We report a 12 year old girl with snakebite, who developed hemothorax 5 days after admission. One liter of blood was aspirated. The bite was presumed to be that of saw scaled viper (Echis carinatus) that resulted in DIC and direct endothelial injury leading to bleed. Selective bleed into the pleural cavity is a rarity.

Key words: Saw scaled viper, Pleural effusion, Hemothorax.

We report a 12-years old female child referred from a rural health centre to our hospital for the management of snake bite on her right foot. She received first aid and 100 units of ASV (anti snake venom) at the referring hospital. At the time of admission, bite marks were found over the right foot with swelling, bluish discoloration, tenderness over the surrounding area and slight oozing of the blood from the bite site. On examination, she was well oriented. Her pulse was 76/minute and blood pressure 100/70 mm Hg, with no symptoms or signs of bleeding from any other site. There were no signs of neurotoxicity. Despite repeated doses of ASV and supportive management, her 20 WBCT (20 minutes whole blood clotting time) remained prolonged.

On thoracostomy, about 1000 mL of blood was aspirated and intercostal tube was kept for drainage of any further collection. During her stay in the hospital she received 800 units of ASV, 8 units of blood transfusion, and 7 units of FFP (fresh frozen plasma) transfusion besides antibiotics. The general condition of the patient improved gradually and was discharged after 25 days of stay in the hospital. Her coagulogram was within normal limits at the time of discharge.

Snake bite is an environmental hazard, particularly in rural areas, causing significant morbidity and mortality. The vipers (saw scaled viper and russell’s viper) are primarily vasculotoxic. The toxins affecting haemostasis have been classified as per their overall effect and include the following: (a) procoagulants due to prothrombin activating toxins and thrombin like enzymes; (b) anticoagulants acting by activating Protein C etc.; (c) platelet activating and anti-platelet function; (d) fibrinolytic activators; and (e) hemorrhagins [5].

Several reports showing bleeding manifestations in the various parts of the body following snake bite have been reported in the past. One report showed hemoperitoneum developing after a Russell’s viper bite [5]. Intracranial bleeding and ischemic stroke following snake bites have also been reported [6]. Another report showed ischemic colitis after a viperine snake bite, which resulted in an emergency laparotomy revealing a necrotic ileum and caecum with the occlusion of the superior mesenteric artery [7].

As in the present case, hemothorax developing after saw scaled viper has not been reported in the literature to the best of our knowledge. In this patient, the levels of FDP (fibrin degradation product) and D-dimer suggested that DIC had occurred. The exact pathophysiology for the development of hemothorax after snake bite is not known. We believe that DIC along with direct endothelial injury as a result of a component in the venom itself such as hemorrhagin is the possible mechanism of hemothorax in this patient. DIC causes fibrin deposits in the micro-circulation, platelets and coagulation factors consump-tion with secondary fibrinolysis leading to bleeding.

Systemic envenomation by snakes can affect various organs of the body due to disturbances in the coagulation pathways. Hemothorax developing as a complication of snake bite has not been reported in the past and should be considered as a possible complication following snake bite.

Contributors: All authors were involved in the management of the case and preparation of the manuscript.

Funding: None; Competing interests: None stated.

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