viewing zoogeographic distribution in Pakistan, elapid bites are more common in the country above Rawalpindi, while mostly viperids in plains.

Dear Muhammad Sharif Khan, This is true for the whole subcontinent. We have elapid bites common in  Punjab, Himachal, Jammu and Kashmir, Nepal, Bihar, and Jharkhand. As we move southward, viperine bites become more common including Maharashtra, Tamilnadu, Kerala, Karnataka, Srilanka. Some states like Rajasthan have Saw scaled vipers whereas most of South India has Russel's viper as the most notorious venomous snake. We have never seen a case of local necrosis post snake bite in Himachal Pradesh, which means that Russel's viper is entirely absent in this region. I am interested in knowing Which snake is the predominant one in the Punjab and Sindh province of Pakistan? How commonly do you find Krait? Do you see a lot of early morning neuroparalysis cases?

neuroparalysis cases are mostly common in the area with vegetation (around lakes etc) while in arid areas echis predominates inn the south, in the heartland Punjab Dabois,n Echis and Bungarus are mixed.

The viperine bites in North India are mild with minimal signs of spontaneous hemorrhage. Most cases are picked by the deranged Whole nlood clotting time. These patients are treated like viper bites then and upto  40% of these develop mild reversible acute kidney injury. 

Dear Vimalraj

The review of published literature shows that 85% of venomous bites in South are hemotoxic. I am an experience of 10 years now in Himachal. We have neurotoxic envenomation in >60%. In studies from nepal neurotoxicity is as high as 90%. 

Every year we admit upto 100 cases of snake bite. I have not seen a single case with local bleb formation or necrosis. This is in contrast to Snake bites in South India where local necrosis, compartment syndrome and even gangrene is commonly reported. Local necrosis occurs despite early and adequate treatment in Russels Viper bites. 

my research does not focus on snake venom virility types

Dear Vimalraj,

This is a good question!

In India there are three main neurotoxic snakes Cobra, Krait, and Russels Viper. Level of neurotoxicity cannot be correlated with type of snakes. But we can tell the type of ssnake by other clinical features. For example Cobra bite is painful and causes local swelling. Russels Viper also causes pain swelling and necrosis locally but Russels viper bite will have hemo nephrotoxicity in addition, which is absent in cobra bite. Both cobra and Russels viper bite humans when they are distubed or stepped upon mostly outside the house. Krait on the other hand inflicts painless bites on people sleeping on floors mostly indoors. Krait bite does not have fang marks and has no local swelling or hemotoxicity. Patient often doesn't wakeup after the bite and thus the patient has profound neurotoxicity with quadriparesis with respiratory failure in the morning. Cobra and Russels viper release more venom than krait but due to painful nature of bite, patient seeks treatment early. Krait bite on the other hand causes slow paralysis but due to painless bite during sleep many patients dont notice the bite and remain untreated for many hours allowing the venom to do the damage.

So rather than the virility and quantity of venom, there are many other features that help us identify the type of snake in neurotoxic envenomations.