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Am. J. Trop. Med. Hyg., 78(6), 2008, pp. 856-861
Copyright © 2008 by The American Society of Tropical Medicine and Hygiene

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CASE REPORT


Fatal Diffuse Thrombotic Microangiopathy after a Bite by the "Fer-de-Lance" Pit Viper (Bothrops lanceolatus) of Martinique

Stéphane Malbranque, Marie Dominique Piercecchi-Marti, Laurent Thomas*, Christophe Barbey, Dominique Courcier, Bernard Bucher, Alex Ridarch, Didier Smadja, AND David A. Warrell
Centre Hospitalier Universitaire, Fort-de-France, Martinique; Service de Médecine Légale et Droit de la Santé, Faculté de Médecine, Marseille, France; Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom

 

ABSTRACT

In Martinique, a man bitten two days earlier by a pit viper (Bothrops lanceolatus) was hospitalized with impaired consciousness and tetraplegia. Investigations confirmed cerebral and myocardial infarctions. Resolving thrombocytopenia was associated with virtually normal blood prothrombin time/activated partial thromboplastin time but increasing hyperfibrinogenemia. Despite specific antivenom treatment, he developed fatal left ventricular failure six days after the bite. At autopsy, multiple cerebral, myocardial and mesenteric infarctions were found. Rupture of mitral chordae tendinae was the likely cause of death. Histopathologic examination showed multi-focal thrombotic microangiopathy with intimal-medial dissection by thrombi extending from foci of endothelial damage in small cerebral, myocardial, pulmonary, mesenteric, and interlobular renal arteries and arterioles. These findings were the causes of infarctions. There was intense angiogenesis in organizing cerebral infarcts. Immunohistochemical analysis showed platelet aggregates and endothelial cells within microthrombi. Viperidae venoms contain vascular endothelial toxins, notably metalloproteinase hemorrhagins, but von Willebrand factor activators or vascular endothelial growth factor–type factors are more likely to have been implicated in this case.

Received November 27, 2007. Accepted for publication January 18, 2008.

Acknowledgments: We thank Aura Kamiguti, Paul L. F. Giangrande, and Gareth Turner for helpful comments and discussions.

Financial support: This study was supported by Centre Hospitalier Universitaire de Fort-de-France

* Address correspondence to Laurent Thomas, Service des Urgences, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique. E-mail: laurent.thomas{at}chu-fortdefrance.fr

Authors’ addresses: Stéphane Malbranque, Unité de Médecine Lé-gale, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique, E-mail: stephane.malbranque{at}chu-fortdefrance.fr. Marie Dominique Piercecchi-Marti, Service de Médecine Légale et Droit de la Santé, Centre Hospitalier Universitaire La Timone, 13385 Marseille Cedex 05, France, E-mail: marie-dominique.piercecchi{at}mail.ap-hm.fr. Laurent Thomas, Service des Urgences, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique, E-mail: laurent.thomas{at}chu-fortdefrance.fr. Christophe Barbey, Cardiologie Interventionnelle et Imagerie Cardiaque, Clinique Saint Gatien, 8 Place de la Cathé drale, 37042 Tours Cedex, France, E-mail: c.barbey{at}ciic.fr. Dominique Courcier, Service de Cardiologie, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique, E-mail: dominique.courcier{at}chu-fortdefrance.fr. Bernard Bucher, Département de Biochimie Médicale, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique, E-mail: b.bucher{at}wanadoo.fr. Alex Ridarch, Service de Radiologie et Imagerie Médicale, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique, E-mail: alex.ridarch{at}chu-fortdefrance.fr. Didier Smadja, Service de Neurologie, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique, E-mail: didier.smadja{at}chu-fortdefrance.fr. David A. Warrell, Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX3 9DU, United Kingdom, E-mail: david.warrell{at}ndm.ac.uk.






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Copyright © 2008 by the American Society of Tropical Medicine and Hygiene.