症例は75歳の女性。主訴は呼吸困難　飼い犬に左手を噛まれた2日後，呼吸困難で近医を受診した。動脈血ガス分析にて低酸素血症を認め，血液検査にて敗血症，播種性血管内凝固症候群，多臓器不全と診断され，当センターに転送された。集中治療（エンドトキシン吸着，持続血液濾過透析）にて軽快し，第14病日退院した。後日，血液培養よりCapnocytophaga canimorsusが検出された。C. canimorsusはイヌ咬傷後の敗血症の原因菌として米国では死亡例も多数報告されており，高齢者・易感染者に重症例が多い。本邦での報告は稀であるが，早期に適切な抗生剤を選択する上で念頭に置くべき病原体と考える。

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We report an unusual case of a 63-year-old man supposedly bitten by a mamushi, who developed shock, bleeding diathesis and serious hematemesis at an early stage. About 10 minutes after the mamushi bite, he fell into shock transiently, and 2 hours later, continious bleeding from the bite wound and an injection site was observed. This platelet count decreased markedly to 1.3×10⁴/mm³ resulting in serious hematemesis. Four hours after the bite, we injected Agkistrodon halys antivenin (6, 000U) with methylpredonisolone sodium succinate 500mg and the bleeding from the bite wound and hematemesis improved remarkably. Twelve hours after the bite, the platelet count had increased to 27.1×10⁴/mm³, and the patient had recovered from the bleeding diathesis. Mamushi bites are sometimes complicated by DIC (disseminated intravascular coagulation) as a result of massive tissue necrosis, however, there was severe thrombocytopenia and bleeding diathesis in this case, even though the local swelling and muscle necrosis were not serious. It is very important to closely monitor patients after mamushi bites, and mamushi antivenin should be used early without hesitation when these complications are observed.

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Non-bacterial thrombotic endocarditis (NBTE) commonly occurs in patients with wasting disease (e.g. malignancy) or with valves damaged following trauma due to intra-cardiac foreign body, scarring or marked turbulence. Although disseminated intravascular coagulation (DIC) is well documented following viperine bite and the underlying mechanism of NBTE is thought to be DIC, there is no report of NBTE in humans following snake bite. We report a young male who following viperine bite developed local swelling, superficial gangrene of tissues at the site of bite, and oliguria and died following multiple cerebral infarcts and acute renal failure. The post-mortem examination showed NBTE of the aortic valve, multiple embolic infarcts of brain, spleen and kidneys, acute tubular necrosis and features of DIC in the brain in the form of fibrin thrombi in the capillaries, perivascular hemorrhages and necrosis.
(Internal Medicine 37: 342-344, 1998)

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