Discussion
Snake venom contains of various toxins that acting systemically and
locally, including, cardiotoxins, myotoxins, hemostasis toxins,
neurotoxins, and renal toxins, that can cause the following disorders
containing rhabdomyolysis, acute kidney injury, paralysis of the
extremities, compartment syndrome, wound necrosis, coagulation disorder,
persistent mydriasis and respiratory distress, cardiac dysrhythmia
[13].
Treatment by antivenom can reduces the envenomation effects on various
systems (coagulation, central nervous system, the cardiovascular and
gastrointestinal system; however, antivenom cannot reverse the effects
of local tissue destruction or necrosis.13 Sever wound
infections such as cellulitis and necroziting fasciitis following
venomous snake bites, are not common; they have been reported in up to
30.8% of patients after a snake bite and require aggressive treatment
[3, 4].
The common signs and symptoms of wound infections and cellulitis, such
as erythema, inflammation, warmth and local pain may develop in the
early hours to days of evolution. However, the risk factors developing
from cellulitis to necrotizing fasciitis secondary to a snake bite
provided have seldom been investigated [13].
One of the most important complications of snake bite with local
envenoming are soft tissue infections. The snake venom with proteolytic
properties causes extensive tissue destruction and devitalization, thus
predisposing the wound to bacterial infection from the snake’s
indigenous oral flora. Although in patients with snake bite, bacteria
are a major cause of wound infection, the role of prophylactic
antibiotics to prevent their formation is discussible. However, the
spectrum of bacteria from the venom and oral cavities of snakes vary
with geographic area as well as with the species and the oral health of
the snake, and these factors cannot easily be extrapolated to snakes in
rest of the world [14].
Our reported patient was a 65 years old man who admitted with chest
pain, tachycardia, fever, cold sweat, chills, frequent nausea, vomiting,
left upper limb edema and decreased level of consciousness. After
assessments and excluding the possibility of heart disease, infectious
diseases and compartment syndrome, due to the burning sensation in the
tip of the third finger of left upper limb after lifting a heavy object
and the occurrence of hemorrhagic and non-hemorrhagic blisters in this
limb with suspected snakebites, standard treatment with Anti-venom
started for the patient and due to the rapid response with this
treatment and the endemicity of the area in terms of snake bites, the
diagnosis was definitive.
Hemorrhagic blisters often form at the site of the bite digits but may
occur at any bite location or even in dependent areas distant from the
bite. These blisters usually do not appear until hours after the bite.
The tissue beneath these blisters is usually healthy, although large
blisters can cause necrosis in their underlying tissue [2].
Coagulopathy, thrombocytopenia, or a combination of the two, may be
present despite a paucity of other local or systemic effect. A decrease
in platelet count, as well as decrease in fibrinogen with elevation of
prothrombin time (PT), may be mild or moderate initially and may either
remain so or continue to worsen for several days following the
envenomation [2]. The standard Anti-venom treatment can reduce these
toxic hemorrhagic and neurotoxic effects [6-8].
However, early usage of antivenom following snake bite, showed a trend
toward a better local outcome within 12 hours. Prophylactic use of
antibiotics was still controversial [7].
Conclusion :
It should be noted that wound infections caused by snake bites if not
treated in a timely manner, can lead to complications such as
necrotizing fasciitis, compartment syndrome, or superimposed bacterial
infection, which require hospitalization, the use of broad-spectrum
antibiotics, and emergency surgical procedures; and since blisters
usually do not appear until hours after the bite, so in cases of local
edema and swelling with hemorrhagic or non-hemorrhagic blisters of
unknown cause, it is recommended to consider snake bite as a
differential diagnosis and consult a clinical toxicology specialists .