Case Study

A 27-year-old man was brought to the emergency department in serious condition. Earlier in the day, he was hiking and had been bitten on his leg by what he thought was probably a black snake. The leg was swollen, and the hiker was extremely lethargic and barely conscious. Additionally, he was bleeding from the site where he was bitten. When blood was drawn, the venipuncture site bled profusely. His lab results follow:

Platelets 27.0 X 109/L (Reference range, 150 to 450 X 109/L)

PFA Not performed

PT 21.2 seconds (Reference range, 11.8 to 14.5)

PTT 53.7 seconds (Reference range, 23.0 to 35.0)

Fibrinogen 110 mg/dL (Reference range, 200 to 400)

D-dimer 3170 ng/mL D-Dimer units (Reference range, 0 to 200)

Given these laboratory results what is the most likely diagnosis? How can you account for his laboratory results? Insights to the Case Study

Notice that the patient's basic coagulation profile was abnormal. His PT and PTT were markedly abnormal, his platelet count was markedly decreased, his fibrinogen was decreased, and his D-dimer was markedly prolonged. DIC was triggered by the snake bite. The venom of poisonous snakes will directly activate factor X or factor II. When this happens, clotting occurs within the vessels at an accelerated rate, consuming all of the clotting factors. Notice that the D-dimer result is extremely elevated. D-dimer is the smallest breakdown product of fibrin. When elevated, it is indicative of cross-linked fibrin within the circulating blood, rather than locally at the site of injury. The patient was given antivenin and supported by blood products until his condition stabilized.

[Case submitted by Wendy Sutula, MS, MT(ASCP), SH, Washington Hospital Center.]

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