From snake envenomation to recovery: A case report on rapid progression and reversal of multi-organ dysfunction

Yamni S V1*, Khaja Mohideen2, Nirmal Kumar3

1Junior Consultant, Department of Anaesthesiology, Kauvery Hospital, Cantonment, Trichy

2Senior Consultant, Department of Anaesthesiology, Kauvery Hospital, Cantonment, Trichy

3Senior Consultant, Department of Anaesthesiology, Kauvery Hospital, Cantonment, Trichy

Background

Snake bites are common, particularly in rural areas worldwide. Snake injects the venom into the body through the site of bite [1]. Prominent venomous species have been traditionally labelled as the ‘big four’, which includes the Cobra, krait, Russell’s viper, and saw-scaled viper [2]. Snakes were classified as neurotoxic (cobra, Kraits), hemotoxic (viper), and myotoxic (sea snakes) [3]. Snake bites can induce a diverse array of symptoms, manifesting both locally and systemically [4]. These manifestations includes local cellulitis, intracranial haemorrhage, disseminated intravascular coagulation, diffuse alveolar haemorrhage with acute respiratory syndrome(ARDS), and acute renal dysfunction [5]. The local and systemic manifestations of snake bite depend on the degree of envenomation. The treatment of toxic snake bite depends upon reassurance, supportive measures, and the definitive treatment of toxic bites by snake antivenin [6]. High rate of morbidity and mortality related to snake bite is due to the delay in seeking medical aid [7].

This case report highlights a rare and severe snakebite envenomation by a Russell’s viper, where the patient developed multiple systemic complications, including AKI, coagulopathy, intracerebral hemorrhage, cardiac arrhythmias, Sheehan’s syndrome, acute angle-closure glaucoma, and ARDS. Despite these challenges, timely intervention and management led to a successful recovery. Through this report, we aim to contribute to the growing literature on the seriousness of snakebite complications and emphasize that early, coordinated treatment can significantly improve outcomes and benefit the community.

Key words: Snake bite; Coagulopathy; DIC; Multiorgan dysfunction; Sheehan’s syndrome.

Case Presentation

A 63 years old male patient with no comorbidities was admitted to Emergency with a history of Russell viper snake bite on the right foot dorsal aspect at his farm. The patient developed pain and swelling in the right foot. At the time of admission patient was conscious and oriented. Blood investigations showed an increase in whole blood clotting time (WBCT), anti-snake venom (ASV) initiated, and 28 vials were given after doing serial WBCT at 6 hourly intervals.

International Normalized Ratio (INR) was 10, coagulopathy was treated with fresh frozen plasma (FFP) 3units, Thrombocytopenia was treated with single donor platelet 6 units, and platelet 10 units. Renal function test was deranged, and hence haemodialysis was initiated and a total of 14 haemodialysis sessions were done.

On day 3, patient developed pulmonary edema with mild to moderate pleural effusion and was treated conservatively. The patient had diminished vision and was diagnosed to have acute angle closure glaucoma due to a snake bite and treated conservatively. Also patient developed type II respiratory failure with fall in GCS, and hence intubated and put on mechanical ventilator support.

On day 4, CT showed subarachnoid haemorrhage with intraventricular haemorrhage, and was treated conservatively as per Neuro surgical opinion

On day 10, tracheostomy was done as there was no improvement in GCS and lung showed features of pneumonia. Broncho alveolar lavage was done, and culture was positive for Klebsiella and treated with antibiotics.

On day 12, patient developed septic shock with hemodynamic instability, inotropes were started, cultures were sent, and antibiotics were escalated.

Day 14, patient developed severe Left ventricular dysfunction, may be due to Toxic myocarditis, and developed atrial flutter (AF) and AF, which was reverted with amiodarone and was managed conservatively.

On day 24, Thyroid function test (TFT) was done, which showed very low TSH, Free T3, Free T4, FSH, and LH and hence was diagnosed to have vasculotoxic snake bite induced pituitary insufficiency. Low-dose thyroxin and cortisol replacement was done. Patient recovered from sepsis, vitals improved, and then weaned off from inotropes. His sensorium and vision gradually improved. Patient improved off from ventilator. Acute kidney injury gradually recovered.

Tracheostomy was decannulated on day 34.

Patient was discharged on day 37 in a stable state.

Discussion

Most of the snake bite occurs during summer season and particularly in the evening similar to the study by ahmed et all [8].The hump-nosed pit viper is predominantly found in South India and Sri Lanka, as reported by Dinesh et al [9]. Snake venom is a complex and has a heterogeneous toxin like cardiotoxin, neurotoxin, myotoxin, hemotoxin, and nephrotoxin that can affect multiple systems leading to their dysfunction like cellulitis, wound necrosis, rhabdomyolysis, acute kidney injury, coagulopathy, paralysis of extremities, respiratory distress, cardiac arrhythmias as mentioned by the study by hemanth et all and Shrestha et all[1,10]. Classical signs of capillary leak syndrome, such as conjunctival congestion, peripheral edema, pulmonary edema, oliguria, and hypotension, were observed in our case, similar to the findings reported by Naveen et al [11]. Typical laboratory and radiological findings include coagulation abnormalities, hemoconcentration, hypoalbuminemia, albuminuria, pleural effusion, ascites, rhabdomyolysis, and deranged renal parameters and deranged thyroid function tests were observed in our case [11].

Traditionally, coagulopathy in snakebite has been referred to as disseminated intravascular coagulation (DIC). However, the term venom-induced consumption coagulopathy (VICC) has been more recently introduced, as it more accurately reflects the clinical presentation and accounts for the absence of several features typically seen in DIC [9]. Snake venom can cause severe neurological complications, including intracerebral haemorrhage and ischemic infarcts from anticoagulant effects due to DIC [5].

Several snake species can cause cardiovascular symptoms and ECG changes. Burmese Russell’s viper may cause pituitary haemorrhage (Sheehan’s syndrome) that occurred in our case, while hypotension and shock are common with bites from rattlesnakes, Bothrops, Daboia, and other vipers. ECG abnormalities like T wave changes, ST elevation, heart block, arrhythmias, atrial fibrillation, or myocardial infarction suggest myocardial involvement as seen in our case [12]. Cardiologist opinion was obtained and medications were carried out.

The occurrence of Acute Respiratory Distress Syndrome (ARDS) occurred in our patient after being bitten by a snake. There are multiple factors associated with the occurrence of ARDS major cause being DIC, secondary to aspiration related to the venom is similar to the study by vikram et all and shimma et all [5,6] patient was timely and properly treated with the joint care of a pulmonary medicine specialist with mechanical ventilation. Patient also had elevated serum creatinine levels due to envenomation-induced acute kidney injury as similar to the case of Vikram et al [5].

In India, polyvalent Anti snake venom (ASV) is the only available combination containing the antibodies against the venom of the four common species of India, including Russell’s viper, cobra, krait, and saw scaled viper [5]. Based on clinical signs, additional antivenom was given. While Ahmed et al reported 20–36 vials, our patient received 28 vials [8].

Once a snakebite is diagnosed, close monitoring is essential. In cases of hemodynamic instability, aggressive management in the ICU is required, including fluid resuscitation with crystalloids or colloids like hydroxyethyl starch for severe interstitial loss. Inotropic support may be needed to maintain MAP regardless of fluid replacement. As reported by Naveen et al [11], most patients required dialysis for acute kidney injury

This case involves a patient who suffered a snakebite to the right foot and developed severe complications, including AKI, thrombocytopenia, coagulopathy, intracerebral hemorrhage, cardiac arrhythmias, Sheehan’s syndrome, acute angle-closure glaucoma, and ARDS. Despite the complexity, the patient was successfully treated with polyvalent anti-snake venom, mechanical ventilation, dialysis, inotropes, and intensive supportive care. Blood parameters were closely monitored, and the patient made a full recovery over 32 days, being discharged on day 37. Early diagnosis and prompt intervention were crucial to the successful outcome.

Conclusion

This case illustrates the severe complications that can arise from Russell’s Viper envenomation, including coagulopathy and multiorgan dysfunction, even with timely administration of ASV and supportive therapy. It highlights the necessity of early recognition, accurate assessment of envenomation severity, and prompt initiation of intensive care. The favourable outcome achieved reinforces that early diagnosis and timely, targeted treatment remain the cornerstone of effective management in snakebite-related toxicological emergencies.

References

  • Shrestha G, Dhungana R, Neupane A, Pokharel A, Rajbhandari S. An ischemic complication of a snake bite: Case report. Int J Surg Case Rep. 2023 Nov;112:108962. doi: 10.1016/j.ijscr.2023.108962. Epub 2023 Oct 13. PMID: 37839257; PMCID: PMC10667865.
  • Mithaiwala, Dhwanil & Raval, Neel & Chavda, Sachi & Tousif, Mohammed & Idrisi, Mohammed & Buddhadev, Mohit. (2022). A Case Report On Neurotoxic Snake Bite. 10.5281/ZENODO.5892325.
  • Virmani, Shruti & Yadav, Avanish. (2017). A CASE OF NEUROTOXIC SNAKE BITE IN A METROPOLITAN CITY (NEW DELHI): PAIN ABDOMEN WITH ANAPHYLAXIS AS A PRESENTATION. Indian Journal of Case Reports. 3. 77-80. 10.32677/IJCR.2017.v03.i02.009.
  • Fadi Aboud, Micheal Assaf, Haim Shtarker,A rare consequence of snakebite: A case report and literature review,Trauma Case Reports,Volume 57,2025,101174,ISSN 2352-6440.
  • G, V. Reddy, Geet, A. Chetan, Sonone, S. Dhupaji Vasculotoxic snake bite induced multi-organ dysfunction- A case report.Asia Pacific Journal of Medical Toxicology, 2021; 10(2): 69-73. doi: 10.22038/apjmt.2021.18232.
  • Motawei, Shimaa. (2019). A snake bite case: The value of timely diagnosis and treatment. Clinical Case Studies and Reports. 2. 10.15761/CCSR.1000131.
  • Makwana, Harsha & Suthar, Nilay & Jadav, Pradip & Thakor, Advait. (2016). Study of Snakebite Patients Admitted in Emergency Medicine Department. Indian Journal of Forensic Medicine & Toxicology. 10. 63. 10.5958/0973-9130.2016.00064.5.
  • Gouda, AhmedSalah & Elnabarawy, Naglaa & Badawy, Sayed. (2017). A study of snakebite envenomation cases admitted to egyptian national poisoning center. Acta Medica International. 4. 34. 10.4103/ami.ami_48_17.
  • Dineshkumar T, Dhanapriya J, Sakthirajan R, et al. Thrombotic microangiopathy due to Viperidae bite: Two case reports. Indian J Nephrol. 2017;27(2):161-164. doi:10.4103/0971-4065.196936.
  • Ramachandar, Hemanth; Temkar, Shreyas; Shah, Aahan; Agarwal, Disha; Deb, Amit K. Snakebite hemotoxin-induced unilateral retinopathy: Case report and review of the literature. Indian Journal of Ophthalmology – Case Reports 4(2):p 545-547, Apr–Jun 2024. | DOI: 10.4103/IJO.IJO_3226_23.
  • KrishnaGJ N, Sivaraman N, Sundaram B. Capillary Leak Syndrome Following Russell’s Viper Envenomation: A Death Bell that Needs Urgent Addressal. 2025; 4 (1):19-21. DOI: 10.5005/jp-journals-11006-0147.
  • Virmani SK. CARDIAC INVOLVEMENT IN SNAKE BITE. Med J Armed Forces India. 2002;58(2):156-157. doi:10.1016/S0377-1237(02)80054-5.

Kauverian Bookshelf

Applied Medical Statistics

Journals

Kauvery Hospital
Find Doctor
Book Appointment