Pulmonary hemorrhage and the management following Russell’s viper (Daboia russelii) envenoming in Sri Lanka

Background: Out of four species of snakes in the family Viperidae in Sri Lanka, Russell’s viper is widely distributed all over the country and causes severe envenoming manifestations such as coagulopathy and neuroparalysis. Most snakebite deaths occur due to its bites in Sri Lanka and systemic bleeding is the most trivial complication associated with coagulopathy caused by these snakes. Pulmonary hemorrhage is one effect which is rarely reported. Case presentation: A 30-year-old previously well male was bitten by a Russell’s viper on his left foot and had mild local pain, moderate swelling and two fang punctures. Two hours after the bite, he developed vomiting with bilateral ptosis and external ophthalmoplegia, so he was given 20 vials of polyvalent antivenom after the prophylactic therapy. Later, he had prolonged whole blood clotting test associated with hematuria, followed by respiratory failure for which he was intubated. He also had blood stained endotracheal tube secretions and pulmonary hemorrhage, revealed by high-resolution computed tomography of the chest. He also developed acute kidney injury, rhabdomyolysis and deep vein thrombosis. He completely recovered and was discharged on day 23. Discussion: Snake venom serine proteinase, metalloprotease, snaclec and L-amino acid oxidase are hemotoxins of Russell’s viper venom that cause venom induced consumption coagulopathy and hemorrhage. Metalloprotease has a direct action on lung microvasculature causing pulmonary hemorrhage. Conclusion: Severe fatal systemic manifestations like pulmonary hemorrhage may occur rarely following Russell’s viper bites.