Dr. Devarajan E, Dr. Naufal Perumpalath, Dr. Athira Prasad, Dr. John J Nalappat, Dr. Saanida MP, Dr. Juvaina PPatient
22 years, male
A 22-year-old male presented with complaints of Russel viper bite followed by pain at the bite site, vomiting and ptosis. On examination, patient had facial puffiness, periorbital and pedal oedema, tachycardia and tachypnoea. No history of any previous comorbidities.
Plain computed tomography of the brain was done. A relatively well-defined hyperdensity of average 65 Hounsfield units noted in the suprasellar region oriented along the pituitary stalk. No hyperdensity was noted involving the pituitary gland. No sellar enlargement or erosions were seen. No other intracranial haemorrhage was noted.
So, the computed tomography diagnosis of snake venom-induced pituitary infundibular haemorrhage was made.
The patient was admitted in the intensive care unit; however, his conditions worsened and succumbed to death after two days.
Snake bites are a relatively common problem in the tropics. The harmful effects of the hemotoxic envenomation from vipers are extensively reported.
Due to the procoagulant and anticoagulant effects of viper venom, both local bleeding manifestations and systemic effects in the form of acute renal injury, myocarditis and pituitary dysfunction are reported (1). The most commonly reported pituitary involvement is of the anterior pituitary with reports of acute and chronic hypopituitarism (2). A Sheehan like picture due to pituitary necrosis from Russel viper envenomation is well documented (3). Posterior pituitary involvement resulting in diabetes insipidus are also described but has less incidence compared to that of anterior pituitary. There has been reported cases of pituitary necrosis following snake bite. We also found case report of subarachnoid haemorrhage (1) and spontaneous intracerebral bleed (4) following hemotoxic envenomation. There is also report of a case of pituitary dysfunction following snake bite with ectopic pituitary bright spot on imaging (5).
However, although the pathophysiology of a pituitary infundibular haemorrhage in snake envenomation is clear, we could not find any case reports of the same in the literature. So pituitary infundibular haemorrhage is a new radiological finding in hemotoxic snake envenomation. So, in an appropriate clinical setting a radiological finding of infundibular haemorrhage should alert the clinician for possibility of hemotoxic envenomation. Also; these patients may go in for panhypopituitarism later and should be followed up with hormonal assays.
 Roy MK, Dutta J, Chatterjee A, et al. An uncommon initial presentation of snake bite-subarachnoid hemorrhage: A case report with literature review. Ann Indian Acad Neurol. 2015;18(3):348-350. doi:10.4103/0972-2327.157182(PMID: 26425018)
 Naik BN, Bhalla A, Sharma N, Mokta J, Singh S, Gupta P, Rai A, Subbiah S, Bhansali A, Dutta P. Pituitary dysfunction in survivors of Russell's viper snake bite envenomation: A prospective study. Neurol India. 2018 Sep-Oct;66(5):1351-1358. doi: 10.4103/0028-3886.241378 (PMID: 30233002).
 Antonypillai CN, Wass JA, Warrell DA, Rajaratnam HN. Hypopituitarism following envenoming by Russell's vipers (Daboia siamensis and D. russelii) resembling Sheehan's syndrome: first case report from Sri Lanka, a review of the literature and recommendations for endocrine management. QJM. 2011 Feb;104(2):97-108. doi: 10.1093/qjmed/hcq214. Epub 2010 Nov 28 (PMID: 21115460).
 Menon G, Kongwad LI, Nair RP, Gowda AN. Spontaneous Intracerebral Bleed Post Snake Envenomation. J Clin Diagn Res. 2017;11(4):PD03-PD04. doi:10.7860/JCDR/2017/25095.9517 (PMID: 28571206)
 Das L, Bhansali A, Ahuja CK, Korbonits M, Dutta P. Acquired ectopic posterior pituitary bright spot due to vasculotoxic snakebite. AACE Clin Case Rep. 2020;6(5):e207-e211. Published 2020 May 4. doi:10.4158/ACCR-2020-0094 (PMID: 32984522)
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