Cobra Bite Mimicking Brain Death in a 2-Year-Old

Clinical Presentation:

A previously healthy 2-year-old boy presented in a comatose state following sudden cardiac arrest. Thirty minutes prior, his right foot became submerged in sewage at home. Shortly thereafter, he collapsed with air hunger and pulselessness, requiring immediate CPR and intubation. Spontaneous circulation returned within two minutes.

Neurological Status on Arrival:

Comatose, no spontaneous breathing
Fixed pupils (3 mm), absent brainstem reflexes (oculocephalic, gag)
Severe hypotonia, no motor response or deep tendon reflexes
No neck stiffness
Bruise at right malleolus, without visible fang marks

Investigations:

Normal: CBC, electrolytes, coagulation profile, ECG, echocardiogram, EEG
CT Brain: Generalized cerebral edema, white cerebellum sign
Venous clotting time: 8 minutes
EEG: No epileptiform discharges or cortical activity reduction
ELISA: Positive for cobra venom toxins

Clinical Course:

Despite 48 hours of unchanging neurological status and suspected brain death, the bruise extended with necrotic changes, raising suspicion of cobra envenomation—common in the child’s suburban area.

Thai cobra antivenom was administered. Within 20 minutes, minimal spontaneous movement was noted.
The child was extubated within 24 hours post-antivenom.
Full neurological recovery followed after weeks of rehabilitation.

Diagnosis: Cobra envenomation presenting with cardiac arrest and brain death-like symptoms, confirmed by ELISA.

Key Clinical Insights:

Cobra neurotoxins can induce flaccid paralysis, apnea, and coma, mimicking brain death—even without visible fang marks.
Timely antivenom administration is critical and may reverse symptoms rapidly.
EEG and careful clinical monitoring can help distinguish between reversible envenomation and irreversible brain injury.

Reference:

Mekmangkonthong A, et al. Case Rep Pediatr. 2024;2024:6630842. https://doi.org/10.1155/2024/6630842

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