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Year : 2022  |  Volume : 9  |  Issue : 4  |  Page : 142-143

Early morning neuroparalytic syndrome – A diagnostic dilemma: A case report

Department of Pediatric, KIMS, Patia, Bhubaneswar, Odisha, India

Date of Submission22-Apr-2022
Date of Decision27-May-2022
Date of Acceptance28-May-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Dr. Reshmi Mishra
Department of Pediatric, KIMS, Patia, Bhubaneswar - 751 024, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcc.jpcc_35_22

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Snakebite is a commonly seen problem in tropical countries like India. Early morning neuroparalytic syndrome and cranial nerve palsies are the usual presentations. Locked-in syndrome (LIS) is a rare presentation. We present a 1-year and 6-month-old female toddler with acute onset of weakness in all four limbs, who developed LIS. The patient was given anti-snake venom on day 3 of admission and fully recovered after 3 weeks of ventilation. Snakebite should be suspected in any child presenting with early-onset neuroparalytic syndrome or LIS even if there is no history of snakebite or any bite mark.

Keywords: Locked-in syndrome, early morning neuroparalytic syndrome, snakebite

How to cite this article:
Sahoo B, Mishra R, Jain MK, Behera JR, Rup AR, Das AK, Patnaik S. Early morning neuroparalytic syndrome – A diagnostic dilemma: A case report. J Pediatr Crit Care 2022;9:142-3

How to cite this URL:
Sahoo B, Mishra R, Jain MK, Behera JR, Rup AR, Das AK, Patnaik S. Early morning neuroparalytic syndrome – A diagnostic dilemma: A case report. J Pediatr Crit Care [serial online] 2022 [cited 2023 Feb 8];9:142-3. Available from: http://www.jpcc.org.in/text.asp?2022/9/4/142/351516

  Introduction Top

Snakebite accounts for 1.2 million deaths, with nearly a quarter being under 15 years.[1] The annual incidence of snakebite in Odisha is between 25,000 and 60,000, with mortality between 400 and 900 annually.[2],[3] Children are more likely to have a severe systemic manifestation of envenomation due to their smaller body mass for venom distribution. Krait bite is very notorious as they are indoor and nighttime biters associated with minimal to no symptoms. The classical clinical constellation, “early morning neuroparalytic syndrome,” is usually seen with krait bite. Despite the high degree of suspicion, the diagnosis may be obscure.

  Case Report Top

A 18-months female toddler presented to the emergency department with history of weakness of lower limbs and slurring of speech for 1 day which progressed to weakness of all four limbs 12 hours before admission. On admission, she was hemodynamically stable with Glasgow Coma Scale (GCS) 12/15; drooping of both eyelids was present. Neurological examination revealed quadriplegia with hypotonia, grade 0/5 in all limbs, hypotonia, and absent superficial and deep tendon reflexes with plantar unresponsive. Within a few hours of admission, GCS deteriorated to 3/15, requiring intubation and mechanical ventilation.

Doll's eye movements, corneal reflexes, and cough reflex were absent. Both pupils were dilated (8 mm) and not reacting to light. Respiratory system examination revealed scattered coarse crepitation at both left infra-axillary regions with vesicular breathing. Cardiovascular and abdominal examinations were clinically normal. On detailed history taking, it was found that the symptoms had started at 2 a.m. when the child was sleeping on the bed. She wake-up started crying and was unable to stand. Within 6 h, the child was unable to sit. The parents did not report any venomous bite.

Infectious etiology was ruled out with a normal complete blood count and C-reactive protein. Serum electrolytes, renal function test, liver function test, cerebrospinal fluid study, and MRI brain were normal. A nerve conduction study showed predominantly axonal motor polyneuropathy affecting both lower and upper limbs. Given the above, the diagnosis of Guillain–Barre syndrome was entertained, and intravenous immunoglobulin started. On day 2, the child had a generalized tonic–clonic convulsion. Electroencephalography (EEG) showed abnormal interictal EEG with epileptiform activity from the temporoparietal region. Although there was no history of snakebite and no bite marks could be detected, parents were interrogated due to strong clinical suspicion, and a snake was found in their house. The patient was given anti-snake venom (ASV) on day 3 of admission. On day 5 of admission, the child developed hypertension. She also had persistent tachycardia. She was managed with ventilator support, intravenous phenytoin, broad-spectrum antibiotics, and nifedipine. However, motor paralysis and low GCS persisted for 3 weeks after that child gradually started opening eyes, responding to parents with the neck movement.

  Discussion Top

A common krait is nocturnally active and leads to a painless early morning bite. Therefore, in 60%–70% of cases, a bite occurs when the patient is asleep, and the bite site is undetectable in 17%.[4] It may present as early morning neuroparalysis (EMNP) with deep coma and absent brainstem reflexes. This patient had EMNP with absent brainstem reflexes, and there was no mark of snakebite over the body. Similar cases have been reported by Mali et al.[5] The risk of mortality is high in younger children with ptosis or cardiac arrest at admission; this can be reduced by timely recognition and early respiratory support.[6]

Elapid (common krait) venom contains alpha- and beta-bungarotoxins which act at the presynaptic and postsynaptic membrane of the motor end plate.[7] Krait venom neurotoxins lead to autonomic disturbance, including abdominal pain, vomiting, perspiration, mydriasis, tachycardia, and hypertension due to decreased cholinergic activities.[8] The patient in this study developed tachycardia, hypertension, and intermittent perspiration during the stay in the pediatric intensive care unit.

Locked-in syndrome (LIS) is a neurological syndrome in which the patient cannot communicate despite being conscious. Snakebite is one of the peripheral causes of LIS, where the elapid neurotoxin acts presynaptically by preventing the release of acetylcholine from the nerve terminals. Previous studies[9],[10] have demonstrated LIS in children, which lasted up to 1 week. The patient in this study started recovering after 3 weeks, although snake venom has been documented to remain in circulation for a maximum of 7 days.[11] Irreversible binding of the toxin to the presynaptic portion makes clinical recovery slow in krait envenomation as recovery occurs only with the formation of new neuromuscular junctions, which could be the cause in this case. Another reason for delayed recovery in this patient could be the delay in treatment with ASV. Unlike other patients where ASV was given within a few hours, this child received it on day 3 of snakebite due to a diagnostic dilemma.

Snakebite should be suspected in any child presenting with early-onset neuroparalytic syndrome or LIS even when there is no history of snakebite or any bite mark and hence promptly treated with ASV that delay in recovery can be avoided.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents have given their consent for the child's images and other clinical information to be reported in the journal. The parents understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Suraweera W, Warrell D, Whitaker R, Menon G, Rodrigues R, Fu SH, et al. Trends in snakebite deaths in India from 2000 to 2019 in a nationally representative mortality study. Elife 2020;9:e54076.  Back to cited text no. 1
Mohapatra BN. Orissa Snake Bite in Coastal Orissa. Available from: http://www.Physicianbyte.com/snakebite. [Last accessed on 2021 May 20].  Back to cited text no. 2
Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, et al. Snakebite mortality in India: A nationally representative mortality survey. PLoS Negl Trop Dis 2011;5:e1018.  Back to cited text no. 3
Kularatne SA. Common krait (Bungarus caeruleus) bite in Anuradhapura, Sri Lanka: A prospective clinical study, 1996-98. Postgrad Med J 2002;78:276-80.  Back to cited text no. 4
Mali LP, Gupta S, Sharma D, Choudhary M. Krait envenomation: Strong suspicion and judicious use of anti-snake venom. Med J DY Patil Univ 2015;8:517-9.  Back to cited text no. 5
  [Full text]  
Samprathi M, Gupta V, Jayashree M, Bansal A, Baranwal A, Nallasamy K. Epidemiology and outcomes of early morning neuroparalytic syndrome following snake bite – A retrospective study. J Trop Pediatr 2020;66:435-40.  Back to cited text no. 6
Prasarnpun S, Walsh J, Awad SS, Harris JB. Envenoming bites by kraits: The biological basis of treatment-resistant neuromuscular paralysis. Brain 2005;128:2987-128  Back to cited text no. 7
Law AD, Agrawal AK, Bhalla A. Indian common krait envenomation presenting as coma and hypertension: A case report and literature review. J Emerg Trauma Shock 2014;7:126-8.  Back to cited text no. 8
[PUBMED]  [Full text]  
Azad C, Mahajan V, Jat KR. Locked-in syndrome as a presentation of snakebite. Indian Pediatr 2013;50:695-7.  Back to cited text no. 9
Gupta SK, Sarmah BK, Bajracharya AS. Peripheral locked-in syndrome following snake envenomation – A case report. J Coll Med Sci Nepal 2016;11:32-4.  Back to cited text no. 10
Mehta SR, Sashindran VK. Clinical features and management of snake bit. Med J Armed Forces India 2002;58:247-9.  Back to cited text no. 11


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