IS THE CONCEPT OF “BIG 4” STILL RELEVANT IN INDIA? COMPARISON OF ENVENOMATION BY HUMP-NOSED PIT VIPER WITH RUSSELL’S VIPER

E. T. Arun Thomas*, Bhagya S., Udayabhaskaran V., K. G. Sajeeth Kumar and N. K. Thulaseedharan

ABSTRACT

Background: Hump-nosed pit viper (Hypnale hypnale) bites are common in the Indian subcontinent, especially in Kerala. In the past, Hump-nosed pit viper was considered as a mildly venomous snake; hence it was not included in the polyvalent anti snake venom manufactured in India. However, there is increasing number of reports of serious complications following envenomation by this species. Aim of the study: To study the complications following Hump-nosed pit viper envenomation and to compare it with Russell’s viper envenomation. Methods: 29 cases of Hump-nosed pit viper envenomation and 15 cases of Russell’s viper envenomation admitted in the Snake Bite Unit of Government Medical College Kozhikode from 1st January 2014 to 31st December 2014 were studied. Only cases in which the species of the biting snake was definitely identified were included. Results: Acute kidney injury was observed in 11 patients (6 cases required hemodialysis) with Hump-nosed pit viper envenomation and 14 patients (8 cases required hemodialysis) with Russell’s viper envenomation. The difference between the number of dialysis-requiring cases in these two groups were statistically insignificant (P=0.058). One patient with Hump-nose pit viper bite and 2 patients with Russell’s viper bite progressed to chronic kidney disease on follow up for 3 months. The renal biopsy of these patients showed cortical necrosis. There was no statistically significant difference in the incidence of coagulopathy and compartment syndrome between two groups. There was one death due to Hump-nosed pit viper bite and it was due to thrombotic thrombocytopenic purpura-like syndrome. Conclusion: Severe acute kidney injury, compartment syndrome and potential to cause renal cortical necrosis and even death following Hump-nosed pit viper envenomation are strong reasons to change the concept of the “Big 4” to “Big 5”. Anti snake venom with activity against Hump-nosed pit viper venom need to be manufactured and be made available in India.

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