Abstract
Introduction:Rhabdophis snakes, which include 27 species, are rear-fanged venomous snakes that are widely distributed from India to East Asia and Russia. Severe envenomation by R. tigrinus (Yamakagashi snake) in Japan and R. subminiatus in Southeast Asia has been reported. The epidemiology of R. tigrinus bites, such as geographical features, the incidence, and changes in the number of bites over time have not been comprehensively examined. Hence, we intended to clarify the epidemiological features of R. tigrinus bites through a careful review of scientific data over the last 50 years in Japan.
Methods: Patient records of R. tigrinus bites between 1971 and 2020 at the Japan Snake Institute were examined retrospectively. The following were ascertained: patient characteristics, clinical symptoms, laboratory data, treatment-related factors, and hospital mortality. These variables were compared in the antivenom and the without-antivenom groups.
Results: Over the 50-year study period, 43 R. tigrinus bites, including five fatal cases, were encountered. Severe cases of R. tigrinus bites have been treated with antivenom since 1985; however, fatalities occurred in 2006 and 2020. R. tigrinus bite cases have been well-distributed in the western part of Japan since 2000. The mortality rate in the antivenom group was significantly lower in the patient group that was not administered the antivenom (0 vs. 23.8%, p = 0.048).
Conclusion: This study clarified the epidemiology of R. tigrinus bites in Japan over a 50-year period. Almost all severe cases of R. tigrinus bites have been treated with the antivenom in the current situation, and fatalities occurred in cases not treated with the antivenom. It is important to diagnose R. tigrinus bites in the early phase of the clinical course. The antivenom, the definitive treatment for R. tigrinus bites, is an unapproved drug. Hence, approval needs to be obtained for the drug.
Introduction
Snakes of genus Rhabdophis include 27 species of rear-fanged venomous snakes that are widely distributed from India to East Asia and Russia. Severe envenomation by R. tigrinus (Yamakagashi snake) in Japan and R. subminiatus in Southeast Asia have been reported (1–5). Their bites lead to venom-induced consumption coagulopathy (VICC), resulting in hemorrhage (6, 7). The experimental use of antivenom against R. tigrinus bites was first tested in 1985 on immunized rabbits (1). Currently, the antivenom against R. tigrinus bites is provided for use only in clinical research because it is an unapproved drug in Japan (1, 4, 8). Our research group is currently working on the supply of antivenom as a serum therapy against R. tigrinus bites (9–13).
The clinical characteristics of R. tigrinus bites in Japan have been studied as part of a national survey from 2000 to 2013 (14), and its treatment (i.e., efficacy of R. tigrinus antivenom) has also been evaluated from 1973 to 2013 (15). However, the epidemiology of R. tigrinus bites, including the change of the geographical distribution and incidence over the time has not been well-studied.
In this study, we aimed to clarify the epidemiological features of R. tigrinus bites in Japan by retrospectively reviewing scientific data over the last 50 years.
Materials and Methods
This study was approved by the Institutional Review Board, St. Luke's International Hospital, with approval number 21-R093.
Patients and Setting
In 1968, the Japan Snake Institute (JSI) was founded in the Gunma Prefecture to conduct research and provide enlightenment on snakes (15). This institute provides medical support to physicians handling patients with venomous snake bites where diagnosis is sometimes achieved based on patient history, laboratory analyses, and clinical symptoms. In this study, we conducted a retrospective review by collecting clinical data and all recorded cases of R. tigrinus bites at JSI from January 1, 1971, to December 31, 2020.
Diagnosis of R. tigrinus Bites
The diagnosis of R. tigrinus bites was based on the patients' description of the snakes and the presence of VICC in patients with hypofibrinogenaemia.
Data Collection
Data on age, sex, date of injury (year), place of injury, clinical symptoms, laboratory analyses, treatment-related factors, and hospital mortality were recorded.
Primary Data Analyses
Statistical Analysis
To compare the data pertaining to patient characteristics, treatment-related factors and outcomes between the antivenom patient group and the without-antivenom group, the Mann–Whitney U-test or the Chi square (χ2) test was used. Furthermore, the Fisher exact test for 2 × 2 categorical variables was used when appropriate. P-values < 0.05 were considered statistically significant. All analyses were completed using the JMP version 11 (SAS, Cary, North Carolina) software.
Results
Demographic and Clinical Characteristics of the Patients
Table 1 summarizes the patient characteristics. Over the 50-year study period, 43 R. tigrinus bite patients were recognized. The median age was 37 years, and 97.7% were men.
Table 1
| Characteristics | All (n = 43) |
|---|---|
| Age (years) | 37 (12–57) |
| Sex, male | 42 (97.7) |
| Clinical symptoms | |
| Nasal bleeding | 4 (10.8) |
| Gum bleeding | 15 (40.5) |
| Bleeding from the bite sites | 29 (80.6) |
| Headache | 6 (16.7) |
| Laboratory data | |
| Platelet counts (× 104/mm3) | 10.9 (5.7–15.6) |
| Fibrinogen (mg/dL) | 35 (20–50) |
| PT-INR | 4.4 (2.3–7) |
| FDP (μg/mL) | 200 (80.3–320) |
| Treatment | |
| PE | 4 (10.8) |
| Outcome | |
| Mortality | 5 (11.9) |
Population characteristics of the patients.
Data are presented as median (interquartile, IQR) for continuous variables and n (percentage) for categorical variables.
PT-INR, prothrombin time international ratio; FDP, fibrinogen degradation products; PE, plasma exchange.
Missing data: Age = 0, Sex male = 0, Nasal bleeding = 6, Gum bleeding = 6, Bleeding from the bite sites = 7, Headache = 7, Platelet counts = 19, Fibrinogen = 19, PT-INR = 23, FDP = 16, PE = 6, Mortality = 1.
Geographical Features of R. tigrinus Bites
R. tigrinus bite cases were found in almost all parts of Japan, except Hokkaido and Okinawa areas, and have been distributed in the western part of Japan since 2000. Fatalities have been limited to the western part, and specifically, there have been two fatalities in the Okayama Prefecture (Figures 1A–C).
Figure 1
Trends in R. tigrinus Bites Over the Last 50 Years
During the past 50 years, there have been several cases with R. tigrinus bites at intervals of 5 years. A fatal case tends to occur approximately once every 10 years (Figure 2A).
Figure 2
Relationship Between Age and Number of R. tigrinus Bite Cases
The relationship between age and the number of R. tigrinus bites is characteristic, with a clear peak in the teens. Fatal cases were observed in the elderly and children (Figure 2B).
Trends in Patients Treated With Antivenom Over the Last 50 Years
The first case of antivenom administration was in 1985, and almost all severe cases have been treated with the antivenom since then (Figure 3).
Figure 3
Comparison of Clinical Characteristics Between the Antivenom and Without-Antivenom Patient Groups
Table 2 presents the clinical features observed in the antivenom and without-antivenom groups. No significant differences were observed in the baseline characteristics and results of laboratory analyses between the two groups. The mortality rate in the antivenom group was significantly lower in the patient group that was not administered the antivenom (0 vs. 23.8%, p = 0.048).
Table 2
| Characteristics | Antivenom group (n = 21) | Without-antivenom group (n = 22) | P |
|---|---|---|---|
| Age (years) | 20 (11–51) | 42 (12–61) | 0.451 |
| Sex, male | 20 (95.2) | 22 (100) | 0.488 |
| Clinical symptoms | |||
| Nasal bleeding | 1 (4.8) | 3 (18.8) | 0.300 |
| Gum bleeding | 8 (38.1) | 7 (43.8) | 0.749 |
| Bleeding from the bite sites | 17 (85.0) | 12 (75.0) | 0.675 |
| Headache | 3 (15.0) | 3 (18.8) | 1.00 |
| Laboratory data | |||
| Platelet counts ( × 104/mm3) | 12.5 (7.3–17.3) | 9.5 (2.9–12.2) | 0.213 |
| Fibrinogen (mg/dL) | 35 (28–50) | 33 (10–52) | 0.532 |
| PT-INR | 5.8 (2.8–7) | 2.6 (2–5.5) | 0.094 |
| FDP (μg/mL) | 262 (173–397) | 160 (70–284) | 0.070 |
| Treatment | |||
| PE | 1 (4.8) | 3(18.8) | 0.296 |
| Outcome | |||
| Mortality | 0 (0.0) | 5 (23.8) | 0.048 |
Comparison of clinical characteristics between the antivenom and without-antivenom patient groups.
Data are presented as median (interquartile, IQR) for continuous variables and n (percentage) for categorical variables.
PT-INR, prothrombin time international ratio; FDP, fibrinogen degradation products; PE, plasma exchange.
Missing data (Antivenom group): Age = 0, Gender male = 0, Nasal bleeding = 0, Gum bleeding = 0, Bleeding from the bite sites = 0, Headache = 1, Platelet counts = 9, Fibrinogen = 4, PT-INR = 8, FDP = 4, PE = 0, Mortality = 0.
Missing data (Without-antivenom group): Age = 0, Gender male = 0, Nasal bleeding = 6, Gum bleeding = 6, Bleeding from the bite sites = 7, Headache = 6, Platelet counts = 10, Fibrinogen = 15, PT-INR = 15, FDP = 12, PE = 6, Mortality = 1.
Details of Fatal Cases
Details of fatalities are provided in Table 3. There have been two deaths since 2000 after the development of the antivenom. Our research group obtained the relevant clinical information after death or brain death in the two fatal cases. None of the fatal cases were treated with R. tigrinus antivenom. Cerebral hemorrhage was observed in least three out of five cases.
Table 3
| Characteristics | Clinical symptoms | Laboratory data | Treatment | Outcome | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Case | Year | Area | Age | Sex | Nasal bleeding | Gum bleeding | Bleeding from the bite sites | Headache | Platelet counts (× 104/mm3) | Fibrinogen (mg/dL) | PT-INR | FDP (μg/mL) | Antivenom | Hospital stay | Brain bleeding |
| 1 | 2020 | Okayama | 80 | M | 0 | 0 | 1 | 0 | 11 | 50 | 2.12 | N/A | 0 | 1 | 1 |
| 2 | 2006 | Fukuoka | 75 | M | 0 | 0 | 1 | 0 | 1.8 | 50 | 2.62 | 271.5 | 0 | 6 | 1 |
| 3 | 1984 | Aichi | 14 | M | 0 | 0 | 1 | 1 | 9 | 5 | N/A | 40 | 0 | 10 | 1 |
| 4 | 1982 | Yamaguchi | 6 | M | 0 | 0 | 0 | 0 | N/A | N/A | N/A | N/A | 0 | 4 | N/A |
| 5 | 1972 | Okayama | 61 | M | 0 | 1 | 1 | 1 | N/A | 20 | N/A | N/A | 0 | 60 | N/A |
Clinical characteristics of fatal cases among R. tigrinus bite patients in Japan (1971–2020).
PT-INR, prothrombin time international ratio; FDP, fibrinogen degradation products; DIC, disseminated intravascular coagulation; PE, plasma exchange; N/A, not available.
Discussion
Over the 50-year study period, 43 cases of R. tigrinus bites, including five fatalities, were identified. Patients with R. tigrinus bites have been treated with the antivenom since 1985, and fatalities occurred in 2006 and 2020 in patients who were not treated with the antivenom.
Our survey showed that R. tigrinus bite cases have been well-distributed in the western part of Japan since 2000. Fatalities have also been limited to the western part. This finding is similar to the cases of pit viper bites reported previously (9, 10) and could be attributed to the short activity period due to the long winter experienced in the Tohoku and Hokuriku regions. Although the number of R. tigrinus cases is uncertain, it is believed that its density is less in the Tohoku and Hokuriku regions than in the western part of Japan mainly due to the varying climatic situations. The density of frogs, which are their bait, is also less in these regions than in western Japan, which affects the snake population.
The population of R. tigrinus is getting smaller (1). However, the number of R. tigrinus bites has remained almost constant. This discrepancy may be because many children, especially those who intentionally play with snakes, are bitten repeatedly, which allows the venom to enter the body and result in toxic bites (16).
Since the development of the antivenom for R. tigrinus bites in 1985, the number of fatalities has been reduced owing to the aggressive administration of the antivenom. However, two fatalities occurred in elderly people, both of whom were confirmed to have died from complications related to R. tigrinus bites. No fatalities have been observed among patients treated with the antivenom, which suggests that it is important to diagnose R. tigrinus bites in patients with unexplained severe coagulopathy (17) in the early phase of the clinical course. Raising awareness not only in the departments of emergency and intensive care but also in the fields of pediatrics and neurosurgery is imperative.
This study clarified the epidemiology of R. tigrinus bites in Japan over a 50-year period. The antivenom was experimentally manufactured by regional health laboratories; however, its sterility and safety were not guaranteed (1). The Ministry of Health, Labor and Welfare of Japan, launched a research group to evaluate the safety and efficacy of the antivenom and to collect information on R. tigrinus bites in 2013 (18). The antivenom is stocked in some institutions and supplied to the hospital under the direction of the principal investigator in this research. Clinical characteristics and details of treatment, including the adverse effects of the antivenom, are recorded for all cases and analyzed to ensure proper safety (14). Therefore, based on the 50-year data, we plan to negotiate with the relevant authorities to obtain approval for the drug. Furthermore, the R. tigrinus species is not only found in Japan but also in Asia, and it is necessary to use these data to educate people in China and other countries where it is considered a non-toxic bite.
We observed some limitations in this study. Ours was a retrospective study, and a small sample size was utilized. There is the possibility of a selection bias since the cases reported were limited to our center only. The consistency of the type of data collected data, and the accuracy of data varied over the 50-year period, particularly in case of the laboratory data varies for the period of 50 years. Furthermore, some cases may have remained undiagnosed or misdiagnosed due to the unusual symptoms associated with this rare snakebite.
Conclusion
Over the 50-year study period, 43 cases of R. tigrinus bites, including five fatal cases, were identified. Almost all severe cases of R. tigrinus bites have been treated with the antivenom in the current situation, and fatalities occurred in patients who were not treated with the antivenom. It is important to diagnose R. tigrinus bites in patients with unexplained severe coagulopathy in the early phase of the clinical course. The antivenom, the definitive treatment for R. tigrinus bites, is an unapproved drug. Hence, it is necessary to obtain approval for this drug.
Funding
This work was supported by the Research Program on Emerging and Re-emerging Infectious Disease from the Japan Agency for Medical Research and Development (AMED) 20fk0108101.
Publisher's Note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Statements
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics statement
The studies involving human participants were reviewed and approved by St. Luke's International Hospital. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.
Author contributions
TH and AS was responsible for conception of the article and drafted and revised the manuscript. AY, KM, NO, MT, and MA revised the manuscript. All authors read and approved the final manuscript.
Conflict of interest
KM was employed by company KM Biologics Co., Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Summary
Keywords
snake envenomation, antivenom, disseminated intravascular coagulation, neglected tropical disease, Yamakagashi
Citation
Hifumi T, Sakai A, Yamamoto A, Morokuma K, Otani N, Takahashi M and Ato M (2022) Rhabdophis tigrinus (Yamakagashi) Bites in Japan Over the Last 50 Years: A Retrospective Survey. Front. Public Health 9:775458. doi: 10.3389/fpubh.2021.775458
Received
14 September 2021
Accepted
30 November 2021
Published
10 January 2022
Volume
9 - 2021
Edited by
Anjana Silva, Rajarata University of Sri Lanka, Sri Lanka
Reviewed by
Kalana Prasad Maduwage, University of Peradeniya, Sri Lanka; Yasuhiro Kuroda, Kagawa University, Japan; Juan J. Calvete, Spanish National Research Council (CSIC), Spain
Updates
Copyright
© 2022 Hifumi, Sakai, Yamamoto, Morokuma, Otani, Takahashi and Ato.
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*Correspondence: Toru Hifumi hifumitoru@gmail.com
This article was submitted to Disaster and Emergency Medicine, a section of the journal Frontiers in Public Health
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.