Table 1 Timeline of events with events and interventions

29/09/2016

Hump-nosed viper bite, admission to local hospital

30/09/2016

Full blood count, serum creatinine, 20-minute whole blood clotting test – normal

Discharged on orally administered analgesics and antibiotics

03/10/2016

Worsening swelling and pain in bite site due to cellulitis, readmitted to local hospital

Started on intravenously administered antibiotics

04/10/2016

Reduced urine output, transferred to National Hospital of Sri Lanka.

Mild shortness of breath, pallor, edema, pulmonary edema

Hemoglobin 7 g/dl, platelets 92,000. Blood picture – microangiopathic hemolytic anemia, LDH 2300 U/l, creatinine 888 μmol/l, ECG – normal

Intravenously administered antibiotics. Hemodialysis with red cell transfusion

05/10/2016 to 07/10/2016

Clinical improvement, resolution of shortness of breath

Platelets 160,000, persistent red cell fragments

Regular hemodialysis

08/10/2016

Acute onset shortness of breath, retrosternal tightening chest pain, and bibasal crackles in both lung fields

ECG – T wave inversion in V3 to V6 and aVL, troponin positive, platelets 205,000, LDH 2100 U/l. Echocardiogram (11/10/2016) – lateral wall dyskinesia

Anticoagulation with enoxaparin renal-adjusted doses, antiplatelet drugs and statins

13/10/2016

Melena

Esophagogastroduodenoscopy, acute bleeding in duodenum

Withheld antiplatelet drugs and anticoagulation, red cell transfusion, omeprazole infusion

16/10/2016

Worsening shortness of breath, fever, respiratory failure

Chest radiogram – bilateral diffuse opacification. Bronchoalveolar lavage – multi-resistant coliforms

Intravenously administered antibiotic changed. Intubation and ventilation with ICU care

24/10/2016

Unilateral limb swelling

Duplex scan of lower limb – ileofemoral deep vein thrombosis

Unfractionated heparin infusion

31/10/2016

Death