Abstract
Although sea snakes (Elapidae) are commonly encountered by fishermen, accurately authenticated envenomings by them are uncommon in clinical literature. We report an authenticated case of Shaw's short, or spine-bellied, sea snake (
Introduction
Sea snakes are venomous elapids (subfamily: Hydrophiinae) found in the shallow coastal waters, estuaries, open ocean, and occasional inland lakes and rivers of tropical and subtropical regions of the Indian and Pacific oceans.
1
Although the venoms of some sea snakes are extensively studied, reported human cases of envenomings are relatively uncommon and have been reported from Malaysia, Sri Lanka, Thailand, and Australia, of which most are without species authentication.2–8 Most authenticated sea snake bites have been caused by the two beaked sea snakes,
Shaw's short sea snake (
Case Report
A 28-year-old male with no known significant past medical history was admitted to District General Hospital, Kilinochchi, a tertiary care center in Northern Sri Lanka, at 0230 h with a reported history of a sea snake bite that occurred 1 hour previously. The victim was a fisherman who had been removing fish from the fishing net on his docked boat on the shore; the snake was trapped in the net, and the patient reported being bitten in the foot. He had reported feeling pain at the bite site immediately after the bite and had applied a tourniquet proximal to the bite site with a rope, applied turmeric on the bite site, and presented to the hospital with the captured snake, which was later identified by a herpetologist (AS) as a juvenile specimen of
The juvenile
On admission, the patient was conscious and rational. There was a faintly visible bite mark on the fourth toe of the right foot. The fourth toe was mildly swollen and had mild pain at the bite site. The patient had no evidence of bleeding or features of neuromuscular paralysis, such as ptosis and ophthalmoplegia. Cardiac and respiratory examinations were unremarkable, with normal pulse rate (68 beats per minute), respiratory rate (16 breaths per minute), and blood pressure (128/84 mm Hg). The 20-min whole blood clotting test (WBCT20) on admission was negative, and the prothrombin time and international normalized ratio (INR) were normal on the first day (Table 1). An electrocardiogram (ECG) revealed sinus bradycardia. The patient was closely monitored for neurological symptoms and respiratory distress. The patient complained of generalized myalgia but did not pass dark-colored urine. The biochemical evaluation revealed mildly elevated plasma lactate dehydrogenase and creatine phosphokinase (CK) levels on the first day of envenoming, indicating mild myotoxicity. The patient did not receive any antivenom because of the unavailability of sea snake antivenom in Sri Lanka. His urine output was normal; however, his serum creatinine levels were elevated on the first day, which gradually became normal over the next couple of days. His low hemoglobin level and marginal platelet count on the first day had improved on the second day. Other biochemical and hematological parameters, as well as the complete urinalysis, were normal, apart from the marginally high prothrombin time and INR on the third day of the bite.
Selected biochemical and hematological parameters of the patient.
Hydration was maintained with intravenous normal saline and oral fluids at 2.5L and 2L per day, respectively. Pain management was achieved with 1 g of oral paracetamol, 3 times daily. The patient remained clinically stable with the resolution of myalgia and continued his routine activities. He was discharged on the fourth day of envenoming. Follow-up for review and repeated laboratory investigations occurred 1 week later. The serum creatinine, prothrombin time, INR, and CK levels were all within normal ranges. No adverse events were reported during the follow-up period.
Discussion
Although sea snakes are commonly encountered by fishermen, authenticated bites with accurate species identification are rarely reported in the literature. As highlighted in a recent case of a fatal sea snake envenoming, even when a snake specimen or a photograph is available for identification, it is of utmost importance to authenticate that it is the same specimen that has bitten the patient before its identity is authoritatively confirmed.12–14
The marginally low hemoglobin in our patient is unlikely to be related to the snakebite and is a common finding in our setting predominately due to iron deficiency anemia. The transient, marginally high INR and prothrombin time on the fifth day are unlikely to be related to the snakebite due to the timing, which is unlikely for a snakebite-triggered coagulopathy. In Sri Lanka, sea snake antivenom is not available, and the only snake antivenom available, the Indian polyvalent antivenom, is not indicated for sea snake envenomings. Therefore, the management of our patient was through supportive therapy. Since the circumstances of sea snake bites are mostly fishing activities, educating the fishermen on the safe removal of accidentally caught sea snakes would help minimize sea snake bites.
Footnotes
Author Contribution(s)
Consent
Written informed consent was obtained from the patient for publishing this case report.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.