Thrombotic Microangiopathy, Hemolytic Uremic Syndrome, and Thrombotic Thrombocytopenic Purpura Following Hump-nosed Pit Viper (Genus: Hypnale) Envenoming in Sri Lanka

Abstract

Thrombotic microangiopathy (TMA), which includes the spectrum of hemolytic uremic syndrome and thrombotic thrombocytopenic purpura, is an uncommon complication of hump-nosed pit viper envenomation. We describe 4 cases of TMA following hump-nosed pit viper (Hypnale spp) bites in Sri Lanka. The first case is a typical TMA that spontaneously resolved with supportive treatments. The second and third cases are related to hemolytic uremic syndrome complicated with acute kidney injury that required hemodialysis. The fourth case is thrombotic thrombocytopenic purpura associated with acute kidney injury that required hemodialysis and therapeutic plasma exchange. For each patient we describe the circumstances of the bite, clinical features, laboratory findings, and management.

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

“…Seven-thousand-and-forty-two articles underwent abstract screening, with 223 full text reviews, and 72 studies selected (Fig 1). These included 31 single case reports [13,15,16,[22][23][24], 31 case series [8,9,14,17,[25][26][27], nine cohort studies [11,[84][85][86][87][88][89][90][91], and one nested case control study (Table 1) [92]. Eighteen studies contained completely or partially duplicated cases which were merged (S5 Table) [9,11,14,23,26,41,60,[66][67][68]75,76,81,[84][85][86]88,92].…”

“…Some studies have proposed TPE as an effective treatment for the acute kidney injury (AKI) of TMA following snakebite [23][24][25]. Associations between TMA following snakebite and HUS have arisen primarily given the apparent renal predominant end organ injury of both disorders [25][26][27]. Whilst TPE is commonly used during the initial presentation of HUS, it is usually unsuccessful.…”

Thrombotic microangiopathy due to Bothrops erythromelas: a case report in Northeast Brazil

“…The thrombotic microangiopathy presented a clinical picture similar to the one of hemolytic uremic syndrome (HUS) 2 , i.e., AKI, thrombocytopenia and microangiopathic hemolytic anemia (MAHA). Although many studies have reported the relationship between TMA and the venom-induced consumption coagulopathy (VICC), TMA in snakebite may occur without VICC 10 , 11 . VICC is characterized by prolonged clotting times caused by activation of the coagulation cascade by prothrombin, thrombin-like enzymes and factor X activators present in the venom 2 , 12 , which resolves after the toxins neutralization.…”

Extracellular vesicles mediate cellular interactions in renal diseases—Novel views of intercellular communications in the kidney

“…TMA has two classic variants, namely hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (Namal Rathnayaka et al, 2019). TMA can also be seen in many clinical scenarios such as positive antiphospholipid antibody in lupus patients, preeclampsia, malignant hypertension, and atypical HUS.…”