Clinical Toxicology (2010) 48, 956–957

Ó 2010 Informa Healthcare USA, Inc.

ISSN 1556-3650 print/ISSN 1556-9519 online
DOI: 10.3109/15563650.2010.533677

SHORT REPORT

Life-threatening hyponatremia after krait bite envenoming –

A new syndrome
JONAS HÖJER1, HA TRAN HUNG2, and DAVID WARRELL3
1
Swedish Poisons Information Centre, Karolinska Institute, Stockholm, Sweden
2
Vietnam Poison Control Center, Hanoi Medical University, Hanoi, Vietnam
3
Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Introduction. Bites by kraits are a major cause of snake bite death in South Asia, mainly because of their venom is paralytic causing
respiratory failure. We describe another life-threatening effect of the venom of some Bungarus species. Case report. We report the death
of a young woman due to severe hyponatremia-induced brain damage after envenoming attributed to a Bungarus multicinctus. Her serum
sodium of 137 mmol/l on admission dropped to 104 mmol/l within 48 h. The patient suddenly deteriorated with seizures and coma and
showed signs of severe cerebral edema. The osmolality and sodium concentration in her urine were high. She died 18 days after the bite.
Discussion. Since this case, a retrospective study and a prospective trial have confirmed the high risk of hyponatremia after envenoming
by B. multicinctus. In addition, a recent study in southern Vietnam has shown that envenoming by the Malayan krait (Bungarus candidus)
also commonly causes profound hyponatremia. Conclusion. Hyponatremia is a potential serious complication in patients envenomed by
B. multicinctus or B. candidus, and appropriate monitoring and management is necessary.
For personal use only.

Keywords Snakes; Metabolic; Respiratory support

Introduction
Krait bites are an important cause of snake bite death in
South Asian countries.1 The cause of death in these victims
is most commonly respiratory failure resulting from res-
piratory muscle paralysis. We present a fatal case which
made us aware of a possible, then unknown life-threatening
effect of the venom of some Bungarus species.
Case report
A previously healthy 17-year-old girl was admitted to hospital
in Hanoi 15 h after being bitten by a snake on her left foot
while in her home in the suburbs of Hanoi. Although the
snake was never seen, the circumstances of the bite and the
evolution of the patient’s signs and symptoms were typical of
envenoming by Bungarus multicinctus (Fig. 1), a common
venomous snake in this area. One hour after the bite she
experienced myalgia, followed by ptosis, pharyngeal pain,
dysphagia, blurred vision, and limb weakness. She was
brought to a district hospital and then referred.
Received 27 August 2010; accepted 18 October 2010.
Address correspondence to Dr. Jonas Höjer MD, PhD, Swedish
Poisons Information Centre, Karolinska Institute, Stockholm,
Sweden. E-mail: jonas.hojer@gic.se
On admission she was fully conscious and her vital signs
were T 36.78C, HR 108 bpm, BP 110/70 mmHg, RR 22/
min and O2-SAT 94%. Routine laboratory tests showed
serum sodium 137 mmol/l, serum potassium 3.8 mmol/l,
and serum chloride 104 mmol/l. One fang puncture mark
was noticed, but there was no local swelling or other
changes. On neurological examination she had bilateral
ptosis, dilated pupils, ophthalmoplegia, jaw paralysis with
inability to open the mouth more than 2 cm, excessive
pharyngeal secretions and a moderate proximal limb
paralysis.
The patient was closely observed in the high-depen-
dency toxicology ward and was able to breathe sponta-
neously for almost 2 days before she suddenly
deteriorated with seizures and coma. After intubation
and start of mechanical ventilation, a CT showed signs of
a diffuse generalized cerebral edema and fundoscopy
revealed bilateral papilloedema. Blood glucose, and
biochemical indices of liver and renal function were
normal but the serum sodium had dropped to 104 mmol/l.
Treatment with intravenous hypertonic saline was started
immediately. The plasma and urine osmolalities on the
next day were 268 and 508 mosm/kg H2O, respectively,
and the simultaneously measured urinary sodium concen-
tration was 222 mmol/l. The serum sodium level was
corrected to 113 mmol/l in 24 h and 127 mmol/l in 48 h,
but her mental status deteriorated and she died 18 days
after the bite.

956

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Fig. 1. Bungarus multicinctus (Chinese krait, many banded krait),
the only krait species recorded in Hanoi. It is also found in several
other Asian countries. (This is not a photo of the actual snake
responsible for the envenoming described in this case report).
For personal use only.
Discussion
This tragic case occurred several years ago, before any
antivenom was clinically available in northern Vietnam. It
prompted a retrospective survey2 in which this case was
included and a prospective antivenom trial3 that have
confirmed the high risk of hyponatremia after proven or
presumed envenoming by B. multicinctus. A recent study in
southern Vietnam4 has shown that envenoming by Malayan
kraits (Bungarus candidus) also commonly causes profound
hyponatremia.
The snake responsible for this case of envenoming was
never seen which limits the value of our report. However, B.
multicinctus is the only species reported from the environs
of Hanoi capable of producing the clinical features that the
patient displayed: bite occurring inside the home during the
evening and progressive descending paralysis in the absence
of any signs of local envenoming.5 The only other
neurotoxic species existing in this area are the cobras Naja
atra and Naja hannah, but their bites cause marked local
envenoming: pain, swelling, blistering and necrosis.
The mechanism underlying the electrolyte disturbance
remains obscure, but the high urinary sodium concentration
in B. multicinctus victims in Hanoi suggests an action of a
natriuretic peptide-like toxin, as has been demonstrated in
the venom of Bungarus flaviceps6 and some other snakes.7
The other conceivable mechanism behind the severe
Clinical Toxicology vol. 48 no. 9 2010
Hyponatremia after krait bite envenoming 957
hyponatremia is the syndrome of inappropriate antidiuretic
hormone secretion (SIADH). SIADH, however, typically
gives rise to a chronic, slowly developing hyponatremia.8
Moreover, in the study from southern Vietnam,4 antidiuretic
hormone (ADH) was measured in several hyponatremic
cases and was found to be low.
It may be argued that the development of acute
symptomatic hyponatremia in this patient should have been
even more rapidly corrected, but the delayed start of sodium
replacement and the large urinary sodium losses made this
difficult to achieve. After this tragic fatality, serum sodium
levels are frequently checked in all krait bitten patients in
Hanoi, and any detected hyponatremia is promptly
corrected. Since then there has been no further case of
severe symptomatic hyponatremia.
Conclusion
Snake bite by some krait species may lead to acute profound
hyponatremia. We strongly recommend that serum electro-
lyte levels are carefully monitored in every patient
envenomed by B. multicinctus or B. candidus, so that life-
threatening consequences of hyponatraemia may be pre-
vented.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this paper.
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