Kounis Syndrome Following Hypnale zara (Hump-Nosed Pit Viper) Bite in Sri Lanka

A 47-y-old man was bitten by a hump-nosed viper (Hypnale zara) and gradually developed retrosternal chest pain associated with ST segment elevation on electrocardiogram. He had normal troponin I levels no evidence of coagulopathy. Initially, he managed as having anterior myocardial infarction thrombolysis. Later, because were normal, suggested to have the type variant Kounis syndrome (allergic coronary artery spasm). This supported high eosinophil counts in peripheral blood. successfully supportive treatment discharged 6 d after snakebite. Cardiac complications are rarely reported bites, clinical reports vasospasm snakebites extremely rare literature. is first known report bite. hypersensitivity vessels induced drugs, snake venom, environmental exposures, foods, stents. Vasospastic allergic angina, infarction, stent thrombosis occluding thrombus infiltrated eosinophils 3 variants this syndrome.1Kounis N.G. syndrome: an update epidemiology, pathogenesis, diagnosis therapeutic management.Clin Chem Lab Med. 2016; 54: 1545-1559Crossref PubMed Scopus (138) Google Scholar The includes either spasm without increased cardiac enzymes troponins or progressing acute raised troponins. angina form pectoris caused arteries, which accompanied transient electrocardiogram (ECG).2Prinzmetal M. Kennamer R. Merliss Wada T. Bor N. Angina I. pectoris; preliminary report.Am J 1959; 27: 375-388Abstract Full Text PDF (1006) It sometimes misdiagnosed (STEMI), it well that venom causes vasospasm.3Priyankara W.D.D. Manoj E.M. Gunapala A. Ranaweera A.G.R.M.A. Vithanage K.S. Sivasubramanium et al.Cardiogenic shock due following cobra bite.Case Rep Crit Care. 2019; 2019: 5185716PubMed Scholar,4Frangides C. Kouni S. 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Kidney injury proven probable cases.Trans 113: 131-142Crossref (11) venom-induced consumption coagulopathy,9Namal Venom coagulopathy uncertain efficacy fresh frozen plasma.Wilderness Environ 2020; 31: 131-143Abstract (5) thrombotic microangiopathy,10Namal Thrombotic microangiopathy, haemolytic uremic thrombocytopenic purpura Lanka.Wilderness 30: 66-78Abstract (16) wounds, amputations digits.6Ariaratnam genus Hypnale comprises species: H hypnale, zara, nepa. former found both Lanka Southwestern India, latter 2 endemic Lanka. Of these species, responsible for bites (80%) encountered over island except peninsula Jaffna north. atrial fibrillation, ischemic changes myocardium, arrest reported,11de N.L. Gooneratne L. Wijewickrama E. Acute microangiopathy bite: case report.J Case Rep. 11: 305Crossref (6) Scholar,12Namal Jayasekara K. fibrillation hypnale) envenoming.Toxicon. 2018; 148: 33-39Crossref (12) although has been reported.12Namal Such zara not described. An extensive search confirms there previous bites. Therefore, we bite previously healthy tea estate worker his left fourth finger at about 1400 while working estate. lives situated Udaniriella, remote village Ratnapura district. nonsmoker does consume alcohol. His family history heart disease. given any native treatments admitted hospital 1545. identified admitting medical officer viper. On admission, severe pain, mild swelling finger, necrosis site (Figure 1), but bleeding. blood pressure 110/80 mm Hg pulse rate 80 beats·min-1. Respiratory 18 breaths·min-1, oxygen saturation room air 99% detected using oximetry. Examination respiratory system, nervous abdomen revealed abnormality. 20-min whole clotting test (WBCT20) admission then 6-hour intervals 24 h negative (<20 min). other laboratory findings white cells (WBC) 9.8×103·μL-1, neutrophils 4280 μL-1 (44% WBC count), 3000 (31% lymphocytes 2080 (21% platelets 280×103·μL-1, Hb 13.1 g·dL-1, international ratio 1.12, activated partial thromboplastin time 38/32 sec. biochemical normal. Around 10 snakebite, patient central retrosternal, nonradiating ECG showed V1-V5 2). Repeat 1 also progressive 3). At time, 100 mmHg 50 transferred care unit further management, thrombolysis done tenecteplase. Subcutaneous enoxaparin mg twice daily, aspirin 75 mg, clopidogrel atrovastatin 40 started monitoring. level (6 onset pain) 0.012 ng·mL-1 (normal <0.034). 2D-echocardiogram apical wall hypokinesia preserved ventricular muscle mass ejection fraction 50%. There ballooning. Because repeat 0.01 (24 first), enoxaparin, aspirin, omitted, dose reduced 20 mg.Figure 3Progressive 12 leads (V1-V5).View Large Image Figure ViewerDownload Hi-res image Download (PPT) During stay, patient’s urine output wound debridement (site bite). day arrangements clinic follow-up. follow-up (done snakebite) 4). fasting sugar lipid profile mo Three months exercise 5). According standard key, 6).Figure 5Normal snakebite.View (PPT)Figure 6Species zara—a male whose total length 342 mm, head 15 tail 56 snout vent 288 ventrals 146, subcaudals 45, mid dorsal rows 15, from Ratnapura, (06°40’N 80°24’E, 130 m [430 ft]). (A) Dorsolateral view. (B) Ventral Note thin black arrows indicate large 5 scales (characteristic feature vipers), thick arrow indicates color bands neck zara), loreal prominent hump zara).View Deficient basal release nitric oxide endothelial dysfunction enhanced vascular smooth contractility involvement Rho/Rho-kinase pathway play important roles pathogenesis spasm.13Kusama Y. Kodani Nakagomi Otsuka Atarashi Kishida al.Variant spasm: spectrum, pathophysiology management.J Nippon Sch. 2011; 78: 4-12Crossref (64) In syndrome, however, inflammatory mediators histamine, chymase, tryptase released mast response. Although facilities serum histamine levels, points our being reaction elevated (3000 μL-1, range 20-500 μL-1). ECG, represents interval between depolarization repolarization ventricles. when contiguous 12-lead ECG. However, 93% young men more precordial leads, V2, concave.14Surawicz B. Parikh S.R. Prevalence female patterns early males females childhood old age.J Am Coll Cardiol. 2002; 40: 1870-1876Crossref (126) Despite its sensitivity, deviation poor specificity because, addition noncardiac elevation. repolarization, hypertrophy, hypertrophic cardiomyopathy, bundle branch block, pericarditis, myocarditis, aortic dissection, Takotsubo Brugada vasospastic angina. hyperkalaemia, pulmonary thromboembolism, pneumothorax, pancreatitis, cholecystitis, hemorrhagic cerebrovascular disease, drug-induced elevation.15Coppola G. Carita P. Corrado Borrelli Rotolo Guglielmo al.ST elevations: always marker infarction?.Indian Heart 2013; 65: 412-423Crossref (26) Snake good source vasoactive substances, envenomation can enhance activity mediators.16Thamaree Sitprija Punyavoravuth Akarasereenont Puckmanee Khow O. al.Effects Russell’s mediator production cultured human umbilical vein cells.J Assoc Thai. 2001; 84: 197-207PubMed may spasms resulting Eosinophilic periarteritis, typically presents localized vasculitis almost sudden death. Diagnosis exclusively autopsy.17Kajihara Tachiyama Hirose Takata Saito Murai al.Eosinophilic periarteritis (vasospastic death), new arteritis: seven autopsy cases review literature.Virchows Arch. 462: 239-248Crossref (27) myocarditis another possibility, outcomes. recorded lowland rainforests therefore called Among systemic effects, coagulopathy, microangiopathic haemolysis, thrombocytopenia bites.7Namal Scholar,18Maduwage Wazil Gawarammana Coagulopthy, death envenoming: Lanka.Toxicon. 58: 641-643Crossref (22) Scholar, 19Namal Jayathunga Microangiopathic anaemia three different species (Genus: 29: 94-101Abstract (10) 20Namal (hump-nosed viper) 71-77Abstract (3) Its complex microangiopathy20Namal even death.18Maduwage cardiotoxicity mainly observed (Daboia russelii) outcomes21Namal RMMK, PEA, SAM. Cardiotoxic effects Ceylon (Suppl.1);62:97.Google Scholar; very rare. T ECGs, study concluded damage seem be bites.22Seneviratne S.L. Gunatilake S.B. Fonseka M.M. Adhikari A.A. H.J. Lack Lankan bites.Ceylon 1999; 44: 70-73PubMed One main investigations needed management angiogram, center angiography percutaneous interventions. patient, initial STEMI; therefore, immediately done. corrected continued than levels. With actual vessels, should owing supply muscle, might tenecteplase administered. possibility later, thrombolytic agents omitted. difficult differentiate STEMI until available; performed reviewing treating prior receiving results. Thus, unnecessarily result transmural ischemia muscle. 11% patients suspected receive unnecessary therapy.23Sharkey S.W. Berger C.R. Brunette D.D. Henry T.D. Impact delivery therapy infarction.Am 1994; 73: 550-553Abstract (70) complicated antivenom currently available nonalcoholic body index (23.1 kg·m-2). Considering circumstantial evidence, risk factors procoagulant, hypothesized thrombin-like enzymes,24Maduwage Scorgie F.E. Shahmy Mohamed F. Abeysinghe al.Hump-nosed incomplete factor consumption.Clin Toxicol (Phila). 51: 527-531Crossref infarction.11de absence excluded, think nonischemic elevations best explanation vasospasms. Normal conveys mismatch flow demand. highlights nature include emphasizes need spp. Acknowledgments: We thank staff wards consultant cardiologists (Dr Hathlahawatta Dr Jamaldeen) Teaching Hospital Author Contributions: Patient (RMMKNR, PEANR); identification getting morphological features (RMMKNR); drafting writing PEANR, SAMK); approval final manuscript SAMK). Financial/Material Support: None. Disclosures: