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Case Reports |
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Viper
Bites in Children
Rajesh R
Joshi*, V Venkatramani** |
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| Snakebites
are a common event in rural India. We report two cases of viper
(vasculotoxic) snakebites from rural areas of Maharashtra.
Two male children bitten by vipers had deranged coagulation
profiles. Prompt treatment led to their total recovery. |
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| Case
Report |
Case
1 : A six year old male child was brought with the history
of viper bite over right leg. He reported to the hospital
4 hours after the bite. He had vomiting, haematuria and swelling
over the right foot. On examination, he was afebrile, frightened
with normal vital parameters. Two fang marks were seen over
the right medial malleolus. The right limb showed evidence
of cellulitis extending upto the knee. Systemic examination
was normal. Investigations showed a haemoglobin (Hb) of 10.8
g%, WBC count 9000/ cu. mm, P67 L31 E2 with normal RBC morphology.
Platelet count was 100,000/cu. mm. Urine examination showed
many RBCs. Blood urea and serum creatinine were normal. Clotting
time was 20 minutes. Prothrombin time (PT) was 30 seconds
against a control of 15 sec.
Case 2 : A six year old male child was brought to the hospital one and
half hours after viper bite on the left leg. He complained of vomiting
with pain and swelling over the bite. On examination his vital parameters
as well as systemic examination was normal, except for two fang marks on
the lateral aspect of the left ankle. Local oedema was present. The patient
developed bleeding from gums 30 min after admission.
Investigations revealed Hb of 9 g%, WBC count 12000/cu. mm. with P75 and
L25. RBC morphology was normal. Urine showed traces of blood. Clotting
time was more than 20 min and PT 35 sec against a control of 15 sec. Platelet
count was 40,000/cu. mm. with normal blood urea and serum creatinine.
Full coagulation profile was not possible as our institution does not have
the facilities and our patients could not afford it from private laboratories.
Both patients received 120 ml of anti-snake vernom (ASV) intravenously
after sensitivity testing and intramuscular tetanus toxoid. Both received
injectable ampicillin, gentamycin and metronidazole. Fresh frozen plasma
and vit K were also administered. Leg elevation with glycerin-magnesium
sulphate dressing over the affected leg was done. 24 hours after administration
of ASV and FFP, clotting time and PT normalized in first patient and in
4 days in the second patient. Bleeding from gums stopped within a day in
second patient.
Second patient developed blisters and cellulitis upto mid-leg on the second
day of admission. In addition to GMS dressings and antibiotics local mupirocin
was applied and the cellulitis decreased on 5th day of admission. The same
day there was peeling of skin and on 11th day a large ulcer of 8 x 10 cm
developed on the dorsum of left foot. He was then referred to surgeon for
debridement. |
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| Discussion |
With
urbanization and cutting of forests, snakebite has become
an important preventable public health hazard. It is believed
that in India about 2 million people are bitten by snakes
and about 15000-30000 cases prove fatal.1 Viper bite gives
rise to a picture dominated by haemorrhagic syndrome and
these bites are more common in human beings than other poisonous
snakebites.2 The haematological abnormalities have been attributed
to anticoagulants, procoagulants, fibrinolysins, haemorrhagins
and haemolysins present in the venom of these snakes.3 Both
coagulant and anticoagulant activities have been ascribed
to snake venom.4 The coagulant effect may ensue from thromboplastin
like activity, activation of factor X and V, thrombin like
activity or even activation of prothrombin. The anticoagulant
effect may result from primary fibrinolysis and inhibition
or destruction of one or more coagulation factors.4 The long
persistence of the coagulation defect suggests that fibrinogen
formation by the liver may be depressed.5
Younger patients are at greater risk because of higher concentration of
venom in relation to body volume available for its distribution.1 There
are three important nonspecific early signs of systemic envenomation i.e.
vomiting, hypotension and polymorphonuclear leucocytosis.1 Most specific
early signs of systemic envenoming may develop within 15 min of the bite
but may be delayed even upto 10 hours.
Apart from general symptoms of snake bite like fright, apprehension, pain,
local swelling, cellulitis, patients present with the following manifestations
of viper bite1:-
| 1. |
Haemorrhagic
bleb at the site of bite |
| 2. |
Uncontrolled
bleeding from the site of bite |
| 3. |
Bleeding
diathesis. Within 2 to 24 hours of bite features
like generalized ecchymosis, purpura and haematomas
appear |
| 4. |
Features
suggestive of Schwartzman like phenomenon, painful
large ecchymosis and purpura, gangrene of lips, tip
of nose, fingers and toes |
| 5. |
Frank
or microscopic haematuria |
| 6. |
Haemoptysis |
| 7. |
Gingival
bleeding |
| 8. |
Haematemesis
and melaena |
| 9. |
Cerebral
haemorrhage |
| 10 |
Acute
renal shutdown |
| 11. |
Shock
and evidence of hepatocellular damage |
| 12. |
Gangrene
of the part bitten by the snake |
Non-clotting of blood is a simple and extremely sensitive bedside test
of systemic envenoming. The bleeding and clotting abnormalities are due
to thrombocytopenia, hypofibrinogenaemia with secondary deficiencies of
factors V and VIII. FDP concentration in blood and urine is increased.
In the cases reported here, both patients showed evidence of haematological
abnormalities i.e. haematuria, bleeding gums. Clotting time and PT were
prolonged in both patients. Both had evidence of cellulitis. Prompt treatment
with ASV, FFP and antibiotics was lifesaving in these patients. |
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| References |
| 1. |
Mishra
NP, Mishra SC. Snake bite quarterly Medical review.
1982; 33 (4) : 1-40. |
| 2. |
Bhat
RN. Viperine snake bite poisoning in Jammu. Journal
of the Indian Medical Association 1974; 63 (12) : 383-92. |
| 3. |
Harvey
J Weiss, Louse I Phillips, William S Hopewell, et al.
Heparin therapy in a patient bitten by a saw scaled
viper (Echis Carinatus), a snake whose venom activates
prothrombin. The American Journal of Medicine 1973;
54 : 653-62. |
| 4. |
Saini
RK, Arya RK. Coagulation defects in snakebite poisoning.
JAPI 1985; 33 (2) : 148-51. |
| 5. |
Harvey
J Weiss, Louse I Phillips, William S Hopewell, et al.
Heparin therapy in a patient bitten by a saw scaled
viper (Echis Carinatus), a snake whose venom activates
prothrombin. The American J Medicine 1973; 54 : 653-62. |
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