Hump-nosed Pit Viper Bite Research Articles

Hypothetical Interventions to Prevent Acute Kidney Injury After Humpnosed Pit Viper Bite

Abstract: Even though the Hump-nosed pit viper bite is the commonest venomous snake bite in Sri Lanka, antivenoms with specific activity against it are not available. Acute kidney injury (A.K.I.) is an important systemic complication accounting for mortality. Therapeutic plasma exchange (TPE) and fresh frozen plasma (F.F.P.) are two interventional options hypothesized to prevent A.K.I. This is by TPE at-tenuating venom antigenemia and F.F.P. by inhibiting nephrotoxic renal injury by immunomodulation, and the additional benefit of replenishment of depleted clotting factors triggered by venom-induced con-sumption coagulopathy implicated in the multifactorial mechanisms of renal injury. Routine interventions on all envenomed patients are not justifiable owing to the rarity and sporadic occurrence of systemic complications, and only patients with coagulopathy should be selected for interventions. The benefit of preventing A.K.I. is most likely with early intervention at the inception of coagulopathy.

Long-term health manifestations of hump-nosed pit viper (Genus: Hypnale) bites

Introduction The hump-nosed pit viper (Genus: Hypnale) is a highly medically significant snake in Sri Lanka, responsible for the majority of venomous snakebites (22–77%). They are found throughout Sri Lanka and the Western Ghats region of India. The venom can lead to two types of effects: acute and long-term. Acutely, bites often result in local symptoms, with less common systemic effects such as acute kidney injury, venom-induced consumption coagulopathy, and thrombotic microangiopathy. Methods We conducted a prospective observational study at Teaching Hospital Ratnapura, Sri Lanka, spanning six years, starting in June 2015. Patients bitten by hump-nosed pit vipers were followed up for two years, with assessments every three months to identify long-term effects. Data was gathered through interviewer-administered questionnaires. Results Out of 728 patients bitten by hump-nosed pit vipers, 22 (3%) were lost to follow-up. Forty-four (6.2%) experienced long-term effects, including chronic kidney disease (24; 3.4%), chronic wounds (five; 0.7%), amputations (five; 0.7%), fasciotomy-related wounds (four; 0.6%), and psychological illnesses (four; 0.6%). There were nine (1.3%) deaths in this group. Among those with chronic effects, 27 (61%) were males, and 17 (39%) were females, with ages ranging from 29 to 82 years (mean 57.6 years). The time it took to diagnose acute kidney injury from the snakebite was 18 h (interquartile range: 15–23.5 h), while the time to diagnose chronic kidney disease was 69 days (interquartile range: 64–74.75 days). In these patients, the estimated glomerular filtration rate was 29.3 mL/min/1.73 m2 (interquartile range: 14–50.75 mL/min/1.73 m2). Among the patients who did not develop long-term complications (662; 91%) 660 (90.7%) experienced local effects, and 82 (11.3%) developed systemic manifestations, including acute kidney injury in 60 (8%) and coagulopathy in 35 (5%). Conclusion Following hump-nosed pit viper bites, a subset of patients may experience long-term health complications, including chronic kidney disease, chronic ulcers, amputations, fasciotomy-related wounds, and psychological illnesses, with chronic kidney disease being the most frequently observed among these manifestations.

Acute ischemic stroke: a rare complication of hump-nosed pit viper (Hypnale spp.) bite: a case report

BackgroundHump-nosed pit viper is a medically important deadly venomous snake in Sri Lanka and is the commonest cause of venomous snakebites in the country. It frequently causes local effects and systemic manifestations such as acute kidney injury and coagulopathy that occur in less than 10% of all bites. This also includes some atypical presentations such as thrombotic microangiopathy and myocardial infarction. Currently, no antivenom is available for hump-nosed pit viper bites in Sri Lanka, and patients are managed with supportive treatment. This case illustrates an acute ischemic stroke following a hump-nosed viper bite, which is the second case in the literature.Case presentationA 71-year-old a Sinhalese male patient presented with left-sided hemiparesis with mouth deviation on day 2 of hump-nosed viper (Hypnale spp.) bite on the right foot. Non-contrast computed tomography of brain showed right ischemic stroke in internal capsule. He was given antiplatelets and statins and continued supportive treatment including limb physiotherapy and speech therapy. He recovered completely and was discharged on day 4 with clinic follow-up.ConclusionsPhysicians should be aware that ischemic cerebral infarcts may occur following hump-nosed pit viper bites.

POS-084 THE ROLE OF SERUM AND URINARY BIOMARKERS IN PREDICTING ACUTE KIDNEY INJURY FOLLOWING SRI LANKAN HUMP-NOSED PIT VIPER ENVENOMING

Hump-nosed pit viper (Hypnale spp.) accounts for the majority of venomous snakebites in Sri Lanka. Acute kidney injury (AKI) is by far the most serious systemic manifestation (1-10%) following hump-nosed pit viper envenoming. This study aimed to identify the value of functional and injury biomarkers in predicting the development of AKI early following hump-nosed pit viper bites.

Hypnale coagulopathy: snake envenomation of a different kind.

Hypnale hypnale is a small pit viper that is known as the hump-nosed pit viper (HNV) or 'Merrem's hump-nosed pit viper' and is endemic to Sri Lanka and the Western Ghats of South India. Previously, it was thought that this viper bite would result in mild systemic or local envenomation, however, we now know that HNV bites could cause severe systemic toxicity and mortality. The most common systemic toxicity of this viper envenomation is coagulopathy, which is known as 'Hypnale coagulopathy'. Hypnale coagulopathy is quite different from the haemotoxicity caused by other vipers. In this paper, an effort has been made to discuss the unique and unpredictable nature of this coagulopathy due to Hypnale envenomation.

Hump-nosed pit viper (Hypnale hypnale and Hypnale zara) envenoming in Deniyaya, Sri Lanka: Epidemiological and clinical features from a prospective observational study

Hypnale hypnale, Hypnale zara and Hypnale nepa are the three species of Hump nosed pit vipers that are implicated in human bites in Sri Lanka. H. zara and H. nepa are two endemic species to the country. The objective of the study was to characterize epidemiology and clinical features after different Hump nosed pit viper species bites.A prospective observational study was conducted in Base Hospital Deniyaya from 2013 to 2015. Hump nosed pit viper as the offending snake was identified when the victims brought live or dead specimens. Species identification of dead specimen was done by a herpetologist. Clinical details were recorded during the hospital stay.83 Hump nosed pit viper bite patients (19–81 years) were studied. Fifty two dead specimens were identified as 39 of H. zara and 13 of H. hypnale by the herpetologist. No H. nepa was identified. Thirty one live snakes were identified as Hump nosed pit vipers and released in to the wild. Envenoming was reported throughout the year. Eighty (96.4%) were daytime bites. Hands (43.4%), feet (55.4%) and arms (1.2%) were affected sites. Sixty two (74.7%) were bitten in tea plantations. All had pain over bite site. Overall, sixty nine (83.1%) had local swelling, seven (8.4%) extensive limb swelling, nineteen (22.9%) haemorrhagic blisters, and seven (8.4%) regional lymphadenopathy. Four (4.8%) patients had incoagulable blood by 20WBCT. H. zara bites had 28.2% haemorrhagic blisters, 7.7% extensive limb swelling and 2.6% coagulopathy. H. hypnale bites had 7.7% each extensive limb swelling and coagulopathy and 23.1% haemorrhagic blisters. None developed elevated serum creatinine. Neurotoxicity was not noted.Hump nosed pit viper bites caused substantial morbidity. Risk factors included day time outdoor activities and occupation. Pain, extensive limb swelling, bite site swelling, haemorrhagic blisters, regional lymphadenopathy and coagulopathy were prominent clinical features. Nephrotoxicity and neurotoxicity were notably absent. Clinical features varied depending on the species implicated.

Hump-nosed Pit Viper Bite in Central Kerala–Remonstrance to Big4 Theory in Snake Bite Envenomation

Hump-nosed Pit Viper Bite in Central Kerala–Remonstrance to Big4 Theory in Snake Bite Envenomation

Kidney injury following envenoming by hump-nosed pit viper (Genus: Hypnale) in Sri Lanka: proven and probable cases.

Hump-nosed pit vipers (Hypnale hypnale) are highly venomous snakes found in Sri Lanka and the Western Ghats region of India. They are the most common cause of venomous snakebites in Sri Lanka, mainly causing local envenoming leading to pain, swelling and necrosis. Systemic envenoming causing acute kidney injury and coagulopathy are more commonly recognized following their bites. A series of 465 patients with hump-nosed viper bites was prospectively studied over four years from January 2014. All patients were assessed and the data were collected by the principal investigator (primary data). Forty-four (9.5%) patients developed acute kidney injury, of which 23 (5%) were proven cases and 21 (4.5%) were probable cases. Of the proven cases, 4 (17%) progressed to chronic kidney disease and 12 (52%) had thrombotic microangiopathy, from which 11 (48%) developed haemolytic uremic syndrome and 1 (4%) had thrombotic thrombocytopenic purpura. Twelve (52%) showed microangiopathic haemolysis and 15 (65%) had thrombocytopenia. Oliguria was observed in 10 (43%) whereas 7 (30%) each had anuria and normal urine output. Ten patients (43%) developed haematuria, from which 6 had microscopic haematuria and 4 had macroscopic haematuria. Proteinuria was observed in 8 (35%). Coagulopathy developed in 3 (13%) patients. In probable cases, 3 (14%) died due to complications of kidney injury. A significant proportion of patients develop acute kidney injury following hump-nosed pit viper bite. Who will develop acute kidney injury or succumb to the venom is unpredictable. Reliable and accessible treatments are a critical unmet need.

Hump-nosed pit viper (Hypnale hypnale) envenoming causes mild coagulopathy with incomplete clotting factor consumption

Context. Limited information exists on the coagulopathy caused by hump-nosed pit viper (Hypnale hypnale) envenoming. Objectives. This study aimed to characterise the coagulopathy in hump-nosed pit viper bites by measuring laboratory clotting times and factor studies. Materials and methods. Cases of hump-nosed pit viper envenoming were included from a prospective cohort study of Sri Lankan snake-bite patients. Patient age, sex, snake identification, time of bite and clinical effects were recorded. Patients did not receive anti-venom because no specific anti-venom to hump-nosed vipers exists. All patients received supportive care and serial 20-min whole blood clotting tests (WBCT20). The prothrombin time (PT), international normalised ratio (INR), activated partial thromboplastin time (aPTT), coagulation factors I, II, V, VII, VIII, IX and X, von Willebrand factor (vWF) antigen and D-Dimer concentrations were measured. The median of highest or lowest test result for each patient was reported with interquartile range (IQR). Results. There were 80 hump-nosed pit viper bites, median age was 37 years (IQR: 26–51 years) and 48 were male. The WBCT20 was positive in one patient. The median highest INR was 1.9 (1.5–2.2; Range: 1.3 to > 12) and median highest aPTT was 54 s (46–72 s; Range: 35–170 s). There was low fibrinogen [median: 1.3 g/L;1, –1.8 g/L; Range: < 0.2–2.9], low factor VIII levels [median: 23%; 16–37%] and low factor V levels [median: 43%; 23–74%]. D-Dimer concentrations [median: 3.4 mg/L; 2–7.4 mg/L] were slightly elevated. Factors II, VII and X and vWF antigen concentrations were normal. Discussion and Conclusions. Hump-nosed pit viper bites result in a mild coagulopathy which is usually not detected by a WBCT20. It is characterised by mild elevation of INR, low fibrinogen and Factors V and VIII which may be consistent with the venom containing a thrombin-like enzyme.

Hump-nosed Pit Viper Bite in Sri Lanka?Unravelling an Enigma

Lack of detailed studies on hump-nosed viper apart for a few isolated case reports had left a void of knowledge for centuries. Consequently, its precise clinical features and management remained an enigma. Detailed clinical studies initiated by me in 1990 and escalated by other investigators in the recent past have accurately identified the different species of Hypnale, and species specific clinical features. Coagulopathy and acute kidney injury (AKI), though rare, are the most important and potentially fatal systemic effects. The lack of efficacy and safety of the currently available antivenom is now well recognised. While haemodialysis can salvage patients developing AKI, use of fresh frozen plasma is an exciting management option to prevent AKI, when used early for selected patients at the inception of coagulopathy. An attempt to develop species specific safe and efficacious antivenom with international collaboration has been initiated.

Hump-nosed Pit Viper Envenomation

Sir, I read the recent report on snake envenomation with a great interest [1]. Kumar et al. reported on importance of pit viper including hump-nosed pit viper and said that “antivenom for this snake is urgently required [1].” Focusing on the present report, although it is a retrospective data with very few indexed cases, the importance of hump-nosed pit viper bite can be seen. Indeed, hump-nosed pit viper is considered a very important snake at present [2]. However, not only the problem of availability of the antivenom, Simpson proposed that “A great many of these primary care hospitals do not treat snakebite, even when snake venom antiserum is available, simply because the doctor lacks confidence in being able to treat the patient [3].” It seems that it is required to have a continuous medical education system to provide the update knowledge to the practitioner on management of snake bite at present.