Correspondence
Ascending Hemorrhagic Signs after a Bite from a Copperhead
N Engl J Med 1997; 336:1262-1263April 24, 1997
- Article
To the Editor:
The development of coagulation defects and associated hemorrhagic complications after envenomation from a crotalid (pit viper) has been well described.1,2 Common manifestations include ecchymosis and oozing, hypofibrinogenemia, thrombocytopenia, and disseminated intravascular coagulation.2-5 After an envenomating snakebite, venom is thought to travel primarily through the lymphatic system.
We recently evaluated a patient with an unusual hemorrhagic manifestation of crotalid envenomation that appears to be related to the lymphatic drainage of venom and venom-induced bleeding.
While rock climbing barefoot, a 26-year-old man was bitten on the toe by a snake that he saw and identified as a copperhead. He had immediate pain and swelling of the toe. Within minutes, a hemorrhagic blister developed at the site of the bite.
Treatment at a local hospital included prophylaxis against tetanus, antibiotic therapy, and elevation of the leg. No laboratory tests were performed. No systemic symptoms developed, and he was discharged after one hour of observation. Approximately two hours later, he noted the gradual development of an ecchymotic area, beginning at the site of the bite and spreading up his leg. He did not seek additional medical attention. After eight hours, the ecchymotic area had reached the groin and was associated with a mild aching sensation but no systemic symptoms (Figure 1Figure 1
Hemorrhagic Appearance of the Leg Two Days after Envenomation of the Toe in a 26-Year-Old Man Bitten by a Crotalid.).We evaluated the patient five days after the bite. An ecchymotic band 7 to 10 cm wide projected from the area of the bite proximally to the groin. A physical examination revealed no adenopathy or venous cords. Microscopic hematuria was absent, and the patient's renal function and platelet count were normal, as were the values for the prothrombin and partial-thromboplastin times. The foot was minimally swollen, but the circumference of the two legs was the same. The physical findings at this time were not consistent with venous thrombosis. No specific therapy was initiated. Over the following two weeks, the ecchymosis gradually cleared, and the patient remained asymptomatic.
We believe that the anatomical location and slow evolution of the ecchymosis were the results of lymphatic drainage of venom, with extravasation into the perilymphatic tissue, producing a local hemorrhagic diathesis. This striking finding may help confirm the diagnosis when a patient presents with a presumed bite from a crotalid.
5 ReferencesJames R. Roberts, M.D.
Michael I. Greenberg, M.D., M.P.H.
Institute for the Treatment of Poisonous Bites and Stings, Philadelphia, PA 19143-19961
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- Citing Articles (1)
Citing Articles
1
Gregory P. Wedin, Daniel E. Keyler, Elisabeth F. Bilden. 2009. Poisons of Animal Origin. .
CrossRef
