Acute pancreatitis following adder bite in the UK: a case report

Case history

A 31-year-old man was admitted to hospital in early September following an adder bite whilst camping in Wales. The patient felt a sharp pain and bleeding at the back of his leg where swelling and two puncture marks later developed (Fig. 1). The pain increased in his leg and hours later he developed epigastric pain which worsened significantly over a week, at which point he presented to hospital. On presentation, he was comfortable, apyrexial and tenderness localised to the epigastrium. He had no signs of peritonism. Pancreatitis was diagnosed due to significantly raised amylase (473 IU/l) in the absence of other pathology using serum blood test, erect chest X-ray and ultrasound of the abdomen. He gave no history of alcohol abuse or prior ingestion of alcohol before onset of symptoms. Investigations revealed no gallstones either as a cause of pancreatitis. He denied any personal or family history of previous pancreatitis. His modified Glasgow score was 0 on admission and was treated with supportive care. He remained stable and was discharged the following day after an uneventful recovery.

Discussion

Adder bites commonly cause fairly minor symptoms. However, these have been known to result in death anywhere between 6–60 h after being bitten; the critical period of observation of the patient is the first 12 h. The early symptoms of adder bite include immediate pain, localised swelling and discolouration within minutes at the site of the bite, as was the case in our patient. There may also be gastrointestinal symptoms such as frequent vomiting and diarrhoea or, as in our case, well-localised epigastric tenderness. The principal effect is swelling which occurs within minutes and is usually localised to the site of the bite. Bruising is distributed in the region of the regional lymph nodes and main lymphatic trunks. Generally, patients recover quickly and deaths are rare with only 14 being recorded in the in the last 100 years.¹

Acute pancreatitis as a complication of adder bites is an extremely rare event with only one other case reported in the English literature.² However, more venomous snakes such as the cobra have been known to cause pancreatitis,³ along other venomous creatures such as bees and the well-Kjellstrom² reported that the patient underwent a laparotomy due to significant abdominal signs suggestive of peritonitis. The delay in the onset of symptoms following envenomation in our patient suggest the time taken for the venom to reach and impact upon the pancreas. Our patient also presented later when most mild-to-moderate acute pancreatitis usually resolves. Simple, standard investigations such as serum amylase and abdominal ultrasound were sufficient to make the diagnosis. Our patient underwent standard supportive care and resolved without any undue complications. Although there are now only two reported cases of adder bite induced pancreatitis, the indolent nature as suggested by our case may indicate more episodes that do not result in hospitalisation.

Conclusions

This case study adds to the limited data on pancreatitis associated with adder bites and highlights that this rare, but important, complication must be considered as an aetiological factor in appropriate circumstances. As suggested in our reported case, pancreatitis secondary to an adder bite appears to follow a natural history typical of most acute pancreatitis secondary to the usual causes and can, therefore, be managed using standard treatment.