Southeast Asian J Trop Med Public Health

CASE REPORT

FATAL NEUROTOXIC ENVENOMATION FROM THE BITE OF A LESSER BLACK KRAIT (BUNGARUS LIVIDUS) IN NEPAL

Ulrich Kuch1, Sanjib Kumar Sharma2, Emilie Alirol3 and François Chappuis3

1Biodiversity and Climate Research Centre (BiK-F), Frankfurt am Main, Germany; 2B.P. Koirala Institute of Health Sciences, Dharan, Nepal; 3Division of International and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland

Abstract. The Lesser Black Krait (Bungarus lividus) is a small, secretive, noctur- nal elapid snake inhabiting Nepal, Bangladesh and India. We report a case of B. lividus bite in Nepal resulting in burning sensation at the bite site and over the whole body, abdominal pain, vomiting, slurred speech, ptosis, and progressive generalized neuromuscular paralysis leading to respiratory distress and death. Only one other case of fatal envenomation by this species has been reported previ- ously in India. This demonstrates that B. lividus contributes to snakebite mortality in South Asia. As few snakebite victims in this region kill and bring the snake and because the clinical syndromes appear similar, envenomation by B. lividus may be misdiagnosed as envenomation by Common Kraits (Bungarus caeruleus). External morphology characters that distinguish B. lividus from B. caeruleus and other krait species are illustrated. Key words: Bungarus lividus, envenomation, snake, neurotoxic, antivenom, Nepal

INTRODUCTION by having normal-sized or only slightly enlarged body scales in the vertebral row The Lesser Black Krait (Bungarus livi- (Fig 1). Only one case of envenomation dus) is a small, secretive elapid snake that by this species has been reported in India has been known to science since 1839. It (Wall, 1910). Here, we describe a proven inhabits eastern Nepal, northwestern Ban- case of B. lividus envenomation docu- gladesh and northeastern India (Shah and mented within the context of epidemio- Tiwari, 2004). It differs from other kraits logical and clinical studies of snakebite envenomations in southeastern Nepal Correspondence: Dr Ulrich Kuch, Biodiversity and Climate Research Centre (BiK-F), Senck- (Sharma et al, 2004; Chappuis et al, 2007). enberganlage 25, 60325 Frankfurt am Main, Germany. CASE REPORT Tel: +49 69 7542 1818; Fax: +49 69 7542 1800 E-mail: [email protected] After combing her hair and putting Prof Sanjib Kumar Sharma, B.P. Koirala Insti- the comb under the pillow of her bed in tute of Health Sciences, Dharan, Nepal. a hut in the UNHCR Beldangi I Refugee E-mail: [email protected] Camp in southeastern Nepal at 8:20 pm, a

960 Vol 42 No. 4 July 2011 Lesser Black Krait (Bungarus lividus) Envenomation in Nepal

Fig 1–The Lesser Black Krait, Bungarus lividus. A, Dorsal and (B) ventral aspect of the adult male (82 cm total length) that caused the bite at Beldangi I Refugee Camp near Damak, Jhapa District, Nepal (26º42.861’ N, 87º41.813’ E; 159 m). C, Adult specimen from Nepal; dorsal view of poste- rior body. Bungarus lividus differs from all other kraits in having a normal-sized or only slightly enlarged mid-dorsal scales (arrows mark scales of the mid-dorsal row). This characteristic distinguishes B. lividus from the only other species of black krait in South Asia, Bungarus niger, and the Common Krait, Bungarus caeruleus (D, drawing from Wall, 1910). E, Adult B. lividus from near Dinajpur, northwestern Bangladesh; top of head, left (F) and right (G) sides of head.

22-year-old Bhutanese refugee was bitten She started complaining about abdominal on her index finger by a snake. The snake pain 30 minutes after leaving the camp had been hiding under the pillow of a tra- and vomited twice during transport. ditional, 60-65 cm high bamboo bed. She Because of a local strike and technical sucked the bitten finger, a tourniquet was problems, the ambulance was held up on immediately applied, and she presented the way to the clinic. In the meantime, her to the primary healthcare center (PHC) of husband and a neighbor found the snake the camp. There, the patient complained of still under the pillow, hit it with a stick, burning pain at the bite site and 5 minutes and brought the snake to the Snake Bite after reaching the PHC vomited once. Treatment Center. During the following 30 minutes, The patient was admitted to the Snake slurred speech developed while referral Bite Treatment Center at 9:45 pm, 1 hour 25 arrangements were made, and she com- minutes after the bite, with one tourniquet plained about feeling hungry and thirsty. applied to her wrist and another one prox- She repeatedly asked for water and the imal to her elbow. The bitten index finger PHC staff noticed her tongue was swol- was slightly swollen. Upon arrival, the pa- len. She was referred to the Snake Bite tient complained about a burning sensa- Treatment Center of the Nepal Red Cross tion all over her body; she was subfebrile. Society of Damak (Jhapa) by ambulance. She had no signs of neurotoxicity and

Vol 42 No. 4 July 2011 961 Southeast Asian J Trop Med Public Health was able to talk normally. About 2 hours around 10 pm, causing death within 24 after admission she vomited 4-5 times. hours (Wall, 1910). Bilateral ptosis developed at 2:00 am (5 We suspect that envenomation by B. hours 40 minutes post-bite) and slurred lividus has so far been mistaken for Com- speech reappeared. Upon the appearance mon Krait (B. caeruleus) envenomation of ptosis, antivenom therapy was initiated because most clinical cases of snakebite following Nepal national guidelines. An with neurotoxicity in this region of South initial dose of 20 ml of Indian polyvalent Asia are diagnosed as “krait”, “cobra” or antivenom (Haffkine Bio-pharmaceutical “Russell’s Viper” envenomation based on Corporation, raised against the venoms clinical syndromes alone (Warrell, 2010 a, of Bungarus caeruleus, Naja naja, Daboia b) – if any diagnosis beyond “snakebite” russelii and Echis carinatus) was given by is attempted. Lack of awareness of the slow IV bolus followed by the infusion of species diversity of venomous snakes, and an additional 40 ml of antivenom over a the rarity with which snake specimens 6 hour period. Five doses of neostigmine are permanently preserved for taxonomic (0.5 mg IM) and atropine (0.6 mg IV) identification, have contributed to the were given at half-hour intervals. Signs popular but erroneous belief that only of paralysis progressed and additional the four species included in the produc- bolus injections of antivenom were given tion of Indian polyvalent antivenoms at two-hourly intervals. A total of 170 ml (B. caeruleus, N. naja, D. russelii and E. of antivenom was administered over an carinatus) are medically important in 8 hour period. Asia (Alirol et al, 2010). Bungarus lividus Despite this, the patient’s condition and B. caeruleus are both nocturnal, and deteriorated rapidly. She developed respi- superficially have a similar morpho- ratory distress and was sent by ambulance logy; their geographic distributions also to Koshi Zonal Hospital in Biratnagar, but overlap (Wall, 1928). Confusion with the died on the way. The snake that had bit- Greater Black Krait (B. niger) is possible, ten the patient was preserved in formalin although envenomation by the latter is and morphological examination revealed likely often ascribed to B. caeruleus. If the that it was an 82-cm-long adult male snake is brought to the clinic, distinguish- B. lividus. ing B. lividus from other species of krait is possible on the basis of external morpho- DISCUSSION logy characteristics (Fig 1). This is the first report of a bite by B. The patient did not respond to Indian lividus in Nepal. Although physician-her- polyvalent antivenom administered at the petologist Frank Wall suggested in 1928 low initial dose regimen recommended that “snakes so common as the black kraits by Nepal national guidelines. Currently (B. lividus and niger) in Assam ... should available antivenoms in South Asia do not furnish many records,” (Wall, 1928) up target B. lividus toxins (Alirol et al, 2010). It to now, only one series of B. niger bites would be useful to collect this species and (Faiz et al, 2010) and a single B. lividus analyze its venom to determine whether bite have been reported. In this previous existing antivenoms are inefficient, or if report, a B. lividus specimen 96.5 cm long only much earlier and larger initial doses had bitten the ankle of a woman sitting are needed for protective neutralization. on the veranda of her hut in Upper Assam The early and correct identification

962 Vol 42 No. 4 July 2011 Lesser Black Krait (Bungarus lividus) Envenomation in Nepal of this species in clinical situations could preserving snakes brought by bite victims help physicians make informed treatment for subsequent study and species identi- decisions and focus on other life-sup- fication (Viravan et al, 1992). Given the porting interventions, such as assisted rarity with which snakes are brought to ventilation (Warrell, 2010 a,b) especially the clinic in Nepal and Bangladesh (Alirol if available antivenoms prove to be inef- et al, 2010; Harris et al, 2010), the develop- fective. More detailed clinical assessment ment of point-of-care immunological or of B. lividus envenomation may reveal molecular diagnostic methods that can characteristic clinico-epidemiological accurately determine the biting species, features. However, the symptoms of this including B. lividus, is needed to quantify patient did not appear to differ signifi- their relative contribution to the regional cantly from the syndrome of B. caeruleus burden of snake bite morbidity and mor- envenomation (Ariaratnam et al, 2010). tality, and to further improve treatment. The development of intense local pain at the bite site is uncommon in krait enve- ACKNOWLEDGEMENTS nomation (Alirol et al, 2010; Warrell, 2010b). The swelling of the bitten finger We thank the Health Assistants of may have been caused or exacerbated by the Nepal Red Cross Society Sub-Chapter the application of tourniquets by the pa- Damak-Jhapa, and the patient’s family tient. The patient’s swollen tongue, also for sharing the circumstantial details of an unusual finding, may reflect an early this case of envenomation and consenting reaction to the venom which she had tried to its publication. This case was previ- to suck from the bite site. ously presented at the Global Issues in The present case underscores the need Clinical Toxinology 2008 Conference in for improving the emergency capacity for Melbourne, Australia. Research was fi- assisted ventilation and related life-saving nancially supported by Vereinigung der measures at all levels of the health system Freunde und Förderer der Johann Wolf- in South and Southeast Asia (eg, Warrell, gang Goethe-Universität Frankfurt am 2010a,b; Islam et al, 2011). As a conse- Main and the research funding program quence of the death of this patient, the “LOEWE – Landes-Offensive zur Ent- training of community health assistants wicklung Wissenschaftlich-ökonomischer in intubation, manual ventilation and Exzellenz” of the Ministry of Higher Edu- airway management in this resource-poor cation, Research and the Arts of the State rural setting and during distance referral of Hessen, Germany. was strengthened, and a high (100 ml) initial dose of polyvalent antivenom for REFERENCES all cases of neurotoxic envenoming was Alirol E, Sharma SK, Bawaskar HS, Kuch U, implemented at this center in agreement Chappuis F. Snake bite in South Asia: a with WHO SEARO guidelines (Warrell, review. PLoS Negl Trop Dis 2010; 4: e603. 2010a). Ariaratnam CA, Sheriff MH, Theakston RD, This case adds to recent publications Warrell DA. Distinctive epidemiologic and highlighting the underestimated diversity clinical features of common krait (Bungarus of snake species involved in envenom- caeruleus) bites in Sri Lanka. Am J Trop Med ation in South Asia (Alirol et al, 2010; Faiz Hyg 2010; 79: 458-62. et al, 2010) and the value of permanently Chappuis F, Sharma SK, Jha N, Loutan L,

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