Question

A 16 year old girl living in Arizona noted a stinging sensation in her right foot while walking through a field. She subsequently developed a painful swelling in her right foot and her right lower leg. Later, she noticed the development of ecchymosis over the same area of the right leg. At the time of an Emergency Room visit, her coagulation studies were:

Platelet Count:                       20,000/cumm

PT:                                          greater than 100 sec

APPT:                                      greater than 3 min

TCT:                                        greater than 3 min

Fibrinogen:                            40 mg%

1. What is the possible diagnosis?

2. What additional tests should be performed to confirm the diagnosis?

3. What type of therapy should be initiated?

Answer 1

1. The possible diagnosis for this scenario is snake bite because of painful swelling and ecchymosis and her platelet and fibrinogen values are lower than normal and PT, APPT and TCT values are increased.

2. The additional investigations to be performed are:

• CBC
• Peripheral blood smear
• Blood urea
• Blood creatinine
• Serum electrolytes
• Arterial blood gas
• Urinalysis for myoglobinuria
• ECG
• Chest X-ray
• X-ray of right leg to rule out any foreign body or retained fang

3. Antisnake venom therapy should be initiated. Peritoneal dialysis in case of renal failure, IV fluids. If significant limb swelling is present orthopedic evaluation with intra compartment and subcutaneous tissue pressure measurements are obtained. Surgical debridement or fasciotomy is rarely indicated.