Serpent strikes, sapien sways: A rare case of bilateral cerebellar infarct following viper bite.

Ischemic stroke following snake bite is rare. We report a posterior circulation infarct involving bilateral cerebellum and occipital lobe following Russell's viper bite in a previously healthy individual. A 50 years old healthy individual, soon after being bitten by the Russel viper on the left foot he developed pain and swelling followed by drooping of eyelids, slurring of speech and giddiness with multiple episodes of vomiting. The patient was administered ASV as well as neostigmine and atropine injections. Following this, the neurological manifestations resolved except dysarthria. CT brain study done was normal. On day 2 of hospitalization, he developed left cerebellar signs (positive finger nose finger test, rebound phenomenon, dysdiadochokinesia, a positive heel shin test). Subsequently, an MRI with MR angiogram was done which showed acute infarcts in bilateral cerebellar hemispheres, with the left superior cerebellar peduncle showing restricted diffusion and low ADC values. Ischemic infarction following viper envenomation has been described by only few authors. In majority of the cases reported, ischemic infarction involved the anterior circulation. The possible mechanisms of infarction in this scenario are discussed. Patient was treated with anti-snake venom and showed a good recovery. Early imaging and early treatment with anti-snake venom is important for a favourable outcome.

Résumé L'AVC ischémique consécutif à une morsure de serpent est rare. Nous rapportons un infarctus de la circulation postérieure impliquant le cervelet et le lobe occipital bilatéraux suite à une morsure de vipère de Russell chez un individu auparavant en bonne santé. Un individu en bonne santé de 50 ans, peu de temps après avoir été mordu par la vipère Russel au pied gauche, il a développé une douleur et un gonflement suivis d'un affaissement des paupières, d'un trouble de l'élocution et de vertiges avec de multiples épisodes de vomissements. Le patient a reçu de l'ASV ainsi que des injections de néostigmine et d'atropine. Suite à cela, les manifestations neurologiques ont disparu sauf la dysarthrie. L'étude cérébrale réalisée par TDM était normale. Au 2ème jour d'hospitalisation, il a développé des signes cérébelleux gauches (test doigt nez doigt positif, phénomène de rebond, dysdiadochokinésie, test talon tibia positif). Par la suite, une IRM avec angiographie IRM a été réalisée qui a montré des infarctus aigus dans les hémisphères cérébelleux bilatéraux, le pédoncule cérébelleux supérieur gauche montrant une diffusion restreinte et de faibles valeurs d'ADC. L'infarctus ischémique consécutif à une envenimation par vipère n'a été décrit que par quelques auteurs. Dans la majorité des cas rapportés, l'infarctus ischémique impliquait la circulation antérieure. Les mécanismes possibles de l'infarctus dans ce scénario sont discutés. Le patient a été traité avec du venin anti-serpent et a montré une bonne récupération. Une imagerie précoce et un traitement précoce avec du venin anti-serpent sont importants pour un résultat favorable. Mots-clés: Infarctus cérébelleux, étude cérébrale par imagerie par résonance magnétique, morsure de vipère.

Meta-analysis of the efficacy of combined Chinese and Western medical treatment versus western medical treatment alone on pit viper bites.

This paper uses Meta-analysis to explore the differences in the clinical efficacy of combined Chinese and Western medical treatment of pit viper bites versus Western medicine alone. By searching English databases (PubMed, Embase and Cochrane Library) and Chinese databases (CNKI, Wanfang and VIP), we collected original studies related to this problem. After data extraction, meta-analysis was performed using 5.2-0 in R language. In this study, a total of 7891 patients with pit viper bites were included in 9 studies. Combined Chinese and Western medicine treatment may be superior to Western medicine treatment alone with an OR of 5.30 and 95% CI of 3.90-7.21. The combined treatment of Chinese and Western medicine has better clinical results in the recovery of local symptoms in patients with pit viper bites and is more effective than conventional Western medicine alone.

An antivenin resistant, IVIg-corticosteroids responsive viper induced thrombocytopenia.

In this case report the hospital management of an acute, severe thrombocytopenia in a 57-year-old man in the north-east of Italy is reported. Thrombocytopenia developed immediately after the viper bite, despite the absence of clinical signs of envenomation. No hemorrhage, ecchymoses or other signs of coagulopathy developed during the hospitalization; two doses of antivenin FAB-Fragments had no effect on thrombocytopenia, which instead responded promptly to intravenous immunoglobulins (IVIg) and glucocorticoids. Direct and indirect anti-platelet antibodies against anti-GP IIb/IIIa and Ia/IIa were detected during the treatment and turned negative after 20 weeks. The rationale of such off-label treatment is the interpretation of the thrombocytopenia as a venom-induced immune thrombocytopenia which led to splenic sequestration of platelets. To our knowledge, there is no literature about venom-induced immune thrombocytopenia against GP IIb/IIIa and Ia/IIa protein in European countries and subsequent response to IVIg and corticosteroids.

Acute Exposure to European Viper Bite in Children: Advocating for a Pediatric Approach.

Viper bite is an uncommon but serious cause of envenoming in Europe, especially in children. Our study aim is to better describe and analyze the clinical course and treatment of viper bite envenoming in a pediatric population. We retrospectively reviewed 24 cases of pediatric viper bites that were admitted to the Pediatric Emergency Department and the Pediatric Intensive Care Unit of the Bambino Gesù Children Hospital in Rome between 2000 and 2020. Epidemiological characteristics of the children, localization of the bite, clinical and laboratory findings, and treatment approaches were evaluated. The median age of the patients was 4.2 years, with male predominance. Most cases of viper bite occurred in the late summer. Most patients required admission to the ward for prolonged observation. The most common presenting signs were pain, local oedema, and swelling. Patients with a high severity score also had a significantly higher white blood cell count and an increase of INR, LDH, and CRP levels. No fatality was reported. Viper bite envenomation is a rare pediatric medical emergency in Italy but may sometimes be severe. A new pediatric severity score may be implemented in the screening of children with viper bites to favor a selective and prompt administration of antivenom.

Upper limb compartment syndrome after a viper bite in a child: A case report.

The occurrence of compartment syndrome after a viper bite is a rare phenomenon and its treatment remains controversial. We report the case of an 11-year-old boy who developed compartment syndrome of the right upper limb following a viper bite. Decompression by fasciotomy was performed urgently with a good outcome. Surgical decompression for compartment syndrome following a viper bite is not a common treatment according to the literature. Fast access to care and antivenom administration seem to be effective at treating the compartment syndrome without recourse to fasciotomy.

Plasmapheresis for Pulmonary Hemorrhage Following Viperine Snakebite: A Case Report with Review of Literature.

INTRODUCTION: Snakebites are one of the commonest occupational hazards in tropical countries and viperine bites are potential to cause systemic toxicity. Coagulopathies and acute kidney injury (AKI) have been documented and easily dealt with in past, but pulmonary hemorrhage has been rarely seen and plasmapheresis has shown promising result for the same. This case reports highlight the effective use of plasmapheresis for pulmonary hemorrhage post-snakebite. BACKGROUND: Viperine snakebite has been associated with high morbidity and mortality due to its toxic systemic envenomization. The important systemic manifestations are coagulopathy, neuromuscular paralysis, AKI, myotoxicity, and cardiovascular collapse. Antivenomization, renal replacement therapy, steroids, and other supportive care are considered to be the mainstay of treatment till date. Pulmonary hemorrhage has been an unusual manifestation of viper bite and rarely reported and steroids have been used in such scenario but with mixed results. Role of plasmapheresis has been documented in the management of snakebite but especially for hematological problems and in limb preservation/salvage strategies. The use of same, for pulmonary hemorrhage has not been studied yet. Here, we present a rare case of pulmonary hemorrhage along with renal failure following viper bite which was successfully treated with plasmapheresis. To the best of our knowledge, it is a rare presentation and has not been reported in the literature reviewed till date. CASE DESCRIPTION: A previously healthy, 36-year-old man presented to our hospital 48 hours after a viper bite. He developed local as well systemic manifestations evident as hemolysis and renal failure. Gradually, he started having hemoptysis followed by respiratory failure requiring ventilatory support. CT chest done was s/o bilateral pulmonary hemorrhages correlating clinically with ongoing tracheal bleed. He had no other bleeding manifestations and had normal coagulation profile. He was initially treated with methylprednisolone therapy, but then did not show any improvement and finally plasmapheresis was done as rescue therapy. Following this, he had improvement in respiratory parameters and settling tracheal bleed with resolution of radiological changes. He was successfully weaned off from the ventilation and also his renal failure also improved with near normalization of pulmonary and renal functions. CONCLUSION: This case highlights the unusual presentation of pulmonary hemorrhage in a patient with viperine bite with normal coagulation and was aggressively managed with plasmapheresis. Hence, plasmapheresis can be used as life-saving modality in patients with systemic envenomization post-viperine bit. HOW TO CITE THIS ARTICLE: Sampley S, Sakhuja V, Bhasin D, Singh K, Singh H. Plasmapheresis for Pulmonary Hemorrhage Following Viperine Snakebite: A Case Report with Review of Literature. Indian J Crit Care Med 2020;24(10):986-990.

Neutrophil Gelatinase-Associated Lipocalin as an Early Diagnostic Biomarker of Acute Kidney Injury in Snake Bite.

BACKGROUND: Snakebite envenomation is a major public health problem in the developing world, and the effects of viper envenomation on renal tissues leading to acute kidney injury (AKI) are well known. However, the usefulness of neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker to detect AKI in viper envenomation cases were not studied much. AIMS AND OBJECTIVES: The present study was undertaken to find out plasma NGAL levels and assess its usefulness among the hospitalized Viperidae group of snakebite victims in predicting acute kidney injury. MATERIALS AND METHODS: The plasma NGAL level was estimated within 6-8 h of all the 184 cases of viper bites along with other laboratory parameters. RESULTS: It was elevated much before the elevation of serum creatinine levels, irrespective of the age, gender, and bite to hospital time. The sensitivity and specificity was 99.37 and 96.15, respectively. Elevated plasma NGAL levels in viper bite helped not only to detect AKI early but also assisted to plan for appropriate intervention. CONCLUSION: It is suggested to include estimation of plasma NGAL in the point of care testing, especially in emergency settings handling snakebite cases. However, more studies are recommended to find out its serial levels in snakebite cases following different kinds of snake envenomation with different clinical and laboratory manifestations in different age groups and gender belonging to different population so as to arrive at valid conclusions.

Status epilepticus and bilateral middle cerebral artery infarction: A rare presentation after viper bite.

Owing to the antihemostatic property of viper venom, hemorrhagic complications including intracerebral hemorrhage are the most commonly encountered after viper bite. Ischemic strokes have been rarely reported after viper envenomation, and its occurrence has been attributed to multiple mechanisms. Postsnakebite seizures are known to occur after neurotoxic bite. Here, we report the case of a viper bite victim who developed status epilepticus within 3 h after viper bite. He had only mild signs of local envenomation, and prolonged whole blood clotting time was the only manifestation of systemic envenomation. Subsequently, he was found to have developed right hemiparesis and global aphasia. Brain imaging revealed large infarcts in bilateral middle cerebral artery (MCA) territories. We report this as a unique case of viper bite which presented to the emergency room with status epilepticus. Moreover, bilateral MCA infarct, as was found in this case, is genuinely rare in scientific literature. Finally, the absence of overt features of envenomation makes this case stand out from other similar reported occurrences.

Résumé En raison de la propriété antihémostatique du venin de vipère, les complications hémorragiques, y compris l'hémorragie intracérébrale, sont les plus courantes. rencontré après morsure de vipère. Des AVC ischémiques ont rarement été signalés après une envenimation par vipère, et son apparition a été attribuée à mécanismes multiples Les crises d'épilepsie postnakebite se produisent après une piqûre neurotoxique. Ici, nous rapportons le cas d'une victime de morsure de vipère qui état de mal épileptique dans les trois heures suivant la piqûre des vipères. Il ne présentait que de légers signes d'envenimation locale et un temps de coagulation du sang total prolongé était la seule manifestation de l'envenimation systémique. Par la suite, il s'est avéré avoir développé une hémiparésie droite et une aphasie globale. L'imagerie cérébrale a révélé de grands infarctus dans les territoires bilatéraux de l'artère cérébrale moyenne (ACM). Nous rapportons cela comme un cas unique de morsure de vipère présenté à la salle d'urgence avec le statut épileptique. De plus, l'infarctus bilatéral à MCA, comme on l'a constaté dans ce cas, est vraiment rare dans littérature scientifique. Enfin, l'absence de caractéristiques évidentes d'envenimation fait que ce cas se distingue des autres cas similaires.

The antivenom efficacy against a viper bite without medical treatment for 3 days: a case report.

Snakebites can be deadly, depending on the course of extremely serious hemorrhagic complications in the absence of antivenom, which remains the only specific and effective treatment, if it is introduced in time. We report the case of a young patient of 18 years, bitten by a snake and receiving only tradition care until admission to intensive care 3 days later, with advanced bleeding and inflammation; four vials of FAV-Africa antivenom were administered and resulted in dramatic improvement in his condition. This result confirms the empirical concept that delay in management should under no circumstances exclude the administration of antivenom.

Acute myocardial infarction associated with thrombotic microangiopathy following a hump-nosed viper bite: a case report.

BACKGROUND: Hump-nosed viper bite is the commonest cause of venomous snakebite in Sri Lanka. Despite initially being considered a moderately venomous snake more recent reports have revealed that it could cause significant systemic envenoming leading to coagulopathy and acute kidney injury. However, myocardial infarction was not reported except for a single case, which occurred immediately after the snakebite. CASE PRESENTATION: A 50-year-old previously healthy Sri Lankan woman had a hump-nosed viper bite with no evidence of systemic envenoming during initial hospital stay. Five days later she presented with bite site cellulitis with hemorrhagic blisters, acute kidney injury, and evidence of microangiopathic hemolytic anemia and thrombocytopenia with normal coagulation studies. She was managed with supportive care that included intravenously administered antibiotics, blood transfusions, and hemodialysis; both her microangiopathic hemolytic anemia and thrombocytopenia improved without any specific intervention. On day 10 she developed: a non-ST elevation myocardial infarction complicated with acute left ventricular failure evidenced by acute shortness of breath with desaturation despite adequate ultrafiltration; new onset lateral lead T inversions in electrocardiogram; raised troponin I titer; and hypokinetic segments on echocardiogram. She was managed with low molecular weight heparin and antiplatelet drugs, which were later discontinued due to upper gastrointestinal bleeding. Her hospital stay was further complicated by hospital-acquired pneumonia and deep vein thrombosis involving her ileofemoral vein. She died on day 33 from the snakebite. CONCLUSIONS: Myocardial infarction after snakebites is rarely reported. This is the first case report of a patient developing a myocardial infarction during the recovery phase of thrombotic microangiopathy following a hump-nosed viper bite. The possibility of thrombotic risk related to thrombotic microangiopathy following hump-nosed viper bite is an area that is poorly studied; it needs further attention.

Acute Interstitial Nephritis Following Snake Envenomation: A Single-Center Experience.

OBJECTIVES: To identify the clinical and histopathological characteristics of patients who develop acute interstitial nephritis (AIN) following snake envenomation. METHODS: A retrospective analysis of patients diagnosed with snake envenomation-induced AIN from October 2013 to November 2014. RESULTS: After snake envenomation, 88 patients developed acute kidney injury (AKI). Biopsies were performed on 7 patients due to nonrecovery of kidney function. Among these, 5 patients had AIN. Thus, AIN accounted for 5.7% of snakebite-related acute kidney injury. All patients had severe envenomation at presentation and had prolonged renal failure. Kidney biopsy found a mixed infiltrate composed of predominantly lymphocytes, with variable proportions of other cells including eosinophils neutrophils and plasma cells. The response rate to corticosteroids was 80%. CONCLUSIONS: AIN after snake bite is not uncommon. AIN needs to be considered in patients with persistent renal failure after snake envenomation. Identifying this complication is of utmost importance because of the potentially reversible nature.

Hyperglycemia is a risk factor for high-grade envenomations after European viper bites (Vipera spp.) in children.

CONTEXT: Hyperglycemia has been described in severe scorpion envenomation, we wanted to analyze if it was applicable to viper bites in children. AIM: To describe clinical, biological, and therapeutic characteristics of 83 children bitten by European viper (Vipera spp.) and to confirm that hyperglycemia is a risk factor for high-grade envenomation. MATERIAL AND METHODS: A retrospective study was conducted between 2001 and 2014 in the pediatric emergency department of a tertiary level children's hospital. Collected data were: age and sex of children; day and time of admission; day, time and circumstances of the accident; snake identification; bite location; envenomation severity; presence of fang marks; prehospital care; laboratory abnormalities, use of specific immunotherapy, associated treatments; length of stay; hospital course. RESULTS: Eighty-three children were included (62 boys, 21 girls). The mean age was 7.4 ± 3.9 years. Bites were most often located on the lower extremities (66%). The classification of envenomation was: 83% low grade (absent or minor envenomation) and 17% high grade (moderate to severe envenomation). All high-grade envenomations received specific immunotherapy (Viperfav(TM), (Aventis Pasteur, MSD, Lyon, France). Being bitten on an upper extremity (odds ratio [OR] 51.1 95% class interval [CI] [6.1-424], p < 0.0001), during the afternoon (OR 13.4 95% CI [1.7-107.9], p = 0.015), feeling violent pain (OR 4.2 95% CI [1.1-16.5], p = 0.023), and high initial plasma glucose level (6.5 ± 1.7 mmol/L versus 5.0 ± 0.9 mmol/L, p = 0.027) were associated with a significant risk of high-grade envenomation. CONCLUSION: We have confirmed a potential link between initial hyperglycemia and the risk of progression to high-grade envenomation as well as its association with other published predictive factors.

Anterior Segment Ischemia in Viper Bite.

PURPOSE: To describe the clinical and histopathological features of post viper bite anterior segment ischemia. METHODS: Seven patients with ocular complications following viper bite referred to uveitis clinic had slit-lamp examination, intraocular pressure (IOP) measurement, and fundus evaluation. Iris and fundus fluorescein angiography was performed on 2 patients. Histopathological examination was performed on iris tissues collected during cataract surgery. RESULTS: Strikingly similar clinical findings were noted, including circumpupillary superficial iris atrophy, mid dilated fixed pupil, marked pigment dispersion, low IOP, and cataract. All clinical signs were noted only in the anterior segment; the posterior segment was normal. Histopathology of iris revealed atrophy of iris stroma, necrotic iris pigment epithelium, and infiltration of T lymphocytes and fibrous membrane. Poor visual outcome was noted in patients with low IOP. CONCLUSION: Viper bite victims presented with clinical and histopathological signs of anterior segment ischemia and secondary inflammatory signs mimicking uveitis.

Complex regional pain syndrome following viper-bite.

BACKGROUND: Complex regional pain syndrome (CRPS) may occur following fractures, surgery or different trauma. Development of CRPS following snake-bite has only been published in three reports (from Turkey, Nepal and Korea), although snake bites occur frequently world-wide. There has been no report from Western Europe. Vipera Berus is a common snake in European countries and the only venomous snake in Norway. We here describe the development of CRPS in a young woman as a consequence of a viper bite (Vipera Berus) in the right arm. METHODS: We performed a clinical investigation (inspection, measurement of skin temperatures, sensory and motor evaluation) of the patient six months following the viper-bite, measurement of thermal thresholds (quantitative sensory testing, QST), measurement of resting sweat output (RSO) and quantitative sudomotor axon reflex (QSART) from both arms. RESULTS: The patient fulfilled the Budapest criteria for a CRPS-condition, with continuous pain and symptoms and findings of autonomic dysfunction. In addition, we found elevated thresholds of warmth and cold, evidence of an affection of afferent A-delta and C-fibres as well as an affection of the efferent sympathetic sudomotor C-fibres by QSART. An increased RSO-volume was in inverse relationship to the decreased QSART result. CONCLUSION AND IMPLICATIONS: It is important to be aware of viper-bite as a possible eliciting event for CRPS for early diagnosis and treatment of a patient. As long-lasting pain and oedema are known complications, it is probable that CRPS after viper-bites previously may have been underdiagnosed. As many patients are unaware of being bit, viper bite should be considered in cases of unexplained sudden pain and swelling of a limb.

Immediate radical fang mark ablation may allow treatment of japanese viper bite without antivenom

Administration of antivenom is currently the standard treatment for snake envenomation. However, it can sometimes cause anaphylactic reactions including urticaria, bronchospasm and hypotension. Furthermore, it may also provoke life-threatening complications, even though the mortality rate is less than 1 percent. In this study, we present a new treatment - immediate radical fang mark ablation - that was successfully performed on five victims of Japanese viper bites without antivenom use. In these five victims of venomous snakebites, surgical debridement was immediately performed. Two patients received a free-skin graft to resurface their wounds while three of them healed conservatively (i.e. by ointment treatment without surgery). After treatment, all patients could return to work. Immediate radical ablation is a recommended procedure that can reduce the amount of venom in tissues, which consequently decreases inflammatory reactions and reduces the necessity for antivenom.(AU)