Systemic bleeding due to consumption coagulopathy and thrombocytopenia due to activation of procoagulants is the leading manifestation and cause of death in Russell's viper systemic envenoming. Thrombotic occlusion of the blood vessels is rare in cases of snakebite. In this report, two adult patients with Russell's viper systemic envenoming presented multiple cerebral infarctions, digital gangrenes and ischaemic organs in addition to typical clinical manifestations of bleeding diathesis and renal involvement. Our findings in these two special cases suggest that the venom-induced coagulopathy and endothelium damage, predisposed by toxin-induced vasoconstriction, might be the possible mechanism of multiple thrombotic vascular occlusions in systemic envenoming of Formosan Russell's viper.The Formosan Russell's Viper (Daboia russelli formosensis) is a subspecies found exclusively in Taiwan. Epidemiologically, it is the sixth most important poisonous snake in Taiwan (Chen et al. 1997;Hung et al. 1997). Snakebites from this viper are very rare, accounting for only 0.4 % of poisonous snakebites in Taiwan (Sawai 1969). Haemorrhagic complications and acute renal failure are the main manifestations and causes of death from Russell's viper systemic envenoming in the South and East Asia area (MyintLwin et al. 1985;Than-Than et al. 1988). The toxic principles, including procoagulant factors V and X, protease and phospholipase A2 are responsible for the toxic manifestations of systemic envenoming (Warrell 1989). Thrombotic occlusions of blood vessels have rarely been described in cases of Russell's viper snakebite (Ameratunga 1972). Here, we report two cases of Russell's viper systemic envenoming with multiple thrombotic occlusions in the vital organs and digitals and discuss the possible mechanisms of the occurrence of thrombosis instead of haemorrhage.
Materials and MethodsTwo cases of Russell's viper snake bites. Case 1. A 67-year-old male was admitted due to mild swelling of the right palm, multiple bruising and change of consciousness after snakebite. He was a healthy farmer and was bitten by a snake on the dorsal side of the right palm while working in a field at 7 a.m. on April 25, 1991. He reported to a local clinic 90 min. later with the offending snake, which he had caught. Two vials of ''haemorrhagic'' snake antivenin (specific for Trimeresurus mucrosqamatous & T. stejnegeri, produced by the Vaccine Center, Center for Disease Control, Taiwan) were incorrectly administered. About 6 hr after the snakebite, ecchymosis, deAuthor for correspondence: Shoei-Yn Lin-Shiau, Institutes of Toxicology and Pharmacology, School of Medicine, National Taiwan University, No.1, Sec 1, Jen-Ai Road, Taipei City, Taiwan 100 (fax 886-2-23410217. e-mail syl/ha.mc.ntu.edu.tw). creased urine excretion, and delirium developed. He was admitted to a regional medical center 12 hr after the snakebite with haemolysis, rhabdomyolysis, acute renal failure, thrombocytopenia, coagulopathy and bleeding from the genitourinary and gastrointest...