Clinico-epidemiology of Hypnale zara (hump-nosed pit viper) envenoming in Sri Lanka

Snakebite-associated acute kidney injury in South Asia: narrative review on epidemiology, pathogenesis and management

Snakebite-associated acute kidney injury (AKI) poses a significant health burden in the South Asia region, resulting in considerable morbidity and mortality. Multiple factors contribute to the pathogenesis of AKI following snakebites, including hypotension, intravascular haemolysis, disseminated intravascular coagulation, rhabdomyolysis, thrombotic microangiopathy (TMA) and direct nephrotoxicity. Clinical features manifest as anuria, oliguria, haematuria, abdominal pain and hypertension. Diagnosis is supported by elevated serum creatinine levels and urine output monitoring. Renal histology studies revealed a spectrum of lesions, including acute tubular necrosis, renal cortical necrosis, glomerulonephritis and TMA. Management strategies centre around timely administration of antivenom, fluid and electrolyte balance and dialysis to improve renal outcomes. While dialysis has demonstrated efficacy in reducing AKI-related mortality rates, the use of fresh frozen plasma and therapeutic plasma exchange may be the subject of some controversy. Understanding the pathophysiological link between coagulopathy, TMA and AKI is important for tailoring effective treatment approaches. Species-specific randomized controlled trials are imperative to evaluate targeted interventions. In tackling the complexities of snakebite-associated AKI and chronic kidney disease, a multidisciplinary approach integrating clinical management with rigorous research efforts is essential. This collaborative endeavour aims to confront the challenges posed by these conditions and improve patient outcomes in the affected regions.

Clinical characteristics, management, diagnostic findings, and various etiologies of patients with Kounis syndrome. A systematic review

BACKGROUND

Kounis syndrome (KS) is defined by the association of acute coronary syndrome secondary to an anaphylactic reaction. KS is often underdiagnosed, and new etiologies have been proposed.

AIMS

To synthesize the available evidence on clinical profile, management, diagnosis, and etiologies in patients with KS.

METHODS

A search was conducted in the following databases: PubMed, Scopus, EMBASE and Web of Science from inception to March 19th, 2024. Case reports, case series, and observational studies were included. Letters to the editor, editorials, comments, notes, narrative reviews, and systematic reviews were excluded.

RESULTS

A total of 190 studies were included (174 case reports, 13 case series, and 3 observational studies, 214 patients). A predominance of male gender was observed (69.63 %). Mean age was 54.4 ± 16.5 years. The most common comorbidities were hypertension (33.64 %), diabetes (16.82 %), and dyslipidemia (16.35 %). The most frequent clinical manifestations were chest pain (66.35 %) and difficulty breathing (34.11 %). Three variants of KS were identified: type I or allergic coronary vasospasm was the most frequent (43.46 %), and type III, the least common (8.88 %). The most frequent etiology was drug use (38.32 %), primarily antibiotics (42.68 %), followed by animal stings or bites (26.17 %). The calculated KS rate was 11.12 per 1000 people. The mortality rate was 7.47 %, and the majority had a favorable outcome (86.92 %) after management.

CONCLUSIONS

KS is a complex and underdiagnosed disease that should be considered as a differential diagnosis in acute coronary syndrome associated with an allergic reaction.

Protobothrops jerdonii (Jerdon's pit viper) and Protobothrops himalayanus (Himalayan lance-headed pit viper) bites: Clinical report on envenomings from North-East India, managed through remote consultation by a national-level Poison control center

Members of the genus Protobothrops are amongst the more than twenty-eight range-restricted Indian pit viper species. Their bites and envenomings are rarely documented from India. Pit viper envenomings can be challenging to treat in the Indian setting, since available antivenoms do not satisfactorily neutralize their venoms. Herein, we present the first Indian reports on bites and envenoming by Protobothrops jerdonii and Protobothrops himalayanus resulting in local effects, coagulopathy and acute kidney injury in the case of the former and possible mild, isolated coagulopathy in the case of the latter; and discuss management-related challenges in the context of absent specific antivenoms.

Hump-Nosed Viper Bite-Associated Thrombotic Thrombocytopenic Purpura: A Rare Complication

Thrombotic thrombocytopenic purpura (TTP) is one of the rarely encountered complications of hump-nosed viper bites, which requires early detection and specific management. Hump-nosed viper bites are well known to affect multiple systems, and it is imperative to identify and manage each complication simultaneously. A 48-year-old patient presented to the hospital following a hump-nosed viper bite, where he subsequently developed local necrosis, acute kidney injury (AKI), and TTP. A diagnosis of TTP was made using the PLASMIC score (which refers to the score's seven components: platelet count; combined hemolysis variable; absence of active cancer; absence of stem-cell or solid organ transplant; mean corpuscular volume (MCV); international normalized ratio (INR); and creatinine) and supporting blood picture findings despite the diagnostic difficulties encountered due to the misleadingly normal automated platelet counts. The patient underwent multiple blood transfusions, 12 cycles of hemodialysis, and two cycles of therapeutic plasma exchange, the latter contributing to a significant improvement in his overall clinical and biochemical markers. In this case presentation, we report a rare case of TTP occurring after a hump-nosed viper bite, with the outcome of the report focusing on the diagnostic difficulties and available therapeutic modalities.

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.

A case report of Ovophis monitcola (Mountain pit-viper) envenoming in northeastern India resulting in prolonged coagulopathy

India is home to a diverse spectrum of medically-significant snakes accounting for the world's largest burden of envenoming, morbidity and mortality. Indian polyspecific antivenom is derived from the venom of four snake species (Daboia russelii, Echis carinatus, Naja naja and Bungarus caeruleus), considered to be responsible for the majority of snakebite morbidity and mortality. The treatment of venomous bites from other less-commonly encountered venomous snake species can be challenging. In this report, we describe the case of a 32-year-old male who presented with features of local cytotoxicity and coagulopathy following a bite from Ovophis monitcola (mountain pit-viper) in Nagaland, northeast India. Local and systemic envenoming, confirmed by bedside and laboratory based clotting assays, failed to respond to polyspecific antivenom and venom-induced consumption coagulopathy persisted for 28 days. Remote consultation with a national Poison Control Centre helped establish the responsible snake species and guide appropriate medical management.

Clinical aspects of snakebite envenoming and its treatment in low-resource settings

There is increasing recognition of the public health importance of snakebite envenoming. Worldwide annual incidence is likely to be 5 million bites, with mortality exceeding 150 000 deaths, and the resulting physical and psychological morbidity leads to substantial social and economic repercussions. Prevention through community education by trained health workers is the most effective and economically viable strategy for reducing risk of bites and envenoming. Clinical challenges to effective treatment are most substantial in rural areas of low-resource settings, where snakebites are most common. Classic skills of history taking, physical examination, and use of affordable point-of-care tests should be followed by monitoring of evolving local and systemic envenoming. Despite the profusion of new ideas for interventions, hyperimmune equine or ovine plasma-derived antivenoms remain the only specific treatment for snakebite envenoming. The enormous interspecies and intraspecies complexity and diversity of snake venoms, revealed by modern venomics, demands a radical redesign of many current antivenoms.

Epidemiological and clinical features of hump-nosed pit viper (Hypnale hypnale and Hypnale zara) envenoming in children

BACKGROUND

Bites by the hump-nosed pit vipers (HNPV) of the genus Hypnale are the commonest type of venomous snakebites in Sri Lanka. Their bites frequently cause local effects while rarely causing systemic envenoming, that may include acute kidney injury and coagulopathy. There are 3 species of genus Hypnale including H. hypnale, H. zara and H. nepa from which latter two are endemic to Sri Lanka. Virtually all studies on HNPV bites in Sri Lanka are focused on adults except two studies in paediatric group. The aims of this study were to describe the epidemiology and clinical manifestations of HNPV bites in a group of children admitted to a tertiary care hospital in Sri Lanka.

METHODOLOGY/PRINCIPAL FINDINGS

This was a prospective observational study carried out in Teaching Hospital Ratnapura, Sri Lanka over 27 months commencing from May 2020 including all children aged up to 14 years with the history of HNPV bites. There were 40 (56%) HNPV bites, of them 28 (70%) were males. The age was 84 months (50.2-120 months). Majority (n = 21;52.5%) were bitten during day-time (06:00-17:59) in home gardens (n = 20; 50%) on lower limbs (n = 24;60%). Most children (n = 30;75%) were admitted to the medical facility < 4 hours after the snakebite [90 min (40-210 min)] and the hospital stay was 4 days (3-5 days). Local envenoming was observed in 38 patients (95%) and systemic effects developed in 4 patients (10%) as mild coagulopathy. Local effects include local pain (n = 30; 94%), swelling (n = 38;95%), blistering (n = 11;27.5%), necrosis at the site of bite (n = 11; 27.5%), regional lymph node enlargement (n = 8;20%) and local bleeding (n = 4;10%). For the local effects, surgical interventions were needed in 10 children (25%) and 3 (7.5%) of them developed acute compartment syndrome leading to fasciotomy. Leucocytosis (n = 28;78%) and eosinophilia (n = 9;27%) were the prominent laboratory findings. All got recovered except in patients with fasciotomy who got permanent scar.

CONCLUSIONS/SIGNIFICANCE

Hump-nosed pit viper bites mostly cause local effects and rarely systemic envenoming in children. Compartment syndrome is common in children following their bites.

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

Background

Hump-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 presentation

A 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.

Conclusions

Physicians should be aware that ischemic cerebral infarcts may occur following hump-nosed pit viper bites.

Clinico-epidemiology and management of hump-nosed pit viper (Hypnale spp.) bites in dogs

Human envenoming from the bite of the abundant hump-nosed pit viper (Hypnale spp.) (HNPV) is a frequent occurrence with victims experiencing unpleasant and sometimes life-threatening consequences. Further, clinico-pathology, treatment and management measures in HNPV envenomed dogs are under recognized. Prospective investigations were performed to assess the clinico-pathology and management options for HNPV envenomed dogs brought to the University of Peradeniya's Veterinary Teaching Hospital from January, 2012 to March 2018. We recorded the local and systemic manifestations, hematological and urinary abnormalities of 78 dogs in which HNPV bite had been witnessed by the owner. Mild swelling, extensive swelling, hemorrhagic blistering and hemorrhagic bullae at the site of bite were observed in 59%, 31%, 6% and 4% of the dogs, respectively. Some dogs were subjected to surgical excision of necrotized tissue including limb amputation. We observed the following systemic clinical effects in envenomed dogs: neurotoxicity (13%), acute kidney injury (AKI) (14%) and coagulopathy (16%). All dogs showed leukocytosis with mean white blood cell count of 25.25 × 103/µL. Mild anemia and thrombocytopenia were detected in 29% of the dogs. There was a significant correlation between extent of local tissue injuries with length of hospitalization (LH). The mean time of coagulopathy observed was 21.3 h (IQR: 8-48 h). In coagulopathic dogs, there was a strong correlation between LH and extent of local tissue injury (rs = 0.7751, P < 0.0001); LH and whole blood clotting time(CT) (rs = 1.0, P < 0.0001); PT and aPTT (rs = 0.4712, P < 0.001). LH was significantly correlated with the development of AKI (p = 0.0013). Lack of specific antivenom (AVS) for HNPV envenoming provided an opportunity to study the remaining treatment options. Therefore, the study allowed the identification of local and systemic effects, hematological abnormalities, possible supportive treatments and drawbacks of management measures for envenomed dogs.