In reply to Mohanty et al

To the Editor:

We are grateful to Mohanty and colleagues for their close reading ¹ of our case report ² and for the chance to clarify why some technical details were condensed. Our intent was to deliver the most practice-relevant lessons for clinicians working in remote Amazonian settings while remaining within the journal's format. In this letter, we address each point in a collegial spirit.

Antivenom Formulation and Dosing Schedule

Our central message concerns timely access to antivenom in the jungle, not the pharmacology of a specific batch. Lot number, protein concentration, and vial-by-vial timing can differ markedly between shipments and, in practice, are rarely known to first-level providers. Including those data would risk obscuring the public-health lesson and would have exceeded the 3,500-word case-report limit set by Wilderness & Environmental Medicine.^3,4 We therefore summarized the treatment in terms most useful to colleagues who face similar supply-chain delays, noting that WHO considers polyspecific antivenom preparations acceptable for B. bilineatus envenomation in regions where monospecific antivenom is unavailable. ³

Use of the Snakebite Severity Score (SSS)

We fully agree that structured tools can enrich clinical reporting. During the prolonged river evacuation, however, treatment decisions hinged solely on how many vials could be procured—not on a numerical score. Moreover, the original SSS was validated for North American crotalids ⁵ and shows limited discrimination in arboreal Bothrops bites with mixed hemotoxic–cytotoxic profiles. Adding a retrospective score would have lengthened the manuscript without altering the management pathway we wished to highlight.

Neurological and Cardiovascular Findings

Serial examinations were consistently unremarkable. The CARE guidelines recommend focusing on clinically pertinent positives to enhance readability, ⁶ while the ICMJE likewise advises against extensive lists of negative data. ⁷ We therefore summarized these systems as “within normal limits,” confident that this conveys their lack of impact on care.

Laboratory Trends

We reported the key parameters—platelet count, INR, and C-reactive protein—that guided additional antivenom dosing. Daily chemistry values normalized quickly and would have required additional tables beyond the journal's allowance. ⁴ Nonetheless, we have invited interested readers to request the full de-identified dataset.

Initial Analgesia with Tramadol

A single 50 mg intravenous dose of tramadol reflected the only opioid stocked in the rural post; under the Peruvian Essential Medicines List, ⁸ it remains a first-line agent where stronger narcotics require triplicate prescriptions. Documenting this reality, though suboptimal, illustrates the resource constraints many practitioners face.

Clinical Photograph

The patient declined publication of identifiable images. ICMJE recommendations stipulate that photographs be used only when essential for scientific purposes and with explicit consent. ⁷ Because our core message centered on delayed antivenom administration rather than wound morphology, we respected the patient's preference.

Editorial Length and Figure Limits

Conforming to Wilderness & Environmental Medicine guidelines ⁴ required careful selection of details most instructive to frontline clinicians: evacuation logistics, antivenom availability, and functional sequelae of tissue necrosis.

Conclusion

We sincerely appreciate the constructive feedback and hope this explanation shows that the omissions were deliberate, grounded in ethical, editorial, and clinical-relevance considerations. We remain happy to share supplementary data privately and welcome further dialogue aimed at improving snakebite care in resource-limited environments.