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Background
Anaphylaxis is a global health problem which is increasing in incidence.1 2 Medical intervention often requires quick diagnosis and timely precise treatment.1 Although the fatality rate for anaphylaxis cases reported in high-income countries appears to be decreasing,1 2 there are many challenges to developing an accurate epidemiological picture. These include substantial selection and information biases in the data available.2 With myriad obstacles to expedient diagnosis and effective care, it is reasonable to suspect that fatality rates remain higher in lower income countries. Diagnosis is established by clinical criterion that may require identification of the cause of anaphylaxis, for which epidemiological data and/or local awareness of elicitors are important contributors and not always available.1 3 The medical literature reports many causes of venom-induced anaphylaxis, but epidemiological data on slow loris bite are very limited.1 3
Venomous slow loris (Nycticebus spp) bites have been reported as a cause of anaphylaxis, both in their wild habitats in Southeast Asia, and among handlers of captive animals.4 One of the main threats to the conservation of slow lorises is illegal wildlife trade partly driven by habitat loss and fragmentation which increases the frequency of human encounters and hence venomous bite incidents.5 6 This is one of myriad health problems related to the global health threats of deforestation, forest fragmentation, biodiversity loss and wildlife trade.7
Case presentation
A man in his late 30s presented with a 30-min history of severe nausea and vomiting. A friend brought him via a 15-min motorbike trip to a nearby emergency unit, where he was cared for by the first author (AM). The vomiting started seconds after a bite from a slow loris (Nycticebus spp) a genus listed in the IUCN Red List of Threatened Species and known to be distributed in the region.8 The patient’s friend reported that he found the loris, which he assumed to be wild and strayed, under a car near their workplace, located adjacent to a fragmented tropical rainforest in rural Indonesian Borneo. The friend then extracted the loris, intending to keep it as a pet, brought it into their workplace and showed it to the patient. When the patient rubbed its head, the loris reportedly bit him on his left middle finger for about 40 s and then the loris was released back to the forest. Other symptoms included lip numbness, hoarseness, drooling, breathlessness and abdominal pain. He had no coryza, cough or fever. He had no recent respiratory symptoms, no history of travel and no known exposure to COVID-19. He had no medical illnesses, no history of surgery, consumed no medications and rarely sought medical care. He reported no history of cat, seasonal, food or drug allergies and had received only COVID-19 and childhood vaccinations. He had a smoking history of 16 pack years and lived alone. He worked primarily in a factory and had no history of pesticide exposure. He did not recall any family history of allergies or any other medical problems.
On physical examination, he was moderately distressed and perspiring profusely. His respiratory rate was 25 breaths/min, blood pressure 120/90 mm Hg, pulse 105 beats/min, temperature 36.9°C and oxygen saturation 99%. His eyes had bilateral conjunctival injection, and there was swelling of his lips and lower eyelids (figure 1). Hoarseness and moderate salivation were also observed. Normal lung sounds were heard with no wheezes. Bowel sounds were increased, and epigastric tenderness was present. Skin examination exhibited no rash or other pathologies. Examination of the bite revealed multiple lacerated wounds on the tip of the right middle finger, 1–5 mm in length and 1 mm in depth (figure 2). An ECG was normal. A routine COVID-19 screening using a rapid antigen test was positive.
The patient’s lips showing angioedema at admission.
The patient’s left middle finger showing the initial bite wound.
The clinical diagnosis of anaphylaxis was established according to the World Allergy Organization (WAO) criterion1 on the basis of the patient’s rapid onset of angioedema, shortness of breath and gastrointestinal symptoms preceded by exposure to a possible elicitor—the slow loris bite.1 3 A wildlife veterinarian (the second author KLS) and a senior family physician (the third author KF) were teleconsulted regarding definitive diagnosis and bite management. Oxygen was delivered at 3 L/min by nasal cannula. One injection of 0.5 mg epinephrine in 1:1000 dilution was given intramuscularly for primary treatment of anaphylaxis. Diphenhydramine 50 mg, dexamethasone 10 mg and ranitidine 50 mg were also given intravenously as adjuncts. Five hundred cc of normal saline was infused intravenously over an hour to maintain tissue perfusion and hydration. Intravenous ondansetron 8 mg was administered for symptomatic relief of nausea.
At 15 min of observation, moderate amounts of urine were reported. A second intramuscular injection of 0.5 mg epinephrine was delivered due to persistent tachypnoea (27 breaths/min). The patient was advised to stay awake and report any symptoms. At 2 hours of observation, vital signs were in the normal range. The patient reported improvement in symptoms; however, palpitations and tremulousness persisted, likely due to the side effects of epinephrine. The diagnosis of acute COVID-19 infection was entertained but considered very unlikely given that the patient’s clinical course and rapid response to epinephrine would have been highly atypical. As the standard precaution in cases of COVID-19 test positivity, the patient was kept in a separate observation room for isolation and close monitoring. His wounds were managed by irrigation and debridement under local anaesthesia. The patient received one 0.5 cc dose of Td (Tetanus-diphtheria) vaccine (40 IU tetanus toxoid, 30 IU diphtheria toxoid) intramuscular. He stayed in the clinic for 12 hours observation and received intravenous diphenhydramine 25 mg, and ranitidine 150 mg every 8 hours and 12 hours, respectively.
At 12 hours after symptom onset, lip numbness, hoarseness, nausea, vomiting and shortness of breath were all improved, and there was no evidence of development of a biphasic anaphylactic reaction. Angioedema amelioration (figure 3) and decreased conjunctival injection were recorded on physical examination. His bite wound showed no sign of infection (figure 4). The patient was released to self-isolation at home. The local health department was notified of his positive COVID-19 test.
The patient’s lips showing amelioration of angioedema at 12 hours after admission.
The patient’s left middle finger showing the bite wound with no sign of infection at 12 hours after admission.
Home medications included amoxicillin 500 mg/clavulanate 125 mg orally every 12 hours for 5 days for wild animal bite infection prophylaxis9 and prednisone 50 mg once orally for biphasic reaction prevention. Oseltamivir 75 mg every 12 hours and a vitamin D, E, and C combination 1 tablet once a day were prescribed for management of his positive COVID-19 antigen test, as recommended by the Indonesian national guidelines in effect at that time, with the intention of preventing or mitigating symptomatic infection.10 For prompt self-treatment of a biphasic reaction, he was also given a tuberculin syringe, prefilled by the doctor with 0.3 mg epinephrine, written instructions on usage and indications and a demonstration of how to use it. Education regarding rabies vaccination and postexposure prophylaxis (PEP) was given with a referral to a government facility where that treatment was thought possible. He was instructed on how to clean and dress his wounds every 24 hours. He was advised to report by telephone symptoms of an anaphylactic biphasic reaction, including shortness of breath, vomiting, hives, swollen eyes and lips, lack of urination or diarrhoea and to report symptoms of COVID-19 manifestation, including cough, fever, anosmia and hypogeusia.
During follow-up calls at 24 and 72 hours after the bite, the patient reported the disappearance of hoarseness and the resolution of swelling in his lower eyelids and lips. He reported the absence of symptoms of an anaphylactic biphasic reaction and the absence of COVID-19 symptoms. He was unable to acquire rabies vaccination due to its unavailability in any local healthcare facility, but he had no signs or symptoms of rabies 1 week after the bite. Referral to an allergist for consultation was offered but was declined due to lack of local access and prohibitive cost.
Two years after this slow loris bite, the patient was interviewed in his language by the author (AM) who transcribed, translated and compiled his comments for the patient perspective. The patient was well, he had had no further health problems, including having never developed any of symptoms of long COVID-19. He articulated some lessons learnt, including the view that wild animals have the right to live free in their habitat and of the importance of living in harmony with the environment. During this interview, the author obtained informed consent for the use of the patient’s case history, including figures, for publication purposes. The patient’s medical course from inciting event through follow-up is summarised in figure 5.
The patient’s course, management and follow-up for slow loris bite anaphylaxis from the bite through 2-year follow-up. ADL activities of daily living, ED, emergency department; GI, gastrointestinal.
Global health problem list
Anaphylaxis is an increasing and under-reported health problem; understanding of slow loris behaviour, bite anaphylaxis and venom activity is limited.
Traditional medical and community knowledge of bite anaphylaxis is valuable and underutilised information sources.
Underserved communities lack resources to manage animal bites and anaphylaxis.
Forest fragmentation and habitat loss are drivers of human-wildlife conflict including, hunting, poaching and the wildlife trade, resulting in biodiversity loss.
Global health problem analysis
Anaphylaxis is an increasing and under-reported health problem; understanding of slow loris behaviour, bite anaphylaxis and venom activity is limited
While under-reported, epidemiologists suspect that the global incidence of anaphylaxis is increasing.1 2 Recent estimates of the global incidence of anaphylaxis are between 50 and 112 episodes per 100 000 people annually with an estimated lifetime prevalence of 0.3%–5.1%.1 3 The precise rate of increase has been difficult to ascertain. Most available data are based on hospital admissions; events treated outpatient or not presented for medical care are generally not included in the data.2 The applicability of the available data to the experience of low-income countries is also open to question, with most epidemiological data on anaphylaxis occurrence and outcomes coming from high-income countries.1 2
The WAO has established simple criteria for likely diagnosis, which provide indications for expedient initiation of treatment. The presumptive diagnosis can be made in either of two ways. First, by recognising (1) involvement of the skin (hives) or mucosal tissue (swelling) with either (2) respiratory symptoms (dyspnoea, wheezing), (3) hypotension or (4) severe gastrointestinal symptoms. Alternatively, the second set of diagnostic criterion is by (1) identifying an exposure to a known or probable allergen with either (2) hypotension or (3) bronchospasm or laryngeal involvement in the absence of typical skin involvement.1 Given the second path for diagnosis, trigger identification is crucial.
Delays in diagnosis and management are associated with worse outcomes including increased mortality.1 3 Quick diagnosis involving trigger identification can be crucial to preventing severe disease and death from venom anaphylaxis in cases where skin and mucosal tissue involvement is absent. Trigger identification is based on regional patterns of anaphylaxis, for example, bee stings are common elicitors in South Korea, while wasp stings predominate in central Europe.1 The lack of regional data makes timely diagnosis of anaphylaxis more problematic in low-income and middle-income countries which lack these data or have data in which some socioeconomic groups are unrepresented or under-represented.2
Slow lorises (Nycticebus spp) are nocturnal prosimian primates from the Nycticebus genus native to Southeast Asia and are one of only two genera (Nycticebus and Xanthonycticebus or pygmy loris) of primates known to cause envenomation, and to do so with a confirmed two-part venom system.11
Brachial gland exudate (BGE) is secreted in a gland located in the medial part of the loris upper arm (figure 6). Before the BGE is injected by the lorises’ powerful tooth comb bite, the venom is believed to be mixed with their saliva.11 It is postulated that lorises access the exudate from their brachial gland by raising their hands before inflicting a bite, licking the BGE before mixing it with saliva in its mouth.11 It is unclear when this rarely observed step is carried out; diagnosis of envenomation is based on bite and symptoms alone. The function of slow loris venom in the natural context is not well understood; different theories on this have been hypothesised including ectoparasite defence, intraspecific antagonistic behaviours and both intraspecific and extraspecific communication.11–14
A slow loris in the venom pose, arms raised to access licking the brachial glands. Original illustration by coauthor Alvi Muldani.
Some of the substances in the slow loris venom system (BGE plus saliva) have been identified, but how they function together to cause the clinical symptoms seen in humans is poorly understood. The BGE secretion protein (BGEsp) molecule is similar to a cat allergen protein (Fel-d-1).11 14–16 It is postulated that both BGEsp and Fel-d-1 may precipitate allergic reactions by mimicking lipocalins, an essential substance in the immune system.11 Another protein, a complement component called C1r, has been found in slow loris saliva, which may contribute to activation of the physiological responses leading to inflammation, swelling and anaphylaxis.11 Slow loris bite wounds in humans can become extremely painful and develop inflammation and paraesthesia (frequent initial symptoms)4 17–22 with festering, infected, slow-healing wounds that can progress to cellulitis.11 19 20
Beyond local injury, loris bites have been reported to cause a variety of additional symptoms in people, including lethargy, headaches, dyspnoea, general malaise and allergic reactions including severe anaphylaxis. All 12 cases of slow loris bite anaphylaxis found in the published literature, plus this case, are summarised in table 1.4 17–22 Our case is the first from Indonesian Borneo and the fifth that occurred outside captivity. In the eight cases which described presentation,4 17 18 21 22 the most common initial symptoms included breathlessness (five patients), paraesthesia (four patients) and angioedema (three patients), with onset occurring anywhere from seconds to 55 min post bite (mean 14.4 min). As the illness progressed, the predominant symptoms were breathlessness (seven patients), angioedema (five patients), abdominal pain, paraesthesia and hypotension (four each), and nausea, hypesthesia, apprehension, chills, general malaise and tachycardia (three each). Notably, our patient presented with nausea and vomiting as initial symptoms, which are less common, before developing other more typical clinical manifestations. In one reported case of severe anaphylaxis, it is suspected that the reaction might have been aggravated by the patient’s known cat allergy.22 A single instance of haematuria in human following severe anaphylaxis has also been reported after a slow loris bite.17
Summary of the clinical presentation of slow loris envenomation anaphylaxis cases reported in the literature
Developing further understanding of the slow loris venom’s mechanism of action could help to develop treatments to reduce symptom severity in envenomation cases, support the understanding of regional patterns of illness triggered by slow loris bite and shed light on important broader questions. This unique and complex venom system is also of considerable research interest in the quest to better understand venom evolution, primate evolution, immunity, wound healing and for the development of new drugs to treat cancer.11
Traditional medical and community knowledge of bite anaphylaxis are valuable and underutilised information sources
Slow loris bites are not uncommon in Southeast Asian forest communities and community members are often well aware of the prevalence and consequences of slow loris bites while also holding beliefs and taboos about the loris. One study, involving interviews conducted with 63 people at 12 villages in five regencies throughout West Java revealed that these Sundanese communities have a taboo forbidding members to disturb or remove the slow loris from their habitats as it is understood that the animal belongs in the forest.23 They believe the loris has the ability to bring bad omens and cause misfortune and disasters such as drought, infertile land and landslides.23 One of the authors (KLS), with over 20 years of field experience working in slow loris conservation, has observed that the local ethnic Malay (Melayu) communities predominant in this locality of Indonesia believe that slow lorises can bring bad luck or ‘sial’ when touched, kept as pets or found around someone’s house, similar to what was reported in West Java.23
In our case, the information provided by community members to the authors and their colleagues about their experiences with slow loris bites added valuable support to the identification of the slow loris bite as the trigger of our patient’s symptoms of anaphylaxis. Some locals in our patient’s community have reported experiencing or observing the loris bite cause significant pain, slow healing, amputation and symptoms of shock. Our patient and his community believed that his illness was related to the bite. His accompanying friend mentioned knowing that the loris bite could cause ‘klembidur’ or hives. The friend was also aware that only individuals sensitive to loris could develop such symptoms, including from non-bite contact. With the current paucity of epidemiological investigations and reports in the medical literature, sharing community knowledge can contribute to building regional databases regarding both venomous bites and triggers of anaphylaxis, which would be valuable to healthcare practitioners and collaborating organisations.
Underserved communities lack resources to manage animal bites and anaphylaxis
Rapid subcutaneous administration of epinephrine is the recommended first-line treatment to both prevent and treat shock in anaphylaxis.1 ,3 Epinephrine injection before arrival to the hospital decreases the likelihood of admission.3 Anaphylaxis severity can be classified into with shock and without shock. Of the 13 cases reported in the medical literature, our case and three others avoided shock and the remaining nine cases fell into shock, including the one patient with a known cat allergy.3 4 17–22 Antihistamines and corticosteroids are recommended only as adjunctive treatment, if at all.2 3 Failing to administer epinephrine or to not provide it promptly increases unfavourable outcomes, including hospitalisation and death.3 This is remarkably common; in retrospective studies in the USA, up to half of patients admitted to emergency departments meeting diagnostic criteria for anaphylaxis do not receive epinephrine.3
It is strongly recommended that every anaphylaxis patient possess and be trained in the usage of an epinephrine autoinjector for the treatment of a biphasic reaction or re-exposure.2 3 However, epinephrine autoinjectors are not available in our setting. In fact, they are only available in 32% of the 195 countries in the world, primarily high-income countries.1 Even when available, their cost is often prohibitive, and some insurers have opted instead to cover much less expensive kits which include a vial of epinephrine and a syringe.24 The WAO guidance states that anaphylaxis patients ‘must’ be prescribed an alternative method of self-administered epinephrine where autoinjectors are not available.1 Multiple sites have used syringes prefilled with epinephrine for patients and caregivers, which, relative to providing vials and syringes, are intended to decrease errors in filling and increase speed of administration.25 There is evidence that syringes filled with 1 mg/mL epinephrine are stable and sterile for at least 90 days25 but more research is needed to better determine the duration of stability and sterility of epinephrine provided in this way, the optimal concentration of epinephrine to use, and to evaluate the best practices for filling and storing the syringes.25 While there is a widespread assumption that autoinjectors are easier for patients to use than prefilled syringes,1 3 25 a randomised trial comparing the two concluded the opposite—that participants had a significantly higher rate of correct use with prefilled syringes than with autoinjectors.26
Our patient was provided with the affordable and available alternative of a tuberculin syringe, prefilled by the doctor with epinephrine, written instructions on usage and indications and was given a demonstration of how to use it. We feel that where epinephrine autoinjectors or commercially prefilled syringes are not available, offering syringes filled by clinic staff with clear instructions on their use, including date of expiration, is an option to seriously consider. In many situations, it may be preferable to discharging anaphylaxis-susceptible patients with only oral antihistamines and/or corticosteroids which have very limited efficacy in the acute setting and are not recommended as first-line interventions.1
Anaphylaxis care, both acutely and in intervening to prevent recurrence, may benefit from allergist involvement.1 Since up to 50% of individuals having an episode of anaphylaxis will have another in the next 25 years,1 recurrence prevention in the long term is an important component of the management of anaphylaxis. Preventative measures include allergen avoidance and desensitisation with immunotherapy, for which current guidelines recommend allergist consults.1 3 Our patient declined this consult because it would have been a 12-hour drive, unaffordable and unlikely to be helpful given that immunotherapy is not yet available for loris venom. Teleconsultation with the allergist, combined with a physical examination by the local physician, is a potential solution to the access problem when an allergist consult would be of benefit. Teleconsultation was helpful in the management of this patient. The veterinarian contributed the zoological perspective including information on slow loris behaviour and the consequences of bites. The senior family physician was a resource on international standards for bite and anaphylaxis care, adapting this to a low-resource remote setting, and provided supportive back-up for a junior physician confronted with an acutely challenging case.
The bite management in this patient was guideline driven,9 but lacked rabies PEP.9 He was given wound cleansing, debridement, antibiotic prophylaxis and tetanus vaccination. Rabies vaccination and PEP were recommended but not locally available, which, unfortunately, is common.27 In Indonesia, in 2019, there were over 100 000 reported cases of bites from rabies-transmitting animals, but only 67% received postexposure vaccination.27 One hundred nine deaths from rabies were reported in Indonesia that year.27 Rabies is considered endemic in the patient’s province; 16 rabies deaths were reported in 2023.28 Despite these alarming figures, many medical facilities in the region do not have access to rabies PEP. In addition to increasing the availability of PEP, public education and awareness about rabies transmission, accessible pet vaccination programmes and pre-exposure vaccines for those in high-risk occupations and locations can all help reduce the risk of rabies transmission and mortality.27
Forest fragmentation and habitat loss are drivers of human-wildlife conflict including hunting, poaching and the wildlife trade, resulting in biodiversity loss
Slow lorises (Nycticebus spp) are native to the island of Borneo where rampant changes in land use and forestation have taken place for decades. In 1900, the island land masses that now comprise Indonesia were almost completely forested (99.2% of the total land area). By 2015, less than half (49.8%) of this land remained as forest.29 Deforestation is primarily of anthropogenic origin caused by logging and forest conversion for agriculture (including monocultures such as oil palm), population growth, increased settlement and infrastructure development.29 Deforestation has fragmented forest habitats, sometimes enclaved by human settlements and human-related activities, and facilitated access to previously inaccessible forest.29 30 The forest our patient resides in had been damaged by farming and agricultural expansion since the early 20th century. After changes in land use policy, some secondary forest regrowth occurred, but given the reduced resilience of secondary forest to drought and fire, 30% of the forest was lost during El Niño events in 1997 and 2015.31 An additional 10% has been lost to illegal individual and timber company logging. This forest remains as a fragment, surrounded by palm oil plantations, with human settlements at its edge.31 32
Habitat loss and forest fragmentation force slow lorises to live in and near human settlements, commonly inhabiting gardens and plantations, increasing the potential for interactions between humans and lorises.6 30 For example, in some areas, researchers have observed that half of loris territory is now in human land use areas.33 Deforestation and road construction also facilitate access to the capture of lorises for trade.34 35 Easy targets for poachers due to their small size and slow locomotion,30 slow lorises are among the primates in Indonesia most frequently captured and traded for pets,14 36 37 contributing to population decline and potential risk of extinction.5 These increases in the human–slow loris interface result in a higher risk of venomous bite incidents from both wild and captive lorises and, hence, possible anaphylactic emergencies. Of the eight loris bites listed in table 1 in which a captivity status is mentioned, three lorises were reported domesticated, three were reported wild but in the process of being caught for domestication and two were reported encountered in the wild without intention of domestication (table 1).4 17–22
As deforestation and forest fragmentation have an impact on biodiversity loss which is known to affect human health in many ways,38 interventions based on One Health and Planetary Health philosophies, including multisectoral and multi-institutional collaborations that concurrently address animal health, human health and environmental health, have shown positive results. Partnerships between non-government organisations (NGOs) and local government can support awareness campaigns regarding the risk of injury and zoonotic transmission from human–wildlife interactions, helping to reduce harmful contact and to decrease inappropriate poaching, hunting and capture of wildlife for pets. One of the authors (KLS) runs a conservation NGO based in Indonesian Borneo which is using this approach by delivering educational interventions to rural communities combined with rabies vaccination programmes, a successful programme to help achieve this goal.
The NGO clinic in which this patient was diagnosed and treated is another successful example of an intervention addressing human and environmental health jointly. At the community’s request, discounted healthcare services have been provided to members of communities committed to ending illegal logging. The NGO has developed and delivered health and conservation education programmes along with training for alternative livelihoods, including organic farming, to replace logging for income generation. At 10-year follow-up, forest loss has slowed dramatically in the project area with concurrent improvement in many health indicators; decreases in malaria, tuberculosis, neglected tropical diseases, chronic obstructive pulmonary disease and diabetes are among the improvements.32 New collaborations between government, NGOs and communities could replicate these approaches and results on a larger scale by listening to, educating and empowering forest communities to protect and sustain the forests and its wildlife, and through this bring benefits to human health.39
Patient’s perspective
I wanted to pet a slow loris brought by my friend, but eventually, when I gently rubbed its head, it bit my right middle finger for about forty seconds before it stopped. In a matter of seconds, I felt my heart pounding so hard, my head was numb like my hairs were pulled, and my vision was surreal and hazy. When I experienced swollen eyes and lips, breathlessness, and unbearable nausea, I asked my friends to bring me to the Clinic. After that, I was not aware of what happened to me. It was the scariest moment of my life, and I felt like I was going to die. I did not know what was going to happen to me if the medical team did not do their best to save my life. When I arrived at the clinic, I was slightly conscious. I saw the nurses and doctor rushing to take care of me. I just prayed and trusted the team with all my heart. Spontaneously, after some injections and an IV line placed in my arms, I felt much better, though when I heard I also had COVID-19 it stressed me out further. I was confused because I had no cough and hadn’t travelled much before.
The next day, the doctor explained to me that I had anaphylaxis from a slow loris bite. I did not expect that a cute animal like slow loris was deadly. The slow loris was found under a car in my workplace near a forest. At first, my friend intended to keep it as a pet, but he returned it to the forest after what happened to me. The community believes that slow loris could cause ‘klembidur’ or hives, but I experienced things differently, I didn’t have hives. After I was discharged from the clinic, I was so happy that the most critical moment of my life had passed. Still, I had to undergo isolation at home for 10 days, and thankfully, I did not experience any worsened symptoms. I was worried it would affect society’s opinion of me and my family because of the COVID-19 I had. My family was looking for rabies vaccination for me and an allergy specialist, as suggested, but we did not find them.
I am worried that similar cases will happen again in the future and the patients will not receive the maximum treatment. I wish the rabies vaccine, and such medical specialities become readily available, especially for my community. The event gave me an important lesson. Now, I have become more concerned about health, especially self-hygiene and healthy lifestyle. Moreover, we have to be more careful about handling something new. Since then, I believed that things that are supposed to be in the forest should stay in the forest. Even though I am an animal lover, now I believe that to love is not to have. Wild animals have the right to live free in their habitat. I encourage everyone that it is important to love nature and to live in harmony with the environment.
Learning points
In under-resourced areas, management of slow loris bites and anaphylaxis is challenged by a lack of medical supplies, and by the limited understanding of the epidemiology, animal behaviour and venom activity involved.
Interventions to address these challenges include increasing rabies vaccine availability, collaborating with local healers and communities to gain understanding of animal bites and anaphylaxis in the area, considering the option of providing prefilled epinephrine syringes to individuals treated for anaphylaxis and involving an interdisciplinary team, including, as needed, medical specialists and veterinarians through telecommunications.
Proven One Health and Planetary Health interventions which concurrently address human, animal and forest well-being have many preventative and therapeutic benefits including the potential to reduce the incidence of harmful human–wildlife encounters and should be replicated.
Successful examples of these interventions include the work of a non-government organisation that provides discounted healthcare and alternative livelihood training to members of communities who stop illegal logging, and of another that combines wildlife conservation with community education and rabies vaccination.
Ethics statements
Patient consent for publication
Acknowledgments
We thank our patient for sharing his story, the clinic community that cares for both the human patients and the forest, Doctor Sakib Burza for advice and encouragement, and the anonymous reviewers for very helpful suggestions.
References
Footnotes
Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: AM is the guarantor and responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, critical revision. KLS and KF: drafting of the text, investigation results and critical revision. All authors gave final approval of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.