S144 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (Special Supplement 2): S144-S146

INTRODUCTIONCommon krait (B. caeruleus) is prevalent in Pakistan,India, Sri Lanka, Nepal and Bangladesh. Snakebitein pregnancy, although rarely reported in medicalliterature,1 carries significant risks to the mother andfetus. We present a case report which, to the best of ourknowledge, is the first of its kind from Pakistan, involvingcommon krait (B. caeruleus). A pregnant lady presentedwith myasthenia like syndrome. She was diagnosed asa case of snakebite due to common krait (Bungaruscaeruleus) based on syndromic approach in SoutheastAsia.

CASE REPORTA primigravida, 22 years old, married for one year,resident of Rawalpindi (Pakistan), having gestationalamenorrhea of 30 weeks, woke-up early morning fromthe carpeted floor of her house, and felt diffuseabdominal pain, with nausea and feeling of change inposition of the fetus. She was taken to Gynaecology andObstetrics Department at Military Hospital, Rawalpindiwhere after initial review by gynaecologist, she wasfound to be alright from gynaecological point of view.Subsequently, she started feeling headache anddiplopia. She was seen by ophthalmologist, where shehad drooping of eyelids, difficulty in breathing andstanding followed by uncontrolled salivation. She had nohistory of urinary or fecal incontinence. She had nohistory of snake / insect bite or taking canned food.

The patient was diagnosed a case of myasthenic crisiswith differential diagnosis of botulism. However, onrepeated inquiry, she noted having itching on inneraspect of left thigh where two prominent fang marks

were found. She was diagnosed as snakebite withcommon krait (B. caeruleus) based on WHO syndromicapproach to snakebite identification in Southeast Asia(i.e. minimal local signs, neurotoxicity and bitten on landwhile sleeping on ground)2,3 and geographical distri-bution of common krait (B. caeruleus) in Rawalpindi.4

On examination, her pulse was 130/minute and respi-ratory rate 34/minute. Systemic examination revealedGlasgow Coma Score 9/15, with bilateral ptosis,diplopia, poor cough reflex and poor neck holding.Power was 3/5 in all four limbs and plantars weredown going bilaterally. Cardiovascular and abdominalexamination was unremarkable. Examination of respi-ratory system showed paradoxical type of respirationwith bilateral equal and vesicular breath sounds. Initialinvestigation revealed that 20 minutes whole bloodclotting test (20 WBCT) was clotted; haemoglobin levelwas 10.2 g/dl; Prothrombin time was 13/13 and PTTKwas 34/34. Echocardiography revealed ejection fraction60% with good left ventricular systolic function.Ultrasound abdomen revealed 30 weeks viablepregnancy.

Patient was provided with ICU care. An initial dose of200 ml of anti-snake venom (ASV) was given along withneostigmine 1.5 mg stat intravenously (i/v) and repeatedthrice at 30 minutes intervals. However, due todeteriorating neurological signs and respiratoryparalysis, she was placed on ventilatory support onsynchronized controlled mandatory ventilation (SCMV)mode. Another 100 ml of ASV was given due tohypotension and shock (blood pressure 90/60 mmHg)and another 200 ml of ASV was given on day 4. Totalamount of ASV administered was 500 ml. On the 4thday, patient developed adult respiratory distresssyndrome (ARDS) and shock (Figure 1) which wasmanaged with vasopressors, injection Piperacillinsodium/Tazobactam sodium 4.5 g i/v 8 hourly andMetronidazole 500 mg i/v 8 hourly.

On day 5 of admission, she developed supraventriculartachycardia (SVT) with heart rate ≥ 250 per minute andhypotension and was managed with DC cardioversion.

CASE REPORT

Envenomation in Pregnancy by Common Krait (Bungarus caeruleus)Haji Muhammad Aftab Alam1 and Syed Badshah Hussain Zaidi2

ABSTRACTSnakebite in pregnant women is rarely reported in medical literature. It is almost non-existent to the best of our knowledgeinvolving common krait (Bungarus caeruleus). The case reported here involved a 30 weeks pregnant young women fromRawalpindi (Pakistan), with myasthenia-like syndrome. The protocol employed in her treatment to cure her is outlined inthis report. The lady recovered, however, there was premature fetal birth with fatal septicaemia.

Key Words: Common krait envenomation. Pregnancy. Treatment. Myasthenia. Fetal loss.

Department of General Medicine1 / Pulmonology2, MilitaryHospital, Mall Road, Rawalpindi.

Correspondence: Dr. Haji Muhammad Aftab Alam,House No. 711, Mohallah Sardar Bahadar Khan,Street Rehmat Ullah, Tehsil and Distt Khushab.E-mail: hmaftabalam@yahoo.com

Received: September 17, 2012; Accepted: June 21, 2013.

Ultrasound for fetal well-being was done which showedsingle alive intrauterine pregnancy with oligohydramnioswithout fetal hydronephrosis. Tracheostomy was doneon day 9, she was placed on spontaneous mode ofventilation on day 11 and tracheostomy removed on 20thday of snakebite.

On the 14th day of admission, patient started havinguterine contractions followed by premature birth of ababy girl and early death because of neonatal sepsis.Patient was discharged from the hospital on 30th day ofadmission.

On follow-up visit, patient had mild tracheal stenosisbeing managed conservatively.

DISCUSSIONReport of snakebite during pregnancy is rare in medicalliterature, especially in Pakistan. A review by Langelyshowed there were only 213 reported cases of snakebiteduring pregnancy from 1966 to May 2009.1 Mothersreceiving antivenom had mortality of 2.1% versus 6.6%in cases not receiving antivenom.1 In hospitalizedpatients, snakebites during pregnancy account for 0.4 to1.8% of hospitalized snakebite victims. Mechanisms offetal death due to snakebite in pregnancy includepremature uterine contraction, direct venom toxicity,abruptio placenta, fetal anoxia, supine hypotensionsyndrome and maternal anaphylaxis.5

Venomous snakes in Southeast Asia belong to Elapidae(Cobras and Kraits) and Vipers (typical vipers and pitvipers). Kraits, identified by alternating black and whitecross-bands across body are found in all South Asiancountries except Philippines. Currently, 12 species ofkraits are recognized in the world.6 In Pakistan, threespecies of kraits are identified. Common kraits(B. caeruleus) is reported throughout Punjab, KhyberPakhtoonkhwa (KPK), Azad Kashmir, Sindh and

Southern Balochistan.4 Common in Indus valley, thisis the only species of kraits found in Rawalpindi (locationwhere this snakebite occurred) and Islamabad.4 Sindhikrait (B. sindanus) is prevalent in Tharparkar,Bahawalnagar and Bahawalpur. Northern Punjab krait(Bungarus s. razai) is reported from Mianwali.4 Study ofadmitted snakebite cases in Pakistan revealed less than5% neurotoxic snakebites, rest were viper bites.7

Snakes can be identified by direct inspection of snake,however, as in most cases, snake is not brought foridentification, therefore, a syndromic approach, studiedby Ariaratnam et al. in Sri Lanka is incorporated intoWHO guidelines for management of snakebite inSoutheast Asia 2010.2,3 WHO recommends that asyndromic approach should be developed fordiagnosing the snake species in different parts of theregion.2 As per this syndromic approach, patient havingparalysis with minimal or no local envenoming and bittenon land while sleeping on the ground, the snakeidentified is krait.2,3 Keeping in view the geographicaldistribution and syndromic approach, the snake wasidentified as common krait (B. caeruleus) in this case.2-4

Abdominal pain is the initial symptom of krait bite andmay mimic surgical abdomen.8 This is followed bydrooping of eyelids, double vision, weakness of limbsand breathing difficulty progressing to neuromuscularparalysis. In an unknown scenario, patient gets-up atnight, with colicky abdominal pain and may bemisdiagnosed as acute abdomen.8 Kraits may havepainless bites and negligible local swelling. The affectedindividual may not even wake-up from sleep whenbitten.2 In a Sri Lankan study, out of the 42 snakebitesdue to B. caeruleus (identified by inspection of deadsnakes) all except one were bitten at night whilesleeping on ground, 13 (31%) patients were not aware ofbite but had woken-up with colicky abdominal pain andin 12 (28%) patients site of bite was undetectable.8

A study was conducted on the role of neostigmine andIndian polyvalent ASV on common krait (B. caeruleus) inIndia.9 Out of 77 patients who were given 10 vials ofpolyvalent anti-snake venom and three doses ofneostigmine 2.5 mg i/v and atropine 0.6 mg at 30minutes intervals, 2 patients died and rest 75 requiredassisted ventilation. Cardiotoxicity detected byarrhythmias or abnormal ECG in snakebite patient isindication of ASV administration.10

Snakebite in pregnancy carries significant risk to themother and the fetus. It is recommended that propermanagement of the envenomed patient, includingprompt transport to hospital, administration of ASV,correction of hypotension, shock and cardiacarrhythmias and early institution of ventilatory support,as seen in this case, can lead to good maternal andfetal outcome. Moreover, awareness and evolution ofsyndromic approach to snake identification in each

Envenomation in pregnancy by common krait (Bungarus caeruleus)

Figure 1: Chest X-ray of patient showing bilateral, homogeneous loss of lunglucency with some sparing of the apices suggestive of ARDS.

Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (Special Supplement 2): S144-S146 S145

Haji Muhammad Aftab Alam and Syed Badshah Hussain Zaidi

S146 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (Special Supplement 2): S144-S146

geographical location of Pakistan as guided by WHOguidelines can lead to reduction in snakebite morbidityand mortality.

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