Case presentation
This study was conducted according to the declaration of Helsinki principles. Also,  guidelines and methodology have been followed in this study. A 65-year-old man referred to the Cardiovascular Center following chest pain with dissemination to the left upper extremity, cold sweats, chills, his had nausea and vomiting, and edema in the left upper extremity. At the time of entering the Cardiovascular Center, the patient had no fever and blood pressure was 113/68mmHg, pulse rate was 76beat/min and respiratory rate was 20 breaths/min. In examination, the ECG had a normal sinus rhythm and showed no changes indicative myocardial infarction. Blood samples were also taken to test for cardiac enzymes, Troponin˂0.2 and BUN = 46 mg/dL and Creatinine = 2.5 mg/dL. After 6 hours, the swelling of the left upper limb progressed and multiple blisters appeared, after which the patient was referred to an infectious center in the northern Iran for examination for infection, necrotizing fasciitis and compartment syndrome. After admission to the infectious center, the patient had a fever (T = 38.5) and tachycardia (PR = 108/min) with decreased level of consciousness. In the emergency room of the infectious center, first the patient’s airway checked out and to monitor his vital signs, cardiac monitoring and pulse oximetry along with oxygen therapy with O2 mask were performed. Blood pressure and respiratory rate were within normal limits, and examination of the lungs, abdomen, and central nervous system showed no abnormal findings. On examination of the left upper limb; there was erythema, warmness, stiffness, non-pitting edema, and limitation of active movement. Also, vesiculobullous lesions were seen on the dorsal surface of the hand to the wrist and both flexor and extensor surfaces of the forearm and arm up to the proximal arm and left axillary area. (figure 1-A, B)
The location and size of the axillary lymph nodes were normal and the left radial pulse was weakly palpable. Also Swelling, redness, and localized infection were seen in the distal third finger of the left hand, and according to the patient’s history of burning sensation in the same finger after lifting a heavy object at home 3 days ago and also the endemicity of his place of habitation raised the probability of a venomous snake bite, and for this reason the patient was transferred to the poisoning ward.
The patient had no history of smoking or drug usage, his had a history of dyslipidemia, hypertension, diabetes mellitus and ischemic heart disease, which had been controlled with appropriate medications and was asymptomatic in routine life.
He also had no history of asthma, allergies, rhinitis, dermatitis or eczema and did not have a history of similar bites in the past.