A 7-year-old girl was admitted to our hospital 15
hours following a snake (viper) bite on her right foot. She received 10
vials of anti-snake venom (ASV) at the local hospital before referral to
our institute.
On examination, she was drowsy with Glasgow Coma
Scale (GCS) score 11/15. The swelling, induration and tenderness of the
local area extended to the knee joint. Her eyes were puffy and she had
anuria for last 12 hours. Complete hemogram showed hemoglobin 10.6 g/dL,
total leucocyte count 12000 /cumm and platelet count 139000/ cumm. Serum
urea and creatinine were 8 mg/dL and 1.1 mg/dL, respectively. Serum
sodium and potassium levels were 136 and 3.8 mEq/L. Bleeding time (BT),
prothrombin time (PT) and activated plasma thromboplastin time (APTT)
were normal. She was given intravenous cefoperazone and 15 more vials of
ASV.
Two hours later, her GCS improved and she passed 80
ml of urine. Her Parotid glands on both sides were now swollen (Fig.
1) and tender with normal overlying skin. Her clinical status
worsened in next 2 hours, and she developed hypotension and muffling of
heart sounds. She was put on inotropes and other supportive care but
could not be revived.
|
Fig.1 Parotid swelling in the patient
of viper envenomation. (See color image at website)
|
The clinical manifestations of viper bite vary from
minor local symptoms to life threatening hepatotoxic or vasculotoxic
features. Bilateral parotid enlargement is mentioned as one of the
clinical signs of viperine envenomation in the Indian National Snakebite
Protocol 2009 [1]. However, this is a rare clinical sign, and has been
only occasionally reported in adult victims [2,3]. The cause of parotid
swelling in viper bite is unknown, but it seems to represent a poor
prognostic outcome [4].
1. General Signs and Symptoms of Viperine
Envenomation. National Snake Bite Management Protocol, 2009. p13.
Available from: http: // www.statehealthsocietybihar.org
/nationalsnakebitemanagementprotocol.pdf. Accessed October 14, 2014.
2. Chakraborty PP, Bhattacharjee R. Bilateral parotid
swelling: An unusual complication of viper bite. J Assoc Physicians
India. 2010;58:460.
3. Deepak M, Basavaprabhu A, Ramapuram JT,
Nithyananda C, Mahalingam S. Bilateral parotid enlargement following
snake bite: A rare sign. Asian Pac J Trop Biomed. 2013;2:154-5.
4. Paul V, Pratibha S, Prahlad KA, Earali J, Francis
S, Lewis F. High-dose anti-snake venom versus low-dose anti-snake venom
in the treatment of poisonous snake bites—a critical study. J Assoc
Physicians India. 2004;52:14-7