TRANSACTIONS OFTHEROYALSOCIETYOFTROPICALMEDICINEANDHYGIENE(1996)90,293 293 Coagulopathy and fibrinolysis following the bite of a hump-nosed viper (Hypnale hypnale) At this stagethe patient was given tetanus toxoid, and 10 ampoules of Serum Institute of India (SII) polyspeci- fit antivenom intravenously. Neither this preparation nor the only other antivenom available in the country, Haffiine antivenom, has any known effect against hump-nosed viper venom. The clotting time about 2 h after antivenom infusion was still >30 min. When the clot finally appeared it dissolved rapidly. The patient was given another 10 amooules of SII antivenom. Bv the thirdY day in hospital hh had developed cellulitis a”nd a haemorrhagic blister at the site of the bite. This was treated surgically, and he was given crystalline penicil- lin, 2 megaunits, and cloxacillin, 500 mg, intravenously every 6 h. By the fourth day following the bite the clot- ting time had become normal (8 min), as had the prothrombin time (11 s; control 11.8; international nor- malized ratio = 0.93), activated pa&al thromboplastin time (26.1 ~1. and thrombin time 114s). Oozing: of blood from ihe s& of the snake bite hah stdpped. Diring this period there was no evidence of bleeding from any other site. The patient recovered without further complica- tion, and was discharged from the hospital on the ninth day following the snake bite. A. P. Premawardena*, S. L. Seneviratne, S. Jayanthi, S. B. Gunatilake and H. J. de Silva Department of Medicine, Faculty of Medicine, University of Kelaniya, l? 0. Box 6, Ragama, Sri Lanka Keywords: hump-nosed viper, Hypnale hypnale, coaguloparhy, fibrinolysis, treatment The hump-nosed viper (HypnaZe hypnale) is a moder- ately venomous snake. Most bites cause predoininantly local effects such as pain, swelling and haemorrhagic blisters at the site of the bite (SELLAHEWA & KUMA- RARATNE, 1994). However, envenomation following its bite can cause systemic effects such as renal failure, and rarely can even be fatal (VARAGUNAM & PANABOKKE, 1970; SAWAI et al., 1983). Coagulation defects following hump-nosed viper bites are extremely rare. There is only one casereport of haemostatic dysfunction following the bite of a h;mp-nosed viper wfien there was no dbubt about the identitv of the snake (DE SILVA et al.. 1994X We report the-second case 01 abnormal bleeding’ten- dency following a verified hump-nosed viper bite, where there was also in viva evidence of excessive fibrmolytic activity. Case report A 55 years old man from Ragama, Sri Lanka, was bit- ten on the hand by a hump-nosed viper (H. hypnale). The snake was killed and brought with the patient to hospital, where it was positively identified. The patient initially had pain and swelling at the site of the bite. The swelling spread proximally and, on admission to hospi- tal half an hour after the bite, it had spread above the el- bow. There was also oozing of blood from the site of the bite, but no bleeding from any other site was noted. There was no past or family history of an abnormal bleeding. tendency, and the patient was not receiving any long-term medication. On examination, he was not pale or icteric. The cardiovascular, respiratory and nervous systems were clinically normal. The urine output was normal, and urine was not blood stained. The clotting time was grossly abnormal. The blood did not clot even after 4 h (normally 2-10 min). The fol- lowing investigations were done: bleeding time (Ivy method), 3 min (normally 2-7); serum fibrinogen, 0.28 g/L (normally 1.8-35); fibrinogen degradation products 6000 ng/mL (normally ~500); platelet count 175 x 109/L haemoglobin 10.5 g/dL, white blood cell count 8.9 x 10$/L (neutrophils 77%, lymphocytes 21%, eosino- phils 2%), blood urea 4.7 mmol/L, serum sodium 132 mmol/L, serum potassium 4.6 mmol/L, aspartate ami- notransferase 4 iu/L, alanine aminotransferase 7 iu/L, urine (protein absent, deposit showed no red or white blood cells); erythrocyte sedimentation rate 4 mm in the first hour. *Author for correspondence (fax +94(l) 538251). Discussion One caseof bleeding diathesis following hump-nosed viper bite has previously been reported in a 5 years old boy from Kandy, Sri Lanka (DE SILVA et al., 1994).That patient had a severecoagulopathy with overt gastrointes- tinal bleeding and acute renal failure which needed di- alysis; the aithors also reported procoagulant, fibri- nolytlc and platelet aggregating activity of the venom in vitro. Our patient developed coagulopathy, and evidence in viva of excessive fibrinolysis. Unlike the previously re- ported case,he had no o;ert bleeding apart from odzing of blood from the site of the bite. Not sunrisinglv. the antivenom preparation we used did not see& to h&e any effect. This caseis further evidence that systemic envenoma- tion does occur following hump-nosed viper bites, and such envenoming can be potentially life-threatening. We recommend, therefore, that haemostasis be investigated in all patients following bites of this species of snake and. as 27% of all snake bites in Sri Lanka are due to hu&p-nosed vipers (DE SILVA & RANASINGHE, 1983), a specific antivenom be developed. References De Silva, A. & Ranasinghe, L. (1983). Epidemiology of snake bite in Sri Lanka. Ceylon MedicalJournal, 28, 144-154. De Silva. A.. Wiiekoon.A. S. B.. Tavasena. L.. Abevsekera. C. K., &en&X& Bao,&ton, &“A: & W>rr$, D.-A. (1954). Haemostatic dysfunction and acute renal fadure following envenoming by Merrem’shump-nosed viper (Hypnale hyp- nale) in Sri Lanka: first authenticated case. Transactions of the Rqal Society of Tropical Medicine and Hygiene, 88,209-212. Sawai, Y., Toriba, M., Itokawa, H., de Silva,A., Perera, G. L. S. & Kottegoda, M. B. (1983). Death from snake-bite in Anuradhapura District. Ceylon MedicalJournal, 28, 163-169. Sellahewa. K. H. & Kumararatne. M. R. (1994). Envenomation by the Lump-nosed viper (Hypnale hypnale). knerican Journal of Tropical Medicine and Hygiene, 51,823-825. Varugunam, T. & Panabokke, R. G. (1970). Bilateral cortical necrosisof the kidneys following snakebite. Postgraduate MedicalJournal, 46,449. Received 10 October 1995; revised 22 November 199.5; accepted for publication 23 November 1995