Acute Renal Failure Following Russell's Viper Envenomation: A Report of Two Cases

鎖鏈蛇咬傷所引起之急性腎衰竭：二病例報告

陳鴻鈞(Hung-Chun Che) ； 賴永勳(Yung-Hsiung Lai) ； 蔡瑞熊(Juei-Hsiung Tsai)

《The Kaohsiung Journal of Medical Sciences》 4卷8期 (1988/08) Pp. 467-472

https://doi.org/10.6452/KJMS.198808.0467

摘要

鎖鏈蛇(Russell’s viper)是臺灣地區常見的毒蛇之一。它同時也是在南洲地區被咬傷導致高死亡率的主要毒蛇；而在蛇咬傷所引起的急性腎衰竭當中，鎖鏈蛇也佔了主要的角色。鎖鏈蛇咬傷所引起的急性腎衰竭其發生率在44到86％之間，而引起溶血性－尿毒症候群（hemolytic-uremic syndrome）者則極少見。本院曾經歷二例此種急性腎衰竭病例，其中一例並發生溶血性－尿毒症候群，特提出報告。
病例一是一名34歲男性，在被梢鏈蛇咬傷左側姆趾後數天內產生乏尿症，貧血（Hct:25.8%），血小板數明顯降低（33×103/ml）及黃疸（Bilirubin(D/I):0.3/5.4mg/dl），血中尿素氮（105mg/dl）及肌酸酐濃度（9.5mg/dl）亦急速升高，尿液檢查出現蛋白尿及顯微血尿，病人遂接受血液透析治療；其血小板數在1週後恢復正常，而3週後出現利尿期，但病人在60天後仍持續有貧血現象（Hct:21.7%），血中尿素氮及肌酸酐濃度也仍偏高（尿素氮及肌酸酐分別是81及6.7mg/dl）。病人在第19天時接受腎臟切片檢查。結果顯示腎絲球間質溶解併有腎絲球內之纖維栓塞，為典型的急性腎皮質壞死併腎小管壞死現象。
病例二為一名50歲男性，在被鎖鏈蛇咬傷右側小腿數天後，發生少尿症、貧血（Hct:31.9%），血小板數降低（99×103/ml）、血中膽色素（Bilirubin(D/I):0.4/1.8 mg/dl）、尿素氮(90mg/dl)及肌酸酐濃度(10.7mg/dl)升高現象，尿液檢查顯示蛋白尿及顥微血尿。病人在接受血液透析治療後情況漸漸改善，其尿量在18天後達到每天2000ml以上，而在35天後血中尿素氮及肌酸酐分別降到18mg/dl及1.8mg/dl，但病人仍持續有貧血現象(Hct:25%)。病人在第20，中受腎臟切片檢查，其結果顯示為典型的急性腎小管壞死。
溶血性－尿毒症候群是一種以溶血性貧血、急性腎衰竭，其致病機轉仍未十分明瞭，可能與瀰漫性血管內凝血（DIC）或其血清之直接腎毒性有關。

並列摘要

Two patients developed acute renal failure after bites by Russell’s viper. Case 1 was a 34-year-old male, who developed anuria, anemia, thrombocytopenia, and jaundice characteristic for hemolytic-uremic syndrome within 24 hours of a snake bite on his left big toe. The patient received intensive hemodialysis 2 days later because of steadily increasing azotemia. The platelet count returned to normal1 week later and the urinary output increased 3 weeks after the snake bite. The patient remained anemic and azotemic for 60 days. Renal biopsy performed on the 19th day afger the bite revealed glomerular mesangial lysis with intraglomerular fibrin thrombi characteristic of acute cortical necrosis with tubular necrosis. Case 2 was a 50-year-old male, who developed oliguria, anemia, thrombocytopenia, azotemia and hyperbilirubinemia within 3days of a snake bite in the right calf area. Intensive hemodialysis was given from the 3rd day after the bite and his renal function remained stable and later gradually improved although anemia persisted after 35 days. Renal biopsy performed on the 20th day after the bite revealed acute tubular necrosis. The pathogenesis of acute renal failure after Russell’s viper envenomation is not clear, disseminated intravascular coagulation and the direct nephrotoxic action of the venom has been postulated.

並列關鍵字

acute renal failure(ARF) ； hemolytic-uremic syndrome(HUS) ； Russell's viper