Two case reports of deadly Himalayan bites with tertiary level care: A snake and a possible scorpion.

In the Himalayan region, there is a prevalence of unknown bites (not much data except media) including snakes with high range of mortality among victims because hilly terrain leads to delay in transportation and delayed initiation of proper treatment due to lack of developed tertiary care centers. These bites can present from local hypersensitivity reactions to neurological, cardiological, respiratory, hematological, musculoskeletal, and renal manifestations. We highlight two cases that presented with delayed and varied manifestations, recovered but delayed with dedicated supportive care. A 25-year-old female presented 3 days after bite from an unknown snake, possibly krait, developed cardiotoxicity, neuroxotoxicity, rhabdomyolysis, and hemolytic features and was managed with antivenom and anticholinesterase therapy along with medroxyprogesterone to facilitate recovery from bite-associated neurotoxicity. A 75-year-old male subjected to an unknown bite possibly a scorpion developed shock which was most likely cardiogenic in nature secondary to toxin and was managed initially using inotropic support. Prazosin was started, and he recovered completely though at a later time. Hence, apart from krait bite presenting as multisystem involvement, anticholinesterase and medroxyprogesterone acetate are vital for survival. Similarly, prazosin has a vital role in the recovery of scorpion bite-induced cardiotoxicity. Many such unknown venomous bites go unreported. Further case studies and case reports are necessary to help redefine the epidemiology of such bites in the Himalayan region that poses a diagnostic and therapeutic challenge.