Mysterious Common Krait Snake: Some Lessons to be Learnt
In the early dawn of August 14, 2011 when a 32 years old male patient was admitted in the second largest Medical College Hospital of Kolkata, India, with the complaints of “abdominal pain”. This patient was treated at that hospital for more than six hours and was discharged. As the patient was not satisfied and had some discomfort in his abdomen, he attended the emergency room of another big Medical College & Hospital in Kolkata. He could manage a paying bed at Calcutta National Medical College & Hospital, India at about 12.10 PM on that day.
This patient had been treated for abdominal pain in the second hospital also, till the evening. Fortunately, one young lady house staff noticed “Bilateral ptosis” of the said patient in the evening. She reviewed the patient once again and got a history of “floor bed” previous night. On leading question, the patient gave a history of “something had bitten from outside the mosquito net”. That there is a “mysterious snake which can inflict painless bite, particularly in open floor bed” was recalled by the young lady doctor. She managed the patient with infusion of ten vials of Indian Polyvalent Anti Snake venom Serum (AVS) rapidly. The patient was saved miraculously.
The young lady doctor did not feel the weight of her “historical diagnosis”. She just narrated the case (after three weeks) to her teacher who taught her snakebite at the Community Medicine department of her medical school, about one year back. She was causal about this incident, however her teacher, who has been known as a “snakebite fanatic”, was excited to know the grand success of his young student.
Now, what the information we can share from this particular case report? First of all, that there is a snake which can inflict painless bite without any local sign (almost invisible bite marks), but can present with pure “abdominal pain” should be known to all the doctors, particularly who are at the emergency rooms (ER). History of floor bed increases the risk of a Common Krait (CK) snake bite. This CK snake has a peculiar tendency to come to the floor beds and why they come to the floor beds, is unknown. There is an ample scope to do research on this particular aspect of CK snake. But the fact is that, there are only a few hundreds of such case histories in the case records of the hospitals where CK bites in the people sleeping on floor beds.
“Sleep breaking abdominal pain” is the commonest presentation of CK bite. Other recorded presentations are sore throat, arthralgia, giddiness, convulsions and neuroparalysis. Whatever may be the presentation, the patient ultimately shows “Bilateral Ptosis”. This bilateral ptosis may develop from two to twenty hours after bite.
So, all the patients presenting with abdominal pain in the early morning, without any tenderness in abdomen, should be admitted and kept under observation for 24 hours. History of floor bed in an endemic area is highly suggestive. There may or may not be any history of any bite. Searching for bite marks would definitely mislead physician. Adequate AVS infusion at the stage of onset of bilateral ptosis is life saving.
Why the doctors of the first big hospital missed the case? Because, “what mind does not know, eyes do not see”. Snakebite is yet a neglected public health problem in Indian subcontinent. Not many medical colleges in this subcontinent regularly prepare the MBBS students to handle cases of snake bites. And interestingly just one class, at the Community Medicine (CM), Public Health, Family Medicine or Emergency Medicine department can make a difference. Calcutta National Medical College is the only medical college in the state of West Bengal, India where snakebite has been regularly taught at the CM department for last four years. Can we promote such a class in all the medical colleges in the Indian subcontinent?
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Dr. Dayal Bandhu Majumdar is a faculty member at Calcutta National Medical College & Hospital, Kolkata, India and the Resource Person for snakebite training at the Government of West Bengal, India. He is the author of a book titled: 50000 Deaths and a Snake Bite Fanatic. He can be reached at the email: [email protected]
Editors’ Note: This article is based on a real incident and the author is the teacher of the lady doctor. This article is licensed under CC-BY-NC. However the author holds the copy rights of the picture of Common Krait used in this article.