Hump-Nosed Pit Viper Envenomation in Western Coastal India: A Case Series

The hump-nosed pit viper (HNPV) has historically been considered less medically significant, causing local envenomation, renal injury, and coagulopathy; however, now, it is known to cause life-threatening complications. We describe the clinical presentation, treatment, and complications of 3 confirmed HNPV bites from the state of Karnataka (southwest coastal India). Patient 1, an 88-y-old woman, reported with the live specimen and developed venom-induced consumption coagulopathy (VICC) and thrombotic microangiopathy leading to acute kidney injury requiring blood product transfusions and dialysis. Patient 2, a 60-y-old woman, reported 3 d after envenomation followed by treatment at another hospital where 30 vials of polyvalent anti-snake venom (ASV) were given. She developed VICC and acute kidney injury requiring dialysis. On Day 9 of treatment, she developed a pontine hemorrhage. She died after a transfer to another treatment center closer to her residence. Patient 3, a 25-y-old man, was brought to our emergency department 6 h after being envenomed. He received topical ayurvedic treatment before arrival. He was unconscious and found to have severe VICC with a massive middle cerebral artery infarct. All 3 patients received Indian polyvalent ASV, which does not cover HNPV envenomation, clearly demonstrating the absence of paraspecificity and neutralization in a clinical setting. To our knowledge, Hypnale hypnale envenomation has not previously been reported from Karnataka state. The diagnosis of HNPV envenomation in a country without snake venom detection kits, under-reporting despite serious complications, financial burdens on rural populations afflicted, and poor outcomes due to the lack of a specific antivenom are discussed.