1
63
The blood samples were however taken after patient had
been transfused in the referring hospital. Urinalysis
series the2snake species was not identified in 24 out of
1
82 cases and the report did not reveal whether the
(
dipstick) showed haemoglobin while urine microscopy
snakes were even seen by witnesses. In our own case
also, the snake was not seen and the specie could not be
determined. Our approach to making the diagnosis is
supported by Blaylock in South Africa who reported that
40% of patients do not see the offending snake but diag-
nosis is made based on presence of paired fang marks or
revealed numerous red blood cells. X-ray of the neck
showed soft tissue swelling. Other investigations includ-
ing liver and kidney function tests were normal. Fifty
millilitres of polyvalent anti-snake venom was pre-
scribed but parents could only afford to buy 30ml which
was administered IV (dissolved in 250ml of 5% Dex-
trose in water) over 2hrs. Intravenous ampicilin-
Cloxacillin combination, metronidazole and topical
chloraphenicol eye drops were administered. Other sup-
portive measures included feeding, monitoring of vital
signs and fluid input-output. At 72hrs after administer-
ing the anti-snake venom, facial swelling subsided sub-
stantially and bedside clotting time reduced to 20 min-
utes. The facial swelling resolved completely within
4
typical findings of envenomation syndrome . It was
noted that the first contact of the patient with hospital
was 10hrs after the bite. That was a significant delay
which wound have made envenomation syndrome to
become full blown. Moreover, the refering hospital did
not have anti-snake venom which further increased the
risk of complications. In rural areas, access road may be
several kilometers away and in our patient the fact that
the bite took place at night contributed to further de-
lay.Several instances of delayed presentation had been
8
up.
days and she was discharged home but lost to follow-
1
3,14
.
reported from various studies in Nigeria
The severity of envenoming depends on volume of
venom injected, the anatomical site of injections(bites
on head and trunk tend to be more complicated), size of
the victim and time lapse between bite and medical at-
Discussion
6
,15
In Nigeria four families of venomous snakes are found
but three species carpet viper (echis ocellatus), black-
necked spitting cobra (Naja nigricollis) and puff adder
tention . In our patient with facial snake bite, the
above mentioned conditions were not favourable. Proba-
bly, the unclear herbal medication first aid and treatment
in the referral hospital probably modified the symptoma-
tology in the patient. Nonetheless, patient still had sig-
nificant facial, neck and upper chest wall swelling which
if it had progressed would have led to severe respiratory
compromise and possibly the need for hyperbaric oxy-
(
Bitis arietans) which belong to viperidae and elapidae
families are the most medically important and associated
7
,8
with envenoming . Most of the snake bites in humans
affect the lowe5r,9,1l0imbs, less often the upper limbs and
rarely the face
. In a series of 103 cases of snake bite
1
6
reported by Madaki et al in Zamko Nigeria, all the bites
were on the limbs and none on the face . The reason
gen . We noted that even though there was some de-
rangement in the haemotologic profile, the values could
have been worse considering the earlier blood transfu-
sion before she presented to us.
9
adduced for the higher propensity of involvement of the
limbs is that the limbs are exposed and vulnerable to
snakes while walking, farming, rearing animals or even
playing by young ones while in the bush. The face is
high above the ground while engaged in the previously
mentioned activities but while lying flat such as during
sleep in snake infested areas, the face is at ground level
and so equally vulnerable as in this patient.
While we recommended 50ml of the anti-snake venom,
parents could only afford to buy 30ml and that was
given accordingly. This brings to the fore the need for
not only making the anti-snake venom readily available
but also at highly subsidized price especially for the
rural poor who are most at risk. This opinion had been
expressed by Habib et al who believe that access to
Most snake bites occur outdoors and accounted for 75%
of cases reported by Mustapha in a series from Gombe,
1
7
snake anti-venom leaves much to be desired . That the
patient was discharged after 8days of admission in our
hospital is equally a rare success story because in the
retrospective review by Avilla Aguero et al in Costa
1
1
Nigeria . However, some snakes such as the African
spitting cobra may enter human dwellings at night and
bite people who are sleeping. Our index patient lived in
a thatched hut located in the bush where snakes are com-
monly found and so was bitten while sleeping during
rainy season. The experience is not surprising because
during rainy season, snake habitats are over flooded
1
2
rica, all the 6 children who had facial snake bites died .
This could have happened because their series included
much more younger children especially infants and un-
der fives who are more prone to severe envenoming.
However, a similar success story to ours was recorded in
2
with water and are disturbed by farming actvities .
6
Therefore snakes may seek shelter in the homes as oc-
curred in our patient. In our index patient, the offending
snake was not identified but the clinical findings espe-
cially puncture sites (fang marks) constituted enough
evidence to support our diagnosis. In a retrospective
review by Avilla et al in Costa rica, a diagnosis of snake
bite was made in a 24month old-child after the scalp
revealed fang marks after shaving the hair in presence of
Costarica in a case report by Quiroga et al . Their case
was younger (3yrs), clinically more serious requiring
intubation, and underwent surgical drainage of multiple
abscesses although he spent longer duration (two weeks)
in hospital before discharge. Our patient was lost to fol-
low-up which is a common challenge in managing rural
poor people in developing countries. Therefore, issues
of psychological complications and any delayed physi-
cal disability that may have arisen later could not be
1
2
disseminated intravascular coagulopathy . In the same