Paralysis and Necrotic Wound Infection Resulting From Monocled Cobra Envenomation

Non-native snake envenomations can be difficult to manage because of challenges obtaining appropriate antivenom and unfamiliarity with the expected clinical effects. This case report describes a 37-year-old man who was envenomated by his pet monocled cobra (Naja kaouthia). He experienced respiratory failure, requiring intubation and mechanical ventilation. Thai king cobra antivenom, recommended by a toxinologist consultant, was obtained from the nearby zoo and administered. The patient was extubated on hospital day (HD) 2. He returned to the hospital two days after initial discharge with worsening erythema, swelling, and purulent discharge from the bite wound. He was treated in the emergency department (ED) and started on intravenous vancomycin and cefepime. The wound culture report found Morganella morganii and Enterococcus faecalis. The patient transitioned to oral antibiotics at discharge on HD 6. The wound developed an eschar, so he underwent debridement, fasciotomy and skin grafting on an outpatient basis. Thirty-six days post-envenomation, he achieved full functional recovery. This case demonstrates some of the challenges inherent to the management of envenomations by non-native snakes. Medical toxicologists and poison control centers can help to find appropriate antivenom and guide treatment.