Post Snake Bite Panhypopituitarism – Delay in Diagnosis or Delayed Presentation

Introduction:
Panhypopituitarism is a condition of inadequate or absent production of the anterior pituitary hormones. Simmonds’ disease was first described in 1914 by the German pathologist Simmond. Post snake bite panhypopituitarism is a described entity. Hypopituitarism following Russell’s viper bite was first reported in 1976 by Eapen et al in three adults from Kerala in South India. Most of the cases are diagnosed long after the snake bite, and this delay has been attributed to clinical inertia and lack of awareness. But on careful analysis of the case reports, it is found that at least a few of them started having symptoms after a latent period, which can be up to 5 years. We present 7 cases of post snakebite hypopituitarism, which were diagnosed late, but also had a delayed onset of symptoms.

Case Description:
Seven patients, who were diagnosed to have post snake bite hypopituitarism between May 2020 and May 2022 were studied. All patients were male. The type of snake, the complications and treatment initially given were studied, and then the time of onset of symptoms of hormonal deficiencies was collected. All patients underwent relevant hormonal tests, including dynamic tests and imaging for pituitary.

All patients were male, all were bitten by Russels viper, all had hypotension after the bite and required blood transfusions and hemodialysis. The mean duration from the snake bite to the diagnosis was 7.75 years. The onset of symptoms were also delayed, with symptoms occurring an average 4.25 years after the snake bite. All patients had symptoms of hypogonadism, which was the first symptom to occur in 5 out of 7 patients. Lethargy, tiredness, weakness were present in all and appeared next, a mean of 6 months later. Symptoms of adrenal insufficiency appeared in all patients, a mean of 2.5 years later. Adrenal crisis occurred in patients, a mean of 13 months later. On hormonal evaluation all patients had panhypopituitarism, (low FSH/LH Testosterone, Cortisol, IGF1, and FT4). MRI done showed empty sella in 5 patients and small anterior pituitary in 2 patients.

Discussion:
Hypopituitarism is an important sequel of Russell’s viper bite in South India. A high degree of suspicion is needed to diagnose this condition following Russell’s viper bite. Contrary to our earlier understanding of post snake bite hypopituitarism, the pituitary damage is not a single time event, but a gradual loss of pituitary function initiated by the snake bite, which results in a delayed appearance of symptoms. The sequence of loss of pituitary hormone functions- Gonadotropin- GH-Thyrotropin-ACTH also points to the same fact. The possible explanation is drawn from the analogy of Sheehan’s syndrome presenting late, where the late presentation is due to an autoimmune destruction, initiated by the snake bite (Anti pituitary antibody positive). The delay in diagnosis is at least contributed by the late appearance of panhypopituitarism, and the diagnosis should be considered in all patients with significant viper bite, presenting with symptoms suggestive of panhypopituitarism, however late may the onset of symptoms be.