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In the case of this patient, the presence of local paresthesias 3. Warrell DA, Davidson NMcD, Greenwood BM, et al. Poisoning
and trembling alone did not merit antivenom therapy in the by bites of the saw-scaled or carpet viper (Echis carinatus) in Ni-
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temic symptoms such as cranial nerve palsy, gastrointestinal in- 4. Chippaux JP, Lang J, Eddine SA, et al. Clinical safety of a poly-
volvement, or respiratory distress. The shortage of antivenom valent F(ab’)2 equine antivenom in 223 African snake envenom-
ations: a field trial in Cameroon. Trans R Soc Trop Med Hygiene.
in sub-Saharan Africa means that its use must be carefully con- 1998;92(6):657–662.
sidered in the context of the severity and clinical evolution of 5. World Health Organization. Guidelines for the Prevention and
the syndrome, as any antivenom wasted in sub-Saharan Africa Clinical Management of Snakebite in Africa. Brazzaville: WHO
is likely to result in death or serious morbidity for future pa- Regional Office for Africa; 2010:1–145.
tients in need of antivenom therapy. While some may question 6. Benjamin JM, Chippaux J-P, Sambo BT, et al. Delayed double
our decision to administer a placebo treatment, it was consid- reading of whole blood clotting test (WBCT) results at 20 and
30 minutes enhances diagnosis and treatment of viper envenom-
ered at length and determined to be the best means of helping ation. J Venomous Animals Toxins Trop Diss. 2018;24(1):38.
our patient with the limited resources available at hand. The 7. Sano-Martins IS, Fan HW, Castro SC, et al. Reliability of the
opportunity to narrow the list of differentials and ameliorate simple 20 minute whole blood clotting test (WBCT20) as an in-
the patient’s symptoms without harmful, costly, or compli- dicator of low plasma fibrinogen concentration in patients enven-
cated interventions was a sensible choice in the context of the omed by Bothrops snakes. Butantan Institute Antivenom Study
Group. Toxicon. 1994;32(9):1045–1050.
case and appeared to work effectively. 8. Chippaux J-P, Amadi-Eddine S, Fagot P. Validité d’un test de diag-
nostic et de surveillance du syndrome hémorragique lors des en-
Acknowledgments venimations vipérines en Afrique sub-saharienne. April 2002:1–4.
The authors would like to thank renowned herpetologist Ste- 9. Isbister GK, Maduwage K, Shahmy S, et al. Diagnostic 20-min
phen Spawls for his photo of the Western purple-glossed snake whole blood clotting test in Russell’s viper envenoming delays
in Figure 3. anti venom administration. 2013;106(10):925–932.
10. Watt G, Padre L, Tuazon ML, et al. Tourniquet application after
cobra bite: delay in the onset of neurotoxicity and the dangers of
This article is dedicated to our coauthor Sanda Ashe, founder sudden release. Am J Trop Med Hygiene. 1988;38(3):618–622.
of the Bio-Ken Snake Farm in Kenya, who sadly died shortly 11. Warrell DA. Bites by venomous and nonvenomous reptiles world-
after the completion of the manuscript. She was an expert in wide. In Auerbach’s Wilderness Medicine E-Book (7 ed., p. 1091).
herpetology and snakebite medicine, and her tireless efforts Philadelphia, PA: Elsevier Health Sciences; 2016.
directly contributed to the education of several generations of 12. Herbert SS, Hayes WK. Denim clothing reduces venom expendi-
snakebite researchers and herpetologists. Sanda was deeply ture by rattlesnakes striking defensively at model human limbs.
Ann Emerg Med. 2009;54(6):830–836.
passionate about her work, and she approached it with a hu- 13. Spawls S, Branch B. The distribution of dangerous snakes in
mility and grace that are rarely encountered. She was truly one Africa. The Dangerous Snakes of Africa. Ralph Curtis Pub;
of a kind, and her contributions to science and humanity will 1995;16.
be sorely missed. 14. Weinstein SA, White J, Keyler DE, et al. Non-front-fanged colu-
broid snakes: a current evidence-based analysis of medical signif-
Financial/Material Support icance. Toxicon. 2013;69:103–113.
None. 15. Pope CH. Fatal bite of captive African rear-fanged snake (Dis-
pholidus). Copeia. 1958;1958(4):280.
16. Silva A, Weerawansa P, Pilapitiya S, et al. First authenticated case
Disclosure of Sri Lankan flying snake (Chrysopelea taprobanica) bite. WEM.
None. 2013;24(3):273–276.
17. Baldé MC, Chippaux J-P, Boiro MY, et al. Use of antivenoms
Ethical Approval for the treatment of envenomation by Elapidae snakes in Guinea,
This patient was treated during the clinical trial of Antivipmyn Sub-Saharan Africa. 2013;19(1):1–8.
Africa in northern Benin, which was cleared by the Comité 18. MD HSB, MBBS PHB. Envenoming by the common krait (Bun-
garus caeruleus) and Asian Cobra (Naja naja): clinical mani-
d’Ethique de la Faculté des Sciences de la Santé de l’Université festations and their management in a rural setting. 2004;15(4):
d’Abomey Calavi du Bénin [Ethics Committee of the Faculty 257–266.
of Health Sciences of the University of Abomey-Calavi, Be- 19. Manock SR, Suarez G, Graham D, et al. Neurotoxic envenoming
nin] in June 2005, renewed in June 2013 (14/06/2013/EC/FSS/ by South American coral snake (Micrurus lemniscatus helleri):
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20. Kurnik D, Haviv Y, Kochva E. A snake bite by the BURROWING
Author Contributions ASp, Atractaspis engaddensis. Toxicon. 1998;37(1):1–5.
JB, CA, and BT carried out the clinical monitoring and as- 21. VSM SM, Sashindran VK. Clinical features and management of
sessment; JB, JPC, and AM carried out the analysis and in- snake bite. Med J Armed Forces India. 2011;58(3):247–249.
terpretation of the data. JB, JPC, KJ, BA, and SA drafted and 22. Margreiter I, Ludin HP. [Psychogenic paraplegia/quadriplegia].
critically revised the manuscript for intellectual content. All Schweiz Med Wochenschr. 1993;123(34):1591–1597.
authors read and approved the final manuscript. 23. Hurwitz TA. Simulated paraplegia: an occasional problem for the
neurosurgeon. Can J Psychiatry. 2017;33(2):147–152.
24. Guanche CA. Tourniquet-induced tibial nerve palsy complicating
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