60Y Female with decreased urine output and rectal bleeding post snakebite, on haemodialysis

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 A 60-year-old female, who is a farmer by occupation presented with the chief complaints of vomiting and blood in stools post snakebite on 24/6/23

History of Presenting Illness:

24/06/23: Patient was apparently asymptomatic before this day. She went to visit her family's farm in the evening when she was bitten by a snake on her right ankle. Within an hour, she was taken to the hospital and was treated there for 3 days. The dead snake was identified as a Russell's Viper. 

26/06/23: She was discharged on the third day. That same evening she had 5 episodes of vomiting and had 6 episodes bloody stools. 

27/06/23: She was brought back to the hospital the next day and on arrival, she had facial puffiness and pain+swelling over her right ankle. She was also experiencing decreased urine output for the past 1 day.

Hospital course: 

27/06/23: Patient was shifted from Emergency Medicine to GM

• Patient has severe anemia (Hb: 3.7g/dL)
• Serum Creatinine: 6.2mg/dL, BUN: 245
  Nephrology consulted; suggested emergency hemodialysis with 2 units PRBC transfusion.
• D-Dimer level: 5590
• Slightly deranged LFTs
• No urine output since admission.

28/06/23:

• Persistent right foot swelling. Suspected cellulitis (↑TLC)
• Elevated BUN and Cr.
• Mild hypokalemia
• Central line dialysis sheath inserted post 2D Echo (R-IJV, modified Seldinger technique)
• Patient has severe anemia and thrombocytopenia, 1 unit PRBC transfused.
• General Surgery consulted for right foot swelling and blood in stools; diagnosed with ext fissure@ 6o clock position. Suggested Sitz bath and MgSO4+glycerin dressing.

30/06/23 and 01/07/23: 

• Patient was reviewed by General Surgery. Suggested treatment was continued and active ambulation was adviced.
• 1 unit PRBC transfused on 30/06/23

03/07/23:

• Fever spikes noted.
• D-Dimer level: 2080
• ↑TLC (11,200)

05/07/23:

• B/L basal crepts were noted and patient was diagnosed with a right sided pleural effusion. (CXR done)
• Down trending serum Cr and BUN
• Mild swelling over Rt foot.

06/07/23:

• Pleural effusion is now B/L. Breath sounds are decreased, with coarse crepts predominantly on the right side.
• Serum creatinine: 4.2mg/dL, BUN: 53, increased from 5/7/23.
• Minimal swelling over the right foot.

08/07/23: Patient was shifted to Nephrology.

09/07/23:

• Deranged LFTs - TB: 1.47mg/dL; ALP: 386IU/L
• Persistent B/L pleural effusion.

        

Russell's Viper and bite site.     

History of past illness:

K/C/O Hypertension (diagnosed on arrival at the current hospital), not on medication 

The patient has had increasing bloating and dyspepsia that began 9 months ago. She complains of abdominal pain that starts after a meal which has led to her avoiding food. 

H/O fracture of right femur 6 years ago due to fall from standing height. (Implant present). She has occasional pain in the affected joint for which she visits her local RMP- takes unknown medication as needed (not using it currently)

H/O fracture of right humerus 15 years ago in a motor vehicle accident. 

No h/o head trauma and LOC

No ENT bleed

Not a K/c/o DM, CVA, CAD,TB asthma

Medication history: 

Uses unknown medication prescribed by local RMP for bloating and joint pain.

Surgical history: 

Tubectomy - 20yrs ago

Personal history

Has decreased appetite that the patient attributes to bloating and reflux. She eats 2 small meals a day and occasionally drinks 1 glass of milk.

Bowel movements: 1-2/day, normal in consistency

Urine output: Decreased urine output on admission with no similar complaints in the past.
5-6 times/day as of 13/07/23, no burning on micturition.

Does not drink alcohol or use tobacco in any form. No other drug use.

Food and drug allergies: No known allergies, avoids eating legumes due to the bloating.

Daily routine

Patient wakes up at 6am --> Cleans her backyard and cooks for herself. Has her first meal at 8am. Goes to visit her family farm. Has lunch at 1pm. Occasionally walks to the store in the evenings. Has dinner at 8pm and goes to bed between 9-10pm. She gets moderate exercise from her daily activities but is much more sedentary than she was 2 years ago, which she attributes to her age and decreased energy.

Family history

No similar complaints in the family.

General physical Examination 

On admission:

Vitals: 

Afebrile

BP: 140/80mmHg

HR: 93bpm

RR: 16cpm

SpO2: 98% on RA

GRBS: 150mg/dL

• Patient is conscious, coherent and cooperative, well oriented to time, place and person. 
• Pallor present 
• No signs of cyanosis, icterus, lymphadenopathy, clubbing
• Right pedal Edema+ at site of snakebite
• JVP normal

                          

Right IJV central line dialysis sheath

Taken on 13/07/23: Resolved edema of the foot.

       

Site of pain due to bloating

                        

Systemic examination

Cardiovascular System: S1, S2 heard, no murmurs.

Respiratory System: BAE+, NVBS 

Per Abdomen: Soft and nontender, no organomegaly. 

CNS: C/C/C, AOx3, no focal neurological defects, CN function intact.

Investigations: 

27/6/23:

ECG

28/6/23: 

ULTRASOUND- ABDOMEN AND PELVIS

Impression: 

1. Grade I RPD changes noted in B/L kidneys
2. Grade II fatty liver

2D ECHO (BEDSIDE)
Impression: 

1. Moderate AR, Mild TR with PAH, trivial MR
2. Sclerotic AV, no AS/MS
3. EF=68
4. Good LV systolic function
5. Diastolic dysfunction +, no PE
6. IVC diameter= 1.06cm

5:17AM

29/6/23: 

30/6/23:

4/7/23: 

2D ECHO 
Impression: 

1. No RWMA
2. Moderate AR, Mild TR with PAH, trivial MR
3. Sclerotic AV, no AS/MS
4. EF=65%
5. Good LV systolic function
6. Diastolic dysfunction +, no PE
7. IVC diameter= 1.12cm

7/7/23: 

ULTRASOUND- ABDOMEN AND PELVIS
Impression: Grade I RPD changes in B/L kidneys.

Provisional diagnosis: Snake venom induced AKI on CKD with right lower limb cellulitis (resolved).

Treatment: 

HAEMODIALYSIS (8 sessions)

BLOOD TRANSFUSION : Blood group: B+

1 UNIT PRBC (28/6/23)

1 UNIT PRBC (30/6/23)

INJ ONDANSETRON 4MG IV STAT

INJ PANTOPRAZOLE 40MG IV/OD

INJ OPTINEURON 10MG IN 500ML NS/IV/OD

INJ LASIX 80MG IV STAT

INJ LASIX 40MG IV/QID

INJ CLEXANE 60MG/SC/OD

INJ FONDAPARINUX 2.5MG/SC/OD

INJ CALCIUM GLUCONATE 10ML IV SLOW/STAT

SYP POTCHLOR 10ML PO/TID

TAB ACETAZOLAMIDE 250MG PO/BID

TAB SHELCAL 500MG PO/OD

TAB NICARDIPINE 10MG PO/BD

INJ ERYTHROPOEITIN 4000U SC ONCE A WEEK

TAB OROFER PO/OD

INJ TAXIM 1G/IV/BD

INJ METRONIDAZOLE 500MG/IV/TID

INJ MEROPENEM 500MG IV BD

0.9% NS/ PLASMALYTE A

IV FLUIDS NS @ 75ML/HR

MGSO4 DRESSING WITH GLYCERIN

SITZ BATH