The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Lindsey R. Baden, M.D., Editor

A Viper Bite
A B

A
46-year-old farmer presented to the emergency department Tajamul Hussain, M.D.
3 hours after his penis was bitten by a snake while he was urinating in Rafi A. Jan, M.D.
an open field. The snake was identified by the patient as gunas, which Sher-i-Kashmir Institute of Medical Sciences
is the local name of the Levantine viper (Macrovipera lebetina). Physical examination Srinagar, India
revealed stable vital signs, with a grossly swollen penis and formation of hemor- salimtajamul@gmail.com
rhagic bullae at the puncture sites (Panel A). Laboratory investigations showed an
initial prothrombin time of 17 seconds (reference value, <12), an activated partial-
thromboplastin time of 34 seconds (reference value, <24), and a fibrinogen level
of 80 mg per deciliter (reference range, 200 to 400). Venous and arterial Doppler
ultrasonography revealed normal flow in the cavernosal and dorsal vessels of the
penis. The patient received polyvalent antisnake venom (a snake antivenom serum
that neutralizes the venom of the cobra, common krait, and viper) with no adverse
effects. At 36 hours after the initiation of treatment, the patients coagulopathy
had resolved and he was discharged home. The swelling subsided 4 days after
discharge, with the formation of necrotic tissue at the puncture sites (Panel B).
The patient had recovered completely at 2-week follow-up.
DOI: 10.1056/NEJMicm1410237
Copyright 2015 Massachusetts Medical Society.

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