Case Report: Delayed Diffuse Alveolar Hemorrhage in Echis sochureki Envenoming, Jodhpur, India.

Snakebite envenoming is a common occupational hazard in the tropics. Venom-induced consumption coagulopathy and acute kidney injury are the most frequently encountered complications of viper bites. Diffuse alveolar hemorrhage (DAH) is an unusual presentation reported rarely in the literature. Our case report highlights the uncommon presentation of delayed pulmonary hemorrhage after snakebite envenoming. A 40-year-old healthy man presented to our emergency department after 6 hours of Echis sochureki (a saw-scaled viper subspecies) bite. He had abnormal coagulation parameters and thrombocytopenia with no signs of acute kidney injury. Transfusion protocols were initiated because of active bleeding and a rapid decrease in hemoglobin levels over next few days. Around day 10, his coagulation profile and hemoglobin were corrected, but he developed hemoptysis with rapidly progressive respiratory distress. Computed tomography of the chest was suggestive of DAH and the patient was started on plasma exchange with pulse methylprednisolone. After the initial worsening, he had rapid symptomatic improvement and radiological resolution. The patient had persistent hypofibrinogenemia, which resolved, and was discharged and remained healthy at the 60-day follow-up. This case highlights a presentation with an initial phase of venom-induced consumption coagulopathy followed by delayed DAH in saw-scaled viper envenoming that was treated successfully with immunosuppressants and plasma exchange.