Cobra envenomation in an elderly female mimicking brain death- A case report

Snake bite envenomation is one of the most toxicology-related cause that can mimic brain death. This is a case report of 73-year-old elderly female, a hypertensive on treatment, who presented with chief complaints of cobra snake bite on the dorsum of right hand. On admission, patient had dyspnea, bilateral ptosis and ophthalmoplegia. In the next 10–15 min, her symptoms got worsened for which she was administered intravenous doses of atropine (2 mg), neostigmine (0.5 mg) and anti-snake venom. She developed respiratory arrest, hence was intubated and was started on mechanical ventilation. On assessment following 12 h post admission, the patient had Glasgow Coma Scale (GCS)-E1V1M1, with pupils bilateral 2.5 mm sluggishly reacting to light. After 36 h post admission, patient began to show signs of recovery. She began to blink her eyes, follow objects and attempted to move her limbs on command. On day 3, Patient was weaned off from the ventilator, extubated two days later and discharged home on Day 7. This case report highlights a unique presentation of cobra bite induced neuroparalytic syndrome mimicking brain death in an elderly patient. Furthermore, the life-threatening presentation of cobra envenomation mandates the use of higher doses of Polyvalent snake antivenom (PSA) to reverse the neuroparalytic toxicity. We should consider the role of anticholinesterase as an adjunctive therapy to PSA in severe cobra envenomation.