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CASE REPORT
Year : 2020  |  Volume : 23  |  Issue : 3  |  Page : 191-194

Hemoperitoneum complicating venomous snakebite: A case report


Department of Internal Medicine, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Submission12-Mar-2019
Date of Decision25-Jan-2020
Date of Acceptance01-Jun-2020
Date of Web Publication7-Oct-2020

Correspondence Address:
Dr. Abdulmumini Yakubu
Department of Internal Medicine, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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DOI: 10.4103/smj.smj_62_19

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  Abstract 


Herein, we report a case of hemoperitoneum complicating venomous snakebite from a carpet viper in a young Nigerian who survived it. Review of the literature indicates that it is a rare presentation and from the available evidence, the first from Nigeria. A peculiar feature was the late presentation. Management has been discussed while highlighting some of its limitations.

Keywords: Carpet viper, EchiTAB-Plus, hemoperitoneum, venomous snakebite


How to cite this article:
Yakubu A, Musa Y, Maiyaki A S, Tambuwal S H. Hemoperitoneum complicating venomous snakebite: A case report. Sahel Med J 2020;23:191-4

How to cite this URL:
Yakubu A, Musa Y, Maiyaki A S, Tambuwal S H. Hemoperitoneum complicating venomous snakebite: A case report. Sahel Med J [serial online] 2020 [cited 2020 Oct 26];23:191-4. Available from: https://www.smjonline.org/text.asp?2020/23/3/191/297459




  Introduction Top


Snakebites are a relatively common occurrence worldwide and are estimated to affect >2.5 million humans annually, of whom more than 100,000 will die.[1] It encompasses a major public health problem among the sub-Saharan African communities including Nigeria.[2] Snakebites cause life-threatening ailment worldwide where its management sometimes requires intensive care. Echis ocellatus, the predominant envenoming species in Nigeria, has been found to contain hemorrhagin, a prothrombin-activating procoagulant causing bleeding, shock, and local tissue reactions or necrosis. Intra-abdominal hemorrhage in the form of hematomas, hemoperitoneum, or both is rare but has been reported from India[3] and Korean[4],[5] and Benin[6] Republics.

In addition to abdominal ultrasonography scan (USS), high-profile investigations such as computed tomography (CT) scan and celiac angiography (CA) to identify the source of bleeding can be very helpful for invasive interventional treatments.[4] However, the mainstay in the treatment of snakebites involves the use of anti-venom, clotting factors and other fractionated blood products, tetanus prophylaxis, and sometimes antibiotics. In developing nations, belief in traditional treatment, scarcity, and high cost of anti-venom have led to late or nonpresentation to hospital with the consequent increase in mortality and morbidity from snakebites.[7]

In this article, we report the case of hemoperitoneum in a young rural dweller with late presentation, who was managed, discharged, and followed up in a resource-poor setting.


  Case Report Top


A 20-year-old farmer referred from a general hospital on account of snakebite on the left toe of 2-week duration. The patient was bitten by a snake on the left toe while walking at night; it was a carpet viper from the patient's description. There was initial minimal bleeding at the site of bite which stopped spontaneously. However, after 2 days, the affected limb became swollen, and bleeding started from the nostrils as well as from an old wound sustained before the bite. There was associated gum bleeding and hematemesis, but no hematuria, hematochezia, or petechial rashes. Bleeding initially subsided following some first-aid measures at home, but after 3 days, he developed progressive abdominal swelling and pain. The patient was then taken to a comprehensive health center where he had two units of whole blood transfused and anti-venom; however, the type of anti-venom could not be ascertained. He was then sent to our facility due to nonimprovement of clinical features. There was no past history of bleeding disorder or features suggestive of chronic liver disease, chronic kidney disease, or peptic ulcer disease.

Examination revealed a severely pale young man with epistaxis, anicteric and no peripheral lymphadenopathy. He had a blood-stained dressing over a bleeding ulcer on the right Achilles tendon. The pulse rate was 118 beats per/ min, small volume, regular. His blood pressure was 95/45 mmHg. His abdomen was distended, with generalized tenderness and moderate ascites, but no organ was palpable. Diagnostic paracentesis yielded bloody, nonclotting aspirate. Initial abdominal girth on admission was 83 cm, which reduced to 78 cm, and subsequently 75 cm before it finally settled at 73 cm by the 3rd day of admission.

Assessment of snakebite with systemic envenomation (coagulopathy) complicated by hemoperitoneum was made. The following investigations were sought:

Admitting bedside whole-blood clotting time (WBCT) was in excess of 20 min.

Complete blood count showed hematocrit of 9%, white cell count (WCC) of 15.2 × 109/L, and platelets of 192 × 109/L. Serum electrolytes were normal; however, urea was 16.6 mmol/L, whereas serum creatinine was 2.0 mg/dl. Serum aspartate transaminase was 79 IU/L, alanine transaminase was 50 IU/L, total serum bilirubin was 2.66 mg/dL, while total protein was 6.9 g/dL. Serology for both hepatitis B virus surface antigen and anti-hepatitis C virus was nonreactive. The prothrombin time was 15 s with an international normalized ratio of 1.08, and activated partial thromboplastin time was 49 s (elevated).

Abdominal ultrasound scan showed intraperitoneal fluid collection with mobile internal echoes. The left psoas muscle appeared inflamed with three well-encapsulated echogenic masses in the left lumbar region presumably organized hematomas.

Abdominal CT scan done on two occasions showed huge, ovoid, well-defined (thick walled), nonenhancing, hypodense mass (HU 30–40) in the left hemi-abdomen inferior to the stomach, inferomedial to the spleen, and anterior to the left kidney. It had an enhancing wall with enhancing internal septation, as shown in [Figure 1] and [Figure 2].
Figure 1: Precontrast abdominal computed tomography scan at the level of kidneys

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Figure 2: Postcontrast abdominal computed tomography scan at the level of kidneys

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Intravenous (IV) EchiTAB-Plus 30 ml in 200 ml of normal saline was started, which continued for about 2 h.

Four units of fresh whole blood was grouped and cross-matched and two pints were transfused immediately, and then one pint daily for the subsequent 2 days.

Six-hourly whole-blood bedside clotting time was checked for 48 h, while abdominal girth was monitored daily throughout the 1 week of the patient's stay in the hospital, and subsequently on each clinic visit for 1 month.

After receiving three vials of EchiTAB-Plus, the patient improved significantly as evidenced by cessation of gum bleeding with normalization of urine output. The WBCT normalized after three prolonged values, and abdominal distention regressed progressively. He also received IV ciprofloxacin and metronidazole. A repeat abdominal ultrasound scan revealed resolution of intraperitoneal fluid collection as well as the encapsulated echogenic masses initially seen in the left lumbar region. The patient was discharged home after a week, and was seen in the medical outpatient clinic after 1 week, 2 weeks, and then 4 weeks with no significant complaints.


  Discussion Top


So far, there have been three reported cases of snakebite-related hemoperitoneum. All the cases were as a result of viper envenoming. The first was from India,[3] while the second and third were from Korean republics.[4],[5] Our index patient is a young sub-Saharan African subsistent farmer from a rural community, which is consistent with the most common target group for snakebite.[6] Victims often disturb or step on snakes while working on the farm or walking back home under poor visibility. The bite occurred on the foot in the evening which is the most common time as reported by Belonwu and Gwarzo.[8] The description of the snake and the complication developed are consistent with carpet viper (Echis ocellatus) which is one of the three most common species in Nigeria.[2] Coagulopathy in the form of gum bleeding, hematuria, hematochezia, epistaxis, or bleeding into the third space is a well-known and clinically significant complication that follows carpet viper bite with serious morbidity and mortality;[6],[9] the findings in our patient were in keeping with earlier reports. One peculiar feature of our patient was his late presentation, i.e., more than 2 weeks after the bite even with features of significant systemic envenomation; this has been well documented in resource-poor settings where very often, there is a strong belief in traditional medication and poor accessibility due to poverty.[10],[11] In this instance, the onset of abdominal pain was what prompted the initial presentation at a comprehensive health center where he was kept for many days before being referred to our center. In all the cases including our case, abdominal pain which corresponded with the onset of massive hemoperitoneum started 3–4 days after the snakebite.[3],[4],[5] Our patient's age agrees with the commonly affected age groups for envenoming.[7]

Viper venoms contain several toxins which act in various ways to cause coagulopathy. Some viper venoms act as anticoagulants by activating Protein C with resultant antithombin III activity. Others are enzymes with procoagulant/prothrombin and increased platelet activation, causing widespread intravascular coagulation and consumption of clotting factors. They also contain disintegrins (Arginylglycylaspartic acid (RGD)-containing proteins) with antiplatelet and fibrinolytic activators and hemorrhagins as well as thrombocytopenic activity, resulting in decreased fibrinogen concentration and increased fibrinogen degradation products and D-dimer levels.[12],[13]

Although we could not assay his fibrinogen, fibrinogen degradation products, protein C, and D-dimer, he was found to have elevated activated partial thromboplastin time; the objective diagnosis of disseminated intravascular coagulation was therefore difficult. The origin of hemoperitoneum following snakebite may be intestinal,[2] hepatic,[3] splenic,[4] and any or multiple intra-abdominal organs. Our patient showed CT evidence of hematoma inferior to the stomach, inferomedial to the spleen, and anterior to the left kidney. Also, there was abdominal ultrasound scan findings of three other distinct hematomas seen in the lumbar region adjacent to the inflamed psoas muscle in addition to hemoperitoneum. CA, which was not available in our facility, was used to determine the hepatic origin of necrosis and rupture in the second-ever reported case in 2007.[3] Sometimes, the location of hematoma is used to anticipate the origin of the bleed. The organs responsible for the intra-abdominal bleed, which adjoin the multiorgan hematoma in our patient, are unknown. Our patient unlike the three previously reported cases, had wound infection as evidenced by elevated white cell count in addition to severe anemia.

Using CA,[3] hepatic artery embolization (HAE) as well as splenic artery embolization (SAE) and splenectomy[4] has been used to treat hemoperitoneum from snakebite. While in the previosly reported Korean cases HAE was hugely successful in one, SAE was not successful in the other case. This was despite the infusion of six vials of Korax freeze-dried anti-venom, three units of fresh frozen plasma, packed cells, and eight units of platelet concentrate in the latter (unsuccessful) case. The patient had to undergo splenectomy. Our patient's dramatic response to a single vial of EchiTAB-Plus (a specialized anti-snake venom developed for the three most common snakes in Nigeria) is consistent with the experiences of excellent efficacy of this locally designed anti-venom.[14] At the time, the anti-venom was supplied free of charge by the Federal Ministry of Health; this easy accessibility devoid of cost had a significant impact on the patient's outcome, which agrees with the previous report.[7] Initial nonresponse to ineffective anti-venoms circulating in the country has been previously highlighted.[7]

In a prospective cross-sectional study from the Benin Republic,[6] all patients admitted to a tertiary hospital with snakebite envenoming were subjected to ultrasonography as indicated by clinical signs including abdomen, lungs, and pericardium. The presence of intestinal parietal hematoma was sought. The results showed the presence of abdominal hematoma in 44% of the patients with evidence of external bleeding, while 13% of the patients had ultrasound evidence of internal bleeding in the absence of external bleeding. This suggests that hemoperitoneum may be grossly underreported.


  Conclusion Top


Hemoperitoneum is a rarely reported but serious complication of viper envenomation requiring multidisciplinary approach to management, which could be quite challenging in resource-poor settings. A high index of suspicion with early serial abdominal Ultrasound scan (USS) starting from the 2nd day of the incident will go a long way to diagnose and mitigate potentially fatal outcomes. Strengthening of hematologic and radiological services will improve diagnostic accuracy in the management of bleeding due to viper envenoming.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chippaux JP. Snake-bites: Appraisal of the global situation. Bull World Health Organ 1998;76:515-24.  Back to cited text no. 1
    
2.
Habib AG. Public health aspects of snake bite care in West Africa: perspectives from Nigeria. Venom Anim Toxins Incl Trop Dis 2013;19:1-7.  Back to cited text no. 2
    
3.
Rothold K, Shelth R, Chayhan G, Asrani A, Raut A. Haemoperitoneum complicating snake bite: Rare CT features. Abdom Imaging 2003;28:820-1.  Back to cited text no. 3
    
4.
Ahn JH, Yoo DG, Choi SJ, Lee JH, Park MS, Kwak JH, et al. Hemoperitoneum caused by hepatic necrosis and rupture following a snakebite: A case report with rare CT findings and successful embolization. Korean J Radiol 2007;8:556-60.  Back to cited text no. 4
    
5.
KangC, Kim DH, Kim SC, Kim DS, Jeong CY. Atraumatic splenic rupture after coagulopathy owing to a snake bite. Wilderness and Env Med 2014: 25, 325-8.  Back to cited text no. 5
    
6.
Tchaou BA, Tové KS De, Tové YS De, Djomga ATC, Aguemon A, Massougbodji A, et al. Contribution of ultrasonography to the diagnosis of internal bleeding in snake bite envenomation. J Venom Anim Toxins Incl Trop Dis 2016;22:1-7.  Back to cited text no. 6
    
7.
Habib AG, Abubakar SB. Factors affecting snake bite mortality in north-eastern Nigeria. Int Health 2011;3:50-5.  Back to cited text no. 7
    
8.
Belonwu RO, Gwarzo GD. Envenomation secondary to facial snake bite:Report of a rare occurrence. Niger J Paediatr. 2015;42:162-4.  Back to cited text no. 8
    
9.
Kim JS, Yang JW, Kim MS, Han ST, Kim BR, Shin MS, et al. Coagulopathy in patients who experience snakebite. Korean J Intern Med 2008;23:94-9.  Back to cited text no. 9
    
10.
Njoku CH, Isezuo SA, Makusidi MA. An audit of snake bite injuries seen at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. Nig Pg Med J 2008;15:112-5.  Back to cited text no. 10
    
11.
Habib AG, Gebi UI, Onyemelukwe GC. Snake bite in Nigeria. Afr J. Sci 2001;30:171-8.  Back to cited text no. 11
    
12.
Marsh N, Williams V. Practical application of snake venom toxins in haemostasis. Toxicon 2005;45:1171-81.  Back to cited text no. 12
    
13.
White J. Snake venoms and coagulopathy. Toxicon 2005;45:951-67.  Back to cited text no. 13
    
14.
Meyer WP, Habib AG, Onayade AA, Yakubu A, Smith DC, Nasidi A, et al. First clinical experience with new ovine Fab Echis ocellatus snake bites antivenom in Nigeria. Randomised comparative trial with institute Pasteur Serum (IPSer) Africa antivenom. Am J Trop Med Hyg 1997;56:292-300.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2]



 

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