Novel Treatment Strategy for Patients with Venom-Induced Consumptive Coagulopathy from a Pit Viper Bite

Park, Eun-jung; Choi, Sangchun; Kim, Hyuk-Hoon; Jung, Yoon Seok

doi:10.3390/toxins12050295

Cited by 16 publications

(31 citation statements)

References 46 publications

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“…VICC is marked by prolonged clotting times, and clotting factor deficiencies (i.e. hypofibrinogenaemia, low factor V, low factor VIII) and an elevated Ddimer [2][3][4][5]. VICC has a rapid onset and resolves with neutralisation or inactivation of the toxins and synthesis of new clotting factors [3,6,7].…”

Section: Introductionmentioning

confidence: 99%

Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis

et al. 2020

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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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Section: Introductionmentioning

confidence: 99%

Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis

et al. 2020

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“…Boomslang venom contains several proteins responsible for the coagulopathic effects it has on blood, including phospholipase A2, snake-venom serine proteinases and snake-venom metalloproteinases that lead to the consumptive coagulopathy. 7 Venom-induced consumptive coagulopathy starts with prothrombin activation (IIIa) and activation of factors IX and X. 2 This leads to fibrinogen being converted to fibrin, reducing circulating fibrinogen levels.…”

Section: Discussionmentioning

confidence: 99%

“…If left unchecked, DIC ensues leading to death. 7 A number of case studies 4 , 8 have shown derangements of whole blood clotting time and standard coagulation tests (PT, PTT, INR and fibrinogen); however, there have been no direct comparisons of coagulation tests with VEA in the setting of boomslang bites. This emphasises the importance of this case report.…”

Section: Discussionmentioning

confidence: 99%

A case report of detecting subclinical coagulopathy in a patient with boomslang (Dipholidus typus) bite

Lalloo

Engelbrecht

et al. 2021

S Afr Fam Pract

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The boomslang (Dipholidus typus) has a predominantly haemotoxic venom. Because of the consumptive nature of the coagulopathy, signs and symptoms are usually delayed by up to 72 h after the bite. Traditional laboratory coagulation assays have a long turnaround time, by which time the patient’s bleeding and clotting profile has changed. A 25-year-old male patient was bitten by a boomslang. Despite two normal laboratory coagulation assay results, a point-of-care rotational thromboelastometry showed low fibrinogen levels, leading to the administration of monovalent antivenom. This report highlights the value of point-of-care thromboelastometry in the care of patients with subclinical boomslang envenomation.

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“…However, TEG is too expensive to be used in low-income settings in which most snakebites occur. There have been no randomized controlled studies undertaken to assess the utility of TEG in patients with VICC [114].…”

Section: Novel Methods To Diagnose Viccmentioning

confidence: 99%

Bedside Coagulation Tests in Diagnosing Venom-Induced Consumption Coagulopathy in Snakebite

Wedasingha

Silva

2020

Toxins

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Venom-induced consumption coagulopathy is the most important systemic effect of snake envenoming. Coagulation tests are helpful to accurately and promptly diagnose venom-induced consumption coagulopathy and administer antivenom, which is the only specific treatment available. However, bedside clotting tests play a major role in diagnosing coagulopathy in low-income settings, where the majority of snakebites occur. We conducted a literature search in MEDLINE® from 1946 to 30 November 2019, looking for research articles describing clinical studies on bedside coagulation tests in snakebite patients. Out of 442 articles identified, 147 articles describing bedside clotting assays were included in the review. Three main bedside clotting tests were identified, namely the Lee–White clotting test, 20-min whole blood clotting time and venous clotting time. Although the original Lee–White clotting test has never been validated for snake envenoming, a recently validated version has been used in some South American countries. The 20-min whole blood clotting time test is the most commonly used test in a wide range of settings and for taxonomically diverse snake species. Venous clotting time is almost exclusively used in Thailand. Many validation studies have methodological limitations, including small sample size, lack of case-authentication, the inclusion of a heterogeneous mix of snakebites and inappropriate uses of gold standard tests. The observation times for bedside clotting tests were arbitrary, without proper scientific justification. Future research needs to focus on improving the existing 20-min whole blood clotting test, and also on looking for alternative bedside coagulation tests which are cheap, reliable and quicker.

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Novel Treatment Strategy for Patients with Venom-Induced Consumptive Coagulopathy from a Pit Viper Bite

Cited by 16 publications

References 46 publications

Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis

Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis

A case report of detecting subclinical coagulopathy in a patient with boomslang (Dipholidus typus) bite

Bedside Coagulation Tests in Diagnosing Venom-Induced Consumption Coagulopathy in Snakebite

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