Diagnostic and therapeutic challenges into snakebite-induced thrombotic microangiopathy: a case report and review of the literature

BACKGROUND: Snakebite envenomation is a significant global health issue, with India accounting for a substantial number of cases, particularly in rural areas. Venom-induced consumption coagulopathy is a common complication; however, thrombotic microangiopathy remains rare and not well understood. Thrombotic microangiopathy is characterized by microvascular thrombosis, microangiopathic hemolytic anemia, thrombocytopenia, and organ dysfunction. Understanding the pathophysiological differences in snakebite-induced thrombotic microangiopathy is critical for optimizing treatment and outcomes. CASE PRESENTATION: We report a case of snakebite-induced thrombotic microangiopathy in a 22-year-old male individual from eastern India who presented with severe thrombocytopenia, acute kidney injury, and neurological deficits. Laboratory investigations revealed schistocytes, elevated lactate dehydrogenase levels, and a PLASMIC score of 6, suggesting thrombotic thrombocytopenic purpura as a subtype of thrombotic microangiopathy. The patient was treated with plasma exchange therapy and supportive measures, including hemodialysis. Initial neurological deterioration, compounded by cerebral edema, necessitated mechanical ventilation. Over time, the patient's condition improved, and he was discharged on day 42 with recommendations for regular nephrology follow-up. CONCLUSION: Snakebite-induced thrombotic microangiopathy may differ from classical thrombocytopenic purpura, potentially involving venom-mediated Von Willebrand factor activation without severe ADAMTS13 deficiency. The use of platelet transfusions before referral may have worsened microthrombus formation and neurological symptoms. This case underscores the need for early recognition of thrombotic microangiopathy in patients who experienced snakebite presenting with thrombocytopenia and microangiopathic hemolytic anemia, even with normal coagulation parameters. Further research is essential to refine diagnostic and management strategies, including cautious platelet transfusion use, to improve outcomes in such complex cases.