Title: An Exceptional Manifestation of Snake Bite

Abstract:

Introduction: Snakebites have become a major health concern in India. The American Society of Tropical Medicine and Hygiene said in India 46,000 people are dying every year from snake bites against the official figure of only 2000. Aplastic anemia is a rare hematological disorder where the bone marrow fails to produce blood cells due to a decrease in the bone marrow stem cells. In about more than 60% of cases, the cause of bone marrow failure is not known and is called idiopathic aplastic anemia.
Case Descriptions: 17-year-old previously healthy boy with no comorbidities presented to the emergency department with a history of suspected snake bite on his right big toe. Investigations showed features of severe DIC (abnormal PT, aPTT, decreased platelets and decreased fibrinogen, increased FDP, D dimer) for which he was given several units of blood products (FFP, PRBC, and platelets). He was also given appropriate doses of anti-snake venom. In the intensive care, he developed severe sepsis and multiorgan dysfunction. During the course of the treatment, his sepsis cleared but we noted that he developed severe pancytopenia in spite of several units of blood products like PRBC and platelets and even after the stoppage of suspecting antibiotics. We did a bone marrow aspiration and trephine biopsy. Bone marrow aspiration showed dilute marrow with occasional scattered normoblast, scattered myeloid cells, and absent megakaryocytes The trephine biopsy showed severe aplastic anemia with the marrow cellularity around 10% which was quite surprising. He became clinically better, especially with the bleeding tendencies. His coagulation parameters started returning to normal. He was discharged and asked to come for regular follow-up. After one month, the bone marrow was repeated which showed a remarkable recovery with 50-60% cellularity and normal trilineage hematopoiesis. In the last follow-up, the blood counts were Hb 12.1g/dl, WBC 5800 per cubic mm, ANC 2000, and platelet 2,16,000. Other blood parameters like were normal.
Discussion: This patient has a very rare manifestation of snake bite producing severe aplastic anemia. To our best knowledge, we could not find a similar case reported in the literature. Any mechanisms postulated for aplastic anemia are futile because of the lack of cases in the literature. This patient was lucky to have a reversible Bone Marrow aplasia which is not common in a short period of time without specific treatment whatever the cause. It may be better to keep the patient on a long-term follow-up as many other similar circumstances (like drugs, chemicals, infections, etc) could lead to a suppression of Bone Marrow in this patient again.
Conclusion: It is possible that the postulation behind the variation in the constituents in the venom which account for this phenomenon could be possible for the cause of the pathology in our case. Any unusual constituent which could have suppressed the bone marrow temporally either directly or through immunological mechanisms could be postulated as the cause in our case. What that particular unusual constituent was, remains a mystery.

Biography:

Hridya Harimohan is a medical graduate from the Kerala university of health sciences. She is a USMLE aspirant, actively pursuing research right from her undergraduate days. She has passed Step 1 and is now preparing for step 2 CK. Her aim is to get accustomed to Advanced Medical health practices and to make it accessible to underserved and underprivileged communities.