a Emilio Ribas Institute of Infectious Diseases , São Paulo , Brazil.
b Vital Brazil Hospital , Butantan Institute , São Paulo , Brazil.
Clin Toxicol (Phila). 2019 Mar;57(3):213-216. doi: 10.1080/15563650.2018.1510129. Epub 2018 Nov 15.
Bothrops snakes are the most frequent agents of snakebites in South and Central America. Acute kidney injury (AKI) is one of its complications and has multifactorial origin. Thrombotic microangiopathy (TMA)-induced AKI in snakebites is uncommon and is not described in Bothrops envenomation.
We report two cases of patients bitten by young Bothrops jararaca who developed AKI induced by TMA. Both patients evolved with mild envenomation and received the specific antivenom within 4 h after the snakebite. None of them had hypotension or shock, bleeding or secondary infection. Patient 1 (P1) was diabetic and using oral hypoglycemic drugs, and patient 2 (P2) was hypertensive without regular use of medication. On admission, both patients had levels of fibrinogen lower than 35 mg/dL, D-dimer higher than 10,000 ng/mL. They evolved with AKI, thrombocytopenia, normal coagulation assays, anemia, lactate dehydrogenase (LDH) elevation, low haptoglobin levels, negative direct antiglobulin test, and presence of schizocytes in peripheral blood. Only P1 required renal replacement therapy, and plasmapheresis was not required. Both patients were discharged and did not require outpatient dialysis, and subsequently had normal creatinine levels.
TMA may occur in Bothrops jararaca envenomation, even in mild cases that received early specific antivenom.
矛头蝮蛇是中南美洲最常见的蛇伤致病蛇种。急性肾损伤（AKI）是其并发症之一，其发病机制具有多因素特点。蛇伤相关性血栓性微血管病（TMA）导致的 AKI 并不常见，在矛头蝮蛇咬伤中也未有相关报道。
我们报告了两例被幼龄矛头蝮蛇咬伤后发生 TMA 相关性 AKI 的患者。两名患者的蛇伤均较轻，并在咬伤后 4 小时内接受了特异性抗蛇毒血清治疗。他们均未出现低血压或休克、出血或继发感染。患者 1（P1）患有糖尿病并服用口服降糖药，患者 2（P2）患有高血压但未规律服用药物。入院时，两名患者的纤维蛋白原水平均低于 35mg/dL，D-二聚体均高于 10,000ng/mL。他们均出现 AKI、血小板减少、正常凝血试验、贫血、乳酸脱氢酶（LDH）升高、低血色素水平、直接抗球蛋白试验阴性和外周血出现裂体细胞。仅 P1 需要肾脏替代治疗，未行血浆置换。两名患者均出院，无需门诊透析，随后肌酐水平恢复正常。
TMA 可能发生于接受早期特异性抗蛇毒血清治疗的轻度矛头蝮蛇咬伤患者中。
