We read with interest the publication on hemothhorax following
Echis carinatus snake bite [1]. Clinical
manifestations of Echis bite envenomation are acute
external bleeding (gum bleeds, hematemesis) or internal (serous
cavities, peri-nephric, retroperitoneal, intra cranial and
hematoma in muscles). Echis venom is a rich source of
procoagulant which convert prothrombin to thrombin resulting in
fibrin deposition which is later fibrinolysed resulting in
hypofibrinogenemia and thrombocytopenia and thus disseminated
intravascular coagulation. Acute uncontrolled bleeding due to
DIC is corrected by blood and blood products rather than heavy
doses of ASV [1]. In a viper bite, initial hypotension and shock
is attributed to various actions of venom such as increased
vascular permeability or leaking syndrome, or by direct action
on vascular smooth muscle [2].
There is no additional advantage of giving
high dose ASV [5]. ASV neutralizes the free circulating venom,
and is unnecessary once venom is attached to receptor site on
red cells, platelets, smooth muscles and endothelium. In such a
situation, one has to counter the after-effects of venom, such
as bleeding and DIC by blood and blood products [1]. Scientists
working on venom should prepare monovalent antivenom and antigen
detection kit to know the species of snake bitten and exact
amount of circulating snake antigen level and dose of ASV needed
to neutralize the same [2].
The authors may also want to keep regular
follow up of this child for possibility of development of
hypopituitarism. Hypopituitarism is reported with Russell’s
viper bite but not due to saw-scaled viper; however, in the
present case authors are not sure of the species [1,2].
E carinatus is found all over
India. The amount of its venom and its toxicity varies according
to geographical regions. The venom of Echis from Jammu
causes severe coagulation defects and renal failure, which is
uncommon in Maharashtra [3]. Antivenom producers in India should
be encouraged to prepare anti snake venom (ASV) from snakes
caught from relevant areas of country [4].
Snake bite is a major public health problem
in India. Unfortunately, public health authorities have given
little attention to this time limit and life threatening medical
emergency, relegating snake bite envenoming to the category of a
major neglected disease of 21
1. Singh V, Digra SK, Slathia SS, Kakkar T.
Hemothorax following Snakebite. Indian Pediatr. 2012;49:242-3.
2. Warrell DA. Snake bite. Lancet.
2010;375:77-88.
3. Bawaskar HS and Bawaskar PH. Profile of
snakebite envenoming in Western Maharashtra. India. Roy.
Soc.Trop.Med.Hyg. 2002;96:79-84.
4. Paul V, Partibah S, Prahlad KA, Earali J,
Francis S, Lewis F, et al. High dose anti-snake venom
versus low doser antivenom in the treatment of poisonous snake
bites: A critical study. J Assoc Physic. 2004;52:14-7.
