Saw scaled viper (Echis
carinatus) is considered
to be the world’s most dangerous snake because
of its highly virulent hemotoxic venom [1]. In
Jammu, saw scaled vipers account for about 95% of the total snake
bites [2]. Envenomation results in local symptoms as well as severe
systemic manifestations that may prove fatal. Hematemesis, malena,
hemoptysis, hematuria, acute renal failure, epistaxis and
hypovolemic shock have been reported as complications [2, 3].
Case Report
We report a 12-years old female child referred
from a rural health centre to our hospital for the management of
snake bite on her right foot. She received first aid and 100 units
of ASV (anti snake venom) at the referring hospital. At the time of
admission, bite marks were found over the right foot with swelling,
bluish discoloration, tenderness over the surrounding area and
slight oozing of the blood from the bite site. On examination, she
was well oriented. Her pulse was 76/minute and blood pressure 100/70
mm Hg, with no symptoms or signs of bleeding from any other site.
There were no signs of neurotoxicity. Despite repeated doses of ASV
and supportive management, her 20 WBCT (20 minutes whole blood
clotting time) remained prolonged.
On 5th day of admission, she developed pallor,
tachycardia and hypotension. On general physical examination, there
was decreased air entry on right side of the chest with dull note on
percussion. Chest X-ray and ultrasonography of the chest
revealed fluid in the pleural cavity. The laboratory findings showed
anemia (hemoglobin 4.5 g/dL), leukocytosis (16500/mm3),
and low platelet count (90,000/mm3).
The patient’s prothrombin time (15 seconds) and activated partial
thromboplastin time (45 seconds) were prolonged. In addition, the
fibrin degradation product levels were raised and D-dimers were
positive.
On thoracostomy, about 1000 mL of blood was
aspirated and intercostal tube was kept for drainage of any further
collection. During her stay in the hospital she received 800 units
of ASV, 8 units of blood transfusion, and 7 units of FFP (fresh
frozen plasma) transfusion besides antibiotics. The general
condition of the patient improved gradually and was discharged after
25 days of stay in the hospital. Her coagulogram was within normal
limits at the time of discharge.
Discussion
Snake bite is an environmental hazard,
particularly in rural areas, causing significant morbidity and
mortality. The vipers (saw scaled viper and russell’s viper) are
primarily vasculotoxic. The toxins affecting haemostasis have been
classified as per their overall effect and include the following: (a)
procoagulants due to prothrombin activating toxins and thrombin like
enzymes; (b) anticoagulants acting by activating Protein C
etc.; (c) platelet activating and anti-platelet function; (d)
fibrinolytic activators; and (e) hemorrhagins [5].
Several reports showing bleeding manifestations
in the various parts of the body following snake bite have been
reported in the past. One report showed hemoperitoneum developing
after a Russell’s viper bite [5]. Intracranial bleeding and ischemic
stroke following snake bites have also been reported [6]. Another
report showed ischemic colitis after a viperine snake bite, which
resulted in an emergency laparotomy revealing a necrotic ileum and
caecum with the occlusion of the superior mesenteric artery [7].
As in the present case, hemothorax developing
after saw scaled viper has not been reported in the literature to
the best of our knowledge. In this patient, the levels of FDP
(fibrin degradation product) and D-dimer suggested that DIC had
occurred. The exact pathophysiology for the development of
hemothorax after snake bite is not known. We believe that DIC along
with direct endothelial injury as a result of a component in the
venom itself such as hemorrhagin is the possible mechanism of
hemothorax in this patient. DIC causes fibrin deposits in the
micro-circulation, platelets and coagulation factors consump-tion
with secondary fibrinolysis leading to bleeding.
Systemic envenomation by snakes can affect
various organs of the body due to disturbances in the coagulation
pathways. Hemothorax developing as a complication of snake bite has
not been reported in the past and should be considered as a possible
complication following snake bite.
Contributors: All authors were involved in
the management of the case and preparation of the manuscript.
Funding: None; Competing interests:
None stated.
References
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