Williams Kristie L, Woslager Megan, Garland Stephanie L, Barton Roger P, Banner William
a Oklahoma Center for Poison and Drug Information , Oklahoma City , OK , USA.
b The Children's Hospital at Saint Francis , Tulsa , OK , USA.
Clin Toxicol (Phila). 2017 Jun;55(5):326-331. doi: 10.1080/15563650.2017.1284334. Epub 2017 Feb 6.
Western Pygmy Rattlesnake (WPR) envenomation reportedly causes refractory and persistent coagulopathy when treated with CroFab (Crotalidae Polyvalent Immune Fab). We report two cases where polyvalent equine anti-viper serum (AntivipmynTRI) was used to treat recurrent coagulopathy in children.
The first patient was a 16-month-old male who was bitten by a confirmed WPR. The patient received a total of 18 vials of CroFab. His labs normalized, swelling gradually improved, and the child was discharged to home. On day 5, the child returned to the emergency department with a great deal of inguinal tenderness. Labs were obtained and the child's INR was >13.1, while the fibrinogen was <60 mg/dL and the d-dimer was 11.72 mg/L. A decision was made to administer Antivipmyn TRI, and the child received a total of 10 vials. Lab values significantly improved: INR 1.2, fibrinogen 93 mg/dL, and d-dimer 4.21 mg/L. The second patient was a 20-month-old male who presented following snake envenomation. The child was administered a total of 22 vials of CroFab over approximately 70 h following envenomation. Physical exam continued to improve, however, lab results showed an increasing INR 1.98, decreasing platelet count 124 × 10 per μL, fibrinogen <60 mg/dL, and d-dimer >20 ug/mL. A total of 15 vials of Antivipmyn TRI were administered to this patient. Following this administration, labs and clinical exam both significantly improved. Labs revealed INR 1.16, fibrinogen 110 mg/dL, d-dimer 3.2 mg/L and platelet count 215 × 10/μL.
CroFab is still the first-line treatment for children bitten by a WPR, but in some cases patients develop a recurrent coagulopathy. The rapid response demonstrated by Antivipmyn TRI leads us to conclude that this is a potential therapy for this clinical situation.
据报道，西部侏儒响尾蛇（WPR）咬伤后，使用克格索法（抗蛇毒血清）治疗会导致难治性和持续性凝血病。我们报告两例使用多价马抗蝰蛇血清（抗蝰蛇毒血清TRI）治疗儿童复发性凝血病的病例。
首例患者为一名16个月大的男性，被确诊为WPR咬伤。该患者共接受了18瓶克格索法治疗。其实验室检查结果恢复正常，肿胀逐渐改善，患儿出院回家。第5天，患儿因腹股沟剧痛返回急诊科。进行了实验室检查，患儿的国际标准化比值（INR）>13.1，纤维蛋白原<60mg/dL，D-二聚体为11.72mg/L。决定给予抗蝰蛇毒血清TRI治疗，患儿共接受了10瓶该血清治疗。实验室检查值显著改善：INR为1.2，纤维蛋白原93mg/dL，D-二聚体4.21mg/L。第二例患者为一名20个月大的男性，在被蛇咬伤后就诊。在咬伤后约70小时内，该患儿共接受了22瓶克格索法治疗。体格检查持续改善，然而，实验室检查结果显示INR升高至1.98，血小板计数降至每微升124×10，纤维蛋白原<60mg/dL，D-二聚体>20μg/mL。该患者共接受了15瓶抗蝰蛇毒血清TRI治疗。给予该血清治疗后，实验室检查和临床检查均显著改善。实验室检查结果显示INR为1.16，纤维蛋白原110mg/dL，D-二聚体3.2mg/L，血小板计数215×10/微升。
克格索法仍然是WPR咬伤儿童的一线治疗方法，但在某些情况下，患者会出现复发性凝血病。抗蝰蛇毒血清TRI显示出的快速反应使我们得出结论，这是针对这种临床情况的一种潜在治疗方法。
