A case report of Citrobacter koseri bacteraemia after transfusion of contaminated red cells.

BACKGROUND: Citrobacter koseri has not been associated to infection caused by blood component transfusions. CASE REPORT: A 46-year-old female patient presented sudden chills, dyspnoea, and tachycardia during a transfusion from a unit of packed red blood cells. Citrobacter koseri was isolated in the two sample collected from the patient and from the content of the packed red blood cells. RESULTS: We report a case of bacteraemia due to a transfusion of contaminated red blood cells. CONCLUSION: C. koseri should be taken into account in bacteraemias caused by transfusion of blood components.

Failure of chloramphenicol prophylaxis to reduce the frequency of abscess formation as a complication of envenoming by Bothrops snakes in Brazil: a double-blind randomized controlled trial.

Bites by many species of venomous snake may result in local necrosis at, or extending from, the site of the bite. The use of prophylactic antibiotics to prevent infection as a complication of local necrotic envenoming is controversial. A double-blind randomized controlled trial was carried out to assess whether antibiotic therapy is effective in this situation. Two hundred and fifty-one patients, with proven envenoming by snakes of the genus Bothrops, admitted to two hospitals in Brazil, between 1990 and 1996, were randomized to receive either oral chloramphenicol (500 mg every six hours for five days) or placebo. One hundred and twenty-two of these patients received chloramphenicol (group 1) and 129 were given placebo (group 2). There were no significant differences between the groups at the time of admission. Necrosis developed in seven (5.7%) patients in group 1 and in five (3.9%) patients in group 2 (P>0.05) while abscesses occurred in six patients (4.9%) in group 1 and in six (4.7%) patients in group 2 (P>0.05). In conclusion, the use of orally-administered chloramphenicol for victims of Bothrops snake bite with signs of local envenoming on admission, is not effective for the prevention of local infections.

Types of arrhythmia among cases of American trypanosomiasis, compared with those in other cardiology patients.

The frequencies of each type of arrythmia were investigated, by age and sex, among 3056 Brazilian patients with cardiac arrhythmia. Each patient investigated had been tested serologically for American trypanosomiasis and 1013 had been found seropositive for the disease. In general, the seropositive 'chagasic' patients were each likely to be suffering from more types of arrhythmia than the seronegative 'non-chagasic', with means of 1.81 and 1.03 types/patient, respectively. Right-branch bundle blocks (RBBB), ventricular extrasystoles (VE) and left anterior hemiblocks (LAHB) were the commonest cardiac arrhythmias among the chagasic patients, and each of these types of arrhythmia (alone or with other types of arrythmia) was more frequent in the chagasic patients than the non-chagasic. The incidence of RBBB among the arrhythmic varied significantly with age in the non-chagasic patients (increasing with age among both the males and females) but not among the chagasic subjects. When the frequencies of each type of arrythmia and each combination of types were compared, the co-occurrence of RBBB and another type of arrhythmia was almost indicative of American trypanosomiasis (occurring in 30.6% of the chagasic subjects but only 2.6% of the non-chagasic). Similarly, only 0.4% of the non-chagasic patients but 7.4% of the chagasic had RBBB, VE and LAHB concurrently. However, the frequencies of RBBB in isolation (i.e. with no other, concurrent, electrocardiographic abnormality), VE in isolation, or LAHB in isolation were not significantly different in the chagasic and non-chagasic patients.

Epidemiology of snakebite in a central region of Brazil.

The aim of this article is to acquire knowledge about the aspects of snakebite epidemiology in a central region of Brazil. From 1993 to 1995, 90 cases of Crotalinae (Bothrops and Crotalus genera) and two cases of Micrurus snakebite were attended to in a general hospital. Epidemiological information about 73 out of the 90 Crotalinae victims was prospectively collected from interviews with the patients and/or their companions. Data from medical records were obtained for the 17 remaining cases. The snakes of Bothrops, Crotalus, and Micrurus genera were responsible for 74, 24 and 2% of the accidents, respectively. Most of the Crotalinae accidents occurred from October to March (68%) and from 06:00 to 12:00 a.m. (93%). Males (89%) and patients between 20 and 30 years-old (27%) were the most common victims. The main bite sites were: foot (24%), leg (23%), hand (22%) and ankle (21%). Among the 73 interviewed Crotalinae victims, farm workers were bitten more frequently (53%). The accidents often occurred during work (59%), and 90% of the patients wore footwear, but 30% were wearing only sandals. Tourniquet, squeezing, suction of the bite site and magic blessing were attempted in 47, 38, 8 and 10% of cases, respectively.

Snakebites in southern Minas Gerais state, Brazil

In Brazil, more than 80 per cent of venomous snakebites are caused by Bothrops and about 10 per cent by Crotalus. This study evaluated 133 reported cases that occurred between 1994 and 1996 in the 52 municipalities covered by the Pouso Alegre Regional Health Center in southern Minas Gerais State. Most of the patients were male (89.5 per cent). The most frequently attacked age bracket was that of people in their twenties, and the most frequently bitten anatomical regions were the lower limbs (77.7 per cent), principally the feet (34.6 per cent). Of the 124 cases stating the snake genus, 62.9 per cent were caused by Crotalus and 37.1 per cent by Bothrops. The conclusion of this study is that although the epidemiology of snakebites in Minas Gerais State is similar to other regions of the country, the percentage of Crotalus bites is much higher

Prognostic factors for local necrosis in Bothrops jararaca (Brazilian pit viper) bites.

The prognostic factors related to envenoming are not very well known. This study aims to identify prognostic factors for necrosis in envenoming by Bothrops jararaca. We analysed 779 medical records of patients bitten by B. jararaca and treated at the Hospital Vital Brazil, Butantan Institute, São Paulo, Brazil, between 1982 and 1990: 111 cases with necrosis were compared with the remaining cases. The length of the snake, the bite site, the month of the accident, pain, oedema, ecchymosis, blisters, systemic bleeding, shock, and the use of tourniquet were statistically associated with the presence of necrosis (P < 0.05) in the univariate analysis. The size of the snake, the bite site (leg and finger), the sex of the patient, the month of the accident, systemic bleeding, and the use of tourniquet were independent prognostic factors within the variables tested in the multivariate analysis. The size of the snake was the most important independent prognostic factor related to the presence of necrosis.

Occupational injuries with captive lance-headed vipers (Bothrops moojeni): experience from a snake farm in Brazil.

We studied occupational injuries with captive lance-headed vipers (Bothrops moojeni) that occurred in a snake farm in south-eastern Brazil from February 1981 to May 1999. The risk of injury, taking into account 13 cases of snake-associated injuries (12 of them snake bites) was 2.73 per 10,000 person-days of work, and 3.51 per 100,000 venom extractions. Thirteen cases of injury occurred in seven workers, whereas 18 workers were never injured, suggesting that some individuals have a higher risk of injury than others perhaps due to lack of concentration or overconfidence. Eight episodes of occupational injuries occurring in four technicians, including a case of eye injury due to splashed venom during extraction, are reported. Assessment of whether envenoming occurred was facilitated by knowledge of the snake species and size, history of recent venom extraction and snake feeding, and examination of snake venom glands. Hypersensitivity reactions (anaphylaxis and serum sickness) to antivenom are a risk particularly to those workers who were bitten more than once and medicated previously. Antivenom therefore should not be administered to these individuals unless there is clear evidence that envenoming occurred or is likely to have occurred. Hypersensitivity to the venom is also a health concern for workers from snake farms.

South American rattlesnake bite and soft-tissue infection: report of a case.

The case of a man bitten by a South American rattlesnake (Crotalus durissus) and who developed an abscess at the site of the bite is reported. Abcesses are a rare complication of this type of envenoming, possibly due to the lack of a strong cytotoxic action of Crotalus durissus venom.

Envenoming by the South American pit viper Bothrops neuwiedi Wagler.

Between 1975 and 1992, 18 cases of envenoming by Bothrops neuwiedi presented at the Hospital Vital Brazil, in São Paulo. Most of these cases were male (67%) and most had been bitten during the day (83%), between November and May (83%), either on the foot/ankle (50%) or hand (39%). Most (72%) of the cases arrived at the hospital 1-6 h after the bite. All presented with pain and most (83%) had oedema, but fewer had ecchymosis (50%), necrosis (17%), abscess (5%) and/or systemic blood-coagulation disorders (12%). Polyspecific Bothrops antivenom was administered to 16 (89%) of the patients. The results of B. neuwiedi bites therefore appear very similar to those of the much better known B. jararaca, even in terms of the gravity of the envenoming. Impairment in blood coagulation, however, seems less frequent among those bitten by B. neuwiedi than in those bitten by B. jararaca.

Bites by the colubrid snake Philodryas olfersii: a clinical and epidemiological study of 43 cases.

Less than 10 cases of bites by Philodryas olfersii (Colubridae) have been reported in the literature. In this study, 43 patients admitted to the Instituto Butantan, São Paulo, Brazil, with the diagnosis of P. olfersii bite from 1982 to 1990 were reviewed. The 32 male (74.4%) and 11 female (25.6%) patients presented mainly from November to February (65%). The most common clinical features were local pain (37.2%), swelling (34.9%), erythema (18.6%) and ecchymosis (9.3%). The 20 minute whole blood clotting test was performed in 11 patients and in all of them the blood was coagulable. Most of the accidents occurred during the hottest months and during daylight hours. The most common bite site was the hands. Severe envenoming is not frequent in these accidents.

Prognostic factors for amputation in the case of envenoming by snakes of the Bothrops genus (Viperidae).

The prognostic factors for amputation following envenoming by snakes of the Bothrops genus were identified from the medical records of 3139 patients. Each of these patients had been bitten by Bothrops sp. and treated in the Hospital Vital Brazil, in São Paulo, Brazil, between 1981 and 1990. The 21 (0.67%) of the patients who had undergone amputation were compared with the 3118 who had not, with respect to the characteristics of the accident, the snake, the victim, the local and systemic manifestations of the envenoming and the treatment. There was an association between amputation and the month of the accident, the time of day when the accident happened, the length of the attacking snake, the anatomical region bitten, systemic bleeding and renal failure. Patients bitten in the fingers, during the cooler months, between 00.00 and 12.00 hours and/or by snakes > 60 cm in length, who developed blisters and abscesses at the site of the bite, systemic bleeding and/or renal failure underwent amputation more frequently than the others (P < 0.05 for each).

[Deaths caused by venomous snakes in the State of São Paulo: evaluation of 43 cases from 1988 to 1993]. / Obitos por serpentes peçonhentas no Estado de São Paulo: avaliação de 43 casos, 1988/93.

UNLABELLED: The prognostic factors and the causes for obit occurrence in ophidian envenoming are yet not completely clear. PURPOSE: To determine the prognostic factors and the most probable causes for obit occurrence in ophidian envenoming. METHODS: In the State of São Paulo were notified 12,639 cases of accidents by venomous snakes from 1988 to 1993. There were 43 deaths (0.34%). The variables from the accident notification reports were compared with the promptuary notes and/or with the death records (in lethal cases). RESULTS: The snake genus was classified in 11,297 accidents and in 41 from the lethal ones. Bothrops was responsible for 9,828 (87%) accidents and 28 (68.3%) deaths, Crotalus for 1,359 (12.0%) accidents and 13 deaths (31.7%) and Micrurus for 110 (1%) accidents and no death (p < 0.05). The information regarding to sex and age of the patients was available, respectively, in 12,620 and 12,527 accidents and in all lethal ones. There were 9,783 (77.5%) male patients in the accidents and 35 (81.4%) in the lethal cases (p > 0.05). Regarding to age, 15.9% of the patients and 41.8% of the ones who died were 50 years-old or more (p < 0.05). The most frequently bitten anatomic regions were: foot (42.2%), hand (20.6%), leg (17.6%), and ankle (13.1%) in the accidents, and foot (35.7%) and leg (35.7%) in the lethal cases (p < 0.05). Coagulation disorders occurred in 34 (91.9%) from 37 patients who died (those where this datum was available). The information above was not available in non lethal cases. The most common manifestations and complications implicated as possible death causes were: acute renal failure (34-79.1%), acute respiratory failure (28-65.1%), shock (18-41.9%), and sepsis (18-41.9%). Among all lethal cases but one without information, 29.4% of the patients died within the first two days after bite and 67.6% within the first 5 days. Acute respiratory failure was most common among the patients who died owing to crotalic envenoming, and sepsis was only seen in bothropic envenoming. CONCLUSION: Most of the accidents and obits are caused by Bothrops; Crotalus envenoming, leg bites, and accidents in 50 year-old patients (or more) are frequently lethal; the most common complication in lethal cases is acute renal failure.

Obitos por serpentes peçonhentas no Estado de Säo Paulo: avaliaçäo de 43 casos, 1988/93 / Obits by venomous snakes in the State of Säo Paulo: evaluation of 43 cases from 1988 to 1993

Sao ainda mal estabelecidos os fatores prognósticos para a ocorrência de óbito nos envenenamentos por serpentes e as causas que o determinam. Objetivo. Determinar, no envenenamento ofídico, os fatores prognósticos e as causas mais prováveis do óbito. Métodos. No período de 1988 a 1993 foram notificados 12.639 casos de acidentes por serpentes peçonhentas no Estado de Sao Paulo, com 43 óbitos (0,34 por cento). Foram comparadas as variáveis obtidas das fichas de notificaçao dos acidentes com aquelas dos prontuários e/ou dos relatórios médicos dos casos de óbito. Resultados. O diagnóstico quanto ao gênero da serpente foi realizado em 11.297 acidentes, sendo 9.828 (87 por cento) por Bothrops, 1.359 (12 por cento) por Crotalus e 110 (1 por cento) por Micrurus, e em 41 casos de óbito, sendo 28 (68,3 por cento) por Bothrops e 13 (31,7 por cento) por Crotalus (p<0,05). Informaçao quanto a sexo e idade dos pacientes foi fornecida em, respectivamente, 12.620 e 12.527 acidentes. Pertenciam ao sexo masculino 9.783 (77,5 por cento) pacientes picados e 35 (81,4 por cento) que faleceram (p>0,05). Tinham 50 anos ou mais 15,9 por cento dos pacientes picados e 41,8 por cento daqueles que faleceram (p<0,05). As regioes anatômicas mais freqüentemente picadas foram: pé (42,2 por cento), maos (20,6 por cento), perna (17,6 por cento) e tornozelo (13,1 por cento), nos acidentes, e pé (35,7 por cento) e perna (35,7 por cento), nos casos de óbito (p<0,05). A alteraçao da coagulaçao ocorreu em 34 (91,9 por cento) de 37 pacientes que evoluíram para o óbito. As manifestaçoes e complicaçoes mais referidas como possíveis causas de óbito foram: insuficiência renal (34-79,1 por cento), insuficiência respiratória (28- 65,1 por cento), choque (18- 41,9 por cento) e septicemia (18- 41,9 por cento). Dentre os pacientes que evoluíram para óbito, excluindo-se um caso sem informaçao, 29,4 por cento faleceram dentro dos primeiros dois dias após a picada. A insuficiência respiratória foi mais comum entre os que faleceram devido ao envenenamento crotálico e a septicemia só foi referida para o envenenamento botrópico. Conclusao. A maioria dos acidentes e dos óbitos é causada por Bothrops; sao mais freqüentemente letais os envenenamentos por Crotalus, as picadas na perna e em pessoas com mais de 50 anos; a complicaçao mais comum nos casos fatais é a insuficiência renal.

Aeromonas hydrophila soft-tissue infection as a complication of snake bite: report of three cases.

Aeromonas hydrophila soft-tissue infection has been associated with fish and reptile bites. There have bee three recent cases from Brazil of abscesses complicating snake bites in which A. hydrophila was isolated from the purulent exudates. One of the snakes responsible for the bites was a specimen of Bothrops moojeni, and the others were most probably also lance-headed vipers. These snakes have a local necrotizing, myotoxic, oedema-inducing venom that must have favoured the multiplication in the injured tissue of A. hydrophila strains, which were probably present in the mouth, fangs or venom of the snakes. The use of a tourniquet by two of the patients probably worsened the local envenoming, and contributed to the occurrence of soft-tissue infection. The patients had a good outcome after the abscesses were incised and drained, and after being treated with chloramphenicol. Chloramphenicol appears to be a good alternative for the empirical treatment of soft-tissue infection complicating snake bite in Brazil, because: it is active against the majority of the anaerobic and aerobic bacteria found in these abscesses, including A. hydrophila; it can be administered by the oral route; and its is inexpensive. Suitable alternatives are cotrimoxazole or fluoroquinolones, to which aeromonads are usually susceptible in vitro, associated with antibiotics, such as clindamycin and metronidazole, with an anti-anaerobic spectrum.

Acidente por serpentes do gênero Bothrops: série de 3.139 casos / Bites by snakes in the genus Bothrops: a series of 3139 cases

Em avaliação dos prontuários médicos de 3.139 pacientes picados por serpentes do gênero Bothrops atendidos no Hospital Vital Brazil (HVB), de 1981 a 1990, observou-se maior acometimento do sexo masculino (75,7%). Em 1.412 casos (45,0%) a serpente foi identificada, sendo 1.376 B. jararaca, 20 B. jararacussu, 11 B. neuwiedi, 2 B. moojeni, 2 B. alternatus e 1 B. pradoi. As regiões anatômicas mais comumente picadas foram: pé (47,5%) e mão (21,3%). O torniquete foi realizado em 38,2% dos casos e sua freqüência diminuiu durante esse período (p < 0,001). As manifestações clínicas mais freqüentes foram: dor (95,6%), edema (95,4%), equimose (56,1%), bolha (13,8%), necrose (16,5%), abscesso (11,0%), sangramento extratecidual (12,3%), insuficiência renal (1,6%) e choque (0,7%). A coagulação sanguínea foi avaliada em 2.990 casos e estava alterada em 1.730 (57,9%). Ocorreram 21 amputações (0,7%) e 9 óbitos (0,3%). A dose de soro administrada no HVB diminuiu ao longo desse período (p < 0,001).

Medical records of 3,139 patients bitten by Bothrops snakes and attended at Vital Brazil Hospital (HVB) from 1981 to 1990 were reviewed. They were more frequent in males (75.7%). In 1,412 cases (45.0%) the snake was classified by species, and 1,376 were B. jararaca, 20 B. jararacussu, 11 B. neuwiedi, 2 B. moojeni, 2 B. alternatus e 1 B. pradoi. The most frequent bitten anatomic regions were: foot (47.5%) and hand (21.3%). Tourniquet was used in 38.2% of the cases and its frequency fell down during the study period (p < 0.05). The clinical features at the bite site were: pain (95.6%), swelling (95.4%), ecchymosis (56.1%), blisters (13.8%), necrosis (16.5%), and abscess (11.0%). Systemic manifestations were: bleeding (12.3%), acute renal failure (1.6%), and shock (0.7%). There were blood coagulation disorders in 1,730 (57.9%) of the 2,990 cases. There were 21 amputations (0.7%) and 9 deaths (0.3%). The average serum dose that was used in treatment fell down during the study period (p < 0.001).

Snake bites by the jararacuçu (Bothrops jararacussu): clinicopathological studies of 29 proven cases in São Paulo State, Brazil.

The jararacuçu, one of the most dreaded snakes of Brazil, southern Bolivia, Paraguay and northeastern Argentina, is a heavily-built pit viper which may grow to a length of 2.2 m. Up to 1000 mg (dry weight) of highly-lethal venom may be milked from its venom glands on a single occasion. It has accounted for 0.8% to 10% of series of snake bites in São Paulo State, Brazil. We examined 29 cases of proven jararacuçu bites recruited over a 20-year period in two São Paulo hospitals. Severe signs of local and systemic envenoming, (local necrosis, shock, spontaneous systemic bleeding, renal failure) were seen only in patients bitten by snakes longer than 50 cm; bites by shorter specimens were more likely to cause incoagulable blood. Fourteen patients developed coagulopathy, six local necrosis (requiring amputation in one) and five local abscesses. Two became shocked and four developed renal failure. Three patients, aged 3, 11 and 65 years, died 18.75, 27.75 and 83 h after being bitten, with respiratory and circulatory failure despite large doses of specific antivenom and intensive-care-unit management. In two patients, autopsies revealed acute renal tubular necrosis, cerebral oedema, haemorrhagic rhabdomyolysis at the site of the bite and disseminated intravascular coagulation. In one survivor with chronic renal failure, renal biopsy showed bilateral cortical necrosis; the patient remains dependent on haemodialysis. Effects of polyspecific Bothrops antivenom were not impressive, and it has been suggested that anti-Bothrops and anti-Crotalus antivenoms should be given in combination.

Snakebite by the bushmaster (Lachesis muta) in Brazil: case report and review of the literature.

The bushmaster (Lachesis muta) of Central and South America, the world's longest pit viper, is capable of injecting a large dose of potent venom when it bites. A 28-year-old man, bitten by a 1.82 m long L. m. muta in Brazil, developed pain and oedema at the bite site, nausea, vomiting, diarrhoea and sweating. There was peripheral neutrophil leucocytosis and evidence of fibrinogen consumption with secondary activation of the fibrinolytic system. Two hours after the bite, eight ampoules of Instituto Butantan Lachesis antivenom was administered, and haemostasis was normal 24 hr later. A review of reports of 20 cases of bites in humans reliably attributed to this snake in Costa Rica, French Guiana, Brazil, Colombia and Venezuela confirms a syndrome of nausea, vomiting, abdominal colic, diarrhoea, sweating, hypotension, bradycardia and shock, possibly autopharmacological or autonomic in origin, not seen in victims of other American crotaline snakes. These, and other symptoms of bushmaster envenoming, are explained by haemorrhagic, coagulant and neurotoxic venom activities. The therapeutic efficacy of non-specific Bothrops/Crotalus polyvalent antivenoms in these cases has been unimpressive. For the treatment of bites by a snake which potentially injects a large dose (> 300 mg dry weight) of venom with a range of life-threatening activities, there is an urgent need to develop more potent specific antivenoms and to treat the dramatic and life-threatening cardiovascular symptoms.