Stroke and snakebite: case report

Acidente vascular cerebral e ofidismo: relato de caso

Stroke and snakebite: case report

Acidente vascular cerebral e ofidismo: relato de caso

Paulo César Santos-Soares^I; Aroldo Bacellar^II; Heitor Portella Povoas^III; Alex Ferreira Brito^IV; Diana Lara Pinto Santana^V

^INeurointensivist, Adult ICU, Hospital Santo Amaro, José Oliveira Foundation, Salvador BA, Brazil

^IIChief, Neurology Department, Hospital São Rafael, Salvador BA, Brazil

^IIICoordinator, Adult ICU, Hospital Santo Amaro, José Oliveira Foundation, Salvador BA, Brazil

^IVSurgeon and Intensivist, Adult ICU, Hospital Santo Amaro, José Oliveira Foundation, Salvador BA, Brazil

^VMedical Student - Universidade Federal da Bahia, Salvador BA, Brazil

ABSTRACT

Snakebites are common and lead to potential complications like neuromyopathies and strokes, these last associated with disturbances of blood coagulation. We report on a 65 years old woman of cerebral intraparenchymal hemorrhage associated with snakebite by a Bothrops jararaca that occurred in the Reconcavo of Bahia, BA, Brazil. The patient was submitted to a surgical evacuation of the hematoma, with a good result. This report is accompanied by a revision about the association among snakebite and neurological complications, emphasizing strokes. Statistics reveal a hight incidence of snakebite in the world, mainly in tropical countries and gets attention for his socioeconomic impact. The clinical and laboratorial characteristics to identify the victims that present a high risk of presenting strokes are discussed in order to identify early those patients, so that they may be treated in a more precocious and effective way.

Key words: snakebite, coagulopathy, stroke, Bothrops.

RESUMO

Acidentes ofídicos são comuns e trazem como potenciais complicações neuromiopatias e doenças cerebrovasculares, estas últimas associadas a distúrbios da coagulação sanguínea. Relatamos sobre uma mulher de 65 anos com hemorragia cerebral intraparenquimatosa associado a acidente ofídico por Bothrops jararaca, ocorrido no Recôncavo Baiano, BA, Brasil. A paciente foi submetida à craniotomia para evacuação cirúrgica do hematoma, com bom desfecho final. Este relato é acompanhado de revisão sobre a associação entre ofidismo e complicações neurológicas, com enfoque as doenças cerebrovasculares. As estatísticas impressionam pela alta incidência de acidente ofídico no mundo, principalmente em países tropicais e chama atenção o seu impacto sócio-econômico. Discutimos os achados clínicos e laboratoriais que identificam quais vítimas apresentam maior risco de apresentar complicações cerebrovasculares a fim de se identificar precocemente esses pacientes, para que possam ser tratados de forma mais precoce e eficaz.

Palavras-chave: acidente ofídico, coagulopatia, acidente vascular cerebral, Bothrops jararaca.

Cerebrovascular diseases (CVD) are the main cause of death in Brazil^1,2 and here deserve special attention and different approach because of uncommon causes like sickle cell disease, Takayasu’s arteritis, cysticercosis, infectious endocarditis, Chagas’ disease, hemorrhagic fevers, gnathostomiasis, leptospirosis, cerebral malaria, puerperal venous thrombosis, tuberculosis and others³.

After approval of the Hospital Ethics Committee and signed informed consent obtained from a patient representative we report a case of another uncommon cause of CVD which is mostly seen in tropical countries: snakebite.

CASE

A 65-year-old woman was admitted to the emergency unit of the Anti-Poison Center, Roberto Santos Central Hospital, with alteration of the language, speech change and right side hemiparesis. Twelve hours before admission she was attacked by a Bothrops jararaca in the rural area of the city of Mata de São João, BA, Brazil, on January 5^th, 2004. She had had systemic arterial hypertension for many years with previous history of CVD with no sequels. The neurological examination after admission showed aphasia, left deviation of labial commissure and contra lateral motor deficit with Babinski signal. The patient evolved with rapid deterioration of consciousness (Glasgow Coma Score 8) and worsening of motor deficit. The trachea was intubated to maintain airway protection and a computed tomography (CT) of the head showed extensive hematoma in the left temporo-parietal lobe, with perilesional edema (Figure). The patient was transferred to the Intensive Care Unit (ICU). The consultant neurosurgeon decided for a direct evacuation of the hematoma.

Three days after the surgical treatment the patient had improved her conscience level (Glasgow Coma Score 10) and motor deficit, subsequently been disconnected from the mechanical ventilation. She was discharged from the ICU and made a full recovery.

DISCUSSION

The incidence of snakebites in the world is high and estimations in about 500 cases for 100000 inhabitants, with more than 20000 deaths annually in Africa, Asia and Latin America. In the United States of America, more than 8000 cases are reported every year⁴. In Europe, the incidence of snakebites range from 15000 to 20000/year, resulting in about 50 deaths⁵.

In Brazil more than 20000 snakebites each year are notified to Ministry of Health. According to the database of the Brazilian General Office of Health Surveillance about 75% of the notified cases are attributed to the serpents of Bothrops gender, 7% Crotalus, 1,5% Lachesis, 3% no poisonous serpents and 0,5% Micrurus. The species of the serpents are not described in about 13% of notified cases.

The registry shows death rate of 1.85% for Crotalus snakes, 0, and 95% for Lachesis, 0.36% for Micrurus and 0.31% for Bothrops⁶. The Central Brazil is an area of high incidence of attacks, being the gender Bothrops, Crotalus and Micrurus responsible for 74%, 24% and 2% of the accidents, respectively⁷.

In the Brazilian Amazonian region, snakebites are described by serpents of the Viperidae family (including the genders Bothrops, Crotalus and Lachesis), Elapidae family (gender Micrurus) and Colubridae family (Philodryas viridissimus, Clelia clelia and Erythrolamprus aesculapii). In a retrospective analysis of 734 patients, Bothrops atrox was responsible for 76% of the cases and Lachesis muta for 10%. Of all patients, 81.3% were male, 50.4% were farmers, 70.2% occurred in the rural area, 72.1% were in productive age (15 to 59 years old) and 57.3% of the patients only received medical treatment after six hours of the attack. This delay is mainly due to the great extension of the area and the inadequacy of public transportation. Most of the time, people have to travel by waterways to arrive at urban center⁸. In a series of 3139 cases of snakebites assisted at the Vital Brazil Hospital of the Butantan Institute between 1981 and 1990, the specie of the serpent was identified in 1412 (45%) cases. Bothrops jararaca was responsible for 1376 cases (97.5%), Bothrops jararacussu 20 cases (1.4%), Bothrops neuwiedi 11 cases (0.8%), Bothrops moojeni 2 cases (0.2%), Bothrops alternatus 2 cases (0.2%) and Bothrops pradoi was responsible for 1 case (0.1%). The accidents predominantly occurred between October and April (83.8%), from 12 to 18 o’clock (42.2%), mostly males (75.7%), with the age ranging from 10 to 40 years old (59.0%). The lower limbs were attacked in 2342 cases (74.7%)⁹. The serpents of medical interest in Brazil belong to gender Bothrops, Crotalus, Lachesis and Micrurus. The social-economic impact of snakebites come from the fact that the population attacked is in productive age, prevailing males, with more common and are attributed to neurotoxin effect and coagulation disturbances of the venom.

Seneviratne et al. at the Department of Neurology of Ratnapura General Hospital in Polonnaruwa, Sri Lanka, enrolled 56 patients admitted with neurological manifestations after snakebite. The most common manifestations were related to the muscular plaque (e.g., double vision, dysphagia and dropping eyelids). Ten patients developed respiratory failure requiring mechanical ventilation and one developed peripheral sensorial neuropathy two weeks after a krait bite. The only death in this series was due to stroke. The autopsy revealed a large intracerebral hemorrhage in the right parietal lobe¹⁰.

It is estimated that CVD occur in 2.6% of the victims of Bothrops snakebite and these are related to hemorrhagic events. Mosquera et al. studied 309 patients bitten by Bothrops spp in the Military Hospital of Guayaquil, Ecuador (252 men, 57 women, and 8 to 82 years old). Eight patients (2.6%) developed CVD, being seven hemorrhagic strokes and one ischemic stroke. Four patients had evidences of systemic hemorrhage and all of them were classified as having degree degree 3 of the SSS (Snakebite Severity Scale).

Except from one woman that had used oral contraception, no other patient had risk factors for stroke. Six of these patients developed stroke six hours after the accident⁴. In a Colombian study that selected 39 patient with snakebites by Bothrops, Porthidium and Bothriechis, hemorrhagic stroke was described in five patients (12.8%)¹¹.

The poison of the Viperidae family serpents (Crotalus, Lachesis and Bothrops) has proteolytic enzymes and polypeptides toxins (e.g., cardiotoxins, bradykinin and histamine), which cause respiratory failure, arrhythmias (disruption of impulse transmission) and hypotension. It releases also some proteases, phospholipases, collagenases and thrombin-like enzymes, wich interfere with normal blood clotting. The combination of these components generates anticoagulant and coagulant effects. The coagulant effect can be due to the presence of the arginine esterase hydrolase, one enzyme that has similar action of the thrombin on platelets aggregation. The fibrinolysis is activated and in association to proteases which destroy the wall of blood vases, cause serious hemorrhage⁵. The bothropic venom is responsible for most accidents causing thrombocytopenia, prolongation of prothrombin and partial thromboplastin times, disseminated intravascular coagulation, and even damage of blood vessels⁴. The Lachesis venom is similar to the Bothrops although it has neurotoxic effect, with symptoms as nausea, vomits, abdominal pain, bradycardia and syncope. The Crotalus venom has effects on blood coagulation and potent neurotoxic effect, with visual alterations (double vision), dropping eyelids, dysphagia, odynophagia and even respiratory failure. Myalgia is also common. The renal failure with tubular necrosis is common in these three types of accidents, because of rabdomyolisis and myoglobinuria. The Micrurus snakebite has mainly a neurotoxic that resembles the symptoms associated to the Crotalicus poisoning.

One study has analyzed 38 patients with coagulopathy after snakebite, 14 (37%) developed thrombocytopenia, 22 (58%) showed hypofibrinogenemia, and 17 (45%) presented prolonged prothrombin time and activated partial thromboplastin times. These alterations continue for two weeks¹². Coagulopathy and intracerebral hemorrhage was reported in an 85-year-old woman attacked by a serpent of Elapidae gender (Notechis scutatus)¹³. Boviatsis et al. published a case of a 65-year-old woman admitted to a local hospital in Athens, Greece with multiple hemorrhagic infarcts in the cerebral hemisphere⁵.

Ischemic phenomena are uncommon and they can be associated to specific types of serpents. Procoagulant activity of the venom, vascular damage and circulatory shock may account for the cerebral infarcts. Lee et al. described an infarct of brainstem resulting in one-and-half syndrome in a 54 year-old man following an attack by a Korean snake (Agkistrodon blomhoffii brevicaudus)¹⁴. Some other few cases of ischemic stroke were reported in the literature^15-17.

Other reports described Guillain-Barre syndrome¹⁸, intestinal ischemia following accident with Lachesis muta¹⁹ and lung hemorrhage caused by Bothrops jararacussu^20,21.

Mortality due to snakebite is associated to renal failure, central nervous system hemorrhage and secondary infection.

Snakebites are common worldwide and can potentially lead to strokes. It is important to identify the potentials victims of neurological complications for a more precocious and effective treatment. The degree as the SSS, systemic blooding and abnormalities in the coagulation system seem to be involved. We call attention for an uncommon etiology of stroke that occur in tropical countries and are particularly important for Brazilian physicians who work in rural areas, as well as the public health authorities.

Received 17 July 2006, received in final form 23 October 2006. Accepted 8 December 2006.

Dr. Paulo César Santos-Soares - Rua Urbano Antônio de Souza - STIEP - 172 / 1204 - 41770-045 Salvador BA - Brasil. E-mail: [e-mail]

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Publication Dates

• Publication in this collection
  05 May 2010
• Date of issue
  June 2007

History

• Accepted
  08 Dec 2006
• Reviewed
  23 Oct 2006
• Received
  17 July 2006