April Oertle1, Justin Assioun2,3, Elizabeth Chang2,3.
1University of Illinois College of Medicine, Rockford, Illinois, United States,
2Division of Emergency Medicine, Rady Children’s Hospital San Diego, San Diego, California, United States,
3Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California, United States.
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Abstract
Crotalidae, commonly known as pit vipers are venomous snakes that include copper heads, water moccasins, and rattlesnakes which inhabit most of North America. Crotalidae possess hollow anterior fangs that deliver venom into subcutaneous tissue, though not all bites result in envenomation.1 Whether venomous or dry, bites can lead to inflammation, infection, and anxiety.3 Systemic symptoms, which indicate that venom was delivered, include nausea, vomiting, hypotension, coagulopathy, and neurotoxicity.3 We present a case of lingual myokymia following a rattlesnake bite in a 9-year-old male, highlighting a distinctive method for rapidly identifying systemic neurotoxic effects post-envenomation. Upon arrival at the pediatric emergency department, he presented with local swelling and four puncture wounds at his left medial malleolus identified as the bite site. Despite unremarkable lab findings, lingual myokymia was noted on physical exam. The patient required two rounds of antivenom with a second dose administered after progressive symptomatology. In addition to examination of the bite site, a simple oral exam which includes an assessment of tongue movement, can help differentiate between venomous bites and dry bites, providing critical information for clinical decision-making in both urban and wilderness contexts. This easily teachable method can empower layperson and clinicians alike to make informed evacuation and clinical decisions based on early identification of systemic neurotoxic effects.
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