Abstract
Snake bite is an acute life threating medical emergency and is included amonst neglected tropical diseases. 1 Every year in India 200,000 people bitten by snakes and >25% are fatal. 2
In Maharashtra, Konkan area, the green pit viper (Trimeresurus gramineus) is uncommon, though this snake has become more common. [ Figure 1]
Case report
We present a 35-year-old man bitten by such a viper on his left hand. There was swelling, oedema, cellulitis with bullous eruption. [ Figure 2] On laboratory evaluation, he was anaemic (Hb 120 g/L), with normal white cell count (4.5 × 109/L) and thrombocytopenia (platelet 1x 109/L), with prolonged clotting times (PT 18 s, INR, 1.35, APPT 47 s) and serum creatinine (123.79umol/L). His 20-min whole blood clotting test (WBCT) was prolonged.
Green pit viper (trimeresurus gramineus) culprit snake.
Swelling, edema, cellulitis with bullous eruption at bite site.
Routine polyvalent snake venom available in India contains antibodies against the ‘big four’ species: common cobra (Naja naja), common krait (Bungarus caerulus), Russell's viper (Daboia russelii), and Saw-scaled viper (Echis carinatus). 2
The standard polyvalent snake venom does not contain antibodies against the green pit viper. There is no evidence of para-specificity of antivenom against other species. 3 Therefore polyvalent antisnake venom in this case was unlikely to contribute to recovery. Symptomatic treatment was given with antibiotic support (ceftriaxone) and 10 ml/kg of fresh frozen plasma. On the fourth day, his coagulopathy reversed and local symptoms improved.
Discussion
Snake bites other than of the ‘big four’ species are progressively increasing. 3 Routine antivenom dose requirement in cases of cobra and krait bites is 200 ml and 300–400 ml for viper bites. 4 Such high dose demands for snake bites quickly exhaust stocks in rural areas. The dose requirement of monovalent antisnake venom to achieve same result is low.
Consequently, newer techniques to identify snakes and the development of species and region-specific antivenom banks are required. Mobile phone apps could be created to assist in the former.
For the latter, the snake venom itself is the first requirement to create an antivenom. Milking of snake venom should be done with government permission (The wild life protection act). Identification of common species of snake from each particular area needs to be mapped out (mobile phone apps could also help in this). Thus regional antivenom banks could be established at suitable central locations for easy accessibility. A longer shelf life, especially using freeze dried antivenom, requires research input. Quality assurance of anti-venoms would be mandatory, so regulation of anti-venom banks would be a government responsibility.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
