Journal of Thrombosis and Thrombolysis

, Volume 48, Issue 3, pp 475–482 | Cite as

Thrombotic microangiopathy in hematotoxic snakebites and its impact on the prognosis: an entity often overlooked

  • Ganesh MohanEmail author
  • Pruthvi Raj Guduri
  • Shamee Shastry
  • Dhivya Kandasamy


Snakebite associated thrombotic microangiopathy (TMA) is a spectrum of disorders characterized by microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury (AKI). We carried out this study to find out the prevalence of TMA in hematotoxic snake envenomation and to analyze its impact on the clinical outcome of patients. Retrospective data were collected from the medical records, hospital and lab information system after institutional ethics committee approval. Hematotoxic snake bite patients were categorized into Group 1 (with TMA) and Group 2 (without TMA). Chi square test, Mann–Whitney ‘U’ test and Odd’s ratio (OR) were used for statistical analysis. Out of 331 snakebite cases admitted, 202 (64.33%) were hematotoxic envenomation with a mean age of 42.26 ± 15.61. Majority were males with a male to female ratio of 2.01:1. Lower limb was the most common site of bite (59.9%). The prevalence of coagulopathy, TMA and AKI observed was 56.4, 18.8 and 37.6% respectively. AKI had a significant risk of undergoing hemodialysis when it was associated with TMA (r = 0.635, OR = 19.3182, P < 0.0001). Higher number of patients in Group 1 received more blood products (r = 0.406, OR = 8.525, P < 0.0001). Prolonged hospital stay (17.25 ± 12.23 vs. 8.86 ± 7.18 days, P < 0.0001) and higher complication rates were (33.33% vs. 11.4%, P < 0.0048) observed in patients with TMA. Snakebite associated TMA has a significant impact on the prognosis and understanding the pathophysiology of this entity will help to formulate guidelines.


Hematotoxic snakebite Thrombotic microangiopathy India Pathophysiology of snakebite associated TMA Therapeutic guidelines 


Author contribution

GM—The concept of this study, Formulated the study design, performed the study, Data analysis and Manuscript preparation. GPR—Data collection. SS—Interpretation of Data, Critical review and final approval of the manuscript. DK—Data analysis and review of the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Gutierrez J, Calvette J, Habib A, Harrison R et al (2017) Snakebite envenoming. Nat Rev Dis Primers 3:17064CrossRefGoogle Scholar
  2. 2.
    Isbister G, Little M, Cull G, McCoubrie D et al (2017) Thrombotic microangiopathy from Australian brown snake (Pseudonaja) envenoming. Intern Med J 37:523–528CrossRefGoogle Scholar
  3. 3.
    Isbister G (2010) Snakebite doesn’t cause disseminated intravascular coagulation: coagulopathy and thrombotic microangiopathy in snake envenoming. Semin Thromb Hemost 36:444–451CrossRefGoogle Scholar
  4. 4.
    Chugh K (1989) Snake-bite-induced acute renal failure in India. Kidney Int 35:891–907CrossRefGoogle Scholar
  5. 5.
    Cobcroft R, Williams A, Cook D, Williams D et al (1997) Hemolytic uremic syndrome following taipan envenomation with response to plasmapheresis. Pathology 29:399–402CrossRefGoogle Scholar
  6. 6.
    Berling I, Isbister G (2015) Hematologic effects and complications of snake envenoming. Transfus Med Rev 29:82–89CrossRefGoogle Scholar
  7. 7.
    Hung D, Wu M, Deng J, Yang D et al (2002) Multiple thrombotic occlusions of vessels after Russell’s viper envenoming. Pharmacol Toxicol 91:106–110CrossRefGoogle Scholar
  8. 8.
    Sitprija V (2006) Snakebite nephropathy (review article). Nephrology 11:442–448CrossRefGoogle Scholar
  9. 9.
    Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity WHO, 1 (2011). Accessed 1 Dec 2018
  10. 10.
    Khwaja A (2012) KDIGO clinical practice guidelines for acute kidney injury. Nephron 120:c179–c184CrossRefGoogle Scholar
  11. 11.
    Casamento AJ, Isbister GK (2011) Thrombotic microangiopathy in two tiger snake envenomations. Anaesth Intensive Care 39:1124–1127CrossRefGoogle Scholar
  12. 12.
    Kularatne S, Wimalasooriya S, Nazar K, Maduwage K (2014) Thrombotic microangiopathy following Russell’s viper (Daboia russelii) envenoming in Sri Lanka: a case report. Ceylon Med J 59:29CrossRefGoogle Scholar
  13. 13.
    Gn Y, Ponnusamy A, Thimma V (2017) Snakebite induced thrombotic microangiopathy leading to renal cortical necrosis. Case Rep Nephrol. Google Scholar
  14. 14.
    Vikrant S, Jaryal A, Parashar A (2017) Clinicopathological spectrum of snake bite-induced acute kidney injury from India. World J Nephrol 6:150CrossRefGoogle Scholar
  15. 15.
    Dhanapriya J, Dineshkumar T, Sakthirajan R, Thirumalvalavan K et al (2017) Thrombotic microangiopathy due to Viperidae bite: two case reports. Indian J Nephrol 27:161CrossRefGoogle Scholar
  16. 16.
    Herath N, Wazil A, Kularatne S, Ratnatunga N et al (2012) Thrombotic microangiopathy and acute kidney injury in hump-nosed viper (Hypnale species) envenoming: a descriptive study in Sri Lanka. Toxicon 60:61–65CrossRefGoogle Scholar
  17. 17.
    Mitrakrishnan J, Bandula C, Mitrakrishnan C, Somaratna K et al (2012) Haemolytic uremic syndrome a hitherto unreported complication of humpnosed viper envenomation. Indian J Hematol Blood Transfus 29:116–118CrossRefGoogle Scholar
  18. 18.
    Masias C, Vasu S, Cataland S (2017) None of the above: thrombotic microangiopathy beyond TTP and HUS. Blood 129:2857–2863CrossRefGoogle Scholar
  19. 19.
    Sunitha K, Hemshekhar M, Thushara R, Santhosh M et al (2015) Inflammation and oxidative stress in viper bite: an insight within and beyond. Toxicon 98:89–97CrossRefGoogle Scholar
  20. 20.
    Isbister G, Buckley N, Page C, Scorgie F et al (2013) A randomized controlled trial of fresh frozen plasma for treating venom-induced consumption coagulopathy in cases of Australian snakebite (ASP-18). J Thromb Haemost 11:1310–1318CrossRefGoogle Scholar
  21. 21.
    Zengin S, Yilmaz M, Al B, Yildirim C et al (2013) Plasma exchange as a complementary approach to snake bite treatment: an academic emergency department’s experiences. Transfus Apher Sci 49:494–498CrossRefGoogle Scholar
  22. 22.
    Mohan G, Guduri PR, Shastry S (2019) Role of therapeutic plasma exchange in snakebite associated thrombotic microangiopathy—a case report with review of literature. J Clini Apher. Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Immunohematology and Blood Transfusion, Kasturba Medical College, ManipalManipal Academy of Higher EducationManipalIndia
  2. 2.Department of Transfusion Medicine, OPD BlockJIPMER Hospital CampusPuducherryIndia

Personalised recommendations