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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 235-237

Diagnosis of antiphospholipid syndrome following snakebite


Department of General Medicine, K.S. Hegde Medical Academy, Ullal, Karnataka, India

Date of Submission05-Feb-2020
Date of Decision22-May-2020
Date of Acceptance13-Jul-2020
Date of Web Publication5-Jan-2021

Correspondence Address:
Mahalingeshwara Bhat
Assistant Professor, B 1907, Siliconia Apartments, Kuttar, Ullal - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCSR.JCSR_9_20

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  Abstract 


Isolated prolongation of activated partial thromboplastin time (aPTT) is an exceedingly rare finding in the event of a snakebite from a haemotoxic snake. Herein, we present the case of a 25-year-old asymptomatic female following snakebite. Laboratory testing revealed prolonged aPTT which persisted inspite of administration of 30 vials of antisnake venom. Further diagnostic testing eventually led to the diagnosis of antiphosholipid syndrome.

Keywords: Antiphospholipid syndrome, prolonged activated partial thromboplastin time, snakebite


How to cite this article:
Bhat M, Kumar R, D'sa I, Naushad AA, Kishore P. Diagnosis of antiphospholipid syndrome following snakebite. J Clin Sci Res 2020;9:235-7

How to cite this URL:
Bhat M, Kumar R, D'sa I, Naushad AA, Kishore P. Diagnosis of antiphospholipid syndrome following snakebite. J Clin Sci Res [serial online] 2020 [cited 2021 Jan 20];9:235-7. Available from: https://www.jcsr.co.in/text.asp?2020/9/4/235/306200




  Introduction Top


Activated partial thromboplastin time (aPTT) is a measure of intrinsic pathway of coagulation cascade in our body. Isolated prolonged aPTT along with a history of bleeding manifestations or easy bruisability is sugges?tive of deficiencies of factors VIII, IX, XI and XII.[1] The most common cause of asymptomatic isolated prolonged aPTT has been found to be presence of lupus anticoagulant.[2] Other differential diagnoses of isolated prolongation of aPTT include specific factor deficiency and patients on treatment with heparin or other anticoagulants.[3] Here, we present a case of a young, asymptomatic female presenting with complaints of snakebite which led to the incidental diagnosis of antiphospholipid syndrome due to a persistently prolonged aPTT. It is a unique and rare finding as only 1%–5% of healthy individuals are found to have asymptomatic antiphospholipid syndrome.[4]


  Case Report Top


A 25-year-old female, who did not have any comorbid conditions, presented with an alleged history of snakebite to the right 2nd toe. She has no family history of bleeding disorders. She is married and has no children. There is no history of menstrual irregularities and no history of abortions. There were no local or systemic symptoms. She was admitted in the intensive care unit (ICU) for observation. Her laboratory reports showed an isolated elevation of aPTT [Table 1] and she was administered anti-snake venom. Her bleeding parameters were monitored 6th hourly and she continued to have an isolated prolonged aPTT [Table 2]. A total of 30 anti-snake venom vials[5] were administered over the first 5 days. She continued to be asymptomatic. Antinuclear antibody (ANA) profile was negative. Lupus anticoagulant was found to be positive. She was shifted out to wards and discharged. After 3 months, her lupus anticoagulant was repeated and found to be positive and she had isolated prolonged aPTT. A diagnosis of antiphospholipid syndrome was made and she was started on low-dose aspirin.
Table 1: Laboratory reports on admission

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Table 2: Activated partial thromboplastin time monitoring

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  Discussion Top


Snakebite is common in India. Haemotoxic snake species belong to the family Viperidae, commonly Russell's vipers, saw-scaled vipers and various pit vipers.[6] Isolated prolongation of aPTT is an exceedingly rare finding in the event of a snakebite from a haemotoxic snake.[7] As the snake in our case was unknown, prolonged aPTT was treated with anti-snake venom (total 30 vials)[5] and bleeding parameters were monitored regularly.

Snake venom phospholipases A2 (enzyme) studied in the family Viperidae, Crotalidae and Elapidae, is known to interfere with coagulation by competing with clotting proteins on the lipid surface.[8] The haematological abnormalities expected from envenomation of these snakes include consumption coagulopathy, consumption of fibrinogen and activation of prothrombin, factor V and factor X.[7] It can be monitored by abnormal prothrombin time/international normalised ratio and fibrinogen levels. Our patient continued to remain asymptomatic, but there was no improvement in her aPTT.

A laboratory error should be ruled out initially and a repeat test with a different assay before a mixing study is recommended.[9] In this case, mixing studies were performed and other specific factor inhibitors were ruled out. Other differential diagnoses were considered. The presence of lupus anti-coagulant is the most common cause of asymptomatic isolated prolongation of aPTT.[2] Other causes, such as, haemophilia due to intrinsic coagulation factor deficiencies usually remain symptomatic with recurrent history of bleeding manifestations.

The diagnostic criteria for the detection of lupus anti-coagulant according to International Society on Thrombosis and Haemostasis require measurement of dilute Russell's viper's venom time and sensitive aPTT. It was found to be positive in our patient on 2 separate occasions, 3 months apart. Tests for other antibodies such as anti-cardiolipin (immunoglobulin G and immunoglobulin M) and anti-beta-2 glycoprotein 1 were not performed. However, ANA profile was negative. Hence this patient was diagnosed to have primary antiphospholipid syndrome. This led to the incidental diagnosis of asymptomatic antiphospholipid syndrome in this young female who initially presented with complaints of snakebite.

A diagnosis of antiphospholipid syndrome should be kept in mind for an asymptomatic patient with an incidental finding of isolated prolonged aPTT as they most commonly have presence of lupus anticoagulant.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Patient Is Clotting: What Do You Mean, the aPTT Is Prolonged? Medscape. Available from: http://www.medscape.com/viewarticle/779301.  Back to cited text no. 1
    
2.
Chng WJ, Sum C, Kuperan P. Causes of isolated prolonged activated partial thromboplastin time in an acute care general hospital. Singapore Med J 2005;46:450-6.  Back to cited text no. 2
    
3.
Rasmussen KL, Philipa M, Tripodi A, Goetze JP. Unexpected, isolated activated partial thromboplastin time prolongation: A practical mini-review. Eur J Haematol. 2020;104:519-25.  Back to cited text no. 3
    
4.
Chaturvedi S, McCrae KR. Diagnosis and management of the antiphospholipid syndrome. Blood Rev 2017;31:406-17.  Back to cited text no. 4
    
5.
Ghosh S, Mukhopadhyay P, Chatterjee T. Management of snake bite in India. J Assoc Physicians India 2016;64:11-4.  Back to cited text no. 5
    
6.
Menon JC, Joseph JK. Complications of hemotoxic snakebite in India. In: Gopalakrishnakone P, Faiz SM, Gnanathasan CA, Habib AG, Fernando R, Yang CC, editors. Toxinology: Clinical Toxinology. Dordrecht: Springer Netherlands; 2013. p. 1-21.  Back to cited text no. 6
    
7.
Berling I, Isbister GK. Hematologic effects and complications of snake envenoming. Transfus Med Rev 2015;29:82-9.  Back to cited text no. 7
    
8.
Verheij HM, Boffa MC, Rothen C, Bryckaert MC, Verger R, de Haas GH. Correlation of enzymatic activity and anticoagulant properties of phospholipase A2. Eur J Biochem 1980;112:25-32.  Back to cited text no. 8
    
9.
Falay M, Senes M, Yücel D, Turhan T, Dagdas S, Pekin M, et al. What should be the laboratory approach against isolated prolongation of a activated partial thromboplastin time? J Clin Lab Anal 2018;32:e22415.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2]



 

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