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Reply to ‘Antivenom treatment for snakebite envenoming’

Nature Reviews Disease Primers volume 10, Article number: 60 (2024) Cite this article

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We would like to thank Jin-Long Wang for his correspondence on our Primer (Gutiérrez, J. M. et al. Snakebite envenoming. Nat. Rev. Dis. Primers 3, 17063 (2017))1, which draws attention to the omission in the Primer of the detection of an enlarged tender lymph node draining the bitten limb as a clinical indication for antivenom administration (Wang, J.-L. Antivenom treatment for snakebite envenoming. Nat. Rev. Dis. Primers https://doi.org/10.1038/s41572-024-00543-9 (2024))2. We note that in both the 20103 and 20164 editions of the Snakebite Management Guidelines by the WHO Regional Office for South-East Asia, enlarged lymph node was included among clinical features of snakebite envenoming, ‘one or more’ of which was listed as indication for specific antivenom treatment.

However, although we mention tender regional lymph node enlargement as a clinical feature of both viperid and elapid envenoming in our Primer, we do not include it in Table 1 (‘Criteria for antivenom treatment’) because we do not regard it as a justifiable sole indication for antivenom. The reason for our decision is that increasing numbers of reports have revealed secondary bacterial wound infections complicating snakebite envenoming. These secondary infections will result in local lymphadenopathy, even in the absence of systemic envenoming, and are an indication for appropriate antibiotics and, in some cases, surgical debridement5. In the early stages of envenoming, before infection is evident, local tender lymph node enlargement, sometimes with overlying bruising and lymphangitic lines, may provide evidence of lymphatic venom spread.

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References

  1. Gutiérrez, J. M. et al. Snakebite envenoming. Nat. Rev. Dis. Primers 3, 17063 (2017).

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  2. Wang, J.-L. Antivenom treatment for snakebite envenoming. Nat. Rev. Dis. Primers https://doi.org/10.1038/s41572-024-00543-9 (2024).

  3. WHO Regional Office for South-East Asia. Guidelines for the management of snakebites 1st edn (WHO, 2010).

  4. WHO Regional Office for South-East Asia. Guidelines for the management of snakebites 2nd edn (WHO, 2016).

  5. Warrell, D. A. & Williams, D. J. Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet 401, 1382–1398 (2023).

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Authors and Affiliations

  1. Experimental Medicine Division, John Radcliffe Hospital, Headington, Oxford, UK

    David A. Warrell

  2. Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica

    José María Gutiérrez

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  1. David A. Warrell
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  2. José María Gutiérrez
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Correspondence to José María Gutiérrez.

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Warrell, D.A., Gutiérrez, J.M. Reply to ‘Antivenom treatment for snakebite envenoming’. Nat Rev Dis Primers 10, 60 (2024). https://doi.org/10.1038/s41572-024-00544-8

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