Rare cardiac sequelae of a hump-nosed viper bite

Abstract

BackgroundThe hump-nosed pit viper (Hypnale hypnale) is the commonest cause for venomous snakebites in Sri Lanka. Previously, it was thought to cause only local envenomation. However recently, several systemic effects and even mortality has been reported. Along with other snakes, such as the Indian cobra (Naja naja), the common krait (Bungarus caeruleus), the Russell’s viper (Daboia russelii) and the saw-scaled viper (Echis carinatus), the hump-nosed viper is now also considered capable of causing lethal envenomation. Unlike other snake species, the systemic manifestations occurring through the bite of a hump-nosed viper, such as acute renal failure, thrombotic microangiopathy etc are rare and unpredictable.Case presentationA 49-year-old Sri Lankan Tamil male presented with a hump-nosed viper bite, which had resulted in a cardiac arrest within half an hour of envenomation. On arrival to the Emergency Treatment Unit, he was unconscious and without spontaneous breathing. Electrocardiography monitoring revealed ST elevation in leads II, III and aVF with reciprocal changes in leads I and aVL—indicating inferior wall infarction—as well as atrial fibrillation. Glasgow Coma Scale was 7/15, which indicated severe brain injury and electroencephalogram on day 10 revealed a low amplitude pattern compatible with diffuse brain damage.ConclusionThis case describes an authenticated case of myocardial infarction in a 49-year-old male following envenomation by a hump-nosed viper in Sri Lanka. This systemic effect of this viper’s bite has not previously been described in the literature. This case report is intended to increase the vigilance for myocardial infarction following hump-nosed viper envenomation.

Cardiovascular Involvement Following Hump Nosed Viper Bite – A Case Series

“…In the past, it was believed that hump nosed viper bite and Russell's viper bite did not cause any significant cardiac involvement [4,5]. However, there have been a few published case reports challenging this view with regard to Russell's viper [6,7]..But we could find only one case report of cardiac involvement due to a hump nosed viper bite [3].…”

“…Systemic manifestation are rare and reported complications include coagulopathy and renal impairment. In general, cardio toxicity following snake bites is rare and cardiac involvement following hump nosed viper bites is extremely rare [3]. We could only find one such case in the literature.…”

“…These compounds have diverse actions. Cardiac involvement could be the combined result of several mechanisms including direct cardiac toxicity, haemorrhage and hypotensive shock following coagulopathy, vascular inflammation and thrombosis, coronary vaso-constriction, anaphylaxis, conduction abnormalities and tachycardia leading to increased oxygen demand [3,6].…”

Cardiovascular manifestations and patient outcomes following snake envenomation: a pilot study

“…3 Cardiac sequelae have also been noted in snakes such as hump-nosed vipers (Hypnale hypnale) whose venom is not neutralised by the polyvalent serum. 8 The exact mechanism by which snake bite envenomation leads to myocardial ischaemia or infarction is unclear. Mechanisms postulated include hypovolemic shock due to bleeding (owing to haemorrhagins or toxic vasculitis), anaphylactic shock, hypercoagulability secondary to disseminated intravascular coagulation (DIC), hyperviscosity secondary to hypovolemia induced haemoconcentration, direct myocardiotoxic effects or coronary spasm due to endothelins, sarafotoxins or anxiety.…”

Prolonged Coagulopathy, Ecchymoses, and Microangiopathic Hemolytic Anemia Following Hump-Nosed Pit Viper (Hypnale hypnale) Bite in Sri Lanka

“…The manifestations of local envenoming, such as pain, swelling, hemorrhagic blistering, and necrosis after hump-nosed pit viper bites are well described in the literature. [5][6][7][8] Moreover, systemic manifestations such as coagulopathy, acute kidney injury, chronic kidney disease, 6,[9][10][11][12][13] thrombotic microangiopathy, 13 ischemic stroke, 14 inferior myocardial infarction, atrial fibrillation, and cardiac arrest 15 have been described, which qualified it as a highly venomous snake. Extensive literature searches on the effects of envenoming by hump-nosed vipers did not find situations of appearance of ecchymotic patches similar to this case described from the wet zone of Sri Lanka.…”