Severe Coagulopathy, Retroperitoneal Hemorrhage and Acute Respiratory Distress Syndrome Following Presumed Green Pit Viper (Trimeresurus spp.) Envenomation: A Case Report from Rural Nepal

Abstract

Introduction: Green pit viper (Trimeresurus spp.) envenomation chiefly results in localized tissue injury and hemotoxic sequelae. But systemic signs, including psoas hematoma, hemoperitoneum and Acute Respiratory Distress Syndrome (ARDS), are quite rare. In places with few resources, it is especially hard to diagnose and treat problems early.

Case presentation: We present the case of a 38-year-old male from rural Nepal who had increasing edema and hemorrhage after a green pit viper envenomation. Laboratory tests showed severe coagulopathy and a quick decline in hemoglobin levels. Ultrasound at the bedside showed a hematoma in the left psoas muscle and significant hemoperitoneum. The patient declined advanced imaging. Then he acquired ARDS and needed therapy in the ICU and CPAP ventilation. The patient got completely better after acquiring antivenom on time and getting care from a group of doctors.

Clinical discussion: The thrombin-like enzymes present in green pit viper venom can induce consumptive coagulopathy and result in spontaneous hemorrhagic consequences. Venom-induced capillary leak and systemic inflammation may lead to ARDS. In this case, bedside ultrasonography functioned as an essential diagnostic alternative in the absence of CT imaging. To get a good result, one needs to respond swiftly and be able to adjust how one manages things.

Conclusion: This case underscores the importance of identifying atypical yet life-threatening systemic effects following green pit viper envenomation. It also highlights how crucial it is to have flexible techniques to diagnose and treat patients in areas with minimal healthcare resources in order to save lives.

Abbreviations: ARDS: Acute Respiratory Distress Syndrome; ICU: Intensive Care Unit; CPAP: Continuous Positive Airway Pressure (continuous positive airway pressure); PT: Prothrombin Time; INR: International Normalized Ratio; APTT: Activated Prothrombin Thromboplastin Time; FFP: Fresh Frozen Plasma; PRBC: Packed Red Blood Cells; Spp.: Species; CBC: Complete Blood Count; CK-MB: Creatine Kinase-MB; CT: Computed Tomography; D-Dimer: Fibrin Degradation Product; ECG: Electrocardiogram; ECHO: Echocardiography; Hb: Hemoglobin; IV: Intravenous; LFT: Liver Function Test; PCV: Packed Cell Volume; PRP: Platelet-Rich Plasma; RFT: Renal Function Test; SOB: Shortness of Breath; SVT: Supraventricular Tachycardia; USG: Ultrasonography (Ultrasound)