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Bentes KO, de Amorim RLO, Barbosa FBA, Ratis da Silva VCP, Valente J, Almeida-Val F, Sachett JDAG, Monteiro W, Sartim MA. Long-term disability after cerebral ischemic stroke following a Bothrops atrox snakebite in the Brazilian Amazon. Toxicon 2024; 247:107793. [PMID: 38838861 DOI: 10.1016/j.toxicon.2024.107793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/23/2024] [Accepted: 06/02/2024] [Indexed: 06/07/2024]
Abstract
Bothrops atrox envenomations in the Brazilian Amazon are responsible for a number of local and systemic effects. Among these, stroke presents the worst prognosis for the patient since it may evolve into disabilities and/or premature death. This complication is caused by coagulation disorders and generates hemorrhagic and thrombotic conditions. This study presents a case report of a 54-year-old female patient who presented extensive cerebral ischemia after a B. atrox envenomation that occurred in the state of Amazonas, Brazil. The patient was hospitalized for 102 days, which included a stay in the intensive care unit. Clinical and laboratory findings indicated a thrombogenic coagulopathy. On discharge, the patient had no verbal response, partial motor response, and right hemiplegia. The assessment carried out four years after discharge evidenced incapacitation, global aphasia and bilateral lower and upper limbs showed hypotrophy with a global decrease in strength. Ischemic stroke is a possible complication of B. atrox snakebites even after antivenom treatment, with the potential to cause debilitating long-term consequences.
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Affiliation(s)
- Karolaine Oliveira Bentes
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | | | | | | | - Jefferson Valente
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | - Fernando Almeida-Val
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brazil
| | - Jacqueline de Almeida Gonçalves Sachett
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brazil
| | - Wuelton Monteiro
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil; Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brazil
| | - Marco Aurélio Sartim
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil; Pró-reitoria de Pesquisa e Pós-graduação, Universidade Nilton Lins, Manaus, AM, Brazil.
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Shankar T, Arora P, Jose JR, Kaushik A. Thrombotic microangiopathy following a white-lipped pit viper envenomation. BMJ Case Rep 2024; 17:e258813. [PMID: 38782420 DOI: 10.1136/bcr-2023-258813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
Certain snake envenomation patients with consumptive coagulopathy, termed venom-induced consumption coagulopathy, develop thrombotic microangiopathy (TMA). Due to predominant renal involvement, TMA is said to resemble haemolytic uraemic syndrome and is treated with haemodialysis. We present a case of a young male who presented to the emergency department after being bitten by a white-lipped pit viper (Trimeresurus albolabris). He developed heart failure in addition to acute kidney injury secondary to TMA. He was treated with 30 vials of anti-snake venom according to national guidelines and underwent haemodialysis. Despite haemodialysis, the patient's ventilatory parameters continued to worsen, necessitating invasive mechanical ventilation. Thus, he was initiated on plasma exchange therapy, to which the patient responded well. TMA has not been reported in Trimeresurus envenomations yet, to the best of our knowledge. Additionally, plasma exchange therapy can be considered an adjunctive therapy for snakebite patients who develop TMA.
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Affiliation(s)
- Takshak Shankar
- Emergency Medicine, AIIMS Rishikesh, Rishikesh, Uttarakhand, India
| | - Poonam Arora
- Emergency Medicine, AIIMS Rishikesh, Rishikesh, Uttarakhand, India
| | - Jewel Rani Jose
- Emergency Medicine, AIIMS Rishikesh, Rishikesh, Uttarakhand, India
| | - Aseem Kaushik
- Emergency Medicine, AIIMS Rishikesh, Rishikesh, Uttarakhand, India
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Isbister GK. The critical time period for administering antivenom: golden hours and missed opportunities. Clin Toxicol (Phila) 2024; 62:277-279. [PMID: 38804828 DOI: 10.1080/15563650.2024.2352026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Antivenom is widely accepted as an effective treatment for snake envenomation. This is despite very limited evidence supporting clinical effectiveness for major envenomation syndromes, and is mainly based on pre-clinical studies and observational studies without control groups. EFFECTIVENESS OF EARLY ANTIVENOM Although antivenom exhibits efficacy by binding to snake toxins and preventing toxic injury in animals if pre-mixed with venom, this efficacy does not always translate to clinical effectiveness. There are many irreversible venom mediated effects that antivenom cannot neutralise or reverse, such as pre-synaptic neurotoxicity and myotoxicity. Fortunately, early antivenom appears to prevent some of these. PRACTICALITIES OF ADMINISTERING ANTIVENOM EARLY With good evidence that early antivenom prevents some envenomation syndromes, the time between bite and antivenom administration must be reduced. This requires improving the initial assessment of snakebite patients, and improving early decision making based on clinical effects. CONCLUSION Until there are improved, simplified, easy to use, rapid and inexpensive tests, whether available in the laboratory or preferably at the bedside that identify systemic envenomation, the key to early antivenom administration is early assessment and decision making based on systemic symptoms, including nausea, vomiting, headache and abdominal pain.
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Liblik K, Florica IT, Baranchuk A. Original algorithms for the detection of cardiovascular involvement of neglected tropical diseases. Expert Rev Cardiovasc Ther 2024; 22:59-74. [PMID: 38308590 DOI: 10.1080/14779072.2024.2315090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/02/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Neglected tropical diseases (NTDs) introduce considerable morbidity and mortality on a global scale, directly impacting over 1 billion individuals as well as their families and communities. Afflicted individuals may have limited access to resources and care in these regions, contributing to a high proportion of chronic, progressive, and systemic disease. The cardiovascular system is at particular risk of demise for several NTDs, yet remains largely unstudied due in part to the lack of robust data collection mechanisms in the most impacted regions. AREAS COVERED The present review is a part of the Neglected Tropical Diseases and other Infectious Diseases affecting the Heart (NET-Heart) Project, aiming at summarizing the current knowledge on cardiovascular implications of NTDs and providing diagnostic as well as management recommendations which can be tailored to low-resource settings. The diagnostic and management algorithms of 13 unique NTDs are presented and summarized. EXPERT OPINION Recognizing cardiac manifestations of NTDs can significantly alter disease trajectory and all physicians benefit from improved knowledge about NTDs. Great potential exists to advance patient care by improving data collection, communication, and international collaboration.
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Affiliation(s)
- Kiera Liblik
- Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
| | - Ioana Tereza Florica
- Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Division of Cardiology, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
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Shankar T, Kaeley N, Rajta M, Pundir A, Kaushik A. Management of Snakebite-Induced Thrombotic Microangiopathy (TMA) With Plasmapheresis. Cureus 2023; 15:e50104. [PMID: 38186452 PMCID: PMC10771023 DOI: 10.7759/cureus.50104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Snakebites affect a lot of people in India. Of these, the hemotoxic snakebites may induce a consumptive coagulopathy, which has been termed now as "Venom-Induced Consumptive Coagulopathy" (VICC). Some patients with VICC develop Thrombotic Microangiopathy (TMA). The primary end-organ damage in TMA is renal, for which hemodialysis is the mainstay of treatment. Recently there has been some focus on plasma exchange as an adjunctive treatment for TMA. Here we present a case of a young male who developed snakebite-induced TMA and who was successfully managed with plasma exchange.
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Affiliation(s)
- Takshak Shankar
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Nidhi Kaeley
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Mukund Rajta
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Ashwani Pundir
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Aseem Kaushik
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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Pierre-Louis O, Resiere D, Alphonsine C, Dantin F, Banydeen R, Dubois MD, Mehdaoui H, Neviere R. Increased Binding of von Willebrand Factor to Sub-Endothelial Collagen May Facilitate Thrombotic Events Complicating Bothrops lanceolatus Envenomation in Humans. Toxins (Basel) 2023; 15:441. [PMID: 37505710 PMCID: PMC10467054 DOI: 10.3390/toxins15070441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/20/2023] [Accepted: 06/30/2023] [Indexed: 07/29/2023] Open
Abstract
Consumption coagulopathy and hemorrhagic syndrome exacerbated by blood anticoagulability remain the most important causes of lethality associated with Bothrops snake envenomation. Bothrops venom also engages platelet aggregation on the injured endothelium via von Willebrand factor (vWF) interactions. Besides platelet aggregation, some Bothrops venom toxins may induce qualitative thrombopathy, which has been in part related to the inhibition of vWF activation. We tested whether B. lanceolatus venom impaired vWF to collagen(s) binding (vWF:CB) activity. Experiments were performed with B. lanceolatus crude venom, in the presence or absence of Bothrofav, a monospecific B. lanceolatus antivenom. Venom of B. lanceolatus fully inhibited vWF to collagen type I and III binding, suggesting venom interactions with the vWF A3 domain. In contrast, B. lanceolatus venom increased vWF to collagen type VI binding, suggesting the enhancement of vWF binding to collagen at the vWF A1 domain. Hence, B. lanceolatus venom exhibited contrasting in vitro effects in terms of the adhesive properties of vWF to collagen. On the other hand, the antivenom Bothrofav reversed the inhibitory effects of B. lanceolatus venom on vWF collagen binding activity. In light of the respective distribution of collagen type III and collagen type VI in perivascular connective tissue and the sub-endothelium, a putative association between an increase in vWF:CB activity for collagen type VI and the onset of thrombotic events in human B. lanceolatus envenomation might be considered.
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Affiliation(s)
- Olivier Pierre-Louis
- Cardiovascular Research Team EA7525, University of the French West Indies (Université des Antilles), 97233 Fort de France, France; (O.P.-L.); (D.R.); (C.A.); (F.D.); (R.B.); (M.-D.D.); (H.M.)
| | - Dabor Resiere
- Cardiovascular Research Team EA7525, University of the French West Indies (Université des Antilles), 97233 Fort de France, France; (O.P.-L.); (D.R.); (C.A.); (F.D.); (R.B.); (M.-D.D.); (H.M.)
- Department of Critical Care Medicine and Toxicology, University Hospital of Martinique (CHU Martinique), 97200 Fort-de-France, France
| | - Celia Alphonsine
- Cardiovascular Research Team EA7525, University of the French West Indies (Université des Antilles), 97233 Fort de France, France; (O.P.-L.); (D.R.); (C.A.); (F.D.); (R.B.); (M.-D.D.); (H.M.)
| | - Fabienne Dantin
- Cardiovascular Research Team EA7525, University of the French West Indies (Université des Antilles), 97233 Fort de France, France; (O.P.-L.); (D.R.); (C.A.); (F.D.); (R.B.); (M.-D.D.); (H.M.)
| | - Rishika Banydeen
- Cardiovascular Research Team EA7525, University of the French West Indies (Université des Antilles), 97233 Fort de France, France; (O.P.-L.); (D.R.); (C.A.); (F.D.); (R.B.); (M.-D.D.); (H.M.)
| | - Marie-Daniela Dubois
- Cardiovascular Research Team EA7525, University of the French West Indies (Université des Antilles), 97233 Fort de France, France; (O.P.-L.); (D.R.); (C.A.); (F.D.); (R.B.); (M.-D.D.); (H.M.)
| | - Hossein Mehdaoui
- Cardiovascular Research Team EA7525, University of the French West Indies (Université des Antilles), 97233 Fort de France, France; (O.P.-L.); (D.R.); (C.A.); (F.D.); (R.B.); (M.-D.D.); (H.M.)
- Department of Critical Care Medicine and Toxicology, University Hospital of Martinique (CHU Martinique), 97200 Fort-de-France, France
| | - Remi Neviere
- Cardiovascular Research Team EA7525, University of the French West Indies (Université des Antilles), 97233 Fort de France, France; (O.P.-L.); (D.R.); (C.A.); (F.D.); (R.B.); (M.-D.D.); (H.M.)
- Department of Cardiology, University Hospital of Martinique (CHU Martinique), 97200 Fort-de-France, France
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Warrell DA, Williams DJ. Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet 2023; 401:1382-1398. [PMID: 36931290 DOI: 10.1016/s0140-6736(23)00002-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/26/2022] [Accepted: 12/18/2022] [Indexed: 03/16/2023]
Abstract
There is increasing recognition of the public health importance of snakebite envenoming. Worldwide annual incidence is likely to be 5 million bites, with mortality exceeding 150 000 deaths, and the resulting physical and psychological morbidity leads to substantial social and economic repercussions. Prevention through community education by trained health workers is the most effective and economically viable strategy for reducing risk of bites and envenoming. Clinical challenges to effective treatment are most substantial in rural areas of low-resource settings, where snakebites are most common. Classic skills of history taking, physical examination, and use of affordable point-of-care tests should be followed by monitoring of evolving local and systemic envenoming. Despite the profusion of new ideas for interventions, hyperimmune equine or ovine plasma-derived antivenoms remain the only specific treatment for snakebite envenoming. The enormous interspecies and intraspecies complexity and diversity of snake venoms, revealed by modern venomics, demands a radical redesign of many current antivenoms.
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Affiliation(s)
- David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Experimental Medicine Division, John Radcliffe Hospital, Headington, UK.
| | - David J Williams
- Regulation and Prequalification Department, World Health Organization, Geneva, Switzerland
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Rathnayaka RMMKN, Nishanthi Ranathunga PEA, Kularatne SAM, Sugathadasa K. Therapeutic Plasma Exchange for Venom-Induced Thrombotic Microangiopathy Following Hump-Nosed Pit Viper (Genus: Hypnale) Bites: A Prospective Observational Study. Wilderness Environ Med 2022; 33:386-398. [PMID: 36244888 DOI: 10.1016/j.wem.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 07/23/2022] [Accepted: 07/26/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION -Thrombotic microangiopathy (TMA), which is the triad of acute kidney injury (AKI), microangiopathic hemolytic anemia (MAHA), and thrombocytopenia, is a rare complication of snakebites, and in Sri Lanka, it is commonly seen with hump-nosed pit viper (HNPV) bites. METHODS -We conducted a prospective observational study of patients with AKI caused by HNPV bites in Teaching Hospital, Ratnapura, Sri Lanka for 6 y, commencing in June 2015. Some patients with TMA underwent therapeutic plasma exchange (TPE) and some did not. These 2 groups were compared. Statistical analysis was carried out using Minitab 18.1. Data were presented as median (IQR). RESULTS -There were 52 (8%) patients with TMA, of whom 21 (45%) were in the TPE group and 26 (55%) were in the non-TPE group. TPE improved time to platelet correction (4 d [IQR, 4-5 d] vs 7 d [IQR, 5-9 d]; P=0.009), time to MAHA correction (5 d [IQR, 3-4 d] vs 7 d [IQR, 6-9 d]; P=0.004), time to prothrombin time (PT)/international normalized ratio (INR) correction (1 d [IQR, 1-2 d] vs 3 d [IQR, 3-4 d]; P=0.003), and time to 20 min whole blood clotting test (WBCT20) correction (2 d [IQR, 1-2 d] vs 3 d [1QR 2-3 d]; P=0.020). Renal recovery was predicted by TPE (P=0.048) and highest creatinine level (P=0.001). There was no association between TPE and dialysis dependency at discharge (P=0.597), length of hospital stay (P=0.220), and the number of dialysis cycles prior to discharge (P=0.540). TPE did not improve the number of blood transfusions (5 packs [IQR, 3-8.5 packs] vs 4 packs [IQR, 0-9 packs]; P=0.290). CONCLUSIONS -TPE is effective for TMA in the early correction of platelet counts, MAHA, PT/INR, and WBCT20 in HNPV bites.
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Affiliation(s)
- R M M K Namal Rathnayaka
- Department of Pharmacology, Faculty of Medicine, Sabaragamuwa University of Sri Lanka, Hidellana, Ratnapura, Sri Lanka; Department of Veterinary Pathobiology, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Peredeniya, Sri Lanka; Intensive Care Unit, Teaching Hospital Ratnapura, Sri Lanka.
| | | | - S A M Kularatne
- Faculty of Medicine, University of Peradeniya, Peredeniya, Sri Lanka
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Brasileiro-Martins LM, Nascimento TP, Silva-Neto AV, Martins F, Cavalcante SA, Martins RB, Marques H, Colombini M, Martins M, Sartim MA, Wen FH, Carlos de Lima Ferreira L, de Almeida Gonçalves Sachett J, Moura-da-Silva AM, Ferreira de Aquino P, Monteiro WM. The severity of acute kidney injury correlates with plasma venom levels in Bothrops atrox envenomings. Toxicon 2022; 219:106924. [PMID: 36126694 DOI: 10.1016/j.toxicon.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/17/2022] [Accepted: 09/11/2022] [Indexed: 11/20/2022]
Abstract
The Brazilian Amazon has high rates of snakebite envenomings (SBEs), with ∼90% caused by Bothrops atrox. Envenomings by this species can trigger local and systemic effects, such as acute kidney injury (AKI). Our aim was to identify predictors of AKI in Bothrops SBEs in patients from Manaus, Western Brazilian Amazon. A total of 127 patients were enrolled, with a predominance of men between 16 and 45 years old from rural areas. Of the 127 patients, 38.6% developed AKI, with 61.2% presenting stage I, 34.7% presenting stage II and 4.1% presenting stage III severity. The age groups 0-10 years and ≥60 years presented a significantly higher frequency of AKI compared to the 11-40 years group. Moderate/severe edema in the affeccted limb was significantly associated with lower risk of AKI [p = 0.01; OR = 0.11 (95%CI 0.02-0.53)]. Nausea [p = 0.01; OR = 54.44 (95%CI = 3.26-909.27)] and high blood urea levels [p = 0.01; OR = 5.38 (95%CI = 2.12-13.66)] were risk factors for AKI. There was a significant positive correlation between circulating venom levels and the highest creatinine serum values during the hospital stay (p = 0.03) and with the difference between the maximum creatinine levels and the creatinine levels on admission (p = 0.02). A positive correlation between serum venom concentrations and creatinine levels suggests a direct or indirect dose-dependent participation of the venom toxins in the pathogenesis of AKI.
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Affiliation(s)
- Lisele Maria Brasileiro-Martins
- School of Health Sciences, Amazonas State University, Manaus, 69065-001, Brazil; Department of Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, 69040-000, Brazil
| | | | - Alexandre Vilhena Silva-Neto
- School of Health Sciences, Amazonas State University, Manaus, 69065-001, Brazil; Department of Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, 69040-000, Brazil
| | - Felipe Martins
- Department of Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, 69040-000, Brazil
| | | | | | - Hedylamar Marques
- Hemostasis Laboratory, Amazonas State Hematology and Hemotherapy Hospital Foundation, Manaus, 69050-001, Brazil
| | - Monica Colombini
- Immunopathology Laboratory, Butantan Institute, São Paulo, 05503-900, Brazil
| | - Marilaine Martins
- Department of Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, 69040-000, Brazil
| | | | - Fan Hui Wen
- Immunopathology Laboratory, Butantan Institute, São Paulo, 05503-900, Brazil
| | | | - Jacqueline de Almeida Gonçalves Sachett
- School of Health Sciences, Amazonas State University, Manaus, 69065-001, Brazil; Department of Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, 69040-000, Brazil
| | | | | | - Wuelton Marcelo Monteiro
- School of Health Sciences, Amazonas State University, Manaus, 69065-001, Brazil; Department of Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, 69040-000, Brazil.
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10
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Rajkumar B, Vishwanath Vinod K, Kar R, Ramasubramani P. Venom induced consumption coagulopathy and performance of 20-min whole blood clotting test for its detection in viperid envenomation. J R Coll Physicians Edinb 2022; 52:232-239. [PMID: 36300884 DOI: 10.1177/14782715221126770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Venom induced consumption coagulopathy (VICC) and its underlying mechanisms have not been fully elucidated in viperid envenomation (VE), especially among Indian patients. We evaluated for VICC in VE, assessed the performance of 20-min whole blood clotting test (20WBCT) for VICC detection and also studied predictors of VICC. Methods: This hospital-based observational study enrolled 103 consecutive patients (age ⩾ 12 years) of snakebite admitted within 24 h of bite, with features of VE. They underwent 20WBCT, prothrombin time (PT)/international normalised ratio (INR), plasma fibrinogen and D-dimer testing during first 24 h after enrolment. Overt VICC (defined by overt bleeding), subclinical VICC (INR ⩾ 1.4 and/or fibrinogen < 2g/L, without overt bleeding), disseminated intravascular coagulation (DIC) (overt/non-overt, defined based on International Society on Thrombosis and Haemostasis (ISTH) DIC score) and primary defibrination (PDF) were evaluated among patients. Results: VICC overall was noted in 77 (≈75%) and overt VICC in 52 (≈50%). DIC (overt/non-overt) was noted in 59 (≈77%) and PDF in 2 (2.6%) patients with VICC. Sensitivity, specificity, positive predictive value and negative predictive value of 20WBCT for VICC detection were 98.7% (95%CI: 92.9–99.9%), 65.4% (95%CI: 44.3–82.8%), 89.4% (95%CI: 83.3–93.5%) and 94.4% (95%CI: 70.4–99.2%) respectively. Severe cellulitis in bitten limb predicted reduced VICC risk. Conclusion: Majority (75%) of patients with VE had VICC and 68% with VICC had overt bleeding. DIC (overt/non-overt) was the predominant contributor to VICC. Though 20WBCT is a good screening test for VICC, false positive results should be kept in mind before deciding on snake antivenom treatment.
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Affiliation(s)
- Bayye Rajkumar
- Department of General Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research [JIPMER], Puducherry, India
| | | | - Rakhee Kar
- Department of Pathology, JIPMER, Puducherry, India
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11
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Chandler S, Isoardi K, Ng S. Snake envenomation: not your average acute kidney injury. Intern Med J 2022; 52:1446-1447. [PMID: 35973953 DOI: 10.1111/imj.15879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/14/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Shaun Chandler
- Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Katherine Isoardi
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Samantha Ng
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Metro South Integrated Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Queensland, Australia
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12
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Reddy SP, Phadnis SA, Kumari P, Sharma N, Sethi J, Pannu AK, Sharma N. Thrombotic microangiopathy in Russel's viper envenomation. QJM 2022; 115:486-487. [PMID: 35323969 DOI: 10.1093/qjmed/hcac081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- S P Reddy
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S A Phadnis
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - P Kumari
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - N Sharma
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - J Sethi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A K Pannu
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - N Sharma
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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13
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Priyankara S, Rathnasiri V, Mihiran T, Premawansa G, Isbister GK, Silva A. Mild venom-induced consumption coagulopathy associated with thrombotic microangiopathy following a juvenile Russell's viper (Daboia russelii) envenoming: A case report. Toxicon 2022; 212:8-10. [PMID: 35351495 DOI: 10.1016/j.toxicon.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/19/2022] [Accepted: 03/22/2022] [Indexed: 11/23/2022]
Abstract
Russell's viper envenoming causes venom-induced consumption coagulopathy (VICC) within hours of a bite, which is associated with thrombotic microangiopathy (TMA) and acute kidney injury (AKI) in a proportion of cases. We report a juvenile Russell's viper bite in which a patient developed mild VICC after the usual 24-h observation period, which was subsequently associated with severe AKI due to TMA. This shows the clinical importance of detecting and treating mild VICC, which may be delayed or not detected with bedside clotting tests.
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Affiliation(s)
| | | | | | | | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
| | - Anjana Silva
- Department of Parasitology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, 50008, Sri Lanka; Monash Venom Group, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia.
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14
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Arora S, Ramachandran N, Hanuman Srinivas B, Ganesh Rajesh N, Parameswaran S. Thrombotic microangiopathy: An under-recognised cause of Chronic Kidney Disease following Viper envenomation. Kidney Int Rep 2022; 7:1441-1442. [PMID: 35685317 PMCID: PMC9171703 DOI: 10.1016/j.ekir.2022.04.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/16/2022] [Indexed: 12/04/2022] Open
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15
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Affiliation(s)
| | - Dag Shapshak
- University of Alabama Birmingham, Birmingham, AL
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16
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Kumar A, Gopalakrishnan M, Kuri HR, Bajpayee A, Kothari N, Garg MK. Case Report: Delayed Diffuse Alveolar Hemorrhage in Echis sochureki Envenoming, Jodhpur, India. Am J Trop Med Hyg 2022; 106:967-969. [PMID: 35100564 PMCID: PMC8922478 DOI: 10.4269/ajtmh.21-1187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/28/2021] [Indexed: 11/07/2022] Open
Abstract
Snakebite envenoming is a common occupational hazard in the tropics. Venom-induced consumption coagulopathy and acute kidney injury are the most frequently encountered complications of viper bites. Diffuse alveolar hemorrhage (DAH) is an unusual presentation reported rarely in the literature. Our case report highlights the uncommon presentation of delayed pulmonary hemorrhage after snakebite envenoming. A 40-year-old healthy man presented to our emergency department after 6 hours of Echis sochureki (a saw-scaled viper subspecies) bite. He had abnormal coagulation parameters and thrombocytopenia with no signs of acute kidney injury. Transfusion protocols were initiated because of active bleeding and a rapid decrease in hemoglobin levels over next few days. Around day 10, his coagulation profile and hemoglobin were corrected, but he developed hemoptysis with rapidly progressive respiratory distress. Computed tomography of the chest was suggestive of DAH and the patient was started on plasma exchange with pulse methylprednisolone. After the initial worsening, he had rapid symptomatic improvement and radiological resolution. The patient had persistent hypofibrinogenemia, which resolved, and was discharged and remained healthy at the 60-day follow-up. This case highlights a presentation with an initial phase of venom-induced consumption coagulopathy followed by delayed DAH in saw-scaled viper envenoming that was treated successfully with immunosuppressants and plasma exchange.
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Affiliation(s)
- Akhilesh Kumar
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India;,Address correspondence to Maya Gopalakrishnan, Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Basni Industrial Estate, Jodhpur, Rajasthan, India. E-mail:
| | - Harshavardhan R. Kuri
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | - Archana Bajpayee
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Nikhil Kothari
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | - Mahendra Kumar Garg
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
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17
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Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice. Toxins (Basel) 2022; 14:toxins14010057. [PMID: 35051033 PMCID: PMC8778654 DOI: 10.3390/toxins14010057] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/05/2023] Open
Abstract
Snakebite is a significant and under-resourced global public health issue. Snake venoms cause a variety of potentially fatal clinical toxin syndromes, including venom-induced consumption coagulopathy (VICC) which is associated with major haemorrhage. A subset of patients with VICC develop a thrombotic microangiopathy (TMA). This article reviews recent evidence regarding snakebite-associated TMA and its epidemiology, diagnosis, outcomes, and effectiveness of interventions including antivenom and therapeutic plasma-exchange. Snakebite-associated TMA presents with microangiopathic haemolytic anaemia (evidenced by schistocytes on the blood film), thrombocytopenia in almost all cases, and a spectrum of acute kidney injury (AKI). A proportion of patients require dialysis, most survive and achieve dialysis free survival. There is no evidence that antivenom prevents TMA specifically, but early antivenom remains the mainstay of treatment for snake envenoming. There is no evidence for therapeutic plasma-exchange being effective. We propose diagnostic criteria for snakebite-associated TMA as anaemia with >1.0% schistocytes on blood film examination, together with absolute thrombocytopenia (<150 × 109/L) or a relative decrease in platelet count of >25% from baseline. Patients are at risk of long-term chronic kidney disease and long term follow up is recommended.
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18
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Coagulopathy following Crotalinae snakebites in northeast Florida. Blood Coagul Fibrinolysis 2022; 33:220-223. [DOI: 10.1097/mbc.0000000000001123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Abstract
SNAKE ENVENOMATION REPRESENTS AN IMPORTANT HEALTH PROBLEM IN much of the world. In 2009, it was recognized by the World Health Organization (WHO) as a neglected tropical disease, and in 2017, it was elevated into Category A of the Neglected Tropical Diseases list, further expanding access to funding for research and antivenoms. However, snake envenomation occurs in both tropical and temperate climates and on all continents except Antarctica. Worldwide, the estimated number of annual deaths due to snake envenomation (80,000 to 130,000) is similar to the estimate for drug-resistant tuberculosis and for multiple myeloma., In countries with adequate resources, deaths are infrequent (e.g., <6 deaths per year in the United States, despite the occurrence of 7000 to 8000 bites), but in countries without adequate resources, deaths may number in the tens of thousands. Venomous snakes kept as pets are not rare, and physicians anywhere might be called on to manage envenomation by a nonnative snake. Important advances have occurred in our understanding of the biology of venom and the management of snake envenomation since this topic was last addressed in the Journal two decades ago. For the general provider, it is important to understand the spectrum of snake envenomation effects and approaches to management and to obtain specific guidance, when needed.
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Affiliation(s)
- Steven A Seifert
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - James O Armitage
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - Elda E Sanchez
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
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20
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Thomazini CM, Sachetto ATA, de Albuquerque CZ, de Moura Mattaraia VG, de Oliveira AK, Serrano SMDT, Lebrun I, Barbaro KC, Santoro ML. Involvement of von Willebrand factor and botrocetin in the thrombocytopenia induced by Bothrops jararaca snake venom. PLoS Negl Trop Dis 2021; 15:e0009715. [PMID: 34478462 PMCID: PMC8445451 DOI: 10.1371/journal.pntd.0009715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/16/2021] [Accepted: 08/06/2021] [Indexed: 12/20/2022] Open
Abstract
Patients bitten by snakes consistently manifest a bleeding tendency, in which thrombocytopenia, consumption coagulopathy, mucous bleeding, and, more rarely, thrombotic microangiopathy, are observed. Von Willebrand factor (VWF) is required for primary hemostasis, and some venom proteins, such as botrocetin (a C-type lectin-like protein) and snake venom metalloproteinases (SVMP), disturb the normal interaction between platelets and VWF, possibly contributing to snakebite-induced bleedings. To understand the relationship among plasma VWF, platelets, botrocetin and SVMP from Bothrops jararaca snake venom (BjV) in the development of thrombocytopenia, we used (a) Wistar rats injected s.c. with BjV preincubated with anti-botrocetin antibodies (ABA) and/or Na2-EDTA (a SVMP inhibitor), and (b) VWF knockout mice (Vwf-/-) injected with BjV. Under all conditions, BjV induced a rapid and intense thrombocytopenia. In rats, BjV alone reduced the levels of VWF:Ag, VWF:CB, high molecular weight multimers of VWF, ADAMTS13 activity, and factor VIII. Moreover, VWF:Ag levels in rats that received BjV preincubated with Na2-EDTA and/or ABA tended to recover faster. In mice, BjV caused thrombocytopenia in both Vwf-/- and C57BL/6 (background control) strains, and VWF:Ag levels tended to decrease in C57BL/6, demonstrating that thrombocytopenia was independent of the presence of plasma VWF. These findings showed that botrocetin present in BjV failed to affect the extent or the time course of thrombocytopenia induced by envenomation, but it contributed to decrease the levels and function of plasma VWF. Thus, VWF alterations during B. jararaca envenomation are an ancillary event, and not the main mechanism leading to decreased platelet counts.
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Affiliation(s)
- Camila Martos Thomazini
- Laboratório de Fisiopatologia, Instituto Butantan, São Paulo-SP, Brazil
- Programa de Pós-Graduação em Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo-SP, Brazil
| | - Ana Teresa Azevedo Sachetto
- Laboratório de Fisiopatologia, Instituto Butantan, São Paulo-SP, Brazil
- Programa de Pós-Graduação em Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo-SP, Brazil
| | | | | | - Ana Karina de Oliveira
- Laboratório de Toxinologia Aplicada, Center of Toxins, Immune-Response and Cell Signaling (CeTICS), Instituto Butantan, São Paulo-SP, Brazil
| | - Solange Maria de Toledo Serrano
- Laboratório de Toxinologia Aplicada, Center of Toxins, Immune-Response and Cell Signaling (CeTICS), Instituto Butantan, São Paulo-SP, Brazil
| | - Ivo Lebrun
- Laboratório de Bioquímica e Biofísica, Instituto Butantan, São Paulo-SP, Brazil
| | | | - Marcelo Larami Santoro
- Laboratório de Fisiopatologia, Instituto Butantan, São Paulo-SP, Brazil
- Programa de Pós-Graduação em Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo-SP, Brazil
- * E-mail: ,
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21
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Zini G, d'Onofrio G, Erber WN, Lee SH, Nagai Y, Basak GW, Lesesve JF. 2021 update of the 2012 ICSH Recommendations for identification, diagnostic value, and quantitation of schistocytes: Impact and revisions. Int J Lab Hematol 2021; 43:1264-1271. [PMID: 34431220 DOI: 10.1111/ijlh.13682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/28/2021] [Accepted: 08/04/2021] [Indexed: 12/26/2022]
Abstract
In 2012, the International Council for Standardization in Hematology (ICSH) published recommendations for the identification, quantitation, and diagnostic value of schistocytes. In the present review, the impact of these recommendations is evaluated. This work is based on citations in peer-reviewed papers published since 2012. The first 2012 ICSH Recommendations have also been revised to incorporate newly published data in the literature and current best laboratory practice. Recommended reference ranges have been proposed for healthy adults and full-term neonates of 1% or less schistocytes. More than 1% of morphologically identified schistocytes on the blood film are considered suspicious for thrombotic microangiopathy. For preterm infants, a normal level of 5% or less is recommended. The fragment red cell count (FRC) generated by some automated hematological analyzers provides a valuable screening tool for the presence of schistocytes. Specifically, the absence of FRCs can be used as a valuable parameter to exclude the presence of schistocytes on the blood film. The validity and usefulness of microscope schistocytes and automated FRCs, respectively, are discussed in the context of the laboratory diagnostic tests used for thrombotic microangiopathies.
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Affiliation(s)
- Gina Zini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Wendy N Erber
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Szu-Hee Lee
- St George Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Yutaka Nagai
- Faculty of Clinical Laboratory, Kansai University of Health Sciences, Osaka, Japan
| | - Grzegorz W Basak
- Department of Haematology, Transplantation and Internal Medicine, The Medical University of Warsaw, Warsaw, Poland.,Transplant Complications Working Party, European Society for Blood and Marrow Transplantation, Warsaw, Poland
| | - Jean-François Lesesve
- Service d'Hématologie Biologique, Centre Hospitalier Régional Universitaire de Nancy, and U1256 INSERM, Université de Lorraine, Lorraine, France
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22
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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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23
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Le HQ, Nguyen NTT, Vo TNA, Van Nguyen T, Do KTN, Ho TTC, Nguyen SN, Phan XT, Nguyen DLM, Kieu DN, Ngo HD, Warrell DA. Envenoming by king cobras (Ophiophagus hannah) in Vietnam with cardiac complications and necrotizing fasciitis. Toxicon 2021; 200:127-133. [PMID: 34302855 DOI: 10.1016/j.toxicon.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 11/18/2022]
Abstract
King Cobra (Ophiophagus hannah) bite is well-known for its potentially fatal neurotoxicity. However, fatalities still occur, despite specific antivenom and respiratory support. Cardiovascular disturbances, which have attracted little attention in published reports of O. hannah envenoming, could contribute to fatality. We present two cases of confirmed O. hannah envenoming in Southern Vietnam in which there were cardiac abnormalities including arrhythmias and electrocardiographic changes, as well as elevated markers of myocardial damage. Cardiac pacing was required. One patient developed critical multi-organ dysfunctions partly explained by extensive necrotizing fasciitis/myositis originating from an Aeromonas sobria wound infection. This resulted in rhabdomyolysis, disseminated intravascular coagulation and acute kidney injury. Specific antivenom reversed neurotoxic effects of envenoming. Additional therapeutic interventions included antibiotics, surgical debridement, continuous renal replacement therapy and therapeutic plasma exchange. Both patients eventually made full recoveries. Apart from the critical problem of rapidly evolving and severe neurotoxicity, our case reports also emphasises the risk of cardiotoxic envenoming, and the complications of an overwhelming secondary bacterial wound infection. We suggest a practical approach to diagnosis and management.
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Affiliation(s)
- Hung Quoc Le
- Department of Tropical Diseases, Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Viet Nam
| | - Ngan Thi Thuy Nguyen
- Department of Tropical Diseases, Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Viet Nam; Oxford University Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam.
| | - Tho Ngoc Anh Vo
- Department of Tropical Diseases, Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Viet Nam
| | - Thuan Van Nguyen
- Department of Tropical Diseases, Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Viet Nam
| | - Khanh Thi Ngoc Do
- Department of Tropical Diseases, Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Viet Nam
| | - Thanh Thi Chi Ho
- Department of Tropical Diseases, Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Viet Nam
| | - Sang Ngoc Nguyen
- Department of Tropical Diseases, Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Viet Nam
| | - Xuan Thi Phan
- Central Intensive Care Unit, Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Viet Nam
| | - Duy Ly Minh Nguyen
- Central Intensive Care Unit, Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Viet Nam
| | - Dung Ngoc Kieu
- Department of Arrhythmia, Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Viet Nam
| | - Hiep Duc Ngo
- Department of Burn and Plastic Surgery, Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Viet Nam
| | - David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, UK
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24
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Liblik K, Byun J, Saldarriaga C, Perez GE, Lopez-Santi R, Wyss FQ, Liprandi AS, Martinez-Sellés M, Farina JM, Mendoza I, Burgos LM, Baranchuk A. Snakebite Envenomation and Heart: Systematic Review. Curr Probl Cardiol 2021; 47:100861. [PMID: 33992425 DOI: 10.1016/j.cpcardiol.2021.100861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/27/2021] [Indexed: 12/15/2022]
Abstract
Snakebite envenomation is a neglected tropical disease which can result in morbidity and mortality. Cardiac implications are poorly understood due to the low frequency of cardiotoxicity combined with a lack of robust information, as snakebites commonly occur in remote and rural areas. This review aims to assess cardiovascular implications of snakebite envenoming and proposes an algorithm for screening of cardiovascular manifestations. A systematic review was performed and 29 articles relating to cardiovascular involvement in snakebite envenomation were selected. Cardiovascular involvement seems to be rare and includes a wide spectrum of outcomes, such as myocardial infarction, ventricular dysfunction, hypotension, cardiac arrest, and myocarditis. In a significant proportion of the cases analyzed (24.39%), the cardiovascular manifestations had major consequences (cardiac arrest, myocardial infarction, malignant ventricular arrhythmias, or death). Clinical monitoring, physical examination, and early electrocardiogram should be considered as key measures to detect cardiovascular involvement in patients with evidence of systemic illness.
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Affiliation(s)
- Kiera Liblik
- Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
| | - Jin Byun
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Clara Saldarriaga
- Department of Cardiology and Heart Failure Clinic, Cardiovascular Clinic Santa Maria, University of Antioquia, Medellín, Colombia
| | - Gonzalo E Perez
- Division of Cardiology, Clínica Olivos, Buenos Aires, Argentina
| | - Ricardo Lopez-Santi
- Division of Cardiology, Hospital Italiano de la Plata, Buenos Aires, Argentina
| | - Fernando Q Wyss
- Division of Cardiology, Clínica Olivos, Buenos Aires, Argentina
| | - Alvaro S Liprandi
- Guatemala Cardiovascular Services and Technology, Cardiosolutions, Guatemala City
| | | | - Juan M Farina
- Hospital General Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Ivan Mendoza
- Tropical Cardiology, Tropical Medicine Institute, Central University of Venezuela, Caracas, Venezuela
| | - Lucrecia M Burgos
- Department of Heart Failure, Pulmonary Hypertension and Heart Transplant, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Adrian Baranchuk
- Division of Cardiology, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada.
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25
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Noutsos T, Currie BJ, Brown SG, Isbister GK. Schistocyte quantitation, thrombotic microangiopathy and acute kidney injury in Australian snakebite coagulopathy [ASP28]. Int J Lab Hematol 2021; 43:959-965. [PMID: 33615713 PMCID: PMC8519151 DOI: 10.1111/ijlh.13497] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/26/2021] [Accepted: 02/06/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The major systemic manifestation of hemotoxicity in human snakebite envenoming is venom-induced consumption coagulopathy (VICC). A subset of patients with VICC develop thrombotic microangiopathy (TMA), in which acute kidney injury (AKI) occurs. We aimed to investigate the association between schistocytosis in snakebite patients with VICC and AKI, compared to non-envenomed patients. METHODS Serial blood films collected from a prospective cohort of snakebite patients (Australian Snakebite Project) were examined. Cases were classified a priori as non-envenomed snakebites (normal controls), envenomed without VICC, partial VICC without AKI, complete VICC without AKI, and VICC with AKI based on defined clinical and laboratory criteria. The percentage of schistocytes between groups was compared and correlated by Kendall's tau b test. RESULTS Seven hundred and eighty blood films from 234 snakebite cases were analyzed. There was a statistically significant correlation (τ = .69, SE .03, P < .001) for schistocytosis between the ordered groups of non-envenomed snakebites, envenomed without VICC, partial VICC without AKI, complete VICC without AKI, and VICC with AKI groups. Patients with VICC and AKI had a platelet nadir median of 42 × 109 /L (interquartile range [IQR] :25-130 × 109 /L), hemoglobin nadir of median 107 g/L (IQR 66-122 g/L), and maximum LDH median of 1128 U/L (IQR 474-3255 U/L). A 1.0% threshold for schistocytosis yielded 90% sensitivity (95% CI: 67%-98%) and 71% specificity (95% CI: 62%-79%) for predicting AKI in patients with VICC. CONCLUSION Schistocyte quantitation has good diagnostic utility in snakebite patients with VICC. A definition of snakebite TMA as MAHA with ≥1.0% schistocytes and thrombocytopenia, would appear to be appropriate.
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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
| | - Simon G Brown
- Centre for Clinical Research in Emergency Medicine, University of Western Australia, Perth, WA, Australia.,Aeromedical and Medical Retrieval Division, Ambulance Tasmania, Hobart, TAS, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
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