Unusual "erythroid loops" in canine blood smears after viper-bite envenomation

Northern Italy is a habitat for many species of viper; Vipera aspis is responsible for most reported bites of humans and animals. Five dogs of different breeds and ages were presented by their owners to a veterinary clinic in northern Italy between September 2004 and August 2007 with a history of being bitten by a viper within the past 2 hours. On physical examination, all of the dogs were depressed, had pale mucous membranes, and had a painful area consistent with a recent viper bite wound on the nose (2), distal front leg (2), or lip (1). Hemoglobinemia and hemoglobinuria were observed in plasma and urine from all dogs. CBCs were done at the time of presentation, daily for 4 days, and 10 days after presentation in all dogs with the exception of one dog that died after 2 days. All dogs had an acute decrease in HCT within 24 hours of presentation; all dogs had neutrophilia, 3/5 had a mildly toxic left shift, and 4/5 had thrombocytopenia. On Diff-Quik-stained blood smears, moderate numbers of echinocytes, spherocytes, and erythrocyte ghosts were observed. In addition, moderate numbers of unusual erythrocyte membrane-like structures ("erythroid loops") were observed. The loops were annular in shape and sometimes disrupted, appearing as thin pale blue bands. Erythrocyte morphologic abnormalities decreased by day 3 and were no longer observed on day 10. The unique appearance of the erythroid loops together with evidence for intravascular hemolysis and other erythrocyte morphologic changes suggest they may be a consequence of erythrocyte lysis. Echinocytes, spherocytes, and erythrocyte ghosts are known to result from the action of phospholipase in viper venom; however, erythroid loops have not been reported previously and their exact mechanism of formation is unknown.