Case Report Patient without neurotoxic symptom after being bitten by an eastern green (Dendroaspis angusticeps)

Masamitsu Shirokawa 1, Kaoruko Seki 1, Yasushi Nakajima 1 Shigeru Koyama 1, Makoto Mitsusada 2

ABSTRACT We describe rare by an (Dendroaspis angusticeps). A 40-years-old man was bitten by an eastern green mamba that he had kept illegally and brought to the emer- gency room within 30 minutes of the bite. We confirmed severe pain, swelling and continuous bleeding from his left index finger. We did not administer considering the risk of anaphylaxis and the time required to obtain it. We simply washed the wound and observed the patient. Swelling spread to the trunk within 3 days and blood blisters formed on his left forearm. A coagulation disturbance that seemed to be caused by the spontaneously improved within 6 days. The blood blisters were all epitheli- alized within 13 days. The patient was discharged on hospital day 44. The focal puncture site was deeply ulcerated and required 136 days to epithelialize. Mamba venom reportedly contains that cause paralysis and death due to respiratory failure, but disordered blood coagulation is rare. Accumulated case reports will help to understand mamba envenomation. (JJAAM. 2011; 22: 777-81) Keywords: snakebite, envenomation, hemostasis, vesicle formation Received on March 29, 2011 (11-029)

We describe a bite by an eastern green mamba that Introduction caused swelling of the entire bitten limb, vesicle formation and disrupted hemostasis instead of Snakebites have not been studied in detail and precise neurotoxic symptoms. statistics are not available. An estimated 2.5 million ven- omous snake bites occur globally per annum 1,2). Case report The (genus Dendroaspis) comprise four known of the African family of A 40-year-old previously healthy man was bitten by an and case reports of snakebites by green mambas are rare. eastern green mamba (Fig. 1) that he had kept illegally as The described symptoms of mamba bites are mostly a pet. He called the emergency medical system 20 min- neurotoxic. This has led to preparations for neurotoxic utes after the bite and was brought to emergency room syndrome such as respiratory failure being recommend- (ER) 10 minutes later. ed. Reports indicate that elapid venom does not contain significant protease activity and it does not characteristi- 1. Physical examination cally produce swelling or subsequent tissue destruction An emergency medical technician applied a tourniquet and necrosis 3-6). to his left upper arm. A puncture mark was found at the ventral side of the left index finger distal to the interpha- 1 Emergency Care Center, Tokyo Metropolitan Hiroo General Hos- langeal (DIP) and proximal interphalangeal (PIP) joints. pital The index finger was dark red and the wound would not 2 Department of Surgery, Yokosuka General Hospital Uwamachi stop bleeding. Swelling spread to the wrist and the index Crrespondence author: Masamitsu Shirokawa, MD; Emergency finger was extremely painful. Vital signs were all normal. Care Center, Tokyo Metropolitan Hiroo General Hospital, 34-10 Ebisu 2-chome, Shibuya, Tokyo 150-0013 Japan

JJAAM. 2011; 22: 777-81 777 Masamitsu Shirokawa, et al

tor-plasmin complex (PIC), < 0.2 µg/ml (normal value < 0.8); tissue plasminogen activator-plasminogen activator inhibitor 1 complex (t-PA･PAI-1), 14.1 ng/ml (normal value, < 50). The WBC count was increased to 12,100 / µl. The Japanese Association for Acute Medicine dissem- inated intravascular coagulat