Displaying publications 1 - 20 of 36 in total

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  1. Managing an Unidentified Jellyfish Sting with Mixed Envenomation Syndrome at a Noncoastal Hospital: Is This a New Form of Jellyfish Envenomation?
    Sivanasworn NK, Anantham G, Jamal SM, Hatta MM, Ismail AK
    Wilderness Environ Med, 2023 Jun;34(2):225-230.
    PMID: 36935280 DOI: 10.1016/j.wem.2023.01.010
    Jellyfish stings are the most common cause of marine envenomation in humans. Various species of box jellyfish have been identified around Penang Island, Malaysia, and these include multitentacled and four-tentacled box jellyfish (class Cubozoa). The typical syndrome following envenomation from these jellyfish has been poorly documented, posing a greater challenge when managing an unidentified jellyfish sting from Penang Island. We report a case of a 32-y-old man from Penang Island who was stung by an unidentified jellyfish while walking into the sea. The patient reported that he felt an immediate and severe electric current‒like pain over both thighs, left flank, and left forearm, followed by chest discomfort and breathlessness. Vinegar was applied over the affected areas, and he was rushed to a hospital, where he was treated with analgesia, steroids, and antihistamine. He refused hospitalization and was discharged against medical advice. He then presented to a noncoastal hospital 377 km away in Kuala Lumpur on the following day with severe pain over the affected sites as well as chest discomfort, shortness of breath, and abdominal cramps. The electrocardiograph demonstrated features of Wolff-Parkinson-White. Serial blood test results showed elevated creatine kinase but normal troponin I levels. The patient was managed symptomatically over a period of 4 d and was discharged with cardiology follow-up. Appropriate health-seeking behavior needs to be emphasized. This case report provides an opportunity to document the signs and symptoms of envenomation from possibly an undescribed jellyfish species near the coastal waters of Penang Island.
  2. Experience of using expired lyophilized snake antivenom during a medical emergency situation in Lao People's Democratic Republic--A possible untapped resource to tackle antivenom shortage in Southeast Asia
    Blessmann J, Hanlodsomphou S, Santisouk B, Krumkamp R, Kreuels B, Ismail AK, et al.
    Trop Med Int Health, 2023 Jan;28(1):64-70.
    PMID: 36416013 DOI: 10.1111/tmi.13833
    OBJECTIVES: To evaluate the safety and efficacy of expired lyophilized snake antivenom of Thai origin during a medical emergency in 2020/2021 in Lao People's Democratic Republic.

    METHODS: Observational case series of patients with potentially life-threatening envenoming who consented to the administration of expired antivenom between August 2020 and May 2022.

    RESULTS: A total of 31 patients received the expired antivenom. Malayan pit vipers (Calloselasma rhodostoma) were responsible for 26 (84%) cases and green pit vipers (Trimeresurus species) for two cases (6%). In three patients (10%) the responsible snake could not be identified. Of these, two presented with signs of neurotoxicity and one with coagulopathy. A total of 124 vials of expired antivenom were administered. Fifty-nine vials had expired 2-18 months earlier, 56 vials 19-36 months and nine vials 37-60 months before. Adverse effects of variable severity were observed in seven (23%) patients. All 31 patients fully recovered from systemic envenoming.

    CONCLUSIONS: Under closely controlled conditions and monitoring the use of expired snake antivenom proved to be effective and safe. Discarding this precious medication is an unnecessary waste, and it could be a valuable resource in ameliorating the current shortage of antivenom. Emergency use authorization granted by health authorities and preclinical testing of expired antivenoms could provide the support and legal basis for such an approach.

  3. Bite envenomation by Latrodectus geometricus (Araneae: Theridiidae) spiders in Malaysia
    Mokhtar AS, Muslimin M, Mat-Saat AY, Ghazali AM, Ismail AK, Abdul-Aziz NM
    Trop Biomed, 2021 Dec 01;38(4):568-577.
    PMID: 35001923 DOI: 10.47665/tb.38.4.100
    We report two confirmed human bite cases by Lactrodectus geometricus , also known as the brown widow spider. These are the first reported bite envenomation incidents by L. geometricus in Malaysia. The incidents occurred in Tawau, Sabah and Paka, Terengganu. Both men were bitten on their ear while putting on motorcycle helmets. The spiders appeared to have nested in the helmets. The dead specimens were collected and sent to the Invertebrate and Vertebrate Neurobiology Laboratory, Department of Parasitology, Universiti Malaya for identification. The species identity was confirmed by DNA barcoding.
  4. Fulltext Puzzle task ERP response: time-frequency and source localization analysis
    Almurshedi A, Ismail AK
    Transl Neurosci, 2015;6(1):187-197.
    PMID: 28123804 DOI: 10.1515/tnsci-2015-0020
    Perceptual decision making depends on the choices available for the presented task. Most event-related potential (ERP) experiments are designed with two options, such as YES or NO. In some cases, however, subjects may become confused about the presented task in such a way that they cannot provide a behavioral response. This study aims to put subjects into such a puzzled state in order to address the following questions: How does the brain respond during puzzling moments? And what is the brain's response to a non-answerable task? To address these questions, ERP were acquired from the brain during a scintillation grid illusion task. The subjects were required to count the number of illusory dots, a task that was impossible to perform. The results showed the presence of N130 over the parietal area during the puzzling task. Coherency among the brain hemispheres was enhanced with the complexity of the task. The neural generators' source localizations were projected to a multimodal complex covering the left postcentral gyrus, supramarginal gyrus, and angular gyrus. This study concludes that the brain component N130 is strongly related to perception in a puzzling task network but not the visual processing network.
  5. Fulltext Rhabdomyolysis due to unidentified jellyfish envenomation in west Malaysian waters
    Loy JS, Khoo CC, Arumugam T, Ngian GH, Ismail AK
    Toxicon X, 2024 Mar;21:100170.
    PMID: 38021315 DOI: 10.1016/j.toxcx.2023.100170
    Jellyfish envenomation is a common marine injury. We report a case of a 9-year-old boy who developed muscle weakness and rhabdomyolysis after a jellyfish sting. He was stung on the face, hands, and feet. He sustained immediate pain and numbness; however no immediate action was taken. He was taken to a primary health clinic and discharged with syrup Paracetamol 15mg/kg/dose and syrup Chlorpheniramine maleate 0.1mg/kg/dose for symptomatic relief. Over the next several days, the pain became generalized involving upper and lower limbs, aggravated by movement, and not alleviated by analgesia nor antihistamine. His condition worsened with the development of weakness of upper and lower limbs and 'tea-colored' urine from day 3 of illness. He received treatment for rhabdomyolysis at a district hospital. Maintaining hydration and urine output and symptomatic relief are central to treatment. His muscle pain and weakness improved. He was discharged well and remained asymptomatic at follow up.
  6. Cross reactivity and lethality neutralization of venoms of Indonesian Trimeresurus complex species by Thai Green Pit Viper Antivenom
    Tan CH, Liew JL, Tan NH, Ismail AK, Maharani T, Khomvilai S, et al.
    Toxicon, 2017 Dec 15;140:32-37.
    PMID: 29051104 DOI: 10.1016/j.toxicon.2017.10.014
    Arboreal pit vipers of the Trimeresurus complex group are medically important species in Indonesia (west of Wallace's line), but there is no specific antivenom produced in the country for treating related envenomation. Instead, the exiting trivalent Indonesian antivenom, Biosave® Serum Anti Bisa Ular (SABU, indicated for envenoming by Malayan pit viper, Javan spitting cobra and banded krait) is often misused to treat Trimeresus envenoming resulting in poor therapeutic outcome. Here, we investigated the cross-reactivity and neutralization capability of Thai Green Pit Viper Antivenom (GPVAV) against the venoms of four Indonesian Trimeresurus species. Consistently, the venoms of Trimeresurus (Trimeresurus) insularis, Trimeresurus (Trimeresurus) purpureomaculatus, Trimeresurus (Parias) hageni and Trimeresurus (Craspedocephalus) puniceus of Indonesia showed stronger immunoreactivity on ELISA to GPVAV than to Biosave®. The findings correlated with in vivo neutralization results, whereby GPVAV was far more effective than Biosave® in cross-neutralizing the lethality of the venoms by a potency of at least 13 to 80 times higher. The efficacy of GPVAV is partly attributable to its cross-neutralization of the procoagulant effect of the venoms, thereby mitigating the progression of venom-induced consumptive coagulopathy. The paraspecific effectiveness of GPVAV against Trimeresurus species envenoming in Indonesia await further clinical investigation.
  7. A case of fatal envenomation by a captive puff adder (Bitis arietans) in Malaysia
    Husain Z, Wicaksono AC, Renault A, Md Zhahir SS, Ismail AK
    Toxicon, 2023 Mar 01;224:107023.
    PMID: 36640813 DOI: 10.1016/j.toxicon.2023.107023
    The Puff Adder (Bitis arietans) is a viper native to Africa and the Middle East. Envenomation by this species often requires the administration of appropriate antivenom in order to achieve a favorable outcome. A patient was bitten in both hands by a captive B. arietans presented to a teaching hospital in Malaysia. The patient developed painful progressive swelling on both limbs that extended to the chest, hypotension, hypokalemia with worsening anemia, thrombocytopenia, coagulopathy, and severe metabolic acidosis. The patient was managed supportively while waiting for the appropriate antivenom, Antivipmyn-Africa, from the Singapore Zoo. The patient developed cardiorespiratory arrest twice and did not recover from the second. The patient was pronounced dead 23 hours post-incident. The local unavailability of the appropriate antivenom may be the most important factor that contributed to the patient's death. There is also a need to amend the Malaysian Wildlife Act in order to prevent such cases from recurring.
  8. A case of rotenone poisoning from ingesting Derris trifoliata Lour. (Tuba fruit/pod) in Malaysia
    Yeoh SL, Choong PS, Zakaria R, Kamaruzaman NA, Md Rashid S, Razali MF, et al.
    Toxicon, 2024 Jan;237:107557.
    PMID: 38072318 DOI: 10.1016/j.toxicon.2023.107557
    Derris trifoliata is mainly found in mangrove area in tropical regions and the plant extract is traditionally used for fishing by poisoning. This is the first case report of rotenone poisoning in a child from ingesting Derris trifoliata seed. The child developed altered consciousness, vomiting, hypotension, metabolic acidosis, and acute kidney injury. Species identification of this case requires the collaborative efforts of various agencies. She survived from the poisoning with no neurological sequelae.
  9. Fulltext Audit of pain management in the emergency department
    Fathil SM, Soong NS, Mustafa NM, Arith A, Ng WN, Bahrum NA, et al.
    Med J Malaysia, 2011 Jun;66(2):89-91.
    PMID: 22106683 MyJurnal
    Pain management in Malaysian Emergency Departments has not been studied well. Convenience sampling was used to recruit 402 patients who presented with acute pain over a 2-week period. The 11-point Numerical Rating Scale was used to quantify pain. Pain relieving medications were prescribed to 178 patients (44.3%) in the Emergency Department. These patients had a median pain score of 7 on arrival. Nonsteroidal anti inflammatory drugs were the most commonly prescribed class of analgesic. Pain was found to be inadequately treated.
  10. Fulltext Intravenous ketamine is as effective as midazolam/fentanyl for procedural sedation and analgesia in the emergency department
    Jamal SM, Fathil SM, Nidzwani MM, Ismail AK, Yatim FM
    Med J Malaysia, 2011 Aug;66(3):231-3.
    PMID: 22111446
    The study compared the effectiveness of ketamine and midazolam/fentanyl as procedural sedation and analgesia agents for reduction of fractures and dislocated joints. Forty-one adult patients were enrolled by convenience sampling. They were randomized to receive ketamine or midazolam/fentanyl. Depth of sedation, pain score, procedural outcome and memory of the procedure were documented. The ketamine group had deeper sedation, but there was no statistical difference in other variables between the two groups. Three patients in the midazolam/fentanyl group had oxygen desaturation. More adverse effects were associated with ketamine. Intravenous ketamine is as effective as midazolam/fentanyl for procedural sedation.
  11. A case of cough induced rib fracture with subcutaneous emphysema and pneumothorax
    Shukri WNA, Ng VH, Ismail AK
    Med J Malaysia, 2019 12;74(6):551-552.
    PMID: 31929488
    Coughing is an important reflex mechanism which enhances the clearance of secretions and particulates from the airways, however repetitive muscle strain due to prolonged coughing may cause the uncommon complication of stress fracture of the ribs. The following is an unusual case of cough induced multiple rib fractures associated with subcutaneous emphysema and pneumothorax which was missed in the emergency setting. Delayed diagnosis and treatment would have been avoided if this uncommon condition was considered as a possibility.
  12. Fulltext The Brain-Gut Clinic in Hospital Universiti Sains Malaysia: Pioneering New Service to Advance Neuro-Gastroenterology and Motility in Malaysia
    Lee YY, Izham N, Mohd Zulkifly MF, Mohamed Mustafar MF, Ismail AK, Mohamed Shah NFFN, et al.
    Malays J Med Sci, 2023 Jun;30(3):1-7.
    PMID: 37425382 DOI: 10.21315/mjms2023.30.3.1
    Neurogastroenterology and motility is a new but advanced subspecialty within gasteroenterology that cater to difficult, persistent and refractory gut-brain symptoms. Hospital USM has the country's first and new state-of-the art motility lab that was recently launched on the 25 May 2023, and is covered in nationwide media. Another first is the Brain-Gut Clinic, established on the 16 November 2022. The clinic is a new concept that builds on unique multiple disciplines in relation to the gut-brain axis. It is hoped that there will be more awareness on the existence of neurogastroenterology and motility among doctors and community, and that more research can be forthcoming to reduce the disease burden.
  13. Bitten by the "flying" tree snake, Chrysopelea paradisi
    Tan TL, Ismail AK, Kong KW, Ahmad NK
    J Emerg Med, 2012 Apr;42(4):420-3.
    PMID: 22154775 DOI: 10.1016/j.jemermed.2011.03.038
    The paradise tree snake, Chrysopelea paradisi, is a rear-fanged colubrid. Like other members of the genus Chrysopelea, it is able to glide through the air, and thus, is commonly known as a "flying snake." There are few documented effects of its bite on humans.
  14. The Assessment of Acute Pain in Pre-Hospital Care Using Verbal Numerical Rating and Visual Analogue Scales
    Ismail AK, Abdul Ghafar MA, Shamsuddin NS, Roslan NA, Kaharuddin H, Nik Muhamad NA
    J Emerg Med, 2015 Sep;49(3):287-93.
    PMID: 26022936 DOI: 10.1016/j.jemermed.2015.02.043
    Prehospital care (PHC) pain evaluation is an essential patient assessment to be performed by paramedics. Pain intensity is frequently assessed using Verbal Numerical Rating Scale (VNRS) or Visual Analog Scale (VAS).
  15. Fulltext Potential economic and clinical implications of improving access to snake antivenom in five ASEAN countries: A cost-effectiveness analysis
    Patikorn C, Ismail AK, Zainal Abidin SA, Othman I, Chaiyakunapruk N, Taychakhoonavudh S
    PLoS Negl Trop Dis, 2022 Nov;16(11):e0010915.
    PMID: 36383562 DOI: 10.1371/journal.pntd.0010915
    BACKGROUND: Despite domestic production of antivenoms in the Association of Southeast Asian Nations (ASEAN) countries, not all victims with snakebite envenomings indicated for antivenom received the appropriate or adequate effective dose of antivenom due to insufficient supply and inadequate access to antivenoms. We aimed to conduct a cost-effectiveness analysis to project the potential economic and clinical impact of improving access to antivenoms when all snakebite envenomings in ASEAN countries were hypothetically treated with geographically appropriate antivenoms.

    METHODOLOGY: Using a decision analytic model with input parameters from published literature, local data, and expert opinion, we projected the impact of "full access" (100%) to antivenom, compared to "current access" in five most impacted ASEAN countries, including Indonesia (10%), Philippines (26%), Vietnam (37%), Lao PDR (4%), and Myanmar (64%), from a societal perspective with a lifetime time horizon. Sensitivity analyses were performed.

    PRINCIPAL FINDINGS: In base-case analyses, full access compared to current access to snake antivenom in the five countries resulted in a total of 9,362 deaths averted (-59%), 230,075 disability-adjusted life years (DALYs) averted (-59%), and cost savings of 1.3 billion USD (-53%). Incremental cost-effectiveness ratios (ICERs) of improving access to antivenom found higher outcomes but lower costs in all countries. Probabilistic sensitivity analyses of 1,000 iterations found that 98.1-100% of ICERs were cost-saving.

    CONCLUSION/SIGNIFICANCE: Improving access to snake antivenom will result in cost-saving for ASEAN countries. Our findings emphasized the importance of further strengthening regional cooperation, investment, and funding to improve the situation of snakebite victims in ASEAN countries.

  16. Fulltext Frequency, geographical distribution and outcomes of pit viper bites in Malaysia consulted to Remote Envenomation Consultancy Services (RECS) from 2017 to 2020
    Qamruddin RM, Safferi RS, Mohamed Ismail Z, Salleh MS, Abd Hamid MNH, Frederic Ng VER, et al.
    PLoS Negl Trop Dis, 2023 Aug;17(8):e0011569.
    PMID: 37585486 DOI: 10.1371/journal.pntd.0011569
    Not all pit viper species are present in every state of Malaysia and their distribution varies according to altitude. There is limited information on pit viper bite incidence and its geographical distribution. This was a cross-sectional study of confirmed pit viper bite cases referred to Remote Envenomation Consultancy Services (RECS) from January 2017 to December 2020. Data was collected following the approval of institutional research ethics committee. Universal sampling methods were used. Confirmed pit viper bite cases in each state, geographical location and the antivenom used were reported. A total of 523 confirmed pit viper bite injuries occurred over the 4-year study period. The majority were Malaysians, male and young adults. Most were non-occupational related (83.9%) and involved the upper limbs (46.8%). The commonest pit viper species involved was Trimeresurus purpureomaculatus (23.7%). Green pit viper antivenom (GPAV) was the most frequent antivenom used (n = 51) with the majority of patients requiring only one dose (3 vials). This study provides a better appreciation of indigenous pit viper species distribution for each state and reflects the requirement of appropriate antivenom to be stocked in each state or district hospital.
  17. Fulltext Frequency, clinical characteristics and outcomes of Tropidolaemus species bite envenomations in Malaysia
    Ismail AK, Abd Hamid MNH, Ariff NA, Frederic Ng VER, Goh WC, Abdul Samat NS, et al.
    PLoS Negl Trop Dis, 2023 Jan;17(1):e0010983.
    PMID: 36598885 DOI: 10.1371/journal.pntd.0010983
    Pit vipers from the genus Tropidolaemus are identified as one of the common causes of snake bite from venomous species in Malaysia. All Tropidolaemus species bite cases referred to the Remote Envenomation Consultation Services (RECS) between 2015-2021 were included. A total of 4,718 snake-related injuries cases consulted to RECS with 310 (6.6%) involved Tropidolaemus species; of these 190 (61.3%) were T. subannulatus and 120 (38.7%) T. wagleri. All the T. subannulatus cases occurred in Sabah and Sarawak while all cases of T. wagleri occurred in Peninsular Malaysia. The majority of patients were male (74.8%) and adults between 18-59 years old (61.2%). The upper limb (56.6%) was the most frequent anatomical region involved. Most cases were non-occupationally related (75.4%). Bites from both species caused local pain (77.1%) and swelling (27.2%). Most patients complained of mild pain (48.0%). Paracetamol (40.0%) was the most common analgesic prescribed. Antivenom was not indicated in all cases. Two patients were given antivenom inappropriately before RECS consultation. Most patients (54.7%) needed hospital observation for less than 24 hours. No deaths occurred in the group studied.
  18. Fulltext A catalyst-free growth of aluminum-doped ZnO nanorods by thermal evaporation
    Suhaimi S, Sakrani S, Dorji T, Ismail AK
    Nanoscale Res Lett, 2014;9(1):256.
    PMID: 24948885 DOI: 10.1186/1556-276X-9-256
    The growth of Al:ZnO nanorods on a silicon substrate using a low-temperature thermal evaporation method is reported. The samples were fabricated within a horizontal quartz tube under controlled supply of O2 gas where Zn and Al powders were previously mixed and heated at 700°C. This allows the reactant vapors to deposit onto the substrate placed vertically above the source materials. Both the undoped and doped samples were characterized using scanning electron microscopy (SEM), field emission scanning electron microscopy (FESEM), energy-dispersive X-ray spectroscopy (EDX), high-resolution transmission electron microscopy (HRTEM) and photoluminescence (PL) measurements. It was observed that randomly oriented nanowires were formed with varying nanostructures as the dopant concentrations were increased from 0.6 at.% to 11.3 at.% with the appearance of 'pencil-like' shape at 2.4 at.%, measuring between 260 to 350 nm and 720 nm in diameter and length, respectively. The HRTEM images revealed nanorods fringes of 0.46 nm wide, an equivalent to the lattice constant of ZnO and correspond to the (0001) fringes with regard to the growth direction. The as-prepared Al:ZnO samples exhibited a strong UV emission band located at approximately 389 nm (E g  = 3.19 eV) with multiple other low intensity peaks appeared at wavelengths greater than 400 nm contributed by oxygen vacancies. The results showed the importance of Al doping that played an important role on the morphology and optical properties of ZnO nanostructures. This may led to potential nanodevices in sensor and biological applications.
  19. Photoluminescence and thermoluminescence dosimetry properties of Ag/Y co-doped ZnO nanophosphor for radiation measurements
    Abdurabu Thabit H, Ismail AK, Kabir NA, Abu Mhareb MH, Al Mutairi AM, Bafaqeer A, et al.
    Luminescence, 2024 Feb;39(2):e4683.
    PMID: 38332469 DOI: 10.1002/bio.4683
    This work explores the thermoluminescence (TL) and photoluminescence (PL) properties of Ag/Y co-doped zinc oxide (ZnO) nanophosphor. The proposed dosimeter was prepared by the coprecipitation method and sintered at temperatures from 400°C to 1000°C in an air atmosphere. Raman spectroscopy was studied to investigate the structural features of this composition. The new proposed dosimeter revealed two peaks at 150°C and 175°C with a small shoulder at high temperature (225°C). The PL spectrum showed strong green emissions between 500 to 550 nm. The Raman spectrum showed many bands related to the interaction between ZnO, silver (Ag), and yttrium oxide (Y2 O3 ). The rising sintering temperature enhanced the TL glow curve intensity. The Ag/Y co-doped ZnO nanophosphor showed an excellent linearity index within a dose from 1 to 4 Gy. The minimum detectable dose (MDD) of the Ag/Y co-doped ZnO nanopowder (pellets) equaled 0.518 mGy. The main TL properties were achieved in this work as follows: thermal fading (37% after 45 days at 1 and 4 Gy), optical fading (53% after 1 h and 68% after 6 h by exposure to sunlight), effective atomic number (27.6), and energy response (flat behavior from 0.1 to 1.3 MeV). Finally, the proposed material shows promising results nominated to be used for radiation measurements.
  20. Unlocking the secrets of banded coral snake (Calliophis intestinalis, Malaysia): A venom with proteome novelty, low toxicity and distinct antigenicity
    Tan KY, Liew JL, Tan NH, Quah ESH, Ismail AK, Tan CH
    J Proteomics, 2019 02 10;192:246-257.
    PMID: 30243938 DOI: 10.1016/j.jprot.2018.09.006
    The Asiatic coral snakes are basal in the phylogeny of coral snakes. Although envenoming by the Asiatic coral snakes is rarely fatal, little is known about their venom properties and variability from the American coral snakes. Integrating reverse-phase high performance liquid chromatography and nano-liquid chromatography-tandem mass spectrometry, we showed that the venom proteome of the Malaysian banded or striped coral snake (Calliophis intestinalis) was composed of mainly phospholipases A2 (PLA2, 43.4%) and three-finger toxins (3FTx, 20.1%). Within 3FTx, the cytotoxins or cardiotoxins (CTX) dominated while the neurotoxins' content was much lower. Its subproteomic details contrasted with the 3FTx profile of most Micrurus sp., illustrating a unique dichotomy of venom phenotype between the Old and the New World coral snakes. Calliophis intestinalis venom proteome was correlated with measured enzymatic activities, and in vivo it was myotoxic but non-lethal to mice, frogs and geckos at high doses (5-10 μg/g). The venom contains species-specific toxins with distinct sequences and antigenicity, and the antibodies raised against PLA2 and CTX of other elapids showed poor binding toward its venom antigens. The unique venom proteome of C. intestinalis unveiled a repertoire of novel toxins, and the toxicity test supported the need for post-bite monitoring of myotoxic complication. SIGNIFICANCE: Malaysian banded or striped coral snake (Calliophis intestinalis) has a cytotoxin (CTX)-predominating venom proteome, a characteristic shared by its congener, the Malayan blue coral snake (Calliophis bivirgata). With little neurotoxins (NTX), it illustrates a CTX/NTX dichotomy of venom phenotype between the Old World and the New World coral snakes. The low toxicity of the venom imply that C. intestinalis bite envenoming can be managed via symptomatic relief of the mild to moderate pain with appropriate analgesia. Systemically, the serum creatine kinase level of patients should be monitored serially for potential complication of myotoxicity. The distinct antigenicity of the venom proteins implies that the empirical use of heterologous antivenom is mostly inappropriate and not recommended.
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