Recurrent, persistent, or late, new-onset hematologic abnormalities in Crotaline snakebite

Background. Hematologic effects from rattlesnake envenomation exhibit a phenomenon of recurrent, persistent or late, new onset (late) abnormalities in some Fab antivenom-treated patients 4 or more days post-envenomation. Indicators that reliably identify or exclude those patients at risk of late hematologic effects have not been developed. Methods. This was a retrospective, observational case series of rattlesnake bite records at two US poison centers. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for D-dimer, fibrinogen, platelets, platelet count trend, INR and PTT associated with late hematologic abnormalities, were determined. Results. Three hundred seventy six cases were reviewed. Sixty cases met inclusion criteria. Overall, 17 of 60 patients (28%) had a hematologic abnormality as a result of envenomation. Eleven of 60 patients (65% of those with a hematologic abnormality; 18% overall) developed late hematologic abnormalities 4 or more days post-envenomation. Four patients had late, new onset hypofibrinogenemia and/or thrombocytopenia. All were associated with early D-dimer elevation and/or platelet rise in response to FabAV treatment, respectively. Normal hematologic parameters in the first 48 h post-envenomation and the lack of a greater than 20% rise in platelets within 4 h post-antivenom administration had a 100% NPV for late hematologic effects. Conclusions. Patients with early onset hypofibrinogenemia, a positive D-dimer, thrombocytopenia, or a 20% increase in platelet count within 4 h post-treatment had a significant likelihood of late hematologic effects. Patients in whom fibrinogen, D-dimer, INR, PTT, and platelet counts remained normal throughout the first 48 h post-envenomation, and who did not exhibit a >20% increase in platelet count within 4 h post-antivenom administration, did not develop late hematologic effects.