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Revista da Sociedade Brasileira de Medicina Tropical

versão impressa ISSN 0037-8682versão On-line ISSN 1678-9849

Rev. Soc. Bras. Med. Trop. vol.52  Uberaba  2019  Epub 17-Jan-2019 

Images in Infectious Diseases

Venom concentrations in blisters and hemorrhagic bullae in a patient bitten by a Taiwan habu (Protobothrops mucrosquamatus)

Chih-Chuan Lin1

Po-Jung Wang2 

Chien-Chun Liu2 

1Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Tao-Yuan, Taiwan.

2 Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.

Except for limb swelling, blisters and hemorrhagic bullae may develop in more severe cases in Taiwan habu snakebite. Nevertheless, little is known about venom concentrations in these wounds.

A 66-year-old man was bitten on his right wrist by a Taiwan habu while cleaning his storage room. Four vials of antivenin were administered at a local hospital. Four hours later, blisters of various sizes and two hemorrhagic bullae developed on his palm and forearm (Figure A). Around 20 hours after the incident, fluid samples from the fang mark blister, another blister, one light-red hemorrhagic bulla, and one dark-red hemorrhagic bulla were aspirated and sent for ELISA testing; venom concentrations in the above samples were 74.4 ng/mL, 140.2 ng/mL, 209 ng/mL, and 209 ng/mL, respectively (Figure B). We removed a total 1109 ng of venom from this patient.

Venom in blisters indicate that they may function as venom depots to which antivenin has poor access and from which venom may be subsequently released. The subsequently released venom may lead to delayed poisoning effects and additional tissue damage.1-3 Aspiration of bullae fluids to eliminate venom depots may be accepted for “decontamination” to prevent further envenomation and reduce tissue damage.

FIGURE A: Multiple blisters and hemorrhagic bullae at 20 h after the bite. 

FIGURE B: Fluids collected from the blisters and hemorrhagic bullae 


1. G Iliyasu, S T Halliru, Z G Habib, A B Tiamiyu, F M Dayyab, S B Abubakar, et al. Blister and Bulla Following Snake Bite in Nigeria: A Prospective Cohort Study. Int J Trop Dis Health. 2014;4(10):1069-77. [ Links ]

2. Jorge MT, Ribeiro LA, O'Connell JL. Prognostic factors for amputation in the case of envenoming by snakes of the Bothrops genus (Viperidae). Ann Trop Med Parasitol. 1999;93(4):401-8. [ Links ]

3. Rojnuckarin P, Mahasandana S, Intragumthornchai T, Sutcharitchan P, Swasdikul D. Prognostic factors of green pit viper bites. Am J Trop Med Hyg. 1998;58(1):22-5. [ Links ]

Financial Support: This work was supported by the Chang Gung Memorial Hospital, Taiwan (grant No. CMRPG3F0241-242 to C.C. Lin). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Recebido: 21 de Abril de 2018; Aceito: 13 de Julho de 2018

Corresponding author: Chih Chuan Lin. ORCID: 0000-0001-6600-8919 e-mail:

Conflict of Interest: The authors declare that there is no conflict of interest.

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License