Bite to Brain: Unwitnessed Pediatric Neurotoxic Envenomation Mimicking Brain Death

Snakebite envenomation is an important yet treatable cause of mortality. When the bite is witnessed, clinical diagnosis is straightforward, enabling prompt administration of anti-snake venom (ASV). However, in the absence of a witnessed event or local bite-site signs, diagnosing snakebite becomes challenging for emergency physicians. Neurotoxic envenomation, particularly from krait species, can closely mimic acute flaccid paralysis (AFP), often leading to diagnostic uncertainty. We report the case of an adolescent girl who presented with AFP and encephalopathy. A 13-year-old girl from a rural area presented in the early morning during the monsoon season with acute flaccid paralysis, coma, and signs of brainstem dysfunction (dilated and fixed pupils, absent doll's eye, and gag reflex). After excluding alternative diagnoses and identifying subtle bite marks, a probable krait bite was considered. The patient made a complete recovery following timely ASV administration, 22 days of mechanical ventilation, and supportive care. Krait bite should be considered in previously healthy children who present with early morning neuroparalytic syndrome (EMNS) or a brain-death-like clinical picture during the monsoon season.