Snake bite on scrotum – a case report

Snake bite on scrotum – a case report

 

Anjum Arshad^1,&, Mateen Azfar¹, Husain Munawwar¹, Usmani A Jawed¹

 

¹Department of Forensic medicine and Toxicology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

 

 

^&Corresponding author
Anjum Arshad, Department of Forensic medicine and Toxicology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

 

 

Since the dawn of civilization, snakes have inspired a mystic feeling of good and evil in human mind. In India popular folklores and deep rooted superstitions have put the asp in some places at the height of God and somewhere at the depth of hell as the evil incarnate. In India, snakes are found everywhere from 12,000 feet altitude of the Himalayas down to Cape Comorin, but different areas have different species preponderance. India is inhabited by more than 60 species of venomous snakes out of which only four have been popularly known to be dangerously poisonous to man; cobra, common krait, Russell viper and Saw Scaled Viper [1]. In India each year approximately 200,000 number of cases of snake bite are reported, out of which 45,000 to 50,000 succumb to death [2]. The problem is so under-rated that it was only added to WHO´s list of neglected tropical diseases in April, 2009 [2]. Many cases are non poisonous in nature, but emotional calamity and fright render them disastrous to the victims and their families.

 

 

According to the history given by the relatives of the patient, and which was substantiated and authenticated by the patient himself upon recovery, he was sleeping on the roof-top of his mud constructed house wearing a “lungi” (the loin cloth). At near to 12:30 am he felt something crawling up his thighs. By the time his reflexes worked the snake bit him on the scrotum and he felt immediate pain followed by little ooze of blood from the bite site. Immediately, driven by fright he caught the snake and threw it violently on the roof. It was killed by stamping over. No effort was made to identify it whether it was the poisonous or non-poisonous variety.

 

The patient was bitten by the snake at about 12.30 am and was brought to the Emergency Section of Jawaharlal Nehru Medical College Hospital, Aligarh, at 06:30 am. In the main city adequate facilities are available for treatment of all sorts of snake bite, including critical care management in the worst eventuality. However, due to ritual-based customs and dogma [2], the victim was treated by home-made ointment (Figure 1). Precious six hours were lost while the patient was shunted from local quack to “tantrik” who generally claim to have cure for all sorts of illnesses.

 

The patient presented with a classic sings of neurotoxicity. He had ptosis, drooling of saliva, sluggishness, apathy, disorientation, slurring of speech, inability to hold neck and difficulty in respiration (Figure 2). On examination of bite site, there was slight redness on inferior aspect of scrotum without any features of swelling, bruising, blistering, local bleeding, etc.

 

The patient was shifted to Intensive Care Unit (ICU) for support of mechanical ventilation and was promptly administered the Anti Snake Venom (ASV). The adjunct therapy included atropine, neostigmine, antibiotic, IV fluids etc. This standard treatment continued, and he was weaned away from the ventilator after 36 hours and later shifted to ward for observation.

 

The patient made a remarkable recovery and was discharged without any sequelae after ten days of hospital admission. The patient was a married man who tied the nuptial knot three months before the unfortunate incident. His wife was not pregnant at the time of the tragic occurrence. Upon recovery he was apprehensive regarding his fertility so he was advised periodic follow up to assess his potency and sperm count.

 

 

In India popular mythologies and unshakable superstitions has cemented in minds of people an inimitable place for snakes. By and large, no population is free from the fear of this little creature. Snakes occupy the extreme ends of spectrum by being worshiped and also being looked as an evil.

 

Due to deep rooted superstitions, strong beliefs and many associated myths, people resort to unscientific methods of management for snake bite thus causing delay in seeking proper treatment. As a result, valuable time is lost in most of the deserving cases. Further, cutting across all distinction between rich or poor, educated or illiterate, it is an ingrained belief that belligerent snake should be burnt after killing as the picture of its killer gets recorded in the eyes of it. Later, people believe the female snake particularly distinguish the killer by seeing the eyes of the killed snake and take revenge. Hence the snake is usually not available to identify its species.

 

Scrotum is a very rare and unusual site for snake bite. Very few cases have been reported in scientific journals. However, till date snake bite on scrotum with negligible local signs and significant systemic toxicity has not yet been reported in scientific journals. The most frequent site of snake bite is the lower extremity [3]. 60%–80% of snake bites occur on the foot, ankle, or leg. Different studies have time and again validated this fact [4]. Probably the higher incidence of snake bite on lower extremity is due to more exposure, easy accessibility, more contact with land, and less protection to the feet. Bites on the head and trunk are also reported and mostly occur when nocturnal species bite people while sleeping [3].

 

 

In Indian subcontinent, people particularly in rural areas sleep on roof tops, which make them prone to Snake bites. There are numerous superstitions associated with snakes and people still rely on traditional measures as first line of treatment, and thus valuable time is lost before patient is brought to hospital.

 

 

The authors declare no competing interests.

 

 

AA collected the data and did analysis and interpretation of literature and made the case report; AM have been involved in collecting pictures and review articles MH drafted the manuscript and did proof reading and JAU have given final approval of the version to be published. All authors read and approved the final manuscript.

 

 

Figure 1:“Homemade” ointment rubbed over the scrotum and on bitten part as a measure of first line of treatment

Figure 2: Patient with typical neurotoxic manifestations (ptosis)

 

 

1. Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, Rodriguez PS, Mishra K, Whitaker R, Jha P; Million Death Study Collaborators. Snake bite mortality in India: A nationally representative mortality survey. PLoS Negl Trop Dis. 2011 Apr 12;5(4):e1018. This article on PubMed


2. WHO SEARO (2010): Guidelines on management of snake-bites. New Delhi: WHO Regional Office for South-East Asia, Available at: http://www.searo.who.int/LinkFiles/BCT_snake_bite_guidelines.pdf. Accessed 1 September 2011


3. Hati AK, Mandal M, De MK, Mukherjee H, Hati RN. Epidemiology of snake bite in the district of Burdwan, West Bengal. J Indian Med Assoc. 1992 Jun;90(6):145-7. This article on PubMed


4. Bhat RN. Viperine Snake bite poisoning in Jammu. J Indian Med Assoc. 1974 Dec 16;63(12):383-92. This article on PubMed