snake bite was added to the world health organization ( who ) neglected list of tropical diseases in 2009 . an estimated 5.5 million people are bitten by snakes per year resulting in 400,000 amputations and between 20,000 and 125,000 deaths annually . a relatively recent report highlighted that one of the highest burdens exist in sub - saharan africa . the incidence of snake bite envenomation in central sub - saharan africa was 3.33/100,000 population with a mortality rate of 0.53/100,000 population . these areas should have access to antivenom and protocols to guide the management of these cases . hospitals where snake bites are uncommon should also have protocols on standby in the event of such cases presenting . the burden of human immunodeficiency virus ( hiv ) in developing countries is substantial . according to who statistics from 2011 , there are over 5.6 million people living with hiv in south africa and over 16 million acquired immune deficiency syndrome ( aids ) orphans living in sub - saharan africa . the effect of hiv on snake bites in south african children has not been described in the literature . hiv has been associated with multiorgan dysfunction but never directly associated with snake bites . the case discussed below is that of a 1-year - old child from a poor community , 300  km west of johannesburg . the burden of mortality for snake bite victims has been shown to occur in poor communities . a 1-year - old child was referred to our tertiary center from a peripheral hospital . he presented 2 days after the snake bite with severe left upper limb swelling extending from the hand up into the axilla and involving the shoulder joint . features of cytotoxic envenomation with a wide area of necrotic skin on the volar aspect of the arm and forearm required extensive debridement postinitial emergency fasciotomy ( fig . polyvalent antivenom ( south african institute of medical research polyvalent snakebite antiserum ) administration was delayed and once obtained was given 4 days after the snake bite . this antivenom is made from the venom of 10 different species including adders , mambas , and cobras . during admission to the pediatric intensive care unit ( picu ) , a persistent thrombocytopenia occurred , caused by either the hiv infection or the snake 's venom ( cytotoxic envenomation presentation in keeping with bitis arietans [ puff adder ] envenomation ) . repeated lower respiratory tract infections and overwhelming sepsis ultimately resulted in the child 's death . left : initial presentation with swelling and demarcation of superficial tissue necrosis extending from the left hand up to the axilla . maggots were found in the axillary region . despite extensive slough that had to be removed , there is substantial morbidity and mortality related to admission of an hiv positive child to a picu . argent showed that these children are more commonly affected by severe respiratory tract infections as in the case described above . before the advent of antiretroviral medication , the mortality rate was 100% in children with aids and 20% in cases of severe pneumonia . hiv may in fact cause a pancytopenia due to either bone marrow hypoplasia or myelofibrosis . symptomatic hiv associated thrombocytopenia occurs most commonly in undiagnosed children with hiv under 2 years of age . initiation of antiretroviral therapy has been shown to be effective in treating hiv - related thrombocytopenia but the response is variable . hiv - related thrombocytopenia was found to be a poor prognostic factor with no specific correlation to the patient 's immune status . this case shows similar findings to presentations from a study done in eshowe , south africa although this patient had a fasciotomy of both his arm and forearm , the tissues were not found to be typical of a compartment syndrome , putting the diagnosis of compartment syndrome in to question . the skin and subcutaneous tissues of the arm and forearm in fact became necrotic and subsequently required extensive debridement . children in this series were also at greatest risk of developing bite site complications and severe and gross swelling . the snake species that bit this child had a combination of hemorrhagic and cytotoxic venom . this was evidenced by massive tissue necrosis of the arm as well as pancytopenia that required transfusion with both packed red cells and platelets . the snake that commonly causes these symptoms of envenomation and is also commonly found in the area in which the patient lived is the african puff adder ( b arietans ) . although the species was not positively identified by a specialist , the clinical features were typical of b arietans . also this is the main cytotoxic species found in this area of south africa , which explains why myotoxic and cytolytic components within the venom contributed to local tissue necrosis . other digestive hydrolases , secondary effects of inflammation , ischemia from thrombosis and compartment syndrome also contribute to local necrosis . currier et al showed that the african puff adder has a high degree of inter - specimen variability in terms of protein expression , immunogenicity , and activity of snake venom metalloproteinases . this variation may have implications for efficacy of antivenom given to patients and may have future consequences in selecting specimens for antivenom production . the effect of hiv on envenomation has not been discussed before in the literature  it is possible that the combination of the hiv - related immunodeficiency was exacerbated by the envenomation in this patient that led to his demise . this case highlights the challenge of treating a cytotoxic snake bite in a young child with hiv and the detrimental outcome of delay in treatment . hiv infection and envenomation were co - contributory in leading to the thrombocytopenia and overwhelming sepsis in this case .