title: Severe puff adder (Bitis arietans) envenomation with coagulopathy.
abstract: BACKGROUND
  The puff adder (Bitis arietans) is a highly toxic venomous snake that is responsible for a large proportion of the venomous snakebites in sub-Saharan Africa, where it is indigenous. Puff adder bites in North America result from snakes in captivity. Although thrombolytic enzymes are present in puff adder venom, significant coagulopathy has not been previously reported with a confirmed puff adder envenomation.
  
  
  RESULTS
  We report a serious puff adder envenomation to the finger, characterized by severe swelling, local tissue necrosis, hypotension, thrombocytopenia, severe coagulopathy, and hemorrhage. Fifteen vials of South Africa polyvalent antivenom were administered, beginning 4.5 hours post-envenomation, with step-wise improvement in hematological abnormalities. Other treatments included vasopressors, ventilatory support, leeches, transfusion, and eventual digit amputation. After a prolonged hospital course, the patient had a good outcome.
  
  
  CONCLUSIONS
  Puff adder envenomation causes tissue necrosis, hypotension, coagulopathy, thrombocytopenia, and spontaneous bleeding. Severe coagulopathy may occur. Physicians treating severe cases should be prepared to administer at least 15 vials of antivenom if needed.
authors.affiliation: Division of Medical Toxicology, Department of Emergency Medicine & Carolinas Poison Center, Carolinas Medical Center, Charlotte, North Carolina 28209, USA. eric.lavonas@carolinashealthcare.org
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Lavonas
authors.forename: Christian A
authors.initials: CA
authors.lastname: Tomaszewski
authors.forename: Marsha D
authors.initials: MD
authors.lastname: Ford
authors.forename: Anna M
authors.initials: AM
authors.lastname: Rouse
authors.forename: William P
authors.initials: WP
authors.lastname: Kerns
mesh_terms: D000328:Adult; D017732:Air Ambulances; D000671:Amputation, Surgical; D000818:Animals; D000997:Antivenins / Q000627:therapeutic use; D001778:Blood Coagulation Disorders / Q000097:blood* / Q000188:drug therapy / Q000473:pathology; D001794:Blood Pressure / Q000502:physiology; D005260:Female; D005385:Fingers / Q000473:pathology / Q000601:surgery; D006801:Humans; D009336:Necrosis; D012909:Snake Bites / Q000097:blood* / Q000188:drug therapy / Q000473:pathology; D017819:Viperidae
chemical_list: D000997:Antivenins