|Year : 2018 | Volume
| Issue : 1 | Page : 10-11
A rare case of common krait envenomation presented with locked-in syndrome masquerading as brain death
Dhruvkumar M Patel1, Mukundkumar V Patel2, Rajeshchandra Mishra3, Greshaben Rajeshkumar Patel4
1 Intern Doctor, Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India
2 Consultant Physician, Dhruv Health Care Multispeciality Hospital, Ahmedabad, Gujarat, India
3 Intensive Care Unit, Medilink Hospital, Ahmedabad, Gujarat, India
4 Intern Doctor, BJ Medical College, Ahmedabad, Gujasrat, India
|Date of Web Publication||10-Oct-2018|
Mukundkumar V Patel
E-10 Amiakhandanand Society 1, Nr. C.T.M, N.H. 8, Amraiwadi, Ahmedabad - 380 026, Gujarat
Source of Support: None, Conflict of Interest: None
Krait (elapid snake) bite may be painless, without evidence of flange marks, and the patient is many times unaware of the bite. This may present as unexplained neuroparalysis and deep coma with absent brainstem reflexes, and it may look like brain death. We present a case of such unexplained neuroparalysis who was diagnosed on clinical ground, and the patient was completely recovered with anti-snake venom (ASV) and supportive treatment. A high index of suspicious, background history of the patient and timely empirical ASV therapy can save the patient from a coma with unexplained neuroparalysis from definite death.
Keywords: Brain death, common krait envenomation, locked-in syndrome
|How to cite this article:|
Patel DM, Patel MV, Mishra R, Patel GR. A rare case of common krait envenomation presented with locked-in syndrome masquerading as brain death. Saudi Crit Care J 2018;2:10-1
|How to cite this URL:|
Patel DM, Patel MV, Mishra R, Patel GR. A rare case of common krait envenomation presented with locked-in syndrome masquerading as brain death. Saudi Crit Care J [serial online] 2018 [cited 2018 Dec 10];2:10-1. Available from: http://www.sccj-sa.org/text.asp?2018/2/1/10/243014
| Introduction|| |
Snakebite is common in rural parts of many tropical Asian countries, and it is agriculture-related occupational hazard. This disease is one of the most neglected disorders of tropical countries as reported by the World Health Organization (WHO). Krait bite is characteristically nocturnal and sometimes with absent flange marks and painless; innocent humans are usual victims who are sleeping on the ground in open area at night. It may present as early morning neuroparalysis (EMNP) with deep coma and absent brainstem reflexes mimicking brain death. Due to lack of snakebite history and nonavailability of specific diagnostic tests, this diagnosis is challenging for critical care physician, and it requires a high index of suspicious. We report a case of EMNP, deep coma with depressed brainstem reflexes, and it was a diagnostic dilemma of brain death for emergency care physician. The patient completely recovered with anti-snake venom (ASV) and supportive measures.
| Case Report|| |
A 35-year-old Asian male working as a laborer was brought to the emergency room at early morning in June 2017 at the tertiary hospital of Ahmedabad, India. He was unconscious with frothing and excessive salivation from the mouth as reported by his wife. On admission, he was comatose with Glasgow Coma Scale of 3/15, with temperature 98.8°F, radial pulse 120/min, blood pressure 130/78 mmHg, shallow respiration 4/min, and SpO2 80% at room air. He was immediately intubated and supported with continuous mandatory ventilation, and intravenous excess was established. He was not having any skin rash, external injury, or bite marks. Neurological examination revealed power grade 0/5 in all limbs, soft neck muscles, hypotonia, and absent superficial and deep tendon reflexes with mute plantar response. Doll's eye movements, corneal reflexes, and cough reflex were absent. Both pupils were dilated (8 mm) and not reacting to light. Respiratory system examination revealed bilateral equal air entry and scattered coarse crepitations at both left infraaxillary region with vesicular breathing. Cardiovascular and abdominal examination were clinically normal. On further enquiry to family members, he had a history of acute colicky abdominal pain followed by vomiting at midnight during sleep, and after that episode, he again went to sleep. He was well before yesterday night and went to sleep in open courtyard of his house on floor bed. Arterial blood gas analysis showed PH of 7.38, PO2 70 mmHg, PCO2 54.3 mmHg, HCO3 28.2 mEq/L, Na+ 140 mEq/L, and K+ 4.2 mEq/L. His biochemical and metabolic panel investigation were within normal limit. An urgent computed tomography head was normal, and he was admitted to intensive care unit and was supported with mechanical ventilation for further management, with broad differential diagnosis of poisoning of psychotropic drugs, acute inflammatory demyelinating neuropathy (AIDP), myasthenic crisis with hypoxia, diffuse encephalomyelitis of unknown origin, and rabies or neuroparalytic snake envenomation being considered. His cerebrospinal fluid and serology study for herpes simplex virus, HIV, cytomegalovirus, and hepatitis C virus were not pointing any specific diagnosis. Due to high index of suspicion, bedside neostigmine challenge and electromyography were decided to check reversible neuromuscular paralysis, and it was suggestive of some postsynaptic reversibility. Because of no other alternate clinical diagnosis, it was decided to give empiric therapeutic trial of ASV of polyvalent type, and he was given injection ASV in recommended dose as per the Indian snakebite ASV guideline. His both pupils returned to normal size and reacted to light, and limbs powder returned to Grade 4/5 after 3 weeks. He denied any history of snakebite and was discharged after 25 days of admission.
| Discussion|| |
Snakebite is one of the common medical emergencies which require intensive care admissions, and the WHO has estimated very high mortality due to snakebite in tropical developing countries. Reasons of this high mortality are poor transportation facilities, tradition of first visit to faith healers before reaching to medical facilities, depriving benefit of initial golden hours of treatment, nonavailability of species-specific and freely available ASV, poverty, and lack of well-defined snakebite prevention measures. Poisonous snakes in India are the Elapidae (cobra and common krait) and Viperidae (Russell's viper, pit viper, and saw-scaled viper). Elapidae venom is neurotoxic, while that of Viperidae venom is cytotoxic. Krait is nonaggressive, shy, nocturnal, cold-blooded snake that often enters human dwelling at night in search of hunting small animals such as mouse. Krait bites are sometimes painless and occur during night and while person is in sleep, and many times, a history of snakebite, witness of snake seen by patients or relatives, and flange marks over body are absent, and victim is also unaware of the bite during the sleep. EMNP with absent brainstem reflexes mimicking brain death with a history of colicky abdominal pain and vomiting, but no history or any marks of snakebite over the body, has been reported as a very rare krait bite case.,,, Elapid venom contains alpha- and beta-bungarotoxins which act at presynaptic and postsynaptic membrane of motor endplate, respectively. Krait venom neurotoxins create autonomic disturbance and it may lead to abdominal pain, vomiting, perspiration, mydriasis, tachycardia, and hypertension because of reduced cholinergic activities. Elapid envenomation acts by two ways, direct neurotoxic effect on central nervous system and it may result in various grades of altered sensorium, and presynaptic or postsynaptic neuromuscular blockage. Our patient was presented as locked-in syndrome with absent brainstem reflexes and fixed dilated unresponsive pupils mimicking brain death. Emergency care physician should not misdiagnose such patients as brain death before confirming it by relevant clinical history and investigations, otherwise potentially treatable human life may be lost.
| Conclusion|| |
Early morning unexplained neuroparalysis or locked-in syndrome with depressed brain stem reflexes and background history of sleeping on floor bed in open house of rural elapid snake endemic area should be treated as krait bite neuroparalysis syndrome and adequate dose of ASV with mechanical ventilation and circulatory support should be continued, even it mimics brain death after excluding another potential alternative diagnosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta YK, Peshin SS. Snake bite in India: Current scenario of an old problem. J Clin Toxicol 2014;4:182.
Bawaskar HS, Bawaskar PH, Bawaskar PH. Snake bite in India: A neglected disease of poverty. Lancet 2017;390:1947-8.
John J, Gane BD, Plakkal N, Aghoram R, Sampath S. Snake bite mimicking brain death. Cases J 2008;1:16.
Agarwal R, Singh N, Gupta D. Is the patient brain-dead? Emerg Med J 2006;23:e05.
Seneviratne U, Dissanayake S. Neurological manifestations of snake bite in Sri Lanka. J Postgrad Med 2002;48:275-8.
] [Full text]
Pawar DK, Singh H. Elapid snake bite. Br J Anaesth 1987;59:385-7.
Mali LP, Gupta S, Sharma D, Choudhary M. Krait envenomation: Strong suspicion and judicious use of anti-snake venom. Med J DY Patil Univ 2015;8:517-9. [Full text]
Prasarnpun S, Walsh J, Awad SS, Harris JB. Envenoming bites by kraits: The biological basis of treatment-resistant neuromuscular paralysis. Brain 2005;128:2987-96.
Law AD, Agrawal AK, Bhalla A. Indian common krait envenomation presenting as coma and hypertension: A case report and literature review. J Emerg Trauma Shock 2014;7:126-8.
] [Full text]
Wijdicks EF. The diagnosis of brain death. N Engl J Med 2001;344:1215-21.