Contribution of focal haemorrhage and microvascular fibrin deposition to fatal envenoming by Russell's viper (Vipera russelli siamensis) in Burma

doi:10.1016/0001-706X(89)90013-2

Acta Tropica

Volume 46, Issue 1, January 1989, Pages 23-38

https://doi.org/10.1016/0001-706X(89)90013-2 Get rights and content

Abstract

In Burma, clinicopathological studies were carried out in three young farmers who died 15, 52 and 36 h after being bitten by Russell's vipers. Clinical features included local swelling, spontaneous systemic bleeding, defibrination, shock, cardiac arrhythmia, hypoglycaemia, coma and oliguria. On admission to hospital, 15, 48 and 21 h after the bites, serum venom antigen concentrations ranged from 50 to 130 ng/ml. Autopsies revealed widespread congestion and bleeding in the lungs, gastrointestinal and renal tracts, adrenals, heart, brain and anterior pituitary. There was histopathological evidence of focal haemorrhage and fibrin deposition at the site of the bite and in the pituitary, lungs and kidneys and acute tubular necrosis. Deposition of fibrin microthrombi results from the action of venom procoagulants. Shock was attributed to increased capillary permeability, revealed clinically by conjunctival oedema. Acute pituitary/adrenal failure in one case was explained by fibrin deposition and haemorrhage in the anterior pituitary — resembling Sheehan's syndrome. Acute tubular necrosis resulted from ischaemia caused by fibrin deposition and to prerenal factors. An intractable cardiac tachyarrhythmia may have been caused by subendocardial and myocardial haemorrhages.

References (46)

A. Date et al.
Renal structure in cortical necrosis following Russell's viper envenomation
J. Trop. Med. Hyg.
(1981)
S. Indraprasit et al.
Acute interstitial nephritis after a Russell's viper snake bite
Clin. Nephrol.
(1986)
Myint-Myint-Than
Changes in the renal tubules in viper envenomation
J.C.M. Shastry et al.
Renal failure following snake bite
A clinicopathological study of nineteen patients
Am. J. Trop. Med. Hyg.
(1977)
M. Aung-Khin
Histological and ultrastructural changes of the kidney in renal failure after viper envenomation
Toxicon
(1977)
M. Aung-Khin et al.
Effects of Russell's viper venom on blood coagulation, platelets and the fibrinolytic enzyme system
Jap. J. Med. Sci. Biol.
(1977)
J. Basu et al.
Acute renal failure following snake bite (viper)
J. Assoc. Phys. India
(1977)
Burma
DMR Working Group on Russell's viper venoid
Trial of Russell's viper venoid. I. Immunization of monkeys with venoid. II. Human immunization with venoid
Trans. R. Soc. Trop. Med. Hug.
(1986)
Burma
DMR Working Group on Russell's viper venoid
Trial of Russell's viper venoid. I. Immunization of monkeys with venoid. II. Human immunization with venoid
Trans. R. Soc. Trop. Med. Hug.
(1986)
E.R. Cardoso et al.
Pituitary apoplexy: a review
Neurosurgery
(1984)
V. Cattell et al.
Focal mesangial proliferative glomerulonephritis in the rat caused by Habu snake venom
A morphologic study
Am. J. Pathol.
(1977)

V. Cattell et al.

Focal mesangial proliferative glomerulonephritis in the rat caused by Habu venom: the effect of antiplatelet agents

Br. J. Exp. Pathol.

(1986)

R.N. Chopra et al.

Action of the Indian Daboia (Vipera russelli) venom on the circulating system

Ind. J. Med. Res.

(1934)

K.S. Chugh et al.

Acute renal failure following snake bite

Am. J. Trop. Med. Hyg.

(1975)

K.S. Chugh et al.

Acute renal failure following poisonous snake bite

Am. J. Kidney Dis.

(1984)

A. Date et al.

Renal ultrastructure in acute tubular necrosis following Russell's viper envenomation

J. Pathol.

(1982)

A. Date et al.

Haemolytic-uraemic syndrome complicating snake bite

Nephron

(1986)

M.G. Davie et al.

Action of some coagulant snake venoms on blood platelets

Nature

(1965)

J. Davy

An Account of the Interior of Ceylon and its Inhabitants, with travels in that island

(1821)

M. Ho et al.

A critical reappraisal of the use of ELISA in the study of snake bite

Toxicon

(1986)

P.M. Jayarajan et al.

Renal involvement in ophidism

J. Assoc. Phys. India

(1979)

R. Jeyarajah

Russell's viper bite in Sri Lanka

A study of 22 cases

Am. J. Trop. Med. Hyg.

(1984)

Khin-Ohn-Lwin et al.

Russell's viper venom levels in serum of snake bite victims in Burma

Trans. R. Soc. Trop. Med. Hyg.

(1984)

C.Y. Lee et al.

Cardiovascular effects of snake venoms

Cited by (58)

Rapid identification of bilateral adrenal and pituitary haemorrhages induced by Russell's viper envenomation results in positive patient outcome
2023, Toxicon
The clinical management of snakebite envenomation (SBE) is challenging in many tropical and subtropical regions of developing countries due to the complex clinical manifestations and inadequate medical infrastructure. Some venomous snakes, such as the Indian Russell's viper (Daboia russelii) cause a wide range of rare complications in addition to their classical envenomation effects. In general, these uncommon complications are often misdiagnosed or not treated promptly due to a lack of awareness about these conditions. Thus, it is critical to report such complications to draw the attention of the healthcare and research communities to improve the clinical management and scientific research of SBE, respectively. Here, we report bilateral adrenal and pituitary haemorrhages in an SBE patient following a bite by Russell's viper in India. The initial symptoms included gum bleeding, swelling, axillary lymphadenopathy and clotting abnormalities. Despite the administration of antivenom, the patient presented palpitation, nausea, and abdominal pain, which were not recovered by combinational therapy with epinephrine and dexamethasone. Further infusion of antivenom did not address these issues and the patient displayed persistent hypotension, hypoglycaemia and hyperkalaemia suggesting an adrenal crisis. Inadequate secretion of corticosteroids was confirmed by laboratory tests, and imaging investigations revealed haemorrhages in both the adrenal and pituitary glands. The patient made a full recovery after treatment with hydrocortisone and thyroxine. This report adds to the growing evidence of rare complications induced by Russell's viper envenomations and it provides relevant guidance to diagnose and treat such complications in SBE victims.
Acute Myocardial Infarction After Russell's Viper (Daboia russelii) Bite
2022, American Journal of Cardiology
Russell's viper (Daboia russelii) is a deadly venomous snake that causes most snakebite deaths in Sri Lanka. It is widely distributed all over the country, and it commonly causes venom-induced consumption coagulopathy and neuroparalysis. Cardiotoxic manifestations after Russell's viper bites are rare. We report a 60-year-old man diagnosed with ST-elevation myocardial infarction after a proved Russell's viper bite.
Thrombotic Microangiopathy, Hemolytic Uremic Syndrome, and Thrombotic Thrombocytopenic Purpura Following Hump-nosed Pit Viper (Genus: Hypnale) Envenoming in Sri Lanka
2019, Wilderness and Environmental Medicine
Citation Excerpt :
Snake envenomation causes venom-induced consumption coagulopathy (VICC), resulting in fibrin deposition and platelet aggregation in small vessels. These thrombi block the blood supply, causing ischemia and organ failure.26 As red blood cells travel through these damaged vessels, they are fragmented, resulting in intravascular hemolysis, which in turn causes hemolytic anemia.
Thrombotic microangiopathy (TMA), which includes the spectrum of hemolytic uremic syndrome and thrombotic thrombocytopenic purpura, is an uncommon complication of hump-nosed pit viper envenomation. We describe 4 cases of TMA following hump-nosed pit viper (Hypnale spp) bites in Sri Lanka. The first case is a typical TMA that spontaneously resolved with supportive treatments. The second and third cases are related to hemolytic uremic syndrome complicated with acute kidney injury that required hemodialysis. The fourth case is thrombotic thrombocytopenic purpura associated with acute kidney injury that required hemodialysis and therapeutic plasma exchange. For each patient we describe the circumstances of the bite, clinical features, laboratory findings, and management.
Twelve month prospective study of snakebite in a major teaching hospital in Mandalay, Myanmar; Myanmar Snakebite Project (MSP)
2019, Toxicon: X
The Myanmar Snakebite Project is an Australian government (Department of Foreign Affairs and Trade) supported foreign aid project in collaboration with the Myanmar government with the aim of improving outcomes for snakebite patients in Myanmar. As part of the project a case record database was established to document prospective cases of snakebite presenting to Mandalay General Hospital, in Upper Myanmar. The study period was 12 months (1-2-2016 to 31-1-2017). Snake identity was based on a mixture of identified dead snakes brought with patients, doctor's clinical opinion and patient identification. 965 patients were enrolled during the 12 month period, of whom 948 were included for analysis. The male: female ratio was 1.58:1. Most cases involved bites to the lower limbs (82.5%) and adults involved in farm work, confirming snakebite as an occupational disease in this community. Motorised transport was by far the most common form of transport to health care and most patients sought care from the health system (87.7%), not traditional healers (11.5%) as their first point of contact. The officially promoted application of a pressure pad, bandage and immobilisation as first aid for snakebite was almost never used, while most patients used some form of tourniquet (92.0%). 85.4% of cases where a snake ID was listed were bitten by Russell's vipers. Russell's viper bites were responsible for all fatalities (9.8% of cases) and all cases of Acute Kidney Injury (AKI). For all cases, clinical features included local swelling (76.5%), local pain (62.6%), AKI (59.8%), incoagulable blood (57.9%), regional lymphadenopathy (39.8%), nausea/vomiting (40.4%), thrombocytopenia (53.6%), abdominal pain (28.8%), shock (11.8%), secondary infection (8.6%), panhypopituitarism (2.1%). AKI required renal replacement therapy (RRT) in 23.9% of cases, all ascribed to Russell's viper bite. Green pit viper bites were the next most common cause of bites (7.6%) and were associated with incoagulable blood (29%) and occasionally shock (5%) and local necrosis (3%), and in one case AKI not requiring RRT. In contrast to Russell's viper bites, green pit viper bite was most likely to occur in the home (49%). Some green pit viper patients were treated with Russell's viper antivenom (15%), presumably because they had incoagulable blood, although this antivenom is not effective against green pit viper envenoming. For the entire patient group, antivenom was given in 80.5% of cases. The most common indications were presence of coagulopathy/non-clotting blood (59.8%), local swelling (47.4%), oliguria/anuria (19.8%), heavy proteinuria (19.4%). A febrile reaction to antivenom was reported in 47.9% of cases, while anaphylaxis, occurred in 7.9% of cases.
Russell's Viper Envenomation-Associated Addisonian Crisis
2018, Wilderness and Environmental Medicine
Snakebite envenomation is an important public health problem in tropical countries. We report a case of bilateral adrenal hemorrhage in a 28-y-old man with Russell's viper bite that occurred in the Sathyamangalam forest range in the Indian state of Tamil Nadu. In this case, a combination of early bite recognition, hospital-based supportive care, corticosteroid therapy, and timely administration of polyvalent antivenom resulted in a favorable clinical outcome.
Prolonged Coagulopathy, Ecchymoses, and Microangiopathic Hemolytic Anemia Following Hump-Nosed Pit Viper (Hypnale hypnale) Bite in Sri Lanka
2017, Wilderness and Environmental Medicine

View all citing articles on Scopus

View full text

Contribution of focal haemorrhage and microvascular fibrin deposition to fatal envenoming by Russell's viper (Vipera russelli siamensis) in Burma

Abstract

J. Trop. Med. Hyg.

Clin. Nephrol.

Am. J. Trop. Med. Hyg.

Histological and ultrastructural changes of the kidney in renal failure after viper envenomation

Toxicon

Effects of Russell's viper venom on blood coagulation, platelets and the fibrinolytic enzyme system

Jap. J. Med. Sci. Biol.

Acute renal failure following snake bite (viper)

J. Assoc. Phys. India

DMR Working Group on Russell's viper venoid

Trial of Russell's viper venoid. I. Immunization of monkeys with venoid. II. Human immunization with venoid

Trans. R. Soc. Trop. Med. Hug.

DMR Working Group on Russell's viper venoid

Trial of Russell's viper venoid. I. Immunization of monkeys with venoid. II. Human immunization with venoid

Trans. R. Soc. Trop. Med. Hug.

Pituitary apoplexy: a review

Neurosurgery

Focal mesangial proliferative glomerulonephritis in the rat caused by Habu snake venom

A morphologic study

Am. J. Pathol.

Focal mesangial proliferative glomerulonephritis in the rat caused by Habu venom: the effect of antiplatelet agents

Br. J. Exp. Pathol.

Action of the Indian Daboia (Vipera russelli) venom on the circulating system

Ind. J. Med. Res.

Acute renal failure following snake bite

Am. J. Trop. Med. Hyg.

Acute renal failure following poisonous snake bite

Am. J. Kidney Dis.

Renal ultrastructure in acute tubular necrosis following Russell's viper envenomation

J. Pathol.

Haemolytic-uraemic syndrome complicating snake bite

Nephron

Action of some coagulant snake venoms on blood platelets

Nature

An Account of the Interior of Ceylon and its Inhabitants, with travels in that island

A critical reappraisal of the use of ELISA in the study of snake bite

Toxicon

Renal involvement in ophidism

J. Assoc. Phys. India

Russell's viper bite in Sri Lanka

A study of 22 cases

Am. J. Trop. Med. Hyg.

Russell's viper venom levels in serum of snake bite victims in Burma

Trans. R. Soc. Trop. Med. Hyg.

Cardiovascular effects of snake venoms