Hypertensive encephalopathy following snake bite in a child: A diagnostic dilemma
An 8 year old male was brought to the hospital with the history of difficulty in breathing since morning and an episode of convulsions followed by unconsciousness while on his way to the hospital. On examination he had increased surface temperature (37.8°C), tachypnoea with paradoxical respiration, tachycardia (124/min), hypertension (210/140 mmHg), Glasgow Coma Scale (GCS) of 3/15 and arterial oxygen saturation (SpO2) of 93% on 4 liters of oxygen. He was immediately intubated with a provisional diagnosis of hypertensive encephalopathy. All investigations being inconclusive to establish a diagnosis, the history was reviewed. It was revealed that at night the child was sleeping on the floor in open air. He suddenly woke up at 3.30 a.m. and complained of severe abdominal pain before going to sleep again. Two hours later he again woke up and complained of difficulty in breathing, swallowing and speaking. He also developed double vision. On his way to the hospital he had an episode of convulsions followed by unconsciousness. Considering the clinical history, physical findings (bulbar and motor paralysis) and inconclusive investigations, an Elapid snake bite was suspected. However, the absence of fang marks or localized swelling and the unusual presentation (hypertension, convulsions and unconsciousness) led to a mistaken diagnosis that stopped us from administering anti snake venom (ASV). Meanwhile the child was managed with ventilator support, Nitroglycerine infusion, intravenous Phenytoin and broad spectrum antibiotics. However, persistent motor paralysis with no improvement in GCS for more than 20 h with no identifiable cause led us to consider an ASV trial. Accordingly, 10 vials of polyvalent anti-venom were administered following which there was a dramatic improvement in both GCS and motor power. However, as he still had abdominal respiration another 10 vials of ASV were administered. Despite the full course of ASV the respiratory muscles appeared weak as tidal volumes generated were low requiring high pressure support mechanical ventilation. A single dose of neostigmine 0.8 mg and atropine 0.1 mg intravenously was given without much improvement. Thereafter the patient was gradually weaned and extubated after 8 days of mechanical ventilation and was discharged from the ICU on the ninth day without any residual morbidity.