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CC BY 4.0 · TH Open 2023; 07(02): e168-e183
DOI: 10.1055/s-0043-1769625
Original Article

Peripheral Arterial Thrombosis following Russell's Viper Bites

Subramanian Senthilkumaran   *
1   Department of Emergency Medicine, Manian Medical Centre, Erode, Tamil Nadu, India
,
Ketan Patel   *
2   School of Biological Sciences, University of Reading, Reading, United Kingdom
,
Elanchezhian Rajan   *
3   School of Pharmacy, University of Reading, Reading, United Kingdom
,
Pradeep Vijayakumar
3   School of Pharmacy, University of Reading, Reading, United Kingdom
,
Stephen W. Miller
4   The Poison Control Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
,
Alexandra Rucavado
5   Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
,
Soheil Gilabadi
3   School of Pharmacy, University of Reading, Reading, United Kingdom
,
Medha Sonavane
3   School of Pharmacy, University of Reading, Reading, United Kingdom
,
Nicholas J. Richards
2   School of Biological Sciences, University of Reading, Reading, United Kingdom
,
Jarred Williams 
3   School of Pharmacy, University of Reading, Reading, United Kingdom
,
Harry F. Williams
6   Toxiven Biotech Private Limited, Coimbatore, Tamil Nadu, India
,
Steven A. Trim
7   Venomtech Limited, Sandwich, United Kingdom
,
Ponniah Thirumalaikolundusubramanian
8   The Tamil Nadu Dr M.G.R. Medical University, Chennai, Tamil Nadu, India
,
José María Gutiérrez
5   Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
,
Sakthivel Vaiyapuri
3   School of Pharmacy, University of Reading, Reading, United Kingdom
› Author Affiliations Funding The authors would like to thank the British Heart Foundation (reference: PG/19/62/34593) and Medical Research Council (reference: MR/W019353/1 & Integrative Toxicology Training Partnership – PhD studentship), United Kingdom, for their funding support for this research.
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Abstract

Envenomings by Russell's viper (Daboia russelii), a species of high medical importance in India and other Asian countries, commonly result in hemorrhage, coagulopathies, necrosis, and acute kidney injury. Although bleeding complications are frequently reported following viper envenomings, thrombotic events occur rarely (reported only in coronary and carotid arteries) with serious consequences. For the first time, we report three serious cases of peripheral arterial thrombosis following Russell's viper bites and their diagnostic, clinical management, and mechanistic insights. These patients developed occlusive thrombi in their peripheral arteries and symptoms despite antivenom treatment. In addition to clinical features, computed tomography angiography was used to diagnose arterial thrombosis and ascertain its precise locations. They were treated using thrombectomy or amputation in one case that presented with gangrenous digits. Mechanistic insights into the pathology through investigations revealed the procoagulant actions of Russell's viper venom in standard clotting tests as well as in rotational thromboelastometry analysis. Notably, Russell's viper venom inhibited agonist-induced platelet activation. The procoagulant effects of Russell's viper venom were inhibited by a matrix metalloprotease inhibitor, marimastat, although a phospholipase A2 inhibitor (varespladib) did not show any inhibitory effects. Russell's viper venom induced pulmonary thrombosis when injected intravenously in mice and thrombi in the microvasculature and affected skeletal muscle when administered locally. These data emphasize the significance of peripheral arterial thrombosis in snakebite victims and provide awareness, mechanisms, and robust strategies for clinicians to tackle this issue in patients.

Keywords

Russell's viper - snakebite envenomation - thrombosis - peripheral arteries - venom

Authors' Contributions

S.S.: study design, data collection, analysis, supervision; K.P.: experimental design, data analysis, writing manuscript; E.R.: data collection, analysis, making figures; P.V.: data collection, analysis, making figures; S.W.M.: data analysis, writing manuscript; A.R.: experimental design, data collection, analysis; S.G.: data collection, analysis; M.S.: data collection, analysis; N.J.R.: data collection, analysis; J.W.: experimental design, data collection, analysis, writing manuscript; H.F.W.: data analysis, writing manuscript; S.A.T.: data analysis, writing manuscript; P.T.: study design, data analysis, writing manuscript; J.M.G.: experimental design, data collection, analysis, writing manuscript, making figures; S.V.: study design, experimental design, data collection, analysis, supervision, writing manuscript.


* These authors contributed equally to this study.




Publication History

Received: 30 November 2022

Accepted: 05 April 2023

Article published online:
17 June 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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