Severe Coagulopathy, Retroperitoneal Hemorrhage, and Acute Respiratory Distress Syndrome Following Presumed Green Pit Viper (Trimeresurus spp.) Envenomation: A Case Report from Rural Nepal

Severe Coagulopathy, Retroperitoneal Hemorrhage, and Acute Respiratory Distress Syndrome Following Presumed Green Pit Viper (Trimeresurus spp.) Envenomation: A Case Report from Rural Nepal | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Severe Coagulopathy, Retroperitoneal Hemorrhage, and Acute Respiratory Distress Syndrome Following Presumed Green Pit Viper (Trimeresurus spp.) Envenomation: A Case Report from Rural Nepal Prabhat Kaphle¹, Pukar Gupta¹, Sarjan Shrestha, Salina Paudel¹, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7551132/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : Green pit viper ( Trimeresurus spp. ) envenomation chiefly results in localized tissue injury and hemotoxic sequelae. But systemic signs, including psoas hematoma, hemoperitoneum, and acute respiratory distress syndrome (ARDS), are quite rare. In places with few resources, it is especially hard to diagnose and treat problems early. Case Presentation : We present the case of a 38-year-old male from rural Nepal who had increasing edema and hemorrhage after a green pit viper envenomation. Laboratory tests showed severe coagulopathy and a quick decline in hemoglobin levels. Ultrasound at the bedside showed a hematoma in the left psoas muscle and significant hemoperitoneum. The patient declined advanced imaging. Then he acquired ARDS and needed therapy in the ICU and CPAP ventilation. The patient got completely better after acquiring antivenom on time and getting care from a group of doctors. Clinical Discussion : The thrombin-like enzymes present in green pit viper venom can induce consumptive coagulopathy and result in spontaneous hemorrhagic consequences. Venom-induced capillary leak and systemic inflammation may lead to ARDS. In this case, bedside ultrasonography functioned as an essential diagnostic alternative in the absence of CT imaging. To get a good result, one needs to respond swiftly and be able to adjust how one manages things. Conclusion : This case underscores the importance of identifying atypical yet life-threatening systemic effects following green pit viper envenomation. It also highlights how crucial it is to have flexible techniques to diagnose and treat patients in areas with minimal healthcare resources in order to save lives. Snake Bite Envenomation Coagulopathy Respiratory Distress Syndrome Case Report Figures Figure 1 Figure 2 Figure 3 Highlights Green pit viper envenomation can cause life-threatening bleeding and ARDS. Bedside ultrasonography is crucial when CT is unavailable. Early antivenom and supportive care improve outcomes. Clinicians in resource-limited settings must vigilantly monitor for delayed complications. This case shows full recovery without invasive procedures or advanced imaging. Introduction Green pit vipers ( Trimeresurus spp. ) are venomous snakes native to Asia, particularly Nepal, where snakebites continue to pose a major public health challenge [ 1 ]. People living in the hilly and Himalayan regions are especially at risk of bites from these snakes, whose venom produces both hemotoxic and cytotoxic effects [ 2 ]. The hemotoxins disrupt normal blood clotting mechanisms, leading to bleeding tendencies, coagulopathy, and thrombocytopenia [ 3 ]. Envenomation commonly causes local symptoms such as swelling, pain, blistering, and tissue necrosis. Although rare, delayed systemic hemorrhagic complications—including hemoperitoneum and deep muscle hematomas—can develop between 2 and 6 days after the bite [ 4 ]. Acute respiratory distress syndrome (ARDS), a severe but uncommon lung disease, can also result from systemic inflammation caused by venom [ 5 ]. We present a unique case of severe coagulopathy associated with psoas hematoma, hemoperitoneum, and acute respiratory distress syndrome (ARDS), treated at a tertiary care hospital in Nepal. This case exemplifies the diagnostic challenges faced in the absence of advanced imaging and is recorded in compliance with CARE Guidelines [ 10 ]. Case Presentation A 38-year-old man from rural Nepal who worked as a farmer got bitten by a presumed green pit viper on the dorsal aspect of his left hand around the base of his thumb while he was working in the field. The patient reported the snake was green; however, species confirmation was not possible due to a lack of photographic evidence or specimen collection, and no herpetological consultation was available. Four hours after the bite, he had his first treatment at a small health post. After 24 hours, he was referred to the nearest provincial hospital. He reported that he was having severe pain (8 out of 10 on the pain scale). On examination, his left forearm was swollen, and the puncture site was continuously bleeding when he came in. His vitals were stable, and there were two separate fang marks and swelling in the area around them. Initial laboratory tests indicated severe coagulopathy: Prothrombin Time (PT): 120 seconds (11–14 seconds is normal) International Normalized Ratio (INR): 9.23 (0.8–1.2) Activated Prothrombin Thromboplastin Time (aPTT): 120 seconds (Reference: 25–40 seconds) Platelets: 38,000/µL (Normal range: 150,000–400,000/µL) Hemoglobin (Hb) levels fell from 18.3 g/dL to 4.1 g/dL in 48 hours. He was admitted to the intensive care unit (ICU) and given 10 vials of polyvalent anti-snake venom over 48 hours ( Table 1 ) . Specific antivenom against the green pit viper is not available in Nepal; therefore, polyvalent antivenom targeting other snakes was administered empirically. The following day, the patient developed an episode of supraventricular tachycardia, which was brought under control using intravenous amiodarone (150 mg in 100 ml NS over 10 min). He said he had pain in his lower abdomen and swelling on the left side of his groin on the third day. A bedside ultrasound revealed a psoas hematoma (8.7 x 3.2 x 2.4 cm) and considerable hemoperitoneum ( Fig. 2 ) . A CT scan was recommended, which was declined by the patient. Supportive therapy included intravenous (IV) fluids, opioids, fresh frozen plasma (FFP), packed cell volume (PCV), and platelet-rich plasma (PRP) transfusions. The patient then had difficulty breathing, low oxygen levels (arterial oxygen saturation (SpO₂) 78% on room air), and bilateral infiltrates on chest X-rays ( Fig. 1 ). CPAP (continuous positive airway pressure) ventilation was initiated in the ICU due to hypoxemia and radiographic evidence of ARDS ( Fig. 3 ) . Over the following week, the patient showed marked clinical improvement. Coagulation parameters gradually normalized, and repeat ultrasonography demonstrated complete resolution of the psoas hematoma. He was subsequently discharged in stable condition without any neurological deficits. Table 1 Hospital course timeline correlating clinical events, laboratory findings, and interventions from Day 1 to 16. Day Key Events and Findings Interventions and Management Status/Remarks Day 1 Snakebite presentation; baseline labs and imaging done Anti-snake venom (10 vials over 48 hours), Vitamin K injection, ICU admission Initial stabilization; coagulopathy treated Day 2 Cardiac arrhythmia (SVT) detected Amiodarone started (150 mg in 100 ml NS over 10 min); cardiac enzymes, including Troponin-I and Creatine Kinase-MB (CK-MB), and echocardiography (echo) were done, and appear normal Cardiac monitoring and management initiated Day 3 Inguinal swelling noted; psoas hematoma detected by USG with considerable hemoperitoneum Surgery consulted; transfused FFP 2 pints Psoas hematoma diagnosis; supportive care maintained Day 4 PT/INR and APTT significantly increased; Hb dropped progressively, reaching a low of 4.1 g/dl FFP 2 pints transfused; antibiotics and analgesics given Coagulopathy worsening, severe anemia management Day 5 SOB developed early-onset bilateral lung effusions on a chest X-ray (CXR) posteroanterior (PA) view and an evolving hemoperitoneum on USG. PRBC (Packed Red Blood Cells) transfusion (3 pints); CPAP started Respiratory support for ARDS Day 6 Persistent coagulopathy; elevated liver function test (LFT) and PT/INR FFP 2 pints transfused Ongoing coagulation correction Day 7 High D-dimer (> 10 mg/l fibrinogen equivalent units (FEU)); further transfusions PRP transfused; continued supportive care Platelet support for thrombocytopenia. Normal value for D-dimer. Day 8 Respiratory status improved; Hb improved Continued monitoring Clinical improvement noted Days 9–11 Serial coagulation tests and clinical assessments ICU supportive care continued Monitoring hematoma progression and coagulation Day 12 Psoas hematoma size decreased on ultrasonography (USG) Surgical consult ongoing; conservative management Hematoma reduction; ongoing observation Days 13–15 Routine coagulation monitoring and supportive care Blood product transfusions as needed Efforts toward stabilization were ongoing Day 16 Patient clinically stable Discharged with follow-up advice Hematoma, ARDS, and Hemoperitoneum resolved Discussion One major component of the green pit viper’s venom resembles thrombin, called thrombin-like enzyme (TLE), which cleaves fibrinopeptide A, producing abnormal fibrin polymerization and a friable fibrin clot, resulting in consumption of fibrinogen, causing low fibrinogen levels in the blood, and this can contribute to spontaneous bleeding [ 6 ]. Although local bleeding is frequent, systemic hemorrhages, including hemoperitoneum and deep muscle hematoma, are uncommon but dangerous side effects [ 6 ]. With an incidence rate of about 0.1%, spontaneous psoas hematoma is a very uncommon clinical entity [ 7 ]. Clinical symptoms of psoas hematoma can include low back, abdominal, or inguinal pain; radiating pain involving the distribution of nerve roots; or chronic, ongoing blood loss [ 7 ]. Potential bleeding tendencies associated with spontaneous psoas hematoma might result in hemorrhagic shock and, in extreme situations, become fatal [ 7 ]. An essential clinical aspect is that a big psoas hematoma may compress and apply pressure on the femoral nerve, leading to paralysis [ 4 ]. Hemoperitoneum is a rare but significant consequence of snake envenomation that needs to be managed by a team of experts, which can be hard to do in places with few resources [ 8 ]. Venom toxins raise the permeability of capillaries, which causes fluid to seep out and leads to ARDS. Immune complex deposition and microthrombotic blockage in lung capillaries also play a role in this process [ 9 ]. The Berlin 2012 criteria are used to diagnose ARDS. These include symptoms starting within 7 days and bilateral chest X-ray opacities without heart failure or fluid overload [ 9 ]. CT imaging is the best way to find deep hematomas and hemoperitoneum. But bedside ultrasound is a useful option when CT is not available, rejected, or not recommended, especially in places with few resources. In Nepal, anti-snake venom is imported from India and targets envenomation by common cobra ( Naja naja ), common krait ( Bungarus caeruleus ), Russell’s vipers ( Daboi resseli ), and saw scaled viper ( Echis carinatus ) [ 11 ]. However, specific antivenom against the green pit viper is not available in Nepal [ 11 ]. As in our case, the patient did not specify any other distinguishing characteristics of the snake other than its green color; therefore, antivenom was administered as a precaution. This case highlights how crucial it is to identify respiratory issues and systemic bleeding in snakebite victims as soon as possible. To improve outcomes, multidisciplinary supportive care and prompt antivenom administration should be used in conjunction with flexible diagnostic techniques like laboratory testing, clinical evaluation, and bedside ultrasound when advanced imaging is not available. Conclusion Green pit viper envenomation can result in life-threatening ARDS and severe coagulopathy, complicated by uncommon systemic bleeding, including psoas hematoma and hemoperitoneum. Improving patient outcomes in resource-constrained environments such as Nepal requires prompt antivenom medication, early diagnosis, and all-encompassing supportive care directed by flexible diagnostic techniques. Abbreviations ARDS Acute Respiratory Distress Syndrome ICU Intensive Care Unit CPAP Continuous Positive Airway Pressure (continuous positive airway pressure) PT Prothrombin Time INR International Normalized Ratio APTT Activated Prothrombin Thromboplastin Time FFP Fresh Frozen Plasma PRBC Packed Red Blood Cells Spp. Species CBC Complete Blood Count CK-MB Creatine Kinase-MB CT Computed Tomography D-Dimer Fibrin Degradation Product ECG Electrocardiogram ECHO Echocardiography Hb Hemoglobin IV Intravenous LFT Liver Function Test PCV Packed Cell Volume PRP Platelet-Rich Plasma RFT Renal Function Test SOB Shortness of Breath SVT Supraventricular Tachycardia USG Ultrasonography (Ultrasound) Declarations Acknowledgment: We thank the intensive care, hematology, and general surgery teams at Provincial Hospital, a tertiary care center in Nepal, for their dedicated patient care. Funding sources: No funding was obtained for this study. The article contains the datasets that support its conclusions. Competing interests: The authors declare that they have no competing interests. Consent for publication: Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent form is available for review by the editor-in-chief of this journal upon request. Ethics approval: Since the subject matter is a case report, ethical clearance was not necessary. Registration of research studies: This is a case report, so registration was not required. Provenance and peer review: Not commissioned or externally peer-reviewed. References Pandey DP, Ghimire A, Shrestha BR. Retrospective Documentation of a Confirmed White-Lipped Green Pit Viper (Trimeresurus albolabris Gray, 1842) Bite in the South-Central Hills of Nepal. Wilderness Environ Med. 2019 Mar;30(1):79–85. Bhatt N, Singh A, Sharma SK. Case Report: Management of Pit Viper Envenoming without Antivenom: A Case Series. Am J Trop Med Hyg. 2020 Jun;102(6):1440–2. Selamat MA, Choon LK, Shamsuddin SR. Local envenomation by a green pit viper complicated by airway obstruction. Turk J Emerg Med. 2025 Jan;25(1):55–8. Kachhwaha A, Kumar A, Garg P, Sharma A, Garg MK, Gopalakrishnan M. This case report discusses delayed compression paralysis that occurred following an iliopsoas hematoma, which developed 30 days after envenomation by a saw-scaled viper (Echis carinatus sochureki). Wilderness Environ Med. 2023 Sep;34(3):366–71. Feola A, Marella GL, Carfora A, Della Pietra B, Zangani P, Campobasso CP. Snakebite Envenoming: A Challenging Diagnosis for the Forensic Pathologist: A Systematic Review. Toxins. 2020 Nov 3;12(11):699. Othong R, Eurcherdkul T, Chantawatsharakorn P. Green Pit Viper Envenomations in Bangkok: A Comparison of Follow-Up Compliance and Clinical Outcomes in Older and Younger Adults. Toxins. 2022 Dec 10;14(12):869. Zhao HH, Guo YF, Zhang SB, Harshita-shahi, Xu HW, Yu B, et al. Spontaneous psoas hematoma following posterior lumbar fusion surgery: a mini literature review. BMC Musculoskelet Disord. 2025 Mar 12;26(1):244. Yakubu A, Musa Y, Maiyaki A, Tambuwal S. Hemoperitoneum complicating venomous snakebite: A case report. Sahel Med J. 2020;23(3):191. G V, Geet A, Sonone S. Vasculotoxic snake bite induced multi-organ dysfunction—a case report. Asia Pac J Med Toxicol [Internet]. 2021 Jun [cited 2025 Jul 14]; 14]; 10(2). Available from: https://doi.org/10.22038/apjmt.2021.18232 https://www.care-statement.org/checklist https://www.edcd.gov.np/uploads/resource/5dec92fc9e365.pdf Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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13:08:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7551132/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7551132/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90909872,"identity":"3593f3a5-2d77-4854-99eb-153ada27adaf","added_by":"auto","created_at":"2025-09-09 13:32:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":541169,"visible":true,"origin":"","legend":"\u003cp\u003eChest X-rays showing progression from early bilateral infiltrates to diffuse consolidation in acute respiratory distress syndrome (ARDS) following green pit viper envenomation (arrows).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7551132/v1/e4f9d888a13fc84306a4c3b6.png"},{"id":90909870,"identity":"a02bff88-3065-4be0-a85c-d3854a6a0978","added_by":"auto","created_at":"2025-09-09 13:32:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":281951,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasonographic findings in green pit viper envenomation showing (A) left psoas hematoma (8.7 x 3.2 x 2.4 cm) (red arrows), (B) evolving hemoperitoneum, and intra-abdominal heterogeneous echogenic collections (red arrows).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7551132/v1/ba0a08a95e0e214f63dea621.png"},{"id":90912317,"identity":"a180bee3-7c7b-4db8-98ac-371b2b93d41a","added_by":"auto","created_at":"2025-09-09 13:48:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":91842,"visible":true,"origin":"","legend":"\u003cp\u003eHospital Course Graphical Timeline (Day 1-16)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7551132/v1/6401198dc1a641503316fac8.png"},{"id":91088675,"identity":"6802b5c3-3b97-4111-91e1-51bd7d91b3c6","added_by":"auto","created_at":"2025-09-11 12:47:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1813005,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7551132/v1/dd0201bc-40e7-49ec-ab6d-055164813955.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Severe Coagulopathy, Retroperitoneal Hemorrhage, and Acute Respiratory Distress Syndrome Following Presumed Green Pit Viper (Trimeresurus spp.) Envenomation: A Case Report from Rural Nepal","fulltext":[{"header":"Highlights","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003eGreen pit viper envenomation can cause life-threatening bleeding and ARDS.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBedside ultrasonography is crucial when CT is unavailable.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEarly antivenom and supportive care improve outcomes.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eClinicians in resource-limited settings must vigilantly monitor for delayed complications.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThis case shows full recovery without invasive procedures or advanced imaging.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eGreen pit vipers (\u003cem\u003eTrimeresurus spp.\u003c/em\u003e) are venomous snakes native to Asia, particularly Nepal, where snakebites continue to pose a major public health challenge [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. People living in the hilly and Himalayan regions are especially at risk of bites from these snakes, whose venom produces both hemotoxic and cytotoxic effects [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The hemotoxins disrupt normal blood clotting mechanisms, leading to bleeding tendencies, coagulopathy, and thrombocytopenia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Envenomation commonly causes local symptoms such as swelling, pain, blistering, and tissue necrosis. Although rare, delayed systemic hemorrhagic complications\u0026mdash;including hemoperitoneum and deep muscle hematomas\u0026mdash;can develop between 2 and 6 days after the bite [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Acute respiratory distress syndrome (ARDS), a severe but uncommon lung disease, can also result from systemic inflammation caused by venom [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. We present a unique case of severe coagulopathy associated with psoas hematoma, hemoperitoneum, and acute respiratory distress syndrome (ARDS), treated at a tertiary care hospital in Nepal. This case exemplifies the diagnostic challenges faced in the absence of advanced imaging and is recorded in compliance with CARE Guidelines [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 38-year-old man from rural Nepal who worked as a farmer got bitten by a presumed green pit viper on the dorsal aspect of his left hand around the base of his thumb while he was working in the field. The patient reported the snake was green; however, species confirmation was not possible due to a lack of photographic evidence or specimen collection, and no herpetological consultation was available.\u003c/p\u003e\u003cp\u003eFour hours after the bite, he had his first treatment at a small health post. After 24 hours, he was referred to the nearest provincial hospital. He reported that he was having severe pain (8 out of 10 on the pain scale). On examination, his left forearm was swollen, and the puncture site was continuously bleeding when he came in. His vitals were stable, and there were two separate fang marks and swelling in the area around them.\u003c/p\u003e\u003cp\u003eInitial laboratory tests indicated severe coagulopathy:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eProthrombin Time (PT): 120 seconds (11\u0026ndash;14 seconds is normal)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eInternational Normalized Ratio (INR): 9.23 (0.8\u0026ndash;1.2)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eActivated Prothrombin Thromboplastin Time (aPTT): 120 seconds (Reference: 25\u0026ndash;40 seconds)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePlatelets: 38,000/\u0026micro;L (Normal range: 150,000\u0026ndash;400,000/\u0026micro;L)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHemoglobin (Hb) levels fell from 18.3 g/dL to 4.1 g/dL in 48 hours.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eHe was admitted to the intensive care unit (ICU) and given 10 vials of polyvalent anti-snake venom over 48 hours \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Specific antivenom against the green pit viper is not available in Nepal; therefore, polyvalent antivenom targeting other snakes was administered empirically. The following day, the patient developed an episode of supraventricular tachycardia, which was brought under control using intravenous amiodarone (150 mg in 100 ml NS over 10 min). He said he had pain in his lower abdomen and swelling on the left side of his groin on the third day. A bedside ultrasound revealed a psoas hematoma (8.7 x 3.2 x 2.4 cm) and considerable hemoperitoneum \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. A CT scan was recommended, which was declined by the patient. Supportive therapy included intravenous (IV) fluids, opioids, fresh frozen plasma (FFP), packed cell volume (PCV), and platelet-rich plasma (PRP) transfusions.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patient then had difficulty breathing, low oxygen levels (arterial oxygen saturation (SpO₂) 78% on room air), and bilateral infiltrates on chest X-rays \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e CPAP (continuous positive airway pressure) ventilation was initiated in the ICU due to hypoxemia and radiographic evidence of ARDS \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Over the following week, the patient showed marked clinical improvement. Coagulation parameters gradually normalized, and repeat ultrasonography demonstrated complete resolution of the psoas hematoma. He was subsequently discharged in stable condition without any neurological deficits.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHospital course timeline correlating clinical events, laboratory findings, and interventions from Day 1 to 16.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKey Events and Findings\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterventions and Management\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStatus/Remarks\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSnakebite presentation; baseline labs and imaging done\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnti-snake venom (10 vials over 48 hours), Vitamin K injection, ICU admission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInitial stabilization; coagulopathy treated\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCardiac arrhythmia (SVT) detected\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAmiodarone started (150 mg in 100 ml NS over 10 min); cardiac enzymes, including Troponin-I and Creatine Kinase-MB (CK-MB), and echocardiography (echo) were done, and appear normal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCardiac monitoring and management initiated\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInguinal swelling noted; psoas hematoma detected by USG with considerable hemoperitoneum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSurgery consulted; transfused FFP 2 pints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePsoas hematoma diagnosis; supportive care maintained\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePT/INR and APTT significantly increased; Hb dropped progressively, reaching a low of 4.1 g/dl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFFP 2 pints transfused; antibiotics and analgesics given\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCoagulopathy worsening, severe anemia management\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSOB developed early-onset bilateral lung effusions on a chest X-ray (CXR) posteroanterior (PA) view and an evolving hemoperitoneum on USG.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePRBC (Packed Red Blood Cells) transfusion (3 pints); CPAP started\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRespiratory support for ARDS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePersistent coagulopathy; elevated liver function test (LFT) and PT/INR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFFP 2 pints transfused\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOngoing coagulation correction\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh D-dimer (\u0026gt;\u0026thinsp;10 mg/l fibrinogen equivalent units (FEU)); further transfusions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePRP transfused; continued supportive care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePlatelet support for thrombocytopenia. Normal value for D-dimer.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay 8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRespiratory status improved; Hb improved\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eContinued monitoring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eClinical improvement noted\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDays 9\u0026ndash;11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerial coagulation tests and clinical assessments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eICU supportive care continued\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMonitoring hematoma progression and coagulation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay 12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePsoas hematoma size decreased on ultrasonography (USG)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSurgical consult ongoing; conservative management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHematoma reduction; ongoing observation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDays 13\u0026ndash;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRoutine coagulation monitoring and supportive care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBlood product transfusions as needed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEfforts toward stabilization were ongoing\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay 16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatient clinically stable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDischarged with follow-up advice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHematoma, ARDS, and Hemoperitoneum resolved\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOne major component of the green pit viper\u0026rsquo;s venom resembles thrombin, called thrombin-like enzyme (TLE), which cleaves fibrinopeptide A, producing abnormal fibrin polymerization and a friable fibrin clot, resulting in consumption of fibrinogen, causing low fibrinogen levels in the blood, and this can contribute to spontaneous bleeding [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although local bleeding is frequent, systemic hemorrhages, including hemoperitoneum and deep muscle hematoma, are uncommon but dangerous side effects [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWith an incidence rate of about 0.1%, spontaneous psoas hematoma is a very uncommon clinical entity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Clinical symptoms of psoas hematoma can include low back, abdominal, or inguinal pain; radiating pain involving the distribution of nerve roots; or chronic, ongoing blood loss [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Potential bleeding tendencies associated with spontaneous psoas hematoma might result in hemorrhagic shock and, in extreme situations, become fatal [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. An essential clinical aspect is that a big psoas hematoma may compress and apply pressure on the femoral nerve, leading to paralysis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Hemoperitoneum is a rare but significant consequence of snake envenomation that needs to be managed by a team of experts, which can be hard to do in places with few resources [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eVenom toxins raise the permeability of capillaries, which causes fluid to seep out and leads to ARDS. Immune complex deposition and microthrombotic blockage in lung capillaries also play a role in this process [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The \u003cb\u003eBerlin 2012 criteria\u003c/b\u003e are used to diagnose ARDS. These include symptoms starting within 7 days and bilateral chest X-ray opacities without heart failure or fluid overload [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. CT imaging is the best way to find deep hematomas and hemoperitoneum. But bedside ultrasound is a useful option when CT is not available, rejected, or not recommended, especially in places with few resources.\u003c/p\u003e\u003cp\u003eIn Nepal, anti-snake venom is imported from India and targets envenomation by common cobra (\u003cem\u003eNaja naja\u003c/em\u003e), common krait (\u003cem\u003eBungarus caeruleus\u003c/em\u003e), Russell\u0026rsquo;s vipers (\u003cem\u003eDaboi resseli\u003c/em\u003e), and saw scaled viper (\u003cem\u003eEchis carinatus\u003c/em\u003e) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, specific antivenom against the green pit viper is not available in Nepal [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. As in our case, the patient did not specify any other distinguishing characteristics of the snake other than its green color; therefore, antivenom was administered as a precaution.\u003c/p\u003e\u003cp\u003eThis case highlights how crucial it is to identify respiratory issues and systemic bleeding in snakebite victims as soon as possible. To improve outcomes, multidisciplinary supportive care and prompt antivenom administration should be used in conjunction with flexible diagnostic techniques like laboratory testing, clinical evaluation, and bedside ultrasound when advanced imaging is not available.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eGreen pit viper envenomation can result in life-threatening ARDS and severe coagulopathy, complicated by uncommon systemic bleeding, including psoas hematoma and hemoperitoneum. Improving patient outcomes in resource-constrained environments such as Nepal requires prompt antivenom medication, early diagnosis, and all-encompassing supportive care directed by flexible diagnostic techniques.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eARDS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAcute Respiratory Distress Syndrome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntensive Care Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCPAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eContinuous Positive Airway Pressure (continuous positive airway pressure)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eProthrombin Time\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eINR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Normalized Ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAPTT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eActivated Prothrombin Thromboplastin Time\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFFP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFresh Frozen Plasma\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePRBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePacked Red Blood Cells\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSpp.\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSpecies\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComplete Blood Count\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCK-MB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCreatine Kinase-MB\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eD-Dimer\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFibrin Degradation Product\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eECG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eElectrocardiogram\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eECHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEchocardiography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHb\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHemoglobin\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntravenous\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLFT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLiver Function Test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePCV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePacked Cell Volume\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePRP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePlatelet-Rich Plasma\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRFT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRenal Function Test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSOB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eShortness of Breath\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSVT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSupraventricular Tachycardia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUSG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUltrasonography (Ultrasound)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment:\u003c/strong\u003e We thank the intensive care, hematology, and general surgery teams at Provincial Hospital, a tertiary care center in Nepal, for their dedicated patient care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources:\u003c/strong\u003e No funding was obtained for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe article contains the datasets that support its conclusions.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent form is available for review by the editor-in-chief of this journal upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u0026nbsp; Since the subject matter is a case report, ethical clearance was not necessary.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistration of research studies:\u003c/strong\u003e This is a case report, so registration was not required.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProvenance and peer review:\u003c/strong\u003e Not commissioned or externally peer-reviewed.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePandey DP, Ghimire A, Shrestha BR. Retrospective Documentation of a Confirmed White-Lipped Green Pit Viper (Trimeresurus albolabris Gray, 1842) Bite in the South-Central Hills of Nepal. Wilderness Environ Med. 2019 Mar;30(1):79\u0026ndash;85.\u003c/li\u003e\n\u003cli\u003eBhatt N, Singh A, Sharma SK. Case Report: Management of Pit Viper Envenoming without Antivenom: A Case Series. Am J Trop Med Hyg. 2020 Jun;102(6):1440\u0026ndash;2.\u003c/li\u003e\n\u003cli\u003eSelamat MA, Choon LK, Shamsuddin SR. Local envenomation by a green pit viper complicated by airway obstruction. Turk J Emerg Med. 2025 Jan;25(1):55\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eKachhwaha A, Kumar A, Garg P, Sharma A, Garg MK, Gopalakrishnan M. This case report discusses delayed compression paralysis that occurred following an iliopsoas hematoma, which developed 30 days after envenomation by a saw-scaled viper (Echis carinatus sochureki). Wilderness Environ Med. 2023 Sep;34(3):366\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eFeola A, Marella GL, Carfora A, Della Pietra B, Zangani P, Campobasso CP. Snakebite Envenoming: A Challenging Diagnosis for the Forensic Pathologist: A Systematic Review. Toxins. 2020 Nov 3;12(11):699.\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Othong R, Eurcherdkul T, Chantawatsharakorn P. Green Pit Viper Envenomations in Bangkok: A Comparison of Follow-Up Compliance and Clinical Outcomes in Older and Younger Adults. Toxins. 2022 Dec 10;14(12):869.\u003c/li\u003e\n\u003cli\u003eZhao HH, Guo YF, Zhang SB, Harshita-shahi, Xu HW, Yu B, et al. Spontaneous psoas hematoma following posterior lumbar fusion surgery: a mini literature review. BMC Musculoskelet Disord. 2025 Mar 12;26(1):244.\u003c/li\u003e\n\u003cli\u003eYakubu A, Musa Y, Maiyaki A, Tambuwal S. Hemoperitoneum complicating venomous snakebite: A case report. Sahel Med J. 2020;23(3):191.\u003c/li\u003e\n\u003cli\u003eG V, Geet A, Sonone S. Vasculotoxic snake bite induced multi-organ dysfunction\u0026mdash;a case report. Asia Pac J Med Toxicol [Internet]. 2021 Jun [cited 2025 Jul 14]; 14]; 10(2). Available from: https://doi.org/10.22038/apjmt.2021.18232\u003c/li\u003e\n\u003cli\u003ehttps://www.care-statement.org/checklist\u003c/li\u003e\n\u003cli\u003ehttps://www.edcd.gov.np/uploads/resource/5dec92fc9e365.pdf\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Snake Bite, Envenomation, Coagulopathy, Respiratory Distress Syndrome, Case Report","lastPublishedDoi":"10.21203/rs.3.rs-7551132/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7551132/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e:\u003cbr\u003e\nGreen pit viper (\u003cem\u003eTrimeresurus spp.\u003c/em\u003e) envenomation chiefly results in localized tissue injury and hemotoxic sequelae. But systemic signs, including psoas hematoma, hemoperitoneum, and acute respiratory distress syndrome (ARDS), are quite rare. In places with few resources, it is especially hard to diagnose and treat problems early.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e:\u003cbr\u003e\nWe present the case of a 38-year-old male from rural Nepal who had increasing edema and hemorrhage after a green pit viper envenomation. Laboratory tests showed severe coagulopathy and a quick decline in hemoglobin levels. Ultrasound at the bedside showed a hematoma in the left psoas muscle and significant hemoperitoneum. The patient declined advanced imaging. Then he acquired ARDS and needed therapy in the ICU and CPAP ventilation. The patient got completely better after acquiring antivenom on time and getting care from a group of doctors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Discussion\u003c/strong\u003e:\u003cbr\u003e\nThe thrombin-like enzymes present in green pit viper venom can induce consumptive coagulopathy and result in spontaneous hemorrhagic consequences. Venom-induced capillary leak and systemic inflammation may lead to ARDS. In this case, bedside ultrasonography functioned as an essential diagnostic alternative in the absence of CT imaging. To get a good result, one needs to respond swiftly and be able to adjust how one manages things.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e:\u003cbr\u003e\nThis case underscores the importance of identifying atypical yet life-threatening systemic effects following green pit viper envenomation. It also highlights how crucial it is to have flexible techniques to diagnose and treat patients in areas with minimal healthcare resources in order to save lives.\u003c/p\u003e","manuscriptTitle":"Severe Coagulopathy, Retroperitoneal Hemorrhage, and Acute Respiratory Distress Syndrome Following Presumed Green Pit Viper (Trimeresurus spp.) Envenomation: A Case Report from Rural Nepal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 13:32:13","doi":"10.21203/rs.3.rs-7551132/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b5706aa4-b80f-4142-8707-bf950d5475a8","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-11T12:38:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-09 13:32:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7551132","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7551132","identity":"rs-7551132","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}