552 TRANSACT~NS

OF THE

ROYALSoc~en OF TROPICAL

MEDICINE

AND

1 Short Report 1 Fatal extradural haematoma after snake bite (Bothrops moojenfi Joao Ark Kouyoumdjian’, Cristina Poliielli, Suzana Margarete A. Lobo and Sergio Mussi Guimares Department of Medicine, Faculdade de Medicina de SdoJosb do Rio Preto, S&o Paulo, Brazil

On 1 October 1989a 13vearsold bov wasbitten on

his left ankle by a snakeiBothrops

&ojmi,

71 cm

long-in the garden of his farmhouseat 2000 h. A few- minutes-later, he developed local pain and swellingand a tourniquet was placedabove the bite region. In the secondhour after the accident, he was admitted to a small village hospital nearby and intravenous antivenom therapy was administered:5 ampoules of Soro Anti-Botropico from Instituto Butantan. About 3 h after the antivenomtherapy, he becameconfused and started presenting attacks of generalized rigidity that afterwards progressedto obvious decerebraterigidity. Nine hours after the snakebite the boy was transferred to the University Hospital. His blood pressurewas 120x80 mm Hg, temperature 35*5”C and pulse 60/min. He had a swelling at the site of the bite, but there was no necrosisor impairment of perfusion (normal pedal and tibial arterial pulse and absenseof cyanosis). There was no apparent evidence of spontaneous bleeding(gastrointestinal,urinary, ungueal, gumsor subcutaneous).Renalfunction wasnormal: no oliguria, blood urea 39 mg %, blood creatinin 0.7 mg %, serum potassium3.5 mEq/litre and serum sodium 140-OmEq/litre. The level of consciousnesswas however altered, with the onset of stupor. At this stagethe boy alsoexhibited anisocoria,the right pupil being larger than the left. Additional intravenous antivenom was administered.The coagulationtime wasnormal on admissionto the University Hospital. Two hourslater, in the intensivecareunit, anisocoria was still present. The patient becamecomatoseand slipped into respiratory paralysisand bilateral midryasis.By now the coagulationtime wasprolonged.A computed tomography scan revealed an extensive right frontal. extradural haematoma.A neurosurgical approachwascontra-indicatedowing to the irresponsive apnoeic coma. The coagulation time became persistentlynormal 24 h after envenomationbut the boy died on 5 October 1989. B. moojeni (Viperidae) envenomation causes(i) *Address for correspondence: Avenida BadyBassitt3896, 15.015-S&0 Jose do Rio Preto, SP, Brazil.

HYGIENE

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local swellingin all cases(100%) followed by complications such as necrosis(So/L),abscess(10%) and compartment syndromes(4%); (ii) abnormality of blood coagulationin 75% of casesbecauseof the depletionof fibrinogen; (iii) systemichaemorrhagein 6% only, which is usually mild in spite of the high incidenceof bloodcoagulationabnormalities;and (iv) renal failure, direct or indirect, in 6% of cases (KOUYOUMDJIAN& POLIZELLI, 1988). The occurrenceof intracranial haemorrhageafter snakebite hasbeendescribedin a few sporadiccases all over the world. Teixeira (cited by ROSENFELD, 1943) described a haemorrhanicfocus destrovinx brain tissue, and BARROS& ~ANUARIO(1986)-de: scribeda subarachnoidhaemorrhagein a 21 yearsold patient, after BothroDs envenomation.WARRELLet al. (1977)described3 cases of subarachnoidhaemorrhage followina the bite of Echis carinatus: 2 were fatal and the oth& also suffered intracerebral haemorrhage. Pituitary haemorrhagehas also beendescribedafter bites bv B. iararacussu (WOLFF, 1958) and Vim-a russelli{TuN:PE et al., l&7), followed by acut; or chronic pituitary failure. In our caseneurologicalsignsdeveloned5 h after the bite (3 h after a&enomtherapy). -The coagulation time wasnormal 7 h after the administrationof antivenom but becameprolonged 2 h later. By this time the clinical picture was an apnoeiccoma. We believe that the extradural haematomaoccurred first becauseof haemorrhagin-induceddamage to the endothelialcells of smallblood vessels,complicated further by blood incoagulability. References Barros, R. S. & Januario, M. C. (1896). Hemorragia subaracnoidea opos acidente ofidico botropico. Relato de case. Arquivos Brasileiros de Neurocirurgia, 5, 253-255. Kouyoumdjian, J. A. & Polizelli, C. (1988). Acidentes ofidicos causados por Bothrops moojeni: relato de 37 cases. Revista do Institute de Medicina Tropical de So Paula, 30, 474432 -

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Rosenfeld, G. (1965). Symptomatology, pathology and treatment of snake bites in South America. In: Venomous Animals and their Venoms, Bucherl, W., Buckley, E. & Deulofeu, V. (editors), 1st edition. New York: Academic Press, pp. 345-383. Tun-Pe, Phillips, R. E., Warrell, D. A., Moore, R. A., Tin-N&we, Myint-Lwin & Burke, C. W. (1987). Acute and chronic pituitary failure resembling Sheehan’s syndrome following bites by Russell’s viper in Burma. Lancet, ii, 763-767. Warrell, D. A., Davidson, N. McD., Greenwood, B. M., Ormerod, L. D., Pope, Hr M., Watkins, B. J. & Prentice, C. R. M. (1977). Poisoning by bites of the saw-scaled or carpet viper (Echis carinarus) in Nigeria. Quarterly Journal of Medicine, 181, 33-62. Wolff, H. (1958). Insuliciencia hipofisaria anterior por picada de ofidio. Arquivos Brasileiros de Endocrinologia e Metabolismo, 7, 2547.

Received 4 December 1990; revised 12 March accepted for publication 13 March 1991

1991;

Fatal extradural haematoma after snake bite (Bothrops moojeni).

552 TRANSACT~NS OF THE ROYALSoc~en OF TROPICAL MEDICINE AND 1 Short Report 1 Fatal extradural haematoma after snake bite (Bothrops moojenfi Joao...
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