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.