Acute leucoencephalopathy with restricted diffusion following cobra envenomation

A previously healthy 18-month-old boy presented with cobra envenomation with neurotoxic symptoms, including bilateral ptosis, bulbar palsy and apneustic breathing pattern, alongside hematotoxic effects including coagulopathy, haemolysis and rhabdomyolysis. On day 4 post-envenomation, the child developed generalised seizures followed by progressive dystonia and encephalopathy. Magnetic resonance imaging revealed bilateral symmetrical diffusion restriction in the subcortical white matter of multiple lobes and the internal capsule posterior limbs, consistent with acute leukoencephalopathy with restricted diffusion (ALERD). Treatment included anti-snake venom, intravenous methylprednisolone and immunoglobulin alongside supportive care. This case highlights ALERD as a rare but serious neurological complication of cobra envenomation in children, likely resulting from combined neurotoxic effects, hypoxic injury and systemic inflammation. Early recognition of this complication is crucial for appropriate management and potential prevention of long-term neurological sequelae.