What are the other Names for this Condition? (Also known as/Synonyms)

• Elegant Pit Viper Snake Bite
• Protobothrops Elegans Snake Bite
• Trimeresurus Elegans Snake Bite

What is Sakishima Habu Snake Bite? (Definition/Background Information)

• The sakishima habu (Protobothrops elegans) is a venomous snake that is found only in the Ryuku Islands, a chain of islands that is part of Japan. The snake belongs to the subspecies of pit vipers, family Viperidae, and is also known as the elegant pitviper
• Pit vipers are termed so, due to the presence of certain heat-sensing organs located in a recess/notch between their eyes and nostrils. Sakishima habu preys on small rodents and amphibians, including birds
• It is mostly a diurnal reptile that can be found in the forests, at the edge of forests (clearances), and near human cultivations, among bamboo and sugarcane crops. It can also climb large plants and small trees
• The snake is grey, or brown, to orange in color (juveniles are lighter in tone) with characteristic black markings, a medium slender body, short tail, and triangular head. Sakishima habu can grow up to 3 or 4 feet in length
• Since the snake is found to reside close to human dwellings and among agricultural crops, contact with humans is not uncommon. Sakishima Habu Snake Bites can cause moderate envenomation (venom injection) and result in possible deaths without early treatment
• The signs and symptoms of Sakishima Habu Snake Bite may include localized pain at the bite site, swelling, and blistering. Systemic symptoms are infrequent, but may include tissue damage, shock, bleeding problems, and rarely kidney function failure
• Early administration of suitable antivenom (or antivenin) is the mainstay of treatment. Apart from this, symptomatic treatment is necessary, which may include pain medication and respiratory support. The prognosis of Sakishima Habu Snake Bite with prompt and effective therapy is usually good

Who gets Sakishima Habu Snake Bite? (Age and Sex Distribution)

• Sakishima Habu Snake Bite may occur to any individual exposed to the snake
• Individuals of any age and gender are prone to snake bites
• The snake is endemic to the Ryuku Islands (Japan) including the Okinawa, Sakishima, Irimoke, Ishigaki, and Miyako islands. It is not reported outside the region

What are the Risk Factors for Sakishima Habu Snake Bite? (Predisposing Factors)

The risk factors for Sakishima Habu Snake Bite include the following factors:

• Living or residing in areas where the sakishima habu is found; there is a high risk for people in the endemic zones, in the country side and rural regions
• Farmers and agriculture workers have a high risk for snake bites in the region (occupational hazard), since the snake can blend into its surroundings and be difficult to spot
• Using unprotected hands to remove weeds and unwanted plants, plucking fruits and flowers, etc.
• Walking barefoot or unprotected through undergrowths, fields, near walk tracks, and forest clearings
• Hiking and trekking in the endemic regions; mountain climbing in unknown terrain
• Venturing outdoors during the night without adequate protection
• Wildlife enthusiasts and scientific study groups, who explore the region
• Keeping them as pets
• Handling dead or live snakes; intentionally or accidentally picking up the snake
• Children, elderly adults, and individuals with weak immune system have a higher risk for severe symptoms

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Sakishima Habu Snake Bite? (Etiology)

Sakishima Habu Snake Bite can take place when one comes into contact with the venomous snake, usually unintentionally or inadvertently.

• The venom is hemotoxic and can cause bleeding and coagulation defects; the severity of symptoms though, depend on a combination of factors such as the size of the snake and the health of the individual bitten
• Most of the bites are on the arms or legs and some reports indicate that in over 80% of the cases, envenomation is observed

What are the Signs and Symptoms of Sakishima Habu Snake Bite?

The signs and symptoms of Sakishima Habu Snake Bite can vary from one individual to another. The signs and symptoms depend on the age (whether child or adult), weight, and overall health status of the individual (whether having an underlying condition or illness). Also, the signs and symptoms vary according to the potency and amount of venom injected.

The signs and symptoms may develop within a few minutes to hours and may include:

• Severe burning pain at the bite site; presence of noticeable fang marks, which may be more than two (or even a single mark may be noted)
• Skin discoloration at the bite site
• Cyanosis - the skin and mucus membranes (including nails and palms) may show bluish discoloration
• Blistering of skin
• Swelling at the bite site that slowly involves a wider region
• Bleeding from the wound
• Chills and sweating
• Breathing difficulties
• Chest pain
• Nausea and vomiting
• Death of tissue (or necrosis) around the affected region or limb, observed within a few days
• Low blood pressure
• Feeling faint or dizzy
• Weakness and malaise

Some of the systemic signs and symptoms may include:

• Bleeding disorder
• Internal hemorrhaging may be noted
• Acute kidney failure, in rare cases
• Neurological symptoms are not usually seen

Note:

• In some cases, the fang marks may not be pronounced or even visible. Sometimes only small scratch marks or lacerations may be observed. Thus, any contact with a sakishima habu merits immediate medical attention
• Severe anxiety may also result in some misleading symptoms of snakebites, such as sweating, fatigue, and shock, even when no bite has taken place (the individual may be imagining), or when it is a dry bite. Nevertheless, even in suspect cases, the presence of any such symptoms requires the attention of a qualified medical professional
• Also, if the individual has been treated using alternative/native medicines, it may present additional confusing symptoms. Thus, it is important to always consult a qualified healthcare provider promptly

How is Sakishima Habu Snake Bite Diagnosed?

Sakishima Habu Snake Bite may be diagnosed using the following tests and exams:

• Complete physical examination with comprehensive evaluation of medical history; a physical examination of the affected site by the physician may be normally sufficient to diagnose a snake bite
• The individual may be asked to provide an account (history) of the events that occurred (what took place and how), if possible
• Assessment of the signs and symptoms exhibited by the individual may be carefully observed
• Blood tests that may include: (many of these tests are repeated over the course of treatment)
  • Complete blood count (CBC) with differential and platelet count
  • White blood cell count
  • Hematocrit blood test: Hematocrit is the proportion of blood that is made up of red blood cells
  • Prothrombin time (PT) and partial thromboplastin time (PTT) tests
  • Fibrinogen blood test
  • Lactate dehydrogenase (LDH) test
  • Serum electrolytes including blood urea nitrogen (BUN) and creatinine levels
  • Arterial blood gas
• Urine test or urinalysis to test for free protein, myoglobin, and hemoglobin levels
• Continuous urine output monitoring is helpful to determine damage to the kidneys, if any
• Electrocardiogram (ECG)
• Kidney function test
• Liver function test

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Sakishima Habu Snake Bite?

The complications of Sakishima Habu Snake Bite may include:

• Multiple bites, causing injection of a large quantity of venom
• Blood clotting defects resulting in severe internal bleeding may take place
• Occasionally, disseminated intravascular coagulation (DIC) resulting in blood clot formation in the body
• Severe deep tissue and muscle damage of the affected leg or hand, which can result in superimposed infections and gangrene formation
• Increased pressure causing compartment syndrome, which is an urgent medical condition
• Loss of limb function; permanent disability
• Rhabdomyolysis from injury to the muscles, caused due to compartment syndrome
• Severe shock
• Seizures and coma
• Kidney failure
• Multiple organ failure

Presence of misleading symptoms due to fear and anxiety, which may be also aggravated by those around the individual, such as one’s family members, can sometimes result in inappropriate or over-treatment.

Antivenom reactions:

• Some individuals may develop an allergic reaction, such as anaphylaxis, to the antivenom that may be serious. This may develop within 10 minutes or even after 6 hours, typically starting with itchiness over the scalp and other skin areas
• Life-threatening anaphylactic reactions that require immediate medical treatment may include:
  • Low blood pressure or hypotension
  • Bronchospasm causing narrowing of the airways (bronchi) resulting in breathing difficulties
  • Angioedema: Swelling of skin tissue layers at various locations including the throat, causing speaking and breathing difficulties
• Serum sickness may develop as a complication of antivenom therapy causing fever, nausea, itchy skin, muscle and joint pain, etc. It may develop after 4 days or even 2 weeks (average 7 days) following the administration of antivenom serum

Cardiovascular, hematological, and kidney abnormalities can result in severe complications including death.

How is Sakishima Habu Snake Bite Treated?

All snake bites should be considered as medical emergencies and evaluated by trained medical professionals, as soon as possible; the first 6-8 hours are particularly vital for preventing life-threatening symptoms. Failure to obtain early assessment and management from the highest level of care (available within the community) may potentially result in severe complications and death.

The following measures may be considered in the treatment of Sakishima Habu Snake Bite, based on the medical evaluation of a trained healthcare professional:

• Administration of intravenous fluids to keep the patient well-hydrated; pain medication
• Administration of anti-snake venom (ASV) to neutralize the venom through slow intravenous injection or infusion method
• Address any signs or early allergic reaction: A close observation of the patient is necessary for a minimum of 60 minutes immediately following antivenom administration, to detect early allergic reactions, if any
• Periodic blood and urine tests are undertaken for 12-24 hours or more
• Tetanus vaccination is usually required, if it is not up to date
• The patient is generally admitted and placed in an ICU setting and monitored for at least a day following the abatement of symptoms; the patient has to be rested and kept warm
• Strict bed rest to prevent trauma may be advocated in case of hemostatic abnormalities that arises from a hemotoxic/cytotoxic venom (the venom can result in increased bleeding tendencies leading to substantial blood loss even to minor trauma)
• If necessary, blood and plasma transfusions for severe cases
• Intubation and respiratory support, if necessary
• Providing life support, such as ventilation assistance and treatment for shock, for those with severe symptoms leading to potential organ failure
• Medications to control blood pressure
• Peritoneal dialysis for acute kidney failure
• Pressure management (using appropriate pressure devices) of affected limb for compartment syndrome
• Removal or necrotic tissue through surgical debridement
• Rehabilitation of the affected limb through physical therapy
• Unless infection or tissue necrosis is observed, the administration of prophylactic antibiotics is generally not recommended in snake bites. However, the healthcare provider will determine whether antibiotics administration is necessary or not, based on one’s individual circumstances

Note:

• Consultation with a medical toxicologist is recommended for all cases requiring the administration of anti-snake venom
• Even though antivenom therapy is the key treatment for systemic envenomation; on its own, it may never be adequate enough to completely resolve the condition. Other supportive and symptomatic measures are always necessary to save the patient
• The dose of antivenom does not vary for a child, adult, or even for a pregnant woman, since the snake typically injects the same quantity of venom into an individual
• Gynecological evaluation may be necessary for pregnant women bitten by snakes to evaluate the health of the fetus
• In many instances, the type of venomous snake involved in the bite is unknown; hence, all vital organs and systems should be closely monitored and treated appropriately, as necessary

How can Sakishima Habu Snake Bite be Prevented?

Sakishima Habu Snake Bite may be avoided by:

• If you spot a sakishima habu, step back slowly and keep a safe distance of at least 8-10 feet or more (between yourself and the snake)
• Be particularly vigilant during peak agricultural activities, harvest times, and rainy periods
• Being alert, if you are in snake-infested regions, particularly containing dangerous species of snakes. Also, if possible, never venture out alone (always have someone along with you)
• Be on the lookout for snakes and other animals while trekking or hiking; also, if you are with a pet, do not allow the pet to wander away
• Always allow snakes crossing your path the right of way
• Always stay on established paths and clearings, while walking in the woods, grasslands, or through thick undergrowths
• Avoid picking up firewood sticks, stones, or rocks without checking the area for any concealed creatures
• Always check before sitting on dead tree logs, stumps, or a pile of rocks; use a stick to stir or probe around the area
• Do not reach out to move or hold bushes or tree branches without properly examining them for any camouflaged creatures such as snakes
• Watch where you place your hands while climbing a ledge, trees, rocky slopes, or mountains
• Carry a snake bite kit, if possible, when traveling through areas containing highly venomous snake species
• Avoiding being outdoors at night in forested areas; be careful while camping outdoors
• Avoid tall grassy areas or thick bushes; if you plan to explore the area, use heavy boots and thick pants
• While walking outdoors at night, use a flashlight or lamp and make constant noise (singing or talking to others) or large stomping sounds that may alert the snake to move away from the region
• Ensure that employers provide adequate protective clothing (gloves, boots, etc.) to those who work in high-risk (for snake bite) occupations such as agriculture or fishing industry
• Natural disasters, such as floods and forest fires, are known to drive out snakes and other creatures into homes seeking shelter. Hence, always remain vigilant when returning home following such situations
• Avoid playing with or teasing snakes such as by touching their tails
• Do not pick up dead snakes - they may be poisonous and still bite through a reflex action
• Do not reach into dark nooks/corners/recesses with your bare hands/foot
• Teach and educate children about the dangers and importance of snakes
• Take steps to educate the members of a community to identify venomous snakes, recognize bite symptoms, and how to avoid encounter with snakes
• Completely avoid any form of native or traditional treatment for snake bites

Both large and small snakes have the potential for severe envenomation; hence, all snake bites should be treated promptly and appropriately.

What is the Prognosis of Sakishima Habu Snake Bite? (Outcomes/Resolutions)

• The prognosis of Sakishima Habu Snake Bite is dependent on the size of the snake, site of bite, age and overall health of the individual, promptness of medical response, and continued observance and treatment of complications following admission of the patient. In many cases, the prognosis is good with immediate treatment and administration of antivenom
• In the absence of adequate treatment, bites resulting in severe symptoms and a few cases of deaths due to envenomation have been mostly reported among elderly adults

Additional and Relevant Useful Information for Sakishima Habu Snake Bite:

• There are four types of habu (referring to venomous pitviper snake in Japanese) in the Okinawa Prefecture and these include the Okinawa habu, hime habu, sakishima habu, and the Taiwan habu
• In some cases, the snake bite may be a ‘dry bite’, meaning that even though there is a bite mark, no venom injection occurs. However, even for dry bites, the patient must be placed under observation and monitored closely for a period ranging anywhere from 12-24 hours, prior to discharge

Depending on the geographical region, either monovalent antivenom or polyvalent antivenom may be administered for systemic envenomation. Monovalent antivenom neutralizes venom of a single snake species only, whereas polyvalent antivenom can neutralize the venom of several snake species.

The snake venom is a highly complex mix of several proteins, enzymes, amino acids, peptide chains, fats, and even certain metals. The bite causing venom injection into the body may be categorized as:

• Intramuscular injection: Long-fanged snakes have a potential for injecting venom directly into the muscles (this is highly infrequent though)
• Intraperitoneal injection: When the snake bite involves the stomach or abdomen region
• Intravenous injection: In very rare cases, the snake fangs may inject venom directly into a blood vessel, releasing venom directly into blood (posing an even greater danger than normal snake bites)
• Subcutaneous injection: A majority of snake bites involve the subcutaneous skin layers (venom is injected just below the skin surface)