Citation Information :
Sampley S, Sakhuja V, Bhasin D, Singh H. Plasmapheresis for Pulmonary Hemorrhage Following Viperine Snakebite: Case Report with Review of Literature. Indian J Crit Care Med 2020; 24 (10):986-990.
Introduction: Snakebites are one of the commonest occupational hazards in tropical countries and viperine bites are potential to cause systemic toxicity. Coagulopathies and acute kidney injury (AKI) have been documented and easily dealt with in past, but pulmonary hemorrhage has been rarely seen and plasmapheresis has shown promising result for the same. This case reports highlight the effective use of plasmapheresis for pulmonary hemorrhage post-snakebite. Background: Viperine snakebite has been associated with high morbidity and mortality due to its toxic systemic envenomization. The important systemic manifestations are coagulopathy, neuromuscular paralysis, AKI, myotoxicity, and cardiovascular collapse. Antivenomization, renal replacement therapy, steroids, and other supportive care are considered to be the mainstay of treatment till date. Pulmonary hemorrhage has been an unusual manifestation of viper bite and rarely reported and steroids have been used in such scenario but with mixed results. Role of plasmapheresis has been documented in the management of snakebite but especially for hematological problems and in limb preservation/salvage strategies. The use of same, for pulmonary hemorrhage has not been studied yet. Here, we present a rare case of pulmonary hemorrhage along with renal failure following viper bite which was successfully treated with plasmapheresis. To the best of our knowledge, it is a rare presentation and has not been reported in the literature reviewed till date. Case description: A previously healthy, 36-year-old man presented to our hospital 48 hours after a viper bite. He developed local as well systemic manifestations evident as hemolysis and renal failure. Gradually, he started having hemoptysis followed by respiratory failure requiring ventilatory support. CT chest done was s/o bilateral pulmonary hemorrhages correlating clinically with ongoing tracheal bleed. He had no other bleeding manifestations and had normal coagulation profile. He was initially treated with methylprednisolone therapy, but then did not show any improvement and finally plasmapheresis was done as rescue therapy. Following this, he had improvement in respiratory parameters and settling tracheal bleed with resolution of radiological changes. He was successfully weaned off from the ventilation and also his renal failure also improved with near normalization of pulmonary and renal functions. Conclusion: This case highlights the unusual presentation of pulmonary hemorrhage in a patient with viperine bite with normal coagulation and was aggressively managed with plasmapheresis. Hence, plasmapheresis can be used as life-saving modality in patients with systemic envenomization post-viperine bit.
Chippaux JP. Snakebites: appraisal of the global situation. Bull World Health Organ 1998;76(5):515–524.
Chugh KS, Pal Y, Chakravarthy RN, Datta BN, Mehta R, Sakhuja V, et al. Acute renal failure following poisonous snake bite. Am J Kidney Dis 1984;4(1):30–38. DOI: 10.1016/S0272-6386(84)80023-2.
Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, Premaratna R, et al. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med 2008;5(11):e218. DOI: 10.1371/journal.pmed.0050218 PMID: 18986210.
Menon JC, Joseph JK, Kulkarni K. Treatment of snakebites: a resume. Cobra 2007;1:1–21.
Sawai Y, Toriba M, Itokawa H, De Silva A, Perera GL, Kottegoda MB. Death from snake-bite in Anuradhapura district. Ceylon Med J 1983;28(3):163–169.
Silveira KSO, Boechem NT, Do Nascimento SM, Murakami YLB, Barboza APB, Melo PA, et al. Pulmonary mechanics and lung histology in acute lung injury induced by Bothrops jararaca venom. Respir Physiol Neurobiol 2004;139(2):167–177. DOI: 10.1016/j.resp.2003.10.002.
De Silva A, Ranasinghe L. Epidemiology of snake-bite in Sri Lanka: a review. Ceylon Med J 1983;28(3):144–154.
Upadhyaya AC, Murthy GL, Sahay RK, Srinivasan VR, Shantaram V. Snake bite presenting as acute myocardial infarction, ischaemic cerebrovascular accident, acute renal failure and disseminated intravascular coagulopathy. J Assoc Physicians India 2000;48(11): 1109–1110.
Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, et al. Snakebite mortality in India: a nationally representative mortality survey. PLoS Negl Trop Dis 2011;5(4):e1018. DOI: 10.1371/journal.pntd.0001018.
Burdmann EA, Jha V. Acute kidney injury due to tropical infectious diseases and animal venoms. a tale of 2 continents. Kidney Int 2017;91(5):1033–1046. DOI: 10.1016/j.kint.2016.09.051.
Karthik S, Phadke KD. Snakebite-induced acute renal failure. A case report and review of the literature. Pediatr Nephrol 2004;19(9): 1053–1054. DOI: 10.1007/s00467-004-1507-z.
World Health Organization (WHO). Guidelines for the management of snake-bites in South-East Asia. New Delhi: WHO; 2010.
Kanjanabuch T, Sitprija V. Snakebite nephrotoxicity in Asia. Semin Nephrol 2008;28(4):363–372. DOI: 10.1016/j.semnephrol.2008. 04.005.
Sitprija V. Snakebite nephropathy. Nephrology (Carlton) 2006;11(5):442–448. DOI: 10.1111/j.1440-1797.2006.00599.x.
Pinho FM, Zanetta DM, Burdmann EA. Acute renal failure after Crotalus durissus snakebite: a prospective survey on 100 patients. Kidney Int 2005;67(2):659–667. DOI: 10.1111/j.1523-1755.2005.67122.x.
Athappan G, Balaji MV, Navaneethan U, Thirumalikolundusubramanian P. Acute renal failure in snake envenomation: a large prospective study. Saudi J Kidney Dis Transpl 2008;19(3):404–410.
Danis R, Ozmen S, Celen MK, Akin D, Ayaz C, Yazanel O. Snakebite-induced acute kidney injury: data from Southeast Anatolia. Ren Fail 2008;30(1):51–55. DOI: 10.1080/08860220701742021.
Dharod MV, Patil TB, Deshpande AS, Gulhane RV, Patil MB, Bansod YV. Clinical predictors of acute kidney injury following snake bite envenomation. N Am J Med Sci 2013;5(10):594–599. DOI: 10.4103/1947-2714.120795.
Harshavardhan L, Lokesh AJ, Tejeshwari HL, Halesha BR, Metri SS. A study on the acute kidney injury in snake bite victims in a tertiary care centre. J Clin Diagn Res 2013;7(5):853–856.
Gnanathasan A, Rodrigo C. Pulmonary effects and complications of snakebites. Chest 2014;146(5):1403–1412. DOI: 10.1378/chest.13-2674.
Kularatne SA. Epidemiology and clinical picture of the Russell's viper (Daboia russelii russelii) bite in Anuradhapura, Sri Lanka: a prospective study of 336 patients. Southeast Asian J Trop Med Public Health 2003;34(4):855–862.
Benvenuti LA, França FO, Barbaro KC, Nunes JR, Cardoso JL. Pulmonary haemorrhage causing rapid death aft er Bothrops jararacussu snakebite: a case report. Toxicon 2003;42(3):331–334. DOI: 10.1016/S0041-0101(03)00167-3.
Palangasinghe DR, Weerakkody RM, Dalpatadu CG, Gnanathasan CA. A fatal outcome due to pulmonary hemorrhage following Russell's viper bite. Saudi Med J 2015;36(5):634–637. DOI: 10.15537/smj.2015.5.10691.
Srirangan A, Pushpakumara J, Wanigasuriya K. A life-threatening complication due to pulmonary haemorrhage following humpnosed viper bite. BMC Pulm Med 2020;20(1):35. DOI: 10.1186/s12890-020-1070-9.
Kornalik F, Vorlova Z. Non-specific therapy of a hemorrhagic diathesis after a bite by a young Bothrops asper (barba amarilla): a case report. Toxicon 1990;28(12):1497–1501. DOI: 10.1016/0041-0101(90)90163-2.
Zengin S, Yilmaz M, Al B, Yildirim C, Yarbil P, Kilic H, et al. Plasma exchange as a complementary approach to snake bite treatment: an academic emergency department's experiences. Transfus Apher Sci 2013;49(3):494–498. DOI: 10.1016/j.transci.2013.03.006.
Rasulov AR, Berdymuradov DB. Intensive therapy in bites of poisonous snakes. Anesteziol Reanimatol 1994(3):59–60.
Szczepiorkowski ZM, Winters JL, Bandarenko N, Kim HC, Linenberger ML, Marques MB, et al. Guidelines on the use of therapeutic apheresis in clinical practice evidence based approach from the apheresis applications committee of the American Society for Apheresis. J Clin Apheresis 2010;25(3):83–177. DOI: 10.1002/jca.20240.
Isbister GK, Little M, Cull G, McCoubrie D, Lawton P, Szabo F, et al. Thrombotic microangiopathy from australian brown snake (Pseudonaja) envenoming. Intern Med J 2007;37(8):523–528. DOI: 10.1111/j.1445-5994.2007.01407.x.
Malbranque S, Piercecchi-Marti MD, Thomas L, Barbey C, Courcier D, Bucher B, et al. Case report: fatal diffuse thrombotic microangiopathy after a bite by the “fer-de-lance” pit viper (Bothrops lanceolatus) of Martinique. Am J Trop Med Hyg 2008;78(6):856–861. DOI: 10.4269/ajtmh.2008.78.856.