PMC5667284_01
Clinical course of an 84-year-old woman following a mamushi (Gloydius blomhoffii) bite on the right elbow. Appearance of the hand (A), upper arm (B), and a vast s.c. hemorrhage on the trunk (C). The hand is severely swollen and the fingers show flexion contracture. Swelling extended distally from the elbow to the hand and proximally to the shoulder joint. D, Initial laboratory data on admission to our hospital. ALT, alanine aminotransferase; AST, aspartate aminotransferase; BE, base excess; BUN, blood urea nitrogen; CK, creatine kinase; Crnn, creatinine; CRP, C-reactive protein; FDP, fibrin degradation products; Hb, hemoglobin; LD, lactate dehydrogenase; pCO2, partial pressure of carbon dioxide; Plt, platelets; pO2, partial pressure of oxygen; pro BNP, amino-terminal pro-brain natriuretic peptide; PT, prothrombin time; PT-INR, prothrombin time - international normalized ratio; RBC, red blood cells; WBC, white blood cells. E, Expanded bowels due to paralytic ileus on abdominal X-ray. F, Free air in the abdomen. G, Excised necrotic sigmoid colon. Note multiple dark-colored ulcers and a perforation. Air in the portal vein (H) and the walls of the intestine (I) on a computed tomography scan.
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Diffuse swelling and a wide s.c. hemorrhage was noted in the right upper limb and trunk (Fig. 1A-C). The initial blood analysis data are shown in Figure 1D. After admission, ileus presenting with evident bowel expansion (Fig. 1E) and occasional melena continued, and finally, abdominal free air was evident on day 19 (Fig. 1F). Emergency surgery revealed sigmoid colon necrosis, and it was resected (Fig. 1G). From day 32, acidosis progressed, the surgical suture in the abdomen was opened, and on day 33, free air was observed in the portal vein and intestine wall ranging from the stomach to the colon (Fig. 1H, I).
Trends in laboratory findings in an 84-year-old woman following a mamushi (Gloydius blomhoffii) bite on the right elbow. A, Trends in creatine kinase (CK) and lactate dehydrogenase (LD) levels and white blood cell (WBC) counts during 40 h after the mamushi bite. B, C, Trends in several parameters during the clinical course. Gray bars show infusion volume. Events are indicated by symbols. CHDF, continuous hemodiafiltration; Crnn, creatinine; CRP, C-reactive protein; Plt, platelets; RBC, red blood cells.
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The trends in the laboratory findings are summarized in Figure 2.
Autopsy findings in an 84-year-old woman who died following a mamushi (Gloydius blomhoffii) bite on the right elbow. A, Findings in each organ. B, Small intestine: some areas are necrotic and bleeding is prominent. C, In half of the area, submucosal bleeding and loss of epithelium are observed. D, Liver, diffuse central necrosis is shown. E, F, Microscopic findings. E, Small intestine, ulceration by the submucosa was seen and the necrotic area extended to the muscle layer. F, Liver, extensive necrosis around the central vein is prominent and many hepatocytes are lost. Structures in the portal area are maintained. This type of necrosis suggests intoxication.
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The findings are summarized in Figure 3. The main macroscopic findings were as follows: small intestine, extensive patchy necrosis; ascending colon, multiple ulcers and bleeding; liver, acute necrosis in a wide area; and kidneys, cortical necrosis (Fig. 3A-D). Histologically, intestinal necrosis extended to the muscle layer, and the liver showed necrosis around the central vein (Fig. 3E, F).