Aural involvement in loxoscelism: case report and literature review

An 11-year-old male presented with fever, rash, and a necrotic lesion on the lobule of the left ear. The lesion became tender and formed an eschar over 4 days. The patient developed leukocytosis, hemolytic anemia, and proteinuria, and was diagnosed with systemic loxoscelism from a brown recluse spider bite. He was managed with supportive therapy and improved in 4 days. Loxoscelism is a clinical diagnosis which should be suspected in an otherwise healthy patient with a necrotic wound, particulary in the endemic Southern and Midwestern United States. Physicians should be aware of this disease entity and its complications.

Envenomations

Numerous types of envenomations may be encountered by health care workers depending on where in North America they work. Clinicians should be familiar with the animals in their region that may lead to envenomation.A rational approach with use of poison center or medical toxicology consultation services ensures that cases are managed appropriately.

Brown recluse spider envenomation: dermatologic application of hyperbaric oxygen therapy

Envenomation from the brown recluse (Loxosceles recluse) spider commonly proceed on one of three clinical pathways. The majority of bites (90%) result in nothing more than a local reaction. They are essentially self-limiting, require little if any attention, and resolve spontaneously. A great majority of the remaining bites will produce necrotic ulcerations of various sizes and dimensions, with systemic sequela ranging from fever to hemolysis and kidney failure. Finally, and in the most rare cases, the patient will succumb a fatal systemic reaction. Current therapeutic options for these wounds remain controversial and include the following: local care, corticosteroids, dapsone, and hyperbaric oxygen (HBO) therapy. This article will review the application of HBO therapy for patients who are envenomated by brown recluse spiders. Information for this manuscript was derived from multiple MEDLINE searches as well as searches of the National Baromedical Service's hyperbaric specialty literature collection.

Immunizations, neonatal jaundice, and animal-induced injuries

PURPOSE OF REVIEW

To concisely review data published over the past year on three topics pertinent to the practicing pediatrician: immunizations, neonatal jaundice, and animal-induced injuries.

RECENT FINDINGS

Updates on immunizations, including varicella and pneumococcus in the post-vaccine era, use of a polyvalent conjugated meningococcal vaccine, and influenza vaccination during a vaccine shortage are discussed. Mortality and morbidity from varicella, and risk of invasive disease from pneumococcal infections have declined. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention released guidelines for the use of a tetravalent meningococcal conjugate vaccine in adolescents 11 years and older. Infants at younger gestational age are at higher risk for developing hyperbilirubinemia. The American Academy of Pediatrics has released new guidelines emphasizing breastfeeding, systematic pre-discharge assessment for risk factors, early follow-up and intervention. Use of home nursing services in the postnatal period is cost-effective. Although the incidence of rabies is low, many receive postexposure prophylaxis. Spider bites cause fewer systemic effects in children than adults. Pet reptile carriage of salmonella necessitates handwashing after handling of animals.

SUMMARY

Recommendations for adolescent meningococcal vaccination, and the impact of varicella and pneumococcal immunization on our communities reflect an evolution in our management of infectious diseases. The latest practice guidelines on hyperbilirubinemia emphasize close follow-up of all newborns after postpartum discharge and even more careful evaluation of those infants near term. Education on rabies prophylaxis, spider bites, and salmonella from pet reptiles should focus on judicious use of resources and the proper handling of pets.

Case report: compartment syndrome after a suspected black widow spider bite

Widow spider envenomations generally produce systemic neurologic syndromes without significant local injury. We report a patient who sustained a black widow spider bite to the left forearm and presented to the emergency department with rhabdomyolysis and compartment syndrome. We documented a decrease in symptoms and compartment pressure after administration of antivenom. No surgical intervention was performed. We believe this report to be the first documenting compartment syndrome associated with black widow spider bite.

Severe systemic reaction to Loxosceles reclusa spider bites in a pediatric population

OBJECTIVE

To report 6 children who had severe systemic reaction after spider bites requiring pediatric intensive care unit admission and to describe their clinical presentation, hospital course, and outcome.

METHODS

A retrospective analysis was done to identify patients presenting with brown recluse spider bites. Charts of children admitted to the intensive care unit were reviewed.

RESULTS

Six previously healthy African-American children, aged 3 to 15 years, with brown recluse spider bites were admitted to the pediatric intensive care unit. All had fever, jaundice, and evidence of hemolytic anemia. Four of 6 children had hypotension. One child developed mental status changes, acute renal failure secondary to rhabdomyolysis, and hyperkalemia and required emergent hemodialysis. All children fully recovered.

CONCLUSION

Although most cases of brown recluse spider bites are benign requiring no intervention, severe systemic reactions may occur in the pediatric population resulting in admission to the pediatric intensive care unit. These systemic reactions may include hemolytic anemia, hypotension, and renal failure.

Brown recluse spider bites: a complex problem wound. A brief review and case study

Brown recluse spiders (Loxosceles reclusa) are responsible for virtually all documented cases of spider bites leading to significant necrosis. The actual spider bite often goes unnoticed for as long as 4 to 6 hours, which makes diagnosis and, therefore, appropriate treatment, difficult. The spider bite generally results in either a necrotic wound or systemic symptoms that can lead to hemolysis. The patient described in this article experienced both complications. Dapsone and hyperbaric oxygen therapy brought the adverse response to the bite under control. The patient was hospitalized for 7 days during treatment for hemolysis and an extensive, necrotic wound. Efforts are underway to develop an assay to provide a definitive diagnosis for the brown recluse spider bite, but none is yet commercially available. Antivenom is scarce; capture of the offending spider appears to be most helpful in the diagnosis and proper treatment of spider bites.

[Spider's bite that develop eyelid necrosis]

CASE REPORT

We report the case of a spider bite in a 7 years-old girl that develop a dermonecrosis and did not need surgical treatment.

DISCUSSION

We analize the mechanisms of these kind of lesions review and update therapeutic management of these kind of lesions.

Morsures d’araignées : les aranéismes d’importance médicale

LIMITED RISKS: Although most species of spiders are venomous, only ten or so are able to induce human envenomations. From a systematic point of view, it is possible to distinguish the araneomorph spiders - or "true" spiders - from the mygalomorph spiders. Dangerous species for humans can be found in both groups. Regarding "true' spiders, two kinds of envenomation are frequent, ubiquitous and potentially severe: latrodectism (neurotoxic symptomatology) due to the Widow spiders of the Latrodectus species,and loxoscelism (viscero-cutaneous symptomatology). Regarding the mygalomorph spiders, the Australian species responsible for atraxism (neurotoxic symptomatology) are considered as the most dangerous. Most of the other mygalomorph spiders, when they bite, only provoke benign loco regional problems. A supplementary defensive weapon exists in certain South-American species: urticating hairs which may induce severe ocular damage.

Brown spiders and loxoscelism

Accidents caused by brown spiders (Loxosceles genus) are classically associated with dermonecrotic lesions and systemic manifestations including intravascular haemolysis, disseminated intravascular coagulation and acute renal failure. Systemic reactions occur in a minority of cases, but may be severe in some patients and occasionally fatal. The mechanisms by which Loxosceles venom exerts these noxious effects are currently under investigation. The venom contains several toxins, some of which have been well-characterised biochemically and biologically. The purpose of the present review is to describe some insights into loxoscelism obtained over the last ten years. The biology and epidemiology of the brown spider, the histopathology of envenomation and the immunogenicity of Loxosceles venom are reviewed, as are the clinical features, diagnosis and therapy of brown spider bites. The identification and characterisation of some toxins and the mechanism of induction of local and systemic lesions caused by brown spider venom are also discussed. Finally, the biotechnological application of some venom toxins are covered.

Clinical course of a loxosceles spider bite in Turkey

We report the first case from Turkey of a dermonecrotic wound associated with possible Loxosceles spider bite and offer the complete clinical course that resulted in a permanent scar. Emergency physicians in western Turkey should be aware of Loxosceles spider bites as a cause of necrotizing wounds.

Coombs-positive hemolytic anemia secondary to brown recluse spider bite: a review of the literature and discussion of treatment

The bite of the brown recluse spider (Loxosceles reclusa) typically results in local, dermonecrotic skin lesions. Rarely, these bites may precipitate systemic disturbances of varying severity collectively known as systemic loxoscelism. The more severe systemic alterations attributed to the venom of this arachnid include hemolytic anemia, multiorgan failure, disseminated intravascular coagulation, or even death. Coombs-positive hemolysis associated with brown recluse spider bites has rarely been documented in the literature. We report 2 cases of systemic loxoscelism in young women associated with severe Coombs-positive hemolytic anemia and systemic symptoms requiring hospitalization. Both patients were treated with aggressive wound care, hematologic monitoring with blood transfusion, and intravenous fluid replacement. Recovery was excellent in both cases. We review the literature and discuss the controversies surrounding the treatment of more severe brown recluse bite reactions.

Loxoscelism: Old obstacles, new directions

Loxosceles spiders have a worldwide distribution and are considered one of the most medically important groups of spiders. Envenomation (loxoscelism) can result in dermonecrosis and, less commonly, a systemic illness that can be fatal. The mechanism of venom action is multifactorial and incompletely understood. The characteristic dermonecrotic lesion results from the direct effects of the venom on the cellular and basal membrane components, as well as the extracellular matrix. The initial interaction between the venom and tissues causes complement activation, migration of polymorphic neutrophils, liberation of proteolytic enzymes, cytokine and chemokine release, platelet aggregation, and blood flow alterations that result in edema and ischemia, with development of necrosis. There is no definitive treatment for loxoscelism. However, animal model studies suggest the potential value of specific antivenom to decrease lesion size and limit systemic illness even when such administration is delayed.

Acute coronary ischemia following centipede envenomation: case report and review of the literature

This is the first known case report of electrocardiographic (ECG) changes suggestive of coronary vasospasm following a centipede envenomation. A 60-year-old man presented to the emergency department (ED) 1 hour after being stung by a 12-cm centipede. He complained of right great toe pain that did not radiate to his leg. The patient had no known ischemic heart disease. He did not describe any exertional symptoms but admitted experiencing weakness. During the ED course, concurrent with obtaining peripheral intravenous access, the patient experienced diaphoresis, dizziness, hypotension, and bradycardia. His ECG showed new ST-T wave changes, which suggested an acute ischemic process. The patient's blood pressure was 89/60 mm Hg, his pulse rate was 47 beats/min, and his respiration rate was 28 breaths/min. In the following hours, ECG findings returned to baseline. His blood pressure improved gradually with fluid resuscitation after approximately 5 hours. Cardiac markers returned to normal in the 13th hour after the event, and the patient underwent exercise stress testing, which was negative. The patient was discharged with cardiology follow-up. Adult patients with centipede envenomation should be closely monitored in anticipation of possible myocardial ischemia due to vasospasm, hypotension, and myocardial toxic effects of the venom. A child receiving the same amount of venom would be potentially at greater risk.

The global epidemiology, syndromic classification, management, and prevention of spider bites

Spiders are carnivorous arthropods that coexist with humans and ambush or ensnare prey. Unlike other arthropods, spiders rarely transmit communicable diseases, and play a critical role in the ecosystem by consuming other arthropods that frequently transmit human diseases, such as mosquitoes and flies. There are more than 30,000 species of spiders, most of which are venomous, but they cannot inflict serious bites due to delicate mouthparts and short fangs. The differential diagnosis of spider bites is extensive and includes other arthropod bites, skin infections, and exposure to chemical or physical agents. However, approximately 200 species from 20 genera of spiders worldwide can cause severe human envenomings, with dermonecrosis, systemic toxicity, and death. Spider bites can usually be prevented by simple personal and domestic measures. Early species identification and specific management may help prevent serious sequelae of spider bites.

Management of spider bites

A request to transport a patient with an arachnid envenomation may not be one of the most common calls the transport team receives, yet an understanding of how to care for such patients can decrease complications and prevent morbidity and mortality. This case outlines a systemic reaction from a black widow spider bite and discusses its subsequent management from initial assessment in the referring emergency department (ED) to discharge.

Brown recluse spider bites to the head: three cases and a review

Consequences of envenomation from the bite of a brown recluse spider (Loxosceles reclusa) range from mild itching to death. The bite of this spider causes the most severe form of arthropod-induced tissue necrosis. These bites pose several challenges to the clinician in that diagnosis can be difficult, systemic manifestations can occur, and healing can be resistant to conventional measures. Bites to the head and neck-particularly the face-are uncommon, and they have not been widely reported in the otolaryngology literature. As experts in facial soft tissue, otolaryngologists and facial plastic surgeons should be able to recognize and treat these lesions. Because no laboratory test is available to identify the cause of symptoms in these cases, the diagnosis is made clinically. Early intervention can make a significant difference in cosmetic outcome, so a high index of suspicion is warranted. Local wound care includes rest, ice, compression, and elevation of the affected part of the body. Drug therapy with dapsone may limit the severity of the bite and prevent complications. Because some bites cause systemic loxoscelism, clinicians should be familiar with its manifestations. When necrosis occurs despite adequate medical treatment, reconstructive procedures should be delayed until healing is complete. We report 3 cases of brown recluse spider bites to the head. These cases illustrate the broad spectrum of the disease course, and they highlight the therapeutic challenges that these lesions pose.

Use of antivenin to treat priapism after a black widow spider bite

Black widow spider envenomation (BWSE) is commonly associated with severe abdominal pain, muscle cramping, and hypertension. Treatment is primarily symptomatic with the use of opiates and benzodiazepines. Priapism is a complication of BWSE that has only rarely been reported. We describe a 17-month-old male who developed priapism after known BWSE. His priapism did not respond to opiates or benzodiazepines, and he was treated with black widow spider antivenin. Complete detumescence followed within several hours. The patient required no additional opiates for pain and was discharged from the hospital the following day. The patient's rapid improvement after antivenin suggests its efficacy in treating BWSE-associated priapism.