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  5. Clinical entry: Walterinnesia sp.

Clinic: Walterinnesia sp.

Examine for venom effects

Local Effects

Bite site

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

Neurological effects

  • Descending flaccid paralysis (rarely progresses to involve bulbar and respiratory muscles):
    • 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.  

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 effects1 Neurological effects2
Walterinnesia sp.    

Other signs & symptoms 

  • Nausea, vomiting (Yayon 1988).
  • Systemic symptoms within 15 min of the bite which included impaired consciousness, diaphoresis, involuntary movements, and later respiratory distress requiring assisted ventilation for 9 days (Abu Baker et al. 2022).

1 Local Effects

  • Local pain, local swelling (Yayon 1988).
  • Local necrosis (Abu Baker et al. 2022).

2 Neurological effects

  • Signs of paralysis (Corkill 1932).
  • "The close phylogenetic relationship between Walterinnesia and Aspidelaps (Pyron et al., 2013) suggests that envenoming by Walterinnesia might result in classical descending post-synaptic paralysis reported after A. lubricus and A. scutatus bites" (Amr et al. 2020). 

Clinical management

First Aid

Local treatment

Bite site

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

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.

ABCDE approach

WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured

Guidelines for the Prevention and Clinical Management of snakebite in Africa

National Snakebite Management Guidelines (2021) WHO Eswatini, Eswatini Antivenom Foundation

Eswatini Antivenom Foundation 

Obey Walterinnesia sp. - specific features

see 'Species-specific envenoming pattern above'.

Key issues:

  • Respiratory failure.

Specific treatment (antivenoms)

WHO Snakebite Information and Data Platform

Guidelines for the Prevention and Clinical Management of snakebite in Africa

References

  • 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 (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

Walterinnesia sp.

Iraq

  • Corkill (1932)
    W. aegyptia (= new: W. morgani), no conclusive identification.

Israel

  • Yayon (1988)
    4 patients; unequivocal identification of W. aegyptia.

 Jordan 

  • Abu Baker et al. (2022)
    1 patient; identification: black snake; review of the literature.

References

  • Abu Baker MA, Al-Saraireh M, Amr Z, Amr SS, Warrell DA.Snakebites in Jordan: A clinical and epidemiological study. Toxicon. 2022 Mar;208:18-30. Epub 2022 Jan 10. PMID: 35026216. https://doi.org/10.1016/j.toxicon.2022.01.005
  • Amr ZS, Abu Baker MA, Warrell DA.Terrestrial venomous snakes and snakebites in the Arab countries of the Middle East. Toxicon. 2020 Apr 15;177:1-15. Epub 2020 Jan 27. PMID: 32001320. https://doi.org/10.1016/j.toxicon.2020.01.012
  • Corkill, N. L. (1932) An inquiry into snake-bite in Iraq. Ind. J. med. Res. 20: 599-625, 679-696
  • Yayon, E., E. Sikular, A. Keynan (1988) Desert black snake (Walterinnesia aegyptia) bites-a presentation of four cases. Harefuah 115: 269-270