Secondary capillary leak syndrome - Plasmapheresis: Is it the answer?

Secondary capillary leak syndrome - Plasmapheresis: Is it the answer? ISSN: 2394-0026 (P)Case Report ISSN: 2394-0034 (O)Secondary capillary leak syndrome - Plasmapheresis: Is it the answer?Mary Grace1*, K J Jacob2, Jayakumar3, Arun P41Associate Professor, 2Additional Professor, 3Associate Professor, 4Junior ResidentDepartment of Medicine, Government Medical College, Thrissur, India *Corresponding author email: [email protected] to cite this article: Mary Grace, K J Jacob, Jayakumar, Arun P. Secondary capillary leaksyndrome - Plasmapheresis: Is it the answer? IAIM, 2015; 2(4): 187-189.Available online at www.iaimjournal.comReceived on: 19-03-2015 Accepted on: 03-04-2015AbstractCapillary leak syndrome is a dreaded complication of snake bite. Various modalities of treatmenthave been tried, but prognosis is very poor. We have reported here a case of poisonous snake bitecomplicated with capillary leak, which survived following plamapheresis.Key wordsSnake bite, Capillary leak, Plasmapheresis.Introduction edema. There was no evidence of neurotoxicityCapillary leak syndrome (CLS) also known as or bleeding manifestations or decrease in urineClarkson’s syndrome, was first described by Dr.Bayard Clarkson in 1960. It is characterized by output. In view of the evidence of local andhypoalbuminemia without albuminuria,hemoconcentration, hypotension and systemic envenomation, he was given 20 vials ofgeneralized edema. Capillary leak syndrome is adreaded complication of snake bite. Various antisnake venom. He subsequently went intomodalities of treatment have been tried, butprognosis is very poor. oligo anuric state with serum creatinine value ofCase report 1.4 mg%, for which renal replacement therapy in28 years old male admitted with snake bite on the form of hemodialysis was initiated. On themedial aspect of left leg near medial malleolus.At the time of admission the patient had second day he developed chemosis, parotidabdominal pain and vomiting with pain at thesite of bite. On examination, there was local swelling, right sided pleural effusion along with severe leukocytosis (total count 39000/cumm) and hemoconcentration (Hemoglobin 15 g%, PCV 46%). On the third day, he developed bleeding manifestations in the form of hematuria, malena, subconjunctival hemorrhage. Laboratory investigations revealed thrombocytopenia (platelet count 30,000/cumm). The coagulation parametersInternational Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 187Copy right © 2015, IAIM, All Rights Reserved.

Secondary capillary leak syndrome - Plasmapheresis: Is it the answer? ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)were persistently normal. On the fourth day, syndrome. First is the prodormal phase whenpatient complained of tightness in the the patient manifests irritability, fatigue,abdominal wall and both forearms. CPK value myalgia, abdominal pain, thirst and syncope.was 2400 units/litre. Myoglobinuria was not Second is the phase of capillary leakage withevident. In view of capillary leak syndrome marked extravasation of intravascular fluid.secondary to ophitoxemia, we started him on Marked hypotension, generalized edema,theophylline, leukotriene antagonists, and high pleural and pericardial effusion, ascites,dose pulse steroid therapy. Despite compartment syndrome, rhadomyolysis, renalhemodialysis and disease modifying treatment failure can occur in this phase. Renal failure is afor capillary leak, renal function tests and common complication. The mechanisms of renalplatelet counts showed a worsening trend. Hb failure include hypotension induced reduceddropped from 15 g% to 8.9 g% and then 7.6 g%. glomerular filtration, acute tubular necrosis andPeripheral smear did not show any evidence of rhadomyolysis associated pigmenturia. Thishemolysis, LDH level was normal (54 units/liter). stage usually lasts for 1-4 days. Third phase isPatient went into hypotension, with worsening characterized by return of fluid back into thechemosis, hemoconcentration, intravascular space and associated polyuria andhypoalbuminemia (serum albumin 2.8 g%, with pulmonary edema. This patient had features ofno evidence of albuminuria) and rising serum envenomation followed by features likecreatinine. Daily plamapheresis and replacement generalized edema, pleural effusion,with fresh frozen plasma was done along with compartment syndrome, rhadomyolysis andcontinuing SLED (slow low efficient dialysis). renal failure [3]. The possibility of thromboticAfter two days of plamapheresis patient started thrombocytopenic purpura was considered, butimproving. Within one week of daily there was no evidence of hemolysis. Theplamapheresis with renal replacement therapy, persistently normal coagulation profile ruled outall the laboratory parameters returned to disseminated intravascular coagulation.normal and the patient could be discharged. Treatment of CLS includes anti-snake venom and supportive care. Disease modifying agents beingDiscussion used in treatment of capillary leak areCapillary leak syndrome (CLS) also known as theophylline, leukotriene antagonists,Clarkson’s syndrome, was first described by Dr terbutaline, plamapheresis, prostacycline,Bayard Clarkson in 1960.It is characterized by corticosteroids and intravenous immunoglobulinhypoalbuminemia without albuminuria, (IG). There is no proven therapy for CLS. Thehemoconcentration, hypotension and prognosis remains very poor. We postulatedgeneralized edema. The underlying mechanism that early recognition of CLS and promptis capillary hyper permeability and extravasation institution of plamapheresis and use of freshof plasma, containing macromolecules up to 900 frozen plasma might have contributed to thekD. CLS can be primary (idiopathic) or secondary successful outcome in this patient.to conditions like poisonous snake bite(ophitoxemia) [1, 2] and dengue hemorrhagic Conclusionfever. Toxins and enzymes present in the snake Capillary leak syndrome is a grave complicationvenom cause increase in the capillary of snake bite with no proven treatmentpermeability leading to leakage of plasma from modalities. Early recognition and institution ofthe intravascular space. There are three phases plamapheresis along with replacement within the clinical presentation of capillary leakInternational Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 188Copy right © 2015, IAIM, All Rights Reserved.

Secondary capillary leak syndrome - Plasmapheresis: Is it the answer? ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)fresh frozen plasma might be life saving in this 2. Bawaskar HS, Bawaskar PH. Snake bitefatal situation. poisoning. J Mahatma Gandhi Inst Med Sci, 2015; 20: 5-14.References 3. B. Purushottam Rao, P. Siva Teja, V. V.1. Syed Moied Ahmed, Mohib Ahmed, Abu Satyanarayana. A Study on the Incidence Nadeem, Jyotsna Mahajan, Adarash and Etiology of Acute Kidney Injury in Choudhary, Jyotishka Pal. Emergency Hemotoxic Snake Envenomation Cases treatment of a snake bite: Pearls from in a Tertiary Care Centre. Journal of literature. J Emerg Trauma Shock, 2008; Evidence based Medicine and 1(2): 97–105. Healthcare, 2015; 2(9): 1312-1316.Source of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 189Copy right © 2015, IAIM, All Rights Reserved.