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Delayed hypopituitarism following Russell’s viper envenomation: a case series and literature review

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Abstract

Purpose

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.

Methods

We retrospectively reviewed data of eight DHP cases and literature to outline the presentation, manifestations, hormonal profiles, and radiological features of DHP following RVE.

Results

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.

Conclusions

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.

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References

  1. Vaiyapuri S, Vaiyapuri R, Ashokan R, Ramasamy K, Nattamaisundar K, Jeyaraj A et al (2013) Snakebite and its socio-economic impact on the rural population of Tamil Nadu, India. PLoS ONE 8(11):e80090

    Article  PubMed  PubMed Central  Google Scholar 

  2. Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F (2010) Snake bite in South Asia: a review. PLoS Negl Trop Dis 4(1):e603

    Article  PubMed  PubMed Central  Google Scholar 

  3. Mohapatra B, Warrell DA, Suraweera W et al (2011) Snakebite mortality in India: a nationally representative mortality survey. PLoS Negl Trop Dis 5(4):e1018. https://doi.org/10.1371/journal.pntd.0001018

    Article  PubMed  PubMed Central  Google Scholar 

  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):38–59

    PubMed  PubMed Central  Google Scholar 

  5. Mehta S, Sashindran V (2002) Clinical features and management of snake bite. Med J Armed Forces India 58(3):247–249. https://doi.org/10.1016/S0377-1237(02)80140-X

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Ahmed SM, Ahmed M, Nadeem A, Mahajan J, Choudhary A, Pal J (2008) Emergency treatment of a snake bite: pearls from literature. J Emerg Trauma Shock 1(2):97–105. https://doi.org/10.4103/0974-2700.43190

    Article  PubMed  PubMed Central  Google Scholar 

  7. Eapen CK, Chandy N, Kochuovarkey KL et al (1976) Unusual complication of snake bite: hypopituitarism after viper bites. In: Ohsaka A, Hayashi K, Sawai Y (eds) Animal, plant and microbial toxins, vol 2. Plenum Press, New York, pp 467–473

    Chapter  Google Scholar 

  8. Tun-Pe, Phillips RE, Warrell DA, Moore RA, Tin-Nu-Swe, Myint-Lwin, Burke CW (1987) Acute and chronic pituitary failure resembling Sheehan’s syndrome following bites by Russell’s viper in Burma. Lancet 2(8562):763–767

    Article  CAS  PubMed  Google Scholar 

  9. Rajagopala S, Thabah MM, Ariga KK, Gopalakrishnan M (2015) Acute hypopituitarism complicating Russell’s viper envenomation: case series and systematic review. QJM 108(9):719–728. https://doi.org/10.1093/qjmed/hcv011

    Article  CAS  PubMed  Google 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

    Article  CAS  PubMed  Google 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

    Article  CAS  PubMed  Google Scholar 

  12. James E, Kelkar PN (2001) Hypopituitarism after viperine bite. J Assoc Phys India 49:937–938

    CAS  Google Scholar 

  13. Srinivasan KG, Srividya S, Usha Nandhini KP, Ramprabananth S (2010) Chronic pituitary failure resembling Sheehan’s syndrome following a bite of Russell’s viper. A case report. Neuroradiol J 23(1):38–41

    Article  CAS  PubMed  Google Scholar 

  14. Bandyopadhyay SK, Bandyopadhyay R, Dutta A, Pal SK (2012) Hypopituitarism following poisonous viperbite. J Indian Med Assoc 110(2):120–122

    PubMed  Google Scholar 

  15. Prabhakar A, Gupta V, Bhansali A, Vyas S, Khandelwal N (2013) Hypopitutarism secondary to snake envenomation. Neurol India 61:310–311

    Article  PubMed  Google Scholar 

  16. Kamath AT, Satish Kumar S (2013) Snake bite and hypopituitarism: ignorance or incompetence? Endocr Abs 31:1–1

    Google 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):697–702

    PubMed  Google Scholar 

  18. Grace M, Shanoj KC (2014) An unusual complication of snake bite. Egypt J Intern Med 26:91–92

    Article  Google Scholar 

  19. Chakrabarti S (2014) Snake-Bite induced panhypopituitarism—an uncommon scenario. Indian J Med Case Rep 3:1–3

    Google 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):55–57

    Google 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):1002

    Google Scholar 

  22. Ratnakaran B, Punnoose VP, Das S, Kartha A (2016) Psychosis in secondary empty sella syndrome following a Russell’s viper bite. Indian J Psychol Med 38(3):254–256

    Article  PubMed  PubMed Central  Google Scholar 

  23. Amalnath D, Baskar D (2016) Multiple endocrine gland apoplexy post-snake bite. JCR 6:479–481

    Article  Google Scholar 

  24. Majumdar R, Mukherjee L, Biswas U, Jana CK (2017) Pituitary apoplexy—a rare and unusual complication following viper bite. Int J Med Sci Public Health 6:429–431

    Article  Google Scholar 

  25. Shivaprasad C (2011) Sheehan’s syndrome: newer advances. Indian J Endocrinol Metab 15(Suppl 3):S203–S207

    Google 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):e0003968

    Article  CAS  PubMed  PubMed Central  Google 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):23–38

    Article  CAS  PubMed  Google 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 75:399–411

    CAS  Google Scholar 

  29. Warrell DA (2009) Researching nature’s venoms and poisons. Trans R Soc Trop Med Hyg 103:860–866

    Article  CAS  PubMed  Google Scholar 

  30. Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N (2002) Pituitary autoimmunity in patients with Sheehan’s syndrome. J Clin Endocrinol Metab 87(9):4137–4141

    Article  CAS  PubMed  Google Scholar 

  31. De Bellis A, Kelestimur F, Sinisi AA, Ruocco G, Tirelli G, Battaglia M et al (2008) Anti-hypothalamus and anti-pituitary antibodies may contribute to perpetuate the hypopituitarism in patients with Sheehan’s syndrome. Eur J Endocrinol 158(2):147–152

    Article  CAS  PubMed  Google Scholar 

  32. Wolff H (1958) Insuficiência hipofisária anterior por picada de ofídio. Arq Bras Endocrinol Metabol 7:25–47

    Google Scholar 

  33. Casewell NR, Wagstaff SC, Wüster W, Cook DA, Bolton FM, King SI, Pla D, Sanz L, Calvete JJ, Harrison RA (2014) Medically important differences in snake venom composition are dictated by distinct postgenomic mechanisms. Proc Natl Acad Sci USA 111(25):9205–9210

    Article  CAS  PubMed  Google Scholar 

  34. Rosén T, Bengtsson BA (1990) Premature mortality due to cardiovascular disease in hypopituitarism. Lancet 336(8710):285–288

    Article  PubMed  Google 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):1169–1172

    CAS  PubMed  Google Scholar 

  36. Prabhakar VKB, Shalet SM (2006) Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J 82(966):259–266

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Tomlinson JW, Holden N, Hills RK, Wheatley K, Clayton RN, Bates AS, Sheppard MC, Stewart PM (2001) Association between premature mortality and hypopituitarism. West Midlands Prospective Hypopituitary Study Group. Lancet 357(9254):425–431

    Article  CAS  PubMed  Google Scholar 

  38. Bengtsson BA (1998) Untreated growth hormone deficiency explains premature mortality in patients with hypopituitarism. Growth Horm IGF Res 8(Suppl A):77–80

    Article  PubMed  Google Scholar 

  39. Crespo I, Santos A, Webb SM (2015) Quality of life in patients with hypopituitarism. Curr Opin Endocrinol Diabetes Obes 22(4):306–312

    Article  CAS  PubMed  Google Scholar 

  40. Hall R, Manski-Nankervis J, Goni N, Davies MC, Conway GS (2006) Fertility outcomes in women with hypopituitarism. Clin Endocrinol (Oxford) 65(1):71–74

    Article  CAS  Google Scholar 

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Acknowledgements

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.

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Authors and Affiliations

  1. Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India

    Channabasappa Shivaprasad, Yalamanchi Aiswarya, Atluri Sridevi, Biswas Anupam, Goel Amit, Boppana Rakesh, Pulikkal A. Annie & Kolly Anish

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  1. Channabasappa Shivaprasad
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  2. Yalamanchi Aiswarya
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Correspondence to Channabasappa Shivaprasad.

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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.

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Shivaprasad, C., Aiswarya, Y., Sridevi, A. et al. Delayed hypopituitarism following Russell’s viper envenomation: a case series and literature review. Pituitary 22, 4–12 (2019). https://doi.org/10.1007/s11102-018-0915-1

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