • Laboratory: Generalized rhabdomyolysis: defined by a serum creatine kinase level > 10,000 U/l
    • ECG: Signs of hyperkalaemia. 

Cardiac Effects

  • Bradycardia, tachycardia, arrhythmias
  • Arterial hypotension
  • Heart failure
  • ECG: Tachyarrhythmias, sinus bradycardia, ST-T wave changes, varying degrees of atrioventricular block, and evidence of hyperkalaemia.

Renal effects

  • Acute kidney injury
  • Loin pain (lower back pain)
  • Renal bed sensitive to percussion
  • Haematuria, haemoglobinuria, myoglobinuria
  • Oliguria (< 400 ml of urine / 24 h), anuria
  • Uraemia (nausea, acidotic breathing, hiccups,pleuritic chest pain, encephalopathy)

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.

   Auto-
pharma-
cological
effects1		 Local
effects2
 		 Haematological effects   

Neurological
effects5

Muscular
effects6

Renal
effects7
 Bleeding3  Coagulopathy4 
Crotalus durissus collilineatus                
Crotalus durissus durissus                
Crotalus durissus terrificus                
Crotalus durissus ruruima                

“The reported consequences of bites from rattlesnakes of the genus Crotalus in South America are manly neuromuscular blockade and rhabdomyolysis, which may cause AKI (Malaque and Gutiérrez 2017). 

Regional differences in symptoms of envenoming due to C. durissus ssp.

In southern Brazil (C. d. terrificus) envenoming is characterised by paralysis, renal failure, a mild local reaction and a high mortality rate (the main component of the venom is crotoxin); adult C. d. durissus do not have much crotoxin, while newborn animals have a lot. The symptoms of envenoming due to C. d. unicolor appear to be somewhere between those of C. d. terrificus and C. d. durissus (Hardy 1992a). 

1Autopharmacological effects

Somnolence, sweating, nausea and vomiting (Cupo et al. 1988, 1990).

(Warrell 2004, 2009, 2023). 

2Local effect

Pain, redness, swelling. Local signs less intense than in Bothrops and Lachesis envenoming. Frequently an absence of further local clinical signs (Malaque and Gutiérrez 2017).

Fatal systemic envenoming by tropical rattlesnakes (Crotalus durissus ssp.) may occur in the absence of local signs (Cupo et al. 1988, 1990, Warrell 2004, 2023).

Hematological effects

3Bleeding

Systemic bleeding

Bleeding is not very common(Malaque and Gutiérrez 2017; Sano-Martins et al. 2001, Warrell 2004).

4Coagulopathy

Type of haemostatic defect

Venom-induced consumption coagulopathy (VICC); thrombocytopenia is rarely recorded (Malaque and Gutiérrez 2017, Sano-Martins et al. 2001). 

5Neurological effects

Preparalytic period: 30–60 min (Rosenfeld 1971); 5-10 minutes (Baum et al. 2019).

Descending paralysis including respiratory muscles with secondary respiratory failure. Paralysis of the extremities and disturbance of the respiratory musculature have only been described rarely (differential diagnosis: rhabdomyolysis) (Cupo et al. 1988;Malaque and Gutiérrez 2017; Rosenfeld 1971).

6Muscular effects

Rhabdomyolysis with secondary AKI. Early increase of CK (with 2 hrs of the bite), peaking at around 24 hrs after the bite Very high levels can be reached (Azevedo-Marques et al. 1985, 1987; Cupo et al. 1988, 1990, 2003, Malaque and Gutiérrez 2017)

7Renal effects

After Crotalus snakebite in South America, the most common complication is AKI due to rhabdomyolysis (Azevedo-Marques et al. 1985, 1987; Malaque and Gutiérrez 2017; Pinoh et al. 2005, 2008; Silveira and Nishioka 1992; Warrell 2004, 2023).

Other effects

Cardiac effects

“The enzymatic profile detected, as well as the pattern of focal involvement observed in muscle biopsies obtained from these patients, suggest that there may be a type of skeletal muscle fibre that is preferentially damaged by C. durissus terrificus venom, i.e., type I and/or IIa fibres, the composition of which is richer in CK-MB and LD1, and is similar to that of cardiac fibres” (Cupo et al. 1990).
“Absence of cardiac involvement and the skeletal muscle origin of CK-MB” in patients described by Cupo et al. (2003). 

Clinical management

See also Clinical Management: South America and the West Indies

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

First Aid

Release of any type of tourniquet follow link above.

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care
Necroses: debridement; split-thickness skin grafting
Systemic antibiotics: standard indications
WHO (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 Crotalus durissus ssp. - specific features

see

  • 'Species-specific envenoming pattern above'

Key issues

see footnotes above.

Specific treatment (antivenoms)

Species-specific evidence

Regional differences in symptoms of envenoming due to C. durissus ssp.

In southern Brazil (C. d. terrificus) envenoming is characterised by paralysis, renal failure, a mild local reaction and a high mortality rate (the main component of the venom is crotoxin); adult C. d. durissus do not have much crotoxin, while newborn animals have a lot. The symptoms of envenoming due to C. d. unicolor appear to be somewhere between those of C. d. terrificus and C. d. durissus (Hardy 1992a). 

Crotalus durissus ssp.

Brazil

  • Pinho FM, Zanetta DM, Burdmann EA. Acute renal failure after Crotalus durissus snakebite: a prospective survey on 100 patients. Kidney Int. 2005 Feb;67(2):659-67. PMID: 15673314. https://doi.org/10.1111/j.1523-1755.2005.67122.x
  • Sano-Martins IS, Tomy SC, Campolina D, Dias MB, de Castro SC, de Sousa-e-Silva MC, Amaral CF, Rezende NA, Kamiguti AS, Warrell DA, Theakston RD. Coagulopathy following lethal and non-lethal envenoming of humans by the South American rattlesnake (Crotalus durissus) in Brazil. QJM. 2001 Oct;94(10):551-9. PMID: 11588214. https://doi.org/10.1093/qjmed/94.10.551 

Crotalus durissus cascavella

Brazil

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61. 

Crotalus durissus collilineatus

Brazil

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61. 

Crotalus durissus cumanensis

Venezuela

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61. 

Crotalus durissus durissus

French Guinea

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61. 

Crotalus durissus marajoensis

Brazil

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61. 

Crotalus durissus ruruima

Brazil, Guyana

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61.

Brazil

  • Asato MS, Cruz Carbonell RC, Martins AG, Mendonça de Moraes C, Chávez-Olórtegui C, Apolonia da Costa Gadelha M, Pereira de Oliveira Pardal P. Envenoming by the rattlesnake Crotalus durissus ruruima in the state of roraima, Brazil. Toxicon X. 2020 Oct 22;8:100061. PMID: 33145491; PMCID: PMC7591384. https://doi.org/10.1016/j.toxcx.2020.100061
  • Pucca MB, Bernarde PS, Rocha AM, Viana PF, Farias RES, Cerni FA, Oliveira IS, Ferreira IG, Sandri EA, Sachett J, Wen FH, Sampaio V, Laustsen AH, Sartim MA, Monteiro WM. Crotalus Durissus Ruruima: Current Knowledge on Natural History, Medical Importance, and Clinical Toxinology. Front Immunol. 2021 Jun 8;12:659515. PMID: 34168642; PMCID: PMC8219050. https://doi.org/10.3389/fimmu.2021.659515 

Crotalus durissus terrificus

Brazil

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere.Ithaca: Cornell University Press; 2004. p. 709–61.
  •  Azevedo-Marques MM, Cupo P, Coimbra TM, Hering SE, Rossi MA, Laure CJ.Myonecrosis, myoglobinuria and acute renal failure induced by South American rattlesnake (Crotalus durissus terrificus) envenomation in Brazil. Toxicon. 1985;23(4):631-6. PMID: 4060176. https://doi.org/10.1016/0041-0101(85)90367-8
  • Azevedo-Marques MM, Hering SE, Cupo P. Evidence that Crotalus durissus terrificus (South American rattlesnake) envenomation in humans causes myolysis rather than hemolysis. Toxicon. 1987;25(11):1163-8. PMID: 3124296. https://doi.org/10.1016/0041-0101(87)90134-6
  • Bucaretchi F, De Capitani EM, Branco MM, Fernandes LC, Hyslop S. Coagulopathy as the main systemic manifestation after envenoming by a juvenile South American rattlesnake (Crotalus durissus terrificus): case report. Clin Toxicol (Phila). 2013 Jul;51(6):505-8. Epub 2013 May 28. PMID: 23713821. https://doi.org/10.3109/15563650.2013.802796
  • Cupo P, Azevedo-Marques MM, Hering SE. Clinical and laboratory features of South American rattlesnake (Crotalus durissus terrificus) envenomation in children. Trans R Soc Trop Med Hyg. 1988;82(6):924-9. PMID: 3257000. https://doi.org/10.1016/0035-9203(88)90044-2
  • Cupo P, Azevedo-Marques MM, Hering SE. Acute myocardial infarction-like enzyme profile in human victims of Crotalus durissus terrificus envenoming. Trans R Soc Trop Med Hyg. 1990 May-Jun;84(3):447-51. PMID: 2260185. https://doi.org/10.1016/0035-9203(90)90358-l
  • Cupo P, de Azevedo-Marques MM, Hering SE. Absence of myocardial involvement in children victims of Crotalus durissus terrificus envenoming. Toxicon. 2003 Dec;42(7):741-5. PMID: 14757204. https://doi.org/10.1016/j.toxicon.2003.10.001
  • Silveira PV, Nishioka Sde A. South American rattlesnake bite in a Brazilian teaching hospital. Clinical and epidemiological study of 87 cases, with analysis of factors predictive of renal failure. Trans R Soc Trop Med Hyg. 1992 Sep-Oct;86(5):562-4. PMID: 1475835. https://doi.org/10.1016/0035-9203(92)90114-r 

Crotalus durissus unicolor

Aruba Island

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61. 

Crotalus durissus vecrandis

Venezuela

  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61. 

Envenoming by snakes kept in captivity outside the geographical distribution of Crotalus durissus terrificus

  • Baum RA, Bronner J, Akpunonu PDS, Plott J, Bailey AM, Keyler DE. Crotalus durissus terrificus (viperidae; crotalinae) envenomation: Respiratory failure and treatment with antivipmyn TRI® antivenom. Toxicon. 2019 May;163:32-35. Epub 2019 Mar 14. PMID: 30880190. https://doi.org/10.1016/j.toxicon.2019.03.009
  • Ekenbäck K, Hulting J, Persson H, Wernell I. Unusual neurological symptoms in a case of severe crotalid envenomation. J Toxicol Clin Toxicol. 1985;23(4-6):357-64. PMID: 2997459. https://doi.org/10.3109/15563658508990645

References

Publications reporting broadly on Crotalus durissus ssp. envenoming

Malaque and Gutiérrez (2017); Pinoh et al. (2008); Warrell (2004).

All references

  • Asato MS, Cruz Carbonell RC, Martins AG, Mendonça de Moraes C, Chávez-Olórtegui C, Apolonia da Costa Gadelha M, Pereira de Oliveira Pardal P. Envenoming by the rattlesnake Crotalus durissus ruruima in the state of roraima, Brazil. Toxicon X. 2020 Oct 22;8:100061. PMID: 33145491; PMCID: PMC7591384.https://doi.org/10.1016/j.toxcx.2020.100061
  • Azevedo-Marques MM, Cupo P, Coimbra TM, Hering SE, Rossi MA, Laure CJ.Myonecrosis, myoglobinuria and acute renal failure induced by South American rattlesnake (Crotalus durissus terrificus) envenomation in Brazil. Toxicon. 1985;23(4):631-6. PMID: 4060176.https://doi.org/10.1016/0041-0101(85)90367-8
  • Azevedo-Marques MM, Hering SE, Cupo P. Evidence that Crotalus durissus terrificus (South American rattlesnake) envenomation in humans causes myolysis rather than hemolysis. Toxicon. 987;25(11):1163-8. PMID: 3124296.
  • https://doi.org/10.1016/0041-0101(87)90134-6
  • Bucaretchi F, De Capitani EM, Branco MM, Fernandes LC, Hyslop S. Coagulopathy as the main systemic manifestation after envenoming by a juvenile South American rattlesnake (Crotalus durissus terrificus): case report. Clin Toxicol (Phila). 2013 Jul;51(6):505-8. Epub 2013 May 28. PMID: 23713821.https://doi.org/10.3109/15563650.2013.802796
  • Baum RA, Bronner J, Akpunonu PDS, Plott J, Bailey AM, Keyler DE. Crotalus durissus terrificus (viperidae; crotalinae) envenomation: Respiratory failure and treatment with antivipmyn TRI® antivenom. Toxicon. 2019 May;163:32-35. Epub 2019 Mar 14. PMID: 30880190.https://doi.org/10.1016/j.toxicon.2019.03.009
  • Cupo P, Azevedo-Marques MM, Hering SE. Clinical and laboratory features of South American rattlesnake (Crotalus durissus terrificus) envenomation in children. Trans R Soc Trop Med Hyg. 1988;82(6):924-9. PMID: 3257000.https://doi.org/10.1016/0035-9203(88)90044-2
  • Cupo P, Azevedo-Marques MM, Hering SE. Acute myocardial infarction-like enzyme profile in human victims of Crotalus durissus terrificus envenoming. Trans R Soc Trop Med Hyg. 1990 May-Jun;84(3):447-51. PMID: 2260185.https://doi.org/10.1016/0035-9203(90)90358-l
  • Cupo P, Azevedo-Marques MM, Hering SE. Clinical and laboratory features of South American rattlesnake (Crotalus durissus terrificus) envenomation in children. Trans R Soc Trop Med Hyg. 1988;82(6):924-9. PMID: 3257000.https://doi.org/10.1016/0035-9203(88)90044-2
  • Cupo P, de Azevedo-Marques MM, Hering SE.Absence of myocardial involvement in children victims of Crotalus durissus terrificus envenoming. Toxicon. 2003 Dec;42(7):741-5. PMID: 14757204.https://doi.org/10.1016/j.toxicon.2003.10.001 
  • Ekenbäck K, Hulting J, Persson H, Wernell I. Unusual neurological symptoms in a case of severe crotalid envenomation. J Toxicol Clin Toxicol. 1985;23(4-6):357-64. PMID: 2997459.https://doi.org/10.3109/15563658508990645
  • Hardy, D. L. (1992a) Geogrophical variation in venom and human envenoming of the neotropical rattlesnake (Crotalus durissus). Abstract. American Soc. of Ichthyologists and Herpetologists/ Herpetologists’ League Annual Meeting, June 4-10, 1992, University of Illinois at Urbana / Campaign. Program and Abstracts: 113-114
  • Malaque, C.M., Gutiérrez, J.M. (2017). South and Central American Snakes. In: Brent, J., et al. Critical Care Toxicology. Springer, Cham.https://doi.org/10.1007/978-3-319-17900-1_146
  • Pinho FM, Zanetta DM, Burdmann EA. Acute renal failure after Crotalus durissus snakebite: a prospective survey on 100 patients.Kidney Int. 2005 Feb;67(2):659-67. PMID: 15673314.https://doi.org/10.1111/j.1523-1755.2005.67122.x
  • Pinho FMO, Yu L, Burdmann EA.Snakebite-induced acute kidney injury in Latin America. Semin Nephrol. 2008 Jul;28(4):354-362. PMID: 18620958.https://doi.org/10.1016/j.semnephrol.2008.04.004
  • Pucca MB, Bernarde PS, Rocha AM, Viana PF, Farias RES, Cerni FA, Oliveira IS, Ferreira IG, Sandri EA, Sachett J, Wen FH, Sampaio V, Laustsen AH, Sartim MA, Monteiro WM. Crotalus Durissus Ruruima: Current Knowledge on Natural History, Medical Importance, and Clinical Toxinology. Front Immunol. 2021 Jun 8;12:659515. PMID: 34168642; PMCID: PMC8219050.https://doi.org/10.3389/fimmu.2021.659515
  • Rosenfeld, G. (1971) Symptomatology, Pathology and treatment of snake bites in South America. In Bücherl, W., E. E. Buckley: Venomous animals and their venoms. Vol. 2. Academic Press, New York: 345-384
  • Sano-Martins IS, Tomy SC, Campolina D, Dias MB, de Castro SC, de Sousa-e-Silva MC, Amaral CF, Rezende NA, Kamiguti AS, Warrell DA, Theakston RD. Coagulopathy following lethal and non-lethal envenoming of humans by the South American rattlesnake (Crotalus durissus) in Brazil. QJM. 2001 Oct;94(10):551-9. PMID: 11588214.https://doi.org/10.1093/qjmed/94.10.551
  • Silveira PV, Nishioka Sde A. South American rattlesnake bite in a Brazilian teaching hospital. Clinical and epidemiological study of 87 cases, with analysis of factors predictive of renal failure. Trans R Soc Trop Med Hyg. 1992 Sep-Oct;86(5):562-4. PMID: 1475835.https://doi.org/10.1016/0035-9203(92)90114-r
  • Warrell DA. Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere. Ithaca: Cornell University Press; 2004. p. 709–61.
  • 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.
  • WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured. https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured; 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 (2010) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010.https://www.who.int/publications/i/item/9789241599139
  • WHO Snakebite Information and Data Platform.https://www.who.int/teams/control-of-neglected-tropical-diseases/snakebite-envenoming/snakebite-information-and-data-platform