Dramatic neuromuscular paralysis following occult snakebites: An awareness for the primary care physician

Abstract

Neurotoxic snakebites are a common emergency in tropical countries and account for significant morbidity and mortality worldwide. Manifestations vary from mild ptosis and ophthalmoplegia to severe flaccid paralysis with ventilatory failure. At times, the neuromuscular paralysis may be severe enough for patients to be misdiagnosed as a locked-in syndrome or brain dead. Occult snakebites, wherein patients are unaware of the bite and fang marks are absent, have been reported in kraits, an endemic neurotoxic snake belonging to the Elapidae family. We report a series of three cases in which young males presented with dramatic neuromuscular paralysis and were likely suffering from elapid snake bites. Each of these patients presented an intriguing clinical challenge and had different in-hospital outcomes. Primary care physicians in the emergency department are usually the first respondents to such patients. Owing to a lack of snake bite history and unavailability of specific diagnostic tests, severe envenomation presents a challenge for physicians, unless they are aware of it and a high level of suspicion is maintained.

Keywords: Brain death mimics; krait envenomation; occult snakebite.

Figure 1

Patient 1 at the time of discharge

Figure 2

Patient 1 at 1-month follow up