Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, OX3 7LJ, UK.
QJM. 2011 Feb;104(2):97-108. doi: 10.1093/qjmed/hcq214. Epub 2010 Nov 28.
Russell's vipers (Daboia russelii and D. siamensis) inhabit 10 South and South East Asian countries. People envenomed by these snakes suffer coagulopathy, bleeding, shock, neurotoxicity, acute kidney injury and local tissue damage leading to severe morbidity and mortality. An unusual complication of Russell's viper bite envenoming in Burma (D. siamensis) and southern India (D. russelii) is hypopituitarism but until now it has not been reported elsewhere. Here, we describe the first case of hypopituitarism following Russell's viper bite in Sri Lanka, review the literature on this subject and make recommendations for endocrine investigation and management. A 49-year-old man was bitten and seriously envenomed by D. russelii in 2005. He was treated with antivenom but although he recovered from the acute effects he remained feeling unwell. Hypopituitarism, with deficiencies of gonadal, steroid and thyroid axes, was diagnosed 3 years later. He showed marked improvement after replacement of anterior pituitary hormones. We attribute his hypopituitarism to D. russelii envenoming. Russell's viper bite is known to cause acute and chronic hypopituitarism and diabetes insipidus, perhaps through deposition of fibrin microthrombi and haemorrhage in the pituitary gland resulting from the action of venom procoagulant enzymes and haemorrhagins. Forty nine cases of hypopituitarism following Russell's viper bite have been described in the English language literature. Patients with acute hypopituitarism may present with hypoglycaemia and hypotension during the acute phase of envenoming. Those with chronic hypopituitarism seem to have recovered from envenoming but present later with features of hypopituitarism. Over 85% of these patients had suffered acute kidney injury immediately after the bite. Steroid replacement in acute hypopituitarism is life saving. All 11 patients with chronic hypopituitarism in whom the outcome of treatment was reported, showed marked improvement with hormone replacement. Unrecognized acute hypopituitarism is potentially fatal while chronic hypopituitarism can be debilitating. Physicians should therefore be aware of this complication of severe envenoming by Russell's vipers, especially in Burma and South India, so that the diagnosis may be made without delay and replacement started with essential hormones such as hydrocortisone and thyroxine.
圆斑蝰（Daboia russelii 和 D. siamensis）栖息于 10 个南亚和东南亚国家。被这些蛇咬伤的人会出现凝血功能障碍、出血、休克、神经毒性、急性肾损伤和局部组织损伤，导致严重的发病率和死亡率。圆斑蝰咬伤的一种不常见并发症是垂体功能减退症，但迄今为止，在其他地方尚未报道过。在这里，我们描述了首例在斯里兰卡被圆斑蝰咬伤后发生垂体功能减退症的病例，回顾了该主题的文献，并就内分泌检查和管理提出了建议。一名 49 岁男子于 2005 年被 D. russelii 咬伤并严重中毒。他接受了抗蛇毒血清治疗，但尽管他从急性中毒中恢复，但仍感觉不适。3 年后，他被诊断为垂体功能减退症，性腺、类固醇和甲状腺轴均存在缺陷。在前垂体激素替代治疗后，他的病情明显改善。我们将他的垂体功能减退症归因于 D. russelii 中毒。已知圆斑蝰咬伤会导致急性和慢性垂体功能减退症和尿崩症，这可能是由于毒液促凝酶和出血素作用于垂体导致微血栓和出血所致。在英语文献中已经描述了 49 例圆斑蝰咬伤后发生垂体功能减退症的病例。急性垂体功能减退症患者在中毒的急性期可能会出现低血糖和低血压。那些患有慢性垂体功能减退症的患者似乎已经从中毒中恢复，但后来出现了垂体功能减退症的特征。这些患者中有超过 85%的人在咬伤后立即发生急性肾损伤。急性垂体功能减退症时类固醇替代治疗是救命的。在报告了治疗结果的 11 例慢性垂体功能减退症患者中，所有患者的症状均明显改善。未识别的急性垂体功能减退症可能致命，而慢性垂体功能减退症可能使人虚弱。因此，医生应该意识到这是由圆斑蝰严重中毒引起的并发症，尤其是在缅甸和印度南部，以便能够迅速诊断并开始用氢化可的松和甲状腺素等必需激素进行替代治疗。
