Coagulopathy after snake envenomation in South Korea

OBJECTIVE

This retrospective study investigated the nature and severity of venom-induced consumption coagulopathy (VICC) and determined the clotting factors involved in VICC in patients after envenomation by South Korea's snakes. Additionally, we studied the effectiveness of antivenom for the treatment of VICC after envenomation.

METHODS

Included patients were divided into three groups according to the severity of VICC (no VICC, partial VICC, and complete VICC). Data, including changes in coagulation parameters during hospitalization and clotting factors at presentation, were collected and analyzed.

RESULTS

One hundred nineteen patients who presented at our emergency department within 3 h after snake envenomation were included. VICC developed in 34 patients (27 patients with partial VICC and 7 patients with complete VICC). Two of 34 patients with VICC required blood transfusions. Five patients with complete VICC had an undetectable fibrinogen concentration at presentation. Three patients with complete VICC had an unmeasurable INR and aPTT within 24 h. The median times of the most extreme values were 10 h for INR, 12 h for aPTT, and 16 h for fibrinogen after presentation in the VICC group. The D-dimer concentration peaked at a median of 63.5 h after presentation. The activities of factors II and X were significantly reduced in the complete VICC group (factor II: 88 (84-99.3)% in the non-VICC group vs. 69 (49.5-83.5)% in the complete VICC group; factor X:94 (83-102) in the non-VICC group vs. 70 (66.5-79.8)% in the complete VICC group), while there was no difference in factor V activity at presentation. The time from bite to first antivenom administration did not correlate with the time course and most extreme concentrations for fibrinogen and D-dimer within the VICC groups.

DISCUSSION AND CONCLUSION

VICC occurs in approximately one-quarter of snakebite patients in South Korea; however, VICC itself does not appear to lead to clinical deterioration. Fibrinogen is an early diagnostic maker for complete VICC. Clotting factors II and X are involved in VICC. Future investigations should explore the mechanism of VICC from Korean snakebites and the effect of antivenom on VICC.

Retrospective evaluation of acute kidney injury in dogs with pit viper envenomation (2008-2017): 56 cases

OBJECTIVES

To describe the clinicopathological characteristics of dogs that develop acute kidney injury (AKI) secondary to pit viper envenomation, and to describe the association between development of AKI and clinical course and outcome.

DESIGN

Retrospective study.

SETTING

University teaching hospital.

ANIMALS

Client-owned dogs treated with at least 1 vial of antivenom following pit viper envenomation and that had at least 2 plasma creatinine concentrations measured during the course of hospitalization.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-three dogs met the inclusion criteria. One was excluded due chronic kidney disease, and 6 were excluded due to nonsteroidal anti-inflammatory drug administration. Of the 56 dogs included in the study, 16 developed AKI (29%). Dogs with AKI received a significantly higher dose of antivenom, 8.7 ± 6.8 total vials versus dogs in the non-AKI group that received 4.2 ± 2.6 vials (P = 0.006). Dogs in the AKI group were significantly more tachycardic (P = 0.028), hypotensive (P = 0.002), had a higher shock index (P = 0.012), and were more likely to receive transfusions with packed red blood cells (P = 0.042) than dogs in the non-AKI group. No significant association was identified between the development of AKI and length of hospitalization. The only factors that were significantly associated with degree of severity of AKI included the receipt of blood transfusion (P = 0.006) and number of vials of antivenom administered (P = 0.03). The development of AKI was significantly associated with outcome (P < 0.001), with 5 of 16 (31%) dogs in the AKI group surviving to discharge, 7 of 16 (44%) dying, and 4 of 16 (25%) being euthanized versus 39 of 40 (98%) surviving to discharge in the non-AKI group and 1 of 40 (2%) dying in hospital.

CONCLUSION

Development of AKI in dogs following pit viper envenomation carries an increased risk of mortality that is associated with severity of shock at presentation and increased doses of antivenom administration.

Reversible atrial fibrillation following Crotalinae envenomation

Background

Cardiotoxicity is a documented complication of Crotalinae envenomation. Reported cardiac complications following snake envenomation have included acute myocardial infarction, electrocardiogram abnormalities and arrhythmias. Few reports exist describing arrhythmia induced by viper envenomation and to our knowledge none describe arrhythmia induced by Crotalinae envenomation. This report concerns the first known case of atrial fibrillation precipitated by rattlesnake bite.

Case presentation

A 73-year-old Caucasian man with a past medical history of hypertension, hyperlipidemia, type 1 diabetes mellitus, and a baseline first-degree atrioventricular block presented to the emergency department following a rattlesnake bite to his left lower leg. He developed pain and swelling in his left leg two-hour post-envenomation and subsequently received four vials of Crotalidae polyvalent immune fab (ovine). At three-hour post-envenomation following transfer to the intensive care unit, an electrocardiogram revealed new-onset atrial fibrillation. An amiodarone drip was started and the patient successfully converted to normal sinus rhythm approximately six hours after he was found to be in atrial fibrillation. A transthoracic echocardiogram revealed mild concentric left ventricular hypertrophy and an ejection fraction of 72%. He was discharged the following day with no hematological abnormalities and a baseline first-degree atrioventricular block.

Conclusion

This is the first documented case of reversible atrial fibrillation precipitated by Crotalinae envenomation. In patients with pertinent risk factors for developing atrial fibrillation, physicians should be aware of the potential for this arrhythmia. Direct toxic effects of venom or structural and electrophysiological cardiovascular abnormalities may predispose snakebite patients to arrhythmia, warranting extended and attentive cardiac monitoring.