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Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 108-110

Sublingual hematoma following viper envenoming

1 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Submission08-May-2018
Date of Acceptance27-Jun-2018
Date of Web Publication13-Aug-2018

Correspondence Address:
Dr. Godpower Chinedu Michael
Department of Family Medicine, Aminu Kano Teaching Hospital, P.M.B. 3452 Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jhrr.jhrr_20_18

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Snakebite envenoming causes considerable morbidity and mortality in rural, agrarian, and poor-resourced communities of Sub-Saharan Africa and Asia. Echis ocellatus (carpet viper) is responsible for most injuries and deaths in Northern Nigeria. Tissue necrosis and hemorrhage are the key features of this snake species. While bleeding can occur into virtually any tissue of the body following snakebite envenoming, sublingual hematoma (SLH) has been scarcely reported. The index patient was an adult female farmer with delayed presentation of SLH following venomous snakebite in a rural Nigerian community. Diagnostic and management challenges were encountered.

Keywords: Envenoming, Nigeria, rural health, sublingual hematoma, viper

How to cite this article:
Michael GC, Aliyu I, Grema BA. Sublingual hematoma following viper envenoming. J Health Res Rev 2018;5:108-10

How to cite this URL:
Michael GC, Aliyu I, Grema BA. Sublingual hematoma following viper envenoming. J Health Res Rev [serial online] 2018 [cited 2021 Jun 16];5:108-10. Available from: https://www.jhrr.org/text.asp?2018/5/2/109/238862

  Introduction Top

The sublingual space is a potential space between the floor of the mouth mucosa and the mylohyoid muscle; it is part of the suprahyoid group of fascial spaces and communicates with the submandibular and submental spaces. The suprahyoid group of fascial spaces receives blood supply mainly from the lingual artery. Hematoma of the sublingual space (sublingual hematoma [SLH]), which sometimes creates a “pseudo-Ludwig's phenomenon,”[1] has been associated with uncontrolled hypertension,[2] anticoagulant treatment,[3] ill-fitted dentures,[4] trauma, and tongue bite. However, in rural Sub-Saharan Africa and Asia where human-snake encounters are prevalent,[5] snakebite envenoming should be considered a possible etiology. An illustrative case is that of a 36-year-old farmer who presented with mouth swelling 9 days after lower limb snakebite at a rural health center in North-Central Nigeria.

  Case Report Top

A 36-year-old female farmer (without health insurance) was brought by her relatives into the emergency room of comprehensive health center, Zamko, Plateau State, North-Central Nigeria, with progressive swelling of the floor of the mouth for 7 days and inability to swallow solid food and speak, general body weakness, and mild respiratory distress on exertion for 2 days. There was associated low-grade, intermittent fever but no cough. There was no history of trauma, toothache, or denture use. However, she had right foot snakebite 9 days earlier in the farm; the snake was identified as carpet viper (Echis ocellatus) by her relatives and was killed. She was treated by a traditional healer with unidentified concoction on the bite wound and orally. However, she noticed swelling of her mouth 2 days later. She had transient but mild gingival bleeding but had no epistaxis, hematuria, or hematochezia. No history suggestive of neurotoxicity (ptosis, dysphagia, or muscle weakness) was observed. Her spouse, also a farmer, was treated for snakebite at the health center 3 years earlier. She was neither a known hypertensive, diabetic, nor used anticoagulants.

On physical examination, she was ill-looking; had no neck swelling, mildly pale, anicteric; but had axillary temperature of 37.8°C. She had some dehydration but absent peripheral lymphadenopathy. Her body mass index was 21.6 kg/m 2 (weight = 58 kg, height = 1.64 m). Her pulse rate was 100 beats per minute, of moderate volume and regular; her systolic and diastolic blood pressures were 110 mmHg and 60 mmHg, respectively. Her apex beat was at the fifth left intercostal space on the mid-clavicular line; the first and second heart sounds were heard. She had a Glasgow coma scale of 15 (E4V5M6). Oral examination revealed a tense, bulging hemorrhagic discoloration of the floor of the mouth completely occluding the mouth, angular drooling of saliva, and halitosis. There were no signs of neurotoxicity (ptosis, muscle weakness). The bite wound on the dorsal surface of the base of right fourth toe had healed. Findings in the respiratory, gastrointestinal, and genitourinary systems were not remarkable.

Her packed cell volume (PCV) was 24%; 20-min whole-blood clotting test (20-MWBCT) was clotted; no malaria parasite on microscopy was observed, random blood glucose was 4.3 mmol/L. She received 1 L of intravenous fluid (normal saline alternated with dextrose saline) 8 hourly for 24 h, 1 g of intravenous ampicillin/cloxacillin 6 hourly, and 500 mg of metronidazole 8 hourly for 48 h for probable sepsis. Twelve hours after admission, she had exploratory needle aspiration of the bulging mass in the floor of mouth which yielded altered blood. A total of 180 mL of altered blood was subsequently aspirated from the sublingual space followed by digital pressure with gauze over tongue to prevent re-accumulation of blood; 10 mL of intravenous slow-push Echis monospecific snake antivenom (South African Institute for Medical Research) was given (over 10 min) for possible secondary systemic envenoming following the procedure. No immediate or delayed allergic reaction to snake antivenom was observed. There was no respiratory distress. On the 3rd day of admission, there was remarkable reduction of the swelling, and she commenced on oral antibiotics, hematinics, and feeding. She made progressive improvements and was discharge on day 7 [Figure 1] with a PCV of 26% while 20-MWBCT remained clotted. She was given hematinics, along with anthelmintic and tetanus (intramuscular tetanus toxoid) prophylaxis. Follow-up 2 weeks later revealed complete resolution of symptoms.
Figure 1: Resolving sublingual hematoma

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  Discussion Top

E. ocellatus (carpet viper) causes most morbidity and mortality in Northern Nigeria.[5] Many snakebite envenomed victims seek care from traditional healers after a bite and only seek orthodox care late as seen in the index patient.[6] Tissue necrosis and hemorrhage are the characteristic features of E. ocellatus; bleeding into the intracranial cavity, broad ligament, and soft tissues has been widely reported.[7],[8] However, sublingual hematoma (SLH) following snakebite is a rare presentation [9] with diagnostic and management challenges.

Generally, the diagnosis of SLH irrespective of the cause is largely clinical;[1] however, it may require computerized tomography (to highlight hematoma), clotting profile, and Doppler ultrasound of neck vasculature to confirm the diagnosis.[2],[3] In addition, there is lack of consensus in the management of SLH. Conservative and surgical approaches have been reported.[10] Conservative management involves identifying and treating the cause of bleeding (e.g. warfarin overdose), close monitoring (to identify worsening symptoms), and securing the airways where necessary while waiting for natural hematoma resolution. The surgical approach also includes hematoma evacuation to rapidly relieve respiratory distress. The surgical approaches have been criticized for increased risk of infection, worsening airway edema, and psychological trauma of the intervention.[10]

However, this case, to the best of our knowledge, is the first case report of SLH following snakebite envenoming managed in a primary care facility, without imaging facilities and established protocol for managing SLH; hence, the diagnosis of SLH was mainly clinical. Fortunately, she was not in respiratory distress and 20-WBCT was clotted suggesting hepatic restoration of clotting factors after the envenomation; therefore, the risk of further bleeding was reduced. Partial hematoma evacuation using needle aspiration resulted in rapid decompression and early resumption of oral functions.

  Conclusion Top

SLH is a rare complication of snakebite envenoming that could present diagnostic and management challenges in rural areas with limited resources. High index of suspicion and a protocol for managing SLH in resource-limited settings, especially in the context of snakebite envenoming, are necessary for successful management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


Staff of Comprehensive Health Centre, Zamko and department of Family Medicine, Jos University Teaching Hospital.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Karmacharya P, Pathak R, Ghimire S, Shrestha P, Ghimire S, Poudel DR, et al. Upper airway hematoma secondary to warfarin therapy: A systematic review of reported cases. N Am J Med Sci 2015;7:494-502.  Back to cited text no. 1
Satpathy S, Guha R, Satpathy A, Guha P. Spontaneous sublingual space hematoma secondary to hypertension: A case report and review of literature. Natl J Maxillofac Surg 2015;6:96-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
Salmi A, Slimani M, Messaif D. Sublingual hematoma under oral anticoagulants. Clin Case Rep Rev 2015;1:167-8.  Back to cited text no. 3
Zeitoun H, Robinson P. A potential hazard for night denture wearers. J Laryngol Otol 1994;108:350-1.  Back to cited text no. 4
Habib AG, Kuznik A, Hamza M, Abdullahi MI, Chedi BA, Chippaux JP, et al. Snakebite is under appreciated: Appraisal of burden from West Africa. PLoS Negl Trop Dis 2015;9:e0004088.  Back to cited text no. 5
Sharma SK, Chappuis F, Jha N, Bovier PA, Loutan L, Koirala S. Impact of snake bites and determinants of fatal outcomes in Southeastern Nepal. Am J Trop Med Hyg 2004;71:234-8.  Back to cited text no. 6
Menon G, Kongwad LI, Nair RP, Gowda AN. Spontaneous intracerebral bleed post snake envenomation. J Clin Diagn Res 2017;11:PD03-4.  Back to cited text no. 7
Addo V, Kokroe FA, Reindorf RL. Broad ligament haematoma following a snake bite. Ghana Med J 2009;43:181-2.  Back to cited text no. 8
Fadare JO, Afolabi OA. Management of snake bite in resource-challenged setting: A review of 18 months experience in a Nigerian hospital. J Clin Med Res 2012;4:39-43.  Back to cited text no. 9
Evgeni B, Leonid K, Schwartz A, Efim R, Amit F, Alexander Z, et al. Spontaneous sublingual hematoma: Surgical or non-surgical management? Int J Case Rep Images 2012;3:1-4.  Back to cited text no. 10


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