Paradoxical viper envenomation: minimal local manifestations with fatal intracranial hemorrhage- an autopsy case report.

Viper envenomation typically presents with prominent local manifestations, including pain, edema, ecchymosis, cellulitis, and tissue necrosis. Severe systemic toxicity in the absence of significant local signs is uncommon. We report an atypical case of a viper envenomation in a 50-year-old male who presented with minimal local manifestations but rapidly developed life-threatening systemic complications. The 20-min whole-blood clotting test was non-clotting on admission. Despite prompt administration of polyvalent anti-snake venom (ASV) and symptomatic management, his condition progressively deteriorated. Non-contrast computed tomography of the brain on day 4 revealed an acute intracerebellar hemorrhage, which showed progressive enlargement on subsequent imaging on day 6, with tonsillar herniation. On the eighth day, he developed rapid hemodynamic deterioration and succumbed. At autopsy, two puncture wounds with mild discoloration were identified on the left foot, without significant local tissue reaction. Internal examination revealed a softened, edematous brain with hemorrhage involving the right cerebellar hemisphere and extending to the base of the skull. The snake, reportedly referred to by the patient as "Bandi," was presumptively identified as Echis carinatus sochureki, a subspecies of the saw-scaled viper commonly seen in the Thar Desert. The cause of death was given as intracranial hemorrhage and its complications secondary to venom-induced consumption coagulopathy (VICC) following vasculotoxic snake envenomation. This case highlights an atypical viper envenomation characterized by severe systemic coagulopathy despite minimal and non-progressive local manifestations. This unusual presentation may reflect inter- and intraspecies variation in venom composition and poses challenges for clinical recognition, management, and forensic interpretation.