Delayed hypopituitarism following Russell’s viper envenomation: a case series and literature review
- 102 Downloads
Hypopituitarism (HP) is an uncommon consequence of Russell’s viper envenomation (RVE). Delayed hypopituitarism (DHP) presents months to years after recovering from snake bites (SB). The clinical presentation, manifestations, and outcomes of DHP following RVE have not been systematically studied. Here, we present a case series of HP following RVE with delayed diagnosis and conduct a literature review.
We retrospectively reviewed data of eight DHP cases and literature to outline the presentation, manifestations, hormonal profiles, and radiological features of DHP following RVE.
Three men and five women, with a mean age at diagnosis of 39.5 ± 11.6 years, were included. The mean duration between snake bite (SB) and HP diagnosis was 8.1 ± 3.6 years. Secondary hypothyroidism and hypogonadotropic hypogonadism were present in all patients. Growth hormone deficiency (GHD) and secondary hypocortisolism were present in 6 (75%) patients. Magnetic resonance imaging (MRI) revealed empty sella and partially empty sella in three patients each (75%). The literature review revealed additional 20 DHP cases (mean age at diagnosis 32.4 ± 10.8 years), with 65% of patients being men. Fatigue, reduced libido, and loss of weight were the commonest symptoms among men. Secondary amenorrhea, fatigue, and loss of appetite were common manifestations among women. Acute kidney injury, GHD, secondary hypothyroidism, hypogonadism, and adrenal insufficiency were reported in 75%, 79%, 95%, 100%, and 85% of patients, respectively.
DHP is an important complication of RVE, and a delay in its diagnosis is associated with significant morbidity. Patients with RVE should be followed up for a long term to identify DHP.
KeywordsRussell’s viper envenomation Snake bite Hypopituitarism Delayed presentation Pituitary necrosis Amenorrhea
We would like to acknowledge the timely help provided by Dr. Nagashree N, Intern Medical Officer at the Vydehi Institute of Medical Sciences and Research Centre in retrieving full text manuscripts. We would also like to thank Mrs. Sumithra Selvan for her help in statistical analysis.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.
Informed consent was obtained from all individual participants included in the study.
- 4.Warrell DA, Gutiérrez JM, Calvete JJ, Williams D (2013) New approaches & technologies of venomics to meet the challenge of human envenoming by snakebites in India. Indian J Med Res 138(1):38–59Google Scholar
- 10.Antonypillai CN, Wass JA, Warrell DA, Rajaratnam HN (2011) Hypopituitarism following envenoming by Russell’s vipers (Daboia siamensis and D. russelii) resembling Sheehan’s syndrome: first case report from Sri Lanka, a review of the literature and recommendations for endocrine management. QJM 104(2):97–108. https://doi.org/10.1093/qjmed/hcq214 CrossRefGoogle Scholar
- 11.Golay V, Roychowdhary A, Dasgupta S, Pandey R (2014) Hypopituitarism in patients with vasculotoxic snake bite envenomation related acute kidney injury: a prospective study on the prevalence and outcomes of this complication. Pituitary 17(2):125–131. https://doi.org/10.1007/s11102-013-0477-1 CrossRefGoogle Scholar
- 12.James E, Kelkar PN (2001) Hypopituitarism after viperine bite. J Assoc Phys India 49:937–938Google Scholar
- 14.Bandyopadhyay SK, Bandyopadhyay R, Dutta A, Pal SK (2012) Hypopituitarism following poisonous viperbite. J Indian Med Assoc 110(2):120–122Google Scholar
- 16.Kamath AT, Satish Kumar S (2013) Snake bite and hypopituitarism: ignorance or incompetence? Endocr Abs 31:1–1Google Scholar
- 17.Golay V, Roychowdhary A, Pandey R, Pasari A, Praveen M, Arora P, Sarkar D (2013) Growth retardation due to panhypopituitarism and central diabetes insipidus following Russell’s viper bite. Southeast Asian J Trop Med Public Health 44(4):697–702Google Scholar
- 19.Chakrabarti S (2014) Snake-Bite induced panhypopituitarism—an uncommon scenario. Indian J Med Case Rep 3:1–3Google Scholar
- 20.Shetty S, Abi MS, Hickson R, David T, Rajaratnam S (2014) Hypopituitarism and autoimmune thyroiditis following snake bite: an unusual clinical scenario. J Assoc Phys India 62(11):55–57Google Scholar
- 21.Sudulagunta SR, Sodalagunta MB, Khorram H, Sepehrar M, Noroozpour Z (2015) Generalized fatigue, amenorrhea due to snake bite? SM J Case Rep 1(1):1002Google Scholar
- 25.Shivaprasad C (2011) Sheehan’s syndrome: newer advances. Indian J Endocrinol Metab 15(Suppl 3):S203–S207Google Scholar
- 26.Isbister GK, Maduwage K, Scorgie FE, Shahmy S, Mohamed F, Abeysinghe C, Karunathilake H, O’Leary MA, Gnanathasan CA, Lincz LF (2015) Venom concentrations and clotting factor levels in a prospective cohort of Russell’s viper bites with coagulopathy. PLoS Negl Trop Dis 9(8):e0003968CrossRefGoogle Scholar
- 27.Than-Than, Francis N, Tin-Nu-Swe, Myint-Lwin, Tun-Pe, Soe-Soe, Maung-Maung-Oo, Phillips RE, Warrell DA (1989) Contribution of focal haemorrhage and microvascular fibrin deposition to fatal envenoming by Russell’s viper (Vipera russelli siamensis) in Burma. Acta Trop 46(1):23–38CrossRefGoogle Scholar
- 28.Proby C, Tha-Aung, Thet-Win, Hla-Mon, Burrin JM, Joplin GF (1990) Immediate and long-term effects on hormone levels following bites by the Burmese Russell’s viper. Q JMed 75:399–411Google Scholar
- 32.Wolff H (1958) Insuficiência hipofisária anterior por picada de ofídio. Arq Bras Endocrinol Metabol 7:25–47Google Scholar
- 35.Bates AS, Van’t Hoff W, Jones PJ, Clayton RN (1996) The effect of hypopituitarism on life expectancy. J Clin Endocrinol Metab 81(3):1169–1172Google Scholar