Two Cases of Early Morning Neuroparalytic Syndrome (EMNS) in the Tropics - Masquerading as Brain Death

Neurotoxicity from elapid bite may masquerade as early morning neuroparalytic syndrome (EMNS). We are reporting a series of two cases who presented as EMNS with absent brain stem reflexes, mimicking brain death. The first case was being considered for potential organ retrieval when the diagnosis was revised, and he recovered completely with Anti-snake venom (ASV). The second patient developed severe anaphylaxis to ASV, which made continuation of the empirical therapy in a comatose patient very tricky. She gradually tolerated a low dose ASV infusion under steroid and adrenaline cover, with reversal of paralysis and coma. Both the patients showed excellent recovery post ASV treatment. A simple bedside Neostigmine challenge test and timely ASV therapy can save many helpless patients of EMNS from certain death.