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RBBS Phenom Analysis

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The RBBS is reported to cause systemic envenoming, local envenoming, anticoagulant coagulopathy and myotoxicity (Churchman et al., 2010). Although neurotoxicity by RBBS venom has been demonstrated in in vitro models, there have been no cases of neurotoxicity in human envenoming (Hart et al., 2013; Ramasamy et al., 2005). Hence RBBS envenoming have not been regarded as severe and antivenom therapy is only recommended for patients with major systemic envenomation (White et al., 2001). In addition, hypersensitivity reactions and anaphylaxis to antivenom administration has been previously described (Churchman et al., 2010; Isbister et al., 2008, et al., 2012a). The rate of antivenom administration did not appear to have any association with increased …show more content…

Of special interest is the occurrence of significant rhabdomyolysis and myoglobinuria in our patient with a peak CK of 116000 U/L at 50 hours despite antivenom administration ≤6 h post envenomation. Previous cases with elevated CK levels have been reported in the Australian Snakebite Project (ASP-11). A 75 year old lady with a peak CK level of 46900 U/L developed severe myotoxicity which resulted in bulbar and intercostal muscle weakness and required non-invasive ventilation support. Another cited case was a 66 year old man who had a peak CK level of 56000 U/L but did not develop anuria or renal impairment. In that study, myotoxicity did not occur in any patients given early antivenom but occurred in 20% of patients who did not receive antivenom or was given delayed antivenom (Churchman et al., 2010). It was also noted that patients with myotoxicity had a longer median length of hospital stay than those with systemic envenomation without myotoxicity (Churchman et al., …show more content…

However, there was a rebound in total venom levels and free venom levels which contributed to the severe rhabdomyolysis that occurred in our patient. TSAV is the current therapy for RBBS envenoming as it is effective, cheaper and a lower mass of equine protein per ampoule is required (Pearn et al., 2000; White et al., 2001). The rebound of venom concentrations post TSAV administration in our patient was very unusual. It is the current understanding is that one vial of antivenom is sufficient to bind all venom as the venom levels were undetectable in patients post antivenom administration (Churchman et al., 2010; Group et al., 2012; White et al.,

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