Case reports

Dendroaspis viridis
Casale and Patel 1974.
Guinea: Lefrou 1951.
Nigeria: Gray 1962.
Côte d'Ivoire: Chippaux et al. 1977.

Dendroaspis jamesoni
Central African Republic: Le Gac and Lepesme 1940.

Dendroaspis angusticeps
South Africa: Visser and Chapman 1978.

Dendroaspis polylepis
Zimbabwe: Blaylock 1982a, Saunders 1980.
Transvaal: Crisp 1985, Krengel and Walton 1967, Louw 1967.
Swaziland: Hilligan 1987.
South Africa: Visser and Chapman 1978 (10 cases, of which 5 were fatalities).

Signs & symptoms

Local effects

Local pain. Minor (erythema, mild oedema) or no local findings (Chippaux et al. 1977, Hilligan 1987, Krengel and Walton 1967).

Neurological effects

Cranial nerve deficits (ptosis, dysarthria, dysphagia), paralysis of the musculature of the extremities and the respiratory musculature (Casale and Patel 1974, Chippaux et al. 1977, Crisp 1985, Gray 1962, Krengel and Walton 1967, Lefrou 1951, Le Gac and Lepesme 1940, Louw 1967, Visser and Chapman 1978).
Muscle fasciculations, muscle spasms (Bodio and Junghanss 1993, pers. comm., Chippaux et al. 1977, Krengel and Walton 1967, Visser and Chapman 1978, Blaylock 1982).

Other signs & symptoms

Vomiting, sweating, tachycardia, arterial hypotension, shock (Hilligan 1987); neither of the 2 patients had neurological (somatic) deficits! Spasmodic epigastric pain (Gray 1962, Chippaux et al. 1977, Krengel and Walton 1967, Visser and Chapman 1978).

Case fatality rate

Mortality high in the absence of medical care if significant amounts of venom have been injected (respiratory failure). Fatalities (Gray 1962, Strover 1967, Visser and Chapman 1978: report of 5 fatalities: 4/5 died within 3–8 h). 

Morbidity

If the victim survives the acute phase, there are generally no sequelae.

First aid

Compression-immobilisation method. As one of the few exceptions, arterial stasis is warranted in the case of mamba bites. Neurological effects, which appear quickly and progress rapidly, can lead to death within a short time (Hilligan 1987, Visser and Chapman 1978).

Treatment (symptomatic)

Endotracheal intubation and artificial respiration (Visser and Chapman 1978).

Treatment (specific)

Antivenin

Polyvalent antivenom (SAIMR, Johannesburg).

Efficacy

Improvement of signs of paralysis as a direct result of the administration of antivenom (Visser and Chapman 1978).
Improvement of shock symptoms as a direct result of the administration of antivenom; the first dose of antivenom was administered within 50 min after the bite. There were no signs of paralysis (Hilligan 1987).
Reduction in the fatality rate for D. polylepis bites from 42 to 15%. In 1/2 cases the antivenom was given within 1 hour, and in 3/4 cases within 3 hours (Christensen 1980).

Dose
70 ml of polyvalent antivenom (SAIMR, Johannesburg) (Hilligan 1987).

Evaluation and recommendations
As far as can be judged from the few case reports, the efficacy of the antivenom depends on the time point of administration, among other things. Antivenom should thus be given as early as possible.  Initial dose: 20–40 ml. Maximum dose: 60–80(–200 ml) (Hilligan 1987). However, it does seem that a relapse of neurological signs and symptoms can also occur (Blaylock 1985). Administration of the specific antivenom reduces mortality due to D. polylepis bites from 42 to 15% (Christensen 1980).