(579) Acute Descending Paralysis: Decisions That Come Back to Bite You

Introduction: Acute neuromuscular paralysis with respiratory failure is fairly common in clinical practice with Guillain-Barre Syndrome (GBS) and Myasthenic Crisis (MC), being common culprits among other causes. Most GBS cases have an ascending paralysis pattern, while bulbar symptoms help differentiate MC from others. We present an unusual case of acute descending pattern paralysis due to rare etiology in North America.

Description: A 33 yo man with agitation, diaphoresis, and tremors was dropped off at the emergency department by his friend and no history was provided. He was tachycardic, hypertensive and disoriented. Initially given IV lorazepam, IV fluids, thiamine, and dextrose but remained combative. While intubation and sedation were being contemplated he developed left eye ptosis, progressing into bilateral ptosis with normal pupils, drooling, dysphagia, dysarthria, dysphonia followed by rapidly progressive descending paralysis with respiratory failure. The patient was intubated and placed on mechanical ventilation. Rest of his exam showed a 3 cm bifurcated superficial laceration on the dorsum of the right hand and intact deep tendon reflexes.
Due to insufficient history, his mobile phone was accessed that revealed pictures of his venomous pet Cobra Snake (Monocled species; Naja Kaouthia) acquired online from Southeast Asia.

His wound was cleaned, immobilization bandaged, tetanus IG and toxoid given. We administered an intravenous monovalent cobra neurotoxin anti-venom acquired from an exotic animal store within 8 hours after an extensive nationwide search. He recovered in 72 hours.

Discussion: Acute descending neuromuscular paralysis etiologies include botulism, diphtheria, atypical GBS and neurotoxic envenomation. A detailed history and examination is therefore, essential to reach the diagnosis.

Cobra venom is composed of a b-neurotoxin phospholipases that inhibit Acetylcholine (ACh) release from presynaptic neurons and a-neurotoxin with curare-like reversible blockage of Ach receptors.

In addition to mechanical ventilation and airway protection, specific cobra neurotoxin anti-venom is required when dense paralysis and respiratory collapse has occurred. Poison Control centers in USA can assist in acquisition of monovalent anti-venoms from particularly Zoos or exotic animal facilities.