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Thrombotic microangiopathy from Australian brown snake (Pseudonaja) envenoming.
Intern Med J. 2007 Aug; 37(8):523-8.IM

Abstract

BACKGROUND

Australian brown snake (genus Pseudonaja) envenoming causes a venom-induced consumptive coagulopathy (VICC). A proportion of cases go on to develop thrombotic microangiopathy characterized by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and acute renal failure (ARF).

AIM

The aim of the study was to define better the natural history and empirical treatments for thrombotic microangiopathy in brown snake envenoming.

METHODS

A review of brown snake bites recruited to the Australian Snakebite Project (ASP), a national multicentre study of snake envenoming was undertaken. Serial data are recorded on clinical effects and laboratory results, including measurement of venom concentrations. We describe cases of thrombotic microangiopathy and compare these to cases without thrombotic microangiopathy.

RESULTS

From 32 cases of brown snake envenoming with severe VICC, four (13%) developed thrombotic microangiopathy, we also included two cases of thrombotic microangiopathy from prior to ASP. All six developed severe thrombocytopenia (<20 x 10(-9)/L), worst 3 days after the bite and resolving over a week, MAHA with fragmented red blood cells on the blood film and five developed anuric ARF requiring dialysis and lasting 2-8 weeks. All six received antivenom, which was delayed compared with other brown snake-envenoming cases. Four were treated with plasmapheresis. The severity and recovery of the thrombocytopenia, anaemia and renal function were similar with and without plasmapheresis. The median length of stay for MAHA cases was 14 days (interquartile range (IQR) 12-14) compared to 1.8 days (IQR 1.3-2) for all other cases.

CONCLUSION

Thrombotic microangiopathy resulting from brown snake bite appears to have a good prognosis and management should focus on early antivenom therapy and supportive care including dialysis. The role of plasmapheresis is yet to be defined.

Authors+Show Affiliations

Tropical Toxinology Unit, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia. geoffrey.isbister@menzies.edu.auNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Case Reports
Journal Article
Multicenter Study
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

17640187

Citation

Isbister, G K., et al. "Thrombotic Microangiopathy From Australian Brown Snake (Pseudonaja) Envenoming." Internal Medicine Journal, vol. 37, no. 8, 2007, pp. 523-8.
Isbister GK, Little M, Cull G, et al. Thrombotic microangiopathy from Australian brown snake (Pseudonaja) envenoming. Intern Med J. 2007;37(8):523-8.
Isbister, G. K., Little, M., Cull, G., McCoubrie, D., Lawton, P., Szabo, F., Kennedy, J., Trethewy, C., Luxton, G., Brown, S. G., & Currie, B. J. (2007). Thrombotic microangiopathy from Australian brown snake (Pseudonaja) envenoming. Internal Medicine Journal, 37(8), 523-8.
Isbister GK, et al. Thrombotic Microangiopathy From Australian Brown Snake (Pseudonaja) Envenoming. Intern Med J. 2007;37(8):523-8. PubMed PMID: 17640187.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Thrombotic microangiopathy from Australian brown snake (Pseudonaja) envenoming. AU - Isbister,G K, AU - Little,M, AU - Cull,G, AU - McCoubrie,D, AU - Lawton,P, AU - Szabo,F, AU - Kennedy,J, AU - Trethewy,C, AU - Luxton,G, AU - Brown,S G A, AU - Currie,B J, PY - 2007/7/21/pubmed PY - 2007/9/26/medline PY - 2007/7/21/entrez SP - 523 EP - 8 JF - Internal medicine journal JO - Intern Med J VL - 37 IS - 8 N2 - BACKGROUND: Australian brown snake (genus Pseudonaja) envenoming causes a venom-induced consumptive coagulopathy (VICC). A proportion of cases go on to develop thrombotic microangiopathy characterized by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and acute renal failure (ARF). AIM: The aim of the study was to define better the natural history and empirical treatments for thrombotic microangiopathy in brown snake envenoming. METHODS: A review of brown snake bites recruited to the Australian Snakebite Project (ASP), a national multicentre study of snake envenoming was undertaken. Serial data are recorded on clinical effects and laboratory results, including measurement of venom concentrations. We describe cases of thrombotic microangiopathy and compare these to cases without thrombotic microangiopathy. RESULTS: From 32 cases of brown snake envenoming with severe VICC, four (13%) developed thrombotic microangiopathy, we also included two cases of thrombotic microangiopathy from prior to ASP. All six developed severe thrombocytopenia (<20 x 10(-9)/L), worst 3 days after the bite and resolving over a week, MAHA with fragmented red blood cells on the blood film and five developed anuric ARF requiring dialysis and lasting 2-8 weeks. All six received antivenom, which was delayed compared with other brown snake-envenoming cases. Four were treated with plasmapheresis. The severity and recovery of the thrombocytopenia, anaemia and renal function were similar with and without plasmapheresis. The median length of stay for MAHA cases was 14 days (interquartile range (IQR) 12-14) compared to 1.8 days (IQR 1.3-2) for all other cases. CONCLUSION: Thrombotic microangiopathy resulting from brown snake bite appears to have a good prognosis and management should focus on early antivenom therapy and supportive care including dialysis. The role of plasmapheresis is yet to be defined. SN - 1445-5994 UR - https://www.unboundmedicine.com/medline/citation/17640187/Thrombotic_microangiopathy_from_Australian_brown_snake__Pseudonaja__envenoming_ L2 - https://doi.org/10.1111/j.1445-5994.2007.01407.x DB - PRIME DP - Unbound Medicine ER -