A 17-year-old male with history of snake bite on upper back while sleeping on the floor and who developed bilateral ptosis and shortness of breath (respiratory rate 24/min, SPO2 87% on room air) was admitted in the emergency department during COVID-19 pandemic. On examination, there were double puncture marks approximately 15 cm below nape of the neck. The patient was hemodynamically stable (HR, 90/min; BP = 120/90 mm Hg). Lyophilized polyvalent anti-snake venom (ASV) was administered in an initial dose of 10 vials administered via intravenous route over a period of 1 h followed by a repeat dose of 10 vials after an hour. Oxygenation was provided with a Ventimask (FiO2 = 0.5), but the patient developed acute type 2 respiratory failure after 2 h and was subsequently intubated after preoxygenation and use of sedative drugs like propofol (Saini et al. 2014).

In line with our institutional protocol, the patient was tested for SARS-CoV-2 virus using real-time reverse transcription-polymerase chain reaction (RT-PCR) assay after admission in the medical emergency department. He was shifted to the COVID ICU for mechanical ventilation and supportive care when reported as positive for COVID-19 infection.

To monitor progression of both pathologies, various biochemical investigations were performed on daily basis (Table 1). Hemogram, electrolytes (sodium, potassium, chloride, calcium, magnesium), renal function test, total proteins, albumin, liver function test, procalcitonin, lactate dehydrogenase (LDH), lactate, pro-BNP, CKMB, and trop T were normal. Blood, urine, and tracheal cultures were sterile, but piperacillin and tazobactam (4.5 G QID) were started empirically after admission. A chest CT examination was deferred, and CXR was used for monitoring as the patient did not develop acute respiratory distress syndrome (ARDS).

Enoxaparin (0.4 ml SC BD) and dexamethasone (6 mg BD) were administered. Over the course of next 3 days, patients GCS improved to 12/15 with (eyes 4, voice 2, motor 6), and the patients ventilatory support was shifted from synchronized intermittent mandatory ventilation (SIMV) to pressure support. After assessing clinical and arterial blood gas parameters, he was subsequently extubated on the 5th day after testing for bulbar reflexes and given intermittent noninvasive ventilation for 2 additional days. He was tested negative for SARS-CoV-2 virus after a week, and the patient was discharged home after 13 days of hospitalization with no neurological deficit. The patient was reviewed in outpatient clinic 4 and 12 weeks later. He had returned to work after 4 weeks of discharge. There was no residual pain or weakness.