Teaching Case

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.