A 46-year-old farmer presented to the emergency department 3 hours after his penis was bitten by a snake while he was urinating in an open field. The snake was identified by the patient as “gunas,” which is the local name of the Levantine viper (Macrovipera lebetina). Physical examination revealed stable vital signs, with a grossly swollen penis and formation of hemorrhagic bullae at the puncture sites (Panel A).
Laboratory investigations showed an initial prothrombin time of 17 seconds (reference value, <12), an activated partial-thromboplastin time of 34 seconds (reference value, <24), and a fibrinogen level of 80 mg per deciliter (reference range, 200 to 400). Venous and arterial Doppler ultrasonography revealed normal flow in the cavernosal and dorsal vessels of the penis. The patient received polyvalent anti–snake venom (a snake antivenom serum that neutralizes the venom of the cobra, common krait, and viper) with no adverse effects. At 36 hours after the initiation of treatment, the patient’s coagulopathy had resolved and he was discharged home. The swelling subsided 4 days after discharge, with the formation of necrotic tissue at the puncture sites (Panel B). The patient had recovered completely at 2-week follow-up.