Deinagkistrodon acutus envenomation: a report of three cases

 

Chin-Lung Cheng^1  2 , Yan-Chiao Mao^2  3  4 , Po-Yu Liu⁵, Liao-Chun Chiang^6  7S, Shu-Chen Liao^4  8, Chen-Chang Yang^3  4 

 

1 Department of Emergency Medicine, Kaohsiung Armed Forces General Hospital, Taipei, Taiwan.

2 Department of Emergency Medicine, Division of Clinical Toxicology, Taichung Veterans General Hospital, Taipei, Taiwan.

3 Department of Medicine, Division of Clinical Toxicology and Occupational Medicine, Taipei Veterans General Hospital, 201 Sec. 2, Shipai Road., Taipei 112, Taiwan.

4 Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan.

5 Department of Medicine, Division of Infection, Taichung Veterans General Hospital, Taichung, Taiwan.

6 National Tsing Hua University, College of Life Sciences, Hsinchu, Taiwan.

7 National Health Research Institutes, National Institute of Infectious Diseases and Vaccinology, Zhunan, Miaoli, Taiwan.

8 Department of Emergency Medicine, Chang Guang Memorial Hospital, Taipei, Taiwan.

 

ABSTRACT

Background

Deinagkistrodon acutus envenomation is associated with severe hematological and wound complications but is rarely described.

Case presentation

Herein, we report three cases of victims bitten by D. acutus and indicate that rapid-onset severe coagulopathy and thrombocytopenia are distinct features of D. acutus snakebite, which are not observed in other crotaline snakebites (i.e., Trimeresurus stejnegeri and Protobothrops mucrosquamatus) in Taiwan. The toxic effects could occur as early as 2 to 3 h following D. acutus envenomation and persist if the administration of specific antivenom is delayed or even not commenced. Based on our findings, 2 to 4 vials of specific antivenom as the first dose should be administered to victims and repeated at 6 to 8 h intervals if coagulopathy or thrombocytopenia persists. Fresh frozen plasma or platelet replacement is probably safe as an adjunct therapy for D. acutus bite in the presence of venom-induced consumptive coagulopathy.

Conclusion

Severe coagulopathy and thrombocytopenia could occur as early as 2 to 3 h after D. acutus envenomation. The current recommendation for antivenom is 2 to 4 vials as the first dose and repeated every 6– to 8 h if coagulopathy or thrombocytopenia persists. These cases studied may be helpful to first-line medical personnel in the early diagnosis and management of D. acutus envenomation among other crotaline snakebites in Taiwan.

 

Key words: Coagulopathy; Thrombocytopenia; Envenomation; Deinagkistrodon acutus; Snakebite

 

Funding

Not applicable.

 

Received: September 30, 2016.

Revised: March 21, 2017.

Accepted: March 23, 2017.

 

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Authors’ contributions

The first two authors, CLC and YCM interpreted the clinical findings and drafted the manuscript. The third to the fifth authors, PYL, LCC, and SCL provided professional opinions in bacteriology of snakebite and snake venomics and antivenomics, and revised the manuscript. The correspondent author CCY designed this study, interpreted the clinical findings and revised the manuscript. All authors read and approved the final manuscript.

 

Competing interests

The authors declare that they have no competing interests.

 

Consent for publication

Written informed consent was obtained from the patients for publication of this case report.

 

Ethics approval and consent to participate

The study protocol was approved by the Institutional Review Board of Taichung Veterans General Hospital (IRB, CE14202A).