血栓性微血管病,溶血性尿毒症综合征和血栓性血小板减少性紫癜:罗素毒蛇(达伯亚罗素ii)在斯里兰卡的罕见表现

R. Rathnayaka, P. Ranathunga, S. Kularatne
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引用次数: 211

摘要

背景:蛇科罗素蝰(Daboia russelii)是斯里兰卡的一种剧毒蛇,是造成最多蛇咬伤死亡的原因。它通常会引起凝血障碍和神经麻痹。血栓性微血管病(TMA)是一种罕见的咬伤并发症,包括急性肾损伤(AKI)、血小板减少症和微血管病性溶血。TMA有两种临床实体,包括溶血性尿毒症综合征(HUS)和血栓性血小板减少性紫癜(TTP),文献中只有很少的关于Russell毒蛇咬伤后TMA和HUS的记录。病例介绍:两名患者在拉塞尔毒蛇咬伤后出现TMA。一名36岁的男性,患有凝血障碍、呼吸衰竭、AKI、HUS症状,他通过抗蛇毒血清和8个周期的血液透析完全康复,并于毒蛇咬伤第19天出院。另一名患者是一名66岁的女性,患有延迟性凝血障碍和持续嗜睡,这是TTP的症状。她需要抗蛇毒血清进行9个周期的血液透析和6个周期的治疗性血浆交换,在医院接受30天后康复,包括重症监护治疗。讨论:罗素毒蛇毒液会激活因子V和X,从而导致毒液引起的消耗性凝血障碍和出血。毒液还会阻断神经肌肉接头并引起神经麻痹,通常表现为上睑下垂和眼外麻痹。它还具有直接的肾毒性作用,从而在肾微血管中沉积纤维蛋白,导致肾缺血。在TMA的HUS-TTP谱中,当有严重的肾脏受累时,建议使用HUS,当神经损伤突出时,诊断为TTP。结论:罗素毒蛇咬伤后可能很少出现TMA和HUS等非典型表现。需要类似观察结果的进一步证据来证实Daboia russelii咬伤后TTP的临床实体。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Thrombotic microangiopathy, hemolytic uremic syndrome and thrombotic thrombocytopenic purpura: Rare manifestations of Russell’s viper (Daboia russelii) envenoming in Sri Lanka
Background: Russell’s viper (Daboia russelii) of Family Viperidae is a highly venomous snake in Sri Lanka and is responsible for the most snakebite deaths. It commonly causes coagulopathy and neuroparalysis. Thrombotic microangiopathy (TMA) including the triad of acute kidney injury (AKI), thrombocytopenia and microangiopathic hemolysis is a rare complication of its bites. There are two clinical entities of TMA including hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) of which, only few records of TMA and HUS following Russell’s viper bites are available in literature.Case presentation: Two patients presented with TMA following Russell’s viper bites. A 36-year-old male who got coagulopathy, respiratory failure, AKI, signs of HUS, and he completely recovered with antivenom and 8 cycles of hemodialysis and discharged on day 19 of snakebite. The other patient was a 66-year-old female who had delayed coagulopathy and persistent drowsiness, the signs of TTP. She required antivenom with 9 cycles of hemodialysis and 6 cycles of therapeutic plasma exchange and got recovered after 30 days in hospital that included intensive care treatments.Discussion: Russell’s viper venom causes activation of Factor V and X which results venom induced consumption coagulopathy and bleeding. The venom also blocks neuromuscular junction and causes neuroparalysis, which are commonly manifested as ptosis and external ophthalmoplegia. It also has direct nephrotoxic effects and there are fibrin depositions in renal microvasculature thereby, causing renal ischemia. In the spectrum of HUS-TTP of TMA, HUS is suggested when there is a severe renal involvement, and TTP is diagnosed when neurological impairment is prominent.Conclusion: Atypical presentations like TMA and HUS may rarely occur following Russell’s viper bites. Further evidence of similar observations is needed to confirm the clinical entity of TTP following Daboia russelii bites.
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期刊介绍: Asia Pacific Journal of Medical Toxicology (APJMT) aims to expand the knowledge of medical toxicology and tries to provide reliable information in this field for medical and healthcare professionals. APJMT mainly focuses on research related to medical toxicology issues in the Asia Pacific region and publishes articles on clinical and epidemiological aspects of toxicology, poisonings emergency care, addiction, drug interactions and adverse effects. The journal accepts and welcomes high quality papers in the form of original articles and rarely review articles, case reports and scientific letters relevant to medical practice in toxicology.
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