Clinic
Case reports
C. horridus ssp.
Bismuth et al. 1983: 1 C. horridus ssp. bite; identification: morphological.
C. horridus atricaudatus
Kitchens et al. 1987: 1 C. horridus atricaudatus bite; identification: morphological.
C. horridus horridus
Schmaier et al. 1980: 1 C. h. horridus bite; identification: stated as unequivocal, however no criteria given.
Weaver et al. 1991: 1 C. h. horridus bite; identification: morphological.
Hasiba et al. 1975: 1 C. h. horridus bite; identification: morphological.
Brick and Gutmann 1982: 1 C. h. horridus bite; identification: morphological.
Brick and Gutmann 1988: 6 C. h. horridus bites; identification: morphological 5/6; no details of criteria 1/6.
Brick et al. 1987: 3 C. h. horridus bites; identification: morphological.
Signs & symptoms
Autopharmacological effects
C. horridus atricaudatus
Nausea, vomiting, diarrhoea, loss of consciousness (arterial hypotension) within 5 min after the bite (Kitchens et al. 1987).
C. horridus horridus
Nausea, vomiting, diarrhoea, recurrent episodes of arterial hypotension and tachycardia (Weaver et al. 1991); among other factors increased capillary permeability with fluid sequestration in the extravascular space; see below "Treatment (symptomatic)".
Local effects
C. horridus atricaudatus
Mild local swelling (Kitchens et al. 1987).
C. horridus horridus
Local pain directly after the bite (Brick and Gutmann 1982, Brick et al. 1987, Hasiba et al. 1975). Marked swelling of the extremity in which the bite occurred (Brick and Gutmann 1982, 1988, Brick et al. 1987). In one case the hand swelled to twice its size within 15 min after the bite (Schmaier et al. 1980). Local swelling with ecchymosis (Hasiba et al. 1975, Weaver et al. 1991). Regional lymph nodes painful on palpation (Hasiba et al. 1975).
Haemostatic effects
C. horridus horridus
Gingival bleeding, conjunctival petechiae shortly after the bite, generalised petechiae within 24 h after the bite, large haematoma in the region of the upper eyelid (Hasiba et al. 1975).
Muscular effects
C. horridus horridus
Asynchronous tremor in the fingers of the bitten extremity within minutes after the bite, which persisted for up to 3 days. No intention tremor (6/6) (Brick and Gutmann 1982, 1988, Brick et al. 1987). At the same time as the tremor, paraesthesia in the perioral region and in the region of all 4 extremities (Brick and Gutmann 1982, 1988, Brick et al. 1987). Continuous, wave-like fasciculations in the entire facial region (bilateral facial myokymia) (6/6) (Brick and Gutmann 1982, 1988, Brick et al. 1987).
C. horridus atricaudatus
See Laboratory and physical investigations.
Case fatality rate
C. horridus atricaudatus
1/1 (Kitchens et al. 1987).
Laboratory and physical investigations
1. Haemostasis
Type of haemostatic defect
C. horridus horridus
Defibrin(ogen)ation through fibrinogen-coagulating ("thrombin-like") activity (Bonilla 1975, Schmaier et al. 1980); platelet aggregation (crotalocytin) (Schmaier and Colman 1980, Schmaier et al. 1980); haemorrhagic activity (the pathogenesis of vessel damage due to haemorrhagins was investigated in mice with the help of the haemorrhagic proteinase IV from C. horridus horridus) (Ownby and Geren 1987).
Haemostatic parameters
| Overview haemostasis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
A
|
A
|
C
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
H | CT | (FSP) | Tc | PT | aPTT | TT | I | FSP | D | II | V | VIII | X | XIII | PC | ATIII | PI | tPA | α2AP | |||||||||||||||||||||||||||||||||||||||||||
|
D
|
B
|
E
|
E
|
E
|
E
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Essential bed-side tests |
Tests for full clinical assessment | Tests for research purposes | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| A | aPTT , PT: C. horridus horridus 3 h after the bite, 18 s (control 11 s); approx. 4 h after the bite, aPTT and PT >150 s. Normalised within 24 h (10 ml of Wyeth antivenom, polyvalent, were administered) (Schmaier et al. 1980). |
| B |
Fibrinogen: Afibrinogenaemia over a period of 64 h (despite hourly administration of cryoprecipitate; no antivenom was administered) (Bismuth et al. 1983). C. horridus horridus Approx. 4 h after the bite 0 mg/dl. Normalised within 24 h (10 ml of Wyeth antivenom, polyvalent, were administered) (Schmaier et al. 1980). Approx. 3 h after the bite 64 mg/dl (normal range 150–450 mg/dl) (Weaver et al. 1991). 18 h after the bite 75 mg/dl (the minimum may already have occurred prior to this) (9 vials of Wyeth antivenom, polyvalent, were administered) (Hasiba et al. 1975). |
| C |
FSP: 2,560 μg/ml approx. 4 h after the bite. Normalised within 24 h (10 ml of Wyeth antivenom, polyvalent, were administered) (Schmaier et al. 1980). 160 μg/ml (normal range <40 μg/ml) 10 h after the bite (Weaver et al. 1991). Increased during the first day after the bite, then constant decrease (9 vials of Wyeth antivenom, polyvalent, were administered) (Hasiba et al. 1975). |
| D |
Platelets: 3 h after the bite 24,000/μl; approx. 4 h after the bite 5,000/μl. It took >5 days for the platelet count to return to normal (10 ml of Wyeth antivenom, polyvalent, were administered) (Schmaier et al. 1980). Approx. 3 h after the bite 17,000/μl (Weaver et al. 1991). Low platelet count in 3 patients within 24 h after the bite (11,000/μl, 14,000/μl, 18,000/μl) (Brick et al. 1987). 2,000/μl 18 h after the bite. Increased to 98,000/μl on the 7th day, in the normal range on the 14th day (9 vials of Wyeth antivenom, polyvalent, were administered) (Hasiba et al. 1975). |
| E | Clotting factors: C. horridus horridus Factors II, V, VII, VIII and X were in the normal range (Schmaier et al. 1980). |
2. EMG
C. horridus horridus
Myokymic discharges of the facial musculature, where fasciculations were visible, and of the musculature of the bitten extremity, where fasciculations were generally not visible due to severe swelling. After administration of antivenom and CaClâ‚‚ i.v. (increase in ionised serum calcium), the myokymia disappeared. These findings suggest that the venom has a reversible effect on peripheral nerves and induces myokymia and paraesthesia (Brick and Gutmann 1982, 1988, Brick et al. 1987).
3. Serum creatinine kinase
C. horridus atricaudatus
2,830,000 IU/dl (at autopsy, severe, acute rhabdomyolysis could be clearly distinguished from post mortem autolysis) (Kitchens et al. 1987).
4. Acute renal failure
C. horridus atricaudatus
Acute renal failure developed secondary to arterial hypotension and/or rhabdomyolysis (Kitchens et al. 1987).
Treatment (symptomatic)
Rapid restoration of normal blood pressure values after replacement of large volumes of fluids i.v. (Weaver et al. 1991).
Treatment (specific)
Antivenoms
1. Crotalidae Polyvalent Immune Fab Antivenom, ovine (immunized with Crotalus adamanteus, Crotalus atrox, Crotaus scutulatus ssp. and Agkistrodon piscivorus) / CroFab™, Savage Laboratories, Melville, New York
see Crotalus sp.
2. Wyeth antivenom (Crotalidae), polyvalent, Philadelphia, USA (no longer in use)
Efficacy
- With regard to the haemostatic effects of the venom:
C. horridus horridus
There are no controlled clinical studies. According to experience from the treatment of individual cases, coagulability improves with antivenom treatment (Weaver et al. 1991). In vitro, the antivenom blocks platelet aggregation (Hasiba et al. 1975, Schmaier et al. 1980). - With regard to the neurological effects of the venom: the facial fasciculations (myokymia) disappeared within hours after antivenom administration. The myokymia in the region of the bitten extremity persisted until the day after the bite in 3 patients. This suggests that biochemical rather than structural changes were the reason for altered nerve excitability (Brick et al. 1987).
Adverse reactions
Itching, erythema, generalised limb pain, fever (39.3°C) on the 6th day after antivenom treatment (12 vials of antivenom were administered) (Weaver et al. 1991).