Hemotoxicity and nephrotoxicity manifestations and tetanus complication following red-tailed green pit viper (Trimeresurus insularis) bite: A case report

Snakebite envenoming is a neglected tropical disease that causes significant suffering, disability, and early death across all continents. In countries with low- and middle-income economies, there is an insufficiency of antivenins both in quantity and quality. This report aims to highlight hemotoxicity and nephrotoxicity manifestations and the rarely reported tetanus complications that may occur following a Trimeresurus insularis viper bite. A 61-year-old male presented to the emergency room with a swollen left arm a day after he was bitten by a viper on his left index finger. The patient was vomiting and experiencing pain. During hospitalization, laboratory findings showed a progressive decline in platelet count with no sign of bleeding and increased levels of urea and creatinine. However, after eight days of hospitalization, the patient began to show signs of tetanus, and we then had to refer him to a more advanced hospital. T. insularis is commonly found in East Java, Bali, and the Lesser Sunda Islands, and is a common cause of snakebites in lowland East Java. The mechanism of thrombocytopenia in snake envenomation is unclear. Metalloproteinases in snake venom can cause microvascular damage followed by bleeding. In conclusion, severe thrombocytopenia from a T. insularis bite can occur alone without a sign of other coagulopathies that can be improved by the only antivenin available in Indonesia and optimal supportive care. Although rare, tetanus from snakebite should be recognized as a possibility. It should be taken into account that one antivenom does not correspond to all species of snakes. Therefore, the type of antivenom procurement should follow the most common species distribution in each region.