Senaka Pilapitiya

Neuromuscular Effects of Common Krait (Bungarus caeruleus) Envenoming in Sri Lanka.

Objective We aimed to investigate neurophysiological and clinical effects of common krait envenoming, including the time course and treatment response. Methodology Patients with definite common krait (Bungarus caeruleus) bites were recruited from a Sri Lankan hospital. All patients had serial neurological examinations and stimulated concentric needle single-fibre electromyography (sfEMG) of orbicularis oculi in hospital at 6wk and 6–9mth post-bite. Principal Findings There were 33 patients enrolled (median age 35y; 24 males). Eight did not develop neurotoxicity and had normal sfEMG. Eight had mild neurotoxicity with ptosis, normal sfEMG; six received antivenom and all recovered within 20–32h. Seventeen patients developed severe neurotoxicity with rapidly descending paralysis, from ptosis to complete ophthalmoplegia, facial, bulbar and neck weakness. All 17 received Indian polyvalent antivenom a median 3.5h post-bite (2.8–7.2h), which cleared unbound venom from blood. Despite this, the paralysis worsened requiring intubation and ventilation within 7h post-bite. sfEMG showed markedly increased jitter and neuromuscular blocks within 12h. sfEMG abnormalities gradually improved over 24h, corresponding with clinical recovery. Muscle recovery occurred in ascending order. Myotoxicity was not evident, clinically or biochemically, in any of the patients. Patients were extubated a median 96h post-bite (54–216h). On discharge, median 8 days (4–12days) post-bite, patients were clinically normal but had mild sfEMG abnormalities which persisted at 6wk post-bite. There were no clinical or neurophysiological abnormalities at 6–9mth. Conclusions Common krait envenoming causes rapid onset severe neuromuscular paralysis which takes days to recover clinically consistent with sfEMG. Subclinical neuromuscular dysfunction lasts weeks but was not permanent. Antivenom effectively cleared venom but did not prevent worsening or reverse neuromuscular paralysis.

Acute Myocardial Infarction following a possible direct intravenous bite of Russell’s viper ( Daboia russelli )

BackgroundRussell’s viper (Daboia russelli) bites lead to high morbidity and mortality in South Asia. Although variety of clinical manifestations is reported in viper bite victims, myocardial ischemic events are rare.Case presentationWe report a unique case of inferior wall ST elevation myocardial infarction due to a Russell’s viper bite over a vein with possible direct intravenous envenoming, in a young male with no past history or family history suggestive of ischemic cardiac disease, from Sri Lanka. In addition, the possible mechanisms of myocardial ischemia in snake bite victims are also briefly discussed.ConclusionImportance of the awareness of physicians on the rare, yet fatal manifestations of snake envenoming is highlighted.

Neurotoxicity in Russell’s viper (Daboia russelii) envenoming in Sri Lanka: a clinical and neurophysiological study

Abstract Context: Russell’s viper is more medically important than any other Asian snake, due to number of envenoming’s and fatalities. Russell’s viper populations in South India and Sri Lanka (Daboia russelii) cause unique neuromuscular paralysis not seen in other Russell’s vipers. Objective: To investigate the time course and severity of neuromuscular dysfunction in definite Russell’s viper bites, including antivenom response. Methodology: We prospectively enrolled all patients (>16 years) presenting with Russell’s viper bites over 14 months. Cases were confirmed by snake identification and/or enzyme immunoassay. All patients had serial neurological examinations and in some, single fibre electromyography (sfEMG) of the orbicularis oculi was performed. Results: 245 definite Russell’s viper bite patients (median age: 41 years; 171 males) presented a median 2.5 h (interquartile range: 1.75–4.0 h) post-bite. All but one had local envenoming and 199 (78%) had systemic envenoming: coagulopathy in 166 (68%), neurotoxicity in 130 (53%), and oliguria in 19 (8%). Neurotoxicity was characterised by ptosis (100%), blurred vision (93%), and ophthalmoplegia (90%) with weak extraocular movements, strabismus, and diplopia. Neurotoxicity developed within 8 h post-bite in all patients. No bulbar, respiratory or limb muscle weakness occurred. Neurotoxicity was associated with bites by larger snakes (p < 0.0001) and higher peak serum venom concentrations (p = 0.0025). Antivenom immediately decreased unbound venom in blood. Of 52 patients without neurotoxicity when they received antivenom, 31 developed neurotoxicity. sfEMG in 27 patients with neurotoxicity and 23 without had slightly elevated median jitter on day 1 compared to 29 normal subjects but normalised thereafter. Neurological features resolved in 80% of patients by day 3 with ptosis and weak eye movements resolving last. No clinical or neurophysiological abnormality was detected at 6 weeks or 6 months. Conclusion: Sri Lankan Russell’s viper envenoming causes mild neuromuscular dysfunction with no long-term effects. Indian polyvalent antivenom effectively binds free venom in blood but does not reverse neurotoxicity.

Exertional heat stroke in a young military trainee: is it preventable?

BackgroundHeat stroke is a life-threatening condition with exertional heat stroke occurring frequently among soldiers and athletes. Because of its common occurrence, many military trainees practice preventive measures prior to any activity requiring severe exertion. Although it is said to be common in practice, different presentations of heat stroke are scarcely described in literature.Case PresentationWe describe a case of an exertional heat stroke in a 23-year-old male Sinhalese soldier who developed early changes of renal failure, liver failure and rhabdomyolysis. The patient initially presented with convulsions, delirium and loss of consciousness to an outside health care facility before being transferred to our institution.ConclusionIt is clear that heat stroke does occur in military trainees while preventive strategies are being practiced. It is important for those who provide healthcare to soldiers to provide proper advice on how to identify impending heat stroke prior to any exercises resulting in severe physical exertion. Further, treating physicians should educate all military trainees about preventive strategies.

Regulation of herbal medicine use based on speculation? A case from Sri Lanka

Chronic Kidney Disease of Unknown aetiology is a significant public health problem in Sri Lanka. The final report by the WHO mission recommended regulation of herbal medicines containing aristolochic acid, which is an established nephrotoxin. The use of Complimentary and Alternative Medicine (CAM) has a history of more than 2500 years in Sri Lanka. Aristolochia species are rarely used in Ayurveda and traditional medicine in Sri Lanka. Before regulating the analysis of herbal preparations using Aristolochia, collecting data from CAM practitioners regarding the use of Aristolochia is necessary. Analysis of Ayurveda pharmacopeia shows the doses used are negligible and some preparations are used for external applications.

A case of severe zinc phosphide poisoning

Zinc phosphide (ZnP) a rodenticide available over the counter, releases phosphine gas that impairs mitochondrial respiration. We report a case of suicide due to ZnP poisoning. She had severe metabolic acidosis, acute pulmonary oedema, acute kidney injury, acute liver failure and coagulopathy. She also had hyperglycaemia, which is rare and a poor prognostic indicator of phosphine gas exposure [1]. Although aluminum phosphide and ZnP poisoning are widely reported in the Indian sub-continent, fatal ZnP poisoning is rare in Sri Lanka [2].

Viper bites complicate chronic agrochemical nephropathy in rural Sri Lanka

Snakebite is a common occupational health hazard among Sri Lankan agricultural workers, particularly in the North Central Province. Viperine snakes, mainly Russell’s viper envenomation, frequently lead to acute renal failure. During the last two decades, an agrochemical nephropathy, a chronic tubulointerstitial disease has rapidly spread over this area leading to high morbidity and mortality. Most of the epidemiological characteristics of these two conditions overlap, increasing the chances of co-occurrence. Herein, we describe four representative cases of viperine snakebites leading to variable clinical presentations, in patients with chronic agrochemical nephropathy, including two patients presented with acute and delayed anuria. These cases suggest the possibility of unusual manifestations of snakebite in patients with Sri Lankan agrochemical nephropathy, of which the clinicians should be aware. It could be postulated that the existing scenario in the Central America could also lead to similar clinical presentations.

First Authenticated Case of Sri Lankan Flying Snake (Chrysopelea taprobanica) Bite

Flying snakes (Genus Chrysopelea) are a group of ophisthoglyphous colubrids in South and South East Asia known for gliding in the air. Of the five species of flying snakes, Sri Lankan flying snake, Chrysopelea taprobanica, is endemic to Sri Lanka. Authenticated bites and the venom characteristics of this uncommon snake remain unknown. We report the first authenticated case of C taprobanica bite, in which a 45-year-old woman had signs of mild local envenoming after the bite, with no evidence of systemic envenoming.