A severe envenomation from the bite of Agkistrodon Blomhoffii brevicaudus

- Figures and Table -

Fig. 1. Agkistrodon Blomhoffii brevicaudus icarcassj

Bites by Agkistrodon Blomhoffii brevicaudus occur commonly in the central and northern parts of China, and Korea. The venom contains a neurotoxin called ƒภ-Agkistrodotoxin.This might be responsible for respiratory paralysis and other neurological symptoms.

Table 1. Laboratory Data on Admission to ICU

ABG(Jackson-Rees)

pH 7.167, PaCO2 52.9 mmHg, PaO2 480.4 mmHg, HCO3- 18.4 mEq/L, BE -10.9 mEq/L

CBC

WBC 24,500/mm3, RBC 6,050,000/mm3, Hb 19.3 g/dl, Hct 59.2, Plt 241,000/mm3

Biochemistry

TP 6.5 g/dl, Alb 3.7 g/dl, LDH 1,309 U/L, GOT 1,627 U/L, GPT 303 U/L, T Bil 1.8 mg/dl, D Bil 0.9 mg/dl, BUN 29.9 mg/dl, Cr 1.6 mg/dl, Na 134 mEq/L, K 4.5 mEq/L, Cl 102 mEq/L, Amy 67 U/L, CK 73,215 U/L, Mgb 244,000 ng/ml, CRP 8.2 mg/dl, BS 282 mg/dl

Coagulation

PT 86.7%, aPTT 28.7 sec, Fbg 341 mg/dl, FDP 5.7 mg/dl

Urine

Occult blood 3+, Protein 2+, RBC +++/hpf

There was an marked elevation in the serum myoglobin concentration and creatine phosphokinase activity. Other abnormal findings include myoglobinuria, respiratory and metabolic acidosis, and elevated hematocrit.

Fig. 2. The left hand, 20 hours after the bite.

Swelling was extended to the left forearm, arm, head and neck, trunk and right arm, requiring left upper extremity fasciotomy.

Fig. 3. Trends in serum myogenic enzyme and urine output.

The serum levels of myogenic enzymes fluctuated during the first 6 days despite fasciotomy and antivenin therapy, but started to decline after initiation of hemodiafiltration.

Fig. 4. Modes of respiratory support.

Ventilatory support was continued for 53 days.

Fig. 5. External ocular paralysis on the 22nd hospital day

External ocular paralysis was noted on the first hospital day and prolonged. It almost disappeared at the time of his discharge from the hospital.

Fig. 6. Electromyogram.

Waxing of ocular orbicular muscle provoked by high frequency repetitive stimulation on the third hospital day.

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