Original Article
Premonitory signs and symptoms of envenoming by common krait (Bungarus caeruleus)
Tropical Doctor 2014, Vol. 44(2) 82–85 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514521802 tdo.sagepub.com
HS Bawaskar1, PH Bawaskar2 and Parag H Bawaskar3
Abstract Between January 2005 and August 2011 141 victims of krait bite poisoning were admitted to the general hospital at Mahad. Clinical signs and symptoms preceding the development of neuroparalysis were analyzed. Fifty-six percent of patients were male. A total of 140 victims reported between midnight and 05:00. Patients awoke in the night due to abdominal colic (85%) and chest pain (72%). Patients gave a history of vomiting (42%), sweating (17%) and excessive salivation (35%). On arrival at hospital, 78% cases had dysphasia with pooling of saliva, 89% had heaviness in both eyelids and ptosis; 12.5% of patients died on the way to hospital while 13.47% died during treatment. In total, 74.46% recovered, and of these 48% needed artificial ventilation. The sudden onset of abdominal colic and vomiting in a person sleeping on the floor without a mosquito net led to neuroparalysis due to krait bite poisoning.
Keywords Krait, neuroparalysis, ptosis, ophthalamoplegia
Introduction
Methods, patients and treatment
Bungarus caeruleus is an Indian krait common in tropical countries. Krait, a venomous snake, is active during the night hours. It enters homes to hunt prey: rats, lizards and small krait. The krait enters and finds a warm environment in bedding and if a person rolls on to a krait, the krait misinterprets this as prey and will bite a person asleep on the floor. As the fangs of the krait are small and short, the victim will experience only tingling or numbness and mild or no pain1. Though the venom is of small molecular size, the delayed manifestation is attributed to poor muscular movement, dermal circulation and slow reflexes during sleep. The high fatality due to krait bite is attributed to the unavailability of anti-snake venom (ASV), delayed and inappropriate administration of ASV, and inexperienced doctors2. Abdominal colic and vomiting are usually attributed to indigestion. Doctors who examined such cases have initially misdiagnosed acute appendicitis, stroke, head injury, ischemic heart disease, food poisoning, trismus, hysteria and Guillain-Barre´ syndrome. Victims are sent for unnecessary investigations including MRI scans of the brain and lumbar puncture.
We analyzed krait bite cases admitted between January 2005 and August 2011. The approximate time of bite was suggested by the onset of abdominal pain, vomiting, excessive salivation, difficulty in deglutition, heaviness of the eyelids, parenthesis, suffocation, dysphonic, nasal twang of voice, weakness in limbs and inability to lift the neck from the pillow (broken neck sign), the inability to protrude the tongue beyond teeth margin, eyelid paresis, pooling of saliva, intensity of expiratory nasal breathing, 1-minute breath interval, power and hypo-reflexia in limbs, all of which were specifically 1 Chairman, Bawaskar Hospital and Research Center, Mahad Raigad, Maharashtra, India 2 Director, Bawaskar Hospital and Research Center, Mahad Raigad, Maharashtra, India 3 Resident in Medicine, Topiwala Medical Collage and BYL Nair Hospital, Mumbai, India
Corresponding author: HS Bawaskar, Bawaskar Hospital and Research Center, Mahad District, Raigad, Maharashtra 402301, India. Email: [email protected]
Bawaskar et al.
83 looked for. The blood pressure, pulse and oxygen saturation were measured and the body searched with a magnifying lens for the site of the bite (Figure 1). The snake was identified by examining the killed specimen or by showing the patient photographs of kraits (Figures 2 and 3). A total of 100 mL of polyvalent antivenom was administered intravenously. Endotracheal intubation and artificial ventilation were administered to a victim with poor nasal expiration, SPO2
Premonitory signs and symptoms of envenoming by common krait (Bungarus caeruleus)
Tropical Doctor 2014, Vol. 44(2) 82–85 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514521802 tdo.sagepub.com
HS Bawaskar1, PH Bawaskar2 and Parag H Bawaskar3
Abstract Between January 2005 and August 2011 141 victims of krait bite poisoning were admitted to the general hospital at Mahad. Clinical signs and symptoms preceding the development of neuroparalysis were analyzed. Fifty-six percent of patients were male. A total of 140 victims reported between midnight and 05:00. Patients awoke in the night due to abdominal colic (85%) and chest pain (72%). Patients gave a history of vomiting (42%), sweating (17%) and excessive salivation (35%). On arrival at hospital, 78% cases had dysphasia with pooling of saliva, 89% had heaviness in both eyelids and ptosis; 12.5% of patients died on the way to hospital while 13.47% died during treatment. In total, 74.46% recovered, and of these 48% needed artificial ventilation. The sudden onset of abdominal colic and vomiting in a person sleeping on the floor without a mosquito net led to neuroparalysis due to krait bite poisoning.
Keywords Krait, neuroparalysis, ptosis, ophthalamoplegia
Introduction
Methods, patients and treatment
Bungarus caeruleus is an Indian krait common in tropical countries. Krait, a venomous snake, is active during the night hours. It enters homes to hunt prey: rats, lizards and small krait. The krait enters and finds a warm environment in bedding and if a person rolls on to a krait, the krait misinterprets this as prey and will bite a person asleep on the floor. As the fangs of the krait are small and short, the victim will experience only tingling or numbness and mild or no pain1. Though the venom is of small molecular size, the delayed manifestation is attributed to poor muscular movement, dermal circulation and slow reflexes during sleep. The high fatality due to krait bite is attributed to the unavailability of anti-snake venom (ASV), delayed and inappropriate administration of ASV, and inexperienced doctors2. Abdominal colic and vomiting are usually attributed to indigestion. Doctors who examined such cases have initially misdiagnosed acute appendicitis, stroke, head injury, ischemic heart disease, food poisoning, trismus, hysteria and Guillain-Barre´ syndrome. Victims are sent for unnecessary investigations including MRI scans of the brain and lumbar puncture.
We analyzed krait bite cases admitted between January 2005 and August 2011. The approximate time of bite was suggested by the onset of abdominal pain, vomiting, excessive salivation, difficulty in deglutition, heaviness of the eyelids, parenthesis, suffocation, dysphonic, nasal twang of voice, weakness in limbs and inability to lift the neck from the pillow (broken neck sign), the inability to protrude the tongue beyond teeth margin, eyelid paresis, pooling of saliva, intensity of expiratory nasal breathing, 1-minute breath interval, power and hypo-reflexia in limbs, all of which were specifically 1 Chairman, Bawaskar Hospital and Research Center, Mahad Raigad, Maharashtra, India 2 Director, Bawaskar Hospital and Research Center, Mahad Raigad, Maharashtra, India 3 Resident in Medicine, Topiwala Medical Collage and BYL Nair Hospital, Mumbai, India
Corresponding author: HS Bawaskar, Bawaskar Hospital and Research Center, Mahad District, Raigad, Maharashtra 402301, India. Email: [email protected]
Bawaskar et al.
83 looked for. The blood pressure, pulse and oxygen saturation were measured and the body searched with a magnifying lens for the site of the bite (Figure 1). The snake was identified by examining the killed specimen or by showing the patient photographs of kraits (Figures 2 and 3). A total of 100 mL of polyvalent antivenom was administered intravenously. Endotracheal intubation and artificial ventilation were administered to a victim with poor nasal expiration, SPO2
