Acute Myocardial Infarction following a possible direct intravenous bite of Russell’s viper (Daboia russelli)

We report a unique case of inferior wall ST elevation myocardial infarction due to a Russell’s viper bite over a vein with possible direct intravenous envenoming, in a young male with no past history or family history suggestive of ischemic cardiac disease, from Sri Lanka. In addition, the possible mechanisms of myocardial ischemia in snake bite victims are also briefly discussed.Importance of the awareness of physicians on the rare, yet fatal manifestations of snake envenoming is highlighted.Envenoming by Russell’s viper (Daboia russelli) is common in Sri Lanka, particularly in North Central Province where it leads to highest number of bites than any other snake [1], causing frequent systemic envenoming [2,3]. Local swelling (92%), local necrosis (8.9%), coagulopathy (77%), neurotoxicity (78%), nephrotoxicity (18%), cardiac effects (3-12%) and myotoxicity (14%) is known to be associated with envenoming by Russell’s vipers [2]. The available antivenom for this snake (Indian polyvalent antivenom), is known to be less effective in treating victims bitten by Sri Lankan Russell’s viper [3].Ischemic cardiac events [2], arrhythmias [4] and cardiac tamponade [5] rarely occur after Russell’s viper bites. Although very rare, myocardial infarction following Russell’s viper bite has been previously reported from Sri Lanka [6]. We report rapid development of inferior wall ST elevation myocardial infarction after Russell’s viper bite, probably due to direct intravenous venom injection.A 33？year old male was admitted to the Emergency Treatment Unit of the Teaching Hospital, Anuradhapura, Sri Lanka, at 07:15 p.m on 09th April 2012, following a Russell’s viper bite to his right ankle. The bite had taken place at 06:30 p.m on the same day when he was returning home after fishing, on a foot path from an inland reservoir. The patient identified the offending snake and noticed blood gushing out from the bite site. The assailant snake was not collected. He developed tightness of the che