Abstract
We describe 70 cases of monocled cobra (Naja kaouthia) bite admitted to Chittagong Medical College Hospital, Bangladesh. The biting snakes were identified by examining the dead snake and/or detecting N. kaouthia venom antigens in patients' serum. Bites were most common in the early morning and evening during the monsoon (May–July). Ligatures were routinely applied to the bitten limb before admission. Thirty-seven patients consulted traditional healers, most of whom made incisions around the bite site. Fifty-eight patients experienced severe neurotoxicity and most suffered swelling and pain of the bitten limb. The use of an Indian polyvalent antivenom in patients exhibiting severe neurotoxicity resulted in clinical improvement but most patients experienced moderate-to-severe adverse reactions. Antivenom did not influence local blistering and necrosis appearing in 19 patients; 12 required debridement. Edrophonium significantly improved the ability of patients to open the eyes, endurance of upward gaze, and peak expiratory flow rate suggesting that a longer-acting anticholinesterase drug (neostigmine) could be recommended for first aid. The study suggested that regionally appropriate antivenom should be raised against the venoms of the major envenoming species of Bangladesh and highlighted the need to improve the training of staff of local medical centers and to invest in the basic health infrastructure in rural communities.
Highlights
The snake was caught, killed, and eventually brought to Chittagong Medical College Hospital (CMCH) where it was formally identified as “zhawra,” the local name for a monocled cobra, N. kaouthia, based on the distinctive single eye marking on the dorsal surface of the hood
The present study of 70 patients bitten by monocled cobras (N. kaouthia; Figure 1A and B) is the largest and most detailed study of envenoming by this species published so far
The identity of the biting snake was established in every case, either by examining the dead snake or by the retrospective detection of venom antigens of N. kaouthia in the patient’s serum using ELISA.[22,23,24]
Summary
The venomous snake fauna of Bangladesh remains poorly characterized, but clinical reports from the regions of Chittagong, Cox’s Bazaar, Khulna, Rajshahi, and Mymensingh have described neurotoxic envenoming, a life-threatening medical emergency that requires treatment with specific antivenom and assisted ventilation in cases of respiratory paralysis.[1,2,3,4,5,6,7,8] In Asia and Africa, envenoming by some cobra species is associated with substantial local soft tissue damage requiring surgical debridement often leading to prolonged hospitalization, scarring, malignant transformation, and potentially permanent disability.[9,10,11,12,13,14] The present study of bites by monocled (monocellate) cobras, Naja kaouthia (Figure 1A and B), forms part of a large prospective study of snakebite in Chittagong Division, Bangladesh. Of the 884 patients, 70 were identified as victims of bites by
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