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Pulmonary haemorrhage causing rapid death after Bothrops jararacussu snakebite: a case report
Toxicon 42 (2003) 331–334 www.elsevier.com/locate/toxicon
Pulmonary haemorrhage causing rapid death after Bothrops jararacussu snakebite: a case report Luiz A. Benvenutia,*, Francisco O.S. Franc¸ab, Ka´tia C. Barbaroc, Jose´ R. Nunesd, Joa˜o L.C. Cardosob a
Laboratory of Pathology, Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr Ene´as de Carvalho Aguiar 44, Sa˜o Paulo, SP 05403-000, Brazil b Vital Brazil Hospital, Butantan Institute, Av. Vital Brazil 1500, Sa˜o Paulo, SP 05503-900, Brazil c Laboratory of Immunopathology, Butantan Institute, Av. Vital Brazil 1500, Sa˜o Paulo, SP 05503-900, Brazil d Forensic Medical Institute of Sa˜o Sebastia˜o, R. Floriano Peixoto 200, Sa˜o Sebastia˜o, SP 11600-000, Brazil Received 1 April 2003; accepted 19 June 2003
Abstract A 36-year old woman was bitten on the left ankle by a Bothrops jararacussu, and died 45 min after the bite. At necropsy, there were local signs of envenoming with haemorrhage, thrombosis and necrosis of the subcutaneous and muscular tissue. Multiple fibrin and platelet thrombi were found in the microcirculation of the heart and lungs, suggesting the occurrence of disseminated intravascular coagulation. Pulmonary haemorrhage probably secondary to the action of haemorrhagins, consumption coagulopathy and disseminated intravascular coagulation was the immediate cause of death. Intravenous inoculation of the venom could have occurred in the present case, which would explain the rapid onset of coagulation disorders, haemorrhage and death. q 2003 Elsevier Ltd. All rights reserved. Keywords: Snakebite; Bothrops jararacussu; Coagulopathy; Pulmonary haemorrhage; Death
1. Introduction Twenty-thousand bites by venomous snakes are reported each year in Brazil; 85% of them are due to Bothrops species (Ribeiro and Jorge, 1997). The venom of these snakes has proteolytic, coagulant and haemorrhagic effects. Local envenoming is characterised by pain, swelling, bleeding, and occasionally blisters, abscess formation and necrosis. Signs of systemic envenoming include gingival haemorrhage, ecchymosis and consumption coagulopathy (Cardoso et al., 1993). Shock is a very important clinical effect of envenoming. Among contributing factors are an angiotensin-converting enzyme inhibitor and a bradykinin potentiator. Death is unusual, occurring in 0.3 –0.5% of the cases, * Corresponding author. Tel.: þ55-11-3069-5251; fax: þ 55-113082-2354. E-mail address: [email protected] (L.A. Benvenuti).
usually a few days after the bite (Ribeiro and Jorge, 1997; Ribeiro et al., 1998). Coagulation disorders occur in almost all fatal cases, and death has been related to acute renal failure, acute respiratory failure, haemorrhage, shock and sepsis (Fan and Cardoso, 1995; Ribeiro et al., 1998). We report the pathological lesions of a woman who died from pulmonary haemorrhage very rapidly after being bitten by a Bothrops jararacussu, one of the most dreaded snake of the Bothrops genus.
2. Case report A 36-year old woman was bitten on the left ankle by a snake. The bite occurred at 8 a.m., close to the Atlantic forest at the beach of Toque – Toque Grande in Sa˜o Sebastia˜o, a coastal town near Sa˜o Paulo City, Brazil. The victim was admitted to the local hospital presenting
0041-0101/03/$ - see front matter q 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0041-0101(03)00167-3
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extensive alveolar haemorrhage and oedema with numerous platelet thrombi in capillaries and venules (Fig. 3). The myocardium showed foci of fibrosis and interstitial haemorrhage; multiple fibrin and platelet thrombi were present in microcirculation (Fig. 3). Immunohistochemical reactivity for factor VIII confirmed the presence of platelets in the pulmonary and myocardial thrombi. The pituitary gland showed no abnormalities.
3. Discussion Fig. 1. Female Bothrops jararacussu 1010 mm long, which caused the reported accident.
irreversible cardiac and respiratory arrest 45 min after the bite. The snake was killed and examined in the laboratory of Herpetology of Butantan Institute. It was an adult female B. jararacussu, measuring 1010 mm (Fig. 1). The distance between the fang tips was 22 mm. The snake’s stomach was empty. A post-mortem examination of the victim was performed by the coroner. The body was that of a well-nourished woman presenting two puncture wounds on the left ankle, 25 mm apart, ecchymosis on the left leg along the course of the great saphenous vein and nasal bleeding. Prominent pulmonary haemorrhage was macroscopically apparent and constituted the cause of death. Samples from the site of the bite, lung, heart and pituitary gland were available for histological analysis. On microscopy, the subcutaneous tissue at the site of the bite showed haemorrhage, areas of coagulative necrosis and fibrin thrombus in one arteriole (Fig. 2). The dermis and epidermis exhibited no pathological alterations. The skeletal muscle below the skin showed areas of necrosis, characterised by contraction, fragmentation and disruption of the myocytes, with amorphous and eosinophilic cytoplasm (Fig. 2). Histological sections of the lungs exhibited
The B. jararacussu snake is found in tropical forests, swamps and river banks of south and southeast states of Brazil. Among the South American Bothrops species, it is considered the most massive one; the largest example registered in the collection of Butantan Institute measured 1760 mm of length. Eight hundred milligrams of venom (dry weight) has been obtained from adult animal at a single milking (Rosenfeld and Belluomini, 1967). The venom from B. jararacussu has lethal potency much higher than venoms of most other Bothrops species; in a recent review of 29 bites caused by this snake, several patients developed shock and oliguria few hours after the bite and there were three deaths (Milani Junior et al., 1997). Bothrops venoms exhibit proteolytic, coagulant and haemorrhagic activities. B. jararacussu venom also causes local myotoxicity (Fan and Cardoso, 1995). Accordingly, we detected muscle necrosis at the site of the bite in the reported case. Several thrombi were present in the microcirculation of the lung and myocardium, suggesting the occurrence of disseminated intravascular coagulation (DIC). Pulmonary haemorrhage constituted the immediate cause of death. The occurrence of haemorrhage is frequent after Bothrops envenoming; however, it usually does not present clinical importance in most cases reported in Brazil (Fan and Cardoso, 1995). Meanwhile, haemorrhage in vital organs, as the brain has been reported as cause of death after
Fig. 2. Site of the snakebite. (A), Recent haemorrhage in the subcutaneous tissue (asterisks) and fibrin thrombus in an arteriole (inset); (B), Myocyte necrosis (asterisks) in the skeletal muscle below the skin. Scale bar ¼ 50 mm.
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Fig. 3. Systemic pathological alterations. (A), Pulmonary haemorrhage and platelet thrombus in an alveolar capillary (arrow); (B), Fibrin thrombus in a myocardial arteriole; (C), Platelet thrombus in a myocardial venule. Scale bar ¼ 50 mm.
Bothrops envenomation (Ribeiro et al., 1998; Pinho and Burdmann, 2001). Haemorrhage after Bothrops envenomation is due to multiple factors (Markland, 1998). Some fractions of the venom act directly on platelets, causing platelet dysfunction (Scarborough et al., 1993; Francischetti et al., 1998), and thrombocytopenia is often found after Bothrops envenoming (Cardoso et al., 1993). Haemorrhagins, which are metalloproteinases found in Bothrops venoms are implicated in the local and systemic bleeding (Kamiguti et al., 1991, 1992; Gutie´rrez, 2002). Although the precise mechanism of action of haemorrhagins is still unknown, there is evidence that these enzymes promote hydrolytic cleavage of the basal lamina of endothelial cells from capillaries and venules, promoting endothelial cell rupture and bleeding (Gutie´rrez and Rucavado, 2000; Gutie´rrez, 2002). Studies using vital microscopy demonstrated that this effect occurred quickly, only a few minutes after the addition of Bothrops venom to the tissue (Lomonte et al., 1994; Rucavado et al., 1995). An interesting point is that although the haemorrhagic activity of B. jararacussu venom is about 1.5 times lower than that of B. jararaca (Roodt et al., 2000), the venom yield of the former species is 6 times greater (Belluomini, 1964). Consumption coagulopathy and activation of many points of the coagulation cascade occur after Bothrops envenoming (Fan and Cardoso, 1995; Milani Junior et al., 1997). Direct prothrombin activation was observed in most Bothrops venoms, alone or combined with thrombin-like and factor X-activator activities (Nahas et al., 1979). The venom of B. jararacussu contain fibrinogen-clotting enzymes, and a serine protease that presents mild thrombin-like activity, with ability to activate factor VIII and to induce platelet aggregation (Hill-Eubanks et al., 1989; Zaganelli et al., 1996). Jararacussin-I, a fibrinogen-clotting enzyme obtained from the venom of B. jararacussu was recently purified, characterised and crystallized (Bortoleto et al., 2002). In the reported case, the clotting activity of
the venom may have provoked fast fibrinogen consumption and development of coagulopathy, contributing to the profuse pulmonary haemorrhage. On the other hand, consumption coagulopathy can also be explained by the occurrence of DIC. In this entity, haemorrhage may occur in several organs and pulmonary haemorrhage was already reported as the immediate cause of death of the patients (Robboy et al., 1973). Additionally, previous reports refer to the occurrence of DIC after bites by snakes of the Bothrops genus (Estrade et al., 1989; Milani Junior et al., 1997). In summary, the prominent pulmonary haemorrhage noticed in the present case was probably due to several factors, as consumption coagulopathy, thrombocytopenia, platelet dysfunction, DIC, and direct action of haemorrhagins. Although, we have no data about the occurrence of hypotension or shock in the reported case, it is interesting to note that the venom of B. jararacussu contains several bradykinin-potentiating peptides. At least one of them is able to inhibit the angiotensin-converting enzyme (Ferreira et al., 1992). Additionally, an acid phospholipase A2 showing dose-related hypotensive action was recently isolated from B. jararacussu venom (Andria˜o-Escarso et al., 2002). The quantity, way of inoculation and composition of the venom are probably the most important factors associated with the severity of envenoming after snakebite. Very rapid onset of DIC and fatal pulmonary haemorrhage after Viperidae bites, as occurred in the reported case is very unusual. In a previous report, the authors hypothesise intravenous inoculation of the venom to explain the rapid onset of severe manifestation after bites by snakes which venom has preferentially a local action (Davidson, 1988). It is possible that this way of inoculation have occurred in the present case; the occurrence of ecchymosis along the course of the great saphenous vein in the bitten leg reinforces this supposition. The coexistence of local signs of envenoming would be explained if we consider that one fang would have injected intravenously and the other one locally.
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Acknowledgements The authors acknowledge the assistance of Dr Ota´vio Marques, Laboratory of Herpetology, Butantan Institute.
References Andria˜o-Escarso, S.H., Soares, A.M., Fontes, M.R., Fuly, A.L., Correa, F.M., Rosa, J.C., Greene, L.J., Giglio, J.R., 2002. Structural and functional characterization of an acid platelet aggregation inhibitor and hypotensive phospholipase A2 from Bothrops jararacussu snake venom. Biochem. Pharmacol. 64 (4), 723–732. Belluomini, H.E., 1964. Produc¸a˜o de veneno de serpentes em cativeiro. Arq. Inst. Biol. 31, 149–154. Bortoleto, R.K., Murakami, M.T., Watanabe, L., Soares, A.M., Arni, R.K., 2002. Purification, characterization and crystallization of Jararacussin-I, a fibrinogen-clotting enzyme isolated from the venom of Bothrops jararacussu. Toxicon 40 (9), 1307–1312. Cardoso, J.L., Fan, H.W., Franc¸a, F.O., Jorge, M.T., Leite, R.P., Nishioka, S.A., Avila, A., Sano-Martins, I.S., Tomy, S.C., Santoro, M.L., 1993. Randomized comparative trial of three antivenoms in the treatment of envenoming by lance-headed vipers (Bothrops jararaca) in Sa˜o Paulo, Brazil. QJM 86 (5), 315–325. Davidson, T.M., 1988. Intravenous rattlesnake envenomation. West J. Med. 148 (1), 45–47. Estrade, G., Garnier, D., Bernasconi, F., Donatien, Y., 1989. Embolie pulmonaire et coagulation intravasculaire disse´mine´e apre`s une morsure de serpent Bothrops lanceolatus. A propos d’une observation. Arch. Mal. Coeur Vaiss. 82 (11), 1903–1905. Fan, H.W., Cardoso, J.L., 1995. Clinical toxicology of snake bites in South America. In: Meier, J., White, J. (Eds.), Handbook of Toxicology of Animal Venom and Poisons, CRC Press, Boca Raton, FL, pp. 667– 688. Ferreira, L.A., Henriques, O.B., Lebrun, I., Batista, M.B., Prezoto, B.C., Andreoni, A.S., Zelnik, R., Habermehl, G., 1992. A new bradykinin-potentiating peptide (peptide P) isolated from the venom of Bothrops jararacussu (jararacuc¸u tapete, urutu dourado). Toxicon 30 (1), 33–40. Francischetti, I.M., Castro, H.C., Zingali, R.B., Carlini, C.R., Guimaraes, J.A., 1998. Bothrops sp. snake venoms: comparison of some biochemical and physicochemical properties and interference in platelet functions. Comp. Biochem. Physiol. C: Pharmacol. Toxicol. Endocrinol. 119 (1), 21 –29. Gutie´rrez, J.M., 2002. Comprendiendo los venenos de serpientes: 50 an˜os de investigaciones en Ame´rica Latina. Rev. Biol. Trop. 50 (2), 377–394. Gutie´rrez, J.M., Rucavado, A., 2000. Snake venom metalloproteinases: their role in the pathogenesis of local tissue damage. Biochimie 82, 841 –850. Hill-Eubanks, D.C., Parker, C.G., Lollar, P., 1989. Differential proteolytic activation of factor VIII-von Willebrand factor complex by thrombin. Proc. Nat. Acad. Sci. USA 86 (17), 6508–6512. Kamiguti, A.S., Cardoso, J.L.C., Theakston, R.D.G., Sano-Martins, I.S., Hutton, R.A., Rugman, F.P., Warrell, D.A., Hay, C.R.M., 1991. Coagulopathy and haemorrhage in human victims of
Bothrops jararaca envenoming in Brazil. Toxicon 29 (8), 961 –972. Kamiguti, A.S., Rugman, F.P., Theakston, R.D.G., Franc¸a, F.O.S., Ishii, H., Hay, C.R.M., 1992. The role of venom haemorrhagin in spontaneous bleeding in Bothrops jararaca envenoming. Thromb. Haemost. 67 (4), 484–488. Lomonte, B., Lundgren, J., Johansson, B., Bagge, U., 1994. The dynamics of local tissue damage induced by Bothrops asper snake venom and myotoxin II on the mouse cremaster muscle: an intravital and electron microscopic study. Toxicon 32 (1), 41 –55. Markland, F.S., 1998. Snake venoms and the hemostatic system. Toxicon 36 (12), 1749–1800. Milani Junior, R., Jorge, M.T., Ferraz de Campos, F.P., Martins, F.P., Bousso, A., Cardoso, J.L.C., Ribeiro, L.A., Fan, H.W., Franc¸a, F.O.S., Sano-Martins, I.S., Cardoso, D., de Ca´ssia Oliveira Ferreira Fernandez, I., Fernandes, J.C., Aldred, V.L., Sandoval, M.P., Puorto, G., Theakston, R.D.G., Warrell, D.A., 1997. Snake bites by the jararacuc¸u (Bothrops jararacussu): clinicopathological studies of 29 proven cases in Sa˜o Paulo State, Brazil. QJM 90 (5), 323 –334. Nahas, L., Kamiguti, A.S., Barros, M.A., 1979. Thrombin-like and factor X-activator components of Bothrops snake venoms. Thromb. Haemost. 41 (2), 314–328. Pinho, F.M.O., Burdmann, E.A., 2001. Fatal cerebral hemorrhage and acute renal failure after young Bothrops jararacussu snake bite. Ren. Fail. 23 (2), 269 –277. Ribeiro, L.A., Jorge, M.T., 1997. Acidente por serpentes do geˆnero Bothrops: se´rie de 3.139 casos. Rev. Soc. Bras. Med. Trop. 30 (6), 475– 480. Ribeiro, L.A., Albuquerque, M.J., Pires de Camargo, V.A.F., Katz, ´ bitos por G., Takaoka, N.Y., Lebra˜o, M.L., Jorge, M.T., 1998. O serpentes pec¸onhentas no Estado de Sa˜o Paulo: avaliac¸a˜o de 43 casos, 1988/93. Rev. Assoc. Med. Bras. 44 (4), 312–318. Robboy, S.J., Minna, J.D., Colman, R.W., Bindorf, N.I., Lopas, H., 1973. Pulmonary hemorrhage syndrome as a manifestation of disseminated intravascular coagulation: analysis of ten cases. Chest 63 (5), 718 –721. Roodt, A.R., Dolab, J.A., Dokmetjian, J.C., Litwin, S., Segre, L., Vidal, J.C., 2000. A comparison of different methods to assess the hemorrhagic activity of Bothrops venoms. Toxicon 38 (6), 865 –873. Rosenfeld, G., Belluomini, H.E., 1967. Coagulant, proteolytic and hemolytic properties of some snake venoms. In: Bu¨cherl, W., Buckley, E.E., Deulofeu, V. (Eds.), Venomous Animals and their Venoms, vol. 2. Academic Press, New York. Rucavado, A., Lomonte, B., Ovadia, M., Gutie´rrez, J.M., 1995. Local tissue damage induced by BaP1, a metalloproteinase isolated from Bothrops asper (Terciopelo) snake venom. Exp. Mol. Pathol. 63 (3), 186–199. Scarborough, R.M., Rose, J.W., Naughton, M.A., Phillips, D.R., Nannizzi, L., Arfsten, A., Campbell, A.M., Charo, I.F., 1993. Characterization of the integrin specificities of disintegrins isolated from American pit viper venoms. J. Biol. Chem. 268 (2), 1058–1065. Zaganelli, G.L., Zaganelli, M.G., Magalha˜es, A., Diniz, C.R., de Lima, M.E., 1996. Purification and characterization of a fibrinogen-clotting enzyme from the venom of jararacuc¸u (Bothrops jararacussu). Toxicon 34 (7), 807– 819.
Pulmonary haemorrhage causing rapid death after Bothrops jararacussu snakebite: a case report Luiz A. Benvenutia,*, Francisco O.S. Franc¸ab, Ka´tia C. Barbaroc, Jose´ R. Nunesd, Joa˜o L.C. Cardosob a
Laboratory of Pathology, Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr Ene´as de Carvalho Aguiar 44, Sa˜o Paulo, SP 05403-000, Brazil b Vital Brazil Hospital, Butantan Institute, Av. Vital Brazil 1500, Sa˜o Paulo, SP 05503-900, Brazil c Laboratory of Immunopathology, Butantan Institute, Av. Vital Brazil 1500, Sa˜o Paulo, SP 05503-900, Brazil d Forensic Medical Institute of Sa˜o Sebastia˜o, R. Floriano Peixoto 200, Sa˜o Sebastia˜o, SP 11600-000, Brazil Received 1 April 2003; accepted 19 June 2003
Abstract A 36-year old woman was bitten on the left ankle by a Bothrops jararacussu, and died 45 min after the bite. At necropsy, there were local signs of envenoming with haemorrhage, thrombosis and necrosis of the subcutaneous and muscular tissue. Multiple fibrin and platelet thrombi were found in the microcirculation of the heart and lungs, suggesting the occurrence of disseminated intravascular coagulation. Pulmonary haemorrhage probably secondary to the action of haemorrhagins, consumption coagulopathy and disseminated intravascular coagulation was the immediate cause of death. Intravenous inoculation of the venom could have occurred in the present case, which would explain the rapid onset of coagulation disorders, haemorrhage and death. q 2003 Elsevier Ltd. All rights reserved. Keywords: Snakebite; Bothrops jararacussu; Coagulopathy; Pulmonary haemorrhage; Death
1. Introduction Twenty-thousand bites by venomous snakes are reported each year in Brazil; 85% of them are due to Bothrops species (Ribeiro and Jorge, 1997). The venom of these snakes has proteolytic, coagulant and haemorrhagic effects. Local envenoming is characterised by pain, swelling, bleeding, and occasionally blisters, abscess formation and necrosis. Signs of systemic envenoming include gingival haemorrhage, ecchymosis and consumption coagulopathy (Cardoso et al., 1993). Shock is a very important clinical effect of envenoming. Among contributing factors are an angiotensin-converting enzyme inhibitor and a bradykinin potentiator. Death is unusual, occurring in 0.3 –0.5% of the cases, * Corresponding author. Tel.: þ55-11-3069-5251; fax: þ 55-113082-2354. E-mail address: [email protected] (L.A. Benvenuti).
usually a few days after the bite (Ribeiro and Jorge, 1997; Ribeiro et al., 1998). Coagulation disorders occur in almost all fatal cases, and death has been related to acute renal failure, acute respiratory failure, haemorrhage, shock and sepsis (Fan and Cardoso, 1995; Ribeiro et al., 1998). We report the pathological lesions of a woman who died from pulmonary haemorrhage very rapidly after being bitten by a Bothrops jararacussu, one of the most dreaded snake of the Bothrops genus.
2. Case report A 36-year old woman was bitten on the left ankle by a snake. The bite occurred at 8 a.m., close to the Atlantic forest at the beach of Toque – Toque Grande in Sa˜o Sebastia˜o, a coastal town near Sa˜o Paulo City, Brazil. The victim was admitted to the local hospital presenting
0041-0101/03/$ - see front matter q 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0041-0101(03)00167-3
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extensive alveolar haemorrhage and oedema with numerous platelet thrombi in capillaries and venules (Fig. 3). The myocardium showed foci of fibrosis and interstitial haemorrhage; multiple fibrin and platelet thrombi were present in microcirculation (Fig. 3). Immunohistochemical reactivity for factor VIII confirmed the presence of platelets in the pulmonary and myocardial thrombi. The pituitary gland showed no abnormalities.
3. Discussion Fig. 1. Female Bothrops jararacussu 1010 mm long, which caused the reported accident.
irreversible cardiac and respiratory arrest 45 min after the bite. The snake was killed and examined in the laboratory of Herpetology of Butantan Institute. It was an adult female B. jararacussu, measuring 1010 mm (Fig. 1). The distance between the fang tips was 22 mm. The snake’s stomach was empty. A post-mortem examination of the victim was performed by the coroner. The body was that of a well-nourished woman presenting two puncture wounds on the left ankle, 25 mm apart, ecchymosis on the left leg along the course of the great saphenous vein and nasal bleeding. Prominent pulmonary haemorrhage was macroscopically apparent and constituted the cause of death. Samples from the site of the bite, lung, heart and pituitary gland were available for histological analysis. On microscopy, the subcutaneous tissue at the site of the bite showed haemorrhage, areas of coagulative necrosis and fibrin thrombus in one arteriole (Fig. 2). The dermis and epidermis exhibited no pathological alterations. The skeletal muscle below the skin showed areas of necrosis, characterised by contraction, fragmentation and disruption of the myocytes, with amorphous and eosinophilic cytoplasm (Fig. 2). Histological sections of the lungs exhibited
The B. jararacussu snake is found in tropical forests, swamps and river banks of south and southeast states of Brazil. Among the South American Bothrops species, it is considered the most massive one; the largest example registered in the collection of Butantan Institute measured 1760 mm of length. Eight hundred milligrams of venom (dry weight) has been obtained from adult animal at a single milking (Rosenfeld and Belluomini, 1967). The venom from B. jararacussu has lethal potency much higher than venoms of most other Bothrops species; in a recent review of 29 bites caused by this snake, several patients developed shock and oliguria few hours after the bite and there were three deaths (Milani Junior et al., 1997). Bothrops venoms exhibit proteolytic, coagulant and haemorrhagic activities. B. jararacussu venom also causes local myotoxicity (Fan and Cardoso, 1995). Accordingly, we detected muscle necrosis at the site of the bite in the reported case. Several thrombi were present in the microcirculation of the lung and myocardium, suggesting the occurrence of disseminated intravascular coagulation (DIC). Pulmonary haemorrhage constituted the immediate cause of death. The occurrence of haemorrhage is frequent after Bothrops envenoming; however, it usually does not present clinical importance in most cases reported in Brazil (Fan and Cardoso, 1995). Meanwhile, haemorrhage in vital organs, as the brain has been reported as cause of death after
Fig. 2. Site of the snakebite. (A), Recent haemorrhage in the subcutaneous tissue (asterisks) and fibrin thrombus in an arteriole (inset); (B), Myocyte necrosis (asterisks) in the skeletal muscle below the skin. Scale bar ¼ 50 mm.
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Fig. 3. Systemic pathological alterations. (A), Pulmonary haemorrhage and platelet thrombus in an alveolar capillary (arrow); (B), Fibrin thrombus in a myocardial arteriole; (C), Platelet thrombus in a myocardial venule. Scale bar ¼ 50 mm.
Bothrops envenomation (Ribeiro et al., 1998; Pinho and Burdmann, 2001). Haemorrhage after Bothrops envenomation is due to multiple factors (Markland, 1998). Some fractions of the venom act directly on platelets, causing platelet dysfunction (Scarborough et al., 1993; Francischetti et al., 1998), and thrombocytopenia is often found after Bothrops envenoming (Cardoso et al., 1993). Haemorrhagins, which are metalloproteinases found in Bothrops venoms are implicated in the local and systemic bleeding (Kamiguti et al., 1991, 1992; Gutie´rrez, 2002). Although the precise mechanism of action of haemorrhagins is still unknown, there is evidence that these enzymes promote hydrolytic cleavage of the basal lamina of endothelial cells from capillaries and venules, promoting endothelial cell rupture and bleeding (Gutie´rrez and Rucavado, 2000; Gutie´rrez, 2002). Studies using vital microscopy demonstrated that this effect occurred quickly, only a few minutes after the addition of Bothrops venom to the tissue (Lomonte et al., 1994; Rucavado et al., 1995). An interesting point is that although the haemorrhagic activity of B. jararacussu venom is about 1.5 times lower than that of B. jararaca (Roodt et al., 2000), the venom yield of the former species is 6 times greater (Belluomini, 1964). Consumption coagulopathy and activation of many points of the coagulation cascade occur after Bothrops envenoming (Fan and Cardoso, 1995; Milani Junior et al., 1997). Direct prothrombin activation was observed in most Bothrops venoms, alone or combined with thrombin-like and factor X-activator activities (Nahas et al., 1979). The venom of B. jararacussu contain fibrinogen-clotting enzymes, and a serine protease that presents mild thrombin-like activity, with ability to activate factor VIII and to induce platelet aggregation (Hill-Eubanks et al., 1989; Zaganelli et al., 1996). Jararacussin-I, a fibrinogen-clotting enzyme obtained from the venom of B. jararacussu was recently purified, characterised and crystallized (Bortoleto et al., 2002). In the reported case, the clotting activity of
the venom may have provoked fast fibrinogen consumption and development of coagulopathy, contributing to the profuse pulmonary haemorrhage. On the other hand, consumption coagulopathy can also be explained by the occurrence of DIC. In this entity, haemorrhage may occur in several organs and pulmonary haemorrhage was already reported as the immediate cause of death of the patients (Robboy et al., 1973). Additionally, previous reports refer to the occurrence of DIC after bites by snakes of the Bothrops genus (Estrade et al., 1989; Milani Junior et al., 1997). In summary, the prominent pulmonary haemorrhage noticed in the present case was probably due to several factors, as consumption coagulopathy, thrombocytopenia, platelet dysfunction, DIC, and direct action of haemorrhagins. Although, we have no data about the occurrence of hypotension or shock in the reported case, it is interesting to note that the venom of B. jararacussu contains several bradykinin-potentiating peptides. At least one of them is able to inhibit the angiotensin-converting enzyme (Ferreira et al., 1992). Additionally, an acid phospholipase A2 showing dose-related hypotensive action was recently isolated from B. jararacussu venom (Andria˜o-Escarso et al., 2002). The quantity, way of inoculation and composition of the venom are probably the most important factors associated with the severity of envenoming after snakebite. Very rapid onset of DIC and fatal pulmonary haemorrhage after Viperidae bites, as occurred in the reported case is very unusual. In a previous report, the authors hypothesise intravenous inoculation of the venom to explain the rapid onset of severe manifestation after bites by snakes which venom has preferentially a local action (Davidson, 1988). It is possible that this way of inoculation have occurred in the present case; the occurrence of ecchymosis along the course of the great saphenous vein in the bitten leg reinforces this supposition. The coexistence of local signs of envenoming would be explained if we consider that one fang would have injected intravenously and the other one locally.
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Acknowledgements The authors acknowledge the assistance of Dr Ota´vio Marques, Laboratory of Herpetology, Butantan Institute.
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