Pulmonary hemorrhage and the management following Russell’s viper (Daboia russelii) envenoming in Sri Lanka

Abstract

Background: Patients presenting to Emergency department following consumption of toxic substances is not an uncommon phenomenon globally. It becomes essential for the Emergency physicians to have in-depth knowledge of all the toxic products available in their locality. In rural parts of South India, the most common method of poisoning is by consumption of pesticides, followed by plant poisons, because of its easy availability. Gloriosa superba is an important medicinal plant growing in several parts of Southeast Asia. All parts of this plant contain several alkaloids including colchicine with the highest concentration in seeds and tubers. Acute intoxication following ingestion of G. superba is indistinguishable from colchicine overdose. Clinical presentation: The symptoms of intoxication can be classified in three phases. Phase 1:(2-24 hours) early gastrointestinal symptoms mimicking gastroenteritis, volume depletion, hypotension, peripheral leucocytosis; Phase 2:(24 to 72 hours) mental status changes, oliguric renal failure, hematopoietic problems, electrolyte imbalance, acid-base disturbance, shock, bone marrow suppression, liver failure, ARDS, arrhythmias, cardiovascular collapse, encephalopathy and neuromuscular involvement; and Phase 3:(1-3 weeks) Recovery typically occurs within few weeks of ingestion but with rebound leucocytosis and alopecia. Case report: We present a patient who ingested Gloriosa superba tubers with suicidal intent and developed acute fulminant liver failure a week after ingestion. Two weeks later, he also developed alopecia. Liver functions gradually improved and normalized after three weeks of hospitalisation. He was provided supportive treatment and he improved remarkably. At discharge, total bilirubin was 1.3 mg/dL, direct bilirubin 0.6 mg/dL, serum urea 15mg/dL and serum creatinine 0.9 mg/dL. On follow-up visits, alopecia showed an improving trend. Conclusion: Colchicine exerts a multiorgan toxicity. Acute fulminant hepatic failure can be a life threatening manifestation of Gloriosa superba poisoning. Hepatic failure can be due to colchicine induced direct hepatic injury with cytolysis. Management is essentially supportive with anecdotal reports showing benefit in plasmapheresis.