Multisystem failure and death due to extensive hemorrhaging and brain herniation subsequent to a bite by an unidentified snake
© The Author(s) 2016
Received: 4 May 2016
Accepted: 4 August 2016
Published: 13 September 2016
Snakebites cause considerable morbidity and mortality in tropical and subtropical countries even though existing treatment methods can prevent most deaths if presentation occurs early to hospitals. Envenomation by unidentified snakes is common in central Sri Lanka. Management of such patients is challenging especially if presentation is late.
Here, we report a case of a 52-year-old man from central Sri Lanka who presented late after being bitten by an unidentified snake. He developed `severe coagulopathy, neurotoxicity, acute kidney injury, and rhabdomyolysis. Subsequently, despite of treatment, he died due to extensive hemorrhaging in many organs. A large intracranial hemorrhage lead to fatal brain herniation.
Envenomation by some snake species can severely affect multiple body systems and give rise to fatal brain hemorrhages and brain herniation. Considering the known effects of local snake venom, the responsible species is likely to be Russell’s viper (Daboia russelii). We recommend some simple measures to reduce the chances of such deaths in the future.
KeywordsSnakebites Snake envenomation Sri Lanka Coagulopathy Acute kidney injury Brain hemorrhage Brain herniation Russell’s viper Case report
Snakebites are a neglected health problem which mainly affects tropical and subtropical countries. At least 100,000 annual deaths occur worldwide due to snakebites , and South Asia (which includes Sri Lanka) is the most heavily affected region . Effective treatment exists if patients come early to hospital . In Sri Lanka, the great majority of people have access to a state hospital within a couple of hours and they are provided with treatment free of charge. Bites by unidentified snakes are common in central Sri Lanka  and elsewhere. Treating them is more challenging, especially if the patient is presented late to a hospital. Doctors are compelled to guess the probable snake species responsible by comparing patients’ symptoms and physical signs with the known patterns of symptoms and signs caused by bites of snake species in the locality. Information on place and the time of the bite may also give clues about the responsible species. Terrestrial elapids’ and vipers’ venom, respectively, cause predominantly neurotoxicity and coagulopathy. Sea snakes, which also are elapids, have venom causing rhabdomyolysis. However, a combination of these toxicities and toxicities on other systems like the kidneys ensues after envenomation by many snake species.
In the experiences of the authors to date and according to published information , hump-nosed viper (H. hypnale and two other moderately venomous endemic hump-nosed viper species) bites are the most commonly reported in hospital practice in the Central Province.
Data on snakebite victims of Sri Lanka and most other developing countries is only based upon those who venture to hospital. Many cases do not come to hospital so the magnitude of the problem is underrepresented [1, 2, 6]. In Sri Lanka, as in many other countries, many people, especially in rural communities, rely on indigenous medical practitioners for treatment of snakebites and patients who go to them do not get recorded. [1, 6]. However, they come to hospitals if and when symptoms get worse . Fatality rates in hospitals for snake bites have greatly reduced in the recent past in Sri Lanka .
A 52-year-old Sri Lankan man was bitten by an unidentified snake on his left foot whilst he was walking along a village footpath (approximately 900 m above sea level) in the Central Highlands of Sri Lanka at about 21.30 h. He was apparently healthy except for diabetes mellitus which had been diagnosed approximately 1 year ago, for which he took oral hypoglycemics haphazardly and was not on regular follow-up. The snake vanished into the vegetation, he walked home (approximately 250 m), and the family summoned an indigenous doctor similar to how their ancestors had done even though a state hospital was about 4 km away. The indigenous doctor arrived after 30 min, applied a herbal paste over the left foot (the formula, a family secret, has been handed down through the generations), made a drink from karapincha (Murraya koenigii) leaves and coconut kernel, gave it to the patient, and chanted some mantras (sacred verses). The patient passed loose stools three times.
As he felt a progressive difficulty to open his eyes and had blurred vision approximately 22 h after the bite, he was taken to the nearby hospital. The doctors there noticed bilateral ptosis and gum bleeding, diagnosed systemic envenomation, and transferred the patient to the Teaching Hospital-Kandy by ambulance.
On arrival (24 h since the bite), his left foot was edematous with two fang marks and with a thin topical herbal paste, there was gum bleeding, and the mouth was reddish with paste of betel nuts he had been chewing (Betel nut is an Asian mild stimulant composed of leaves of Piper beetle, seeds of Areca catechu, and lime). There was bilateral ptosis, external ophthalmoplegia; his pulse rate was 90/min, his blood pressure was 110/80 mm mercury, respiratory rate was 48/min, and a few bilateral crepitations were auscultated in his lungs that disappeared after nebulization with salbutamol (albuterol). Arterial oxygen saturation was 96 % whilst he was on oxygen via a face mask. His abdomen was normal on examination. When an intravenous line was started, there was bleeding from the puncture site. He was conscious, rational, and well-oriented. Both pupils were equal and central and reacted to light. He could lift his head off the bed but could not do so against resistance during the assessment of neck muscle power. In all limbs, his muscle tone, power, and tendon reflexes were normal.
The summary of laboratory investigations
Whole blood clotting time (WBCT)
>20 min → >20 min
Total white cell count
21.32 × 109/l (neutrophils 79.8 %)
24.16 × 109/l (neutrophils 88.2 %)
4.0–10.0 × 109/l (neutrophils 50.0–70.0 %)
46 × 109/l
138 × 109/l
150–450 × 109/l
Creatine kinase CK2
2.4 mg/dl → 3.56 mg/dl
124 mmol/l → 129 mmol/l
132 mmol/l → 129 mmol/l
5.4 mmol/l → 4.9 mmol/l
3.9 mmol/l → 5.2 mmol/l
Serum alanine transaminase (ALT)
Serum aspartate transaminase (AST)
Activated partial thromboplastin time (APTT)
Control 32.0 (30–45) s
International normalized ratio (INR)
Arterial blood PH
7.2 → 7.32
Random blood sugar
Nevertheless, there were no new external bleedings.
The infusion of mannitol and furosemide was prescribed to control intracranial pressure. We contemplated the infusion of ASV again. A doctor from the neurosurgical team was summoned to see the patient, but immediate surgical intervention was ruled out considering high risk of bleeding and overall condition (American society of anesthesiologists—category 5) of the patient. Before finishing the neurosurgical assessment, the patient developed a cardiac arrest and our attempts to resuscitate him failed.
There were hematomas at the bite site and the site where the femoral vein was catheterized for hemodialysis. There were subendocardial hemorrhages in the heart. Both kidneys were edematous. There was blood into both pelvicalyceal systems and hemorrhages in both lungs as well.
We discussed the relevant issues under three subheadings.
Identification of the snake species responsible
On admission to our hospital, this patient had features of neurotoxicity, coagulopathy, and local edema at the bite site suggesting systemic envenomation likely to be by a Russell’s viper. Dry bites are rare with Russell’s vipers as they usually deliver a full dose of venom when biting. Saw-scaled viper bites are extremely rare whilst krait bites are rare in the Central Highlands of Sri Lanka . The venom of both deadly local kraits is unlikely to cause coagulopathy and significant local edema. Spectacled cobra venom is unlikely to cause severe coagolopathy or acute kidney failure. Hump-nosed viper venom is not known to cause neurotoxicity despite ischemic strokes being reported post-bite . Subsequent detection of acute kidney injury may be caused by a hump-nosed viper too but more likely to be by Russell’s viper venom. Severe myotoxicity with neurotoxicity is classically associated with sea snakes but the area is inland highlands and sea snake bites do not result marked local reactions. Russell’s viper venom also can cause severe myotoxicity and neurotoxicity . It is uncommon to see all those systems get severely affected as in this patient after a snakebite. The time, venue of incident, and bite to foot also point towards Russell’s viper [3, 7]. However, the patient had no abdominal pain (which is usually associated with serious Russell’s viper envenomation) .
Why he died and possible measures to improve outcome of similar cases
The Indian polyvalent ASV is the only ASV available in Sri Lankan hospitals at present. This covers venoms of the “big four” lethal snakes of the Indian subcontinent namely Russell’s viper, saw-scaled viper, spectacled cobra, and the common krait but not the venom of other species. Although causing frequent reactions (such as the case of this patient), the ASV is fairly effective in preventing death if administered early to counter the venom of those species. The decision to infuse (and repeat) should be made carefully if the snake is unidentified. Late presentation to hospital had reduced the chances of his survival. His walking after the bite may have accelerated systemic spread of injected venom. The availability of an intensive care unit bed and quicker availability of laboratory reports would have made management of this patient much easier. Aside from the hospital admission delay, any beneficial or harmful effects of indigenous doctor’s treatment on his disease process are unknown to us.
This patient was the breadwinner of his family. He and most local victims of snakebites are in productive years of their lives , which is another reason for primary prevention of snakebites. He was wearing rubber slippers and walking with the aid of the light of his mobile phone instead of a torch at the time of the bite which made him vulnerable. Education of the public about identification of snakes with lethal venom (using color photos/videos) may also help to reduce incidences like this.
Some clinical manifestations of Sri Lankan Russell’s viper envenomation are reported to be different from that of the same species in continental Asia . A monospecific ASV was developed locally to address this issue but was not very successful . A polyvalent ASV that covers venom of H. hypnale (responsible for most snakebites) and at least other five lethal terrestrial snake species of Sri Lanka would have been more useful to treat the patient bitten by an unidentified snake. One ongoing project is developing a polyvalent ASV that covers venoms of local snakes with international help .
Snake species with venom that can cause similar symptoms
A recent case report from India describes a large intracerebral hemorrhage following a suspected snakebite which was successfully treated with neurosurgery . Brain hemorrhages following envenomation by D. russelii, Pseudonaja textilis, Notechis scutatus, E. carinatus, and Bothrops species have been reported from various countries [2, 12, 13]. However, we did not find any reported cases of brain hemorrhages and edema leading to supratentorial and tonsillar herniation of the brain that caused death after being bitten by an unidentified snake. Many snake species with venom with hematotoxicity or myotoxicity and snakes with both toxicities like D. russelii, Oxyuranus scutellatus, and N. scutatus can cause acute kidney injury. There are at least 16 snake species that can cause nephrotoxicity [3, 14]. Snakebites are attributed to up to 70 % of acute kidney injury cases in some Asian countries .
Bites by some snake species rarely cause severe brain hemorrhages and edema that lead to brain herniation and death, and it is useful to keep this possibility in mind when managing patients with severe envenomation. If snakebite victims with coagulopathy complain of headaches, it is worth doing a NCCT scan of the brain, vigorous promotion of using a good torch at night, and wearing footwear that covers the whole foot when walking on rural footpaths especially at night may help to reduce snakebites in high-risk areas. Promotion of hospitalization as soon as possible with the affected limb immobilized may help to reduce morbidity and mortality of snakebite victims. Increasing the number of intensive care beds in state hospitals may help to give better care to patients with serious envenomation.
Whole blood clotting time
Activated partial thromboplastin time
International normalized ratio
Noncontrast CT scan
We sincerely thank all members of the hospital staff who helped us in management of this patient, all who helped us to publish the case report, the widow of the patient for giving consent to publish this case report, and Mr. Rahul Alvares for consenting to use the photo of Russell’s viper. Special thanks to Dr. M. Sivasubramaniam who did the autopsy and kindly gave the post-mortem findings including photographs.
No funding received.
Availability of data and materials
This is not a research project that generated data, only a case report. All the data related to our discussion, conclusions are included in the manuscript.
All the authors contributed to the management of the patient under the leadership of LKRK. NDBE wrote the manuscript. All authors approved the final manuscript after perusal.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the legal next of the kin (widow) of the patient for publication of this case report and accompanying images (the patient died). A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Ethics approval and consent to participate
This is not a research project involving people or animals, only a case report. Therefore, the requirement in our local setting is to get consent for publication.
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