Sciresol Sciresol https://ijpccr.com/# International Journal of Preclinical & Clinical Research 2583-0104 10.51131/IJPCCR/v3i4.22.46 Case report Intracranial Haemorrhage — A Life Threatening Consequence of Venom Induced Consumption Coagulopathy in Snake Bite: A Rare Case Report Prasad Nirnay M 1 Kauser Md Murtuza 1 Kumar S R Vagesh drvagsr@gmail.com 1 Prashanth G 1 Department of General Medicine, Basaveshwara Medical College and Hospital Chitradurga, Karnataka India 3 4 97 2022 Abstract

Snake bite envenomation is an acute life-threatening medical emergency. India which is called as the land of snake charmers has an incidence of 1.2 million deaths due to snake bite from 2009 to 2019 with an average mortality of 58,000 1. Ophitoxaemia rarely results in neurological conditions such as an Intracerebral Hemorrhage (ICH) which occurs with venom induced consumptive coagulopathy. We discuss the case report of a 52-year-old man with H/O an unknown snake bite who developed Acute Subarachnoid Hemorrhage (SAH) and multiple micro hemorrhages in B/L cerebral hemispheres.

Keywords Intracranial haemorrhage Snake bite Venom induced coagulopathy None <bold id="strong-2af6b909b68a42979c7aaafe0ba579e9">Case Report</bold>

A 52-year-old male patient presented to the emergency with an A/H/O unknown snake bite on his left foot at around 2:30pm near his house.

The patient was brought to the emergency after 7 hours post the bite. He was conscious, oriented and communicative. There were signs of local envenomation such as tenderness, swelling at the bite site up until the ankle. The patient was able to move all 4 limbs and pupils were BERL.

ON examination of vitals, the patient had SBP of 76mmHg, DBP was not recordable, pulse rate of 130bpm with SpO2 of 96% @RA. The patient was immediately given bolus of 2-pint IV Fluids post which the patient’s BP was 100/60mmHg. After an abnormal 20-minute whole blood clotting test, Anti Snake Venom (ASV) 100ml and supportive treatment was initiated as per standard protocol.

Blood investigations revealed thrombocytopenia with elevated Prothrombin Time/ International Normalized Ratio (PT/INR). Elevated levels of total and indirect bilirubin along with raised Lactate dehydrogenase levels were suggestive of hemolytic anemia. The patient had deranged serum creatinine levels indicative of AKI along with elevated CPK total. ECG showed T wave inversions in V3,V4,V5,V6, II leads and Highly sensitive Troponin T test showed elevated values.

Evaluation parameters

Test Name

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BIOCHEMISTRY

RENAL FUNCTION TEST 1

      SERUM URIC ACID

5.7

-

-

-

-

-

-

-

-

-

32

2.4

-

      BLOOD UREA

40

54

69

80

68

39

-

-

40

-

32

23

25

      SERUM CREATININE

1.5

2.2

2.6

2.2

1.7

1.2

-

-

0.7

-

2.2

0.6

0.7

CBC

      HB (HEMOGLOBIN)

-

10.0

-

7.2

9.0

9.0

8.9

9.5

10.1

-

9.4

-

9.0

      PLATELET COUNT

-

1.15

-

1.3

1.03

1.08

1.08

2.04

2.95

-

3.88

-

7.34

      TC (WBC COUNT)

-

28610

-

17230

17,400

13200

13,800

15,290

31,820

-

28,030

-

10700

PT INR (PROTHROBIN TIME)

      P. Time

-

25.7

-

14.0

12.5

-

-

-

-

-

-

-

-

      Control

-

11.3

-

13.5

12.5

-

-

-

-

-

-

-

-

      INR

-

2.27

-

1.2

1.0

-

-

-

-

-

-

-

-
Acute Subarachnoid Hemorrhage (SAH) Micro Hemorrhages Multiple Intraventricular

Intravenous mannitol along with Antiepileptic Drug (AED) was immediately administered to the patient and neurosurgery consultation was sought, who advised for conservative management. Meanwhile, the edema from the left foot had extended all the way to the mid-thigh and an emergency surgery consultation was sought who opined it was left lower limb cellulitis with compartment syndrome and advised for an emergency fasciotomy to be done.

The Emergency fasciotomy under local anesthesia was carried out and the patient was transfused with 1 pint Packed Red Blood Cells (PRBC) and fresh frozen plasma (FFP).

Necessary dressing and IV antibiotics were given over the next couple of days and the patient’s condition improved steadily post which he was discharged.

Discussion

Snake bite envenomation resulting in neurological complications such as intracerebral hemorrhage (ICH) and infarcts are rare and more often than not they are infrequently documented.

The most common coagulopathy associated with snake-bite envenoming is Venom Induced Consumptive Coagulopathy (VICC) 2. The other etiopathogenesis include endothelial damage, immune-mediated vasculitis and systemic hypotension 3.

The delayed appearance for Intracerebral Hemorrhage (ICH) must be because of delayed seepage of venom from deeper reservoirs in the bite site or due to disassembly of antigen antibody complex resulting in circulation of the now unbound venom constituents. This probably could be the reason for the delayed appearance of Intracerebral Hemorrhage (ICH) as quoted by Kularatne SAM et al., 4 and Kumar N et al., 5.

Only 1% of the patients with coagulopathy in snake bite develop Intracerebral Hemorrhage (ICH) 6.

 Conclusion

Intracerebral Hemorrhage (ICH) due to ophitoxaemia is a potentially fatal complication and from treatment with Anti Snake Venom (ASV), timely surgery if indicated and supportive treatment with Fresh Frozen Plasma (FFP) and blood products can improve patient’s outcome.

 References Study estimates more than one million Indians died from snakebite envenoming over past two decades 2020 https://www.who.int/news/item/10-07-2020-study-estimates-more-than-one-million-indians-died-from-snakebite-envenoming-over-past-two-decades Menon G Kongwad L I Nair R P Gowda A N Spontaneous Intracerebral Bleed Post Snake Envenomation J Clin Diagn Res 2017 11 4 3 4 2249-782X JCDR Research and Publications https://doi.org/10.7860%2FJCDR%2F2017%2F25095.9517 Chaudhary S C Sawlani K K Malhotra H S Singh J Snake bite-induced leucoencephalopathy BMJ Case Reports 2013 2013 bcr2012007515 1757-790X BMJ https://doi.org/10.1136%2Fbcr-2012-007515 Kularatne S A M Sivansuthan S Medagedara S C Maduwage K Silva A De Revisiting saw-scaled viper (Echis carinatus) bites in the Jaffna Peninsula of Sri Lanka: distribution, epidemiology and clinical manifestations Transactions of the Royal Society of Tropical Medicine and Hygiene 2011 105 10 591 597 0035-9203 Oxford University Press (OUP) https://doi.org/10.1016/j.trstmh.2011.07.010 Kumar N Mukherjee S Patel M P Shah K B Kumar S A case of saw scale viper snake bite presenting as intraparenchymal haemorrhage: case report Int J Health Sci Res 2014 4 10 333 340 https://www.ijhsr.org/IJHSR_Vol.4_Issue.10_Oct2014/47.pdf Berling Ingrid Brown Simon G A Miteff Ferdi Levi Christopher Isbister Geoffrey K Intracranial haemorrhages associated with venom induced consumption coagulopathy in Australian snakebites (ASP-21) Toxicon 2015 102 8 13 0041-0101 Elsevier BV https://doi.org/10.1016/j.toxicon.2015.05.012