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Table of Contents    
Year : 2013  |  Volume : 61  |  Issue : 3  |  Page : 310-311

Hypopitutarism secondary to snake envenomation

1 Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission10-Apr-2013
Date of Decision11-Apr-2013
Date of Acceptance30-May-2013
Date of Web Publication16-Jul-2013

Correspondence Address:
Vivek Gupta
Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.115077

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How to cite this article:
Prabhakar A, Gupta V, Bhansali A, Vyas S, Khandelwal N. Hypopitutarism secondary to snake envenomation. Neurol India 2013;61:310-1

How to cite this URL:
Prabhakar A, Gupta V, Bhansali A, Vyas S, Khandelwal N. Hypopitutarism secondary to snake envenomation. Neurol India [serial online] 2013 [cited 2020 Jul 8];61:310-1. Available from:


This report presents an unusual case of hypopituitarism following snake envenomation. There are many causes of hypopituitarism, commonest being pituitary tumors.

A 25-year-old female presented with amenorrhea of 5 years duration. The patient had history of snake bite 5 years back on the left foot followed by swelling of the left leg, facial puffiness, abdominal distension, oliguria, hematuria and altered sensorium. Subsequently the patient had renal failure and had hemodialysis for the same. Since then the patient developed amenorrhea, poor appetite, cold intolerance, excessive sleepiness and generalized tiredness. Laboratory parameters were: T4 0.42 μg/d, T3 0.195 μg/ml, thyroid stimulating hormone 5.34 μIU/ml, luteinizing hormone 0.72 IU/L, follicle-stimulating hormone 2.09 mIU/ml, prolactin 3.15 ng/ml and cortisol 32.67 nmol/l. Magnetic resonance image (MRI) showed sella filled with cerebrospinal fluid [Figure 1]a and a very thin rim of soft-tissue along the floor of sella [Figure 1]b and [Figure 2]a. A faint rim of enhancing tissue was seen on contrast images suggestive of a remnant pituitary gland [Figure 2]b.
Figure 1: Coronal magnetic resonance image T2WI (a) and T1WI (b) images of the sella. The anterior pituitary gland is barely visible as thin soft tissue along the floor of sella (arrow)

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Figure 2: Sagittal T1WI pre (a) and post contrast (b) images. A thin rim of enhancing tissue is seen along the floor and posterior wall of the sella suggestive of remnant pituitary tissue (arrow in 2b)

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From the history and the clinical course which the patient had following snake bite 5 years back, it suggests probably the patient had Russell's viper envenomation. Russell's viper envenomation can lead to acute or chronic hypopituitarism. [1] Russell's viper venom has several biologically active procoagulant enzymes that lead to rapid activation of factors V, X amongst other steps in the clotting cascade. This leads to formation of fibrin crosslinks, which are promptly lysed by the fibrinolytic system. Eventually this leads to disseminated intravascular coagulation and coagulopathy develops. Pathologically microthrombi and hemorrhages are seen in the pituitary gland. The anterior pituitary is affected more commonly that the posterior pituitary. [2] An atrophic pituitary gland may be seen on imaging like in this patient. In an observational study of 96 patients with vasculotoxic snake bite, 9.37% of the patients showed evidence of hypopituitarism. However, of these patients only one had evidence of pituitary atrophy on MRI. [3] This study suggest the rarity of imaging changes in such cases. The chronic form is seen in patients who have recovered from systemic envenomation and is characterized by hormonal deficiency and clinical features of endocrine deficiency. [4] In Asian countries, where snake bite is common the knowledge of this rare entity and its imaging findings is important.

 » References Top

1.Tun-Pe, Phillips RE, Warrell DA, Moore RA, Tin-Nu-Swe, Myint-Lwin, et al. Acute and chronic pituitary failure resembling Sheehan's syndrome following bites by Russell's viper in Burma. Lancet 1987;2:763-7.  Back to cited text no. 1
2.Antonypillai CN, Wass JA, Warrell DA, Rajaratnam HN. Hypopituitarism following envenoming by Russell's vipers (Daboia siamensis and D. russelii) resembling Sheehan's syndrome: First case report from Sri Lanka, a review of the literature and recommendations for endocrine management. QJM 2011;104:97-108.  Back to cited text no. 2
3.Golay V, Roychowdhary A, Dasgupta S, Pandey R. Hypopituitarism in patients with vasculotoxic snake bite envenomation related acute kidney injury: A prospective study on the prevalence and outcomes of this complication. Pituitary 2013;PMID: 23456212. [epub ahead of print]  Back to cited text no. 3
4.Murthy GL, Krishanaprasad A, Srinivasan VR, Sundaram S. Acute pituitary necrosis following snake envenomation. J Assoc Physicians India 2002;50:452-3.  Back to cited text no. 4


  [Figure 1], [Figure 2]

This article has been cited by
1 Acute hypopituitarism complicating Russell’s viper envenomation: case series and systematic review
S. Rajagopala,M.M. Thabah,K.K. Ariga,M. Gopalakrishnan
QJM. 2015; 108(9): 719
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