A 15-year-old Pakistani boy with no significant past medical history presented to The Liaquat University Hospital (LUH) with marked left foot swelling and gingival bleeding. He was bitten on the dorsal surface of his left foot by a Saw-Scaled Viper, commonly known as Lundi Bhala. The attendants gave the main author information about the snake's appearance and size.
At a local hospital, he was given four ampules of Anti-Snake Venom (ASV) diluted in 500ml Normal Saline 0.9%. After receiving treatment, he was referred here.
Upon admission, the patient's vitals were stable with no sign of fever. Their blood pressure was 100/60 mmHg, pulse rate was 100 beats/min, respiratory rate was 22 breaths/min, and spO2 was 99% on room air. Laboratory testing was performed on blood samples, and the results can be found in Table 1. Despite receiving Inj. Transamine IV stat and Inj. Vit K 5mg IV stat, the patient experienced frequent episodes of gingival bleeding. This indicated the possibility of Overt Venom-Induced Consumptive Coagulopathy (VICC)6, which was later confirmed by the whole blood clotting test (20WBCT) > 20 minutes, PT > 40 seconds, aPTT > 50 seconds, Platelets count < 60,000, frequent gum bleeding7 and d-dimer of 10.57mg/L (normal range is upto 5mg/L)8,9,10.
Table 1
Laboratory data of patient over the course of 5 days.
| | Days | Ref. | 1st | 2nd | 3rd | 4th | 5th |
| | Hb (g/dl) | 12–16 | 13.1 | 10 | 4.2 | 3 | 2.2 |
| | MCV (fL) | 76–96 | 76.4 | 74.3 | 72.2 | 70 | 68 |
| | WBC Count ( (103 /µL) | 4–10 | 11.01 | 13.2 | 14.1 | 15.2 | 16.1 |
| CBC Parameters | Band forms (%) | 20–45 | 0 | 0 | 0 | 0 | 0 |
| | Segmented Forms (%) | 40–75 | 85.4% | 80.2% | 83.5% | 84.2% | 83.1% |
| | Platelet Count (103 /µL) | 150–400 | 60 | 35 | 27 | 20 | 18 |
| | ESR | 0–25 | 32 | 37 | 40 | 50 | 55 |
| | Bleeding Time (BT) | 3 min | 2 min | 2 min | 2 min | 2 min | 2 min |
| | Clotting Time (CT) | 11 min | > 11 min | > 11 min | > 11 min | > 11 min | > 11min |
| Coagulation Parameters | PT | 12 sec | 40 sec | 40 sec | 50 sec | 50 sec | 50 sec |
| | APTT | 28 sec | > 50 sec | > 50 sec | > 60 sec | > 60 sec | > 60 sec |
| | Urea (mg/dl) | 15–50 | 20 | 50 | 76 | 148 | 160 |
| Renal Function Tests | Creatinine(mg/dl) | 0.5–0.8 | 0.3 | 1.2 | 1.46 | 4.0 | 4.5 |
| | Total Serum Bilirubin (mg/dl) | 0.1–1 | 0.65 | 1.15 | 2.69 | 4.35 | 5.45 |
| Liver Function Tests | Direct Serum Bilirubin (mg/dl) | < 0.3 | 0.15 | 0.15 | 0.15 | 0.15 | 0.15 |
| | Indirect Serum Bilirubin (mg/dl) | 0.2–0.9 | 0.5 | 1.5 | 2.54 | 4.2 | 5.3 |
Upon examination of the left foot, there was erythema, warmth, non-pitting edema, and limitation of active movement. Small fluid-filled blisters with localized bleeding were present around the fang marks as shown in Fig. 1; Cellulitis was diagnosed. Within 24 hours, the blisters spread distally and progressed into hemorrhagic & venom filled bullae, as shown in Fig. 2. The CBC results showed a total white blood cell count ≥ 11000 cells/mm3 and segmented forms ≥ 80%, indicating progression from Cellulitis to Necrotizing Fasciitis4. There were different types of bullae classified based on appearance, as reported by Lin et al11. A black-colored necrotic bulla was observed, which has not been reported yet in the literature, as shown in Fig. 1.
On day 3, the patient’s condition worsened with frequent episodes of frank hematuria. The Hb dropped from 13.1mg/dl to 4.2mg/dl while Platelet count also dropped from 60x109L to 27x109L, with PT > 60 sec, aPTT > 50 sec and INR > 1.5. Five ampules of Anti-Snake Venom (ASV) diluted in 500ml 0.9% Normal Saline were given promptly. Also, Eight packets of FFPs, eight packets of Cryoprecipitate, two pints of Platelets & PCVs were transfused throughout the day but patient’s condition did not improve.
The patient unfortunately experienced acute renal failure, intravascular hemolysis, and severe thrombocytopenia on the third day, despite receiving the best available treatment. On examination, patient was tachypneic, pale, jaundiced and hemorrhagic bullae were on the left leg extending up to the knee, with generalized edema and erythema. Close monitoring of the patient's vitals showed a blood pressure of 80/60 mmHg, pulse of 120 beats per minute, respiratory rate of 30 breaths per minute, and temperature of 102oC. The laboratory results indicated an elevated white blood cell count (WBC) of 14.1×103 /µL with 83.5% neutrophils and an ESR of 40, leading to the diagnosis of systemic septicemia with a bite wound as the infective foci. The treatment plan was quickly adjusted with the addition of Inj. Augmentin 1.2g IV T.D.S and Inj. Linezolid 600mg IV B.D to ensure a prompt and effective recovery.
On the last day, patient’s biochemical investigations revealed Urea of 160 mg/dl and Creatinine of 4.5mg/dl, prompt hemodialysis was planned after consulting with nephrologists but unfortunately later that day, patient went into gasping and ultimately, brain death took place. Systemic Septicemia leading to multi organ dysfunction (MOD) & unavailability of resources were declared as the cause of death.