# Bite to Brain: Unwitnessed Pediatric Neurotoxic Envenomation Mimicking Brain Death

## TL;DR

A teenage girl's mysterious brain-like symptoms were caused by a krait snakebite, highlighting the importance of considering neurotoxic envenomation in similar cases.

## Contribution

The paper emphasizes the need to consider krait bites in children presenting with brain-death-like symptoms during monsoon seasons.

## Key findings

- A 13-year-old girl with acute flaccid paralysis and encephalopathy recovered after being treated for a probable krait bite.
- Krait envenomation can mimic brain death and acute flaccid paralysis, leading to diagnostic challenges.
- Early morning neuroparalytic syndrome during monsoon season should prompt consideration of neurotoxic snakebites.

## Abstract

Snakebite envenomation is an important yet treatable cause of mortality. When the bite is witnessed, clinical diagnosis is straightforward, enabling prompt administration of anti-snake venom (ASV). However, in the absence of a witnessed event or local bite-site signs, diagnosing snakebite becomes challenging for emergency physicians. Neurotoxic envenomation, particularly from krait species, can closely mimic acute flaccid paralysis (AFP), often leading to diagnostic uncertainty. We report the case of an adolescent girl who presented with AFP and encephalopathy.

A 13-year-old girl from a rural area presented in the early morning during the monsoon season with acute flaccid paralysis, coma, and signs of brainstem dysfunction (dilated and fixed pupils, absent doll’s eye, and gag reflex). After excluding alternative diagnoses and identifying subtle bite marks, a probable krait bite was considered. The patient made a complete recovery following timely ASV administration, 22 days of mechanical ventilation, and supportive care.

Krait bite should be considered in previously healthy children who present with early morning neuroparalytic syndrome (EMNS) or a brain-death-like clinical picture during the monsoon season.