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  1. Terrestrial snakes
  2. Indian Subcontinent and Southeast Asia
  3. Biomedical Database
  4. Pit Vipers
  5. Clinical entry: Hypnale sp.

Clinic: Hypnale sp.

Examine for venom effects

Autopharmacological effects

  • Nausea, vomiting
  • Sweating
  • Urticaria, angiooedema
  • Arterial hypotension / hypovolaemic shock (transient, recurrent; immediate; delayed (CLS))
  • Diarrhoea
  • Bronchospasm 

Local Effects

  • Pain
  • Tender local (spreading) swelling
  • Blistering
  • Lymphangiopathy and lymphadenopathy
  • Necrotic skin

Haematological effects 

  • Clotting disturbances:
    • Bleeding from the fang marks and from injuries, in particular ones that are not located in the region in which venom application occurred.
    • Bleeding into the skin (ecchymosis, petechiae)
    • Gingival bleeding, bleeding from the nose, conjunctiva, haematemeis, bleeding per rectum, including melaena, haematuria, haemoptysis.
    • Oliguria, anuria (VICC / AKI)
  • Bleeding and/or haemolytic anaemia:
    • Arterial hypotension (haemorrhagic shock)
    • Acute abdomen (intra-abdominal bleeding!)
    • Loin pain/renal bed sensitive to percussion (ischaemia, renal haemorrhage!)
    • Local neurological signs, meningism, coma (intracranial bleeding!)
    • Pale sclera (bleeding, haemolysis!)
    • Oliguria, anuria (arterial hypotension / AKI!)

Species-specific envenoming pattern

The assessment of the envenoming pattern is based on the data from publication in which the identification of the snakes is clearly specified and in accordance with accepted criteria.

  

Autopharma-
cological 
effects1
 

 Local effects2 Haematological effects Renal effects6
Bleeding3  Coagulopathy4 Thrombotic 
microangiopathy5		  
AHypnale hypnale            
BHypnale nepa            

AHypnale hypnale

1Autopharmacological effects 

Nausea, vomiting, abdominal and chest pain, headache (Joseph et al. 2006).

2Local effects

  • Local pain and swelling (extensive),
  • necrosis.


Haematological effects

3Bleeding

  • Gingival bleeding, gastrointestinal bleeding, haematuria, anaemia.

4Type of haemostatic defect

  • Weak, direct fibrinogen-coagulating and weak fibrinolytic activity and platelet-aggregating activity,  thromoytopenia (De Silva et al. 1994).
    • Clotting time: >15 min for up to and as long as 8 days after the bite (De Silva et al. 1994).
    • Platelets: minimum 86,000/mm³ on the 1st day after the bite. From the 2nd day after the bite ≥150,000/mm³ (De Silva et al. 1994).
    • Blood incoagulability was first detected between 15 min and 48 h after the bite (Ariaratnam et al. 2008).

5Thrombotic microangiopathy 

  • Description of patients with TMA with and without AKI (Herath et al. 2012, Joseph et al. 2006).

“TMA include disseminated intravascular coagulation, microangiopathic haemolytic anaemia diagnosed by finding schistocytes in peripheral blood films, thrombocytopenia, and acute kidney injury associated with arteriolar and capillary microthrombi. TMA with acute kidney injury is increasingly recognised in patients envenomed by Russell’s vipers and a variety of other species.” (Warrell and Williams 2023).
See also Noutsos et al. (2020, 2022).

6Renal effects

  • Acute renal failure (AKI). 10% in the study of Ariaratnam et al. (2008); AKI and TMA (Herath et al. 2012).
  • chronic kidney disease (Herath et al. 2011).

Morbidity

  • Chronic kidney disease (renal histology of 6 CKD patients showed predominant glomerular sclerosis and interstitial nephritis); dialysis and renal transplantation (Herath et al. 2011).
  • Anaemia; blood transfusion

Case fatality

Due to haemorrhage, renal failure.

BHypnale nepa

2Local effects

  • Only mild (De Silva 1989, Ariaratnam et al. 2008)

Clinical management

See also Clinical Management: Indian Subcontinent and Southeast Asia

for advice on post-First Aid measures, diagnosis (clinical, laboratory) and treatment (supportive, antivenom).

First Aid

Release of any type of tourniquet follow link above.

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care
WHO (2010, 2016) 

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

Follow SAMPLE & ABCDE ApproAch

Obey Hypnale sp. - specific features

see 

  • 'Species-specific envenoming pattern' above

and

Key issues

See footnotes above.

Specific treatment (antivenoms)

References

see also references in section 'species specific evidence' (below).

  • Noutsos T, Currie BJ, Lek RA, Isbister GK. Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis. PLoS Negl Trop Dis. 2020 Dec 8;14(12):e0008936. PMID: 33290400; PMCID: PMC7748274. https://doi.org/10.1371/journal.pntd.0008936
  • Noutsos T, Currie BJ, Wijewickrama ES, Isbister GK. Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice. Toxins (Basel). 2022 Jan 14;14(1):57. PMID: 35051033; PMCID: PMC8778654. https://doi.org/10.3390/toxins14010057
  • WHO-ICRC Basic Emergency Care: approach tothe acutely ill and injured (2018)
    https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured
  • WHO ABCDE Approach
    https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
  • WHO (2010) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139
  • WHO (2016) Guidelines for the management of snakebites. 2nd edition. https://www.who.int/publications/i/item/9789290225300
  • WHO Snakebite Information and Data Platform
    https://www.who.int/teams/control-of-neglected-tropical-diseases/snakebite-envenoming/snakebite-information-and-data-platform
  • Warrell DA. Venomous and poisonous animals. In: Farrar J, Garcia PJ, Hotez T, Junghanss T, Kang G, Laloo D (eds.). Manson’s tropical diseases. 24th ed. Elsevier; 2023.
  •  Warrell DA, Williams DJ. Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet. 2023 Apr 22;401(10385):1382-1398. PMID: 36931290. https://doi.org/10.1016/s0140-6736(23)00002-8 

Species-specific evidence

Hypnale hypnale

India (Kerala)

  • Joseph et al. (2007)
    5 patients (identfication: morphological)

Sri Lanka

  • De Silva (1981) 
    Hypnale hypnale     bite; identification: morphological.
  • De Silva et al. (1994) 
    1 Hypnale hypnale bite; identification: morphological.
  • Ariaratnam et al. (2008) 
    301 patients; identification: snakes brought to the hospital.
  • Herath et al. (2012)
    13 patients; identified
  • Herath et al. (2012) 
    11 patients: identification: in the hospital by attending clinicians and consultants.
  • Namal Rathnayaka (2019) 
    4 patients; identification: 2 killed snakes; 1 "identified by the attending medical offices";1 not mentioned.
  • Puthra et al. (2020) 
    1 patient; identification: morphological.
  • Ratnatunga, N. (2012) “Chronic kidney disease in snake envenomed patients with acute kidney injury in Sri Lanka: a descriptive study,” Postgraduate Medical Journal. Oxford University Press (OUP). doi: 10.1136/POSTGRADMEDJ-2011-130225.

Hypnale nepa

  • Ariaratnam et al. (2008) 
    1 patient; identification: snake brought to the hospital.
  • de Silva (1989) 
    1 patient

References

  • Ariaratnam CA, Thuraisingam V, Kularatne SA, Sheriff MH, Theakston RD, de Silva A, Warrell DA. Frequent and potentially fatal envenoming by hump-nosed pit vipers (Hypnale hypnale and H. nepa) in Sri Lanka: lack of effective antivenom. Trans R Soc Trop Med Hyg. 2008 Nov;102(11):1120-6. Epub 2008 May 2. PMID: 18455743. https://doi.org/10.1016/j.trstmh.2008.03.023 
  • de Silva, A., 1989. Hypnale nepa bite: first record. Proceedings of the Kandy Society of Medicine 11, 8—10.
  • de Silva A, Wijekoon AS, Jayasena L, Abeysekera CK, Bao CX, Hutton RA, Warrell DA. Haemostatic dysfunction and acute renal failure following envenoming by Merrem's hump-nosed viper (Hypnale hypnale) in Sri Lanka: first authenticated case. Trans R Soc Trop Med Hyg. 1994 Mar-Apr;88(2):209-12. PMID: 8036678. https://doi.org/10.1016/0035-9203(94)90301-8
  • H M N J Herath, A W M Wazil, D T D J Abeysekara, N D C Jeewani, K G A D Weerakoon, N V I Ratnatunga, E H C K Bandara, S A M Kularatne, Chronic kidney disease in snake envenomed patients with acute kidney injury in Sri Lanka: a descriptive study, Postgraduate Medical Journal, Volume 88, Issue 1037, March 2012, Pages 138–142, https://doi.org/10.1136/postgradmedj-2011-130225
  • Herath N, Wazil A, Kularatne S, Ratnatunga N, Weerakoon K, Badurdeen S, Rajakrishna P, Nanayakkara N, Dharmagunawardane D. Thrombotic microangiopathy and acute kidney injury in hump-nosed viper (Hypnale species) envenoming: a descriptive study in Sri Lanka. Toxicon. 2012 Jul;60(1):61-5. Epub 2012 Mar 26. PMID: 22483846. https://doi.org/10.1016/j.toxicon.2012.03.015
  • Joseph JK, Simpson ID, Menon NC, Jose MP, Kulkarni KJ, Raghavendra GB, Warrell DA. First authenticated cases of life-threatening envenoming by the hump-nosed pit viper (Hypnale hypnale) in India. Trans R Soc Trop Med Hyg. 2007 Jan;101(1):85-90. Epub 2006 Jul 12. PMID: 16839578. https://doi.org/10.1016/j.trstmh.2006.03.008
  • Namal Rathnayaka R, Ranathunga PAN, Kularatne SA. Thrombotic Microangiopathy, Hemolytic Uremic Syndrome, and Thrombotic Thrombocytopenic Purpura Following Hump-nosed Pit Viper (Genus: Hypnale) Envenoming in Sri Lanka. Wilderness Environ Med. 2019 Mar;30(1):66-78.  Epub 2019 Jan 31. PMID: 30711421. https://doi.org/10.1016/j.wem.2018.10.003
  • Puthra S, Pirasath S, Hemal Sugathapala AG, Gnanathasan A. Thrombotic microangiopathy following hump-nosed viper 'Hypnale' envenomation. SAGE Open Med Case Rep. 2020 Sep 10;8:2050313X20944308. PMID: 32963785; PMCID: PMC7488610. https://doi.org/10.1177/2050313X20944308
  • Ratnatunga, N. (2012) “Chronic kidney disease in snake envenomed patients with acute kidney injury in Sri Lanka: a descriptive study,” Postgraduate Medical Journal. Oxford University Press (OUP). doi: 10.1136/POSTGRADMEDJ-2011-130225.