Publications by authors named "Julian White"

64 Publications

Characteristics and significance of "green snake" bites in Myanmar, especially by the pit vipers Trimeresurus albolabris and Trimeresurus erythrurus.

Toxicon 2021 Nov 22;203:66-73. Epub 2021 Sep 22.

University of Adelaide, Adelaide, SA, 5000, Australia; Department of Renal Medicine, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia.

Snakebite is an important problem in Myanmar. Regionally, bites by Eastern Russell's vipers, Daboia siamensis (Viperidae, Viperinae), and monocled cobras, Naja kaouthia are considered medically important, but those categorised as "green snake" bites are not. However, these may include bites by green pit vipers, Trimeresurus spp. (Viperidae, Crotalinae) for which no antivenom is available in Myanmar. Elsewhere in Southeast Asia, these snakes are reported to cause local and systemic envenoming. As part of the Myanmar Snakebite Project, prospective case data were collected over 3 years from five hospitals in the Mandalay region. These included 3803 snakebite cases reported from Mandalay region. Of these, 355 were listed as bites by a witnessed green-coloured snake. In 22 cases, the snakes responsible were retained and preserved, then expertly identified; 21 were medically important white-lipped pit vipers (Trimeresurus albolabris), and one as an Asian vine snake, Ahaetulla prasina (Colubridae, Ahaetuliinae) which is not of medical importance. Among confirmed Trimeresurus albolabris bites, 15/21 developed swelling of the bitten limb, and 3/21 coagulopathy, defined as a positive 20-min whole blood clotting test (20WBCT). None developed necrosis, blistering, thrombocytopenia or acute kidney injury (AKI). Of the remaining 333 patients bitten by green snakes that were not specifically identified, 241 (72%) developed swelling of the bitten limb, and 62 (19%) coagulopathy. AKI occurred in 21/333 patients, but only one required dialysis. At least 10/21 of the cases with AKI in this study were more likely to represent bites from Trimeresurus spp. than D. siamensis because the snake responsible was brought into the hospital, examined and described by the treating physician as "green-coloured". This study describes a previously unpublished case of AKI from envenoming by T. erythrurus in Yangon, and reviews cases of AKI following bites by this species and T. albolabris in Myanmar. This confirms that, at least on rare occasions, Trimeresurus spp. envenoming can cause AKI. This has important implications for snakebite management in Myanmar as the finding of local swelling, coagulopathy and AKI is generally considered pathognomonic of D. siamensis envenoming. Further collection of confirmed Trimeresurus spp. bites is required in Myanmar in order better to define the syndrome of envenoming and to assess the possible need for antivenom against Trimeresurus spp. in this country.
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http://dx.doi.org/10.1016/j.toxicon.2021.09.008DOI Listing
November 2021

Snakebite Envenoming Diagnosis and Diagnostics.

Front Immunol 2021 28;12:661457. Epub 2021 Apr 28.

Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark.

Snakebite envenoming is predominantly an occupational disease of the rural tropics, causing death or permanent disability to hundreds of thousands of victims annually. The diagnosis of snakebite envenoming is commonly based on a combination of patient history and a syndromic approach. However, the availability of auxiliary diagnostic tests at the disposal of the clinicians vary from country to country, and the level of experience within snakebite diagnosis and intervention may be quite different for clinicians from different hospitals. As such, achieving timely diagnosis, and thus treatment, is a challenge faced by treating personnel around the globe. For years, much effort has gone into developing novel diagnostics to support diagnosis of snakebite victims, especially in rural areas of the tropics. Gaining access to affordable and rapid diagnostics could potentially facilitate more favorable patient outcomes due to early and appropriate treatment. This review aims to highlight regional differences in epidemiology and clinical snakebite management on a global scale, including an overview of the past and ongoing research efforts within snakebite diagnostics. Finally, the review is rounded off with a discussion on design considerations and potential benefits of novel snakebite diagnostics.
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http://dx.doi.org/10.3389/fimmu.2021.661457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8113877PMC
October 2021

A rare presentation of Eagle syndrome.

N Z Med J 2020 10 30;133(1524):126-128. Epub 2020 Oct 30.

Department of ENT, Waikato Hospital, Hamilton.

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October 2020

Risks and realities of single vial antivenom recommendations for envenoming by Australian elapid snakes.

Med J Aust 2020 07 11;213(1):46-46.e1. Epub 2020 Jun 11.

Women's and Children's Hospital Adelaide, Adelaide, SA.

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http://dx.doi.org/10.5694/mja2.50651DOI Listing
July 2020

Clinical importance of the Mandalay spitting cobra (Naja mandalayensis) in Upper Myanmar - Bites, envenoming and ophthalmia.

Toxicon 2020 Sep 3;184:39-47. Epub 2020 Jun 3.

Nuffield Department of Clinical Medicine, University of Oxford, UK. Electronic address:

Examination of 18 cobras brought to three hospitals in the Mandalay Region by patients bitten or spat at by them distinguished 3 monocled cobras (Naja kaouthia) and 15 Mandalay spitting cobras (N. mandalayensis), based on their morphological characteristics. We confirm and extend the known distributions and habitats of both N. mandalayensis and N. kaouthia in Upper Myanmar. Clinical symptoms of local and systemic envenoming by N. mandalayensis are described for the first time. These included local swelling, blistering and necrosis and life-threatening systemic neurotoxicity. More information is needed about the clinical phenotype and management of bites by N. mandalayensis, the commoner of the two cobras in Upper Myanmar. Since the current cobra antivenom manufactured in Myanmar has lower pre-clinical efficacy against N. mandalayensis than N. kaouthia, there is a need for more specific antivenom therapy.
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http://dx.doi.org/10.1016/j.toxicon.2020.05.023DOI Listing
September 2020

Risks and realities of single vial antivenom recommendations for envenoming by Australian elapid snakes.

Med J Aust 2019 12 22;211(11):492-493.e1. Epub 2019 Aug 22.

Women's and Children's Hospital, Adelaide, SA.

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http://dx.doi.org/10.5694/mja2.50314DOI Listing
December 2019

Reply to Rzymski and Klimaszyk regarding comment on "Mushroom poisoning: A proposed new clinical classification".

Toxicon 2019 03 19;160:59. Epub 2019 Feb 19.

Dept. for Clinical Toxicology at II, Med. Klinik, TU, München, Munich, Germany.

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http://dx.doi.org/10.1016/j.toxicon.2019.02.007DOI Listing
March 2019

Inadequate knowledge about snakebite envenoming symptoms and application of harmful first aid methods in the community in high snakebite incidence areas of Myanmar.

PLoS Negl Trop Dis 2019 02 15;13(2):e0007171. Epub 2019 Feb 15.

Department of Renal Medicine, Royal Adelaide Hospital, Adelaide, Australia.

Introduction: Every year millions of people in developing countries suffer from snakebite, causing a large number of deaths and long term complications. Prevention and appropriate first aid could reduce the incidence and improve the health outcomes for those who suffer bites. However, many communities where snakebite is a major issue suffer from a lack of information about prevention and first aid measures that a family or community member could take to prevent severe envenoming, complications and poor outcomes. Myanmar suffers from a high burden of snakebites with a large number of deaths. As part of a health services and community development program, a community survey was conducted to identify communities' knowledge about snakebite and their sequelae, and knowledge and practice about first aid and health services use.

Method: 4,276 rural residents of Kyaukse and Madaya townships in the Mandalay region were recruited by cluster sampling, involving random selection of 144 villages and random sampling of 30 households from each village. One adult member of each household was interviewed using a structured questionnaire.

Results: The incidence of snakebite was 116/100,000 people. Respondents reported 15 different types of snakes in the area, with Russell's Viper, Cobra and Green snakes as the most common. 88% of the people informed that working in the fields and forests was when most of the bites occur. A majority knew about snakebite prevention methods such as wearing long boots. However, only a few people knew about the specific symptoms caused by snakebites. Only 39% knew about the correct methods of first aid. More than 60% mentioned tourniquet as a first aid method, though this may cause significant complications such as ischaemia of the limb. 88% said that they would take a snakebite victim to a government hospital, and 58% mentioned availability of antivenom as the reason for doing this. At the same time, the majority mentioned that traditional methods existed for first aid and treatment and 25% mentioned at least one harmful traditional method as an effective measure that they might use.

Conclusion: The community is aware of snakebites as a major public health issue and know how to prevent them. However, the high incidence of snakebites point to lack of application of preventive methods. The community recognise the need for treatment with antivenom. However, inadequate knowledge about appropriate first aid methods, and a reliance on using tourniquets require a targeted education program. Existing knowledge in communities, albeit insufficient, provides a good starting point for mass media educational campaigns.
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http://dx.doi.org/10.1371/journal.pntd.0007171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6395000PMC
February 2019

A comprehensive approach to managing a neglected, neglected tropical disease; The Myanmar Snakebite Project (MSP).

Toxicon X 2019 Jan 7;1:100001. Epub 2018 Dec 7.

University of Adelaide, Adelaide SA 5000, Australia.

Snakebite is predominantly an occupational disease affecting poor rural farmers in tropical regions and was recently added to the World Health Organisation list of Neglected Tropical Diseases (NTD). We document an overview of methodologies developed and deployed in the Myanmar Snakebite Project, a foreign aid project largely funded by the Australian Government, with the core aim to "improve outcomes for snakebite patients". A multidisciplinary team of experts was assembled that worked in a collaborative manner with colleagues in Myanmar, first to identify problems related to managing snakebite and then develop interventions aimed to improve selected problem areas. A broad approach was adopted, covering antivenom production, antivenom distribution and health system management of snakebite. Problems identified in antivenom production included poor snake husbandry resulting in poor survival of captive specimens, lack of geographical diversity; poor horse husbandry, resulting in high mortality, inadequate stock acquisition protocols and data collection, and inappropriate immunisation and bleeding techniques; and inadequate production capacity for freeze dried antivenoms and quality control systems. These problems were addressed in various ways, resulting in some substantial improvements. Antivenom distribution is being reorganised to achieve better availability and utilisation of stock. Health system management of snakebite was assessed across all levels within the area selected for the study, in Mandalay region. A comprehensive community survey indicated that hospital statistics substantially underestimated the snakebite burden, and that access to care by local villagers was delayed by transport and cost issues compounded by lack of antivenom at the most peripheral level of the health service. A health system survey confirmed under-resourcing at the local village level. Prospective case data collection initiated at tertiary hospitals indicated the extent of the snakebite burden on health resources. Interventions initiated or planned include training of health staff, development of a core of senior trainers who can "train the trainers" nationwide in a sustainable way, development and deployment of management guidelines and algorithms for snakebite and a distribution of solar powered fridges to remote health facilities to allow storage of antivenom and prompt treatment of snakebite cases before transfer to major hospitals, thereby reducing the "bite to needle" time.
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http://dx.doi.org/10.1016/j.toxcx.2018.100001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7285917PMC
January 2019

Twelve month prospective study of snakebite in a major teaching hospital in Mandalay, Myanmar; Myanmar Snakebite Project (MSP).

Toxicon X 2019 Jan 7;1:100002. Epub 2018 Dec 7.

University of Adelaide, Adelaide, SA, 5000, Australia.

The Myanmar Snakebite Project is an Australian government (Department of Foreign Affairs and Trade) supported foreign aid project in collaboration with the Myanmar government with the aim of improving outcomes for snakebite patients in Myanmar. As part of the project a case record database was established to document prospective cases of snakebite presenting to Mandalay General Hospital, in Upper Myanmar. The study period was 12 months (1-2-2016 to 31-1-2017). Snake identity was based on a mixture of identified dead snakes brought with patients, doctor's clinical opinion and patient identification. 965 patients were enrolled during the 12 month period, of whom 948 were included for analysis. The male: female ratio was 1.58:1. Most cases involved bites to the lower limbs (82.5%) and adults involved in farm work, confirming snakebite as an occupational disease in this community. Motorised transport was by far the most common form of transport to health care and most patients sought care from the health system (87.7%), not traditional healers (11.5%) as their first point of contact. The officially promoted application of a pressure pad, bandage and immobilisation as first aid for snakebite was almost never used, while most patients used some form of tourniquet (92.0%). 85.4% of cases where a snake ID was listed were bitten by Russell's vipers. Russell's viper bites were responsible for all fatalities (9.8% of cases) and all cases of Acute Kidney Injury (AKI). For all cases, clinical features included local swelling (76.5%), local pain (62.6%), AKI (59.8%), incoagulable blood (57.9%), regional lymphadenopathy (39.8%), nausea/vomiting (40.4%), thrombocytopenia (53.6%), abdominal pain (28.8%), shock (11.8%), secondary infection (8.6%), panhypopituitarism (2.1%). AKI required renal replacement therapy (RRT) in 23.9% of cases, all ascribed to Russell's viper bite. Green pit viper bites were the next most common cause of bites (7.6%) and were associated with incoagulable blood (29%) and occasionally shock (5%) and local necrosis (3%), and in one case AKI not requiring RRT. In contrast to Russell's viper bites, green pit viper bite was most likely to occur in the home (49%). Some green pit viper patients were treated with Russell's viper antivenom (15%), presumably because they had incoagulable blood, although this antivenom is not effective against green pit viper envenoming. For the entire patient group, antivenom was given in 80.5% of cases. The most common indications were presence of coagulopathy/non-clotting blood (59.8%), local swelling (47.4%), oliguria/anuria (19.8%), heavy proteinuria (19.4%). A febrile reaction to antivenom was reported in 47.9% of cases, while anaphylaxis, occurred in 7.9% of cases.
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http://dx.doi.org/10.1016/j.toxcx.2018.100002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286100PMC
January 2019

Mushroom poisoning: A proposed new clinical classification.

Toxicon 2019 Jan 12;157:53-65. Epub 2018 Nov 12.

Dept. for Clinical Toxicology at II, Med. Klinik, TU, München, Munich, Germany.

Mushroom poisoning is a significant and increasing form of toxin-induced-disease. Existing classifications of mushroom poisoning do not include more recently described new syndromes of mushroom poisoning and this can impede the diagnostic process. We reviewed the literature on mushroom poisoning, concentrating on the period since the current major classification published in 1994, to identify all new syndromes of poisoning and organise them into a new integrated classification, supported by a new diagnostic algorithm. New syndromes were eligible for inclusion if there was sufficient detail about both causation and clinical descriptions. Criteria included: identity of mushrooms, clinical profile, epidemiology, and the distinctive features of poisoning in comparison with previously documented syndromes. We propose 6 major groups based on key clinical features relevant in distinguishing between poisoning syndromes. Some clinical features, notably gastrointestinal symptoms, are common to many mushroom poisoning syndromes. Group 1 - Cytotoxic mushroom poisoning. Syndromes with specific major internal organ pathology: (Subgroup 1.1; Primary hepatotoxicity); 1A, primary hepatotoxicity (amatoxins); (Subgroup 1.2; Primary nephrotoxicity); 1B, early primary nephrotoxicity (amino hexadienoic acid; AHDA); 1C, delayed primary nephrotoxicity (orellanines). Group 2 - Neurotoxic mushroom poisoning. Syndromes with primary neurotoxicity: 2A, hallucinogenic mushrooms (psilocybins and related toxins); 2B, autonomic-toxicity mushrooms (muscarines); 2C, CNS-toxicity mushrooms (ibotenic acid/muscimol); 2D, morel neurologic syndrome (Morchella spp.). Group 3 - Myotoxic mushroom poisoning. Syndromes with rhabdomyolysis as the primary feature: 3A, rapid onset (Russula spp.); 3B, delayed onset (Tricholoma spp.). Group 4 - Metabolic, endocrine and related toxicity mushroom poisoning. Syndromes with a variety of clinical presentations affecting metabolic and/or endocrine processes: 4A, GABA-blocking mushroom poisoning (gyromitrins); 4B, disulfiram-like (coprines); 4C, polyporic mushroom poisoning (polyporic acid); 4D, trichothecene mushroom poisoning (Podostroma spp.); 4E, hypoglycaemic mushroom poisoning (Trogia venenata); 4F, hyperprocalcitoninemia mushroom poisoning (Boletus satanas); 4G, pancytopenic mushroom poisoning (Ganoderma neojaponicum). Group 5 - Gastrointestinal irritant mushroom poisoning. This group includes a wide variety of mushrooms that cause gastrointestinal effects without causing other clinically significant effects. Group 6 - Miscellaneous adverse reactions to mushrooms. Syndromes which do not fit within the previous 5 groups: 6A, Shiitake mushroom dermatitis; 6B, erythromelagic mushrooms (Clitocybe acromelagia); 6C, Paxillus syndrome (Paxillus involutus); 6D, encephalopathy syndrome (Pleurocybella porrigens).
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http://dx.doi.org/10.1016/j.toxicon.2018.11.007DOI Listing
January 2019

Development of an ELISA assay to determine neutralising capacity of horse serum following immunisation with Daboia siamensis venom in Myanmar.

Toxicon 2018 Sep 11;151:163-168. Epub 2018 Jul 11.

Royal Adelaide Hospital, South Australia, Australia; University of Adelaide, South Australia, Australia. Electronic address:

Snakebite envenoming is a serious problem in Myanmar. The great majority of snakebite in this country is due to Russell's Viper (Daboia siamensis). For many years, the Burma Pharmaceutical Industry has produced a monovalent antivenom to Russell's Viper in horses. At present, the only way of determining the level of antibody against D. siamensis venom in hyperimmune horse serum is to perform venom neutralisation tests in mice. In this study, we describe the development of an in vitro ELISA assay to estimate neutralising capacity of horse serum. We found a strong correlation between the ELISA assay and the venom neutralisation test in mice (r = 0.982). The assay is robust and has sufficient sensitivity (92%) and specificity (96%) to replace the venom neutralisation test in mice during the immunisation phase in horses.
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http://dx.doi.org/10.1016/j.toxicon.2018.07.012DOI Listing
September 2018

Snakebite incidence in two townships in Mandalay Division, Myanmar.

PLoS Negl Trop Dis 2018 07 9;12(7):e0006643. Epub 2018 Jul 9.

Department of Renal Medicine, Royal Adelaide Hospital, Adelaide, Australia.

Introduction: The global incidence of snakebite is estimated at more than 2.5 million cases annually, with greater than 100,000 deaths. Historically, Myanmar has one of the highest incidences of venomous snakebites. In order to improve the health outcomes of snakebite patients in Myanmar, access to accurate snakebite incidence data is crucial. The last population-based study in Myanmar was conducted more than a decade ago. In 2014, the Ministry of Health and Sports data from health facilities indicated an incidence of about 29.5 bites/ 100,000 population/year (a total of 15,079 bites). Since data from health facilities lack information about those who do not seek health care from government health services, a new population-based survey was conducted in 2 rural areas of Mandalay region. The survey data were compared to those obtained from healthcare services.

Method: 4,276 rural respondents in Kyaukse and Madaya townships in Mandalay Division were recruited using cluster sampling that involved random selection of 150 villages and random sampling of 30 households from each village. One adult member of each household was interviewed using a structured questionnaire.

Results: One respondent from each of 4,276 households represented 19,877 residents from 144 villages. 24 people in these households had suffered snakebite during the last one year giving an annual incidence of 116/100,000. During the last ten years, 252 people suffered snakebites. 44.1% of the victims were women. 14% of the villages reported 4 or more bites during the last ten years, whereas 27% villages reported no snakebites. 92.4% of the victims recovered fully, 5.4% died, and 2% suffered long term health issues. One victim was reported to have died from causes unrelated to the snakebite. While there was no statistically significant difference between outcomes for children and adults, 4 of 38 of those under 18 years of age died compared to 7 of 133 adults between 19 to 40 years of age.

Conclusion: This incidence reported by the community members points to substantially more snakebites than the number of snakebite patients attending health facilities. This higher incidence points to the need for a nation-wide population-based survey, community education about gaining access to care where antivenom is available, and to the potential need for a larger supply of antivenom and expansion of medical care in rural areas.
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http://dx.doi.org/10.1371/journal.pntd.0006643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6053239PMC
July 2018

Why snakebite patients in Myanmar seek traditional healers despite availability of biomedical care at hospitals? Community perspectives on reasons.

PLoS Negl Trop Dis 2018 02 28;12(2):e0006299. Epub 2018 Feb 28.

Department of Renal Medicine, Royal Adelaide Hospital, Adelaide, Australia.

Background: Snakebite is a major public health problem in many developing countries. Farmers are particularly exposed to snakes, and due to their rural location often experience delays in accessing formal healthcare. The reasons to use traditional healers may include difficulties in accessing formal healthcare, certain beliefs about snakes and snake venom, tradition, and trust in the capacity of traditional healers. Traditional healing, however, may have serious consequences in terms of delays or added complications. There is little in-depth current information about the reasons for its continued use for snakebite. As part of a health services development project to improve health outcomes for snakebite patients, community attitudes to the use of traditional healers were explored in the Mandalay region of Myanmar.

Methodology & Findings: With the objective of learning from local communities, information was generated in three communities using participatory appraisal methods with the communities, and focus group discussions with the local healthcare staff. Many snakebite victims in these communities use traditional healing. Reasons include transport difficulties, low cost for traditional healing, inadequacy of anti-snake venom in the formal healthcare sector, and traditional beliefs, as traditional healing practices are rooted in many cultural and traditional factors. The communities reported that even if access to medical care were improved, traditional healing would continue to be used.

Conclusion: These findings point to the need for working with traditional healers for prevention, appropriate first aid and timely access to effective treatment for snakebite.
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http://dx.doi.org/10.1371/journal.pntd.0006299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5847227PMC
February 2018

Local morbidity from red-bellied black snake (Pseudechis porphyriacus, Elapidae) envenoming: Two cases and a brief review of management.

Toxicon 2018 Feb 19;142:34-41. Epub 2017 Dec 19.

Toxinology Department, Women's and Children's Hospital, 72 King William St, North Adelaide, South Australia 5006, Australia; Department of Paediatrics and Reproductive Medicine, University of Adelaide School of Medicine, 30 Frome Street, Adelaide, South Australia 5005, Australia.

The red-bellied black snake (Pseudechis porphyriacus, Elapidae) is one of several species of venomous snakes most commonly implicated in human and domestic animal envenoming in Australia. Human systemic envenoming can present with myotoxicity that may include myoglobinuria; hemoglobinuria and intravascular hemolysis; thrombocytopenia, anticoagulant coagulopathy, and, rarely, mild cranial nerve palsies. Pseudechis porphyriacus envenoming can also feature significant local morbidity such as ecchymoses, bleeding, pain and necrosis. Some envenomed patients may develop progressive thickness necrosis independent of secondary infection, and occasionally require surgical debridement. Uncommonly, some digital envenoming may cause more severe deeper tissue pathology that justifies dermotomy and/or distal phalangeal amputation. Presented are two patients with significant local morbidity from P. porphyriacus envenoming. An 18-month old girl received a protracted envenoming on her right foot, while a 38-year old male professional zoologist was envenomed on the third digit of his right hand. Each patient experienced myotoxicity, one had anticoagulant coagulopathy, and both developed clinically significant local morbidity including persistent bleeding, ecchymoses, local necrosis and pain; each required extensive treatment and variably prolonged admission. Noted also were transiently elevated D-dimer with low-normal or normal fibrinogen levels. The progressive necrosis and subsequent chronic pathologic changes with ischemia of the latter patient's digit eventually required a dermotomy and amputation of the distal phalanx. The pediatric patient did not require extensive wound debridement, but experienced prolonged difficulty in ambulation because of slowly resolving wound discomfort. Factors that may contribute to the severity of local morbidity of P. porphyriacus envenoming are considered, and management of envenoming by this taxon is briefly reviewed.
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http://dx.doi.org/10.1016/j.toxicon.2017.12.047DOI Listing
February 2018

Neurotoxicity with persistent unilateral ophthalmoplegia from envenoming by a wild inland taipan (Oxyuranus microlepidotus, Elapidae) in remote outback South Australia.

Toxicon 2017 Oct 8;137:15-18. Epub 2017 Jul 8.

Toxinology Department, Women's and Children's Hospital, 72 King William Street, North Adelaide, South Australia, 5006, Australia; Department of Paediatrics and Reproductive Medicine, University of Adelaide School of Medicine, 30 Frome Street, Adelaide, South Australia, 5005, Australia.

Introduction: A case of life threatening envenoming by a wild specimen of the inland taipan, Oxyuranus microlepidotus, is described. There have been 11 previously well-documented envenomings by O. microlepidotus, but only 2 were inflicted by wild snakes. Envenomed patients have presented predominantly with defibrinating coagulopathy and neurotoxicity.

Case Report: The victim was seeking to observe members of an isolated population of this species and was envenomed while attempting to photograph an approximately 1.5 m specimen. He reported feeling "drowsiness" and blurred vision that progressed to ptosis; he later developed dysphagia and dysarthria. The patient was treated with 1 vial of polyvalent antivenom, which was later followed with an additional two vials of taipan monovalent. He was intubated during retrieval, and recovered after 3 days of intensive care. He had a right ophthalmoplegia that persisted for approximately 1 week post-envenoming. Despite a positive 20-min whole blood clotting test, defibrination coagulopathy was absent, and there was no myotoxicity, or acute kidney injury.

Discussion: Physicians presented with a patient envenomed by O. microlepidotus should remain cognizant of the possible variability of medically important venom toxins in some populations of this species. Some patients seriously envenomed by this species may develop persistent cranial nerve palsies. When clinically indicated, prompt provision of adequate antivenom is the cornerstone of managing O. microlepidotus envenoming. Rapid application of pressure-bandage immobilization and efficient retrieval of victims envenomed in remote locales, preferably by medically well-equipped aircraft, probably improves the likelihood of a positive outcome.
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http://dx.doi.org/10.1016/j.toxicon.2017.07.006DOI Listing
October 2017

Reply to Isbister and Page: Further discussion of an illuminated case of presumed brown snake (Pseudonaja spp.) envenoming.

Clin Toxicol (Phila) 2015 Nov;53(9):926-7

b Departments of Emergency Medicine and Intensive Care , Flinders University Medical Center , Bedford Park , Adelaide , South Australia , Australia.

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http://dx.doi.org/10.3109/15563650.2015.1096369DOI Listing
November 2015

An instructive case of presumed brown snake (Pseudonaja spp.) envenoming.

Clin Toxicol (Phila) 2015 8;53(8):834-9. Epub 2015 Jul 8.

Flinders Medical Centre, Bedford Park , Adelaide, South Australia , Australia.

Context: Several species of medically important Australian elapid snakes are frequently involved in human envenoming. The brown snake group (Pseudonaja spp., 9 species) is most commonly responsible for envenoming including life-threatening or fatal cases. Several Pseudonaja spp. can inflict human envenoming that features minor local effects, but may cause serious systemic venom disease including defibrination coagulopathy, thrombocytopenia, micro-angiopathic hemolytic anemia (MAHA) and, rarely, paralysis. Pseudonaja envenoming is typically diagnosed by history, clinical assessment including occasional active clinical bleeding noted on physical examination (e.g. from venipuncture sites, recent cuts, etc.), and laboratory detection of coagulopathy (prolonged activated partial thromboplastin time [APTT]/INR, elevated D-dimer, afibrinogenemia and thrombocytopenia). Lack of verified identity of the envenoming snake species is a common problem in Australia and elsewhere. Identification and confirmation of the envenoming Australian snake taxon is often attempted with enzyme sandwich immunoassay venom detection kits (SVDKs). However, the SVDK has limited utility due to unreliable specificity and sensitivity when used to detect venoms of some Australian elapids. Antivenom (AV) remains the cornerstone of treatment, although there is debate concerning the recommended dose (1 vs. 2 or more vials) necessary to treat serious Pseudonaja envenoming. Envenomed patients receiving timely treatment uncommonly succumb, but a proportion of seriously envenomed patients may exhibit clinical or laboratory evidence of myocardial insult.

Case Details: An 88-year-old woman presented her dog to a veterinarian after it had sustained a bite by a witnessed snake, reportedly an eastern brown snake (Pseudonaja textilis, Elapidae). The woman became suddenly confused, and lost consciousness at the veterinary office. After transport to hospital, she denied any contact with the snake, but developed large haematomas at intravenous (i.v.) catheter insertion sites; blood tests revealed a severe defibrination coagulopathy, consistent with envenoming by a brown snake. An SVDK-tested urine sample was negative. A non-contrast CT of her head showed a minor subacute infarction of the left corona radiata. A twelve-lead ECG was normal, but her troponins were mildly elevated (39 ng/L). A diagnosis of brown snake envenoming was made and she received 2 vials of brown snake AV i.v., without adverse incident. Thirty min post AV her Glasgow Coma Score (GCS) had improved from 13 to 15 (normal). At 3.5 h post AV all bleeding from i.v. sites ceased, although her troponin T level peaked at 639 ng/L, supporting a diagnosis of non-ST elevated myocardial infarction (NSTEMI).

Discussion: Severe brown snake envenoming may occur in the absence of a perceived bite, and AV is temporally associated with improvement in clinical findings and coagulopathy. However, severe envenoming by this species can be complicated by cardiovascular events that in the circumstance of incomplete or absent history may confuse the primary diagnosis and affect patient outcome.
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http://dx.doi.org/10.3109/15563650.2015.1059947DOI Listing
November 2015

In Response to How Not To Train Your Dragon: A Case of Komodo Dragon Bite, by Borek and Charlton.

Wilderness Environ Med 2015 Dec 18;26(4):572-3. Epub 2015 May 18.

Department of Toxinology, Women's and Children's Hospital, 72 King William St., North Adelaide, South Australia, Australia.

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http://dx.doi.org/10.1016/j.wem.2015.04.003DOI Listing
December 2015

Reply to Vikrant and Verma about "Monitor Lizard Envenoming".

Ren Fail 2015 May 2;37(4):740-1. Epub 2015 Apr 2.

Toxinology Department, Women's and Children's Hospital , North Adelaide , South Australia.

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http://dx.doi.org/10.3109/0886022X.2015.1006116DOI Listing
May 2015

Latrodectism and effectiveness of antivenom.

Ann Emerg Med 2015 Jan;65(1):123-4

Department of Toxinology, Women's and Children's Hospital, North Adelaide, South Australia, Australia.

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http://dx.doi.org/10.1016/j.annemergmed.2014.08.022DOI Listing
January 2015

Do spiders vector bacteria during bites? The evidence indicates otherwise.

Toxicon 2015 Jan 21;93:171-4. Epub 2014 Nov 21.

Toxinology Department, Women's & Children's Hospital, North Adelaide, SA 5006, Australia.

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http://dx.doi.org/10.1016/j.toxicon.2014.11.229DOI Listing
January 2015

A phoenix of clinical toxinology: white-tailed spider (Lampona spp.) bites. A case report and review of medical significance.

Toxicon 2014 Sep 9;87:76-80. Epub 2014 Jun 9.

Toxinology Department, Women's & Children's Hospital, North Adelaide 5006, Australia. Electronic address:

The Australian white-tailed spiders ("WTS"; Lamponidae: notably Lampona cylindrata &Lampona murina) have a continuing reputation on Internet sites as a cause of skin ulceration, labelled "necrotic arachnidism", despite an increasing number of peer-reviewed publications debunking this reputation, with >135 confirmed cases now reported without any evidence of necrosis. We present here a case of confirmed WTS bite in a 42-year old male, followed for over a month, with photos of bite site signs and no development of skin ulceration/necrosis. The patient was initially alarmed by information on the Internet suggesting local necrosis would result from the bite. We discuss the evolution of knowledge about bites by the WTS, and the persistence of misconceptions about their factually mild medical significance.
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http://dx.doi.org/10.1016/j.toxicon.2014.05.021DOI Listing
September 2014

The Australian mulga snake (Pseudechis australis: Elapidae): report of a large case series of bites and review of current knowledge.

Toxicon 2014 Jul 13;85:17-26. Epub 2014 Apr 13.

Toxinology Department, Women's & Children's Hospital, North Adelaide, SA 5006, Australia.

Background: The mulga snake (Pseudechis australis) is the largest terrestrial venomous snake in Australia. It is capable of inflicting severe and occasionally fatal envenoming, but there have been few studies of P. australis bites.

Objectives: To highlight and reinforce the main features of P. australis envenoming and to provide a clearer picture of the epidemiology of bites from this species.

Methods: Selected case records kept by the Toxinology Dept. (Women's and Children's Hospital, Adelaide, Australia) were reviewed retrospectively to determine definite P. australis bites.

Inclusion Criteria: definite cases where the snake was identified by a competent person and/or lab specimens (bite site/urine) tested positive for "black snake" using CSL snake venom detection kit in a locality within the known range of P. australis, but without sympatry with other Pseudechis spp.

Exclusion Criteria: where the snake could not be clearly identified under criteria above. Epidemiological and clinical information was recorded and analysed for the definite cases.

Results: A total of 27 cases were identified as definite P. australis bites; there were no fatalities. The median age was 35.5 years (IQR 51-23) and 80% of bites occurred in males. More bites occurred in the warmer months (Dec-March) and in those handling/interfering with snakes. Seven people were bitten whilst asleep at night. 21/27 patients developed systemic envenoming (based on signs, symptoms and laboratory results) and 17 cases received antivenom. Local bite site pain (18) and swelling (17) were common as were non-specific generalised symptoms such as nausea, vomiting and headache. Myotoxicity (11) and anticoagulant coagulopathy (10) occurred frequently; haemolysis was seen in fewer cases (3). Two patients developed local tissue injury around the bite site requiring further treatment.

Conclusions: This study confirms previous reports about P. australis bites with respect to high rates of envenoming, commonly associated with pain and swelling and systemic effects of rhabdomyolysis and anticoagulant coagulopathy. Systemic envenoming, even severe cases, responds well to antivenom therapy. Compared to other Australian snakes, a high proportion of bites occur in people asleep at night. Medically significant local tissue injury around the bite site may occur and may be associated with inappropriate first-aid, particularly the vascular occlusive type.
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http://dx.doi.org/10.1016/j.toxicon.2014.04.003DOI Listing
July 2014

The short course in toxinology: training the trainers.

Authors:
Julian White

Toxicon 2013 Jul 23;69:114-9. Epub 2013 Mar 23.

Toxinology Department, Women's & Children's Hospital, North Adelaide SA 5006, Australia.

Clinical toxinology is the medical discipline dealing with the diagnosis, treatment and prevention of toxin diseases caused by exposure to venomous animals and poisonous animals, plants and mushrooms. Currently there is no national or international organisation accrediting or training doctors in this discipline. A few courses covering some aspects of clinical toxinology exist, either with limited curricula, or with only a minor clinical focus, or with a very regional, non-global focus. The only comprehensive clinical toxinology course is the one provided in Adelaide, Australia, running regularly since 1997. Hundreds of doctors from many nations have attended the course since 1997. This course covers venomous animals, poisonous animals, plants and mushrooms, from a full global perspective, with an international faculty and an exit exam. Though lasting only one week, extensive pre-reading material is mandated. The current Course Handbook is about 500 pages. Emphasis is on clinically relevant information and is focused on the needs of doctors treating cases. While it is expected that attendees will have, or acquire, direct experience managing cases of toxin disease and will use the knowledge and skills gained in the course in direct patient care, they may also act as resource people in their home region/nation to promote increased skills in clinical toxinology amongst the wider medical workforce. This course may form the nucleus from which IST can develop a global accredited training scheme in clinical toxinology. Such a scheme will require input from diverse global regions and will be far more comprehensive and over a much longer time than the current Short Course, though likely will incorporate the Short Course in some way, or a derivative of it.
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http://dx.doi.org/10.1016/j.toxicon.2013.03.008DOI Listing
July 2013

Clinical toxinology specialty training.

Authors:
Julian White

Toxicon 2013 Jul 19;69:120-5. Epub 2013 Mar 19.

Toxinology Dept., Women's & Children's Hospital, North Adelaide, SA 5006 Australia.

Clinical toxinology is the medical discipline dealing with the diagnosis, treatment and prevention of toxin diseases caused by exposure to venomous animals and poisonous animals, plants and mushrooms. Currently there is no national or international organisation accrediting or training doctors in this discipline, but the role of the IST in this area is the subject of a recently approved revised Constitution. A few courses covering some aspects of clinical toxinology exist, either with limited curricula, or with only a minor clinical focus, or with a very regional, non-global focus. The only comprehensive clinical toxinology course is the one provided in Adelaide, Australia, running regularly since 1997. This course may form the nucleus from which IST can develop a global accredited training scheme in clinical toxinology. Such a scheme will require input from diverse global regions and will be far more comprehensive and over a much longer time than the current Short Course, though may incorporate the Short Course in some way, or a derivative of it. Accreditation of medical expertise in clinical toxinology will be required at the national level and this might be accomplished by the IST working with existing national medical specialty organisations and governments, with the IST supervising the training and accreditation requirements and the national organisations providing the framework for registration of medical expertise at the local level.
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http://dx.doi.org/10.1016/j.toxicon.2013.03.007DOI Listing
July 2013

Non-front-fanged colubroid snakes: a current evidence-based analysis of medical significance.

Toxicon 2013 Jul 24;69:103-13. Epub 2013 Feb 24.

Department of Toxinology, Women's and Children's Hospital, 72 King William St., North Adelaide, South Australia, Australia.

Non-front-fanged colubroid snakes (NFFC; formerly and artificially taxonomically assembled as "colubrids") comprise about 70% of extant snake species and include several taxa now known to cause lethal or life threatening envenoming in humans. Although the medical risks of bites by only a handful of species have been documented, a growing number of NFFC are implicated in medically significant bites. The majority of these snakes have oral products (Duvernoy's secretions, or venoms) with unknown biomedical properties and their potential for causing harm in humans is unknown. Increasingly, multiple NFFC species are entering the commercial snake trade posing an uncertain risk. Published case reports describing NFFC bites were assessed for evidence-based value, clinical detail and verified species identification. These data were subjected to meta-analysis and a hazard index was generated for select taxa. Cases on which we consulted or personally treated were included and subjected to the same assessment criteria. Cases involving approximately 120 species met the selection criteria, and a small subset designated Hazard Level 1 (most hazardous), contained 5 species with lethal potential. Recommended management of these cases included antivenom for 3 species, Dispholidus typus, Rhabdophis tiginis, Rhabdophis subminiatus, whereas others in this subset without commercially available antivenoms (Thelotornis spp.) were treated with plasma/erythrocyte replacement therapy and supportive care. Heparin, antifibrinolytics and/or plasmapheresis/exchange transfusion have been used in the management of some Hazard Level 1 envenomings, but evidence-based analysis positively contraindicates the use of any of these interventions. Hazard Level 2/3 species were involved in cases containing mixed quality data that implicated these taxa (e.g. Boiga irregularis, Philodryas olfersii, Malpolon monspessulanus) with bites that caused rare systemic effects. Recommended management may include use of acetylcholinesterase inhibitors (e.g. neostigmine) and wound care on a case-by-case basis. Hazard level 3 species comprised a larger group capable of producing significant local effects only, often associated with a protracted bite (eg Heterodon nasicus, Borikenophis (Alsophis) portoricensis, Platyceps (Coluber) rhodorachis). Management is restricted to wound care. Bites by Hazard level 4 species comprised the majority of surveyed taxa and these showed only minor effects of no clinical importance. This study has produced a comprehensive evidence-based listing of NFFC snakes tabulated against medical significance of bites, together with best-practice management recommendations. This analysis assumes increasing importance, as there is growing exposure to lesser-known NFFC snakes, particularly in captive collections that may uncover further species of significance in the future. Careful and accurate documentation of bites by verified species of NFFC snakes is required to increase the evidence base and establish the best medical management approach for each species.
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http://dx.doi.org/10.1016/j.toxicon.2013.02.003DOI Listing
July 2013
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