Confirmed Ceylon krait (Bungarus ceylonicus) envenoming in Sri Lanka resulting in neuromuscular paralysis: a case report

Compendium of medically important snakes, venom activity and clinical presentations in Ghana

BACKGROUND

Snake bite envenoming (SBE) is one neglected tropical disease that has not received the needed attention. The sequelae of burdensome disability and mortality impact the socioeconomic life of communities adversely with little documentation of SBE in health facility records in Ghana. This study details SBE and snake distribution, habits/habitats, type of venom expressed and clinical manifestations.

METHODOLOGY

We conducted a structured thematic desk review of peer reviewed papers, books and reports from repositories including PubMed, World Health Organization (WHO) and Women's & Children's Hospital (WCH) Clinical Toxinology Resources using bibliographic software EndNote and search engine Google Scholar with the following key words; snakes, medical importance, snake bites, venom and venom type, envenomation, symptoms and signs, vaccines, venom expenditure, strike behaviour and venom-metering + Ghana, West Africa, Africa, World. We also reviewed data from the District Health Information Management System (DHIMS) of the Ghana Health Service (GHS). Outcome variables were organized as follows: common name (s), species, habitat/habit, species-specific toxin, clinical manifestation, antivenom availability, WHO category.

FINDINGS

Snake bites and SBE were grouped by the activity of the expressed venom into neurotoxic, cardiotoxic, haemorrhagic, cytotoxic, myotoxic, nephrotoxic and procoagulants. Neurotoxic snake bites were largely due to elapids. Expressed venoms with cardiotoxic, haemorrhagic, nephrotoxic and procoagulant activities principally belonged to the family Viperidae. Snakes with venoms showing myotoxic activity were largely alien to Ghana and the West African sub-region. Venoms showing cytotoxic activity are expressed by a wide range of snakes though more prevalent among the Viperidae family. Snakes with neurotoxic and haemorrhagic venom activities are prevalent across all the agro-ecological zones in Ghana.

CONCLUSION/SIGNIFICANCE

Understanding the characteristics of snakes and their venoms is useful in the management of SBE. The distribution of snakes by their expressed venoms across the agro-ecological zones is also instructive to species identification and diagnosis of SBE.

Acute neuromuscular paralysis, rhabdomyolysis and long lasting neurological deficits in Ceylon krait (Bungarus ceylonicus) bites: Two authentic cases from a serpentarium in Sri Lanka

The Ceylon krait (Bungarus ceylonicus) is a highly venomous elapid snake endemic to Sri Lanka. Its bites are rare and only seven reports are found in the literature. Therefore, the clinical manifestations and natural history of envenoming of Ceylon krait are not well studied yet. Neuroparalysis is the main clinical manifestation of their bites. We report two cases of proven Ceylon krait bites of two young snake keepers working in a serpentarium. They developed acute neuroparalysis, abdominal pain and a period of amnesia. The first patient developed myalgia and increased level of serum creatine kinase suggestive of rhabdomyolysis. One was treated with Indian polyvalent antivenom and both recovered with some long-lasting clinical disabilities namely impairment of sensation of the bitten arm and persistent refraction errors in the eyes in the first patient. The second patient had persistent marked nystagmus.

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Ceylon krait (Bungarus ceylonicus) is endemic to Sri Lanka and bites rarely.

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Two authentic bites are described.

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Both developed neuromuscular paralysis manageable without assisted ventilation.

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Long lasting deficits were sensory impairment of bitten arm, refraction errors and nystagmus.