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Das DS, Mohapatra RK, Mohanty RR, Patel RK. Acute ischaemic stroke and deep vein thrombosis following snakebite. BMJ Case Rep 2024; 17:e259071. [PMID: 38719248 PMCID: PMC11085697 DOI: 10.1136/bcr-2023-259071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024] Open
Abstract
Snakebite envenomation remains a neglected tropical public health issue claiming thousands of lives every year. It is a common medical emergency and a threat to the impoverished populations of low-income and middle-income countries including India. A combination of ischaemic stroke and deep vein thrombosis is a devastating duo complication of snake bite, with no literature report to date. Here, the authors report an unusual case of a young woman developing ischaemic stroke and deep vein thrombosis following snakebite even after the use of antivenom. MRI brain showed right thalamic infarct with haemorrhagic transformation and, ultrasound Doppler revealed right lower limb deep vein thrombosis. The pathophysiology of deep vein thrombosis and ischaemic stroke is complex. It is believed that the activation of the coagulation cascade, complement system together with endothelial injury and immune activation leads to inflammation, thrombosis and occlusion of smaller and even larger vessels.
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Affiliation(s)
- Dhriti Sundar Das
- General Medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
| | - Rakesh Kumar Mohapatra
- General Medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
| | - Rashmi Ranjan Mohanty
- General Medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
| | - Ranjan Kumar Patel
- Radiodiagnosis, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
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Sun I, Lee ST, Chen YG, Mao YC, Chen FC, Chen YH, Tsai SH, Ho CH. Thromboembolic events following a pit viper bite from Protobothrops mucrosquamatus (Taiwan Habu): A report of two cases. Toxicon 2024; 238:107572. [PMID: 38145881 DOI: 10.1016/j.toxicon.2023.107572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/01/2023] [Accepted: 12/17/2023] [Indexed: 12/27/2023]
Abstract
Protobothrops mucrosquamatus, also known as the Taiwan Habu, is a venomous snake prevalent in Taiwan. It is accountable for most snakebites in the region. The toxin of the Taiwan Habu has significant hemorrhagic potential. However, patients bitten by this snake often suffer more local injuries than systemic ones. This report presents two cases of individuals bitten by the Taiwan Habu who subsequently experienced thromboembolism. In the first case, an 88-year-old male, bitten on his fourth toe, suffered a cerebral infarction 32 hours post-bite. In the second case, an 82-year-old female, bitten on her ankle, experienced cardiac arrest 19 hours later. Both patients promptly received antivenom and showed no signs of coagulopathy either before or after the snakebite. However, elevated coagulation factor VIII levels were observed in the first case. Our aim is to understand the mechanism behind these thromboembolic events. This report emphasizes the unusually high level of coagulation factor VIIIa and highlights the need for further investigation into the mechanisms involved. Consequently, physicians should assess the risk of thromboembolic events in snakebite patients by evaluating coagulation factors during treatment.
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Affiliation(s)
- I Sun
- Department of Emergency Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung City, 80284, Taiwan; Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan
| | - Siou-Ting Lee
- Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan; Department of Obstetrics and Gynecology, Taoyuan Armed Forces General Hospital, Taoyuan City, 32551, Taiwan
| | - Yu-Guang Chen
- The Division of Hematology and Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan
| | - Yan-Chiao Mao
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung City, 40705, Taiwan
| | - Feng-Chen Chen
- Department of Emergency Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung City, 80284, Taiwan; Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan
| | - Yen-Hsiu Chen
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan
| | - Cheng-Hsuan Ho
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan; Institute of Toxicology, College of Medicine, National Taiwan University, Taipei City, 100233, Taiwan.
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Cerebral Complications of Snakebite Envenoming: Case Studies. Toxins (Basel) 2022; 14:toxins14070436. [PMID: 35878174 PMCID: PMC9320586 DOI: 10.3390/toxins14070436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 02/01/2023] Open
Abstract
There are an estimated 5.4 million snakebite cases every year. People with snakebite envenoming suffer from severe complications, or even death. Although some review articles cover several topics of snakebite envenoming, a review of the cases regarding cerebral complications, especially rare syndromes, is lacking. Here, we overview 35 cases of snakebite by front-fanged snakes, including Bothrops, Daboia, Cerastes, Deinagkistrodon, Trimeresurus, and Crotalus in the Viperidae family; Bungarus and Naja in the Elapidae family, and Homoroselaps (rare cases) in the Lamprophiidae family. We also review three rare cases of snakebite by rear-fanged snakes, including Oxybelis and Leptodeira in the Colubridae family. In the cases of viper bites, most patients (17/24) were diagnosed with ischemic stroke and intracranial hemorrhage, leading to six deaths. We then discuss the potential underlying molecular mechanisms that cause these complications. In cases of elapid bites, neural, cardiac, and ophthalmic disorders are the main complications. Due to the small amount of venom injection and the inability to deep bite, all the rear-fanged snakebites did not develop any severe complications. To date, antivenom (AV) is the most effective therapy for snakebite envenoming. In the six cases of viper and elapid bites that did not receive AV, three cases (two by viper and one by elapid) resulted in death. This indicates that AV treatment is the key to survival after a venomous snakebite. Lastly, we also discuss several studies of therapeutic agents against snakebite-envenoming-induced complications, which could be potential adjuvants along with AV treatment. This article organizes the diagnosis of hemotoxic and neurotoxic envenoming, which may help ER doctors determine the treatment for unidentified snakebite.
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Zeng X, Hu J, Liang X, Wu Y, Yan M, Zhu M, Fu Y. Acute cerebral infarction following a Trimeresurus stejnegeri snakebite: A case report. Medicine (Baltimore) 2019; 98:e15684. [PMID: 31169670 PMCID: PMC6571248 DOI: 10.1097/md.0000000000015684] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Acute cerebral infarction after snake bites is rare. The underlying mechanism causing the thrombotic process remains complex and unknown. PATIENT CONCERNS We herein describe a 49-year-old female who was bitten by a Trimeresurus stejnegeri. After 4 days of biting, she developed acute ischemic infarct. DIAGNOSIS The patient exhibited right side weakness and speech disturbances. Brain computed tomography (CT) scan showed no sign about cerebral hemorrhage symptoms, and brain magnetic resonance imaging (MRI) showed acute ischemic infarct in the left territory. The patient confirmed a diagnosis of acute cerebral infarction following a T. stejnegeri bite. INTERVENTIONS The patient received an injection of polyvalent anti-snake venom serum, neuroprotective therapy, and anti-platelet aggregate treatment. OUTCOMES At the 3-month follow-up visit, the patient's left lower extremity swelling disappeared, the right limb muscle strength recovered, and the modified Rankin scale (mRS) score was 4 points. LESSONS The patient was diagnosed with acute ischemic infarct interrelated to snake bite; further investigations were needed to ascertain mechanism. The clinicians should pay more attention to identify potential victims of neurologic complications, to reduce the mortality rate of snake bite.
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Abraham A K, John L. Hemotoxic Snakebite Presenting with Bilateral Blindness Due to Ischemic Occipital Infarcts. Indian J Crit Care Med 2019; 23:99-101. [PMID: 31086455 PMCID: PMC6487605 DOI: 10.5005/jp-journals-10071-23125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cerebrovascular complications are rare following a Viperidae snake envenomation, let alone ischemic ones. This catastrophic hemorrhaging cascade is widely known to cause a wide array of manifestations. Its manifestations can range from skin bleeds to fatal intracranial or organ hemorrhages. Our patient had cortical blindness secondary to an ischemic occipital infarct following a hemotoxic snakebite - a seemingly distinct oxymoron. The physician should be mindful of the fact that a hemotoxic snakebite can deceptively bring in ischemic attacks as well. Toxic vasculitis, thrombotic angiopathies, widespread vasospasm and endothelial damage are believed to shoulder a part of the disease process that can bring about tissue ischemia. Key Messages Hemotoxic snake envenomation can have devastating effects. Apart from dealing with the threat of coagulopathy, the physician must also be alert to the ironical ischemic aftermath that can equally bring in misery. Our patient had one such complication-bilateral cortical blindness resulting from bilateral occipital ischemic infarcts. The physician must be aware that a hemotoxic snakebite can even instigate ischemic dilemmas, i.e. cerebrovascular infarcts, as well. How to cite this article Kodiatte Abraham A, Livingston J. Hemotoxic Snakebite Presenting with Bilateral Blindness Due to Ischemic Occipital Infarcts. Indian J of Crit Care Med 2019;23(2): 99-101.
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Affiliation(s)
- Kodiatte Abraham A
- Department of Medicine, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Livingston John
- Department of Cardiology, Christian Medical College and Hospital, Ludhiana, Punjab, India
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Al-Sadawi M, Mohamadpour M, Zhyvotovska A, Ahmad T, Schechter J, Soliman Y, McFarlane SI. Cerebrovascular Accident and Snake Envenomation: A Scoping Study. INTERNATIONAL JOURNAL OF CLINICAL RESEARCH & TRIALS 2019; 4:133. [PMID: 31528777 PMCID: PMC6746409 DOI: 10.15344/2456-8007/2019/133] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Snake envenomation is associated with serious complications including infections, bleeding and, in rare occasions, thrombosis. Previous work by our group examined the association of snakebite and acute myocardial infarction. In this systematic review we aim to assess the clinical characteristics and outcomes of acute cerebrovascular accidents that are reported to be extremely rare complications of snake envenomation. METHODS We performed a literature search for reports on stroke associated with snake envenomation between Jan 1995 to Oct 2018, and summarized their characteristics. RESULTS Eighty-three published cases were reviewed. 66.3% of the cases were younger than 50 years of age. The mean time for the onset of the symptoms is 23.8±10.9 hours after exposure. 77.1% of the cases found to have ischemic stroke, 20.5% with intra-cranial hemorrhage and both infarction and hemorrhage in 2.4%. Mortality was reported in 16.9% with mean time between onset of the symptoms and death is 4.2 days. CONCLUSION Stroke secondary to snake envenomation is a rare but serious complication. Once stroke is suspected, initiating appropriate management is crucial in reducing morbidity and mortality associated with this potentially fatal complication of snake envenomation.
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Affiliation(s)
- Mohammed Al-Sadawi
- Department of Internal Medicine, Division of Cardiovascular
Disease, State University of New York, Downstate Medical Center, Brooklyn, NY 11203,
USA
| | - Maliheh Mohamadpour
- Department of Internal Medicine, Division of Cardiovascular
Disease, State University of New York, Downstate Medical Center, Brooklyn, NY 11203,
USA
| | - Angelina Zhyvotovska
- Department of Internal Medicine, Division of Cardiovascular
Disease, State University of New York, Downstate Medical Center, Brooklyn, NY 11203,
USA
| | - Tahir Ahmad
- Department of Internal Medicine, Division of Cardiovascular
Disease, State University of New York, Downstate Medical Center, Brooklyn, NY 11203,
USA,Department of Emergency Medicine State University of New
York, Downstate Medical Center, Brooklyn, New York, USA
| | - Joshua Schechter
- Department of Emergency Medicine State University of New
York, Downstate Medical Center, Brooklyn, New York, USA
| | - Yasmin Soliman
- Department of Internal Medicine, Division of Cardiovascular
Disease, State University of New York, Downstate Medical Center, Brooklyn, NY 11203,
USA
| | - Samy I. McFarlane
- Department of Internal Medicine, Division of Cardiovascular
Disease, State University of New York, Downstate Medical Center, Brooklyn, NY 11203,
USA,Corresponding Author: Prof. Samy I.
McFarlane, Divisions of Cardiovascular Disease,and Endocrinology, Department of
Internal Medicine, State University of New York, Downstate Medical Center,
Brooklyn, New York,11203, USA, Tel: 718-270-6707, Fax: 718-270-4488;
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Moutaouakkil Y, el Jaoudi R, Tadlaoui Y, Adouani B, el cadi MA, Serragui S, Cherrah Y, Lamsaouri J, Bousliman Y. Envenimations ophidiennes au Maroc : revue de la littérature. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2018. [DOI: 10.1016/j.toxac.2018.07.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cerebrovascular Injury Following Scorpion Sting and Snake Envenomation: A Case Series. Can J Neurol Sci 2018; 45:669-674. [PMID: 30289088 DOI: 10.1017/cjn.2018.328] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Neurological complications following snake and scorpion bite are diverse. Literature regarding patterns of cerebrovascular injury (CVI) and outcomes among these patients is scarce. This is a descriptive study of the clinical profile, brain imaging findings, mechanisms of injury, vascular territory involvement and outcomes of CVI following scorpion and snake envenomation, in a tertiary care center in South India.MethodologyPatients with scorpion sting- and snake envenomation-related complications were retrospectively enrolled. Neuroimaging was performed on five patients with each envenomation, and they were found to have neurological involvement. On imaging, three patients were found to have a CVI. Clinical, radiological parameters and outcomes of these patients were studied. We also performed a review of the literature and analyzed the finding of all the cases.ResultIn all, three patients each had evidence of CVI in imaging. An additional 32 reports of scorpion sting-related CVI and 35 reports of snake envenomation-related CVI were identified from the literature. There was a male predominance among these patients. Mean age of the patients with scorpion sting was 42.8 years as compared with 33 years for the patients with snake envenomation. Features of severe envenomation were present in all patients. Persistently depressed sensorium and new-onset focal neurological deficits were seen in 70% of all patients. Infarcts were seen in 88% of patients with snake envenomation and 53% of patients with a scorpion sting. Mortality was 28% among patients with a scorpion sting as compared with 8% with snake envenomation. CONCLUSION Cerebrovascular injuries are uncommon neurological manifestations following scorpion and snake envenomation. These tend to occur in younger patients. Infarcts are more common than bleeds.
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A Horned Viper Bite Victim with PRES. Case Rep Neurol Med 2017; 2017:1835796. [PMID: 28487791 PMCID: PMC5402235 DOI: 10.1155/2017/1835796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/23/2017] [Accepted: 03/23/2017] [Indexed: 11/17/2022] Open
Abstract
Neurological complications of snake bites have been well documented in the literature as neuromuscular paralysis and cerebrovascular complications; posterior reversible encephalopathy syndrome was rarely described. A 23-year-old lady presented near full term of her pregnancy with a horned snake Cerastes cerastes bite; after successful delivery she started complaining of altered mental status and visual disturbance with ulceration over the site of the snake bite. On admission, the patient had Glasgow Coma Score of 12, blood pressure 130/80 mmHg, temperature 38°C, sinus tachycardia at 120 beats per minute, severe dehydration, and reduction in visual acuity to "hand motion" in both eyes with poor light projection and sluggish pupillary reactions. CT brain was not conclusive; MRI revealed features of PRES. Treatment was mostly supportive within one week; the patient regained consciousness; visual disturbance, however, persisted. This patient as well as the few previously described cases highlights PRES as a possible complication of snake bites.
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