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.

Approach to Study the Efficacy and Safety of New Complementary and Alternative Medicine Formulations: Lesson during COVID-19 from Sri Lanka.

COVID-19 affected Sri Lanka from early 2020, a time of considerable ignorance accompanied by wide media coverage of a devastating epidemic in Italy and Europe. Many were attracted to complementary and alternative medicine (CAM) or traditional medicine (TM) in this desperate situation. Several preparations were claimed to be effective against COVID-19 globally. Dammika Bandara Syrup© was one such preparation promoted for preventing and treating SARS-CoV-2 infection. It was based on bees' honey, pericarp and mace of Myristica fragrans (nutmeg), the seed of Foeniculum vulgare and fresh rhizome of Zingiber officinale, all believed to have anti-viral properties. Following an unpublished clinical study claiming efficacy, Dammika Bandara Syrup© gained wide media publicity and political patronage. The producer claimed of Goddess Kali revealing the formula added an anthropological, cultural, and religious complexity to the issue. The demand for the product increased rapidly as a debate raged both in public and in the parliament on utilizing such products in combating COVID-19. The Department of Ayurveda, which is statutorily responsible for regulating CAM/TM had to respond to the situation. The legislation to regulate such indigenous medicinal products was weak, and the crisis deepened as thousands converged to the production facility, defying mobility restrictions introduced to control COVID-19. This led to the Ministry of Health requesting academics to form a team and conduct a clinical trial to prove its efficacy. This paper outlines the process and issues faced during the regulatory approval for the trial in a polarized political environment. Some health professionals accused the researchers of bowing to political pressure and questioned the scientific justification for the trial. However, the team considered this as an opportunity to streamline a path for research into CAM/TM therapies in situations such as COVID-19. Several processes were identified and addressed, such as the provisional registration of CAM preparations, assessing the potential efficacy of a CAM product, confirmation of authenticity and safety, standardization and supervision of production respecting cultural identities, obtaining approval for human use, choice of comparators, and ethical issues. We believe the study has helped set standards and a benchmark for CAM and TM research in Sri Lanka.

Epidemiology and clinical features of Hypnale nepa (hump-nosed pit viper) envenoming in Sri Lanka.

Sri Lanka homes 3 species of hump-nosed pit vipers including Hypnale Hypnale, H. zara and H. nepa from which, latter 2 are endemic to the country. Even though former 2 are the subject of several publications, no major clinical studies have been done regarding H. nepa bites. As these snakes confine only to central hills of the country, their bites are very rare. The objectives of this study were to describe epidemiological and clinical features of H. nepa bites. A prospective observational study was conducted for patients admitted with H. nepa bites to Teaching Hospital, Ratnapura, Sri Lanka for 5 years commencing from June 2015. Species identification was done using a standard key. There were 14 (3.6%) patients with H. nepa bites of which 9 (64%) were males and 5 (36%) were females. Their age ranged from 20 to 73 years (median 37.5). Seven bites (50%) occurred on lower limbs. Majority of bites (10; 71%) happened at daytime [0600-1759 h] in tea estates (8; 57%). Most patients (8; 57%) were admitted within 1-3 h from bite. Hospital stay was 2.5 days (IQR 2-3). Local envenoming was observed in all patients including local pain and swelling [mild (7; 50%), moderate (5; 36%), severe (2; 14%)], local bleeding (1; 7%) and lymphadenopathy (1; 7%). Nonspecific features were observed in 3 (21%). Systemic manifestations were found in 2 (14%) including microangiopathic haemolytic anaemia and sinus bradycardia. Two (14%) had myalgia. H. nepa bites frequently cause local envenoming. But, rarely systemic manifestations may occur.

Cat-eyed snake (Genus: Boiga) bites in Sri Lanka: First authentic case series.

Cat snakes (Genus: Boiga) are considered to be of lesser medical important in Sri Lanka, as their bites are known to cause only mild local effects such as local pain and swelling at the site of the bite. Five species of cat snakes are found in Sri Lanka, of which three are endemic. They are widely distributed all over the country. Out of seven cases of cat snake bites, including six adults and one child, five developed only mild local effects and two did not have any symptoms. Any of them did not develop systemic manifestations. The snakes responsible were the Sri Lanka cat snake (Boiga ceylonensis), Forsten's cat snake (Boiga forsteni), and also Ranawana's cat snake (Boiga ranawanei) which is the first report in Sri Lanka.

Blood transfusion in severe dengue infection: a case series.

BACKGROUND: Dengue is still a recurrent challenge to the global population, without specific antiviral therapy. Clinical management strategies are aimed to mitigate the deaths. The use of blood products in dengue is recommended mainly in cases of bleeding. CASE PRESENTATION: We prospectively collected data on Sri Lankan dengue cases in the Teaching Hospital, Peradeniya, Sri Lanka from 2017, and selected ten severe cases where blood transfusions were involved in the management. The series comprises seven females and three males, with a median age of 36 years (range 12-53 years). All patients were critically ill at the time of blood transfusion, with dramatic stabilization of vital parameters after the transfusions. Only one patient had detectable bleeding, while five patients had occult blood loss as indicated by dropping hematocrit. Even though four patients had stable hematocrit, they had metabolic acidosis. Two patients had a very high increase of hepatic transaminases along with acidosis. Two patients had myocarditis with dropping hematocrit, suggestive of occult bleeding. CONCLUSIONS: Clinical deterioration despite fluid management commonly occurs due to occult bleeding in dengue infection. Blood transfusion is lifesaving in such cases of blood loss, acidosis, and severe hepatic damage. The mechanism of this effect needs an explanation, such as enhanced oxygen delivery to the tissues and hemostasis to hypothesize a few possibilities.

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.

Therapeutic Plasma Exchange for Venom-Induced Thrombotic Microangiopathy Following Hump-Nosed Pit Viper (Genus: Hypnale) Bites: A Prospective Observational Study.

INTRODUCTION: -Thrombotic microangiopathy (TMA), which is the triad of acute kidney injury (AKI), microangiopathic hemolytic anemia (MAHA), and thrombocytopenia, is a rare complication of snakebites, and in Sri Lanka, it is commonly seen with hump-nosed pit viper (HNPV) bites. METHODS: -We conducted a prospective observational study of patients with AKI caused by HNPV bites in Teaching Hospital, Ratnapura, Sri Lanka for 6 y, commencing in June 2015. Some patients with TMA underwent therapeutic plasma exchange (TPE) and some did not. These 2 groups were compared. Statistical analysis was carried out using Minitab 18.1. Data were presented as median (IQR). RESULTS: -There were 52 (8%) patients with TMA, of whom 21 (45%) were in the TPE group and 26 (55%) were in the non-TPE group. TPE improved time to platelet correction (4 d [IQR, 4-5 d] vs 7 d [IQR, 5-9 d]; P=0.009), time to MAHA correction (5 d [IQR, 3-4 d] vs 7 d [IQR, 6-9 d]; P=0.004), time to prothrombin time (PT)/international normalized ratio (INR) correction (1 d [IQR, 1-2 d] vs 3 d [IQR, 3-4 d]; P=0.003), and time to 20 min whole blood clotting test (WBCT20) correction (2 d [IQR, 1-2 d] vs 3 d [1QR 2-3 d]; P=0.020). Renal recovery was predicted by TPE (P=0.048) and highest creatinine level (P=0.001). There was no association between TPE and dialysis dependency at discharge (P=0.597), length of hospital stay (P=0.220), and the number of dialysis cycles prior to discharge (P=0.540). TPE did not improve the number of blood transfusions (5 packs [IQR, 3-8.5 packs] vs 4 packs [IQR, 0-9 packs]; P=0.290). CONCLUSIONS: -TPE is effective for TMA in the early correction of platelet counts, MAHA, PT/INR, and WBCT20 in HNPV 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.

Acute Myocardial Infarction After Russell's Viper (Daboia russelii) Bite.

Russell's viper (Daboia russelii) is a deadly venomous snake that causes most snakebite deaths in Sri Lanka. It is widely distributed all over the country, and it commonly causes venom-induced consumption coagulopathy and neuroparalysis. Cardiotoxic manifestations after Russell's viper bites are rare. We report a 60-year-old man diagnosed with ST-elevation myocardial infarction after a proved Russell's viper bite.

Molecular Characterization of Rickettsial Agents in Ticks (Acari: Ixodidae) from Sri Lanka.

Because the majority of spotted fever group rickettsiae are transmitted to humans by tick bites, it is important to understand which ticks might play a role in transmission of rickettsial pathogens in Sri Lanka. The purpose of our study was to conduct molecular surveillance of 847 ticks collected in different locations in central Sri Lanka to determine which were infected with Rickettsia and Anaplasmataceae. Molecular methods were used to identify the ticks and the agents detected. Most ticks (Amblyomma, Haemaphysalis, and Rhipicephalus) were collected by flagging, and lower number was collected from dogs, cattle, pigs, a pangolin, and tortoises. Five spotted fever genotypes were identified: a Rickettsia africae-like agent in Amblyomma larvae, Rhipicephalus massiliae and a related genotype identified in association with the tropical type of Rhipicephalus sanguineus from dogs and Rhipicephalus haemaphysaloides from dogs and cattle, and Candidatus R. kellyi and another novel genotype (SL94) in R. haemaphysaloides. Twenty-three ticks were positive for Anaplasmataceae, including one Anaplasma and two Ehrlichia genotypes. Because the sequence database for both ticks and rickettsial agents from Sri Lanka and southern India is not extensive, additional molecular characterization of the tick species of Sri Lanka and their rickettsial agents is required to understand their pathogenic potential more completely. However, several of the agents we identified in this survey may well be pathogenic for humans and domestic animals, and should be considered as a part of epidemiological surveillance and patient management.

Purpura fulminans following hump-nosed pit viper (Hypnale hypnale) envenoming: A rare complication of snakebites.

Hump-nosed pit vipers of the genus Hypnale are highly venomous and reputed for the commonest venomous snakebites in Sri Lanka. They frequently cause local manifestations and less commonly cause systemic effects such as acute kidney injury and coagulopathy. There is no antivenom currently available in Sri Lanka for their envenoming. However, more and more complications of Hypnale bites are being recently described. Purpura fulminans, one of the rare complications of snakebites that we report following authentic Hypnale hypnale bite. A 58-year-old female was bitten by a hump-nosed viper and developed bilateral toe gangrenes, ultimately ended up with amputations. She got recovered with loss of toes in both feet for 46 days treatment at hospital.

Use of intravenous N-acetylcysteine in acute severe hepatitis due to severe dengue infection: a case series.

BACKGROUND: Dengue fever is a common mosquito borne viral infection. Severe dengue fever associated severe hepatitis carries high mortality. Based on the beneficial effect of N-acetylcysteine (NAC) in paracetamol poisoning and non-acetaminophen induced liver failure, it is used in dengue fever associated hepatitis in clinical practice. We aim to study the reversal of liver enzymes with NAC in the setting of severe hepatitis due to severe dengue infection. METHODS: A retrospective analysis was conducted on hospitalized 30 adults with severe dengue fever with severe hepatitis. These 30 patients had aspartate transaminase (AST) and alanine transaminases (ALT) more than 500 U/L and/or PT INR (prothrombin time and international normalized ratio) more than 1.5. They were treated with NAC infusion of 100 mg/h for 3 to 5 days. RESULTS: The mean age of the group was 49.9 ± 11.46 years and 18 (60%) patients were males. Nineteen patients (63%) developed dengue shock. Of them 12 patients (40%) developed hepatic encephalopathy. Median AST on the day of administration of NAC was 1125 U/L interquartile range (IQR) 1653.25 while median ALT was 752 (IQR 459.25). There was a statistically significant reduction of both ALT (p = 0.034) and AST (p = 0.049) from day 1 to 4 after NAC infusion. Rise of platelet count between day 1 and day 4 also showed statistically significant difference (p = 0.011) but the reduction of prothrombin time and international normalized ratio (PT/INR) from 1 to day 4 did not show statistical significance difference. Mean duration of treatment with NAC was 3.61 ± 0.75 days while mean length of hospital stay was 6.2 ± 1.27 days. Only one patient died (3.3%). None of the patients reported adverse drug reaction due to NAC. CONCLUSION: Majority of patients demonstrated marked clinical and biochemical improvements and they recovered fully. We observed faster and significant recovery of liver enzymes following administration of NAC. Based on the above findings, this study provides preliminary evidence for the beneficial effect of NAC in severe hepatitis in dengue infection with greater survival benefits.

In vivo anticancer effects of Momordica charantia seed fat on hepatocellular carcinoma in a rat model.

BACKGROUND: Momordica charantia or bitter melon is a well-known vegetable with a number of therapeutic actions in Ayurvedic medicine. Alpha-eleostearic acid, a conjugated trienoic fatty acid present in bitter melon is proven to have anticancer properties. Crude seed oil from local bitter melon varieties could be an effective and economical anticancer therapy. OBJECTIVE(S): The study was conducted to evaluate the anticancer effect of the crude oil from the seeds of Matale green variety of bitter melon on a hepatocellular carcinoma-induced rat model. MATERIALS AND METHODS: Hepatocellular carcinoma (HCC) was experimentally induced in Wistar rats. Crude seed oil of Matale green bitter melon (MGBM) was supplemented to one treatment group in concurrence with carcinoma induction and to another treatment group after the development of carcinoma. After 168 days, gross morphological, histopathological, biochemical, hematological and gene-expression analysis of treated and control groups were performed. RESULTS: Oral supplementation of MGBM seed oil showed a statistically significant reduction (p < 0.05) in the average number, diameter and area of hepatic dysplastic nodules and a reduction in the size of histopathological neoplastic lesions in both treatment groups compared to the non-treated control group. The expression of tumor suppressor gene p53 and anti-apoptotic gene Bcl-2 were significantly increased while the expression of apoptotic gene caspase 3 was significantly reduced in the treatment group when MGBM supplementation was in concurrence with carcinogenesis (p < 0.05). CONCLUSION: Crude seed oil from the MGBM has anticancer effects against experimentally induced HCC in Wistar rats, specially when supplemented in concurrence with carcinoma induction.

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

BACKGROUND: Hump-nosed vipers of the genus Hypnale are the most common cause of venomous snakebites in Sri Lanka. The genus includes three species: Hypnale hypnale, Hypnale zara and Hypnale nepa. Of them, H. hypnale bites are the most common and are the subject of many publications. The epidemiology and clinical features of bites by the other two species have been less investigated. METHODS: We conducted a prospective observational study of H. zara bites from January 2015 to June 2020 at the Teaching Hospital, Ratnapura, Sri Lanka. Data were collected for 5.5 years in the wet zone of the island, where the principal investigator did assessment of all patients and the data collection. RESULTS: H. zara envenoming was confirmed through identification of dead or live snake specimens brought with the patients. Of the 480 patients with proven hump-nosed viper bites, H. zara bites accounted for 105 (22%), including dry bites (n=5 [5%]) and envenoming (n=100 [95%]), with gender distribution of 65 (62%) males and a mean age of 43.1 y. Most bites occurred on the lower limbs (n=71 [68%]) in the daytime (n=69 [66%]) in home gardens (n=45 [43%]). A total of 100 (95%) patients had local manifestations, including pain (n=100 [95%]), swelling (n=100 [95%]), bleeding (n=20 [19%]), bruising (n=11 [10%]), lymphadenopathy (n=10 [9%]), necrosis at the bite site (n=9 [9%]) and blistering (n=8 [8%]). Seven (6.7%) patients showed systemic effects, including acute kidney injury (n=2 [2%]), microangiopathic haemolysis (n=2 [2%]), sinus bradycardia (2 [2%]) and one (1%) each had coagulopathy, thrombotic microangiopathy, Kounis syndrome and ischaemic changes on electrocardiography. Eosinophilia was a significant haematological finding (n=26 [25%]) and 16 (15%) had leucocytosis and 15 (14%) had neutrophilia. Ninety six percent of patients (n=101) recovered. Antivenom is not available for hump-nosed viper bites in Sri Lanka and therefore patients were managed conservatively. CONCLUSIONS: This study shows that H. zara bites mainly cause local envenoming and rarely systemic effects.

Paediatric cases of Ceylon krait (Bungarus ceylonicus) bites and some similar looking non-venomous snakebites in Sri Lanka: Misidentification and antivenom administration.

Ceylon krait (Bungarus ceylonicus) of the family Elapidae is a highly venomous endemic species inhabiting in the wet zone and some parts of the intermediate climatic zones of Sri Lanka. Clinical records of its bites are rare and limited to five case reports in the literature. It is of interest to note that there are several non-venomous snakes in Sri Lanka having similar morphological appearance to kraits causing identification difficulties which lead to unnecessary and unindicated administration of antivenom. We report two paediatric cases of proven Ceylon krait bites and three adult patients with similar looking non-venomous snakebites. These children were 1½ and 13 years old and developed neuroparalysis without progressing to respiratory failure and recovered. Both the children were administered Indian polyvalent antivenom which has not developed against endemic Ceylon krait venom. The two adult patients also received antivenom due to the misidentification without clinical and laboratory evidence of envenoming.

Human Otoacariasis in Two Climatically Diverse Districts in Sri Lanka: Seasonality, Risk Factors, and Case Notes.

PURPOSE: Otoacariasis is a parasitic otopathy reported in many parts of the world. This study presents the seasonal pattern, risk factors, and case notes on human otoacariasis in two climatically different districts: Anuradhapura and Kandy in the Dry and Wet/Intermediate zone of Sri Lanka, respectively. METHODS: Ticks removed from the ear canal of patients were collected. Risk factors of otoacarisis were determined by a case/control follow-up study. RESULTS: Nymphal Dermacentor auratus (90.8%) was the main tick species associated otoacariasis. In the Kandy District, infestation was year-round, while in the Anuradhapura District, it was seasonal with a peak in December-February. Children < 10 years were a risk group in both districts. Females were a risk group in the Kandy District. Engagement in outdoor activities was a risk factor in both districts. In addition, the presence of wildlife and domesticated animals were risk factors in the Kandy and Anuradhapura districts, respectively. The treatment protocols in the two hospitals were different. An infant with otoacariasis from the Anuradhapura District developed rickettsia. CONCLUSIONS: Although the tick species was the same, seasonality, risk groups, and risk factors in the two districts were different which could be due to the establishment and persistence of tick populations influenced by biotic and abiotic factors.

Kounis Syndrome Following Hypnale zara (Hump-Nosed Pit Viper) Bite in Sri Lanka.

A 47-y-old man was bitten by a hump-nosed viper (Hypnale zara) and gradually developed retrosternal chest pain associated with ST segment elevation on electrocardiogram. He had normal troponin I levels and no evidence of coagulopathy. Initially, he was managed as having anterior ST elevation myocardial infarction with thrombolysis. Later, because troponin levels were normal, he was suggested to have the type I variant of Kounis syndrome (allergic coronary artery spasm). This was supported by high eosinophil counts in peripheral blood. He was successfully managed with supportive treatment and discharged 6 d after the snakebite. Cardiac complications are rarely reported after hump-nosed viper bites, and clinical reports of coronary vasospasm after snakebites are extremely rare in the literature. This is the first known report of Kounis syndrome after a hump-nosed viper bite.

Venom-Induced Consumption Coagulopathy Following Hump-Nosed Pit Viper (Genus: Hypnale) Envenoming in Sri Lanka: Uncertain Efficacy of Fresh Frozen Plasma.

INTRODUCTION: Hump-nosed pit vipers (Hypnale spp) cause the highest number of venomous snakebites in Sri Lanka. Bites commonly cause local envenoming leading to local pain, swelling, and necrosis of the site of the bite. Acute kidney injury is the most common systemic manifestation, and some patients develop venom-induced consumption coagulopathy (VICC). Genus Hypnale comprises 3 species. Of them, H hypnale is found in Sri Lanka and the Western Ghats region of India. The other 2 (H nepa and H zara) are endemic species in Sri Lanka. METHODS: This study included 500 patients with hump-nosed viper bites studied prospectively over 4.5 y starting June 2014. All patients were assessed and the data were collected by the principal investigator (primary data). A subgroup of patients who developed VICC is described. There were 2 groups, including proven (patients with the specimen of the snake) and probable (specimen of snake not available) bites. RESULTS: Thirty (n=500; 6%) patients developed VICC; of them, 17 (3%) were proven cases, and 13 (2%) were probable cases. In both groups, 24 (80%) recovered, 2 (7%) progressed to chronic kidney disease, 1 (3%) died of severe hemostatic dysfunction, and 3 (10%) were lost to follow-up. Systemic bleeding was observed in 16 patients (53%), including hematuria (microscopic and gross) in 8 (27%) and venipuncture bleeding in 5 (17%). Eleven (37%) developed local bleeding at the site of the bite. Fresh frozen plasma was administered to 20 patients (67%), among whom only 11 (55%) experienced early correction of VICC. In both groups, 15 (50%) developed acute kidney injury, and 2 (7%) progressed to chronic kidney disease. Microangiopathic hemolysis was observed in 18 patients (60%) and thrombocytopenia in 16 (53%). Thrombotic microangiopathy was detected in 13 patients (43%), of whom 10 (33%) developed hemolytic uremic syndrome and 2 (7%) had thrombotic thrombocytopenic purpura. Of patients with VICC in the proven group, 94% (n=16) was caused by H hypnale and 1 (6%) was caused by H zara. In the proven group, median international normalized ratio was 3.7 (interquartile range 1.6-5.0); in the probable group, it was 5.0 (interquartile range 2.1-5.4). CONCLUSIONS: We found that 6% of patients develop hemostatic dysfunction after hump-nosed viper bites. However, which patients will develop coagulopathy or die of envenoming is unpredictable. Reliable and accessible treatments are unmet essential needs because antivenoms for these bites are currently not available in the country. Therapy with fresh frozen plasma has doubtful efficacy in early correction of VICC and needs further evaluation.

Systemic bleeding including pulmonary haemorrhage following hump-nosed pit viper (Hypnale hypnale) envenoming: A case report from Sri Lanka.

Out of seven venomous land snake species of Sri Lanka, hump-nosed pit viper (Hypnale spp.) causes the commonest venomous snakebites. It is widely distributed all over the country except in the peninsula of Jaffna. The genus has three species naming H. hypnale, H. zara and H. nepa. They frequently cause local envenoming and rarely cause coagulopathy and acute kidney injury. Systemic bleeding is the most trivial complication associated with coagulopathy caused by these snakes and pulmonary haemorrhages are one of them which are rarely reported. Antivenoms are currently not available for genus Hypnale bites in Sri Lanka. We describe a fatal case of pulmonary haemorrhage caused by a proven hump-nosed viper (Hypnale hypnale) bite associated with other systemic bleeding manifestations and thrombotic microangiopathy. This is the first known case of pulmonary and intracranial haemorrhages caused by hump-nosed viper bite.