Redefining the Role of Therapeutic Plasma Exchange in Complications of Envenomation Refractory to Anti-snake Venom: A Case Series

Overview

Journal Asian J Transfus Sci

Specialty Hematology

Date 2024 Jan 26

PMID 38274951

Authors

Davood Bava

P H Akhilesh Kumar

Anubhav Gupta

Saptarshi Mandal

Archana Bajpayee

Maya Gopalakrishnan

Md Atik Khan

Affiliations

Soon will be listed here.

Abstract

Introduction: Saw-scaled viper () belongs to the Viperidae family. Its venom is hemotoxic and contains several small peptides and proteins affecting the coagulation system. Commonly used anti-snake venom (ASV) products in India are reported to be ineffective or less effective in cases with bites by which are commonly found in desert areas in Rajasthan. Although therapeutic plasma exchange (TPE) has been successful in patients with snakebite envenomation in the past, American Society for Apheresis guidelines 2019 included this indication under category III with grade 2C recommendation.

Aim And Objectives: To report the safety and efficacy of therapeutic plasma exchange procedures in the setting of ASV refractory envenomation.

Materials And Methods: Four patients admitted to our institute in 2021 September with an alleged history of snake bites and who underwent at least one cycle of therapeutic plasma exchange were assessed for clinical outcome, laboratory parameters, and blood product consumption.

Results: Three adult patients and one pediatric patient are included in this case series, all of them males. Indication for TPE in one case was suspected diffuse alveolar hemorrhage (DAH), while in all the other cases was thrombotic microangiopathy (TMA). All received a variable number of sessions from 2 to 5 and 1.3-1.5 plasma volume was removed on an average per cycle. The endpoint of TPE was the resolution of DAH in one while a reduction in lactate dehydrogenase and an increase in platelet count was in TMA cases. Consumption of blood products was drastically reduced in all four patients after starting the procedure. All the adult patients fared well on follow-up while the child had developed acute cortical necrosis and was dialysis-dependent. It has been noted in the previous studies too that a subset of snakebite-induced TMA cases was getting converted to chronic kidney disease and becoming dialysis dependent in the long run.

Conclusions: In regions where ASV treatment failure is very common, therapeutic plasma exchange is a safe and effective complementary treatment modality along with supportive care.

References

Weis J, Whatley R, Glenn J, Rodgers G . Prolonged hypofibrinogenemia and protein C activation after envenoming by Echis carinatus sochureki. Am J Trop Med Hyg. 1991; 44(4):452-60. DOI: 10.4269/ajtmh.1991.44.452. View

Bawaskar H . Snake venoms and antivenoms: critical supply issues. J Assoc Physicians India. 2005; 52:11-3. View

Casewell N, Harrison R, Wuster W, Wagstaff S . Comparative venom gland transcriptome surveys of the saw-scaled vipers (Viperidae: Echis) reveal substantial intra-family gene diversity and novel venom transcripts. BMC Genomics. 2009; 10:564. PMC: 2790475. DOI: 10.1186/1471-2164-10-564. View

Senji Laxme R, Khochare S, Souza H, Ahuja B, Suranse V, Martin G . Beyond the 'big four': Venom profiling of the medically important yet neglected Indian snakes reveals disturbing antivenom deficiencies. PLoS Negl Trop Dis. 2019; 13(12):e0007899. PMC: 6894822. DOI: 10.1371/journal.pntd.0007899. View

Noutsos T, Currie B, Isoardi K, Brown S, Isbister G . Snakebite-associated thrombotic microangiopathy: an Australian prospective cohort study [ASP30]. Clin Toxicol (Phila). 2021; 60(2):205-213. DOI: 10.1080/15563650.2021.1948559. View

Sagheb M, Sharifian M, Moini M, Salehi O . Acute renal failure and acute necrotizing pancreatitis after Echis carinatus sochureki bite, report of a rare complication from southern Iran. Prague Med Rep. 2011; 112(1):67-71. View

Mohan G, Guduri P, Shastry S . Role of therapeutic plasma exchange in snake bite associated thrombotic microangiopathy-A case report with review of literature. J Clin Apher. 2019; 34(4):507-509. DOI: 10.1002/jca.21691. View

Valenta J, Stach Z, Michalek P . Snakebite Envenoming by Sochurek's Saw-scaled Viper Echis Carinatus Sochureki. Prague Med Rep. 2016; 117(1):61-7. DOI: 10.14712/23362936.2016.6. View

Ghezellou P, Albuquerque W, Garikapati V, Casewell N, Kazemi S, Ghassempour A . Integrating Top-Down and Bottom-Up Mass Spectrometric Strategies for Proteomic Profiling of Iranian Saw-Scaled Viper, , Venom. J Proteome Res. 2020; 20(1):895-908. PMC: 7613007. DOI: 10.1021/acs.jproteome.0c00687. View

10.

Mohan G, Guduri P, Shastry S, Kandasamy D . Thrombotic microangiopathy in hematotoxic snakebites and its impact on the prognosis: an entity often overlooked. J Thromb Thrombolysis. 2019; 48(3):475-482. DOI: 10.1007/s11239-019-01868-z. View

11.

Padmanabhan A, Connelly-Smith L, Aqui N, Balogun R, Klingel R, Meyer E . Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher. 2019; 34(3):171-354. DOI: 10.1002/jca.21705. View

12.

Sanhajariya S, Duffull S, Isbister G . Pharmacokinetics of Snake Venom. Toxins (Basel). 2018; 10(2). PMC: 5848174. DOI: 10.3390/toxins10020073. View

13.

Rogalski A, Soerensen C, Op den Brouw B, Lister C, Dashevsky D, Arbuckle K . Differential procoagulant effects of saw-scaled viper (Serpentes: Viperidae: Echis) snake venoms on human plasma and the narrow taxonomic ranges of antivenom efficacies. Toxicol Lett. 2017; 280:159-170. DOI: 10.1016/j.toxlet.2017.08.020. View

14.

Kochar D, Tanwar P, Norris R, Sabir M, Nayak K, Agrawal T . Rediscovery of severe saw-scaled viper (Echis sochureki) envenoming in the Thar desert region of Rajasthan, India. Wilderness Environ Med. 2007; 18(2):75-85. DOI: 10.1580/06-WEME-OR-078R.1. View

15.

Barlow A, Pook C, Harrison R, Wuster W . Coevolution of diet and prey-specific venom activity supports the role of selection in snake venom evolution. Proc Biol Sci. 2009; 276(1666):2443-9. PMC: 2690460. DOI: 10.1098/rspb.2009.0048. View

16.

Zengin S, Yilmaz M, Al B, Yildirim C, Yarbil P, Kilic H . Plasma exchange as a complementary approach to snake bite treatment: an academic emergency department's experiences. Transfus Apher Sci. 2013; 49(3):494-8. DOI: 10.1016/j.transci.2013.03.006. View

17.

Suraweera W, Warrell D, Whitaker R, Menon G, Rodrigues R, Fu S . Trends in snakebite deaths in India from 2000 to 2019 in a nationally representative mortality study. Elife. 2020; 9. PMC: 7340498. DOI: 10.7554/eLife.54076. View

18.

Bhatia S, Vasudevan K . Comparative proteomics of geographically distinct saw-scaled viper () venoms from India. Toxicon X. 2020; 7:100048. PMC: 7322182. DOI: 10.1016/j.toxcx.2020.100048. View

19.

Warrell D . Snake bite. Lancet. 2010; 375(9708):77-88. DOI: 10.1016/S0140-6736(09)61754-2. View

20.

Gopalakrishnan M, Yadav P, Mathur R, Midha N, Garg M . Venom-Induced Consumption Coagulopathy Unresponsive to Antivenom After Echis carinatus sochureki Envenoming. Wilderness Environ Med. 2021; 32(2):221-225. DOI: 10.1016/j.wem.2021.01.004. View