Sochureki, the different saw- scaled viper: Challenges are many!

Area of Science:

• Toxicology
• Herpetology
• Clinical Medicine

Background:

• Snakebite envenoming is a significant public health issue in the Indian subcontinent, with underreporting being a common challenge.
• Antivenom therapy in India is primarily based on the "Big 4" snake species, with antivenom production often sourced from snakes in the southern region.

Observation:

• A case of saw-scaled viper (SSV) envenoming presented with an atypical combination of thrombotic microangiopathy (TMA) and venom-induced consumption coagulopathy (VICC).
• The patient's condition was refractory to the standard Indian polyvalent antivenom, and unfortunately, the patient succumbed to the envenoming.

Findings:

• The specific snake subspecies involved was identified as *Echis carinatus sochureki*.
• Venom-induced consumption coagulopathy (VICC) is the predominant coagulopathy in SSV bites, distinct from disseminated intravascular coagulation (DIC).
• The co-occurrence of TMA, particularly in *E. carinatus sochureki* bites, contributes to organ failure and is often misattributed to DIC.

Implications:

• This case underscores the critical need to differentiate VICC from DIC in SSV bites to guide appropriate clinical management.
• The ineffectiveness of the currently available Indian polyvalent antivenom against *Echis carinatus sochureki* envenoming necessitates the development of region-specific or broader-spectrum antivenoms.
• Understanding the unique pathophysiology, including the role of TMA, is crucial for improving outcomes in patients bitten by this viper subspecies.