Clinical Toxicology

ISSN: 1556-3650 (Print) 1556-9519 (Online) Journal homepage: http://www.tandfonline.com/loi/ictx20

Coral snake bites (Micrurus spp.) in Brazil: a review

of literature reports
Fbio Bucaretchi, Eduardo Mello De Capitani, Ronan Jos Vieira, Cinthia K.
Rodrigues, Marlene Zannin, Nelson J. Da Silva Jr, Luciana L. Casais-e-Silva &
Stephen Hyslop
To cite this article: Fbio Bucaretchi, Eduardo Mello De Capitani, Ronan Jos Vieira, Cinthia
K. Rodrigues, Marlene Zannin, Nelson J. Da Silva Jr, Luciana L. Casais-e-Silva & Stephen
Hyslop (2016) Coral snake bites (Micrurus spp.) in Brazil: a review of literature reports, Clinical
Toxicology, 54:3, 222-234, DOI: 10.3109/15563650.2015.1135337
To link to this article: http://dx.doi.org/10.3109/15563650.2015.1135337

Published online: 25 Jan 2016.

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Date: 27 June 2016, At: 06:59

CLINICAL TOXICOLOGY, 2016

VOL. 54, NO. 3, 222234
http://dx.doi.org/10.3109/15563650.2015.1135337

REVIEW

Coral snake bites (Micrurus spp.) in Brazil: a review of literature reports

Fabio Bucaretchia,b, Eduardo Mello De Capitania,c, Ronan Jose Vieiraa,c, Cinthia K. Rodriguesd, Marlene Zannind,e,
Nelson J. Da Silva Jrf, Luciana L. Casais-e-Silvag and Stephen Hyslopa,h
a

Campinas Poison Control Center, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil;
Department of Pediatrics, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil; cDepartment of
Clinical Medicine, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil; dSanta Catarina Poison
Control Center, Federal University of Santa Catarina (UFSC), Florianopolis, Santa Catarina, Brazil; eDepartment of Pathology, Health Science
Center, Federal University of Santa Catarina (UFSC), Florianopolis, Santa Catarina, Brazil; fDepartment of Biology, Pontifical Catholic University of
Goias, Goiania, Goias, Brazil; gInstitute of Health Sciences, Federal University of Bahia (UFBA), Salvador, Bahia, Brazil; hDepartment of
Pharmacology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil

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ABSTRACT

ARTICLE HISTORY

Context: In the Americas, the main representatives of the family Elapidae are coral snakes of the genus
Micrurus, of which 33 species are in Brazil. They are the smallest cause of venomous snakebite in Brazil.
We analyzed literature reports of coral snake bites in Brazil from 1867 to 2014, and provide a brief review
of case series and reports of coral snake bites in the Americas in general. Methods: Only reports with
clinical descriptions of envenomation were included. The variables recorded included identification of
the offending snake, patients age, sex, bite site, clinical manifestations, treatment, including antivenom
and anticholinesterase drugs, and general evolution of the cases. 30 published reports describing bites
caused by Micrurus spp. in Brazil were identified and involved 194 distinct cases. Since no information on
the clinical manifestations was available in 44 cases, the analysis was restricted to 25 reports (150 cases).
Results: Most patients were from southern (61.3%; primarily Santa Catarina state, 60%) and southeastern
(20%) Brazil and were male (70.7%), with a median age of 27 years (interquartile interval = 18 to 40 years).
The offending snakes were described in 59 cases (M. corallinus 36, M. frontalis 12, M. lemniscatus 5, M.
hemprichi 2, M. filiformis 1, M. ibiboboca 1, M. spixii 1 and M. surinamensis 1); in 22 cases only the genus
(Micrurus spp.) was reported. Of the 143 cases in which the bite site was recorded, most involved the
hands (46.2%) and feet (26.6%). The main clinical features were local numbness/paresthesia (52.7%), local
pain (48%), palpebral ptosis (33.3%), dizziness (26.7%), blurred vision (20.7%), weakness (20%), slight local
edema (16%), erythema (16%), dysphagia (14.7%), dyspnea (11.3%), inability to walk (10.7%), myalgia
(9.3%), salivation (8%) and respiratory failure (4.3%). Fang marks were described in 47.3% of cases and
14% of bites were classified as asymptomatic. A slight increase in total blood creatine kinase was
reported in 3 children, suggesting mild myotoxicity. Therapeutic procedures included coral snake
antivenom (77.3%), anticholinesterase drugs (6%), and mechanical ventilation (3.3%). Two patients
reported in 1933 developed paralysis/respiratory failure and died 6 h and 17 h post-bite. Four more
deaths probably caused by coral snakes were reported (2 in 1867, 1 in 1959, 1 in 1962), but no clinical
information was available. Discussion: Neuromuscular blockade was the hallmark of systemic
envenomation by Micrurus spp., with signs of myasthenia such as weakness and ptosis that may
evolve to paralysis and respiratory failure. Local features, mainly numbness/paresthesia and pain, were
frequently reported, with the pain being intense in some cases. Although myotoxicity has been detected
in experimental studies with Micrurus spp. venoms, few human reports described laboratory findings
compatible with myotoxicity. Conclusion: Most coral snake bites reported in Brazil were caused by M.
corallinus and M. frontalis, with several patients showing signs of acute myasthenia. Serious
complications such as paralysis with respiratory failure were observed but comparatively rare. The
deaths occurred where respiratory support (mechanical ventilation) was unavailable when needed.

Received 17 September 2015

Revised 28 November 2015
Accepted 18 December 2015
Published online 25 January
2016

Introduction
In the Americas, the main terrestrial representatives of the
family Elapidae are coral snakes of the genera Leptomicrurus,
Micrurus, and Micruroides, of which 40 taxa with a wide
geographic distribution occur in Brazil (Figure 1).[15] Bites by

KEYWORDS

Coral snakes; Elapidae;

envenomation; Micrurus
spp.; snakebites

coral snakes are uncommon throughout the Americas and are

the smallest cause of venomous snakebite in Brazil, accounting
for 1% (N 191) of the 20,073 bites by venomous snakes for
which the genus was officially notified in 2014.[6] However, the
true incidence is probably lower, since several cases reported

CONTACT Fabio Bucaretchi

bucaret@fcm.unicamp.br
Departamento de Pediatria e Centro de Controle de Intoxicacoes, Faculdade de Ciencias Medicas,
Universidade Estadual de Campinas (UNICAMP), Rua Tessalia Vieira de Camargo, 126, Cidade Universitaria Zeferino Vaz, 13083-887 Campinas, SP, Brazil
2016 Taylor & Francis

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CLINICAL TOXICOLOGY

223

those of M. frontalis [13,23] and M. lemniscatus [13,14] have a

predominantly postsynaptic action.
Despite the large number of Micrurus spp. found in Brazil
(Figure 1), there are in fact few clinical reports involving these
snakes in this country. In this work, we analyzed the literature
reports of coral snake bites in Brazil and provide a brief review
of case series and case reports of coral snake bites in the
Americas in general. This report provides a useful summary of
coral snake bites in Brazil for researchers with limited access to
foreign literature in Portuguese.

as Micrurus spp. bites were probably caused by non-venomous

coral snake mimics, such as colubrids of the genera Oxyrhopus,
Erythrolampus, Liophis, Pliocercus, Simophis, and others, erroneously identified as true coral snakes.[1,7,8] The low incidence
of bites by coral snakes is confirmed by records from the
Instituto Butantan, a referral institution in Sao Paulo city,
southeastern Brazil, from 1902 to 1945 and 1954 to 1977,
which indicate that of 10,301 bites by venomous snakes, 9177
were by lanceheads (Bothrops spp.), 1064 by rattlesnakes
(Crotalus durissus ssp.), 42 by coral snakes (Micrurus spp.), and
18 by bushmasters (Lachesis muta), with 2 deaths in the series
of bites by Micrurus spp.[912]
Micrurus venoms are neurotoxic,[1316] myotoxic,[17,18]
nephrotoxic,[18] hemorrhagic,[15] and edematogenic,[16] with
some also being hemolytic.[19] However, in humans, neuromuscular blockade is the hallmark of systemic envenoming by
Micrurus spp.,[13] with local manifestations such as edema and
myonecrosis being much less common than in laboratory
animals. The neurotoxins responsible for this blockade
are either presynaptically active phospholipases A2 (PLA2;
1214 kDa) that block the release of acetylcholine,[20] or
postsynaptically active three-finger toxins (3-FTx; 68 kDa, with
no enzymatic activity) that block nicotinic cholinergic receptors
by competing with acetylcholine.[21] Pharmacological studies
by Vital Brazil and co-workers indicated that the venom of
M. corallinus has a predominantly presynaptic action,[22] while

Methods
We reviewed the reports of coral snake bites in humans in
Brazil from 1867 to 2014 to determine the species involved,
geographical region/origin, the clinical features described, the
treatment used, and the outcome. For this, we searched
electronic databases (EMBASE, PubMed/Medline, SciELO, and
LILACS, the latter two covering collections of Brazilian and
other Latin-American scientific journals) using key words in
Portuguese and English, including some MeSH terms, such as
mordidas/picadas de serpentes (snake bites), cobra coral
(coral snakes), envenenamento (envenomation), Elaps (an
earlier taxonomic designation for the genus Micrurus),
Micrurus, coral snakes, snake bites, and envenomation. In
addition, we manually searched standard textbooks on

North

Northeast

L. collaris collaris
L. narduccii melanotus
L. scutiventris
RR
M. albicinctus
M. annellatus annellatus
M. annellatus bolivianus
M. averyi
M. brasiliensis
AM
M. filiformis
M. diana
M. hemprichii hemprichii
RO
M. hemprichii ortoni
M. hemprichii rondonianus
AC
M. isozonus
M. langsdorffii
M. lemniscatus lemniscatus
M. diutius
Central-west
M. lemniscatus helleri
M. albicinctus
M. mipartitus
M. brasiliensis
M. nattereri
M. frontalis
M. ornatissimus
M. hemprichii hemprichii
M. pacaraimae
M. lemniscatus helleri
M. paraensis
M. paraensis
M. psyches
M. pyrrhocryptus
South
M. putumayensis
M. spixii martiusi
M. altirostris
M. remotus
M. spixii spixii
M. corallinus
M. spixii spixii
M. surinamensis
M. decoratus
M. spixii martiusi
M. tricolor
M. frontalis
M. spixii obscurus
M. lemniscatus carvalhoi
M. surinamensis
M. silviae

M. brasiliensis
M. corallinus
M. filiformis
M. ibiboboca
M. lemniscatus carvalhoi
M. paraensis
M. potyguara
M. spixii martiusi
M. surinamensis

AP

PA

MA

CE

RN
PB

PI

PE
AL

TO

SE
BA

MT
DF

Southeast

GO
MG

M. brasiliensis
M. corallinus
M. decoratus
M. frontalis
M. lemniscatus carvalhoi

ES

MS
SP

RJ

North

PR
SC

Northeast
Central-west

RS

Southeast
South

Figure 1. Coral snake taxa (genera Leptomicrurus and Micrurus) found in Brazil, according to geographical region. Adapted from Carvalho et al. [2] with additional data
from Campbell and Lamar,[3] Bernils and Costa,[4] and Uetz and Hosek.[5] State abbreviations: AC: Acre; AL: Alagoas, AM: Amazonas; AP: Amapa; BA: Bahia; CE: Ceara;
DF: Distrito Federal (Federal Capital Territory); ES: Esprito Santo; GO: Goias; MA: Maranhao; MG: Minas Gerais; MS: Mato Grosso do Sul; MT: Mato Grosso; PA: Para;
PB: Paraba; PE: Pernambuco; PI: Piau; PR: Parana; RJ: Rio de Janeiro; RN: Rio Grande do Norte; RO: Rondonia; RR: Roraima; RS: Rio Grande do Sul; SC: Santa Catarina;
SE: Sergipe; SP: Sao Paulo; TO: Tocantins.

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224

F. BUCARETCHI ET AL.

toxicology/toxinology, abstracts published in congress proceedings and academic dissertations, as well as the reference
lists of all the publications that were consulted. We also
included two cases of envenoming based on personal
communications.
Only reports with clinical descriptions of envenomation
were considered in the analysis. The variables recorded
included identification of the offending snake, patients age,
sex, bite site, clinical manifestations, treatment given, including
antivenom and anticholinesterase drugs (edrophonium and
neostigmine), and general evolution of the cases. When
available, we accessed and reviewed the original medical
charts or spreadsheets from the reports in order to collect
additional useful information that had not been included in the
original manuscripts.
All the data were entered into a digital databank designed
specifically for this study. Demographic and clinical data are
shown as actual numbers or percentages for categorical
variables, and as the median and the 25th and 75th percentiles
(interquartile interval, IQI) for continuous variables.

Results
Thirty reports describing bites caused by Micrurus spp. in Brazil
were identified and involved 194 distinct cases, i.e. no
repetitive cases in the 30 reports.[912,2448] Since no
information on the clinical manifestations was available in 44
cases,[9,11,12,24,27] the analysis was restricted to 150 cases
(Table 1).[10,25,26,2848]
Most of the patients were from southern (61.3%; primarily
Santa Catarina state, 60%) and southeastern (20%) Brazil and
were male, with a median age of 27 years. Of the 143 cases in
which the bite site was recorded, most involved the hands
46.2% and feet 26.6%. The offending snake was reported in
81 cases (54%), with most bites being caused by M. corallinus
(n 36) followed by M. frontalis (n 12) (Table 2 and Figure 2).
From 1992 to 2014, regional Poison Control Centers contributed the majority of reports (n 128, 85.3%; Santa Catarina
90,[29,35,38,44,47] Bahia 19,[41] Campinas 12,[34,37,40]
Belo-Horizonte 2,[39,45] Para 2,[43] Rio Grande do Sul
1,[36] Pernambuco 1,[42] and Joao Pessoa 1.[48]
Patients showed local effects (74%) such as local numbness/
paresthesia 52.7%, local pain 48%, and systemic neurotoxic

Table 1. Case reports of coral snake bites (Micrurus spp.) in Brazil, showing the author(s), year and type of publication, description of the clinical manifestations of
envenoming (yes/no), fatal outcome, number of cases included in this review, and identification of the offending species.
Authors (year)[Reference]

Type of publication
(language)

New cases
(deaths)

No clinical
description

Wucherer (1867)[24]
Brazil and Brazil Filho (1933)[25]
Yered (1942)[26]
Fonseca (1949)[9]
Machado and Rosenfeld (1971)[27]
Rosenfeld (1971, 1972)[10,11]
Ribeiro and Jorge (1986)[28]

Article (P)
Article (P)
Article (P)
Book (P)
Article (P)
Book chapter (E, P)
Abstract (P)

2 (2)
5 (2)
1
15
1 (a)
13 (2a)
7

2
1
0
15
1
11
0

Coelho et al. (1992)[29]

Manuel et al. (1993)[30]
Nishioka et al. (1993)[31]
Seligman (1993)[32]
Fan and Cardoso (1995)[12]
Santos et al. (1995)[33]
Vital Brazil and Vieira (1996)[34]
Nedel et al. (1997)[35]
Warrell (2004)[36]
Bucaretchi et al. (2006)[37]

Article (E)
Abstract (P)
Article (E)
Article (P)
Book chapter (E)
Book chapter (P)
Article (E)
Abstract (P)
Book chapter (E)
Article (E)

3
1
1
1
14
1
2
34
3
9

Rodrigues and Zannin (2006)[38]

Academic dissertation (P)

51

Babo et al. (2007)[39]

Vieira and Bucaretchi (2007)[40]
Casais-e-Silva and Brazil (2009)[41]
Ferreira et al. (2009)[42]
Pardal et al. (2010)[43]
Manso et al. (2010)[44]
Lopes et al. (2011)[45]
Castro et al. (2013)[46]
Torres et al. (2013)[47]
Lordao et al. (2014)[48]
Silva Junior (2014)
Total

Abstract (P)
Abstract (E)
Article (P)
Abstract (P)
Article (E)
Abstract (P)
Abstract (P)
Academic dissertation (P)
Abstract (P)
Abstract (P)
Personal communication (P)
30

1
1
19
1
2
1
1
1
1
1
1
194 (6)

0
0
0
0
0
0
0
0
0
0
0
44

Cases included in this review; offending

species
0
4;
1;
0
0
2;
7;

0
0
0
14
0

1;
1;
1;
0
1;

M. frontalis (1), M. lemniscatus (1)

M. corallinus
M. frontalis (1), M. corallinus (1)
M. corallinus (5), M. frontalis (1),
M. lemniscatus carvalhoi (1)
M. corallinus
M. lemniscatus carvalhoi
M. frontalis
M. hemprichii

0
0

3; M. frontalis (1), M. corallinus (1), M. spixii (1)

11c; M. frontalis (2), M. lemniscatus (1),
Micrurus spp. (1)
88 b; M. corallinus (25), M. frontalis (4),
Micrurus spp. (11)
1; M. lemniscatus lemniscatus
1
19; Micrurus spp. (10)
1
2; M. surinamensis (1), M. filiformis (1)
1; M. corallinus
1
1; M. frontalis
1; M. corallinus
1; M. ibiboboca
1; M. hemprichii ortoni
150; M. corallinus (36), M. frontalis (12),
M. lemniscatus (5), M. hemprichii (2),
M. spixii (1), M. surinamensis (1), M.
filiformis (1), M. ibiboboca (1) and Micrurus
spp. (22).

E: English; P: Portuguese.
a
These 2 deaths include the autopsy reported by Machado and Rosenfeld (1971).
b
88 cases, including the 3 cases described by Coelho et al (1992) and 34 cases reported by Nedel et al (1997).
c
Eleven cases including the 2 cases reported by Vital Brazil and Vieira (1996).

CLINICAL TOXICOLOGY

Table 2. Sex, age, bite site, snake identification, and origin (geographic
region) reported for 150 individuals bitten by coral snakes in Brazil.

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Findings

Sex
Male
Female
Not reported
Age in years
Cases reported
Median (IQI; limits)
Bite site
Fingers/hand
Toes/foot
Leg/thigh
Arm/forearm
Others
Not reported
Snake identification
M. corallinus
M. frontalis
M. lemniscatus
M. hemprichii
M. filiformis
M. ibiboboca
M. spixii
M. surinamensis
Micrurus spp.
Geographic region of Brazil
South
Southeast
Northeast
North
Central-west

106
41
3

70.7
27.3
2.0

143
27 (18-40; 170)

95.3

66
38
25
8
6
7

44.0
25.3
16.7
5.3
4.0
4.7

36
12
5
2
1
1
1
1
22

24.0
8.0
3.3
1.3
0.7
0.7
0.7
0.7
14.7

92
30
22
5
1

61.3
20.0
14.7
3.3
0.7

Interquartile interval (IQI) 1st and 3rd quartile values.

manifestations (59.3%) such as palpebral ptosis 33.3%, blurred

vision 20.7%, weakness 20%, dysphagia 14.7%, dyspnea
11.3%, inability to walk 10.7%, salivation 8%, and inability to
stand up 4.7%. Fang marks were detected in 47.3% of cases,
and 14% of the patients were described as asymptomatic (Table
3). The interval between the bite and hospital admission was
reported in 72 of the 89 patients who developed signs of
systemic neurotoxic envenomation (median 3 h, IQI: 15 h,
limits 20 min29 h), with 70 patients showing signs of myasthenia upon admission. Two patients showed delayed clinical
features of systemic envenomation, one 12 h[26] and the other
20 h post-bite.[28]
Myalgia was reported in 14 patients (9.3%). In addition, a
slight increase in total blood creatine kinase (CK) was
detected in three children: two cases involved bites by
M. corallinus one was a 1-year-old male (CK 500 U/L;
reference value RV5215 U/L) with signs of acute myasthenia,
i.e. ptosis, salivation, and muscular weakness,[44] while the
other was an 11-year-old male (CK 1766 U/L; RV5175 U/L)
with signs of systemic envenomation (ptosis and superficial
breathing).[30] The third case involved a 3-year-old male bitten
by M. frontalis (CK 1354 U/L; RV5225 U/L) who developed
only local pain, with no clinical features of systemic
envenomation.[46]
The two personal communications involved herpetologists.
The first individual was bitten by M. spixii in Manaus, capital of
the northern Brazilian state of Amazonas, and developed

M. corallinus

M. frontalis

M. lemniscatus

M. surinamensis

M. ibiboboca

M. hemprichii

M. spixii

225

M. filiformis

Figure 2. Coral snakes (Micrurus spp.) responsible for cases of human envenomation in Brazil. Photographs provided by the co-author Nelson J. Da Silva Jr.

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226

F. BUCARETCHI ET AL.

persistent pains in the joints, bones, and all tooth sockets but
there was no information regarding the bite site or use of
antivenom (Paulo Buhrnheim, cited in Warrell, 2004).[36] The
second involved an individual who was bitten on the hand by a
50-cm long specimen of M. hemprichii ortoni, while working in
the Brazilian Amazon basin in 1989; there were only transient,
mild local manifestations (local pain, slight edema, and
paresthesia), with complete recovery 68 h post-bite; treatment
with antivenom was not required (N. J. Da Silva Jr, personal
written communication, 2014). Three years later, this same
individual was accidentally bitten on the right little finger by a
55-cm long M. fulvius during academic activity in a university
zoology laboratory in the United States. This second envenomation was more severe, with radiating intense local pain, local
numbness, myalgia, thoracic pain, and an increase in CK (peak
of 1753 U/L, 8 h post-bite). Although recommended by the
local medical staff, the patient refused treatment with antivenom, arguing that he had not developed neurotoxic
systemic manifestations.
The use of coral snake antivenom was reported in 116 cases
(77.3%), of which 26 showed no signs of systemic neurotoxic

Table 3. Main clinical features reported for 150 patients bitten by coral snakes in
Brazil.
Features

Local manifestations
Paresthesia
Pain
Fang marks
Slight edema
Erythema
Radiating pain
Systemic manifestations
Palpebral ptosis
Dizziness
Blurred vision
Weakness
Dysphagia
Superficial respiration/dyspnea
Inability to walk
Myalgia
Diplopia
Salivation
Conjunctival hyperemia
Somnolence
Headache
Inability to stand up
Vomiting
Abdominal pain
Thoracic pain
Ophthalmoplegia
Fasciculations
Asymptomatic
Therapeutic procedures
Coral snake antivenoma
Systemic neurotoxic envenomation
Only local features
Asymptomatic
Number of vials reported
Number of vials: median (IQI; limits)
Anticholinesterase drugs
Neostigmine
Edrophonium
Positive response (neostigmine)b
Mechanical ventilation

111
79
72
71
24
24
8
89
50
40
31
30
22
17
16
14
13
12
9
9
9
7
6
6
6
5
3
21

74.0
52.7
48.0
47.3
16.0
16.0
5.3
59.3
33.3
26.7
20.7
20.0
14.7
11.3
10.7
9.3
8.7
8.0
6.0
6.0
6.0
4.7
4.0
4.0
4.0
3.3
2.0
14.0

116
89
20
6
115
10 (10 to 10; 2 to 30)
9
8
1
5
5

77.3
59.3
13.3
4.0
76.7

Interquartile interval (IQI) 1st and 3rd quartile values.

a
Coral snake antivenom soro antielapdico.
b
Positive response: improvement of muscle weakness.

6.0
5.3
0.7
3.3
3.3

envenomation (20 had exclusively local manifestations and six

were asymptomatic). The amount of antivenom (in terms of the
number of vials) was reported for 115 patients, with a median
dosage of 10 vials (10 mL/vial). Nine patients (6%) were also
treated with anticholinesterase drugs (edrophonium test 1;
neostigmine 8),[29,32,34,36,37,43] with a positive response
(improvement of muscle weakness) being observed in five
patients (two patients bitten by M. frontalis, with the remaining
three probably also being bitten by this species).[29,34,36,40]
Mechanical ventilation was used in five patients: three bitten
by M. corallinus (two 1-year-old children and a 66-year-old
man),[38,47] an 18-year-old man bitten by M. surinamensis,[43]
and a 28-year-old man bitten by an unidentified coral
snake.[45] In three cases, the duration of mechanical ventilation was reported to be 12 h,[45] 48 h,[43] and 72 h.[47]
Brazil and Brazil Filho[25] described two deaths from coral
snake bites in Brazil. The first case (1922) was a local curandeiro
(medicine man) bitten by M. lemniscatus in Maranhao, northeastern Brazil, who died 17 h post-bite after developing
impaired vision and paralysis. There was no additional information regarding other clinical features or the treatment used.
The second case (1932) was a previously healthy 19-year-old
man bitten by an unidentified coral snake in the municipality of
Niteroi, Rio de Janeiro, southeastern Brazil. The patient
reported local and radiating pain and local numbness, and
manifested palpebral ptosis, blurred vision, dysphagia, salivation, and progressive muscular weakness, with difficulty in
standing and walking. Despite treatment with coral snake
antivenom (Institute Vital Brazil, Niteroi, RJ; 20 mL subcutaneous 1 h post-bite), the patient developed respiratory failure
and died of asphyxia 6 h post-bite. In neither of these cases,
was mechanical ventilation possible at the time. Although the
snake involved in the second case was not brought for
identification, the authors speculated that the patient had
probably been bitten by M. corallinus, since antivenom was
ineffective in reversing the neurotoxicity. At the time,
coral snake antivenom provided by the Institute Vital
Brazil was produced with venoms from M. frontalis and
M. lemniscatus.[25]

Discussion
The rarity of bites by Micrurus spp. has been attributed to their
burrowing habits, small to medium size, low aggressivity, short
anterior fixed fangs, and the limited angle of opening of the
mouth, which makes it difficult for these snakes to inject
venom into humans.[1,3] On the other hand, the attractive
coloration of coral snakes and the ease with which they can be
confused with similarly colored non-venomous colubrid
mimics has led, in several cases, to inappropriate or imprudent
handling that could partly account for the high frequency of
bites to the fingers/hands. Indeed, there are reports of
envenomation in children who were playing with coral
snakes,[49] including a 1-year-old girl bitten in the mouth by
M. corallinus.[44] Bites to the fingers/hands during handling
would allow the snake to hold on and chew, thereby providing
time for venom inoculation.[50]
As shown here, most bites resulted in local manifestations,
such as numbness/paresthesia and local pain sometimes

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Table 4. Case reports, case series, and epidemiological studies of coral snake bites (Micrurus spp.) in the Americas (excluding Brazil), showing the author(s), year, type
of study, country, offending species, and the number of cases studied, including the number of patients treated with mechanical ventilation and the outcome (death).
Authors (year)[Reference]

Type of
study (language)

True (1883)[61]

CR (E)

USA

Gloyd (1938)[69]
Werler and Draling (1950)[70]
Neill (1957)[62]

CR (E)
CR (E)
CS (E)

USA
USA
USA

Ramsey and Klickstein (1962)[63]

McCullough and Gennaro (1963)[64]
Andrews et al (1968)[67]
Moseley (1966)[65]
Parrish and Khan (1967)[66]
Russell (1967)[72]
Bolanos (1982)[52]

CR (E)
CR, R (E)
CS (E)
CR (E)
CS (E)
CS (E)
CS, EA (S)

Pettigrew and Glass (1985)[60]

Pifano et al (1986)[59]
Kitchens and Van Mierop (1987)[50]
Norris and Dart (1989)[51]
Esteso et al. (1989)[58]
Otero et al. (1992)[54]
Kuch and Freire (1998)[56]
Ayerbe et al. (2000)[53]
Morgan et al. (2007)[71]
Manock et al. (2008)[57]
Norris et al. (2009)[101]
Walter et al. (2010)[103]

CR (E)
CR (S)
CS (E)
CR (E)
CS (S)
CR (S)
CR (E)
CS, EA (S)
CS, EA (E)
CR (E)
CR (E)
MO (E)

USA
USA
USA
USA
USA
USA
Costa Rica,
Colombia and
Argentina
Mexico
Venezuela
USA
USA
Argentina
Colombia
Ecuador
Colombia
USA
Ecuador
USA
USA

Wood et al. (2013)[68]

de Roodt et al. (2013)[73]

CS (E)
EA (E)

USA
Argentina

Sasaki et al. (2014)[49]

Otero-Patino (2014)[55]

CS (E)
CS (E)

USA
Colombia

Country

Offending species (n)

Species identified as M. fulvius in one case; 3
more cases probably bitten by M. fulvius and 3
by M. tener
M. tener (1)
M. tener (1)
Mentioned 19 individuals probably bitten by
M. fulvius and one by M. tener
M. fulvius (1)
M. fulvius (1)
Probably involved only M. fulvius bites
M. fulvius (1)
M. fulvius (6) and M. tener (5)
Micruroides euryxanthus (4)
M. mipartitus (4), M. alleni (1), M. clarki (1),
M. frontalis (1), M. nigrocinctus (1), M. spixii (1)
M. laticollaris (1)
M. isozonus (1)
Probably involved only M. fulvius bites
M. tener (1)
Probably involved only M. pyrrhocryptus bites
M. dumerilii (1) and M. mipartitus (1)
M. bocourti (1)
M. mipartitus decussatus (3)
Species identified as M. tener in 22 cases
M. lemniscatus helleri (1)
Probably an M. fulvius bite
Probably involved M. fulvius, M. tener and
Micruroides euryxanthus bites
Probably involved only M. fulvius bites
Probably included M. corallinus, M. frontalis,
M. lemniscatus, M. altirostris, M. pyrrhocryptus
and M. baliocoryphus
Probably involved only M. fulvius bites
M. dumerilii (10), M. mipartitus (9),
M. nigrocinctus (2), M. dissoleucus (1) and
M. isozonus (1)

Cases
(MV; deaths)
7 (0; 4)
1 (0; 0)
1 (0; 0)
20 (0; 4)
1
1
14
1
11
4
9
1
1
39
1
7
2
1
3
96
1
1
1254

(1;
(0;
(0;
(0;
(0;
(0;
(0;

0)
1)
0)
0)
1)
0)
2)

(0; 0)
(1; 0)
(6; 0)
(0; 0)
(0;0)
(0; 0)
(0; 0)
(0; 0)
(1a; 0)
(1; 0)
(0; 1)
(ND; 0)

387 (11; 0)
46 (0; 0)
4 (1; 0)
24 (13; 4)

CR: case report; CS: case series; E: English; EA: epidemiological analysis; MO: medical outcomes; MV: mechanical ventilation; ND: not described; R: review; S: Spanish.
a
Respiratory support (MV) was provided because of status epilepticus in a patient with chronic seizure disorder but without paralysis.

reported as intense/excruciating pain,[31] as well as signs of

systemic neurotoxicity. Fang marks were described in almost
half of the cases; however, the absence of such marks does not
exclude the possibility that venom was inoculated and that
there may be neurotoxic manifestations.[51] These features
are similar to those described for bites by coral snakes
from other regions/countries of South America (Colombia:
M. mipartitus,[5255] M. dumerilii,[52,53,55] M. clarki,[52]
M. dissoleus,[55] M. spixii,[52] M. isozonus,[55] and M. nigrocintus[55]; Ecuador: M. bocourti [56] and M. lemniscatus helleri;[57]
Argentina: M. frontalis [52] and M. pyrrhocryptus;[58] Venezuela:
M. isozonus [59]), Central America (M. nigrocinctus and M. alleni
in Costa Rica)[52] and North America (M. laticollaris [60] in
Mexico, and M. fulvius [49,50,6168] and M. tener[66,6971] in
the USA) (Table 4). Systemic neurotoxic envenomation is very
uncommon after M. tener snake bites,[66,6971] whereas
intense local pain has frequently been described, with some
patients needing opioids for pain relief.[66,6971] Bites by the
small Sonoran coral snake Micruroides euryxanthus are very
rare, with no severe cases being reported.[72] Apart from the
present study, de Roodt et al. [73] analyzed 46 coral snake bites
reported to the Argentinian Ministry of Health (Programa
Nacional de Ofidismo, 19792003); there was no identification
of the offending species but the authors noted that six species

of Micrurus occur in Argentina (M. corallinus, M. frontalis,

M. lemniscatus, M. altirostris, M. pyrrhocryptus, and M. baliocoryphus), with the highest frequency of bites being recorded in
northern provinces where M. pyrrhocryptus predominates.
Although some patients may show no clinical symptoms
(dry-bites),[28,37,38,50,66,68] the potential severity of
envenomation should always be considered in the clinical
analysis, including the risk of delayed paralysis that may occur
several hours (718 h) post-bite.[50,66,68] An illustrative
example was reported by Manock et al., [57] who described
the case of a 27-year-old man bitten by a 120 cm long
specimen of M. lemniscatus helleri in the Amazon basin of
Ecuador. The patient was admitted 20 min post-bite with a
complaint of excruciating local pain that required morphine for
alleviation; the first signs of systemic neurotoxicity appeared
only 14 h post-bite. Antivenom (Panamerican Suero Anticoral
Polyvalente, Instituto Clodomiro Picado, IgG, equine origin, 10
vials, intravenous; 1 mL of antivenom neutralizes 0.3 mg of
M. nigrocintus, 0.3 mg of M. dumerilii, and 0.125 mg of M. fulvius
venoms) was available only at 50 h post-bite, but was
ineffective. The patient required mechanical ventilation
during evolution (72 h post-bite; 4 d of intubation) and was
discharged 15 d post-bite, with persistent limb weakness and
urinary incontinence; he eventually recovered.

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228

F. BUCARETCHI ET AL.

Figure 3. (A) Juvenile M. corallinus (15 cm long) that caused serious envenomation (respiratory failure) in a 1-year-old male. (B) Aspect of the bite site, on the left
index finger, with two fangs mark, erythema and slight edema.[47] Photographs with authors permission.

While most bites have apparently been caused by adult

snakes, juvenile snakes can also cause serious envenomation,
as described for two 1-year-old males who developed respiratory failure after being bitten on the finger by a 15 cm long
M. corallinus (Figure 3) [47] and on the hand, by a 25 cm long
M. mipartitus[55]; both patients required respiratory support/
mechanical ventilation for 3 d.
Important myotoxicity has been detected in experimental
studies with venoms from several Micrurus spp., and is
apparently greater in venoms with higher PLA2 activity, such
as those of M. fulvius, M. nigrocinctus and M. pyrrhocryptus.[17,18] Although generalized myalgia, suggestive of systemic myotoxicity, was not uncommon in the cases reviewed
here, only a few reports of coral snake bites in humans have
described laboratory findings, such as an increase in CK,
compatible with myotoxicity.[50,57,60] In the present series,
only three cases, all of them children, showed a slight increase
in CK that was suggestive of mild myotoxicity; two of them also
had signs of neurotoxic systemic envenomation.[30,44,46]
Kitchens and Van Mierop [50] described more intense
myotoxicity, with higher CK levels in two patients probably
bitten by M. fulvius (peak levels of 7000 U/L and 18 000 U/L);
both patients had systemic neurotoxic envenomation, with
one (CK 7000 U/L) requiring mechanical ventilation.
There have been no clinical reports of coagulopathy, even
for severe cases of envenomation by various Micrurus spp.
Manock et al. [57] described a possible exception to this
generalization that involved a patient bitten by M. lemniscatus
helleri who showed transient thrombocytopenia (86,000 and
90,000 platelets/mm3 at 10 h and 60 h post-bite, respectively)
and mild coagulopathy with no signs of bleeding. Micrurus
lemniscatus venom has anticoagulant activity in vitro and
in vivo.[14] Jorge da Silva and Aird [74] also noted that venom
from two subspecies (M. l. helleri and M. l. lemniscatus) had
marked thrombin-like activity in vitro. However, the extent to
which this thrombin-like activity contributed to the mild
coagulopathy in this case is unclear. In addition, although
C-type-lectins capable of influencing platelet activity occur in
Micrurus venoms,[75] their effect on platelet function has yet to
be assessed.

Antivenom therapy
Coral snake antivenom has been produced in Brazil since 1911,
however, the first report of its therapeutic use dates from
1930.[25] Brazilian coral snake antivenom is currently obtained
by immunizing horses with a mixture of venoms from two
species, M. frontalis and M. corallinus,[37] and, since the 1960s,
has been manufactured as Fab2.[10,76,77] According to the
two official Brazilian manufacturers (Instituto Butantan, Sao
Paulo, SP, and Fundacao Ezequiel Dias, Belo Horizonte, MG),
1 mL of antivenom (soro antielapdico bivalente; 1 vial 10 mL)
neutralizes 1.5 mg of reference M. frontalis venom in
mice.[37,77]
From the early 1900s to the 1940s, antivenoms in Brazil were
commonly administered only subcutaneously,[9] whereas from
1945 to the 1980s, antivenoms were administered subcutaneously and intravenously simultaneously.[10,78,79] In view of
the potentially lethal outcome of coral snake bites, since 1987
the Brazilian Ministry of Health has systematically recommended an empirical dose of 10 vials of antivenom given
intravenously for Micrurus spp. bites, regardless of the severity
of envenoming upon admission to hospital. This recommendation may explain why, in the present study, of the 116
patients treated with antivenom, 76/116 (65.6%) were treated
with 10 vials and 12 (10.3%) with410 vials. Based on a review
of this recommended protocol, the Brazilian Ministry of Health
has recently suggested a new algorithm for treating individuals
bitten by coral snakes (Figure 4),[77] partly as an attempt to
minimize the misuse and wastage of antivenom in the current
period of reduced antivenom production by the official
manufacturers.
Antivenom therapy is generally recommended for all
patients with early signs of acute myasthenia, e.g., ptosis and
muscle weakness, after coral snake bites, and before paralysis
becomes established since, even after antivenom administration, complete paralysis may take days or weeks to
resolve.[36,47,50,57,66,68] Based on this reasoning, there was
probably no indication for antivenom in 26 patients of the
present series since they showed no systemic neurotoxic
manifestations (Table 3). However, the question and clinicians

CLINICAL TOXICOLOGY

229

Suspected OR confirmed
coral snake (Micrurus spp.) bite
Suspected OR confirmed
envenomation:
monitoring required

Acute myasthenia
WITH PARALYSIS

Only local manifestations

Acute myasthenia WITHOUT PARALYSIS

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Observation
(24 h)

Onset of
MYASTHENIA

AV: 5 vials IV

Effective
treatment

NO
MYASTHENIA
Discharge

Onset of
PARALYSIS

AV: 10 vials IV
Provision of respiratory support
Consider tests with anticholinesterase
drugs

Figure 4. Algorithm for the treatment of patients bitten by coral snakes in Brazil (adapted from the Brazilian Ministry of Health, 2014).[77].

dilemma in such cases is whether patients admitted with only

local manifestations, or who may be asymptomatic, would
have progressed to paralysis if they had not received
antivenom.[37,50,68] An example of this dilemma is provided
by Wood et al. [68] who described a patient bitten by M. fulvius
admitted with no clinical features of envenomation but who
developed delayed symptoms of envenomation (12 h postbite) that quickly evolved to respiratory failure and required 24
d of intubation, despite treatment with six vials of North
American Coral Snake Antivenom (Wyeth antivenin, lyophilized IgG of equine origin; the reconstituted contents of each
10 mL vial neutralize 250 mouse LD50 or 2 mg of M. fulvius
venom). These authors highlighted that waiting to treat only
patients who start to show signs/symptoms of systemic
neurotoxic envenomation does not exclude the possibility of
a severe outcome.[68]
Pharmacokinetic studies may be useful for understanding the
pathophysiology of envenomation and for establishing more
appropriate treatment, including first aid measures and the use
of antivenom.[80,81] An experimental study using a central
lymph-cannulated sheep model showed the contribution of the
lymphatic system to the absorption and systemic bioavailability
of M. fulvius venom after subcutaneous injection.[80] This study
indicated that the inoculation site (subcutaneous) may serve as a
depot to prolong venom absorption (mean absorption time
393 58 min; tmax 162 29 min; t 261 55 min), with very
low levels of venom being detected in organs and urine; the
steady state observed after subcutaneous administration was
apparently maintained by slow absorption from the site of
inoculation.[80] After intravenous antivenom administration (2 h
post-venom injection), the serum venom concentration falls
quickly to unquantifiable levels.[81] These results may help to
explain the delayed neurotoxic manifestations described in
some patients bitten by coral snakes, as noted
above.[50,57,66,68]

Based on manual venom extractions, Carvalho et al.

reported maximum venom yields for M. frontalis and
M. corallinus of 32.5 mg (mean: 18.9 mg, 130 milkings; mean
body length: 82 cm) and 17.6 mg (mean: 15.5 mg, 13 milkings;
mean body length: 66 cm), respectively. These authors also
studied venom yields from 13 other Micrurus taxa from Brazil,
with M. surinamensis providing the largest maximum and mean
venom yields (53 mg and 40.5 mg, respectively).[2] Although
caution is required in extrapolating the results of neutralization
studies in experimental animals to the clinical setting, these
venom yields nevertheless suggest that four vials of Brazilian
coral snake antivenom (sufficient to neutralize 60 mg of
reference M. frontalis venom in mice) would probably be
enough to neutralize the maximum venom yield of M. frontalis,
in contrast to the 100 mL administered to the 88 patients
indicated above; the volume of antivenom required to
neutralize the venoms of other species may vary considerably,
depending on the antivenom cross-reactivity with these
venoms.
Micrurus venoms are considered good immunogens, with
good antivenom cross-reactivity that neutralizes the lethal
activity of venoms from several species found in Brazil.[82,83]
However, the regular availability of coral snake antivenom is
problematic for various reasons, including the difficulty in
acquiring and maintaining coral snakes in captivity for venom
extraction and the small amount of venom that can be
extracted per snake.[2,84] In addition, questions still remain
about the efficacy of antivenoms for treating bites by
offending species from different geographic origins. Tanaka
et al. [85] studied the biochemical activities (PLA2, hyaluronidase and proteolytic activities) and lethality (LD50 in mice) of
venoms from nine species of Micrurus, eight of them (M.
altirostris, M. corallinus, M. frontalis, M. hemprichii, M. ibiboboca,
M. lemniscatus, M. spixii, and M. surinamensis) from different
geographic regions of Brazil and one (M. fulvius) from North

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230

F. BUCARETCHI ET AL.

America; they also analyzed the antigenic cross-reactivity and

neutralizing capacity of Institute Butantan coral snake antivenom against these venoms. Neutralization assays in vivo and
in vitro showed that the antivenom did not fully neutralize the
activities of all venoms. The authors concluded that this lack of
complete neutralization reflected the existence of qualitative
and quantitative variations in Micrurus venoms and suggested
that modifications in the immunization scheme, i.e. the
inclusion of other venoms in the antigenic mixture, may be
needed to generate a more effective coral snake antivenom.[85] Indeed, some authors have advocated that regional
cooperation to produce a multivalent continental Micrurus
antivenom against the main species of clinical relevance
should be encouraged and could perhaps overcome problems
related to regional and intergeneric venom variations.[84,86]
In addition to Brazil and Costa Rica, Mexico (Coralmyn,
Instituto Bioclon, Fab2, equine lyophilized antivenom raised
against M. nigrocinctus)[87] and Argentina (Suero Anti-Micrurus
del Instituto Nacional de Produccion de Biologicos Dr. Carlos G.
Malbran, Fab2, equine origin, 1 vial 10 mL; manufactured with
a mixture of several Argentinian Micrurus venoms) also
produce coral snake antivenoms.[73,84] Wyeth antivenin
produced in the USA against M. fulvius was discontinued in
2003; however, after tests performed by the manufacturer that
met adequate safety and potency requirements, the Food and
Drug Administration (FDA) extended the expiration date of
several lots, with lot 4030024 expiring in April, 2016.[88] Since
the discontinuation of M. fulvius antivenom production by
Wyeth, there has been renewed interest in the potential
usefulness of other commercial antivenoms for neutralizing
M. fulvius venom, with neutralization being reported with
Costa Rican antivenom to M. nigrocinctus,[89] antivenom
(Coralmyn) against Mexican Micrurus species,[84,87] and an
antivenom against the Australian tiger snake, Notechis scutatus.[90] Coralmyn antivenom is effective in neutralizing the
venoms of M. fulvius and M. tener, the two coral snakes of
medical importance in the USA.[87] These commercial antivenoms could provide an alternative for treating bites by
M. fulvius and M. tener in the USA, but FDA approval has yet to
be granted for this.

Respiratory support
Antivenom remains the mainstay for adequate management of
coral snake envenomation. However, respiratory support, such
as intubation and conventional mechanical ventilation, can
improve the outcome of patients who develop severe
envenomation with paralysis evolving to respiratory failure[38,43,45,47,49,50,55,57,59,63,68]; indeed, the unavailability of adequate respiratory support probably contributed
to several fatal cases reported in the literature
(Table 4).[24,25,27,52,55,61,62,64,66] According to OteroPatino (2015, personal written communication), of the four
deaths from coral snake bites recorded in Colombia from 1989
to 1998 (5-year-old male, 20-year-old female, 20-year-old male,
and 25-year-old female),[55] none of them was treated with
antivenom or mechanical ventilation; the offending species
was identified in three cases (M. dumerilii, n 2; M. mipartitus,
n 1).

The first description of successful respiratory support in

severe coral snake envenomation using mechanical ventilation
was described by Ramsey and Klickstein,[63] in a 62-year-old
patient bitten by M. fulvius, in which a non-invasive Drinker
respirator or iron lung was used. A review of coral snake bites
followed-up by the Florida Poison Information Center Network
(19982010, a geographical area of M. fulvius), showed that 11
patients (2.8%) were treated with mechanical ventilation,[68] a
frequency similar to the 3.3% observed in the present analysis.
In contrast, Otero-Patino[55] reported that 13 of 24 patients
bitten by coral snakes in Colombia were treated with intubation and mechanical ventilation. Unfortunately, respiratory
support may still be not available in under-resourced health
systems in poor rural areas of Latin America.

Anticholinesterase medications
Anticholinesterase medications may be useful in patients
bitten by elapid snakes in which paralysis is caused predominantly or exclusively by postsynaptic neurotoxins acting at the
neuromuscular junction, as demonstrated by Watt et al., in a
placebo-controlled study of the usefulness of edrophonium for
patients envenomed by the Philippine cobra (Naja naja
philippinensis), a South-east Asian elapid species.[91] Since
coral snake venoms are also rich in postsynaptic neurotoxins,
anticholinesterase drugs would be expected to be beneficial in
treating bites by these snakes. Indeed, in the present survey,
we found favorable responses to neostigmine in five patients
involving two confirmed bites by M. frontalis and three others
probably bitten by this species.[29,34,36,40] In Brazil, this
efficacy was initially demonstrated for coral snakes by Vital
Brazil and co-workers in dogs and monkeys (Cebus sp.)
envenomed with M. frontalis venom.[13] Anticholinesterases
may be useful in serious bites by M. frontalis if antivenom is
unavailable or if there is a delay in obtaining a sufficient
amount for treatment; these drugs may also be useful in
patients who, despite receiving the highest recommended
doses of antivenom, show delayed or no recovery from
paralysis,[37] or even recurrent systemic neurotoxic
manifestations.[40]
Although M. lemniscatus venom also produces neuromuscular blockade through a postsynaptic action that is partially
and transiently antagonized by neostigmine in rat phrenic
nerve-diaphragm in vitro,[13,14] there has been no report
confirming the clinical effectiveness of anticholinesterases after
envenoming by this species; indeed, in a case of envenoming
by M. lemniscatus helleri in Ecuador, the patient did not
respond to anticholinesterase treatment.[57] Similarly, there
was also no response to anticholinesterase treatment (edrophonium test) in a patient bitten by M. laticollaris in
Mexico.[60] Studies in vitro have shown that while the
neuromuscular blockade produced by a variety of Micrurus
species, e.g., M. altirostris,[92] M. laticollaris,[93] M. nigrocinctus,[94] M. pyrrhocryptus,[95] and M. spixii,[96] involves interaction with postsynaptic nicotinic receptors, the reversal by
neostigmine is often minimal/discrete (generally530%) and
transitory, with no significant long-term protection against
progressive neuromuscular blockade. In this regard, it is worth
recalling that most coral snake venoms are a mixture of

CLINICAL TOXICOLOGY

presynaptic (PLA2-type) and postsynaptic (3-FTx) neurotoxins,

with blockade by PLA2-type neurotoxins being insensitive to
reversal by anticholinesterases. Together, these findings indicate that postsynaptic nicotinic blockade by venom toxins
does not imply reversal by anticholinesterases. These observations also suggest the need for caution in extrapolating the
potentially beneficial effects of anticholinesterase drugs
observed in vitro to clinical envenoming by coral snakes.

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Pressure-immobilization
Pressure-immobilization bandages are frequently used in some
countries where envenomations by elapid snakes with neurotoxic venoms are common, e.g., Australia, in order to impede
lymphatic venom absorption from the bite site and delay
systemic envenomation.[97] Although no clinical trials have
assessed the benefits of pressure-immobilization bandages as a
first aid measure,[97] including for bites by Micrurus spp.,
experimental studies have demonstrated that pressure-immobilization bandages can delay the onset of the symptoms of
envenomation and increase the survival time in pigs injected
with M. fulvius venom.[98,99] However, simulated snakebite
scenarios have shown that physicians and lay people may have
some difficulties in properly applying such bandages.[100]

Fatal cases
Fatal outcome after coral snake bites is rare. In addition to the
two deaths reported by Brazil and Brazil Filho (1933), there are
reports of four more deaths in Brazil (Table 1), but no clinical
information of the envenomations could be obtained for these
cases. These reports include two deaths (one each from the
states of Minas Gerais and Bahia) cited by Wucherer (1867),[24]
and two (in 1959 and 1962, recorded in the fatal snakebites list
of the Hospital Vital Brazil, Instituto Butantan, Sao Paulo, from
1954 to 1965) mentioned by Rosenfeld.[11] An autopsy was
done in one of the fatal cases reported by Rosenfeld; this case
involved a 50-year-old man probably bitten by M. corallinus on
the coast of Sao Paulo and who died 6 h post-bite during
transportation to Hospital Vital Brazil in 1962. Microscopic
analysis at autopsy revealed slight edema, necrosis, hemorrhage and leucocyte infiltration at the probable bite site, as
well as hemoglobin cylinders in the renal tubules suggestive of
rhabdomyolysis or intravascular hemolysis.[27] Although not
reported in humans, intravascular hemolysis has been
described in a case series of dogs bitten by M. fulvius.[101]
Poison Control Centers represent an important source of
information concerning coral snake bites, as reported by
Morgan et al. [71] (case series of M. tener snakebites, Texas
Poison Center Network, 20002004) and Wood et al. [68] (case
series of eastern coral snakebites, Florida Poison Center
Network, 19982010). Walter et al. [102] analyzed the severity
of coral snake bites in the USA published in the American
Association of Poison Control Centers Annual Reports from
1983 to 2007 (n 1254) and identified 37 cases with a major
outcome (life-threatening exposure). In the present analysis,
most of the cases were reported by eight Brazilian Poison

231

Control Centers,[29,3445,47,48] mainly from southern Brazil

(n 92).
The major limitation of the present analysis was that for
several cases, the clinical information was incomplete since not
all of the relevant data could be retrieved from the original
sources. Nevertheless, this summary and overview of Micrurus
spp., bites in Brazil should provide a stimulus for additional
clinical studies of these fascinating but clinically under-studied
snakes. Specifically, collaborative and prospective clinical
studies might be designed to (1) establish more precise clinical
indications for antivenom use, including the number of vials,
(2) assess the true efficacy of Brazilian coral snake antivenom
against bites by all indigenous Micrurus spp. of clinical
relevance, and (3) use ELISA (enzyme-linked immunosorbent
assays) to confirm the diagnosis in patients bitten by unidentified coral snakes with no neurotoxic manifestations at
hospital admission and to assess the clinical usefulness of
detecting circulating venom levels at distinct post-bite and
post-antivenom intervals.[103,104] To date, there has been
only one report of the clinical usefulness of ELISA after coral
snake bite in humans; this case involved a post-mortem proof
of envenomation in a 38-year-old male bitten by M. fulvius in
Lee County, Florida.[105]
In contrast to Australia, where ELISA-based snake venom
detection kits are used to distinguish among the elapid genera
most commonly implicated in human envenomation and may
assist in determining the appropriate use of monovalent
antivenom in patients with systemic envenomation,[106,107]
we feel that there is little rationale for developing similar kits
for widespread use in Brazil since (1) envenomation by coral
snakes is very uncommon, (2) all medically important coral
snakes belong to the same genus, unlike Australia where
several elapid genera are involved, (3) there is currently only
one official coral snake antivenom in clinical use in Brazil, and
(4) the major systemic manifestation of envenomation by coral
snakes is neurotoxicity; this clinical profile clearly distinguishes
envenomation by coral snakes from that by lanceheads
(Bothrops spp. and related genera) and bushmasters (Lachesis
spp.) that produce marked local effects, local and systemic
hemorrhage, and coagulopathy, and by Crotalus durissus ssp.
(rattlesnakes) that produce marked neuromyotoxicity and
coagulopathy.[108]
In conclusion, most coral snake bites in Brazil have been
caused by M. corallinus and M. frontalis. Local effects, such as
paresthesia, numbness and pain, and systemic signs of acute
myasthenia were the most frequently reported manifestations.
Serious complications such as paralysis with respiratory failure
were also observed but were comparatively rare. Antivenom
therapy is generally recommended for all patients with early
signs of acute myasthenia. Mechanical ventilation may improve
the outcome of patients who evolve to respiratory failure and
anticholinesterase medications may be useful in serious bites
by M. frontalis and possibly other species with a predominantly
postsynaptic mode of neuromuscular blockade.

Disclosure statement
The authors report that they have no conflicts of interest.

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