Abstract
Hump-nosed viper bites are frequent in southern India and Sri Lanka. However, the published literature on this snakebite is limited and its venom composition is not well characterized. In this case, we report a patient with thrombotic thrombocytopenic purpura-like syndrome following envenoming which, to the best of our knowledge, has not been reported in the literature before. A 55-year-old woman from southern Sri Lanka presented to the local hospital 12 hours after a hump-nosed viper (Hypnale hypnale) bite. Five days later, she developed a syndrome that was characteristic of thrombotic thrombocytopenic purpura with fever, thrombocytopenia, microangiopathic hemolysis, renal impairment and neurological dysfunction in the form of confusion and coma. Her clinical syndrome and relevant laboratory parameters improved after she was treated with therapeutic plasma exchange. We compared our observations on this patient with the current literature and concluded that thrombotic thrombocytopenic purpura is a theoretically plausible yet unreported manifestation of hump-nosed viper bite up to this moment. This study also provides an important message for clinicians to look out for this complication in hump-nosed viper bites since timely treatment can be lifesaving.
Highlights
Hump-nosed vipers of the genus Hypnale have three species Hypnale hypnale (Figure 1), Hypnale nepa and Hypnale zara [1]
Humpnosed viper bites are the commonest cause of snake envenoming in Sri Lanka accounting for 22 to 77% of all snakebites in different series [3]
If we follow the evidence that Venom induced consumptive coagulation (VICC) is unrelated to organ failure and Thrombotic microangiopathy (TMA) can happen without VICC by a separate mechanism, an acquired hemolytic uremic syndrome (HUS)-like syndrome will explain the clinical picture seen in patients with renal failure after a hump-nosed viper bite [12]
Summary
Hump-nosed vipers of the genus Hypnale have three species Hypnale hypnale (Figure 1), Hypnale nepa and Hypnale zara [1]. The patient was unable to protect her airway and was moved to the medical intensive care unit following elective endotracheal intubation in the ward At this point it was observed that the platelet count had progressively dropped since admission (Figure 3). The platelet count picked up to 250,000/μL, lactate dehydrogenase level and other biochemical parameters such as liver and renal function tests were within normal limits at the point of discharge She was clinically well and gradually returning to her daily routine at home two weeks later in the follow up clinic. Followed up annually at the local hospital with regard to renal functions as cortical necrosis and chronic kidney disease, a potential complication of hump-nosed viper bites
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