A CASE OF SNAKE BITE WITH UNUSUAL COMPLICATIONS AND REVIEW OF LITERATURE

Snakebites, including poisonous ones, are common occurrence in tropical countries and are endemic during summer months. However, snake bite remains a neglected public health problem in resource limited countries like India. The snake venom may cause local cytotoxicity, hemotoxicity, neurotoxicity and myotoxicity. Cardiac involvement is not usually encountered and has not been extensively discussed. It is however reflected in ECG changes, echocardiographic changes, raised cardiac enzymes and new unexplained cardiac events.We recently managed case of cobra envenomation who presented with features of cytotoxicity leading to extensive cellulitis, coagulopathy and neuroparalysis. He was managed with polyvalent anti-snake venom (ASV) administration and supportive treatment. He recovered from neuroparalysis and was successfully weaned off the ventilator. Three days later, he developed ischemic cerebral infarction and left ventricular failure (LVF). Electrocardiography showed fresh ST-T changes in anterior and inferior leads. Echocardiography revealed features of severe, left ventricular (LV) dysfunction, markedly reduced ejection fraction (LVEF 20-25%) and mid-basal to apical akinesia. The patients LVF was managed with diuretic and resolved over next 48 h. Repeat echo after three days showed marked improvement in LVEF to 50% and only mild hypokinesia of akinetic segments. The transient LVF and echo findings were suggestive of the diagnosis of stress (Takotsubo) cardiomyopathy. We report this case for its unusual complications and review the relevant literature.