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Journal of Forensic and Legal Medicine: Milap Sharma, Shaurya Kalia, Seema Sharma
Journal of Forensic and Legal Medicine: Milap Sharma, Shaurya Kalia, Seema Sharma
Journal of Forensic and Legal Medicine: Milap Sharma, Shaurya Kalia, Seema Sharma
Case report
An eleven year old boy with pain abdomen and early morning
neuroparalytic syndrome
Milap Sharma*, Shaurya Kalia, Seema Sharma
Department of Pediatrics, DRPGMC, Kangra, H.P., India
a r t i c l e i n f o a b s t r a c t
Article history: An 11 year old boy presented with pain abdomen and tenderness all over body when he got up from
Received 10 June 2015 sleep early in the morning and subsequently had one vomiting after 30 min. He had no other significant
Received in revised form past medical history. The child was shifted to nearby health facility where he was managed as a case of
21 December 2015
acute abdomen on the basis of suggestive history and clinical findings. Within 2 h after the onset of
Accepted 4 May 2016
Available online 24 May 2016
clinical features suggestive of acute abdomen the patient went on to develop marked ptosis and flaccid
quadriplegia. The young boy underwent a sequence of clinical tests which were noncontributory. Based
on the clinical picture, a differential diagnosis of hypokalemic paralysis, botulism, Miller Fischer syn-
Keywords:
Elapid
drome and EMNS were considered. Through exclusion, the most probable diagnosis for the symptoms
Envenomation was elapid envenomation hence he was started on anti-snake venom (ASV) with working diagnosis of
Paralysis EMNS. Within 2 h, he began to show improvement. This recovery with ASV suggests the possibility of
Early morning neuroparalytic syndrome elapid envenomation.
EMNS © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
An eleven-year-old boy after having dinner with his family at 9 physical examination he was unable to hold his head unsupported,
p.m. went to sleep an hour later in the same room as his mother. At had marked ptosis (Fig. 1) and quadriparesis with power of 2/5 over
midnight, his sleep was disturbed by itching over left pinna, which all joints and negative Babinski's sign. His GCS was 10/15 (E2M4V4),
the boy ignored and it was attributed to mosquito bite. His sleep temperature was 98.6 F, pulse was regular at a rate of 100 bpm,
then remained undisturbed until he woke up at 4 a.m. and com- oxygen saturation was more than 97%, blood pressure was 100/
plained of non-colicky, continuous and dull aching epigastric pain 70 mm Hg and respiration was labored and abdomino-thoracic at a
which was followed by one episode of nonbilious vomiting con- rate of 24 breaths/min. The child was in severe distress secondary
taining only food particles. Subsequently the boy complained of to his epigastric discomfort, altered sensorium and had tenderness
generalized pain and tenderness all over body and developed all over body. His lungs were clear to auscultation. There was no
weakness which lead to difficulty in getting up from sitting posi- frothing from mouth. His voice was low toned and he made mur-
tion. In next 2 h the boy was not able to sit unsupported. There was muring sounds on deep painful stimulus. Both the pupils were
no history of loose motions, hematuria, subcutaneous bleeds, dilated and there was complete external ophthalmoplegia. The
constipation, malaena, jaundice, burning micturition, convulsions, patient's extremities showed no edema and capillary refill time was
rash, any drug intake or similar illness in any other family member. less than 2 s. S1 and S2 heart sounds were normal, and no murmurs
The child continued to have pain abdomen and was taken to nearby were detected.
health institution. The attending physician started the manage- Routine laboratory tests revealed a normal complete blood
ment on the lines of acute abdomen. The child didn't show any count and normal plasma values for sodium, potassium, chloride,
improvement and was referred to next center. bicarbonate, and magnesium. Serum amylase level was normal.
The child presented in the triage area of pediatric emergency of Whole blood clotting time (WBCT) was less than 20 min. Pro-
the hospital where he was referred to at 6.45 a.m. on same day. On thrombin time and activated partial thromboplastin time were
normal. His cerebrospinal fluid examination was unremarkable and
EEG did not show any epileptiform activity. Renal function test,
liver function test and X-ray chest were also normal.
* Corresponding author. The condition of the child had deteriorated considerably since
E-mail addresses: dr.milapsharma66@gmail.com (M. Sharma), sk.griffinix@
first complaint of epigastric pain. The examination of site of itching
gmail.com (S. Kalia), seema406@rediffmail.com (S. Sharma).
http://dx.doi.org/10.1016/j.jflm.2016.05.002
1752-928X/© 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
80 M. Sharma et al. / Journal of Forensic and Legal Medicine 42 (2016) 79e81
started immediately even in the absence of snake-bite marks. Anti- communicating with the other authors about progress, sub-
venom treatment alone cannot be relied upon to save the life of a missions of revisions and final approval of proofs. We confirm that
patient with bulbar and respiratory paralysis.14 Patients continue to we have provided a current, correct email address which is acces-
die of asphyxiation because some doctors believe that anti-venom sible by the Corresponding Author.
alone is sufficient treatment, though this patient did not require
assisted ventilation. Increased collaboration between clinicians, References
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