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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2015  |  Volume : 26  |  Issue : 2  |  Page : 335-338
Spontaneous peri-nephric hematoma in a patient with acute kidney injury following Russell's viper envenomation

Department of Nephrology, Institute of Postgraduate Medical Education and Research, Kolkata, India

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Date of Web Publication3-Mar-2015


Snake bite envenomation is a common cause of acute kidney injury (AKI) in the tropics and severe coagulopathy with bleeding manifestations is usually seen, especially with viperine bites. We present a case of a 34-year-old male who had developed AKI following Russell's viper envenomation along with disseminated intravascular coagulation. The patient was seemingly improving during the course of his treatment but subsequently developed a spontaneous unilateral peri-nephric hematoma and finally succumbed to this complication. This is a rare presentation that can be clinically innoccuous in a disease where there are multiple bleeding manifestations and, carries a very poor outcome.

How to cite this article:
Golay V, Roychowdhary A, Pandey R. Spontaneous peri-nephric hematoma in a patient with acute kidney injury following Russell's viper envenomation. Saudi J Kidney Dis Transpl 2015;26:335-8

How to cite this URL:
Golay V, Roychowdhary A, Pandey R. Spontaneous peri-nephric hematoma in a patient with acute kidney injury following Russell's viper envenomation. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 May 18];26:335-8. Available from: https://www.sjkdt.org/text.asp?2015/26/2/335/152500

   Introduction Top

Spontaneous peri-nephric hematoma is a rare entity and has been traditionally observed with conditions such as renal tumors or vascular diseases. [1] Because of varied clinical manifestations, the diagnosis is often missed, contributing to the mortality and morbidity associated with this condition. Imaging modalities play an important part in the diagnosis of perinephric hematoma. Vasculotoxic snake bites are an important cause of renal failure in the developing tropical countries and blood dyscra sias with bleeding manifestations are a common accompaniment. [2] We present a case of isolated spontaneous peri-nephric hematoma in a patient following Russell's viper envenomation. We could not find a similar clinical report in the literature, making this case a rare presentation.

   Case Report Top

This 34-year-old male patient had a Russell's viper bite in the left foot while working in the field, which was followed by local pain, swelling and decreased urine output, associated with hematuria, within six hours of the bite. He was managed conservatively in the local hospital and received anti-snake venom (ASV) in recommended doses. Following this, he was referred to our center. On examination, he had bleeding manifestations in the form of gum bleed, sub-conjunctival hemorrhage and palatal petechiae. The urine output in the previous 24 h was only 400 mL, the blood pressure (BP) was 86/60 mm Hg and the pulse rate (PR) was 110/min. The baseline investigations at admission showed blood urea of 124 mg/dL, creatinine of 2.4 mg/dL, hemoglobin of 14 g/dL, total leukocyte count of 34,000/μL and platelet count of 30,000/μL. His coagulation profile was checked and showed evidence of disseminated intravascular coagulation (DIC) in the form of deranged prothrombin time (PT), activated partial thromboplastin time (aPTT), raised fibrin degradation products (FDP) and d-dimer and decreased fibrinogen. He received additional doses of ASV (total of 300 mL) and was then initiated on hemodialysis (HD), which was administered every alternate day; all the sessions were heparin free in view of the coagulopathy. After initiation of dialysis, his BP gradually stabilized and there was clinical improvement. However, he continued to be anuric. The serum creatinine gradually increased to a maximum of 6 mg/dL during the next four days. He was also given platelet and fresh frozen plasma (FFP) transfusions.

On the eighth day of admission, he developed a dull aching pain in the abdomen, which was poorly localized and associated with nausea and vomiting. There was no history of trauma over the abdomen and no evidence of fresh episodes of obvious bleeding manifestations. On examination, there was fullness in the right lumbar and iliac regions with mild tenderness and guarding. An ultrasound was performed that showed a hypo-echoic collection around the upper pole of the right kidney appearing to compress the underlying parenchyma [Figure 1]. A non-contrast computerized tomographic (CT) scan of the abdomen was performed that showed a large peri-nephric hyper-dense collection around the right kidney extending into the retro-peritoneum [Figure 2]. The patient's BP was 90/60 mm Hg, PR was 110/min and platelet count was 80,000/μL; the PT, aPTT and fibrinogen levels were normal but d-dimer and FDP levels were elevated. He was given additional platelet and FFP transfusions. We finally lost the patient after two days of resuscitation due to refractory shock.
Figure 1: Ultrasound film showing a hypo-echoic collection around the upper pole of the right kidney with mild compression of the underlying kidney.

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Figure 2: Non-contrast computerized tomographic scan of the abdomen showing a large perinephric hyperdense collection around the right kidney extending into the retroperitoneum.

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   Discussion Top

Venomous snake bites are common in tropical countries and contribute to 3% of AKI in India and up to 40% in Myanmar. [3] Snake venoms generally cause cellular injury through enzymes, polypeptide toxins, cytokines and/or mediators. The snakes that cause renal failure produce venom that is either myotoxic or hemotoxic, resulting in rhabdomyolysis, intravascular hemolysis, DIC or hemorrhage. [2] The mechanism by which DIC occurs varies with the type of venom. The venom of Echis carinatus directly activates prothrombin to thrombin, [4] while the venom of Russell's viper activates Factor X, thereby inducing rapid thrombin formation in the presence of Factor V, calcium ions and phospholipids. [5] Plasmapheresis and blood exchange have been tried in snake envenomation, but it is not practical as they need to be performed before the venom fixes to the tissues. [6],[7] HD improves muscular symptoms in sea-snake bite; this suggests that dialysis removes some post-synaptic neurotoxins with small molecular weight. [8]

Bleeding manifestations following viperine bites can be both traumatic and spontaneous. Traumatic bleeding could be from recent wounds, including prolonged bleeding from the fang marks and from old partly healed wounds. Common manifestations of spontaneous systemic bleeding include those from the gums, epistaxis, bleeding into the tears, intracranial hemorrhage, hemoptysis, hematemesis, rectal bleeding or melena, hematuria, vaginal bleeding, ante-partum hemorrhage in pregnant women and bleeding into the mucosa, skin and retina. [9] There are many reports of rare manifestations of bleeding following snake bite envenomation, including hemoperitoneum, [10] broad ligament bleeding [11] and hemothorax. [12] However, we could not find any reported cases, to the best of our knowledge, in the published literature of snake bite as a cause of isolated spontaneous peri-renal hematoma.

The majority of causes of spontaneous renal hematomas are renal tumors, vascular diseases, infections and idiopathic. There are also reports of cases associated with blood dyscrasias, pre-eclampsia, etc. [1] Spontaneous renal hematoma may present with "Lenk's triad," which consists of acute flank pain, tenderness and symptoms of internal bleeding. However, various presentations have been described in the literature and sometimes may even mimic acute abdominal conditions such as acute appendicitis, perforated viscus or dissecting aneurysm. [13]

In our case, the probable cause of the perinephric hematoma is the coagulopathy associated with Russell's viper envenomation. Although this coagulopathy is generalized, the occurrence of a spontaneous peri-nephric hematoma seems to be a rare presentation. In light of the varied clinical manifestation and poor clinical outcome, it should be suspected and detected early.

   References Top

Zhang JQ, Fielding JR, Zou KH. Etiology of spontaneous perirenal hemorrhage: A meta-analysis. J Urol 2002;167:1593-6.  Back to cited text no. 1
Sitprija V. Snakebite Nephropathy. Nephrol 2006;11:442-8.  Back to cited text no. 2
Chugh KS. Etiopathogenesis of acute renal failure in the tropics. Ann Natl Acad Med Sci (India) 1987;23:88-99.  Back to cited text no. 3
Chugh KS, Mohanty D, Pal Y, Das KC, Ganguly NK, Chakravarty RN. Hemostatic abnormalities following Echis carinatus (saw scaled viper) envenomation in the rhesus monkey. Am J Trop Med Hyg 1981;30:1116-20.  Back to cited text no. 4
Macfarlane RG. Russell's viper venom. Br J Haematol 1967;13:437-51.  Back to cited text no. 5
Cobcroft RG, Williams A, Cook D, Williams DJ, Masci P. Hemolytic uremic syndrome following taipan envenomation with response to plasmapheresis. Pathology 1997;29:399-402.  Back to cited text no. 6
Peiris OA, Wimalaratne KD, Nimalasuriya A. Exchange transfusions in the treatment of Russell's viper bite. Postgrad Med J 1969;45: 627-9.  Back to cited text no. 7
Sitprija V, Sribhibhadh R, Benyajati C. Haemodialysis in poisoning by sea-snake venom. Br Med J 1971;3:218-9.  Back to cited text no. 8
Warrell DA. Guidelines for management of snake bites. WHO 2010.  Back to cited text no. 9
Rathod K, Sheth R, Chavhan G, Asrani A, Raut A. Hemoperitoneum complicating snake bite: Rare CT features. Abdom Imaging 2003; 28:820-1.  Back to cited text no. 10
Addo V, Kokroe FA, Reindorf RL. Broad Ligament Haematoma Following a Snake Bite. Ghana Med J 2009;43:181-2.  Back to cited text no. 11
Singh V, Digra SK, Slathia SS, Kakkar T. Hemothorax Following Snakebite. Indian Pediatr 2012;49:242-3.  Back to cited text no. 12
Baishya RK, Dhawan DR, Sabnis RB, Desai MR. Spontaneous subcapsular renal hematoma: A case report and review of literature. Urol Ann 2011;3:44-6.  Back to cited text no. 13
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Correspondence Address:
Dr. Vishal Golay
Department of Nephrology, Institute of Postgraduate Medical Education and Research, Kolkata
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DOI: 10.4103/1319-2442.152500

PMID: 25758885

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