Presumptive thrombotic thrombocytopenic purpura following a hump-nosed viper (Hypnale hypnale) bite: a case report

Abstract

Hump-nosed viper bites are frequent in southern India and Sri Lanka. However, the published literature on this snakebite is limited and its venom composition is not well characterized. In this case, we report a patient with thrombotic thrombocytopenic purpura-like syndrome following envenoming which, to the best of our knowledge, has not been reported in the literature before. A 55-year-old woman from southern Sri Lanka presented to the local hospital 12 hours after a hump-nosed viper (Hypnale hypnale) bite. Five days later, she developed a syndrome that was characteristic of thrombotic thrombocytopenic purpura with fever, thrombocytopenia, microangiopathic hemolysis, renal impairment and neurological dysfunction in the form of confusion and coma. Her clinical syndrome and relevant laboratory parameters improved after she was treated with therapeutic plasma exchange. We compared our observations on this patient with the current literature and concluded that thrombotic thrombocytopenic purpura is a theoretically plausible yet unreported manifestation of hump-nosed viper bite up to this moment. This study also provides an important message for clinicians to look out for this complication in hump-nosed viper bites since timely treatment can be lifesaving.

Snakebite Induced Thrombotic Microangiopathy Leading to Renal Cortical Necrosis

“…At present, there is paucity of literature on TMA following snakebites in contrast to venom-induced consumptive coagulopathy (VICC), a commoner and well-known haematological complication of snakebites [ 1 – 3 ]. This is probably because TMA has been recognised as a complication of snakebites [ 4 ] and has been reported in this series of cases [ 5 ].…”

“…It has been suggested that, in all cases of VICC, there is a potential for TMA to develop but it only manifests in some patients [ 1 ]. However, cases of TMA have recently been reported to occur even in the absence of VICC, raising the possibility of an acquired HUS-like syndrome that is independent of VICC [ 3 , 4 ]. This has led to the suggestion that a toxin in the venom may be precipitating endothelial damage that culminates to TMA [ 3 , 7 ].…”

Viscoelastic testing in benign hematologic disorders: Clinical perspectives and future implications of point‐of‐care testing to assess hemostatic competence

“…The interplay between coagulation and inflammation in Takayasu arteritis remains poorly understood as does Normal VET variables [169][170][171] While the inciting events (dengue fever, trauma, and hump-nosed viper envenomation) varied, the consistent coagulation profiles using TEG suggest a possible limitation in diagnosis, which warrants further investigation Treatments guided by VETs:…”

A blood bond: evolutionary, pathophysiological and biodiscovery implications of coagulotoxic snake venoms

“…The functional variation extended to the patterns of fibrinogen chain cleavage as revealed in the SDS PAGE gels ( Just as the neurotoxicity exhibited by some species in this clade of snakes are unique, so too is the thrombin generating activity of C. rhodostoma. In contrast, D. acutus was more like the typical Asian pit-viper, which are broadly known for their haemorrhagic-shock inducing venoms (Cheng et al, 2017;Debono et al, 2019c;Hutton et al, 1990;Joseph et al, 2007;Maduwage et al, 2013a;Rojnuckarin et al, 1998;Warrell et al, 1986;Withana et al, 2014). Haemorrhagic effects are a result of anticoagulation mechanisms, or a net anticoagulant outcome.…”

“…Asian viper venoms are well known for effects on bite victims including haemorrhagic shock, necrosis and thrombocytopenia, spontaneous haemorrhage and acute kidney injury (Ariaratnam et al, 2008;de Silva et al, 1994;Herath et al, 2012;Joseph et al, 2007;Maduwage et al, 2013a;Maduwage et al, 2013b;Tang et al, 2016;Weerakkody et al, 2016;Withana et al, 2014).…”