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Acute Myocardial Infarction (AMI) Treated with Snake Antivenom. Case Rep Emerg Med 2021; 2021:9945296. [PMID: 34697575 PMCID: PMC8541847 DOI: 10.1155/2021/9945296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/04/2021] [Indexed: 11/18/2022] Open
Abstract
Cardiac complications following snakebites are uncommon but fatal. Here, we discuss a case of a snakebite that led to acute myocardial infarction (AMI). Forty-five-year-old male presented to the emergency room with snakebite on the right middle finger. He was given symptomatic treatment and admitted for observation. His vital signs and initial investigations were normal except for the white blood count that was high. During observation, he developed vomiting and bradycardia. He was diagnosed with a right bundle branch block on ECG. The patient developed chest pain after a few hours and was diagnosed with AMI on ECG. The toxicology team started antivenom therapy. His troponin kept rising initially but later started coming down without percutaneous intervention (PCI). He was treated successfully with antivenom therapy and discharged.
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Chaisakul J, Khow O, Wiwatwarayos K, Rusmili MRA, Prasert W, Othman I, Abidin SAZ, Charoenpitakchai M, Hodgson WC, Chanhome L, Chaiyabutr N. A Biochemical and Pharmacological Characterization of Phospholipase A 2 and Metalloproteinase Fractions from Eastern Russell's Viper ( Daboia siamensis) Venom: Two Major Components Associated with Acute Kidney Injury. Toxins (Basel) 2021; 13:521. [PMID: 34437392 PMCID: PMC8402394 DOI: 10.3390/toxins13080521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 12/21/2022] Open
Abstract
Acute kidney injury (AKI) following Eastern Russell's viper (Daboia siamensis) envenoming is a significant symptom in systemically envenomed victims. A number of venom components have been identified as causing the nephrotoxicity which leads to AKI. However, the precise mechanism of nephrotoxicity caused by these toxins is still unclear. In the present study, we purified two proteins from D. siamensis venom, namely RvPLA2 and RvMP. Protein identification using LCMS/MS confirmed the identity of RvPLA2 to be snake venom phospholipase A2 (SVPLA2) from Thai D. siamensis venom, whereas RvMP exhibited the presence of a factor X activator with two subunits. In vitro and in vivo pharmacological studies demonstrated myotoxicity and histopathological changes of kidney, heart, and spleen. RvPLA2 (3-10 µg/mL) caused inhibition of direct twitches of the chick biventer cervicis muscle preparation. After administration of RvPLA2 or RvMP (300 µg/kg, i.p.) for 24 h, diffuse glomerular congestion and tubular injury with minor loss of brush border were detected in envenomed mice. RvPLA2 and RvMP (300 µg/kg; i.p.) also induced congestion and tissue inflammation of heart muscle as well as diffuse congestion of mouse spleen. This study showed the significant roles of PLA2 and SVMP in snake bite envenoming caused by Thai D. siamensis and their similarities with observed clinical manifestations in envenomed victims. This study also indicated that there is a need to reevaluate the current treatment strategies for Thai D. siamensis envenoming, given the potential for irreversible nephrotoxicity.
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Affiliation(s)
- Janeyuth Chaisakul
- Department of Pharmacology, Phramongkutklao College of Medicine, Bangkok 10400, Thailand;
| | - Orawan Khow
- Queen Saovabha Memorial Institute, Thai Red Cross Society, Bangkok 10330, Thailand; (O.K.); (L.C.); (N.C.)
| | | | - Muhamad Rusdi Ahmad Rusmili
- Kulliyyah of Pharmacy, International Islamic University Malaysia, Bandar Indera Mahkota, Kuantan 25200, Malaysia;
| | - Watcharamon Prasert
- Department of Pharmacology, Phramongkutklao College of Medicine, Bangkok 10400, Thailand;
| | - Iekhsan Othman
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 46150, Malaysia; (I.O.); (S.A.Z.A.)
| | - Syafiq Asnawi Zainal Abidin
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 46150, Malaysia; (I.O.); (S.A.Z.A.)
| | | | - Wayne C. Hodgson
- Monash Venom Group, Department of Pharmacology, Biomedical Discovery Institute, Monash University, Clayton, VIC 3800, Australia;
| | - Lawan Chanhome
- Queen Saovabha Memorial Institute, Thai Red Cross Society, Bangkok 10330, Thailand; (O.K.); (L.C.); (N.C.)
| | - Narongsak Chaiyabutr
- Queen Saovabha Memorial Institute, Thai Red Cross Society, Bangkok 10330, Thailand; (O.K.); (L.C.); (N.C.)
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Namal Rathnayaka RMMK, Nishanthi Ranathunga PEA, Kularatne SAM. Kounis Syndrome Following Hypnale zara (Hump-Nosed Pit Viper) Bite in Sri Lanka. Wilderness Environ Med 2021; 32:210-216. [PMID: 33775497 DOI: 10.1016/j.wem.2020.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 11/29/2022]
Abstract
A 47-y-old man was bitten by a hump-nosed viper (Hypnale zara) and gradually developed retrosternal chest pain associated with ST segment elevation on electrocardiogram. He had normal troponin I levels and no evidence of coagulopathy. Initially, he was managed as having anterior ST elevation myocardial infarction with thrombolysis. Later, because troponin levels were normal, he was suggested to have the type I variant of Kounis syndrome (allergic coronary artery spasm). This was supported by high eosinophil counts in peripheral blood. He was successfully managed with supportive treatment and discharged 6 d after the snakebite. Cardiac complications are rarely reported after hump-nosed viper bites, and clinical reports of coronary vasospasm after snakebites are extremely rare in the literature. This is the first known report of Kounis syndrome after a hump-nosed viper bite.
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Affiliation(s)
- R M M K Namal Rathnayaka
- Intensive Care Unit, Teaching Hospital Ratnapura, Sri Lanka; Department of Pharmacology, Faculty of Medicine, Sabaragamuwa University of Sri Lanka, Hidellana, Ratnapura; Department of Veterinary Pathobiology, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Peredeniya, Sri Lanka.
| | | | - S A M Kularatne
- Faculty of Medicine, University of Peradeniya, Peredeniya, Sri Lanka
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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: 22] [Impact Index Per Article: 5.5] [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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Wijewickrama ES, Gooneratne LV, Gnanathasan A, Gawarammana I, Gunatilake M, Isbister GK. Thrombotic microangiopathy and acute kidney injury following Sri Lankan Daboia russelii and Hypnale species envenoming. Clin Toxicol (Phila) 2020; 58:997-1003. [PMID: 32067496 DOI: 10.1080/15563650.2020.1717509] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/18/2019] [Accepted: 01/12/2020] [Indexed: 10/25/2022]
Abstract
Context: Thrombotic microangiopathy (TMA) resulting in acute kidney injury (AKI) is an important complication of venomous snakebites. We aimed to describe TMA secondary to Russell's viper (Daboia russelli) and hump-nosed viper (Hypnale spp.) bites and assess the effect of different treatments.Materials and methods: We undertook a prospective observational study of patients with AKI secondary to snakebite over a two-year period. Data recorded included: demographic details, clinical and laboratory features, treatment, complications and outcomes, until hospital discharge and at three months post-discharge. TMA was defined as the development of microangiopathic hemolytic anemia and thrombocytopenia along with AKI. Treatment with therapeutic plasma exchange (TPE; also known as plasmapheresis) and/or fresh frozen plasma (FFP) was determined by the treating clinician. Antivenom was given to all patients with evidence of systemic envenoming following Russell's viper bites.Results: Fifty-nine patients were included in the analysis. Thirty-three (56%) were males and median age was 56 years. Forty-five (76%) developed TMA while a further 11 and two developed isolated thrombocytopenia and microangiopathic hemolytic anemia, respectively. Presence of TMA was associated with increased dialysis requirements (5 vs. 3) and longer hospital stay (18 vs. 12 days). Of the patients with TMA, nine received TPE with or without FFP infusions. The use of TPE was not associated with improved outcomes in patients with TMA based on requirement for blood transfusion, recovery of thrombocytopenia, requirement of dialysis and duration of hospital stay. Patients who did not receive TPE had better renal function at three months compared to patients who received this treatment.Conclusion: Presence of TMA in patients with Daboia and Hypnale bites was associated with a more prolonged course of AKI. Patients with TMA who were treated with TPE did not have improved early or late outcomes compared to patients who were not treated with TPE.
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Affiliation(s)
- Eranga S Wijewickrama
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Lalindra V Gooneratne
- Department of Pathology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Ariaranee Gnanathasan
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Indika Gawarammana
- Department of Medicine and South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Mangala Gunatilake
- Department of Physiology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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Wijewickrama ES, Gooneratne LV, Gnanathasan A, Gawarammana I, Gunatilake M, Isbister GK. Severe acute kidney injury following Sri Lankan Hypnale spp. envenoming is associated with thrombotic microangiopathy. Clin Toxicol (Phila) 2020; 59:296-302. [PMID: 32870056 DOI: 10.1080/15563650.2020.1810695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
CONTEXT Acute kidney injury (AKI) is the most serious clinical manifestation of the Sri Lankan hump-nosed pit viper (Hypnale spp.) bites. Thrombotic microangiopathy (TMA) is increasingly recognized in association with AKI in cases of Hypnale spp envenomation. We investigated AKI in a cohort of cases of Hypnale envenomation, its association with TMA and the early diagnostic value of common biomarkers for AKI occurring. MATERIALS AND METHODS We conducted a prospective observational study of suspected viper bites and included 103 confirmed cases of Hypnale envenomation, based on venom specific enzyme immunoassay of blood. AKI was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Thrombotic microangiopathy was diagnosed based on thrombocytopenia (platelet count < 150,000 × 103/μL) and microangiopathic haemolytic anaemia (MAHA). We investigated the diagnostic performance of creatinine, platelet count and INR for AKI within 4 h and 8 h post-bite by area under the receiver operator characteristic curve (AUC-ROC). RESULTS Ten patients developed AKI: seven AKI stage 1 and three AKI stage 3. Ten patients (10%) developed thrombocytopaenia while 11 (11%) had MAHA. All three AKI stage 3 had thrombocytopaenia and MAHA fulfilling the criteria for TMA. Two of them presented with oliguria/anuria and all three required haemodialysis. Serum creatinine within 4 h post-bite was the best predictor of AKI with AUC-ROC of 0.83 (95% CI: 0.67-0.99) and was no better within 8 h of the bite. CONCLUSIONS We found that AKI is uncommon in Hypnale spp. envenomation, but an important serious complication. Severe AKI was associated with TMA. A creatinine within 4 h post-bite was the best predictor of AKI.
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Affiliation(s)
- Eranga S Wijewickrama
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Lalindra V Gooneratne
- Department of Pathology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Ariaranee Gnanathasan
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Indika Gawarammana
- Department of Medicine and South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Mangala Gunatilake
- Department of Physiology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia.,South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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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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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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