title: Recurrent and persistent coagulopathy following pit viper envenomation.
abstract: BACKGROUND
  Coagulation abnormalities following crotaline (pit viper) snakebite have traditionally been considered short-lived, but laboratory studies have rarely been reported beyond the first few days of treatment for envenomation. During the course of an antivenom clinical trial, we observed coagulation defects as late as 2 weeks following envenomation.
  
  
  OBJECTIVE
  To document and characterize the recurrence or persistence of coagulopathy among patients envenomed by pit vipers and treated with a Fab antivenom.
  
  
  METHODS
  Patients with moderate pit viper envenomation were enrolled in a multicenter, prospective clinical trial. A Fab-based antivenom preparation, antivenom polyvalent crotalid (ovine) Fab, was administered in all cases. Platelet count, fibrinogen level, presence of fibrin split products, prothrombin time, and partial thromboplastin time were determined before treatment and at standard intervals during the following 2 weeks.
  
  
  RESULTS
  Of 38 patients completing the study, 20 (53%) had recurrent, persistent, or late coagulopathy 2 to 14 days after envenomation. Thrombocytopenia occurred in patients with prior thrombocytopenia; hypofibrinogenemia occurred only in those with prior hypofibrinogenemia or positive fibrin split products. No patient experienced significant spontaneous bleeding. One patient with coagulopathy developed minor bleeding following minor surgery 12 days after envenomation.
  
  
  CONCLUSIONS
  Prolonged or recurrent coagulopathy may occur after envenomation by North American pit vipers. Patients treated with Fab-based antivenom may benefit from periodic rather than single-bolus dosing. Patients with coagulopathy should undergo close monitoring during the first 2 weeks after snakebite.
authors.affiliation: Department of Pediatrics, University of Arizona Health Sciences Center and Arizona Poison and Drug Information Center, Tucson 85724, USA.
authors.forename: L V
authors.initials: LV
authors.lastname: Boyer
authors.forename: S A
authors.initials: SA
authors.lastname: Seifert
authors.forename: R F
authors.initials: RF
authors.lastname: Clark
authors.forename: J T
authors.initials: JT
authors.lastname: McNally
authors.forename: S R
authors.initials: SR
authors.lastname: Williams
authors.forename: S P
authors.initials: SP
authors.lastname: Nordt
authors.forename: F G
authors.initials: FG
authors.lastname: Walter
authors.forename: R C
authors.initials: RC
authors.lastname: Dart
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000818:Animals; D000997:Antivenins / Q000627:therapeutic use*; D001778:Blood Coagulation Disorders / Q000097:blood / Q000139:chemically induced / Q000188:drug therapy* / Q000209:etiology*; D002648:Child; D002908:Chronic Disease; D003435:Crotalid Venoms / Q000627:therapeutic use*; D005340:Fibrinogen / Q000378:metabolism; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000627:therapeutic use*; D008875:Middle Aged; D010314:Partial Thromboplastin Time; D010976:Platelet Count; D011517:Prothrombin Time; D012008:Recurrence; D012909:Snake Bites / Q000150:complications*; D013997:Time Factors; D014757:Viper Venoms / Q000009:adverse effects*; D017819:Viperidae
chemical_list: D000997:Antivenins; D003435:Crotalid Venoms; D007140:Immunoglobulin Fab Fragments; D014757:Viper Venoms; D005340:Fibrinogen