Case of the Month: A case of venom induced ‘Ballant’s syndrome’ in a patient with snake bite

Contributed by

Dr Prathvi Nandalike, Assistant Professor,

Dr Rahul R Raikar, MCH Neurosurgery resident,

Dr Nimrah Fathima, Assistant Professor,

Dr Sandhya Rani, Assistant Professor

Corresponding author email:prathvinandalike@gmail.com 

Clinical scenario:

A 35 year old male , a farmer by occupation presented  with Weakness of Left upper limb and lower limb of  9 days duration .

6 days prior to the current presentation he had a snake bite at  his little finger of Right hand ,while working in his fields at Pattasaragu village, following which patient went to nearby temple and while walking in the temple, patient lost his consciousness and fell down

He was taken to nearby hospital by the bystanders ,where  the patient was treated with medications in the form of anti snake venom , iv fluids and referred to VIMS,Bellary .

While transportation he suddenly  became irritable and attendants  noticed there was paucity of movements on left upper limb and left lower limb.

Examination :  The examination on arrival revealed  he was in altered sensorium and did not respond to  verbal commands .

There was No h/o swelling at the bite site.

He had normal systemic examination .

He was immediately intubated as his oxygen saturation was low.

After two days of hospital admission ,the patient became conscious and responded to verbal commands and later he  was extubated.

Detailed neurological showed normal   higher Mental Functions

Memory -Immediate – intact Recent – intact

Remote – intact Attention – normal

Mood / Affect – Normal

Cranial nerves normal except vision lost in temporal side of left eye and nasal side of left eye confirmed by perimeter.

Left lower limb – Extension at hip and knee joint, externally rotated, foot inverted , plantar flexed .motor system

Bulk equal both sides.

Hypotonic in left upper and lower limbs with power of 3/5 in both upper and lower limbs.

Superficial reflexes abdomen and cremasteric absent and plantar extensor in left lower limb with brisk deep tendon reflexes in left side.

Sensory system and cortical sensations intact with no meningeal irritation signs  and symptoms and circumduction gait.

Investigations :

Routine blood investigation shows slightly raised hemoglobin with normal renal, liver function tests.

MRI brain shows right MCA and PCA territory acute infarcts and left occipital lobe infarcts. 

Hospital course :

The patient was intubated  

Patient was administered with 20 ASVs with Neostigmine and atropine and calcium gluconate and other  supportive measures like iv fluids.

Extubated after 2 days

He became conscious and had  left side hemiparesis 

 Patient improved  gradually and was stable in discharge with slight improvement in left upper and lower limb and  was able to walk with support. 

Teaching message: 

All cases of snake bite should be evaluated for any CNS  involvement because it causes haemorrhage in the brain or CVT but this patient had acute infarcts in right internal capsule and left occipital lobe. Imaging in the form of CT /MRI may be indicated in relevant cases .

References :

1. Neurological complications of venomous snake bites: a review O H Del Brutto et al. Acta Neurol Scand. 2012 June. https://doi.org/10.3390/toxins14070436.
2.  Russell, F.E. When a snake strikes. Emerg. Med. 1990, 22, 21–43. [Google Scholar] Gold, B.S.; Barish, R.A.; Dart, R.C. North American snake envenomation:
3. Diagnosis, treatment, and management. Emerg. Med. Clin. N. Am. 2004, 22, 423–443. [Google Scholar] [CrossRef]
4. Kasturiratne, A.; Wickremasinghe, A.R.; de Silva, N.; Gunawardena, N.K.; Pathmeswaran, A.; Premaratna, R.; Savioli, L.; Lalloo, D.G.; de Silva, H.J. The global burden of snakebite: A literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med. 2008, 5, e218.