Terrestrial Snakebites in the South East of the Arabian Peninsula: Patient Characteristics, Clinical Presentations, and Management

and Management. PLoS ONE 6(9): e24637. doi:10.1371/journal.pone.0024637 Terrestrial Snakebites in the South East of the Arabian Peninsula: Patient Characteristics, Clinical Presentations, and Management Juma M. Alkaabi 0 1 Mariam Al Neyadi 0 1 Fakhra Al Darei 0 1 Mariam Al Mazrooei 0 1 Jawaher Al Yazedi 0 1 Abdishakur M. Abdulle 0 1 Vineet Gupta, University of Pittsburgh Medical Center, United States of America 0 This retrospective case series study was conducted by the Department of Internal Medicine, Faculty of Medicine & Health sciences, UAE University in collaboration with three main hospitals in the region; Tawam, and Al-Ain hospitals; Al-Ain, UAE, and Buraimi Hospital; Buraimi, Sultanate of Oman. The three hospitals provide emergency services in the region around the clock. The estimated catchment population size in the region is approximately 650 , 000 (Al Ain 500,000 and Buraimi 150,000) 1 1 Department of Internal Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University , Al Ain , United Arab Emirates , 2 Department of Internal Medicine, Buraimi Hospital , Buraimi, Sultanate of Oman Background: To describe the characteristics, clinical presentations, management and complications of snakebites in the border region between Al-Ain, United Arab Emirates (UAE) and Buraimi, Sultanate of Oman. Methodology/Principal Findings: We carried out a retrospective review of medical records to study snakebite cases over four-year duration at three tertiary hospitals. Overall, 64 snakebite cases were studied with median hospitalization of 2 (interquartile range [IQR] 1-4) days. The majority of cases were male (87.5%), and most (61%) of the incidents occurred during summer months. The bite sites were predominantly (95%) to the feet and hands. Main clinical features included pain, local swelling, and coagulopathy, blistering and skin peeling. Overall, there were no deaths, but few major complications occurred; extensive skin peeling (n = 5, 8%), multi-organ failure (n = 1, 1.5%), and compartment syndrome (n = 1, 1.5%). Polyvalent anti snake venom (ASV), analgesia, tetanus toxoid, intravenous fluids, and antibiotics such as ampicillin, cloxacillin, and cephalosporins were commonly instituted as part of treatment protocols in the three hospitals. Conclusion: The overwhelming majority of bites occurred during summer months, and envenomations were more common in, relatively, young male farmers, but with no serious clinical complications. Prevention and treatment strategies should include increasing public awareness, developing management guidelines, and manufacturing specific ASV for a wide spectrum of the local venomous snakes. - Snakebites are a common problem in many parts of the world and account for a considerable morbidity and mortality due to envenomation [1,2]. Recent studies have shown that snake envenomation is more common among poor communities with the highest burden of mortality being reported in countries least able to cope with the high cost of anti snake venom (ASV) treatment [3]. Such burden has been reported in, among other countries, South and Southeast-Asia, and Sub-Saharan Africa [2,4]. However, little is known about the magnitude of snakebites in the Middle East, and more so in the Arabian Gulf countries. Whilst, snakebites are not widely reported in this part of the world, available data in the literature indicates that the most common venomous snakes in the Middle East are vipers; Cerastes gasparetti, Echis carinatus, Echis coloratus, and Pseudocerastes persicus [5,6,7], and non-vipers; mainly Colubridae, Atractaspididae and Elapidae species [8,9]. The in-land and arid ecoregion in the South Eastern part of the Arabian Gulf i.e. United Arab Emirates (UAE) and Oman comprises sparse vegetations, sand dunes, gravel plains, rugged mountains, and scattered oases. In particular, the climate in AlAin and Buraimi cities, located in the border between the two countries (Figure 1), is relatively less humid, though warm in nature, with abundant agricultural activities as compared to the major coastline cities of the two countries. Such climate may constitute a favorable habitat for higher incidents of snakebites [2]. We, therefore, carried out a retrospective case series study to review medical records with the aim of describing patient characteristics, clinical presentations, and management of snakebites in three regional tertiary hospitals. Materials and Methods Participating hospitals were selected based on the realization that ASV was available only at these government hospitals. Medical records were reviewed if the final discharge diagnosis indicated an incident of snakebite based on the electronic registry of the study sites (hospitals). Snakebite was recorded if the subjects have seen the snake or if the appearance of the puncture sites was convincingly of snakebite. The exclusion criteria included any other forms of bites which are not in keeping with snakebites. Cases of snakebites were reviewed over duration of four years from December 2005 to December 2009. A data collection sheet was used to extract relevant information pertaining patient characteristics, clinical presentations, laboratory investigations, and treatment regimens. Three medical students collected the data as part of a summer research assignment and the students were involved in the study design, data collection, and data interpretation process. Prior to data collection, students were given orientation sessions on how to extract uniform and accurate data from the medical records. To minimize interpersonal variability in the data collection process, all students worked as a team. The collection sheet was pre tested in 10 cases and, where applicable, changes were made accordingly. Subsequently, the principal investigator reviewed the quality and accuracy of the collected data before and after data entry. Given the retrospective nature of the study, there was no direct involvement of human subjects, and thus no written or verbal consent was necessary. The protocols of this study were approved by the Al-Ain Medical District Human Research Ethics Committee, and Buraimi Hospital. Statistical Methods Standard descriptive and analytical statistical methods for univariate and bivariate analysis, such as mean, median, standard deviation (SD), Chi-square, Mann-Whitney tests and Spearmans correlation coefficient were used. For all analyses SPSS v18.0 was used. P-values,0.05 (2-sided where applicable) were considered statistically significant. Table 1 shows the demographic characteristics of the study population. A total of sixty-four cases (87% males) of snakebites were studied. On average, the annual frequency of snakebite was 6 in Buraimi; 6 in Al Ain; and 4 in Tawam. There were no statistically significant changes in the number of snakebite cases between the four studied years (P,0.6). This might, however, be attributed to the short duration of the observation and the (...truncated)