A different snake . . .

About a week back, we had a young lady of 16 years brought to Emergency Room in a supposedly comatose state after a snake had coiled around her leg. The patient alone had seen the snake and had told relatives before she became unconscious that the snake did not bite her.

There were no obvious bite marks and it was not difficult to come to a conclusion that she was well conscious although appearing a bit drowsy. She also seemed to have a ptosis which on careful examination was not there. The clotting time was normal. 

The only issue was a low blood pressure reading of 80/40 mm Hg. We gave her some intravenous fluids and she did not respond to that. And we concluded that this was her normal blood pressure. Later, we found out that there were problems in her family and we diagnosed her as having an acute conversion reaction – a psychological response to difficult situations.

We gave her a small dose of anti-depressant. However, she did not seem to do fine. She continued to remain drowsy. She could communicate when we called her. She could even walk to the toilet without help. She also narrated to us that she was taking some ayurvedic drugs for her psychological condition.

The next day being a Sunday, we could do any investigations. Her condition remained the same.

On Monday, we sent a battery of tests – complete blood count, liver function and renal function.

Her total count came as 1200/cu mm with a predominant lymphocyte picture. Hemoglobin and platelets were normal. The liver and renal function also came as normal.

There were only two major things that we were looking at – either a blood dysgracia most probably secondary to her ayurvedic medications or a haematological malignancy.

We referred her to a higher centre.

This is the second time that I’ve come across a suspected snake bite being diagnosed with something else more serious. The previous time was 4 years back at NJH, when we diagnosed disseminated tuberculosis in a patient who came with an unknown bite. 

An unusual presentation

JO was a 15 year old jovial boy who suddenly took up sick with fever about a month back. He was sick for almost 2 weeks and was treated successfully elsewhere. After discharge, JO’s father noticed that his son was not his former self. He suspected something was wrong.

His suspicion turned out to be true within a couple of days, when JO became unconscious gradually. Even his family did not take the way he became unconscious seriously as it looked more of JO becoming more and more sleepy over the day.

When JO was wheeled into our Acute Care, he was hardly breathing. JO had something very bad in his brain. He was running a high fever and had anisocoria. We had to do a CT Scan. But, JO was hardly breathing on his own.

After almost 2 days of mechanical ventilation, we could wean out JO from the ventilator. Considering the sort of diagnoses that a young boy with anisocoria can have, we were anxious for the CT Scan Brain. With a backup for ventilation, we rushed him to the nearest town for the CT Scan.

The CT Scan showed a hypodense area in the periventricular white matter of the right temporal region.

After he returned, the anisocoria stayed. However, a fundoscopy did not show any features of a raised Intracranial Tension. With a guarded prognosis, we took a decision for a lumbar puncture. The family readily agreed . . . in fact, we had not given them even a day for their JO to survive.

Lumbar puncture was suggestive of a partially treated bacterial meningitis with a higher protein levels than usual. Considering the long history of the illness, we took a decision to come to a diagnosis of Tuberculous Meningitis.

JO has responded well to anti-tuberculosis treatment. However, he’s yet to be completed fit for discharge.

We’re blessed to be a blessing in the life of JO and his family. Kindly pray that this young boy will be completely healed.