Table 1.
Summary of the items recorded from the 35 papers included in the retrospective study.
| References | Country | Victim Age/Sex |
Work-Related | Hospital Admission / Antivenom |
Time Interval Bite-Death | Snake Family |
Bite Area Site Macroscopical Findings |
Bite Area Histological Findings |
Autopsy Macroscopical Findings |
Autopsy Histological Pattern |
|---|---|---|---|---|---|---|---|---|---|---|
| Barraviera B et al., 1989 [11] | Brazil | 60/M | n.a. | Yes/Yes | 4–5 d | Rattlesnake Viperidae |
Right leg. Ulceration covered with a blood-stained scab. |
Local edema and inflammatory signs. Focal myonecrosis. | n.a. | K: acute tubular necrosis |
| Barraviera B et al.,1989 [11] | Brazil | 59/M | n.a. | Yes/Yes | 5 d | Rattlesnake Viperidae |
Right leg. Two punctiform erythematous lesions. |
No signs of inflammation. | n.a. | Li: parenchymal necrosis. |
| Benvenuti LA et al., 2003 [12] | Brazil | 36/F | n.a. | Yes; No | 45 min | Bothrops jararacussu Viperidae |
Left ankle. Two puncture wounds 25 mm apart. Ecchymosis on the left leg along the great saphenous vein. |
Local hemorrhage, thrombosis, and coagulative necrosis of the subcutaneous and muscular tissue. | L: hemorrhage. | PG: normal. H: fibrosis and interstitial hemorrhage. L: extensive alveolar hemorrhage and edema with numerous platelet thrombi in capillaries and venules. DIC. |
| Blaylock RSM et al., 2002 [13] | South Africa | 40/M | Yes | Yes; Yes | 1 h 15 min | Puff Adder (Bitis Arientas) Viperidae |
Left wrist. Single puncture wound. |
Extensive hemorrhage between muscle bundles and connective tissue. | H: myocardium soft and flabby with hemorrhagic RA. L: edema and congestion. Li; K: pale aspect. |
n.a. |
| Blumenthal R et al., 2019 [14] | South Africa | 27/M | Yes | Yes; Yes | 3 d | Black Mamba (Dendroaspis polylepis) Elapidae |
Right hand. Single puncture mark. |
Subcutaneous hemorrhage. Minimal skin necrosis and hemorrhage at the puncture site. |
Diffuse fresh hemorrhages around the vocal cords, the epiglottis, and in the LV. H: petechiae overlying the anterior and posterior epicardial. |
B: hypoxic-ischemic encephalopathy. H: diffuse hemorrhages. L: fibrinosuppurative consolidation. |
| Chen L et al., 2013 [15] | China | 43/M | n.a. | Yes (at the end); n.a. | 5 d | Agkistrodom halysViperidae | Right foot. 0.3 cm-long laceration made of two pairs of thin stripes. Right foot swollen and ecchymotic. |
Subcutaneous hemorrhage and cellulitis. | Diffuse edema and congestion. | K: Toxic nephropathy, proximal tubular epithelial degeneration, and necrosis, protein and pigment cast in the distal tubules. |
| Chen L et al., 2013 [15] | China | 4/M | n.a. | Yes; n.a. | 2 d | Agkistrodom halysViperidae | Right foot. 1.2 × 0.5 cm snakebite wound. |
n.a. | Diffuse edema and congestion.S: anemic aspect. | B, T, K: congestion. H, L: edema and congestion. |
| Curry SC et al., 1985 [16] | USA | 44/F | No | Yes; Yes | 15 d | Rattlesnake Viperidae |
Right calf. Two fang marks surrounded by an area of discoloration. |
Area of tissue disruption leading toward a vein. Small eschar over the site of fang penetration through epidermidis. | B, Li, S: enlarged and congested. H: lightly dilated and flabby; superficial hemorrhages. L: expanded and indurated. |
B: focal hemorrhages in the leptomeninges. L: severe ARDS. K: eosinophilic proteinaceous casts in small tubules. |
| Karlawad M et al., 2017 [17] | India | 75/M | Yes | Yes; Yes | 3 h | n.a. | Scrotum. Two punctured wounds surrounded by an area of discoloration. |
Ulcerated stratified squamous epithelium with sub-epithelial tissue showing congested blood vessels and edema. | Diffuse congestion. | L: interstitial and intra-alveolar edema with rupture of alveoli. H: unremarkable. |
| Keith J et al., 2012 [18] | Australia | 69/F | No | Yes; Yes | 2 d | Australian Brown Snake (Pseudonaja textilis) Elapidae |
Foot. | n.a. | B: swollen with tonsillar herniation and V-shaped hemorrhage within the cerebellum. | Unremarkable. |
| Kitchens CS et al., 1987 [19] | USA | 67/M | No | Yes; Yes | 2 d 12 h | Canebrake Rattlesnake (Crotalus Horridus Atricaudatus) Viperidae |
Left Hand. Two puncture wounds. |
Rhabdomyolysis. The left thenar muscle disclosed a sparse infiltration of PMNs. | M: soft consistency underlying the bite. | H: patchy myocardial necrosis. L: hemorrhagic pulmonary edema; small scattered pulmonary thrombi consistent with terminal DIC. K: massive acute tubular necrosis. M: rhabdomyolysis of the skeletal muscles. |
| Malbranque S et al., 2008 [20] | Martinique |
74/M |
Yes | Yes; Yes | 10 d | Fer-de-Lance (Bothrops lanceolatus) Viperidae | Left elbow. Fang puncture marks 20 mm apart surrounded by a swollen area. |
n.a. | Serous effusions in the peritoneal, pericardial, and pleural cavities. B: edema with petechiae. H: infarcts of different ages and sizes. L: edematous and congested. |
B: ischemic changes; thrombotic lesions were confined to the sub-arachnoid space. H: Fibrinous pericarditis and scattered ischemic foci in the LV. L: thrombotic lesion within the small pulmonary arteries and the capillaries of the inter-alveolar septa. K: thrombotic lesion within the small renal inter-lobular vessels and, to a localized extent. I: thrombotic lesion in the small intestine and colon. |
| Malhotra P et al., 2005 [21] | India | 27/F | n.a. | Yes; Yes | n.a. | n.a. | Left foot. Fang marks. |
n.a. | Unremarkable. | B: extensive perivascular demyelination and limphocyte cuffing. K: acute tubular necrosis. |
| Marsh N, et al., 2007 [22] | USA (captivity) |
33/F | No | No; No | n.a. | Gaboon viper (Bitis gabonica) Viperidae | Left hand. Two puncture wounds 11–12 mm apart surrounded by a swollen and bloody area. |
n.a. | Ecchymoses of the head, trunk and extremities, the periorbital areas, and left orolaryngeal/mandibular angle. L: hemorrhagic appearance and congestion. |
n.a. |
| McGarity BH et al., 1991 [23] | Australia | 40/M | n.a. | Yes; Yes | 2 d | Tiger snake (Notechis scutatus) Elapidae | Left heel. | n.a. | B: edematous; right tentorial and subfalcial herniation; massive right intracerebral hemorrhage, with rupture into the right basal ganglia and cerebellum. | n.a. |
| Milani R Jr et al., 1997 [24] | Brazil | 3/F | No | Yes; Yes | 18 h 40 min | Jararacuçu (Bothrops jararacussu) Viperidae | Left thigh. Three widely spaced fang puncture marks. |
Extensive rhabdomyolysis with hemorrhagic foci. Hemorrhage and necrosis in the dermis and hemorrhage in subcutaneous fat near the site. | B: edema. | L: hemorrhages with inflammatory infiltration of neutrophils in septa and alveoli and deposition of intra-alveolar fibrin. Li: hepatic sinusoids and portal tracts infiltrated with PMNs. P: fatty necrosis with hemorrhage of the parenchymal cells. |
| Milani R Jr et al., 1997 [24] | Brazil | 65/M | n.a. | Yes; Yes | 4 d 9 h | Jararacuçu (Bothrops jararacussu) Viperidae | Left calf. Two fang punctures surrounded by a ring of bruising. |
Necrosis of muscle fibers and interstitial hemorrhage in the region of the wound. | B: subarachnoid petechiae and edema. | B: ischemic necrosis of the mucosa and in small cortical and meningeal vessels with local meningeal hemorrhage and cerebral edema. Li: fatty (alcoholic) liver with evidence of shock. I: fibrin thrombi in small sub-mucosal vessels. AG: focal hemorrhages in the medulla, with depletion of the zona fasciculata. K: acute tubular necrosis DIC. |
| Moar JJ et al., 2016 [25] | South Africa | 23/M | Yes | Yes; No | Several hours | Rinkhal (Hemachatus haemachatus) Elapidae | Right forearm. Two bite marks each 3 mm in diameter and 1.5 cm apart. |
Displaced and disrupted fragments of adnexal structures into the depths of the wound, together with hemorrhaging into the surrounding interstitium, and compression of the collagen bundles of the dermis with collagen displacement and disruption. | B, L: edema and petechial hemorrhages. | B: Extravasation of erythrocytes into the surrounding Virchow–Robin spaces. H: in LV marked interstitial vascular dilatation and congestion with focal subendocardial papillary muscle fibrosis. L: ARDS. Li: portal vessels congestion and widening by reticulin and a portal triaditis. S: sinusoidal dilatation and congestion; mantle zone hyperplasia. K: interstitial vascular and glomerular capillary loop dilatation and congestion with a chronic inflammatory cell infiltrate. |
| Namal Rathnayaka RMMK et al., 2018 [26] | Sri Lanka | 42/M | Yes | Yes; No | 16 d | Hump nose Viper (Hypnale Hypnale) Viperidae |
Right foot. | n.a. | B: a small infarct (1.5 cm–1 cm) in the basal ganglia. H: reduced lumen of the left coronary artery. |
L: hemorrhages. K: acute tubular necrosis. H: normal. |
| Namal Rathnayaka RMMK et al., 2019 [27] | Sri Lanka | 66/M | No | Yes; No | 4 d | Hump nose Viper (Hypnale Hypnale) Viperidae |
Left foot. Two fang punctures. |
n.a. | B, H, L: hemorrhages. | L: edema and hemorrhage. |
| Namal Rathnayaka RMMK et al., 2017 [28] | Sri Lanka | 43/M | No | Yes; Yes | 11 d | Russell’s viper (Daboia russelii) Viperidae | Right foot. Swelling of the leg. |
n.a. | B: infarcted area of parietal lobes. K: petechial hemorrhages. |
B: hemorrhages, thrombi, and congested blood vessels. H, L, K: normal. |
| Norris RL et al., 2009 [29] | USA | 38/M | No | No; No | 2 h | Coral snake (Micrurus fulvius) Elapidae | Right Hand; Left Arm. Fresh 6 mm linear abrasion and multiple punctuate abrasions in a small group. |
n.a. | L: congestion. | Unremarkable. |
| Okamoto O et al., 2017 [30] | Japan | 84/F | Yes | Yes; Yes | 35 d | Mamushi (Gloydius Blomhoffii) Viperidae | Right elbow. | n.a. | Li: acute necrosis. I: extensive patchy necrosis at the small intestine; multiple ulcers and bleeding at the ascending colon. K: cortical necrosis. |
Li: necrosis around the central vein. I: necrosis extended to the muscle layer. K: glomerular necrosis. |
| Paulis MG et al., 2016 [31] | Egypt | 9/F | No | No; Yes | n.a. | Egyptian Cobra (Naja Haje) Elapidae | Right leg. Five pairs of fang marks with almost fixed distance between the paired ones, all surrounded by erythema and little swelling. |
n.a. | Internal organ congestion. | n.a. |
| Paulis MG et al., 2016 [31] | Egypt | 6/F | No | No; No. | n.a. | Egyptian Cobra (Naja Haje) Elapidae | Left leg. Two pairs of fang marks, each pair was symmetrical, all surrounded by erythema and little swelling. |
n.a. | Internal organ congestion. | n.a. |
| Paulis MG et al., 2016 [31] | Egypt | 4/F | No | No; No. | n.a. | Egyptian Cobra (Naja Haje) Elapidae |
Right leg. Multiple fang marks close to each other surrounded by erythema. |
n.a. | Internal organ congestion. | n.a. |
| Pramod Kumar GN et al., 2013 [32] | India | 68/M | n.a. | Yes; n.a. | 4 d | n.a. | Right thigh. Bluish black discoloration of the outer aspect of the right thigh and of the right leg. Multiple blisters and ulcerative necrosis. Extravasation of blood in the subcutaneous plane. |
n.a. | Unremarkable (coexistence of gastric and kidney cancers). | n.a. |
| Quain, 1852 [33] | England (captivity) |
30/M | Yes | Yes: No. | 1 h 30 min | Hooded Snake - Cobra de Capello (Naja tripudians) Elapidae | Face. Three puncture marks surrounded by an ecchymotic area. |
n.a. | Congestion of all internal organs, particularly of the spleen. | n.a. |
| Rathnayaka RMMKN et al., 2017 [34] | Sri Lanka | 53/M | n.a. | Yes; Yes | 26 d | Russell’s viper (Daboia russelii) Viperidae | Right Leg. Swollen area. |
n.a. | B: infarcted area of parietal lobes of the brain. K: reduced cortico-medullary demarcation in both kidneys and petechial hemorrhages. |
n.a. |
| Sarkar N et al., 2018 [3] | India | 27/M | No | No; No. | almost 6 h | Banded Krait (Bungarus faciatus) Elapidae | Hand. Two pin-point punctured wounds, subcutaneous deep, placed 8 mm apart. |
n.a. | Internal organ congestion K: bilateral cortico-medullary hemorrhage and congestion. |
K: interstitial hemorrhage; inflammatory cell infiltration and swelling. |
| Sarkar N et al., 2018 [3] | India | 26/F | No | No; No | almost 6 h | Banded Krait (Bungarus faciatus) Elapidae | Right shoulder. Two pin-point punctured wounds. |
n.a. | Internal organ congestion K: bilateral cortico-medullary hemorrhage and congestion. |
K: interstitial hemorrhage and inflammatory cell infiltration. |
| Sarkar N et al., 2018 [3] | India | 4/F | No | No; No | almost 6 h | Banded Krait (Bungarus faciatus) Elapidae | Right foot. | n.a. | Internal organ congestion. K: bilateral cortico-medullary hemorrhage and congestion. |
K: increased cytoplasmatic eosinophilia and occasional surface blebbing of the renal tubular epithelial cell (early ischemic injury). |
| Silva A et al., 2013 [35] | Sri Lanka | 19/M | No | Yes; Yes | 1 d 22 h | Indian Krait (Bungarus caeruleus) Elapidae | n.a. | n.a. |
H, L, K: Petechial hemorrhages and edema. | n.a. |
| Silva de Oliveira S et al., 2017 [36] | Brazil | 59/F | No | Yes; Yes | 2 d | Jaracaca do Norte (Bothrops atrox) Viperidae | Right foot. Ecchymotic and swollen area. |
n.a. | B: Subarachnoid and intraparenchymal hemorrhage. | n.a. |
| Soe S et al.,1993 [37] | Myanmar | 13/M | n.a. | n.a.; n.a. | n.a. | Russell’s Viper (Vipera Russelli) Viperidae |
n.a. | n.a. | n.a. | K: Glomerular changes: endothelial swelling, increased cells; degeneration and necrosis of the tubules, and fibrin deposition. |
| Soe S et al.,1993 [37] | Myanmar | 15/F | n.a. | n.a.; n.a. | n.a. | Russell’s Viper (Vipera Russelli) Viperidae |
n.a. | n.a. | n.a. | K: Glomerular changes: endothelial swelling, increased cells; degeneration and necrosis of the tubules, and fibrin deposition. |
| Soe S et al.,1993 [37] | Myanmar | 15/F | n.a. | n.a.; n.a. | n.a. | Russell’s Viper (Vipera Russelli) Viperidae |
n.a. | n.a. | n.a. | K: Glomerular changes: endothelial swelling, increased cells; degeneration and necrosis of the tubules, and fibrin deposition. |
| Soe S et al.,1993 [37] | Myanmar | 49/M | n.a. | n.a.; n.a. | n.a. | Russell’s Viper (Vipera Russelli) Viperidae |
n.a. | n.a. |
n.a. | K: Glomerular changes: endothelial swelling, increased cells; degeneration and necrosis of the tubules, and fibrin deposition |
| Sutherland SK, 1992 [38] | Australia | 16/F | No | Yes; n.a. | 1 h | Brown snake (Pseudonaja Textilis) Elapidae | Right heel. Fang marks 5 mm apart. |
n.a. | Unremarkable. | n.a. |
| Sutherland SK, 1992 [38] | Australia | 27/F | n.a. | Yes; n.a. | 1 h 30 min | Brown snake Elapidae | n.a. | n.a. | Unremarkable. | n.a. |
| Sutherland SK, 1992 [38] | Australia | 61/F | NO | Yes; No | 1 h 30 min | Brown snake Elapidae | Right ankle. |
n.a. | Small retroperitoneal hemorrhage. | n.a. |
| Sutherland SK, 1992 [38] | Australia | 51/M | n.a. | Yes; Yes | 1 h | Taipan Elapidae |
n.a. | n.a. | Unremarkable. | n.a. |
| Sutherland SK, 1992 [38] | Australia | 2/F | No | No; No | n.a. | Brown snake Elapidae | Left leg. Two minute puncture wounds. |
n.a. | L: congestion and edema with numerous petechial hemorrhages on the visceral pleurae. | n.a. |
| Sutherland SK, 1992 [38] | Australia | 42/M | No | Yes; Yes | 5 h 30 min | Taipan Elapidae |
n.a. | n.a. | Unremarkable. | n.a. |
| Sutherland SK, 1992 [38] | Australia | 60/M | Yes | Yes; Yes | 25 min | Brown snake Elapidae | Right Foot. |
n.a. | Unremarkable. | n.a. |
| Sutherland SK, 1992 [38] | Australia | 35/M | No | No; No | 35 min | Brown snake (Pseudonaja Textilis) Elapidae | Right hand. | n.a. | H: Coronary arteries disease. Li: cirrhosis. |
n.a. |
| Sutherland SK, 1992 [38] | Australia | 48/F | No | No; No | 30 min | n.a. | Right Foot. Two tiny puncture wounds. |
n.a. | n.a. | Quantities of venom in urine that reacted to tiger snake venom. |
| Than-Than et al., 1989 [39] | Myanmar | 19/M | Yes | Yes (at the end); Yes | 14 h | Russell’s Viper (Vipera Russelli Siamensis) Viperidae |
Ankle. bruising area. |
n.a. | L: petechial hemorrhages. | PG: marked acute congestion. L: intraseptal capillaries were congested and contained fibrin thrombi as did some of the large pulmonary vessels, erythrocytes in the alveoli but no definite hemorrhage. S: red pulp congested with pseudoamyloid change in the central arterioles of some of the malpighian corpuscles. Li: congested with some nonspecific inflammatory cells. K: the glomerular tufts were congested and some contained fibrin thrombi; early tubular necrosis. B, H, AG: normal. |
| Than-Than et al., 1989 [39] | Myanmar | 17/M | Yes | Yes (at the end); Yes | 1 d 12 h | Russell’s Viper (Vipera Russelli Siamensis) Viperidae |
Foot. | Hemorrhage, necrosis, and the presence of fibrin thrombi in small vessels. Subcutaneous fibrofatty tissue heavily infiltrated by a mixture of PMNs, leucocytes, lymphocytes, and eosinophils. Dense acidophilic homogeneous fibrin-like material in the surrounding blood vessels. | Serous fluid in the pleural and peritoneal cavities. B: edema. PG, AG: diffusely hemorrhagic. H, L: petechial hemorrhages. K: demarcation between dark red medulla and pale cortex. |
PG: congestion and hemorrhage with foci of fibrinous material. H: numerous focal hemorrhages on the epicardial and endocardial surfaces. L: intense capillary wall congestion. AG: patchy congestion and focal hemorrhages. K: glomerular congestion; marked congestion of the medulla and corticomedullary junction with interstitial hemorrhages; early tubular necrosis. |
| Than-Than et al., 1989 [39] | Myanmar | 15/F | Yes | Yes; Yes | 2 d 4 h | Russell’s Viper (Vipera Russelli Siamensis) Viperidae |
Foot. | n.a. | B: edematous and congested. Large blood clot (5 × 12 mm) in the pituitary fossa. PG: dark grey in color and hemorrhagic parenchyma. L, H, St: subserosal hemorrhage. AG: hemorrhagic. K: Blood clots in the pelvises. Contrasting red medulla and pale cortex. |
B: edematous with dilatation of perineuronal and Virchow-Robin spaces. PG: extensive areas of hemorrhage and intense congestion of the sinusoids. L: acute alveolar wall congestion without hemorrhage, fibrin thrombi or edema. S: expansion of the red pulp. K: glomerular congestion with slight increase in cellularity. Early tubular necrosis. |
| Tibballs J et al., 1991 [40] | Australia | 11/M | No | Yes; Yes | Less than 1 d | Tiger snake (Notechis scutatus) Elapidae | Left wrist. | n.a. | B: multiple intracerebral hemorrhages and subarachnoid collections of blood. | n.a. |
| Tilbury CR et al., 2016 [41] | Congo | 46/M | Yes | Yes; Yes | 2 h 20 min | Burrowing Asps (Atractaspis corpulenta) Lamprophiidae | Left hand. Punctuation-shaped wound (!), 2.5 mm in length surrounded by a non-specified rash. |
Disruption of the epidermal and dermal tissue layers, with associated fresh hemorrhage. | Diffuse congestion of the organs. H: flabby. L: edematous and congested. |
H: acute ischemic changes, foci of contraction band necrosis with no accompanying inflammatory response. L: prominent pulmonary edema and severe pulmonary congestion. |
| Tranca S et al., 2016 [42] | Romania | 56/M | n.a. | Yes; Yes | n.a. | Vipera Berus Viperidae | Right tight. Two puncture wounds surrounded by a purpuric area. |
Diffuse epidermal necrosis associated with micro-hemorrhages and micro-thrombosis in the dermis and hypodermis. | H, L: edema. | B: edema and hemorrhagic lesions in the leptomeninges. H: myocardial fibrosis, epicardial and interstitial hemorrhages. L: atelectasia and pulmonary hemorrhagic edema. Li: diffuse hepatic necrosis. I: enteral necrosis and acute mucosal hemorrhages. K: acute tubular necrosis. |
| Varagunam T et al., 1970 [43] | Sri Lanka | 30/M | Yes | Yes; No | 11 d | Pit-Viper (Agkistrodom hypnale) Viperidae | Left hand. Scars of two fang marks. |
n.a. | K: larger, external surface was smooth with many areas of necrosis or hemorrhage; necrotic areas confined to the cortices; the medullae were congested. H, L, Li, S, I, AG: normal. |
Li: early fatty changes. K: irregular areas of coagulative necrosis in the cortices; both glomeruli and tubules were involved in the necrotic process; Necrosis in many intralobular arteries and arterioles. |
| Wankhede AG, 2004 [44] | India | 25/M | Yes | Yes, n.a. | 1 d | Russell’s Viper (Vipera Russelli Siamensis) Viperidae | Right ankle. Two puncture wounds of diameter 1.5 mm each and 2.3 cm apart and puncture lacerated wounds one 7 mm below the lateral puncture wound, 1.5 cm in length, and the second 1.6 cm below the medial puncture wound 6 mm in length. |
n.a. | B: petechial hemorrhages, congestion and edema. L: congestion and edema. |
Unremarkable. |
| Warrell DA et al., 1976 [45] | Nigeria | 10/M | No | No; No | 2 h | Egyptian Cobra (Naja Haje) Elapidae | Right hand. Two fang punctures 2 cm apart, surrounded by a swollen area. |
n.a. | Unremarkable. | B, H: normal. |
AG: adrenal glands; ARDS: acute respiratory distress syndrome; B: brain; DIC: disseminated intravascular coagulation; H: heart; I: intestine; K: kidneys; L: lungs; Li: Liver; LV: left ventricle; M: muscle; n.a.: not available; P: pancreas; PG: pituitary gland; PMNs: polymorphonuclear leukocytes; RA: right atrium; S: spleen; St: stomach; T: thymus.