Case Report: Delayed Diffuse Alveolar Hemorrhage in Echis sochureki Envenoming, Jodhpur, India

Abstract

Snakebite envenoming is a common occupational hazard in the tropics. Venom-induced consumption coagulopathy and acute kidney injury are the most frequently encountered complications of viper bites. Diffuse alveolar hemorrhage (DAH) is an unusual presentation reported rarely in the literature. Our case report highlights the uncommon presentation of delayed pulmonary hemorrhage after snakebite envenoming. A 40-year-old healthy man presented to our emergency department after 6 hours of Echis sochureki (a saw-scaled viper subspecies) bite. He had abnormal coagulation parameters and thrombocytopenia with no signs of acute kidney injury. Transfusion protocols were initiated because of active bleeding and a rapid decrease in hemoglobin levels over next few days. Around day 10, his coagulation profile and hemoglobin were corrected, but he developed hemoptysis with rapidly progressive respiratory distress. Computed tomography of the chest was suggestive of DAH and the patient was started on a plasma exchange with pulse methylprednisolone. After the initial worsening, he had rapid symptomatic improvement and radiological resolution. The patient had persistent hypofibrinogenemia, which resolved, and was discharged and remained healthy at the 60-day follow-up. This case highlights a presentation with an initial phase of venom-induced consumption coagulopathy followed by delayed DAH in saw-scaled viper envenoming that was treated successfully with immunosuppressants and plasma exchange.

Delayed Compression Paralysis Following an Iliopsoas Hematoma 30 Days After Saw-Scaled Viper (Echis carinatus sochureki) Envenoming: A Case Report

“…12 -15 Possible reasons for delayed complications are persistent venom hemorrhagins and hemolysins with VICC and defibrination syndrome possibly due to ineffective antivenom response. 2 Though the initial focus in our patient was on other life-threatening complications (bleeding, AKI, and pneumonia), nerve compression symptoms lasting beyond 1 mo of the bite resulting in a serious disability is an important sequela that deserves to be highlighted. Femoral neuropathy following iliopsoas hematoma is a rare complication that has been reported postoperatively and in patients with bleeding diathesis (hemophilia) or anticoagulant use.…”

“…E c sochureki , a subspecies of E carinatus , common in Rajasthan, is increasingly being implicated in prolonged coagulopathy resulting from an inadequate antivenom response. 2,9,10 The ineffectiveness of antivenom is a serious problem in this part of the country, where transfusion support and supportive care are the only management a healthcare provider can offer in the event of a viper bite. Most of the complications, hospital stay, and morbidity could have been prevented and addressed by a more effective antivenom in this patient.…”

“…Snakebite envenoming is a neglected tropical disease estimated to cause 0.8 deaths (0.5-1.0) per 100,000 people globally, and India had the greatest absolute number of snakebite envenoming deaths of >50,000 annually; in addition, snake bite envenoming resulted in long-lasting disabilities and sequelae in at least another 400,000 people. [1][2][3] As the World Health Organization mandate to reduce snakebite mortality by half by 2030 is drawing near, there is a serious need to focus on survivors and mitigating their disabilities. 4,5 In this report, we highlight a case of saw-scaled viper (Echis carinatus sochureki) envenoming in Rajasthan, which is a high-burden state in India for both snakebite envenoming and deaths, with a disabling complication of painful limb paralysis following a pelvic hematoma compressing the lumbar plexus 30 days after the snakebite.…”