SNAKE ENVENOMATION SIMULATING ST ELEVATION MYOCARDIAL INFARCTION

Objectives: Each year approximately 5000 venomous snakebites are seen in the United States. Envenomation syndromes commonly include local tissue reaction, coagulopathy, nephrotoxicity, and neurotoxicity. Cardiotoxicity, although uncommon, can occur but usually presents with dysrhythmias. Myocardial infarction after envenomation has rarely been reported with a culprit artery identified in all those cases. Herein, we discuss a case of snake bite simulating ST-elevation myocardial infarction (STEMI). Our patient is a 49-year-old male with no pertinent past medical history who presented as a trauma transfer after an accidental snake bite to his left hand. Prior to the transfer, the patient was intubated at the outside hospital for respiratory distress and Crotalidae polyvalent immune fab (Crofab) was initiated. Upon arrival, the patient acutely succumbed to hemodynamic compromise requiring initiation of vasopressor support with norepinephrine. EKG obtained revealed ST elevations in leads II, III and aVF. Troponin was elevated at 3.363 ng/ml. Additionally, the patient’s vasopressor requirements continued to worsen and therefore the patient was taken to the cardiac catheterization lab for an emergent coronary angiography. Interestingly, coronaries were patent with no thrombus identified, however, was found to have severe left ventricular dysfunction with an ejection fraction of 20-30%, elevated filling pressures, and decreased gradient across the aortic valve. His hospital course was further complicated by acute kidney injury, compartment syndrome of the left hand, and pneumatosis intestinalis, and was treated appropriately. After three months of prolonged hospitalization, the patient was eventually discharged to a rehabilitation facility. Our case illustrates severe cardiotoxicity after snake envenomation. Even though our patient did not require any percutaneous coronary intervention, an angiogram was warranted given the clinical presentation. Further research is warranted on STEMI following snake bite.

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