Eina! Four-year-old recovers after cobra bites his face during SA holiday

A boy who was bitten on the face by a spitting cobra was resuscitated in a rural hospital and saved by an antidote.

The four-year-old Dutch boy's ordeal, during a safari holiday to SA with his parents, has been revealed by the reconstructive surgeons who treated him when he returned home.

Willem Rinkel, from Utrecht University Medical Centre, said the boy's case was a warning that the increasing pre-pandemic popularity of safaris in Southern Africa “may confront more tourists with the effects of snake bites”.

However, the patient's almost total recovery with the help of mime therapy — a form of physiotherapy — showed potentially fatal snake bites could be survived with only “transient disability”.

Rinkel's paper about the boy's case, published in the surgical reconstruction case-study journal JPRAS Open, said the boy was lucky he was sleeping when the snake bit him.

"[He had] a small wound from a single fang under his right eye. The fact that he was asleep presumably saved his eyes,” he said.

The boy flew home after his life was saved with antivenin, and 12 days after being bitten he arrived at Rinkel's hospital with paralysed right cheek and lower eyelid muscles and a painful swelling.

“A clinical diagnosis of an incomplete facial paralysis caused by snake venom neurotoxins was made, with subsequent fat necrosis and abscess formation,” said Rinkel. “Two incisions were made to drain the abscess, which was filled with a milky, sterile fluid.”

A week later, the cheek was less inflamed but it had hardened, the boy had lost some of the feeling in his lower eyelid, and the nasolabial fold — the crease in the skin between the bottom of the nose and the corner of the mouth — had disappeared.

The philtrum, which is the narrow groove under the centre of the nose, had deviated to the left and paralysis was affecting the lower eyelid, the right upper lip and the “smiling” muscles.

Rinkel and his team began mime therapy, which includes massage of the face, breathing and relaxation techniques, exercises with a mirror to co-ordinate both sides of the face and reduce involuntary muscle contraction, and exercises for eye and mouth closure.

“After four months, a significant improvement in facial nerve function was observed,” said Rinkel. Seven months after the attack the boy could close his right eye again and smile.

The scar tissue had softened and there were no involuntary muscle contractions, and 21 months after the bite the asymmetry of the boy's face had subsided.

Rinkel said cobra venom was highly toxic, and the Mozambican spitting cobra normally aimed for the eyes of their enemies and was accurate from up to 3m away.

“The venom is used to paralyse other snakes, various small vertebrates, toads and lizards. They mainly devour rodents and are therefore found near houses,” he said. “Most literature on bites report attacks during night-time, with many of their victims asleep.

“Surgical methods to recover facial paralysis include nerve repair, nerve grafting, nerve transfer, static slings, muscle transfers and functional muscle transplantation.

“Our case illustrates that patience and conservative treatment, possibly supported by the beneficial effects of mime therapy, resulted in virtually full recovery of a cobra bite-induced facial paralysis.

In 2017, the World Health Organisation added snake bites to its list of neglected tropical diseases. They are estimated to affect between 1.8 million and 2.5 million people a year, with between 94,000 and 125,000 victims dying.

“An unknown proportion of patients survives with permanent disability caused by local tissue necrosis and organ dysfunction,” said Rinkel.

“Most victims are farmers and children living in isolated rural areas, resulting in high socioeconomic impact for their surroundings.”

Rinkel said written consent had been obtained to publish the case report and use photographs of the boy.

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