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Cañas CA, Vecino MJ, Posso-Osorio I. Atypical Hemolytic Uremic Syndrome in a Patient With Bothrops asper Envenomation. Wilderness Environ Med 2021; 33:109-115. [PMID: 34740531 DOI: 10.1016/j.wem.2021.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/29/2022]
Abstract
Bothrops asper envenomation is common in Colombia and is characterized by local tissue injury and venom-induced consumption coagulopathy (VICC). Rarely, thrombotic microangiopathy is associated with envenomation by this species. The case of a 57-y-old man with B asper bite and envenomation on the left foot is presented. The patient was admitted 8 h after the event and progressively developed edema, hemorrhage at the site of the bite, and hemorrhagic blisters. His coagulation test results (prothrombin and partial thromboplastin times) were prolonged, and his fibrinogen levels were severely reduced. The diagnosis of VICC was made. Administration of Colombian polyvalent viper antivenom controlled the VICC within a few hours. Subsequently, the patient developed severe microangiopathic anemia, thrombocytopenia, and acute kidney injury. A diagnosis of thrombotic microangiopathy was made, and the patient met the criteria for hemolytic uremic syndrome. Management with hemodialysis in addition to therapeutic plasma exchange and replacement with fresh frozen plasma was indicated. The patient's condition resolved 14 d later. To the best of our knowledge, this is the first case of B asper envenomation in which the patient presented with hemolytic uremic syndrome after VICC. A proposal is made regarding the pathogenesis of this chain of events.
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Affiliation(s)
- Carlos A Cañas
- Department of Internal Medicine, Unit of Rheumatology, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia.
| | - Milly J Vecino
- Department of Internal Medicine, Unit of Rheumatology, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Iván Posso-Osorio
- Department of Internal Medicine, Unit of Rheumatology, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
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2
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Noutsos T, Currie BJ, Isoardi KZ, Brown SGA, Isbister GK. Snakebite-associated thrombotic microangiopathy: an Australian prospective cohort study [ASP30]. Clin Toxicol (Phila) 2021; 60:205-213. [PMID: 34328386 DOI: 10.1080/15563650.2021.1948559] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Snakebite-associated thrombotic microangiopathy (TMA) occurs in a subset of patients with venom-induced consumption coagulopathy (VICC) following snakebite. Acute kidney injury (AKI) is the commonest end-organ manifestation of TMA. The epidemiology, diagnostic features, outcomes, and effectiveness of interventions including therapeutic plasma-exchange (TPE), in snakebite-associated TMA are poorly understood. METHODS We reviewed all patients with suspected or confirmed snakebite recruited to the Australian Snakebite Project (2004-2018 inclusive), a prospective cohort study, from 202 participating Australian hospitals across the country. TMA was defined as anemia with schistocytosis. RESULTS 2069 patients with suspected snakebite were enrolled, with 1158 (56.0%) systemically envenomed, of which 842 (72.7%) developed VICC, from which 104 (12.4%) developed TMA. Of those systemically envenomed, TMA occurred in 26% (13/50) taipan, 17% (60/351) brown, and 8% (16/197) tiger snakebites. Thrombocytopenia was present in 90% (94/104) of TMA cases, and a further eight (8%) had a > 25% decrease in platelets from the presentation. Patients with TMA were significantly older than non-TMA patients with VICC (53 [35-61] versus 41 [24-55] years, median [IQR], p < 0.0001). AKI developed in 94% (98/104) of TMA patients, with 34% (33/98) requiring dialysis (D-AKI). There were four deaths. In D-AKI TMA cases, eventual dialysis-free survival (DFS) was 97% (32/33). TPE was used in five D-AKI cases, with no significant difference in DFS or time to independence from dialysis. >90-day follow-up for 25 D-AKI cases (130 person-years) showed no end-stage kidney disease but 52% (13/25) had ≥ stage 3 chronic kidney disease (CKD). CONCLUSION Our findings support a definition of snakebite-associated TMA as anemia with schistocytosis and either thrombocytopenia or >25% drop in platelet count. AKI occurring with snakebite-associated TMA varied in severity, with most achieving DFS, but with a risk of long-term CKD in half. We found no evidence of benefit for TPE in D-AKI.
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Affiliation(s)
- Tina Noutsos
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Bart J Currie
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Katherine Z Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia.,Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| | - Simon G A Brown
- Centre for Clinical Research in Emergency Medicine, University of Western Australia, Perth, Australia.,Aeromedical and Medical Retrieval Division, Ambulance Tasmania, Hobart, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
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3
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Noutsos T, Currie BJ, Lek RA, Isbister GK. Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis. PLoS Negl Trop Dis 2020; 14:e0008936. [PMID: 33290400 PMCID: PMC7748274 DOI: 10.1371/journal.pntd.0008936] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 12/18/2020] [Accepted: 10/30/2020] [Indexed: 02/06/2023] Open
Abstract
Snakebite is a neglected tropical disease with significant morbidity and mortality. Thrombotic microangiopathy (TMA) is an important but poorly understood complication of snakebite associated with acute kidney injury (AKI). Numerous treatments have been attempted based on limited evidence. We conducted a systematic review of TMA following snakebite using a pre-determined case definition of blood film red cell schistocytes or histologically diagnosed TMA. The search strategy included major electronic databases and grey literature. We present a descriptive synthesis for the outcomes of AKI, dialysis free survival (DFS), other end-organ damage, overall survival, and interventions with antivenom and therapeutic plasmapheresis (TPE). This study was prospectively registered with PROSPERO (CRD42019121436). Seventy-two studies reporting 351 cases were included, predominantly small observational studies. Heterogeneity for study selection, design, reporting and outcomes were observed. The commonest envenoming species were hump-nosed vipers (Hypnale spp.), Russell's viper (Daboia russelii) and Australian brown snakes (Pseudechis spp.). The prevalence of TMA was at least 5.4% in proven and probable Hypnale bites, and 10-15% of Australian elapid envenomings, AKI occurred in 94% (293/312) of TMA cases, excluding case reports. The majority of cases with AKI required dialysis. Included prospective and retrospective cohort studies reporting interventions and renal outcomes showed no evidence for benefit from antivenom or TPE with respect to DFS in dialysis dependant AKI. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment for quality of accumulated evidence for interventions was low. The major complication of TMA following snakebite is AKI. AKI improves in most cases. We found no evidence to support benefit from antivenom in snakebite associated TMA, but antivenom remains the standard of care for snake envenoming. There was no evidence for benefit of TPE in snakebite associated TMA, so TPE cannot be recommended. The quality of accumulated evidence was low, highlighting a need for high quality larger studies.
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Affiliation(s)
- Tina Noutsos
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Flinders Health and Medical Research Institute, Flinders University, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Bart J. Currie
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Rachel A. Lek
- Flinders Health and Medical Research Institute, Flinders University, Australia
| | - Geoffrey K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
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4
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Hump-nosed pit viper (Hypnale hypnale and Hypnale zara) envenoming in Deniyaya, Sri Lanka: Epidemiological and clinical features from a prospective observational study. Toxicon 2020; 189:19-23. [PMID: 33144122 DOI: 10.1016/j.toxicon.2020.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 11/22/2022]
Abstract
Hypnale hypnale, Hypnale zara and Hypnale nepa are the three species of Hump nosed pit vipers that are implicated in human bites in Sri Lanka. H. zara and H. nepa are two endemic species to the country. The objective of the study was to characterize epidemiology and clinical features after different Hump nosed pit viper species bites. A prospective observational study was conducted in Base Hospital Deniyaya from 2013 to 2015. Hump nosed pit viper as the offending snake was identified when the victims brought live or dead specimens. Species identification of dead specimen was done by a herpetologist. Clinical details were recorded during the hospital stay. 83 Hump nosed pit viper bite patients (19-81 years) were studied. Fifty two dead specimens were identified as 39 of H. zara and 13 of H. hypnale by the herpetologist. No H. nepa was identified. Thirty one live snakes were identified as Hump nosed pit vipers and released in to the wild. Envenoming was reported throughout the year. Eighty (96.4%) were daytime bites. Hands (43.4%), feet (55.4%) and arms (1.2%) were affected sites. Sixty two (74.7%) were bitten in tea plantations. All had pain over bite site. Overall, sixty nine (83.1%) had local swelling, seven (8.4%) extensive limb swelling, nineteen (22.9%) haemorrhagic blisters, and seven (8.4%) regional lymphadenopathy. Four (4.8%) patients had incoagulable blood by 20WBCT. H. zara bites had 28.2% haemorrhagic blisters, 7.7% extensive limb swelling and 2.6% coagulopathy. H. hypnale bites had 7.7% each extensive limb swelling and coagulopathy and 23.1% haemorrhagic blisters. None developed elevated serum creatinine. Neurotoxicity was not noted. Hump nosed pit viper bites caused substantial morbidity. Risk factors included day time outdoor activities and occupation. Pain, extensive limb swelling, bite site swelling, haemorrhagic blisters, regional lymphadenopathy and coagulopathy were prominent clinical features. Nephrotoxicity and neurotoxicity were notably absent. Clinical features varied depending on the species implicated.
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Mota SMB, Albuquerque PLMM, Silva Júnior GBD, Daher EDF. Thrombotic microangiopathy due to Bothrops erythromelas: a case report in Northeast Brazil. Rev Inst Med Trop Sao Paulo 2020; 62:e53. [PMID: 32725056 PMCID: PMC7384591 DOI: 10.1590/s1678-9946202062053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/04/2020] [Indexed: 11/22/2022] Open
Abstract
Bothrops erythromelas are serpents that belong to the Viperidae family, which are the main species responsible for human snakebites in Ceara State, Northeast Brazil. Thrombotic microangiopathy (TMA) is an uncommon group of disorders characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia and acute kidney injury (AKI), and occurrence after snakebites have been rarely reported. In this report, we described the case of a 57 year-old-man without comorbidities who was bitten by a Bothrops erythromelas on his right ankle. He presented with pain, edema and local bleeding. Symptomatology and laboratory tests were compatible with the diagnosis of TMA. He received specific antivenom and fluids replacement without any anaphylactic reaction. The conservative treatment was effective and there was no need for red blood cells transfusion or plasmapheresis. The aim of this report was to describe the first case of thrombotic microangiopathy following Bothrops erythromelas envenoming in the Northeast Brazil, providing insights about important mechanistic pathways of Bothrops snakebite-associated TMA and how to change the prognosis of the disease.
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Affiliation(s)
- Sandra Mara Brasileiro Mota
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | | | | | - Elizabeth De Francesco Daher
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
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Rathnayaka RMMKN, Ranathunga PEAN, Kularatne SAM. Kidney injury following envenoming by hump-nosed pit viper (Genus: Hypnale) in Sri Lanka: proven and probable cases. Trans R Soc Trop Med Hyg 2020; 113:131-142. [PMID: 30544230 DOI: 10.1093/trstmh/try120] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/20/2018] [Accepted: 10/24/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hump-nosed pit vipers (Hypnale hypnale) are highly venomous snakes found in Sri Lanka and the Western Ghats region of India. They are the most common cause of venomous snakebites in Sri Lanka, mainly causing local envenoming leading to pain, swelling and necrosis. Systemic envenoming causing acute kidney injury and coagulopathy are more commonly recognized following their bites. METHOD A series of 465 patients with hump-nosed viper bites was prospectively studied over four years from January 2014. All patients were assessed and the data were collected by the principal investigator (primary data). RESULTS Forty-four (9.5%) patients developed acute kidney injury, of which 23 (5%) were proven cases and 21 (4.5%) were probable cases. Of the proven cases, 4 (17%) progressed to chronic kidney disease and 12 (52%) had thrombotic microangiopathy, from which 11 (48%) developed haemolytic uremic syndrome and 1 (4%) had thrombotic thrombocytopenic purpura. Twelve (52%) showed microangiopathic haemolysis and 15 (65%) had thrombocytopenia. Oliguria was observed in 10 (43%) whereas 7 (30%) each had anuria and normal urine output. Ten patients (43%) developed haematuria, from which 6 had microscopic haematuria and 4 had macroscopic haematuria. Proteinuria was observed in 8 (35%). Coagulopathy developed in 3 (13%) patients. In probable cases, 3 (14%) died due to complications of kidney injury. CONCLUSION A significant proportion of patients develop acute kidney injury following hump-nosed pit viper bite. Who will develop acute kidney injury or succumb to the venom is unpredictable. Reliable and accessible treatments are a critical unmet need.
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Affiliation(s)
- R M M K Namal Rathnayaka
- Intensive care unit, Provincial General Hospital, Ratnapura, Sri Lanka.,Department of Veterinary Pathobiology, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Sri Lanka.,Postgraduate Institute of Medicine, University of Colombo (Clinical Pharmacology and Therapeutics), Sri Lanka
| | | | - S A M Kularatne
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka
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7
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Noutsos T, Currie BJ, Isbister GK. Snakebite associated thrombotic microangiopathy: a protocol for the systematic review of clinical features, outcomes, and role of interventions. Syst Rev 2019; 8:212. [PMID: 31439028 PMCID: PMC6706936 DOI: 10.1186/s13643-019-1133-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 08/13/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy is an uncommon complication of snake envenoming associated with a subset of snakebite cases presenting with venom-induced consumption coagulopathy. It presents with microangiopathic haemolytic anaemia and thrombocytopenia. Available studies are predominantly small retrospective observational studies only. Renal end organ injury appears common. It has variably been likened to either thrombotic thrombocytopenic purpura or atypical haemolytic uraemic syndrome. Many studies report acute kidney injury, with dialysis required in a subset of patients. Some studies suggest a role for treatment with plasmapheresis. Interpretation of the literature is complicated by variable nomenclature and historically poor case definitions of both venom-induced consumption coagulopathy and thrombotic microangiopathy associated with snake envenoming. METHODS The main objective of this systematic review is to synthesise the worldwide experience of snakebite-associated thrombotic microangiopathy with respect to its features and outcomes, and collate any evidence for the role of plasmapheresis as treatment. A predetermined case definition of confirmed or suspected snakebite with either blood film evidence of microangiopathic haemolytic anaemia or histological evidence of thrombotic microangiopathy will be used. This case definition will determine the search terms and study inclusion criteria. Relevant studies will be identified by electronic database, published conference abstracts, and grey literature search. This systematic review will be performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The quality of included studies will be assessed by a proposed tool for evaluating the methodological quality of case reports and case series. Results will be reported by a descriptive synthesis with a focus on the presenting features; outcomes of acute kidney injury, dialysis-free survival, other end organ damage, and overall survival; and any evidence of a role for treatment with plasmapheresis. The quality of accumulated evidence will be assessed via the Grading of Recommendations, Assessment, Development, and Evaluations framework. DISCUSSION It is anticipated that eligible studies will consist of small observational studies. Evidence gathered from this review will provide the first broader understanding of the clinical features, outcomes, prognosis, and management of snakebite-associated thrombotic microangiopathy. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019121436.
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Affiliation(s)
- Tina Noutsos
- Menzies School of Health Research, Charles Darwin University, Darwin, NT Australia
- College of Medicine and Public Health, Flinders University, Adelaide, SA Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, NT Australia
| | - Bart J. Currie
- Menzies School of Health Research, Charles Darwin University, Darwin, NT Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, NT Australia
| | - Geoffrey K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW Australia
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Mohan G, Guduri PR, Shastry S, Kandasamy D. Thrombotic microangiopathy in hematotoxic snakebites and its impact on the prognosis: an entity often overlooked. J Thromb Thrombolysis 2019; 48:475-482. [DOI: 10.1007/s11239-019-01868-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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An Atypical Clinical Manifestation of a Hump-Nosed Pit Viper Envenomation. Case Rep Med 2019; 2019:4172395. [PMID: 31073311 PMCID: PMC6470431 DOI: 10.1155/2019/4172395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/12/2019] [Accepted: 03/21/2019] [Indexed: 11/18/2022] Open
Abstract
Envenomations by hump-nosed pit vipers (HNVs) are frequent in Sri Lanka and in South India. Until recently, HNV was considered a moderately venomous snake. Here, we report a case of a previously healthy female developing all the known serious complications, plus some previously unreported complications following a HNV envenomation. She had muscarinic symptoms like profuse sweating and salivation within a couple of minutes and a seizure several minutes after envenomation. Her acute kidney injury (AKI) was swift onset and progressed to end-stage renal failure at three months. She had mild parotid swelling, crepitations in her lungs, and edema of the bitten leg. She had evidence of microangiopathic hemolytic anemia and hemolytic uremic syndrome as well. She developed local tissue necrosis, a non-ST-elevation myocardial infarction (non-STEMI), and anterior ischemic optic neuropathy (AION) following the envenomation. We believe the best explanation for her swift onset complication is intravascular injection of venom. We believe ischemia due to thrombotic microangiopathy has contributed to local tissue necrosis. Those ischemia and kidney failure have contributed to non-STEMI and AION. We illustrate the issue of the sluggish progress made by medicine in understanding the complications of envenomation by using HNV as an example.
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Thrombotic Microangiopathy, Hemolytic Uremic Syndrome, and Thrombotic Thrombocytopenic Purpura Following Hump-nosed Pit Viper (Genus: Hypnale) Envenoming in Sri Lanka. Wilderness Environ Med 2019; 30:66-78. [DOI: 10.1016/j.wem.2018.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 11/21/2022]
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Rao IR, Prabhu AR, Nagaraju SP, Rangaswamy D. Thrombotic Microangiopathy: An Under-Recognised Cause of Snake-bite-related Acute Kidney Injury. Indian J Nephrol 2019; 29:324-328. [PMID: 31571738 PMCID: PMC6755934 DOI: 10.4103/ijn.ijn_280_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Thrombotic microangiopathy (TMA) as a cause of snake-bite-induced acute kidney injury (AKI) is rarely reported. Very little is known about the clinical course, optimal management, and prognosis of this entity. We describe a series of snake-bite-induced TMA and compare their outcomes with those without TMA. Methods: This was a single-center retrospective study of patients with AKI following snake envenomation admitted between January 2012 and December 2017. Demographic profile, clinical parameters, and outcomes were studied. TMA was diagnosed based on presence of triad of microangiopathic hemolytic anemia, thrombocytopenia, and AKI, and groups with and without TMA were compared. Results: Of 103 patients with AKI following snake bite, 19 (18.5%) had clinical evidence of TMA. All patients with TMA had advanced azotemia (mean peak serum creatinine 9.5 ± 3.0 mg/dL), with 18 (95%) requiring renal replacement therapy (RRT). Thirteen (68%) had either complete or partial recovery of renal functions, two (10%) progressed to end-stage renal disease, and one died (three patients were lost to follow-up). Age ≥50 years, presence of oliguria/anuria, anti-snake venom dose ≥10 vials, and urea ≥80 mg/dL at presentation were independently associated with TMA (P < 0.05). RRT requirement (95% vs. 57%), mean number of RRT sessions (18 vs. 4.5 sessions), and hospital stay ≥7 days (84% vs. 58%) were higher in patients with TMA (P < 0.05), but patient outcomes did not differ. Conclusions: In conclusion, TMA was seen in 18.5% of patients with snake-bite-related AKI in our study and was associated with almost universal need for RRT, longer duration on RRT, and hospital stay compared with patients without TMA.
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Affiliation(s)
- Indu Ramachandra Rao
- Department of Nephrology, Kasturba Medical College and Hospital, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Attur Ravindra Prabhu
- Department of Nephrology, Kasturba Medical College and Hospital, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shankar Prasad Nagaraju
- Department of Nephrology, Kasturba Medical College and Hospital, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Dharshan Rangaswamy
- Department of Nephrology, Kasturba Medical College and Hospital, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Bucaretchi F, Pimenta MMB, Borrasca-Fernandes CF, Prado CC, Capitani EMD, Hyslop S. Thrombotic microangiopathy following Bothrops jararaca snakebite: case report. Clin Toxicol (Phila) 2018; 57:294-299. [PMID: 30444155 DOI: 10.1080/15563650.2018.1514621] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
CONTEXT Thrombotic microangiopathy (TMA) is an uncommon and severe complication of snakebites, and is similar, in general, to hemolytic-uremic syndrome (HUS). We describe a case of TMA following envenomation by Bothrops jararaca. CASE DETAILS A 56-y-old-woman with controlled hypertension was transferred from a primary hospital to our ER ∼7 h after being bitten by B. jararaca in the distal left leg. She developed edema extending from the bite site to the proximal thigh, associated with intense radiating local pain, local paresthesia and ecchymosis at the bite site. Laboratory features upon admission revealed coagulopathy (20 min whole blood clotting time - WBCT20 > 20 min), thrombocytopenia (76,000 platelets/mm3) and slight increase in serum creatinine (1.58 mg/dL; RV < 1.2 mg/dL). Upon admission, the patient was treated with bothropic antivenom and fluids replacement. During evolution, her thrombocytopenia and anemia worsened, with blood films showing fragmented red cells, haptoglobin consumption, increase in serum lactate dehydrogenase, and progressive increase of serum creatinine (KDIGO stage = 3). No RBC transfusion, renal replacement therapy or plasmapheresis was done. The patient showed progressive improvement from day nine (D9) onwards and was discharged on D20; there was complete recovery of hemoglobin levels at follow-up (D50). ADAMTS-13 activity, assayed 10 months post-bite, was within reference values. DISCUSSION TMA following snakebite has been reported mainly in India, Sri Lanka and Australia, with several patients needing renal replacement therapy. Although controversial, plasmapheresis has also been used in some cases. Our patient developed microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury, a triad of features compatible with TMA similar to HUS. Despite the severity, the outcome following conservative treatment was good, with complete recovery.
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Affiliation(s)
- Fábio Bucaretchi
- a Department of Pediatrics, School of Medical Sciences , State University of Campinas (UNICAMP) , Campinas , Brazil.,d Campinas Poison Control Center, School of Medical Sciences , State University of Campinas (UNICAMP) , Campinas , Brazil
| | - Maíra M Branco Pimenta
- d Campinas Poison Control Center, School of Medical Sciences , State University of Campinas (UNICAMP) , Campinas , Brazil
| | - Carla F Borrasca-Fernandes
- a Department of Pediatrics, School of Medical Sciences , State University of Campinas (UNICAMP) , Campinas , Brazil.,d Campinas Poison Control Center, School of Medical Sciences , State University of Campinas (UNICAMP) , Campinas , Brazil
| | - Camila Carbone Prado
- d Campinas Poison Control Center, School of Medical Sciences , State University of Campinas (UNICAMP) , Campinas , Brazil
| | - Eduardo Mello De Capitani
- b Department of Clinical Medicine, School of Medical Sciences , State University of Campinas (UNICAMP) , Campinas , Brazil.,d Campinas Poison Control Center, School of Medical Sciences , State University of Campinas (UNICAMP) , Campinas , Brazil
| | - Stephen Hyslop
- c Department of Pharmacology, School of Medical Sciences , State University of Campinas (UNICAMP) , Campinas , Brazil.,d Campinas Poison Control Center, School of Medical Sciences , State University of Campinas (UNICAMP) , Campinas , Brazil
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13
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Namal Rathnayaka RMMK, Nishanthi Ranathunga PEA, Ranaweera J, Jayasekara K, Kularatne SAM. Cardiac arrest and atrial fibrillation in a patient after hump-nosed pit viper (Hypnale hypnale) bite. Toxicon 2018; 148:33-39. [PMID: 29608921 DOI: 10.1016/j.toxicon.2018.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/09/2018] [Accepted: 03/28/2018] [Indexed: 11/19/2022]
Abstract
A 42-year-old previously healthy male patient died 16 days after a proven hump-nosed pit viper (Hypnale hypnale) envenoming due to multi-organ failure. On admission he had cardiac arrest that recovered from cardiopulmonary resuscitation then developed atrial fibrillation which was reverted to normal rhythm by application of synchronized electrical cardioversion. He also had persistent coagulopathy and thrombotic microangiopathy comprising the triad of microangiopathic haemolysis, acute kidney injury and thrombocytopenia. This is the second reported case with cardiac complications following hump-nosed pit viper bites in Sri Lanka.
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Affiliation(s)
- R M M K Namal Rathnayaka
- Intensive Care Unit, Provincial General Hospital, Ratnapura, Sri Lanka; Department of Veterinary Pathobiology, Faculty of Veterinary Medicine & Animal Science, University of Peradeniya, Sri Lanka; Postgraduate Institute of Medicine, University of Colombo (Clinical Pharmacology and Therapeutics), Sri Lanka.
| | | | | | | | - S A M Kularatne
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka
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14
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Margabandhu S, Ranjit S, Jayakumar I, Sundaramoorthy C, Janarthanan M, Reddy J, Thiagarajan M, Jayamoorthy S, Vishwanathan L. Therapeutic plasma exchange for pediatric nonrenal disease indications and outcomes: A single-center experience. Asian J Transfus Sci 2018; 12:127-135. [PMID: 30692797 PMCID: PMC6327757 DOI: 10.4103/ajts.ajts_123_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Outcome data in pediatric plasma exchange, especially in nonrenal indications are scarce. We aimed to evaluate its role and outcome in our patients. SUBJECTS AND METHODS A retrospective study of children admitted in the year 2016 to the Pediatric Intensive Care Unit requiring plasma exchange for nonrenal indications was undertaken. Plasma exchange was given as adjunctive therapy along with primary treatment for the disease concerned. Demographic and clinical data were studied, and descriptive statistical analysis was carried out. RESULTS Ten children underwent plasma exchange during this 1-year period with a male: female ratio of 3:2 and a mean age of 10 years (range 3-16 years). The indications were acute disseminated encephalomyelitis (n = 2), acute neuromyelitis optica (n = 1), catastrophic antiphospholipid antibody syndrome secondary to systemic lupus erythematosus (SLE) (n = 1), severe SLE with cerebritis/hemophagocytic lymphohistiocytosis (HLH) (n = 2), severe dengue sepsis with HLH/multi-organ dysfunction syndrome (n = 2), and thrombotic microangiopathy secondary to snake bite envenomation (n = 2). All received either 1.5 or 2 times plasma volume exchange (mean sessions - 4, range = 1-6). The mean duration of stay in hospital was 17.2 days (range = 3-40 days), and follow-up was 78 days (range = 3-180 days), with the majority of children (8/10, 80%) survived from the catastrophic illness at the time of discharge. Two children (2/10, 20%) succumbed due to the disease per se in severe dengue sepsis in one and enterobacteriaceae sepsis (hospital-acquired pneumonia) in another. CONCLUSION Plasma exchange was found to be beneficial as complementary therapy in a critical care setting, especially for nonrenal indications.
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Affiliation(s)
| | - Suchitra Ranjit
- Department of Paediatric Intensive Care Unit, Apollo Children's Hospitals, Chennai, Tamil Nadu, India
| | - Indira Jayakumar
- Department of Paediatric Intensive Care Unit, Apollo Children's Hospitals, Chennai, Tamil Nadu, India
| | - Chitra Sundaramoorthy
- Department of Paediatric Rheumatology, Apollo Children's Hospitals, Chennai, Tamil Nadu, India
| | - Mahesh Janarthanan
- Department of Paediatric Rheumatology, Apollo Children's Hospitals, Chennai, Tamil Nadu, India
| | - Jayakumar Reddy
- Department of Paediatrics, Apollo Children's Hospitals, Chennai, Tamil Nadu, India
| | - Meena Thiagarajan
- Department of Paediatrics, Apollo Children's Hospitals, Chennai, Tamil Nadu, India
| | - Shyamala Jayamoorthy
- Department of Paediatrics, Apollo Children's Hospitals, Chennai, Tamil Nadu, India
| | - Latha Vishwanathan
- Department of Paediatrics, Apollo Children's Hospitals, Chennai, Tamil Nadu, India
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15
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Snakebite Induced Thrombotic Microangiopathy Leading to Renal Cortical Necrosis. Case Rep Nephrol 2017; 2017:1348749. [PMID: 28884034 PMCID: PMC5572091 DOI: 10.1155/2017/1348749] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/16/2017] [Indexed: 11/24/2022] Open
Abstract
Renal complications from snakebite result in high mortality and morbidity. Acute kidney injury (AKI) occurs in 5–30% of cases. Renal manifestation could include acute tubular necrosis, cortical necrosis, interstitial nephritis, glomerulonephritis, and vasculitis. We present a case of thrombotic microangiopathy (TMA) resulting in renal cortical necrosis. Renal biopsy showed fibrin thrombi in glomeruli and arterioles with cortical necrosis. Our patient progressed to end-stage renal disease.
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16
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Dineshkumar T, Dhanapriya J, Sakthirajan R, Thirumalvalavan K, Kurien AA, Balasubramaniyan T, Gopalakrishnan N. Thrombotic microangiopathy due to Viperidae bite: Two case reports. Indian J Nephrol 2017; 27:161-164. [PMID: 28356675 PMCID: PMC5358163 DOI: 10.4103/0971-4065.196936] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Snake bite is mainly an occupational hazard and causes serious health problems in rural India. Acute kidney injury (AKI) occurs in 5-30% cases. Renal pathologic findings include acute tubular necrosis, cortical necrosis, interstitial nephritis, glomerulonephritis, and vasculitis. Thrombotic microangiopathy (TMA) occurrence after a snake bite is reported rarely. Here, we present two patients who developed TMA after viper bite treated with hemodialysis and plasmapheresis. Renal biopsy showed fibrin thrombi in glomeruli and arterioles with cortical necrosis. One patient progressed to end-stage renal disease and other was lost to follow-up. TMA should be considered as a possible pathogenesis of AKI after snake bite. The role of plasma exchanges in snake bite TMA is yet to be defined.
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Affiliation(s)
- T Dineshkumar
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - J Dhanapriya
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - R Sakthirajan
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - K Thirumalvalavan
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - A A Kurien
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - T Balasubramaniyan
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - N Gopalakrishnan
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
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17
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Withana M, Rodrigo C, Gnanathasan A, Gooneratne L. Presumptive thrombotic thrombocytopenic purpura following a hump-nosed viper (Hypnale hypnale) bite: a case report. J Venom Anim Toxins Incl Trop Dis 2014; 20:26. [PMID: 24987409 PMCID: PMC4077548 DOI: 10.1186/1678-9199-20-26] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/10/2014] [Indexed: 11/25/2022] Open
Abstract
Hump-nosed viper bites are frequent in southern India and Sri Lanka. However, the published literature on this snakebite is limited and its venom composition is not well characterized. In this case, we report a patient with thrombotic thrombocytopenic purpura-like syndrome following envenoming which, to the best of our knowledge, has not been reported in the literature before. A 55-year-old woman from southern Sri Lanka presented to the local hospital 12 hours after a hump-nosed viper (Hypnale hypnale) bite. Five days later, she developed a syndrome that was characteristic of thrombotic thrombocytopenic purpura with fever, thrombocytopenia, microangiopathic hemolysis, renal impairment and neurological dysfunction in the form of confusion and coma. Her clinical syndrome and relevant laboratory parameters improved after she was treated with therapeutic plasma exchange. We compared our observations on this patient with the current literature and concluded that thrombotic thrombocytopenic purpura is a theoretically plausible yet unreported manifestation of hump-nosed viper bite up to this moment. This study also provides an important message for clinicians to look out for this complication in hump-nosed viper bites since timely treatment can be lifesaving.
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Affiliation(s)
- Milinda Withana
- National Hospital, University Medical Unit, Colombo, Sri Lanka
| | - Chaturaka Rodrigo
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25 Kynsey Road, Colombo 08, Sri Lanka
| | - Ariaranee Gnanathasan
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25 Kynsey Road, Colombo 08, Sri Lanka
| | - Lallindra Gooneratne
- Department of Pathology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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18
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Shivanthan MC, Yudhishdran J, Navinan R, Rajapakse S. Hump-nosed viper bite: an important but under-recognized cause of systemic envenoming. J Venom Anim Toxins Incl Trop Dis 2014; 20:24. [PMID: 24948957 PMCID: PMC4062887 DOI: 10.1186/1678-9199-20-24] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 05/30/2014] [Indexed: 11/17/2022] Open
Abstract
Hump-nosed viper bites are common in the Indian subcontinent. In the past, hump-nosed vipers (Hypnale species) were considered moderately venomous snakes whose bites result mainly in local envenoming. However, a variety of severe local effects, hemostatic dysfunction, microangiopathic hemolysis, kidney injury and death have been reported following envenoming by Hypnale species. We systematically reviewed the medical literature on the epidemiology, toxin profile, diagnosis, and clinical, laboratory and postmortem features of hump-nosed viper envenoming, and highlight the need for development of an effective antivenom.
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Affiliation(s)
| | | | - Rayno Navinan
- Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Senaka Rajapakse
- Department of Clinical Medicine, and project lead, Tropical Medicine Research Unit, University of Colombo, Colombo, Sri Lanka
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