Sampley Supriya, Sakhuja Vinay, Bhasin Deepak, Singh Kuldeep, Singh Harpal
Department of Pulmonology and Critical Care, Medical Intensive Care Unit, Max Super Speciality Hospital, Mohali, Punjab, India.
Department of Nephrology, Max Super Speciality Hospital, Mohali, Punjab, India.
Indian J Crit Care Med. 2020 Oct;24(10):986-990. doi: 10.5005/jp-journals-10071-23635.
Snakebites are one of the commonest occupational hazards in tropical countries and viperine bites are potential to cause systemic toxicity. Coagulopathies and acute kidney injury (AKI) have been documented and easily dealt with in past, but pulmonary hemorrhage has been rarely seen and plasmapheresis has shown promising result for the same. This case reports highlight the effective use of plasmapheresis for pulmonary hemorrhage post-snakebite.
Viperine snakebite has been associated with high morbidity and mortality due to its toxic systemic envenomization. The important systemic manifestations are coagulopathy, neuromuscular paralysis, AKI, myotoxicity, and cardiovascular collapse. Antivenomization, renal replacement therapy, steroids, and other supportive care are considered to be the mainstay of treatment till date. Pulmonary hemorrhage has been an unusual manifestation of viper bite and rarely reported and steroids have been used in such scenario but with mixed results. Role of plasmapheresis has been documented in the management of snakebite but especially for hematological problems and in limb preservation/salvage strategies. The use of same, for pulmonary hemorrhage has not been studied yet. Here, we present a rare case of pulmonary hemorrhage along with renal failure following viper bite which was successfully treated with plasmapheresis. To the best of our knowledge, it is a rare presentation and has not been reported in the literature reviewed till date.
A previously healthy, 36-year-old man presented to our hospital 48 hours after a viper bite. He developed local as well systemic manifestations evident as hemolysis and renal failure. Gradually, he started having hemoptysis followed by respiratory failure requiring ventilatory support. CT chest done was s/o bilateral pulmonary hemorrhages correlating clinically with ongoing tracheal bleed. He had no other bleeding manifestations and had normal coagulation profile. He was initially treated with methylprednisolone therapy, but then did not show any improvement and finally plasmapheresis was done as rescue therapy. Following this, he had improvement in respiratory parameters and settling tracheal bleed with resolution of radiological changes. He was successfully weaned off from the ventilation and also his renal failure also improved with near normalization of pulmonary and renal functions.
This case highlights the unusual presentation of pulmonary hemorrhage in a patient with viperine bite with normal coagulation and was aggressively managed with plasmapheresis. Hence, plasmapheresis can be used as life-saving modality in patients with systemic envenomization post-viperine bit.
Sampley S, Sakhuja V, Bhasin D, Singh K, Singh H. Plasmapheresis for Pulmonary Hemorrhage Following Viperine Snakebite: A Case Report with Review of Literature. Indian J Crit Care Med 2020;24(10):986-990.
蛇咬伤是热带国家最常见的职业危害之一，蝰蛇咬伤有可能导致全身中毒。过去已记录到凝血障碍和急性肾损伤（AKI），且易于处理，但肺出血很少见，血浆置换对此显示出了有前景的效果。本病例报告强调了血浆置换在蝰蛇咬伤后肺出血治疗中的有效应用。
蝰蛇咬伤因其有毒的全身中毒而与高发病率和死亡率相关。重要的全身表现包括凝血障碍、神经肌肉麻痹、AKI、肌毒性和心血管衰竭。迄今为止，抗蛇毒血清治疗、肾脏替代治疗、类固醇及其他支持性护理被认为是主要的治疗方法。肺出血一直是蝰蛇咬伤的一种不寻常表现，很少被报道，类固醇曾用于这种情况，但结果不一。血浆置换在蛇咬伤治疗中的作用已有文献记载，但主要用于血液学问题及肢体保全策略。其在肺出血治疗中的应用尚未得到研究。在此，我们报告一例蝰蛇咬伤后罕见的肺出血合并肾衰竭病例，该病例通过血浆置换成功治愈。据我们所知，这是一种罕见的表现，在迄今为止查阅的文献中尚未有报道。
一名36岁既往健康男性在被蝰蛇咬伤48小时后就诊于我院。他出现了局部和全身表现，表现为溶血和肾衰竭。逐渐地，他开始咯血，随后出现呼吸衰竭，需要通气支持。胸部CT显示双侧肺出血，临床与持续的气管出血相关。他没有其他出血表现，凝血指标正常。他最初接受甲泼尼龙治疗，但未显示任何改善，最终进行血浆置换作为抢救治疗。此后，他的呼吸参数有所改善，气管出血停止，影像学改变消失。他成功脱机，肾衰竭也有所改善，肺和肾功能接近正常。
本病例突出了蝰蛇咬伤患者出现凝血正常的肺出血这一不寻常表现，并通过血浆置换积极治疗。因此，血浆置换可作为蝰蛇咬伤后全身中毒患者的救命方法。
Sampley S, Sakhuja V, Bhasin D, Singh K, Singh H. 蝰蛇咬伤后肺出血的血浆置换治疗：一例报告并文献复习。《印度重症监护医学杂志》2020;24(10):986 - 990。
