Case Report: Bothrops lanceolatus Snakebite Surgical Management-Relevance of Fasciotomy

Abstract

Bothrops lanceolatus is an endemic Crotalidae species in Martinique, where approximately 30 cases of envenoming are managed yearly. Envenoming characteristics from Bothrops species include local tissue damage, systemic bleeding, and hemodynamic alterations. We hereby report a case of severe envenomation following B. lanceolatus snakebite to the right calf. Severe local manifestations developed progressively up to the lower limb despite adequate antivenom therapy. Systemic manifestations of venom also occurred, resulting in intensive care therapy. Surgery exploration revealed soft tissue necrosis, friability of the deep fascia, and myonecrosis. The patient needed multiple debridement procedures and fasciotomy of all leg compartments and anterior compartment of the thigh. Diagnosis of necrotizing fasciitis was confirmed by positive Aeromonas hydrophila blood cultures. This clinical case illustrates that major soft tissue infection, including necrotizing fasciitis may occur after snakebite. Abnormal coagulation tests should not delay surgical management, as severe envenoming is a life-threatening condition.

Figure 1.

Bothrops lanceolatus (“Fer-de-Lance”). This figure appears in color at www.ajtmh.org.

Figure 2.

Envenoming emergent management protocol for patients suspected of envenomation by Bothrops lanceolatus (Intensive and Emergency Care Department [pole Réanimation Anesthésie SAMU, SMUR, URgences (RASSUR)]—University Hospital of Martinique).

Figure 3.

Graphic (A) and images (B and C) showing the extension of the lymphedema (dermographism in red dotted line) compared with the bite (red star) at day 1. This figure appears in color at www.ajtmh.org.

Figure 4.

(A) Subfascial necrotizing myositis of the lateral compartment. (B) Fasciotomy of the four compartments by lateral approach. (C) Fasciotomy of the anterior compartments of the thigh by anterolateral approach. This figure appears in color at www.ajtmh.org.

Figure 5.

Delayed healing by local collagen fibrosis near the debridement zone of the bite (day 8). This figure appears in color at www.ajtmh.org.