Journal of Medical Society

CASE REPORT
Year
: 2015  |  Volume : 29  |  Issue : 1  |  Page : 51--53

Multiple infarctions involving cerebral and cerebellar hemispheres following viper bite


Rajesh M Kumar1, Ramesh P Babu1, Amit Agrawal2,  
1 Department of Medicine, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India
2 Department of Neurosurgery, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India

Correspondence Address:
Dr. Rajesh M Kumar
Department of Medicine, Narayana Medical College Hospital, Nellore - 524 003, Andhra Pradesh
India

Abstract

The Russell«SQ»s viper is one of the most dangerous and commonly encountered vasculotoxic poisonous snakes in India that is responsible for most snakebite mortalities. Usually hemorrhagic stroke is the sequel of viper bite; however, ischemic stroke is increasingly recognized and reported in the literature. In rural areas, there is a need to keep the possibility of cerebral infarction as one of the differential diagnoses of neurological deterioration following Russell«SQ»s viper«SQ»s bite, as early identification of neurological complications can lead to a more effective treatment. In the present article, we discuss a case of a young male who was presented with both supra- and infratentorial infarcts.



How to cite this article:
Kumar RM, Babu RP, Agrawal A. Multiple infarctions involving cerebral and cerebellar hemispheres following viper bite.J Med Soc 2015;29:51-53


How to cite this URL:
Kumar RM, Babu RP, Agrawal A. Multiple infarctions involving cerebral and cerebellar hemispheres following viper bite. J Med Soc [serial online] 2015 [cited 2019 Dec 13 ];29:51-53
Available from: http://www.jmedsoc.org/text.asp?2015/29/1/51/158938


Full Text

 INTRODUCTION



The Russell's viper is one of the most dangerous and commonly encountered vasculotoxic poisonous snakes in India, and it is responsible for most snakebite mortalities. [1],[2],[3],[4],[5] Usually, hemorrhagic stroke is the sequel of viper bite; however, ischemic stroke is increasingly recognized and reported in the literature. [3],[5],[6],[7],[8],[9],[10],[11],[12],[13] In the present article, we discuss a case of a young male who was presented with both supra- and infratentorial infarcts.

 Case Report



A 32-year-old man was admitted to our Emergency Department for snakebite (around half an hour after the bite) on his left foot, which he sustained in the fields. The onlookers identified the snake as Russell's viper. He received primary treatment at an outside hospital. At the time of bite, he complained of severe pain and when he was received in the emergency, he was in altered sensorium, irritable and restless. Local examination showed two deep fang marks with associated erythema and edema. There was bleeding from the mouth. His pulse rate was 146 beats per minute. Respiratory rate was 28 per minute. Blood pressure was 100/60 mmHg; SpO 2 was 98% at 4 L/min oxygen. Neurologically, he was in altered sensorium (Glasgow coma scale - E1V2M5). Pupils were bilaterally equal and reacting to light. In view of the poor Glasgow coma scale, the patient was immediately intubated. After stabilizing the vitals, he was shifted for CT scan, following which he was kept on elective ventilation in intensive care unit. Blood investigations at the time of admission revealed hemoglobin, 13.9 g/dL, normal urea and creatinine levels (CPK) 10,045 IU/L (<200 IU/mL) and urine myoglobin >700 ng/ml (<40 ng/ml). Prothrombin time was 15.7 s (range, 11-16 s; control, 13.4 s), INR was 1.19 and APTT was 13.4 (control,13.2); bleeding and clotting time were in normal range. Carotid and vertebral Doppler were normal. Echocardiography was normal. After the test dose, the patient received 10 vials of anti-snake venom (ASV) followed by seven vials three times a day for a period of five days. In view of oral bleeding, he received fresh frozen plasma (FFP). CT scan on the day of admission was apparently normal [Figure 1]. Supportive measures, including injection tetanus toxoid and prophylactic antibiotics were also given. However, he did not make any significant improvement and on day 4 after admission, he underwent MRI brain that showed multiple infarcts involving right temporal, occipital and left cerebellar hemispheres [Figure 2]. He was continued on elective ventilation and on 10 th day tracheotomy was performed. He could be weaned off from ventilator; however, he did not improve significantly in his neurological status. At the time of discharge, the patient was opening eyes spontaneously and obeying commands, but weakness of all the four limbs was persistent.{Figure 1}{Figure 2}

 DISCUSSION



The viper venom comprises a mixture of numerous enzymes with opposing effects, some of the enzymes causes hypofibrinogenemia, hypoprothrombinemia, thrombocytopenia and fibrinolysis; few are potent proteases (e.g., arginine esterase hydrolase) acting as activators of clotting factors X and V, thereby promoting coagulation. [14] In addition to these, few enzymes (i.e., hyaluronidase) cause damage to the connective tissues, leading to enhanced toxin dissemination. [3] Following snakebite, complex interactions of these enzymes usually lead to consumption coagulopathy, coagulation failure and intracranial hemorrhage. [2],[3],[15],[16],[17] Apart from the local manifestations such as pain, edema, bleeding and necrosis, there may be systemic features, including hypotension, shock, acute renal failure, weakness, dizziness and nausea. [5],[18],[19],[20] Most common neurological complications include drowsiness, confusion, fainting, dizziness, blurred vision, loss of muscle coordination and convulsions. [5],[18],[19],[20] Recently, ischemic infarction following viper bite is increasingly reported and various mechanisms for ischemic infarction have been proposed. [3],[4],[5],[7],[13],[15],[20],[21],[22] The possible explanations for cerebral infarction can be vessel wall-damaging toxin in the venom leading to thrombosis, microthrombi formation as a sequel to low-grade dissemination of intravascular coagulopathy, and hypotension leading to ischemia and infarction. [4],[5],[8],[13],[15],[23] The basic principles of management are adequate hydration, control of blood pressure and central venous pressure, and management of local infection with appropriate antibiotics and dressings. [6] In spite of the normal coagulation profile, the patient had clinical evidence of bleeding (oral bleeding). There are reports from Indian subcontinent that FFP or cryoprecipitate can be recommended when there is clinical bleeding despite giving antivenin therapy; [24] however, there are no well-designed studies to support this assumption and a need for trials to demonstrate effectiveness of transfusion therapy in the setting of clinical bleeding despite giving antivenin therapy has been recommended. [25] It has been reported that with immediate ASV treatment, the outcome is better; [5],[7],[26],[27] however, there are reports of development of cerebral infarct despite early treatment with ASV (even within 1 hour of envenomation). [5] In spite of the aggressive management, outcome of patients of snakebite presenting with features of infarction remain poor, more so when the posterior circulation is involved. [6]

 CONCLUSION



In summary, snakebites are common particularly in rural areas and there is a need to keep the possibility of cerebral infarction as one of the differential diagnosis of neurological deterioration following Russell's viper's bite, as early identification of neurological complications can lead to a more effective treatment.

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