Diagnosing Syndrome-Like Microangiopathic Hemolytic Anemia After Pit Viper Envenomation: Overcoming Laboratory Gaps...

Snakebite envenomation remains a significant yet often overlooked health challenge in Nepal, particularly in its rural and hilly regions. While venom-induced consumption coagulopathy (VICC) is commonly observed with viper bites, microangiopathic hemolytic anemia (MAHA) is an extremely rare complication, especially with green pit vipers (Trimeresurus spp.). MAHA is often underdiagnosed in low-resource settings due to the absence of definitive laboratory diagnostics. We report a case of a 47-year-old woman from rural Nepal who was bitten by a presumed green pit viper (Trimeresurus spp.). She developed local swelling, ecchymosis, hematuria, anemia, thrombocytopenia, and coagulopathy. MAHA was diagnosed clinically based on syndromic presentation and serial hematologic monitoring, despite the unavailability of a peripheral blood smear. Due to species-specific antivenom unavailability, the patient was treated with supportive care and blood product transfusions, and she achieved complete recovery without any renal complications. This case highlights the diagnostic challenges of MAHA in settings lacking definitive laboratory tests. It emphasizes the importance of clinical vigilance and syndromic diagnosis. Prompt, appropriate supportive management can lead to favorable outcomes even without antivenom availability. MAHA should be considered in snakebite victims presenting with thrombocytopenia and anemia. Strengthening diagnostic capacity and improving access to species-specific antivenoms are critical for reducing morbidity and mortality from snakebite envenomation in resource-limited settings.