Clinical case report based study Severe hypertension in elapid envenomation Ramachandran Meenakshisundaram a, b, c , Subramanian Senthilkumaran a, * , Martin Grootveld c , Ponniah Thirumalaikolundusubramanian b a Department of Emergency and Critical Care Medicine, Sri Gokulam Hospitals and Research Institute, 3/60, Meyyanur Road, Salem, Tamil Nadu, India b Chennai Medical College Hospital and Research Centre, Irungalur, Trichy, Tamil Nadu, India c Institute for Materials Research and Innovation, University of Bolton, Deane Street, Bolton BL3 5AB, United Kingdom article info Article history: Received 4 June 2012 Accepted 7 August 2012 Available online 27 February 2013 Keywords: Elapid Hypertension Krait Snakebite abstract Snakebite is not an uncommon medical emergency in India; however, symptoms of autonomic dysfunction in snakebite are rare. The elapid snake envenomation is a frequent occurrence in India, and the krait bite is prevalent in the south Indian region. Here, we present three cases of snakebite with severe hypertension and requiring intravenous nitroglycerin (NTG). As the level of blood pressure (BP) decreased significantly following antisnake venom (ASV) injection in all three cases, it is likely that snake venom-induced dysautonomia might have contributed to severe hypertension in such patients. Clinical and therapeutic challenges of these cases are highlighted, so that practitioners coping with medical emergencies in resource-limited situations can consider snake (krait) bite in the differential diagnosis, and also manage effectively according to corroborative clinical evidences. Copyright Ó 2013, SciBioIMed.Org, Published by Reed Elsevier India Pvt. Ltd. All rights reserved. 1. Introduction Snake envenomation is a common medical emergency in India with an estimated mortality rate of 35,000e50,000 people per annum. 1 Indeed, elapid snake envenomation has been recorded as a frequent occurrence in India, in which the common (or ‘Indian’) krait species (Bungarus caeruleus) is also included. The classic symptoms observed in krait bite (which is often described as painless) are early morning symptoms such as abdominal pain or cramps, 2 together with progressive muscular paralysis which often commences with ptosis. Here, we present three cases of elapid envenomation with se- vere hypertension requiring intravenous antihypertensives. Inter- estingly, snake (krait) bite was unknown to all three individuals, but was brought out after an elaborate history and conducting a detailed physical examination. These cases are presented to create an awareness of such issues amongst those practicing under resource-limited environs wherein snakebites are prevalent. 2. Case reports 2.1. Case 1 A 26-year-old male farmer was referred to the emergency room in the early morning from a peripheral hospital for high blood pressure (BP). He complained of giddiness, abdominal pain, and vomiting. His past medical or family history was not contributory. He was a nonsmoker, nonalcoholic, and not taking any form of medication. He had never been diagnosed to have hypertension, diabetes, or kidney diseases, and was using neither traditional herbal medication nor illicit drugs. He also denied having febrile episodes or any particular fear, anxiety, or emotional distress. On admission, his supine brachial BP was 240/180 mmHg with a strong peripheral pulse, and there was no significant difference in the measurements between the arms. The physical examination including fundus revealed no abnormalities. Laboratory tests including complete blood count, serum electrolytes (with an ex- pected low potassium level), hepatic and renal function tests, coagulation profile, toxicology screen, urinary catecholamines, and renin/aldosterone were unremarkable. An electrocardiogram showed normal sinus rhythm without any evidence of left ven- tricular hypertrophy. The urinalysis showed no proteinuria. Chest radiograph, ultrasound of the abdomen, and a head-computed to- mography scan were found to be noncontributory toward hyper- tension. Meanwhile, 90 min after admission, he developed ptosis and external ophthalmoplegia, and complained of difficulty in breathing, swallowing, and speaking. He became cyanotic and his level of sensorium started declining. He was electively intubated and mechanically ventilated. Even with adequate sedation, there was a fluctuation in heart rate and the BP remained persistently high (range: 220e240 mmHg systolic and 160e180 mmHg dia- stolic). Though intravenous nitroglycerin (NTG) infusion was commenced to control hypertension, BP levels remained the same * Corresponding author. E-mail address: maniansenthil@yahoo.co.in (S. Senthilkumaran). Contents lists available at SciVerse ScienceDirect Journal of Cardiovascular Disease Research journal homepage: www.elsevier.com/locate/jcdr 0975-3583/$ e see front matter Copyright Ó 2013, SciBioIMed.Org, Published by Reed Elsevier India Pvt. Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcdr.2013.02.008 Journal of Cardiovascular Disease Research 4 (2013) 65e67