Neurotoxic Snakebite Presenting with Early Neck Pain and Muscle Weakness: A Case Report of a Diagnostic Pitfall.

Abstract

Introduction: Neurotoxic envenomation often presents with non-specific neurological symptoms and minimal local signs, which can delay appropriate diagnosis and treatment. This is the first reported case of a neurotoxic snakebite presenting with an atypical symptom of unilateral neck pain.

Case report: A 12-year-old girl was referred to our emergency centre with neck weakness progressing to quadriplegia, attributed to a fall while playing. A diagnosis of acute flaccid paralysis secondary to cervical trauma was made and treated at the first hospital; however, she developed respiratory distress and was transferred to our centre. Clinical examination and computed tomography ruled out cervical cord injury. A diagnosis of neurotoxic envenomation was considered, given our centre's high snakebite burden and the symptom of descending flaccid paralysis. Despite initiating antivenom and supportive treatment, the patient died. As the death was sudden and unexplained, medicolegal autopsy was done. Meticulous examination revealed a suspicious mark over the right foot. Chemical analysis on a skin sample from the site tested positive for snake venom, confirming envenomation.

Conclusion: This case highlights the diagnostic challenge posed by atypical presentations of neurotoxic snakebite, especially in the absence of a clear history. In endemic areas, flaccid paralysis should prompt clinical suspicion of snakebite. Early recognition and timely administration of antivenom are crucial to prevent fatal outcomes. This case also underscores the need for strengthening diagnostic tools and forensic confirmation to avoid missed or delayed diagnoses, which carry serious medicolegal and public health implications.