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. 2018 Dec 27:24:43.
doi: 10.1186/s40409-018-0179-2. eCollection 2018.

Clinical and laboratory features distinguishing between Deinagkistrodon acutus and Daboia siamensis envenomation

Hung-Yuan Su  1   2 , Shih-Wei Huang  3 , Yan-Chiao Mao  4 , Ming-Wen Liu  3 , Kuo-Hsin Lee  1   2 , Pei-Fang Lai  3 , Ming-Jen Tsai  5
Affiliations

Clinical and laboratory features distinguishing between Deinagkistrodon acutus and Daboia siamensis envenomation

Hung-Yuan Su et al. J Venom Anim Toxins Incl Trop Dis. .

Abstract

Background: There are 6 species of venomous snakes in Taiwan. Two of them, Deinagkistrodon acutus (D. acutus) and Daboia siamensis (D. siamensis), can cause significant coagulopathy. However, a significant proportion of patients with snakebites cannot identify the correct snake species after envenomation, which hampers the application of antivenom. Hence, the differential diagnosis between the two snakebites by clinical presentations is important. This study aims to compare their clinical and laboratory features for the purpose of differential diagnosis between the two snakebites.

Methods: We retrospectively reviewed the medical records of patients who arrived at the emergency department due to D. acutus or D. siamensis envenomation, between 2003 and 2016, in one medical center in eastern Taiwan. Since these snakebites are rare, we also included 3 cases reported from another hospital in central Taiwan.

Results: In total, 15 patients bitten by D. acutus and 12 patients by D. siamensis were analyzed. Hemorrhagic bulla formation and the need for surgical intervention only presented for D. acutus envenomation cases (Both 53.3% vs. 0.0%, P = 0.003). As to laboratory features, lower platelet counts (20.0 × 103/μL [interquartile range, 14-66 × 103/μL] vs. 149.0 × 103/μL [102.3-274.3 × 103/μL], P = 0.001), lower D-dimer level (1423.4 μg/L [713.4-4212.3 μg/L] vs. 12,500.0 μg/L [2351.4-200,000 μg/L], P = 0.008), higher proportion of patients with moderate-to-severe thrombocytopenia (platelet count < 100 × 103/μL) (80% vs. 16.7%, odds ratio (OR) = 20.0, 95% CI, 2.77-144.31; P = 0.002), and lower proportion of patients with extremely high D-dimer (> 5000 ng/mL) (16.7% vs. 66.7%, adjusted OR = 0.1 (95% CI, 0.01-0.69; P = 0.036) were found among cases of D. acutus envenomation compared to D. siamensis envenomation. The combination of hemorrhagic bulla, thrombocytopenia, and a lack of extremely high D-dimer had good discriminatory power (area under the curve (AUC) = 0.965; 95% CI, 0.904-1.00) for distinguishing D. acutus from D. siamensis envenomation.

Conclusions: The presentation of moderate to severe thrombocytopenia (platelet count < 100 × 103/μL) and hemorrhagic bulla formation may indicate D. acutus envenomation. However, the envenomed patient with extremely high D-dimer levels may indicate a D. siamensis envenomation. These findings may help diagnose and select the right antivenom in patients with unknown snakebites who present significant coagulopathy.

Keywords: Coagulopathy; Daboia siamensis; Deinagkistrodon acutus; Snakebite; Thrombocytopenia.

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Conflict of interest statement

The institutional review board of the Hualien Tzu Chi Medical Center approved the study protocol (IRB106–128-B).Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Receiver-operating characteristic (ROC) curves for the different combinations of clinical manifestations in distinguishing D. acutus envenomation from D. siamensis envenomation. Thrombocytopenia means platelet count < 100 × 103/uL
See this image and copyright information in PMC

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