Lachesis Bites in Brazil: 2 Cases
Rodrigo C. G. de Souza1; Ana Paula Bhering Nogueira2; Tiago Lima3; João Lui
November 21, 2007
View comments about this article!
The enigma of the north margin of the Amazon River: proven Lachesis bites in Brazil, report of two cases, general considerations about the genus and
Rodrigo C. G. de Souza1; Ana Paula Bhering Nogueira2; Tiago Lima3; João Luiz C. Cardoso4
Reprinted from Bull. Chicago Herp. Soc. 42(7):105-115
1 Itacaré Medical Foundation, Itacaré, Bahia State,
2 Physician, Municipality of Itacaré, Bahia State, Brazil
3 Biologist, Belo Horizonte, Minas Gerais State, Brazil
4 Vital Brazil Hospital - Butantan Institute, São Paulo, São Paulo State, Brazil
Abstract: Confirmed snakebite accidents involving Lachesis vipers (“surucucu”) are rare in the
literature. We present two cases that occurred recently in the southern region of Bahia State - Brazil. These two cases were singled out of a series of nine
accidents. Both presented intense local pain, edema, mild local ecchymosis, local hemorrhage and dramatic systemic alterations within the first 30 minutes
after the bite: hypotension, vomit and diarrhea, sinus bradycardia configuring a pre-chock state. Both
patients were treated with antivenom within 60 minutes of the accident: one received 20 I.V. vials of Bothropic-Lachetic Antivenom ('BLA' - Butantan
Institute) and the other received 10 I.V. vials of Bothropic-Lachetic Antivenom (Butantan Institute). Both patients recovered fully. Few laboratorial tests
were made and both snakes were positively identified. Accidents in the north margin of the Amazon River seem to present different signs and symptoms. The
objective of this case report is to contribute for a better understanding of these envenomings and of the genus as a whole, aiming at early diagnosis and
treatment of Lachesis snake bites.
Keywords: Lachesis, Bushmaster, snakebite, case report, poisoning.
Proven Lachesis-inflicted accidents are rare in scientific literature while,
on the other hand, the genus is given almost mythological status by common folk. According to the Villas-Boas brothers (indigenists and field man, who dedicated most of their lives to making first contact with previously unknown indian tribes in
the Amazon where `white man' had never set foot before in the late 40s), “[Lachesis] is the only venomous snake of Brazil that might actually
attack a human being”
(Villas-Boas, 1994). In ancient Tupi-Guarani Indian language, “surucucu” stands for “one who strikes
. Exploratory expeditions to South America such as those carried on by
Von Spix and Von Martius (1817-1820) brought back to Europe weird,
exaggerated accounts of huge snakes attacking campfires, such as the one below, by John Manley (1851):
Figure 1: Note published in London in 1851 reporting the alleged Lachesis' “Antipathy to fire” (Manley, John
Those who actually deal with Lachesis on a daily basis, find it of “calm
disposition and delicate constitution” (Boyer, 1989). However, when cornered, wounded, thermally
disoriented or guarding eggs, the genus may react in a very particular way. In the words of the experienced Rob Carmichael (pers.
“As far as safety goes, I never work with these snakes unless I am 100% focused and alert. I keep many
elapids (including king cobras), bothrops, crotalines, etc. but nothing strikes more concern in me than these bushmasters. I fully know that a bite could end
my life, which is why when I work with the bushmasters, I don't work with any other snake that day... I want to make sure that I am ready, focused, relaxed
and ready for anything. So far, I have found the bushmasters to be amazingly calm and wonderful animals, however, I also have experienced first hand the full
wrath of this species... Even a 16' king cobra coming full steam at me didn't scare me as much as an 8' bushmaster in full “I want to kill you” mode did a
year ago. It made me completely re-think my strategies and safety procedures when working with them. But, for the most part, they have been very easy going
and I think staying calm, deliberate and keeping movements slow and always working on the bushmaster's terms is the best course of action.”
This dauntless behavior, its almost mythical status and even religious associations with “the evil one”
fuel the ongoing slaughter of the species. In the case of the Atlantic Bushmasters (Lachesis muta rhombeata), the destruction of 93% of its natural habitat makes it a highly endangered species, classified as “Vulnerable” by the “International Union
for the Conservation of Nature”.
In six years in the region of Ilhéus - Bahia State - Brazil, we have
positively identified eight accidents as caused by Lachesis, the most recent ones on 01/21/2007
and 02/28/2007. A ninth accident took place just before our arrival in the region and resulted in the almost instant death of J.A.D., a 7 year old boy, who
went out of his impoverished house at night to pee, stepped on an animal and was bitten more than once according to the family.
If there is venom inoculation, the first 60 minutes of these accidents are always dramatic and similar to the evolution of the
hypovolemic shock: severe hypotension may occur within 20 minutes, along with hypothermia as low as 35°C, vomiting, diarrhea, abdominal pain, difficulty to swallow, sensorial disorientation,
sinus bradycardia, and eventually shock and cardiac arrest. Although these signs and symptoms are the
norm in our experience, while reviewing the literature we found out that there is no general agreement around the onset of such signs and symptoms, something
that could be explained at least in part by the difficulty in determining the genus which actually caused the accident (Hardy and
Haad, 1998), specially in the Amazon area where large Bothrops atrox
(Linnaeus, 1758) are commonly confused with (small) Lachesis specimens. Out of these eight
cases, we chose to report only two, in which the animals are still alive, positively identified and photographed.
T.L., professional herpetologist and Biologist, male, 23 years old, healthy,
140 pounds, was bitten on the top of his head by a 2,00m male Lachesis at 11:40 of 05/27/2005 while working with de Souza in the Serra Grande Center:
Sequence of events from 05/27/2005, 11:40am on:
Time since bite (hours:minutes)
Pain in the entire face, throat and neck.
Profuse sweating, upper abdominal pain, vomiting.
Hypotension, weak pulse, sinus bradycardia, pale, profuse sweating, pre-shock.
Drowsy, vision, hearing and speech alterations, hypersalivation and great difficulty to swallow.
In the car, on the way to hospital, we started infusion of saline solution, atropine, metoclopramide and dopamine.
Not rousable, carried to the ICU of Regional Hospital, Ilhéus, Bahia.
Watery diarrhea. Blood pressure upon admission at 60 x 40 mmHg.
Infusion of 1,000ml of saline solution up to this point.
Preparation for antivenom therapy. See Observation 1 below.
12 IV vials of Bothropic - Lachetic Antivenom diluted in SGI 5% + another 500 ml of saline solution 0,9%.
Meperidine 40mg I.M Check Observation 2 below.
End of antivenom infusion. Drowsy. Profuse bleeding at the wound site
Blood pressure at 100 x 60mm Hg.
5th 500ml of saline solution.
Local pain even with meperidine.
Profuse bleeding in the inoculation site. Pain in knee joints.
Vagomimetic symptoms still present. Recovering consciousness.
Intense diffuse head pain. Diarrhea, drowsiness, vomiting.
Profuse local bleeding persists.
Blood pressure at 90 x 40 mmHg.
Protection of gastric mucosa against bleeding (vomiting, stress)
Blood pressure at 90 x 60 mmHg
6th 500ml saline solution I.V. infusion.
Coagulation of the bleeding at the wound site.
Figure 2C (scale in centimeters)
Urinary debt + (Sui Generis)
Blood pressure at 80 x 40 mmHg.
Blood pressure at 90 x 50 mmHg.
Blood pressure at 60 x 30 mmHg.
Additional 8 I.V. vials of BLA (Butantan)
Normal renal function biochemistry.
Edema from left eye extending to back portion of head and neck,
Hemodynamically stable all day long; normal macroscopic aspect of urine. No bleeding at wound site. Mild local ecchymosis on face and
Gastrointestinal bleeding (melaena) without hemodynamic repercussion.
Stable; vital signs within normal parameters.
Hemodynamically stable with normal kidney function biochemistry.
"Preparation for antivenom therapy" according to “Handbook for Diagnosis and Treatment of accidents with poisonous animals” (Brasília
- Health Ministry - National Health Foundation/1998). It should be stressed however, that Bucaretchi et al.,
2002, have demonstrated that this routine is not only inefficient but potentially harmful.
The use of Meperidine may aggravate the vagomimetic symptomatology and cause respiratory depression, requiring extra care if it is
used for pain control.
Vomiting did not become a major problem/symptom due to early administration of metoclopramide, 10 minutes after the
Late biochemistry (4 - 7 days after the accident, performed in Belo Horizonte/Minas Gerais State) indicating consumption of
coagulation factors on the occasion of the accident and a slow recovery in the following days.
Ambulatorial Follow-up for 21 days (D1-D21)
Blood urea or serum creatinine at 43 mg/dl and 1,0 mg/dl, respectively
C Reactive Protein: 2,6 mg/dl
Prothrombin Time (Quick): 18,6 seconds
Prothrombin activity: 56%
Platelet count: 251.000 / mm3
Prothrombin Time: 15,4 seconds
"Serum disease”, fever, dermatitis, painful knee/elbow joints, jaundice ++/4+.
This is the only available biochemistry. While treating this patient, we only had C.T. performed (> 30 min. always). Most of Brazilian hospitals of the
public health system (SUS) are poor and lack just about everything. However, whenever possible, one should rely on exams such as: complete hemogram
(neutrophil leukocytosis, hematocrit may rise in the early stages due to hemoconcentration because of increase permeability
of capillaries). Later on, the hematocrit falls due to bleeding in the interstitial space. Another essential exams are: INR, Prothrombin Time, FDP, renal
function and continuous cardiac monitoring as well. As far as late symptoms are concerned, articular pain was the most noticeable, along with great
difficulty to swallow solid food due to gastritis.
Patient J.A.S., male, 49 years old, professional herp keeper at CEPLAC, a federal agency for cocoa
research, was bitten in the medium 1/3 of the left forearm on 10/02/2006 at 8:30am by a two meter male Lachesis fed 15 days before. Upon clinical examination, only one inoculation point was found.
J.A.S. suffers from high blood pressure and is under regular medication, but on that specific morning he
reports to have forgotten to take his 25mg of Captopril - this might have saved his life.
The first symptom was severe pain, and the patient immediately drove his car for 20 minutes to a nearby
hospital, where he arrived “in the limit of his strength”. Upon admission, systolic blood pressure was
70 mmHg with no detectable diastolic blood pressure. The patient also presented intense sweating, diarrhea, upper abdominal pain and great difficulty to
Infusion of saline solution 0,9% + metoclopramide + 10 I.V vials of "Bothropic-Lachetic Antivenom" (BLA -
Butantan) were simultaneously administered. Coagulation time could not be measured (over 30 minutes) and remained like that for the next 24 hours, during
which he had compressive bandage around the wound site. The patient developed a moderate systemic reaction to the antivenom (figure 3 below). After 24 hours of hospitalization blood pressure stabilized, bleeding at the inoculation point stopped, urinary debt was over 40
ml/hour with normal macroscopic aspect so, after another two days under observation, he was discharged for an ambulatorial follow-up. The left arm remained
sore for two weeks.
Figure 3: J.A.S. back to work 14 days after the accident, handling the same animal involved in the accident
All confirmed accidents by Lachesis should be
considered life-threatening since even mere scratches, one fang inoculations and accidents with babies or youngsters (Ripa, 2002)
, characterized by small amounts of poison delivered may still provoke early systemic symptoms, something we do not observe in the
sympatric Bothrops genus, where the size
of the animal is the most important prognostic factor: bigger animal = more venom = more damage (Ribeiro et al., 1989). By saying this, we do not intend to affirm that the amount of venom delivered is unimportant for the clinical evolution, since in vitro, the neurotoxic action of the venom is dose-dependant. On the other hand, based on our experience,
we infer the existence of a “Minimum Activating Dose” (M.A.D.) which triggers all symptomatology. It is worth noticing that this “M.A.D.” is way below the
400mg potentially delivered by adult Bushmasters.
Regarding the biochemistry of the Lachesis
venom, the following activities have been described:
Plasminogen activation, which increases the permeability of blood vessels, promoting edema and indirectly helping to lower blood pressure
since large amounts of plasma may be lost from the vascular compartment. (Sanchez et al., 2000 ; Hermogenes et al., 2006)
Coagulant activity where toxins such as the so called "thrombin-like" enzymes act upon the fibrinogen, forming small clots that will be
deposited in organs like kidneys and lungs and eventually obstructing capillary blood flow. (Magalhães et al., 1973, 1979, 1981,
1993a,b,c, 1997, 2003)
Hemorrhagic activity caused by metalloproteinases commonly called hemorragines, which directly damage
capillary walls. The hemorrhagic and coagulant activities overlap each other and will trigger local and
systemic hemorrhagic disorders. (Rucavado et al.,
1999; Estevão-Costa et al., 2000 a,b ; Souza et al., 2001; Sanchez et al.,
Inflammatory action, mostly due to thrombin-like serine proteinases, phospholipase A2 (PLA2), metalloproteinases, histamine, serotonin, nitric oxide, by-products of the
metabolism of the arachidonic acid, leukocyte recruitment and release of cytokines, and lymphoedema.
Activities (A) and (C) are also important actors in this process. We believe that the immune system also play a major part here, bringing to the wound site
activated macrophages, oxygen radicals, gamma interferon, tumor necrosis factor among other “Big Guns”.(Silva et al., 1985;
Warrel,1989 ; Soares et al., 1998)
Proteolytic activivity due to direct action of proteases (thrombins in special), metalloproteinases, important myotoxic and cytolytic venom factors.
Necrosis may be aggravated by ischemia due to thromboembolic alterations, eventual use of tourniquet and compartment syndrome (unlikely to happen in
Lachesis bites). Proteolytic action is
seldom seen if specific antivenom is administrated within the third hour of the accident. (Otero et al., 1998)
Myotoxic action, due to the action of PLA2s among other enzymes, generating an inflammatory infiltrate composed of polymorphonuclear
leukocytes and macrophages, found around necrotic cells and in the interstitial space. Inexperienced surgeons may easily confuse the deposition of hemorrhagic debris over the
muscle with direct myotoxic effects on the muscles (necrosis) but, given the chance to act due to delayed treatment or insufficient neutralization, the PLA2s
will induce necrosis of skeletal muscle fibers.(Otero et al., 1998; Fuly et al.,2000; Damico et al. 2005)
Defibrinating activity resulting in incoagulability, a consumption coagulopathy (of factors II, VIII, IX and X, with normal platelet counts) that also occurs because of the direct
action of thrombin on fibrinogen and, also, because several proteins with enzymatic activity such as the PLA2 and proteinases inhibit blood clotting. (Yarleque et al., 1989; Magalhães et al., 1993b;
Otero et al., 1998; Estevão-Costa et al., 2000)
Indirect hemolytic activity, thus called (indirect) because lectins mediate the process. Direct hemolysis is observed in some bee and
elapid envenomings, with direct destruction of the cell wall. (Otero et al., 1998; Haad, 1980-81).
"Kininogen-like action", auto-pharmacological in nature since the venom will make the body release substances like bradykinin and
kallikrein that will induce hypotension. (Diniz
et al., 1992; Giovani-de Simoni et al., 1997, Felicori et al., 2003; Weinberg et al., 2004)
Action of the bradykinin potentiating peptides that interfere with the metabolism of bradykinin, making it last longer in the blood,
contributing to a longer lasting hypotension. (Soares et al., 2005)
Neurotoxic action, recently described and based on the isolation of the basic PLA2
since its purified form from lachesis venom called LmTX-1, induced an irreversible block in
neuromuscular transmission in vitro, in concentrations as low as 1 g/ml.
(Damico et al., 2005; Damico et al., 2006)
We believe that the so-called “activation of the parasympathic autonomous nervous
system” can be considered partly neurotoxic in nature, where kinins36 and phospholipases
play a major role. Therefore, in Lachesis, the abnormally quick shock onset seems best explained
by a Synergy Hypothesis, in which neurotoxicity, vasodilatation and leaks to interstitial space, independently play a part.
One could only speculate as the causative factor of
specific clinical alterations such as dysphagia or the “vagal triad” (hypotension, diarrhea, vomiting -
and why not, a fourth element: sinus bradycardia) or sensorial disorders (to colors, deafness,
uncoordinated march) that will take place within 30-45 minutes after a bushmaster bite in Brazil, BUT it is not speculation to affirm that these clinical
features can be considered pathognomonic of the genus that caused the accident, as noted by Jorge et
“A review of reports of 20 cases of bites in humans reliably
attributed to this snake [Lachesis] in Costa Rica, French Guyana, Brazil, Colombia and Venezuela confirms a syndrome of nausea, vomiting, abdominal colic,
diarrhea, sweating, hypotension, bradycardia and shock, possibly auto-pharmacological or autonomic in origin, not seen in victims of other American crotaline
Bothropic accidents may lead to shock and hypotension and even death within one hour of inoculation, but
such events are rare (Cardoso et al., 2003; Haad, 1980-81). Statistics of a major ER (H.P.S João XXIII)
in Belo Horizonte/Brazil, show that only 5% of all bothropic accidents present hemodynamic alterations such as blood pressure drops upon
admission (Cecilia Haddad, pers. com.). A series of 29 accidents involving Bothrops jararacussu (Lacerda, 1884), normally the worst bothropic accident, presented two (6,8%)
hemodynamically unstable patients (Milani et al., 1997). Therefore, hemodynamic repercussion as well as
all morbidity in the bothropic accident is dose-dependent. It isn't so in Lachesis, probably due
to the combination of factors described above. As long as at least the “M.A.D.” is inoculated, the synergy of effects, will produce major blood pressure
drops in humans with unsurpassed speed.
Our observations about how dangerous these intoxications may be in humans are in agreement with recent accidents with North American
herpetologists and also with a series presented by Bolaños e Rojas in 1982 where 3 of 4 patients died, even with early (but insufficient) antivenom
therapy (Ripa, 2002; Bolaños and Rojas, 1982). Adult Lachesis may reach or exceed 3.40m TL (Ditmars, 1933; Campbell and Lammar, 2004)
and according to Bolaños (1972), can inoculate 333mg or more of venom (Bolaños, 1972) but, although there are usually great amounts of toxins to be neutralized, the severity of the symptoms is not necessarily related to the
amount of venom injected. The unique, dose-independent body response to the overwhelming synergic hypothesis, which includes direct actions of the
poison, auto-pharmacological events and individual characteristics, something also noted by other author-victim (Ripa, 2002), can be taken as a standpoint
for further studies on the fundamentals of the “M.A.D.” concept.
The present work diverges of that presented by Burnheim and Souza and others ( Sá-Neto, 1995; Souza, 1999) developed in Manaus area (Amazonas State),
where statistics suggest that only 15% of Lachesis accidents present the "vagal triad" as a
clinical feature, probably due to (1) inclusion of "dry-bites" in their series (“only about 50% of people bitten by venomous
snakes are actually envenomed”- (Warrel, 1989)
; (2) wrong information (common) by patients as to which animal caused the accident; (3) wrong classification by M.D.s (common) of
the snake brought to the hospital; (4) mistakes in the application/interpretation of ELISA tests; or maybe the clinical practice of the M.D.s working in the
north margin of the Amazon river is revealing a totally different pattern of venom action when compared to the Atlantic coast and north of Mato Grosso State
envenomings. Here is the enigma.
Only accidents by Lachesis acrochorda
(Garcia,1896) in Colombia should present low or none "vagal simptomatology" (Campbel , Lammar and Warrel, 2004), but Haad et al ( Haad, 1980-81;
Hardy and Haad, 1998) presented three cases from Colombia in which “the triad” was observed. It has been experimentally proved
that samples of venom from Brazil, Costa Rica, and Colombia did display toxic and enzymatic differences (Hardy and Haad,
1998; Otero et al., 1998), but all induced a qualitatively similar pathophysiological profile in
vitro (Otero et al., 1998). We will comment further down (see map below) on clinical variations in
Lachesis accidents in humans as described by Warrel (Campbell, Lammar
and Warrel, 2004), keeping Haad and Hardy in mind: that "we are not mice".
Maybe the observations (85 % of absence of "vagal symptoms") of our colleagues of the “north margin” will also fit in Warrels' observations, since the venom
does present variations within populations, seasons, age of the animals (Gutierrez, 1990), and that can
also lead to wrong readings of ELISA tests. Coincidentally, Ripa in his latest work proposed the extension of the range distribution of Lachesis muta rhombeata to the entire forest south of
the Amazon river, and not only in the Atlantic coast (Ripa, 2002).
Our position is clear: bushmaster bites in Brazil, or at least in the south of the Amazon river and in the Atlantic rainforest, without extreme and immediate local pain and edema and without early (20 minutes) gastrointestinal
(diarrhea, vomiting) and cardiovascular (hypotension) repercussion, is not a Lachesis bite.
There is no such thing as “walk for two days for help”, “deny local pain” or “refuse hospitalization” if you have been bitten by a “surucucu” (and had venom
injected in your organism). In one accident in Serra Grande, Bahia, January 21st, 2007,
"N.R." was knocked out by hypotension and could not make the 40 minute walk to town to get help, being saved by his wife who rushed for an ambulance right
after killing the snake, extracting her tongue and forcing the husband to swallow it as an “antidote”.
Such “treatments” should be viewed as acts of despair due to the abandonment by the public health system of geographically
isolated populations, until very recently. However, we've also collected in the region ethnobotanic approaches, such as the “graviola tea” (Anonna
muricatta) which is now being tested for possible anti-emetic and/or vasoactive properties.
Since we are talking about the treatment of snakebites that can quickly lead to life threatening conditions, as far as treatment is
concerned, the tourniquet issue inevitably arises. Such practice has not been abolished. It has saved lives in Australia and South Africa (Fairley, 1929; Chritensen, 1963) in accidents with Elapids. Taipans (Oxyuranus), “the deadliest” in popular interpretations of the LD 50 in mice, will cause systemic alterations in 3 hours, progressively worsening, reaching critical status around the 12th hour and killing 20 hours after the bite (White, 1995) so, “their accidents” are medical emergencies like ours (Lachesis) are. However,
a study in Brazil involving the use of tourniquet in accidents with Crotalus durissus
(Amaral et al, 1998) proved it to be inefficient. So since we believe in
the M.A.D and the instant pain reveals that it may already been delivered into the body, and an
arterial tourniquet in such circumstance could only be efficient if applied within a minute or two of the accident,
something hard to do, and last but not least, the procedure is
controversial in Viperidae, we do not recommend its use.
In Serra Grande, we carry a kit of ampoules and syringes, ethylepinephrine cloridrate, adrenaline,
atropine, metoclopramide for I.M. use and also saline solution for I.V. use; working in pairs (at least) is essential. In case 1, “T.L.” was not able to make
a phone call within 15 minutes of the bite.
The field administration of the antivenom must take into consideration the impossibility of quick rescue
and the feasibility of controlling eventual reactions with limited resources. Alternating (12-20 vials of 10ml ampoules) I.M. and I.V. administration to
intentionally delay absorption for safety reasons (Pepin et al, 1995; Riviere et al., 1997), does not
prevent the onset of complications such as major exanthem and bronchospasm,
so it is wise to be ready for these medical emergencies. Allergic tests have been shown to be ineffective (Warrel, 1989). As soon as the patient makes it to the nearest hospital,
signs and symptoms such as blood pressure drops, bleeding at the wound site, or the "triad" will reveal the need of more antivenom, “better late than
sorry”. If none of these signs are present and the patient can be considered hemodynamically stable with proper urinary debt, it is time
to face other complications edema being one of them.
Fasciotomies seem to have no indication in Lachesis bites. In Brazil, the concept of Compartment Syndrome (C.S.), an event of the first 24 hours, is still plagued with empiricism. Statistics
from Vital Brazil Hospital ( França and Cardoso, 1989; Bueno, 1996) show that C.S. was observed in only
1,4% of all Bothrops accidents, locally more aggressive than Lachesis. Precise indication could avoid further expoliation, blood loss, risk of infection, longer hospitalization time, and costs. The “usually
disappointing” (Warrel, 1989) results of fasciotomies can be explained, at least in part, by the lack of reliable parameters upon which the decision has to
be made (compartment pressure above 45 mm Hg and doppler revealing obstruction to blood flow) and to the fact that muscle swelling and necrosis can be
attributed to direct action of venom injected in the area.
The possibility of late blood pressure drops, bleeding to the digestive system and reaction to antivenom therapy demands in hospital
observation for 48-72 hours and ambulatorial follow-up for the next 30 days. Infection in the wound site can turn into a major complication if deep fascial
progression is undetected below normal looking skin. Common agents are: D group streptococcus,
Enterobacter sp., Providencia rettgeri, Providencia sp., Escherichia coli, Morganella morganii, Clostridium
sp., Aeromonas hydrophila, Proteus
mirabilis, Acinetobacter alcoaceticum, Pseudomonas aeruginosa and Klebisiela pneumonae (Bolaños et al 1982; de Andrade et al 1989; Jorge et al.,1990)
Close attention also to “serum disease” around the 20th day (sore joints, fever, dermatitis), mesenteric
thrombosis (Rosenthal et al., 2002) and intracranial bleeding (Eric
Jennings, pers. com.) that can be of early (first 24 hours.) or late (fifth day) onset:
Figure 4: Intracranial bleeding 24 hours after a Lachesis bite, causing the death of a 23 year old man. Accident near Santarém/Pará State, in 2003.
(Courtesy Dr. Eric Jennings)
Figure 5: Intracranial bleeding in a 57 year old man 5 days after a Lachesis bite; the patient survived neurosurgery. We do not know of any other cases
where the patient survived intracranial bleeding in ophidism,wordlwide. Great and historical job by
Dr. Jennings, again near Santarém/Pará State in 2003. (Courtesy Dr. Eric Jennings)
It is important to remember that the doses of antivenom are the same in children as in adults, and that the anti-bothropic antivenom will
not neutralize the coagulant factor of Lachesis poison, so its use is not recommended (Ramza et al, 1994). Heparin has also no indication in Lachesis bites.
Lachesis bites should be considered medical emergencies, regardless of the size of the animal. In Brazil,
they can happen anywhere in the Brazilian Atlantic rainforest remnants, from Rio de Janeiro State up to Rio Grande do Norte State, parts of Ceará
State (Feitosa et al., 1997; Freitas, 2005), possibly in "Parque do Rio
Doce" or “Zona da Mata” in Minas Gerais State and in the Amazonic region as a whole. The animal is highly dependent and adapted to the preserved rainforest
of medium altitude (high humidity and low temperatures).
Figure 6: Dark areas denote “Lachesis Territory”.
From the medical standpoint, the academic discussion if Lachesis should
maintain its subspecific differentiation (Ripa, 2002) or should be considered as two populations of the
same species (Fernades et al., 2004), is irrelevant.The present edition of rules of the "International
Code of Zoological Nomenclature" (Fourth Edition, ISBN 053301-006-4) maintains the trinominal status (subspecific) for South American bushmasters, but its true that the concept of subspecies in herpetology
is highly questionable.
It is of great medical importance however, to keep in mind that the venoms of both populations (coastal &
amazonic) are similar (Otero et al., 1998) and the clinical features in intoxications should also be
similar. However, important variations such as local effects and C.N.S. activation have been described (Campbell, Lammar and
Warrel, 2004). The venom of the amazonic animal has greater hemorrhagic activity, whereas the venom of the Atlantic Rainforest
animal has greater coagulant activity (Otero et al., 1998). It is not clear at this point, how these
differences fit in the puzzle of the “north margin enigma”.
Whoever ventures in “Lachesis Territory” should recognize the risk, work in
pairs with a pre-determined evacuation plan, carry and in remote areas carry an emergency kit similar
to the one used in Serra Grande, knowing how to use it in order to avoid early and severe hypotension, and to allow oral intake of liquids or medication (blocking vomiting) while on the way to the nearest hospital.
Until the lyophilized version of the antivenom for
human use reaches the Brazilian market, refrigeration between 3-8°C and respect to expiration dates dictate its effectiveness when needed. A well-planned
distribution among major towns will help avoid the tragedy of late treatment: death, suffering and costs. In our series, the efficient distribution meant
eight lives saved without any permanent handicap. The costs issue also leads us to affirm that tests such as ELISA are recommended but not necessary to
differentiate Lachesis accidents from the others.
The statistic probability of accidents in the Amazon region, 76% Bothrops x 17% Lachesis (Ramza et al., 1994), indicate that the obvious antivenom to be distributed (and carried
around) in these areas is the highly effective (Pardal et al., 2004) "Bothropic-Lachetic
Antivenom" (BLA) but attending physicians in ERs in the darker areas in the map above should also keep in mind that Crotalus is also present in the Amazon and in some coastal biomes of Atlantic Rainforest (“restingas”) in
Piauí state (Freitas, 2005) and that Micrurus (some without the red rings), all share the well preserved forest with Lachesis
Notification of snake bites is compulsory in Brazil, but most of our statistics remain unreliable due to
under-notification, general ignorance about such accidents, and work overload in underequipped and
understaffed ERs, all of which might contribute to wrong planning in the distribution of the BLA throughout the vast Brazilian territory. A good example of
this is an old review of medical records in the Ilhéus area that points to Lachesis accidents figures around 0,5%. Although this particular accident is uncommon due of the ecobiology of the animal and its usually calm disposition, it is not as rare this figure (0.5%) seems to indicate,
as noted by Baard (Ramza et al., 1994) and in the present work.
While we watch in real time the burning down of the Amazon and the progressive destruction of the residual
7% of the Atlantic Rainforest, signaling a dire future of Lachesis in the wild, isolated actions
such as the Serra Grande breeding center try to compensate the damage already done via programs that may generate animals for antivenom production,
reintroduction of animals to their native habitat and advanced pharmacological research.
Figure 7: “Baby Atlantic Surucucu”, Núcleo Serra Grande, in Itacaré/Bahia State - Brasil (de
To Dr Ronaldo Souza, our greatest inspiring and driving force in this article
To Drs. Daniela Damico from UNICAMP and Fatima Furtado from Butantan Institute, for the deep insights in the
biochemistry of Lachesis venom.
To Dr Cecilia Haddad, for sharing her experience in the Toxinology Department of
"H.P.S João XXIII-BH-MG", one of our major E.Rs.
To Paulo de Tarso, director of YONIC, a non-governmental organization that has financed the Serra Grande
Amaral CF, Campolina D, Dias MB, Bueno CM, Rezende NA. Tourniquet ineffectiveness to reduce the severity of envenoming after Crotalus durissus snake bite
in Belo Horizonte, Minas Gerais, Brazil; Toxicon, 36(5):805-8, May-1998.
Bolaños OR. Toxicity of Costa Rica snake venoms for white mouse; Amer. J.
Trop. Med.Hyg.,21:360-363, 1972.
Bolaños R, Rojas O, Flores C. Aspectos biomedicos de cuatro casos de mordedura de serpiente por Lachesis muta
(Ophidia:Viperidae) in Costa Rica; Revista de Biologia Tropical,30(1):53-58,1982.
Donald M.Boyer, Lyndon A. Mitchell and James B. Murphy.
Reproduction and Husbandry of the Bushmaster at the Dallas Zoo. Inter. Zoo Yb (1989) 28:190-194
Bucaretchi F, SRF Herrera, S Hyaslop, EC Bacarat, RJ
Vieira. Snakebites by Crotalus durissus ssp. in children in Campinas/São Paulo/Brazil; Revista do Instituto Brasileiro de Medicina Tropical de São Paulo,
Bueno Pereira Pr. Síndrome compartimental nos acidentes botrópicos; Tese de doutoradoUSP,1996
Campbel J, Lammar W, Warrel
D. "The venomous reptiles of the western hemisphere", Volume II, First Ed., Cornell University Press
Cardoso, França, Fan, Malaque, Haddad Jr..
"Animais Peçonhentos do Brasil - Biologia, Clínica e Terapêutica dos Acidentes", Servier/Fapesp - 1a Edição, 2003.
Christensen, P A, South African
Medical Journal, 1969, 43, 1253.
Damico DC, Bueno LG, Rodrigues-Simioni L, Marangoni S, Da Cruz-Höfling MA, Novello JC; Neurotoxic and myotoxic
actions from Lachesis muta muta (surucucu) whole venom on the mouse and chick nerve-muscle preparations; Toxicon, vol. 46, no2, pp. 222-229, 2005.
Damico DC, Bueno LG, Rodrigues-Simioni L, Marangoni S, da Cruz-Hofling MA, Novello JC. Functional characterization of a basic D49 phospholipase A2
(LmTX-I) from the venom of the snake Lachesis muta muta (bushmaster); Toxicon, 47(7):759-65. Epub 2006 Apr 19.
de Andrade Jg et al. Estudo
bacteriológico de abscessos causados por picada de serpente do gênero Bothrops - Rev Inst Med Trop São Paulo; 31(6): 363-7, 1989.
de Freitas MA,
Silva TFS. A Herpetofauna da Mata Atlântica Nordestina; pg 14; 1a edição; Editora USEB; 2005.
de Souza, Reproduction of the Atlantic Bushnaster
(Lachesis muta rhombeata) for the first time in Captivity - Bull. Chicago Herp. Soc. 42(3):41-43, 2007
Diniz MR, Oliveira EB. Purification and
properties of a kininogenin from the venon of Lachesis muta (bushmaster); Toxicon, 30(3):247-58, 1992.
Estêvão-Costa MI, Martins MS, Sanchez EF,
Diniz CR, Chávez-Olórtegui C. Neutralization of the hemorrhagic activity of Bothrops and Lachesis snake venoms by a monoclonal antibody against mutalysin-II;
Toxicon, 38(1):139-44, 2000 Jan.
Estêvão-Costa MI, Diniz CR, Magalhães A, Markland FS, Sanchez EF. Action of metalloproteinases mutalysin I and II on
several components of the hemostatic and fibrinolytic systems; Thromb Res, 99(4):363-76, 2000 Aug 15.
Fairley, N H, Medical Journal of Australia,
1929, 1, 377.
Feitosa RFG, Melo IMLA, Monteiro, HSA. Epidemiologia dos acidentes por serpentes peçonhentas no estado do Ceará - Brasil; Revista da
Sociedade Brasileira de Medicina Tropical; 30(4):295-301, jul-ago, 1997.
Felicori LF, Souza CT, Velarde DT, Magalhães A, Almeida AP, Figueiredo S,
Richardson M, Diniz CR, Sanchez EF. Kallikrein-like proteinase from bushmaster snake venom; Protein Expr Purif, 30(1):32-42, 2003 Jul.
Chávez-Olórtegui C, Sanchez EF. Specific identification of Lachesis muta muta snake venom using antibodies against the plasminogen activator enzyme, LV-PA;
Toxicon, 45(6):803-6, 2005 May.
Fernandes DS, Franco FL, Fernandes R. Systematic revision of the Genus LACHESIS DAUDIN, 1803 (SERPENTES, VIPERIDAE);
Herpetologica, 60(2), 245-260, 2004
França FOS, Cardoso JLC. Estudo retrospectivo da evolução dos acidentes botrópicos; Rev Inst Med Trop São Paulo;
31(2): 84-90, 1989.
Fuli AL, Calil-Elias S, Zingalli, Guimaraes JA, Melo PA. Myotoxic activities of an acidic phopholipoase A2, isolated from
Lachesis muta (Bushnaster) snake venom. Toxicon 2000;38;(7):961-72.
Giovani-de-Simone S, Aguiar AS, Gimenez AR, Novellino K, De Moura RS.
Purification, properties and N-terminal amino acid sequence of a kallikrein-liks enzyme from the venom of Lachesis muta rhombeata (Bushmaster); J Protein
Gutierrez JM, Avila C, Camacho Z, Lomontr B. Ontogenetic chages in the venom opf the snake Lachesia muta stenophrys
(bushmaster) fropm Costa Rica. Toxicon 1990;28(4):419-26
Haad JS. Acidentes humanos por las serpientes do genero Bothrops Lachesis; Mem. Instituto
Butantan, 44-45:403-423, 1980/81
Hardy Sr., DL, Haad JJS. A review of venom toxinology and epidemiology of envenoming of the bushmaster (Lachesis)
with report of a fatal bite; Bull. Chicago Herp.Soc. 33(6):113-123, 1998.
Hermogenes AL, Richardson M, Magalhaes A, Yarleque A, Rodriguez E, Sanchez
EF. Interaction of a plasminogen activator proteinase, LV-PA with human alpha2-macroglobulin;Toxicon,47(4):490-4,2006,Mar 15.
Jorge MT, Mendonça JS,
Ribeiro LA, Silva MLR, Kusano EJU, Cordeiro CLS. Flora bacteriana da cavidade oral, presas e veneno de Bothrops jararaca: possível fonte de infecção no local
da picada; Rev. Inst. Med. Trop. S. Paulo; v.32 n.1, São Paulo, jan./fev. 1990
Jorge MT, Sano-Martins IS, Tomy SC, Castro SC, Ferrari RA, Ribeiro LA,
Warrell DA. Snakebite by the bushmaster (Lachesis muta) in Brazil: case report and review of the literature;Toxicon;35(4):545-54,1997Apr.
A., Oliveira GJ, Diniz CR. Proteases de serpentes brasileiras I. Separação da enzima coagulante (clotase) de veneno de Lachesis muta; Cien. Cult., 25:43,
1973, São Paulo.
Magalhães A, Diniz CR. Purification and partial characterization of the thrombin-like enzyme from the venom of Lachesis muta
noctivaga; Toxicon, 17, suppl. n. 1:112, 1979.
Magalhães A, Oliveira GJ, Diniz CR. Purification and partial characterization of a thrombin-like
enzyme from venom of the bushmaster snake, Lachesis muta noctivaga; Toxicon, 19:279-294, 1981.
Magalhães HPB, Rogana E, Magalhães A, Mares-Guia ML.
Effect of N-x-dansyl-(p-guanidine) phenylalanide piperdine (1-2581) on activity of a thrombin-like enzyme of Lachesis muta muta venom; Toxicon, 31:35, 1993a.
Magalhães HPB, Dusse LMS, Vieira LM, Souza MO, Magalhães A. Platelet aggregating activity of thrombin-like enzyme from Lachesis muta muta venom;
Toxicon, 31:34, 1993b.
Magalhães HPB, Monteiro MR, Mares-Guia M, Rogana E. Trombin-like enzyme from Lachesis muta muta: Topographical analysis and
specificity of its active site by means of the binding of aminides and guanidines as competitive inhibitor and peptidyl-p-nitroanilide as
substrates;Toxicon, 31:25, 1993c.
Magalhães A, Monteiro MR, Magalhães HPB, Mares-Guia M, Rogana E. Thrombin like enzyme from Lachesis muta muta
venom: Isolation and topographical analysis of its active site by means of binding of amidines an guanidines as competitive inhibitors; Toxicon, 35:1549-
Magalhaes A, Ferreira RN, Richardson M, Gontijo S, Yarleque A, Magalhães HP, Bloch C, Sanchez EF. Coagulant thrombin-like enzymes from
the venoms of Brazilian and Peruvian bushmaster (Lachesis muta muta) snakes. Comp Biochem Physiol B Biochem Mol Biol, 136(2):255-66, 2003 Oct
Manley, John. in "Notes and Queries: and inter-communication for literary men, artists, antiquaries, genealogists, etc.", Vol. IV no 190 - 29/11/1851 -
Milani Junior R, Jorge MT, de Campos FP, Martins FP, Bousso A, Cardoso JL, Ribeiro LA, Fan HW, Franca FO, Sano-Martins IS, Cardoso D, Ide
Fernandez C, Fernandes JC, Aldred VL, Sandoval MP, Puorto G, Theakston RD, Warrell DA. Snake bites by the jararacucu (Bothrops jararacussu):
clinicopathological studies of 29 proven cases in Sao Paulo State, Brazil; QJM, May, 90(5):323-34, 1997.
Otero R, Furtado MF, Gonçalves C, Núñez V,
García ME, Osorio RG,Romero M, Gutiérrez JM. Comparative study of the venoms of three subspecies of Lachesis muta (bushmaster) from Brazil, Colombia and
Costa Rica; Toxicon, 36(12):2021-7, 1998 Dec
Pardal PP, Souza SM, Monteiro MR, Fan HW, Cardoso JL, Franca FO, Tomy SC, Sano-Martins IS, de Sousa-e-
Silva MC, Colombini M, Kodera NF, Moura-da-Silva AM, Cardoso DF, Velarde DT, Kamiguti AS, Theakston RD, Warrell DA. Clinical trial of two antivenoms for the
treatment of Bothrops and Lachesis bites in the north eastern Amazon region of Brazil; Trans R Soc Trop Med Hyg. 2004 Jan; 98(1):28-42.
S,Lutsch C,Grandgeorge M,Scherrmann JM.Snake F (ab')2 antivenon from hiperimmunized horse:pharmacokinetics following intravenous and intramuscular
administrations in rabbits; Pharm Res 1995;12(10):1470-3.
Ramza Bard. Ineficácia do antiveneno Botrópico na neutralização da atividade coagulante do
veneno de Lachesis muta muta. Relato de caso e comprovação experimental; Rev Inst Med Trop São Paulo, 36(1):77-81, jan fev 1994
Ripa D. The
Bushmasters (Genus Lachesis Daudin, 1803) Morphology in evolution and behavior - Ripa ecologica,copyright 2002.
Ribeiro LA, Jorge MT. Fatores
prognósticos da evolução das manifestações locais em acidentes por serpentes do Gênero Bothrops. Rev. Soc. bras. Med. trop., 22 (supl.): 68-69, 1989.
Riviere G,Choumet V,Audebert F,Sabourand A,Debray M,Scherrmann JM,Bonn C.Effect of antivenon on venom pharmacokinetics in experimentally envenomed
rabbits toward an optimization of antivenom therapy; J Pharmacol Exp Ther 1997;281(1):1-8.
Rosenthal R, Meier J, Koelz A, Muller C, Wegmann W,
Vogelbach P. Intestinal ischemia after bushmaster (Lachesis muta) snakebite - a case report; Toxicon, 40(2):217-20, 2002 Feb.
Rucavado A, Sanchez EF,
Franceschi A, Magalhães A, Gutierrez JM. Characterization of the local tissue damage induced by LHF-II, a metalloproteinase with weak hemorragic activity
isolated from Lachesis muta muta snake venom; Toxicon (1999) 1297-1312.
Sá Neto RP, dos Santos MC. Aspectos clínicos comparativos do acidente
botrópico e laquético; Rev. Soc. Bras. Med. Trop. 1995:28 (supl.):173
Sanchez EF, Santos CL, Magalhães A, Diniz CR, Figueiredo S, Gilroy J,
Richardson M. Isolation of a proteinase with plasminogen-activating activity from Lachesis muta muta (bushmaster) snake venom; Arch. Biochem Biophys, 378
Sanchez EF, Souza CT, Bello CA, Richardson M, Oliveira EB, Magalhães A. Resolution of isoforms of mutalysin II, the
metalloproteinase from bushmaster snake venom; Toxicon, 41(8):1021-31, 2003 Jun.
Silva LM, Diniz CR, Magalhães A. Purification and partial
characterization of an arginine ester hydrolase from the venom of the bushmaster snake, Lachesis muta noctivaga; Toxicon, 23 (4):707-18,1985.
Silveira Bueno. Vocabulário tupi-guarani português - 4a edição (1986); pg. 297; Editora Brasilivros, São Paulo/SP.
Soares MR, Oliveira-
Carvalho AL, Wermelinger LS, Zingali RB, Ho PL, Junqueira-de-Azevedo Ide L, Diniz MR. Identification of novel bradykinin-potentiating peptides and C-type
natriuretic peptide from Lachesis muta venom; Toxicon, 46(1):31-8, 2005 Jul.
Soares MR, Oliveira-Carvalho AL, Wermelinger LS, Zingali RB, Ho PL,
Junqueira-de-Azevedo Ide L, Diniz MR. Identification of novel bradykinin-potentiating peptides and C-type natriuretic peptide from Lachesis muta venom;
Toxicon, 46(1):31-8, 2005 Jul.
Villas Boas, O & Villas Boas, C; "Marcha para Oeste: A Epopéia da Expedição Roncador-Xingú", Editora Globo, pg. 116,
Warrell DA. "Snake bites in 5 continents" in "Horizons in Medicine", Royal College of Physicians of London, Editora Bailliere Tindall,
Oxford UK, 1989.
Weinberg ML, Felicori LF, Bello CA, Magalhães HP, Almeida AP, Magalhães A, Sanchez EF. Biochemical properties of a bushmaster snake venom serine proteinase
(LV-Ka), and its kinin releasing activity evaluated in rat mesenteric arterial rings; J Pharmacol Sci, 96(3):333-42, 2004 Nov.
Yarleque A, Campos S,
Escobar E et al. Isolation and characterization of a fibrinogenclotting enzyme from venom of the snake Lachesis mutamuta;Toxicon,7:1189-1196,1989
Lachesis Bites in Brazil: 2 Cases
by liliana on August 17, 2009
Mail this to a friend!
i'm completely fascinated by Surucucus (lachesis mutha, or lachesis notivaga)since i was a child in Bahia/Brazil. i grew up in the Reconcavo area and in part of the state there are/were Surucucus too. My dad always tell me histories about the day my grandfather faced a Surucucu during a fishing, it happened because my gandfather was with a ''candeeiro'' a kind of light in his hand, and the snake came very agressive!
Lachesis Bites in Brazil: 2 Cases
by Cipriano on October 2, 2012
Mail this to a friend!
wow, great article. I hate snakes and the reason is shown in this article why i hate them.
You are not subscribed to discussions on this article.
Other Snake Bite Articles
I Should Be Dead
Snakebite in Sri Lanka
Being Bit By the Big One