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An interesting case of snake bite with necrotizing fasciitis

Authors:
Hardeep Kaur at INHS Asvini
Hardeep Kaur
Gaurav Mahajan at INHS Asvini
Gaurav Mahajan
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Abstract

Snake bites are associated with various immediate life threatening complications depending upon the type of venom injected. Most of the immediate complications are well taken care of by timely intervention and use of ASV. However, a very high index of suspicion is needed to identify which patients would go on and develop the less common and delayed complications such as necrotizing fasciitis.
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Vol. 5 - No.3 May-June 2018 91 JOURNAL OF PEDIATRIC CRITICAL CARE
Introduction
Military cantonments are often infested with snakes
due to presence of thick bushes, peculiar fl ora and
their relatively remote location. Although most of the
snakes found in India are considered non-poisonous
but poisonous snakes do exist depending upon the
geographical location. Even in poisonous snake bites,
many bites may be dry bites but nevertheless the scene
creates a panic situation and fear of impending death
in the mind of patient. Most poisonous bites cause
neurological and haematological complications which
are often well taken care by timely administration
of anti-snake venom but some of the relatively rare
complications are diffi cult to be dealt with and cured.
We present one such interesting case of snake bite
in a young girl where we encountered a relatively
rare complication of necrotizing fasciitis following a
venomous bite which was successfully managed over
a period of six weeks.
Case history
10 years old female child was brought by parents with
history of being bitten by a snake accidentally. Child
stepped over a snake lying beneath her bed and was
bitten by snake over left foot. Snake was killed and
brought to hospital by parents. Though identifi cation
of snake was diffi cult as it was badly mutilated, it
resembled Russel’s viper. Child was wincing in pain
and was restless.
On examination, Temperature was 98.2º F, Pulse rate-
140/min, Blood Pressure- 100/60 mm Hg, Respiratory
Rate - 20/min, SpO2 - 96% at room air. Detailed
examination revealed fang marks in web space of 3rd
and 4th toe of left foot (Figure 1).
Figure 1: Fang marks at the bite site
Dorsum of foot and the bite site were swollen. Foot
was warm to touch. All peripheral pulses were
palpable. No apparent signifi cant bleeding/ooze was
seen from the bite site. There was no ptosis, dysphagia,
respiratory distress or loss of consciousness. No
neurological defi cit seen. There was no evidence of
haematuria, any GI bleed or ENT bleed. Systemic
examination was essentially normal.
Initial Investigation reports revealed Hemoglobin
of 11.5g/dl, Total Leucocyte Count was 7000/cmm
(Polymorphs - 67%, Lymphocytes - 27%, Monocytes
- 02% and Eosinophiles - 04%). Peripheral smear
showed no signs of haemolysis/toxic granules. Initial
An Interesting Case of Snake Bite With Necrotizing Fasciitis:
A Case Report
Hardeep Kaur*, Gaurav Mahajan**
*Head, Dept Of Pediatrics, **Head, Dept Of Medicine, Military Hospital Nasirabad, Ajmer, Rajsthan, India
Received: 16-May-18/Accepted: 25-Jun-18/Published online: 30-Jun-18
DOI- 10.21304/2018.0503.00396
Case Report
ABSTRACT
Snake bites are associated with various immediate life threatening complications depending upon the type of venom
injected. Most of the immediate complications are well taken care of by timely intervention and use of ASV. However,
a very high index of suspicion is needed to identify which patients would go on and develop the less common and
delayed complications such as necrotizing fasciitis.
Keywords: Anti-snake venom, ASV, Whole blood clotting time, Necrotizing fasciitis
Correspondence:
Dr.Hardeep Kaur, Dept Of Paediatrics,Military Hospital Nasir-
abad ,Ajmer, Rajasthan, 305601,India.
Email: harry5071@gmail.com, Phone:+917055500672
JOURNAL OF PEDIATRIC CRITICAL CARE
CASE REPORT
92
Vol. 5 - No.3 May-June 2018
An Interesting Case of Snake Bite With Necrotizing Fasciitis
20 min WBCT was normal. However, local swelling
started increasing as shown in Figure 2.
Figure 2: Initial rapidly increasing swelling of foot
Tenderness was present over the bite site and dorsum
of foot. There was no discoloration of foot initially.
Peripheral pulses were well felt. In view of local signs
of envenomation and possibility of bite by poisonous
snake (viper), 20 min WBCT was repeated. Repeat
test revealed no clot formation. Patient was pre-
medicated with injection Hydrocortisone and Injection
Pheniramine. IV access established at two different
sites. Oxygen was kept ready and patient was started
on ASV by slow IV @ 1ml/min. However, patient
started having anaphylactoid reaction in the form
of chills/rigors, tachycardia and respiratory distress.
ASV was discontinued and patient was again given
Injection Hydrocortisone and Injection Pheniramine.
Adrenaline (1:1000) was given @ 0.01mg/kg/IM.
Oxygen support given by mask @ 3lt/min. After the
vital parameters stabilised, patient was again started
on ASV which was tolerated well this time. Patient
was given total 30 vials of ASV until her 20 min
WBCT became normal. However, patient continued
to have local swelling and tenderness which was
thought to be due to cytotoxic effects of snake venom.
At this juncture, patient was also started on broad
spectrum antibiotics. After around 24 hours, local
skin discoloration started. Pain relief was given by
Inj paracetamol. Limb elevation and other supportive
care was given simultaneously. However, there was
rapidly progressive swelling and discoloration of
foot over next 48 hours. Peripheral pulses were well
felt even at this stage and there was no evidence of
haemolysis. Gradually, pus collection started and
patient was shifted to operation theatre for pus
drainage and wound debridement (Figure 3).
Figure 3: Wound debridement
Pus culture grew Pseudomonas aeruginosa which
was resistant to fl uoroquinolones and cephalosporins.
Patient developed necrotizing fasciitis, a relatively
rare complication of snake bite despite timely
ASV and broad spectrum IV antibiotics. Later, she
underwent skin grafting to cover up the large defect
left following wound debridement (Figure 4).
Figure 4: Graft at the site of debridement
She recovered completely following skin grafting and
is under regular follow up.
Discussion
There are about 236 species of snakes in India, most
JOURNAL OF PEDIATRIC CRITICAL CARE
CASE REPORT
93
Vol. 5 - No.3 May-June 2018
of which are non- poisonous. Their bites, apart from
causing pain reaction and local injury do not cause
any harm to the victim. There are only 13 known
species that are poisonous and of these only four,
namely cobra, Russell’s viper, saw scaled viper and
common krait are considered highly venomous and are
responsible for most of the poisonous bites in India1.
Many species like hump nosed pit viper and krait
are known to cause delayed symptoms as happened
in our case. This hump nosed pit viper can cause life
threatening symptoms in victim. There is a need to
identify all the poisonous species to manufacture ASV
against all of them and hence abandon the concept of
these big four2.
Secondary infection of snakebite wounds is recognised,
but occurs relatively infrequently3. Infections are
more likely to be severe in case of cobra and viper
bite as they carry more pathogenic organisms in their
mouth4. The fl ora of snake mouths typically includes
enteric gram negative organisms which are usually
resistant to commonly used antimicrobials5 and hence
can cause massive tissue injury, local necrosis, sepsis
and necrotizing fasciitis.
Conclusion
Necrotizing fasciitis following venomous snake bites
is uncommon especially in healthy population without
any co morbidities. Therefore, patient needs to be
kept under observation for at least 24-48h irrespective
of the type of bite. High index of suspicion is required
to identify secondary wound infection, sepsis and
necrotizing fasciitis in a case of venomous bite.
Source of funding: Nil
Confl ict of interest: Nil
References
1. Warrell DA.WHO/SEARO Guidelines for the Clinical
Management of Snakebite in the Southeast Asian Region.SE
Asian J Trop Med Pub Health 1999; 30:1-85.
2. Simpson ID, Norris RL. Snakes of medical importance: is
the concept of big four still relevant and useful? Wilderness
Environ Med 2007; 18:2-9.
3. Garg A, Sujatha S, Garg J, Acharya N, Parija S. Wound
infections secondary to snakebite. J Infect Dev ctries
2008;3:221-3.
4. Lam KK ,Crow P, Ng KH, Shek KC, Fung HT, Ades GA.
Cross-sectional survey of snake oral bacterial fl ora from
Hong Kong, SAR, China. Emerg Med J 2011;28: 107-14.
5. Colinon C, Jocktane D, Brothier E, Rossolini GN, Cournoyer
B, Nazaret S. Genetic analysis of pseudomonas aeruginosa
isolated from healthy captive snakes: evidence of high inter
and intrasite dissemination and occurrence of antibiotic
resistance genes. Environ Microbiol 2010; 12: 716-29.
How to cite this article:
Kaur H , Mahajan G. An Interesting Case of Snake Bite with Necrotizing Fasciitis Type of article: Case report. J Pediatr Crit Care
2018;5(3): 91-93.
How to cite this URL:
Kaur H , Mahajan G. An Interesting Case of Snake Bite with Necrotizing Fasciitis Type of article: Case report. J Pediatr Crit Care
2018;5(3): 91-93.
Available from: http://jpcc.in/userfiles/2018/0503-jpcc-may-jun-2018/JPCC0503014.html
An Interesting Case of Snake Bite With Necrotizing Fasciitis
... Dermonecrosis resulting from venom injury can therefore easily expand, and degrades into a necrotising softtissue infection, i.e. necrotising fasciitis. [16][17][18][19][20] Necrotising fasciitis following snakebite has been reported from India, [21,22] Nigeria, [23] French Guiana, [14] Taiwan, [24] Zambia [25] and Vietnam, [26] and seems to be more common following bites by Naja atra as reported from Taiwan and China. Serratia marcescens, Aeromonas hydrophile, Aeromonas sobria, M. morganii, Enterococcus spp. ...
... and Bacteroides fragilis have all been implicated as causative organisms. [14,21,22,24,26] A recent study from China suggests that, as for necrotising fasciitis, early radical surgical debridement (venom decontamination and removing of devitalised tissue) and empirical broad-spectrum antibiotics (combating invading bacteria) should be considered as treatment of severe cytotoxic cobra envenomation in order to restrict local tissue damage. [19] Prior to managing this case, we did not recognise or fully appreciate the degree to which an underlying necrotising fasciitis or a severe inflammatory response complicates and plays a role in the clinical presentation of victims of N. n. nigricincta snakebites, and probably misinterpreted it as direct effects of envenomation. ...
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