The Hump-nosed Pit viper (Hypnale hypnale) is capable of causing life threatening symptoms.

The Hump-nosed Pit viper ( Hypnale hypnale ) called churutta in the local language, is a member of the Pit viper family which can be found in Kerala, Karnataka, Maharashtra, Goa, Tamil Nadu and possibly adjacent states. The Pitviper family, of which there are about 15 in India, have been regarded as mildly venomous for the past 100 years. Treatment advocated in the event of a bite, was to take analgesics and rest for 48 hours. Full recovery was anticipated.


Hump-nosed Pit viper	Saw Scaled Viper

However, research carried out at LFSRU determined that the Hump-nosed Pitviper is capable of causing fatal symptoms.

Case History and Development

A Patient presented at the LFSRU 36 hours after being bitten on the right ankle by a confirmed Hump-nosed Pitviper. He was complained of headache, nausea, abdominal pain, chest pain, local pain and swelling of the right ankle. He was conscious and oriented. Pulse rate was 40/ minute, respiratory rate 28/minute, BP 100/60.

On Admission

	There was tender right inguinal lymphadenopathy.
	Urine output was only 400 ml over the first 24 hours. On admission
	Whole blood clotting time [Lee and White] was 11 minutes
	Bleeding time [Ivy] 3 minutes
	Total leucocyte count 8.2 x 109/l ( polys 69%, lymph 30%, eos 1%)
	Haemoglobin 10.4 gm/dl
	Blood urea 55mg
	Serum creatinine 2.9m
	Serum sodium 136meq/l
	Serum potassium 3.9meq/l
	Platelet count 90 x 109/l.
	Urine: 2+ proteinuria.

In view of the decreased platelet count, raised blood urea, serum creatinine and local reaction at the bite site, the patient was given 40ml of Bharat polyvalent antivenom (covering Naja, Bungarus, Daboia and Echis) because the snake was believed to have been a viper, probably Echis.

On the Second day, there was:

	Puffiness of the face and bilateral pedal oedema.
	Urine output had declined to 300ml/24 hr.
	Platelet count was 40 x 109/l
	Blood urea 117mg
	Serum creatinine 4.8mg
	Serum potassium 4.1meq/l.

He was transfused 5 units of platelets.

On the third day of admission

	Urine output had decreased to 200ml/24hr
	The patient became drowsy and disoriented
	Blood urea 137mg
	Serum creatinine 6.46mg
	Serum potassium 3.3meq/l
	Platelet count 32 x 109/l.

In view of his acute renal failure, the patient was given daily haemodialysis, while his platelet count was between 50x 109 and 60 x109/l.

On the eighth day

The Patient: had haemoptysis became breathless, hypotensive and drowsy with an oxygen saturation of 70%.

He was intubated and connected to a ventilator.

He underwent a total of 15 haemodialyses and was weaned off the ventilator after 19 days. Ultimately he made a good recovery and was discharged after a hospital stay of 90 days with no local necrosis.

Conclusions

1.	The Hump-nosed Pit viper is capable of causing life threatening symptoms.
2.	The normal polyvalent antivenom is not effective against this species.
3.	Symptoms involving coagulopathy can be late developing and persistant
4.	Key measures are clotting time using the 20 Minute Whole Blood Clotting Test, Serum Creatinine and Platelets.
5.	Care must be taken with snake identification of the Saw Scaled Viper in areas where the Hump-nosed Pit viper occurs. Confusion between the species may have contributed to this problem remaining undiscovered.

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The Hump-nosed Pit viper (Hypnale hypnale) is capable of causing life threatening symptoms.

Hump-nosed Pit viper

Saw Scaled Viper

The Hump-nosed Pit viper is capable of causing life threatening symptoms.

Care must be taken with snake identification of the Saw Scaled Viper in areas where the Hump-nosed Pit viper occurs. Confusion between the species may have contributed to this problem remaining undiscovered.