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Clinic

 

Daboia russelii russelii

Studies

Northwest India

Chugh et al. 1975: 8 cases with acute renal failure; identification: snake killed and then identified 2/8, description by the patient or witnesses to the accident 5/8, unidentified 1/8; the investigators found that the clinical picture corresponded to that of a Vipera russelli russelli bite (= Daboia russelii russelii) in all cases.


South India

Date and Shastry 1982: 9 cases with acute renal failure; identification: description by the patient or witnesses to the accident.

Matthai and Date 1981: 42 cases (children with acute renal failure); identification: snake killed and then identified 12/42, description by the patient or witnesses to the accident 17/42, unidentified 13/42; the investigators found that the clinical picture corresponded to that of a Vipera russelli bite (= Daboia russelii) in all cases; it is further argued that experience in India shows that all patients with acute renal failure following a snakebite who brought in the snake for identification had been bitten by V. russelli.

Case reports

North India
Ahuja and Singh 1954: 1 case; identification morphological.

South India

Date and Shastry 1981: identification: description by the patient or witnesses to the accident; recognition from photographs.

Eapen et al. 1976: 3 cases; snakes not identified; in analogy to investigations from Myanmar, V.  russelli most probably the cause (see Vipera russelli siamensis (= Daboia russelli siamensis).

Signs & symptoms

Autopharmacological effects

Vomiting, diarrhoea, abdominal pain (Ahuja and Singh 1954).

Local effects

Local pain and swelling 42/42. Onset more or less immediately after the bite, at the latest after 72 h, resolution within 10 days (Matthai and Date 1981).

Local stabbing pain and swelling (extending to the groin) (Ahuja and Singh 1954).

Haemostatic and haemolytic effects

(primary? in the context of DIC?)

Gingival bleeding, epistaxis, haematemesis, haematuria, haemorrhagic schock (Ahuja and Singh 1954).

Gingival bleeding 38/42, haematuria 33/42, ecchymosis 30/42, haematemesis 24/42, melaena 24/42 (bleeding commenced within 2–3 h, gingival bleeding first), icterus 8/42 (Matthai and Date 1981).

Clinical signs of hypopituitarism (bleeding and deposition of fibrin microthrombi in the anterior hypophysis) (Than-Than et al. 1989; Eapen et al. 1976; Anatonypillai et al. 2010, see also Daboia russelii siamensis).

Neurological effects

Possible in south India (Warrell 1989).

Muscular effects

Possible in south India (Warrell 1989).

Renal effects

Acute renal failure: anuria within 42 h after the bite (42/42), anuria within 3 h after the bite (8/42). Acute renal failure occurred more commonly in children than in adults (p < 0.001); the acute renal failure persisted for 10–25 days (Matthai and Date 1981).

Morbidity

Acute and chronic hypopituitarism, including diabetes insipidus (Eapen et al. 1984, Anatonypillai et al. 2010, see also Daboia russelli siamensis), chronic renal failure.

Case fatality rate

6/42 children with acute renal failure (causes: peripheral cardiovascular collapse, pulmonary oedema, hyperkalaemia, sepsis, bleeding from the peritoneal dialysis catheter) (Matthai and Date 1981).

3/8 patients with acute renal failure. All 3 fatalities had histological evidence of renal cortical necrosis (Chugh et al. 1975).

1 fatality (probable cause haemorrhagic shock) (Ahuja and Singh 1954).

Laboratory and physical investigations

1. Haemostasis
Type of haemostatic defect
Disseminated intravascular coagulation.

 

Haemostatic parameters

 

Overview haemostasis
   
A
 
   
B
 
C
 
   
E
 
                     
 
H CT (FSP) Tc PT aPTT TT I FSP D II V VIII X XIII PC ATIII PI tPA α2AP
       
 
F
     
 
D
     
 
G
 
G
             
 

Essential

bed-side

tests

Tests for full clinical assessment Tests for research purposes
H haemorhagic effects
+ definite evidence in
human envenoming
CT full blood clotting test
(FSP)  FSP rapid test
Tc platlets
PT prothrombin time
aPTT partial thromboplastin time
TT thrombin time
I fibrinogen
FSP  fibrinogen split products
D D-dimer
II, V, VII, X, XIII
  clotting factors
PC protein C
ATIII antithrombin III
PI plasminogen
tPA tissue plasmin activator
α2AP α2-antiplasmin
 
In this overview, the deviations from normal
are recorded for those haemostasis para-
meters only, for which good evidence is
documented in the literature.
    
A

Clotting time (CT): prolonged clotting time 39/42 (Matthai and Date 1981); clotting time 5–30 min (Chugh et al. 1975); blood incoagulable (Ahuja and Singh 1954).

B

PT: 15–40 s (Chugh et al. 1975).

C

aPTT: 30–120 s (Chugh et al. 1975).

D

Fibrinogen: hypofibrinogenaemia 14/15 (Matthai and Date 1981).

20–290 mg/100 ml (Chugh et al. 1975).

E

FSP: up to 160 μg/100 ml.

F

Platelets: thrombocytopaenia 33/42 (Matthai and Date 1981).

26,500–203,000/mm³ (Chugh et al. 1975).

G

Clotting factors: factor V: 10–95% (Chugh et al. 1975); factor VIII: 10–90 % (Chugh et al. 1975).


2. Leucocytes
Leucocytosis 42/42 (Matthai and Date 1981).

3. Haemoglobin
Anaemia 33/42 (Matthai and Date 1981).

4. Serum creatinine, serum potassium
Serum creatinine 318–1,237 μmol/l; potassium 4.2–7.2 mmol/l (Matthai and Date 1981).

5. Renal biopsy

Histology: acute tubular necrosis (aetiology: ischaemia due to DIC) (Matthai and Date 1981).

Histology: cortical necrosis (aetiology: ischaemia due to DIC) (Date and Shastry 1982); cortical necrosis (3/8 patients with acute renal failure; none survived despite intermittent dialysis) (Chugh et al. 1975).

Treatment (symptomatic)

Dialysis necessary in 33/42 children with acute renal failure (Matthai and Date 1981).

Treatment (specific)

Antivenom
Polyvalent antisnake venom serum, Haffkine, Mumbai, India.

Dose
80–120 ml (Matthai and Date 1981).
Efficacy

  • With regard to local cytotoxicity: no data.
  • With regard to the formation of necroses: no data.
  • With regard to shock symptoms: no data.
  • With regard to the haemostatic effect: no data.
  • With regard to acute renal failure: children who received antivenom within 2 h after the bite had a lower probability of developing acute renal failure than those who received it later (p < 0.001); if acute renal failure did develop, it was less severe in those children who received antivenom within 2 h after the bite than in those who received it later (severity assessed according to the need for dialysis) (p < 0.001) (Matthai and Date 1981).

South India

The unsatisfactory efficacy of the Polyvalent antisnake venom serum, Haffkine, in south India appears to be explained by the geographic variability in venom composition (Jayanthi and Gowda 1988).