Snake Envenomation Causing Distant Tracheal Myonecrosis

Snakebites are often believed to be poisonous. However, this is not always the case. In fact, each bite differs from snake to snake, depending on if the snake is poisonous and if there is envenomation. Venom in pit viper snakebites is often associated with local necrosis. The abundant literature selections and research articles justify local myonecrosis due to envenomation, but there is not much in the literature regarding myonecrosis at a site distant from the snakebite. We hereby present a case of a 42-year-old man who was transferred to our emergency department after a rattlesnake bit him twice. The patient, besides developing local myonecrosis at the site of the snakebite, developed necrosis of the scrotum as well as tracheal pressure myonecrosis at the site of the endotracheal tube balloon. In this review, we will attempt to discuss the myonecrosis pathophysiology and management related to the rattle snakebite. 1. Introduction Out of the 3000 snake species found worldwide, only about 15% are dangerous to the human population [1]. In the United States specifically, approximately 20 of the 120 native snakes are venomous [1]. Snake venom can be classified into five different categories: hemotoxic, neurotoxic, necrotoxic, cardiotoxic, and nephrotoxic. The predominant effect depends on which family the snake belongs to. The degrees of intoxication due to envenomation are described in Table 1 [2]. Table 1: Degree of intoxication due to envenomation. Envenomation can lead to different levels of intoxication, depending on several factors: snake size, species, amount of venom injected, location of bite, treatments provided, timing of treatments, and previous medical history [1]. When examining the pit viper snake exclusively, the following results may occur due to envenomation: puncture wounds, pain, ecchymosis, lymphangitis, hemorrhagic bullae, and necrosis (or tissue destruction) [3]. Local necrosis due to viper bites usually appears to be ischemic and develops slowly over weeks, presenting like dry gangrene [4]. 2. Case Presentation A 42-year-old male, reportedly at a bonfire on the beach, was bitten by a rattlesnake twice, allowing for double envenomation. He was taken to the outlying facility where he was in anaphylactic shock, was intubated, and was started on vasopressor therapy with norepinephrine. The patient received six vials of Crotalidae Polyvalent Immune Fab (Ovine) (CroFab) and was transferred to our facility on a ventilator. Patient WBC was 13.1/L, hemoglobin 16？gm/dL, hematocrit 49.8%, and platelet count 279,000/L. Patient blood glucose was