278 Complex regional pain syndrome (CRPS) type-1 following snake bite: a case report B Bhattarai, 1 BP Shrestha, 2 TR Rahman, 1 SK Sharma 3 and M Tripathi 1 1 Department of Anaesthesiology and Critical Care, 2 Department of Orthopaedics, 3 Department of Internal Medicine, BP Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal Corresponding author: Dr. Balkrishna Bhattarai, MD, Additional Professor, Department of Anaesthesiology and Critical Care, BP Koirala Institute of Health Sciences (BPKIHS), Ghopa, Dharan-18, Nepal, e-mail: bhattaraibk@yahoo.com ABSTRACT The pathophysiological mechanism and clinical course of complex regional pain syndrome (CRPS) type-1 still remain ill defined. Both the treatment and the prediction of the outcome of the treatment are difficult. Abnormal neurohumoral and inflammatory mechanisms have been implicated in its causation usually following trivial noxious event in an extremity. However, to the best of our knowledge CRPS type-1 following snakebite has not been reported yet in the literature. We here report a case of an aggressive CRPS type-1 following a mountain pit viper bite, locally known as Gurube (Ovophis monticola monticola) in a 55-year-old lady. The clinical condition responded well to the therapy with serial sympathetic blockade of the limb with local anaesthetics, non-steroidal antiinflammatory analgesic, antiepileptic, antidepressant and physiotherapy. Our experience in managing this patient and associated pathophysiology in development of CRPS type-1 are discussed. Keywords: snake bite, local toxicity, complex regional pain syndrome type-1, pain, sympathetic block Complex regional pain syndrome (CRPS) type-1 is a chronic pain syndrome involving limbs. It usually develops following a trivial noxious event. It is characterized by edema, changes in the blood flow, abnormal sudomotor activity (sweating) in the region of the pain, or allodynia. 1 The triggered vicious cycle of pain and sympathetic overactivity leads to osteoporosis in the affected limb. 2 Increased blood flow to the bone consequent to alteration of haemodynamics has been attributed to the development of osteoporosis. 3 Etiological factors described include trauma, infection, neoplasm, systemic diseases and many other non- specific conditions including inflammation and immobility. 4 However, CRPS type-1 following snakebite has not yet been reported in the literature. Management of a patient who developed CRPS type-1 following snakebite and the associated pathophysiology in the development of same has been presented here. CASE REPORT A 55-year-old lady from Phurumba Village Development Committee of remote mountainous Taplejung District of Nepal presented to the orthopedic department of our hospital with complaints of pain and swelling of her left hand. She was then referred to our pain clinic for further management. She gives history of bite by a snake locally known as Gurube Sarpa (Ovophis monticola monticola) on her left ring finger 3 weeks prior to presentation to the pain clinic. Following the bite patient had severe burning pain and swelling of the left hand. A tourniquet was applied initially but was removed within one hour. She took local herbal treatment (nature not known) topically along with oral ibuprofen for pain relief but did not receive any anti snake venom due to unavailability. The affected hand became darkish brown in color without any perceptible pain relief. Although the swelling decreased to start but its colour worsened from darkish brown to greyish. Pain in hand, however, persisted to restrict the mobility of her hand. In 2 weeks time after the bite, the stiffness of the wrist and other small joints of the hand worsened and the hand became tender to even slightest touch. The pain started to ascend to the proximal part of the limb. The hand remained swollen and the skin became shiny and cold. She could not move her limb due to pain. She felt anxious and her sleep was disturbed by the pain. On examination the skin of the affected hand was pale, greyish in colour with shiny texture. It was oedematous (non-pitting), cold, moist and tender to touch. The wrist and other small joints of the limb were stiff. X-ray of the hand showed demineralization of the bones of the hand (Fig.1). Biochemical and haematological test results were within normal limits. Based on these findings, the provisional diagnosis of CRPS type-1 was made and the treatment modality was planned. Patient’s left stellate ganglion was blocked with injection of 8 ml of 0.5% bupivacaine using anterior approach. The patient was given oral diclofenac 50mg twice daily, amitryptylline 25mg once daily and capsule gabapentin 300mg twice daily along with limb Case Report Nepal Med Coll J 2008; 10(4): 278-280