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Extending knowledge of the clinical picture of Balkan adder (Vipera berus bosniensis) envenoming: The first photographically-documented neurotoxic case from South-Western Hungary.
Toxicon. 2018 Mar 01; 143:29-35.T

Abstract

We report a severe envenoming associated with minimal local symptoms following a Balkan adder (Vipera berus bosniensis) bite in South-Western Hungary. A 63-year-old male with a history of hypertension and sinus bradycardia (45/min) was bitten by a sub-adult specimen of V. b. bosniensis in Somogy County on 04 May 2017. The patient was transported to and treated at the Emergency Department of "Moritz Kaposi" General Hospital, Kaposvár. Locally only pain and minimal swelling with a small haematoma developed on the bitten finger. The abdominal muscles were very tender and guarding was detected upon palpation on the way to hospital. The patient, who had taken his telmisartan (80 mg) tablet in that morning, complained of nausea and dizziness during the first medical examination. The systemic signs included fluctuations in blood pressure (115/85-165/105 mmHg), ECG changes (transient horizontal ST depression in V5-6, and sinus tachycardia (90/min)), severe diarrhoea and vomiting (in 7 episodes). Descending neuromuscular paralysis appeared in the next morning, including complete bilateral ptosis with external ophthalmoplegia, and binocular diplopia. Single-fiber electromyography confirmed the neuromuscular block in the frontalis muscle innervated by the facial nerve. Intense dizziness with uncoordinated movement emerged on the 3rd day. The laboratory findings were mild, including anaemia, hypokalaemia, elevated glutamic-pyruvic transaminase and C-reactive protein levels. The absolute neutrophil count remained almost completely normal. Supportive care and monovalent antivenom (Viper Venom Antitoxin®, Biomed, Warsaw) were applied. The patient was discharged from hospital on the 4th day, although recovery was not complete until 9 days after the bite. This is the first photographically-documented case of neurotoxic envenoming from the South-Western Hungarian distribution range of V. b. bosniensis.

Authors+Show Affiliations

"Moritz Kaposi" General Hospital, Department of Emergency Medicine, Tallián Gyula u. 20-32, H-7400 Kaposvár, Hungary; University of Pécs, Faculty of Health Sciences, Doctoral School of Health Sciences, Vörösmarty u. 4, H-7621 Pécs, Hungary.Pfizer Hungary Ltd., Medical Division, Alkotás u. 53, H-1123 Budapest, Hungary. Electronic address: tamas.malina80@gmail.com."Moritz Kaposi" General Hospital, Department of Neurology, Tallián Gyula u. 20-32, H-7400 Kaposvár, Hungary."Moritz Kaposi" General Hospital, Department of Emergency Medicine, Tallián Gyula u. 20-32, H-7400 Kaposvár, Hungary."Moritz Kaposi" General Hospital, Department of Neurology, Tallián Gyula u. 20-32, H-7400 Kaposvár, Hungary."Moritz Kaposi" General Hospital, Department of Surgery, Tallián Gyula u. 20-32, H-7400 Kaposvár, Hungary.

Pub Type(s)

Case Reports
Journal Article

Language

eng

PubMed ID

29305081

Citation

Varga, Csaba, et al. "Extending Knowledge of the Clinical Picture of Balkan Adder (Vipera Berus Bosniensis) Envenoming: the First Photographically-documented Neurotoxic Case From South-Western Hungary." Toxicon : Official Journal of the International Society On Toxinology, vol. 143, 2018, pp. 29-35.
Varga C, Malina T, Alföldi V, et al. Extending knowledge of the clinical picture of Balkan adder (Vipera berus bosniensis) envenoming: The first photographically-documented neurotoxic case from South-Western Hungary. Toxicon. 2018;143:29-35.
Varga, C., Malina, T., Alföldi, V., Bilics, G., Nagy, F., & Oláh, T. (2018). Extending knowledge of the clinical picture of Balkan adder (Vipera berus bosniensis) envenoming: The first photographically-documented neurotoxic case from South-Western Hungary. Toxicon : Official Journal of the International Society On Toxinology, 143, 29-35. https://doi.org/10.1016/j.toxicon.2017.12.053
Varga C, et al. Extending Knowledge of the Clinical Picture of Balkan Adder (Vipera Berus Bosniensis) Envenoming: the First Photographically-documented Neurotoxic Case From South-Western Hungary. Toxicon. 2018 Mar 1;143:29-35. PubMed PMID: 29305081.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Extending knowledge of the clinical picture of Balkan adder (Vipera berus bosniensis) envenoming: The first photographically-documented neurotoxic case from South-Western Hungary. AU - Varga,Csaba, AU - Malina,Tamás, AU - Alföldi,Viktória, AU - Bilics,Gergely, AU - Nagy,Ferenc, AU - Oláh,Tibor, Y1 - 2018/01/02/ PY - 2017/09/15/received PY - 2017/12/11/revised PY - 2017/12/30/accepted PY - 2018/1/7/pubmed PY - 2019/1/10/medline PY - 2018/1/7/entrez KW - Ataxic nystagmus KW - Neurotoxic phospholipase A(2) KW - Ptosis KW - South-Western Hungary KW - V. b. bosniensis SP - 29 EP - 35 JF - Toxicon : official journal of the International Society on Toxinology JO - Toxicon VL - 143 N2 - We report a severe envenoming associated with minimal local symptoms following a Balkan adder (Vipera berus bosniensis) bite in South-Western Hungary. A 63-year-old male with a history of hypertension and sinus bradycardia (45/min) was bitten by a sub-adult specimen of V. b. bosniensis in Somogy County on 04 May 2017. The patient was transported to and treated at the Emergency Department of "Moritz Kaposi" General Hospital, Kaposvár. Locally only pain and minimal swelling with a small haematoma developed on the bitten finger. The abdominal muscles were very tender and guarding was detected upon palpation on the way to hospital. The patient, who had taken his telmisartan (80 mg) tablet in that morning, complained of nausea and dizziness during the first medical examination. The systemic signs included fluctuations in blood pressure (115/85-165/105 mmHg), ECG changes (transient horizontal ST depression in V5-6, and sinus tachycardia (90/min)), severe diarrhoea and vomiting (in 7 episodes). Descending neuromuscular paralysis appeared in the next morning, including complete bilateral ptosis with external ophthalmoplegia, and binocular diplopia. Single-fiber electromyography confirmed the neuromuscular block in the frontalis muscle innervated by the facial nerve. Intense dizziness with uncoordinated movement emerged on the 3rd day. The laboratory findings were mild, including anaemia, hypokalaemia, elevated glutamic-pyruvic transaminase and C-reactive protein levels. The absolute neutrophil count remained almost completely normal. Supportive care and monovalent antivenom (Viper Venom Antitoxin®, Biomed, Warsaw) were applied. The patient was discharged from hospital on the 4th day, although recovery was not complete until 9 days after the bite. This is the first photographically-documented case of neurotoxic envenoming from the South-Western Hungarian distribution range of V. b. bosniensis. SN - 1879-3150 UR - https://www.unboundmedicine.com/medline/citation/29305081/Extending_knowledge_of_the_clinical_picture_of_Balkan_adder__Vipera_berus_bosniensis__envenoming:_The_first_photographically_documented_neurotoxic_case_from_South_Western_Hungary_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0041-0101(17)30419-1 DB - PRIME DP - Unbound Medicine ER -