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Severe Thrombocytopenia and Dermonecrosis after Loxosceles Spider Bite in a 3-Year-Old Child

2013; Elsevier BV; Volume: 163; Issue: 4 Linguagem: Inglês

10.1016/j.jpeds.2013.04.057

1097-6833

Carina Levin, Dganit Rozemman, Waheeb Sakran, Raphaël Halevy, Sarit Peleg, Ariel Koren,

Bartonella species infections research

A 3-year-old girl was admitted for sudden onset of 12 hours of high fever, vomiting, malaise, and skin rash the day prior to admission, with no history of trauma or drugs. The patient showed a petechial and morbilliform rash, swelling, redness and a dry dark blue-purple lesion on the right big toe (Figure). Blood tests showed thrombocytopenia (18 × 109/L), high C-reactive protein, and no signs of disseminated intravascular coagulation. A presumptive diagnosis of loxoscelism was made, based on the clinical picture in an endemic area during the warm season. The patient was treated with antibiotics until blood and wound cultures appeared negative and prednisone for 5 days, and was discharged after 4 days with resolution of the systemic symptoms and laboratory improvement. The dermonecrosis underwent desquamation and healing within 3 weeks. Loxoscelism describes the reactions and lesions caused by bites from spiders of the genus Loxosceles.1Dyachenko P. Ziv M. Rozenman D. Epidemiological and clinical manifestations of patients hospitalized with brown recluse spider bite.J Eur Acad Dermatol Venereol. 2006; 20: 1121-1125Crossref PubMed Scopus (30) Google Scholar, 2McDade J. Aygun B. Ware R.E. Brown recluse spider (Loxosceles reclusa) envenomation leading to acute hemolytic anemia in six adolescents.J Pediatr. 2010; 156: 155-157Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 3Malaque C.M. Santoro M.L. Cardoso J.L. Conde M.R. Novaes C.T. Risk J.Y. et al.Clinical picture and laboratorial evaluation in human loxoscelism.Toxicon. 2011; 58: 664-671Crossref PubMed Scopus (48) Google Scholar In Israel, certified bites of L rufescens have been reported and many cases of loxoscelism have been described.1Dyachenko P. Ziv M. Rozenman D. Epidemiological and clinical manifestations of patients hospitalized with brown recluse spider bite.J Eur Acad Dermatol Venereol. 2006; 20: 1121-1125Crossref PubMed Scopus (30) Google Scholar, 4Efrati P. Bites by Loxosceles spiders in Israel.Toxicon. 1969; 6: 239-241Crossref PubMed Scopus (17) Google Scholar Most bites are benign, but local and/or systemic reactions can appear. The typical local manifestation is dermonecrosis. Systemic symptoms include morbilliform rash, fever, chills, nausea, vomiting, malaise, arthralgia, and myalgia; hemolytic anemia and leukocytosis; less frequent thrombocytopenia, disseminated intravascular coagulation, renal failure, multiorgan failure, and even death, more commonly in children than in adults.1Dyachenko P. Ziv M. Rozenman D. Epidemiological and clinical manifestations of patients hospitalized with brown recluse spider bite.J Eur Acad Dermatol Venereol. 2006; 20: 1121-1125Crossref PubMed Scopus (30) Google Scholar, 2McDade J. Aygun B. Ware R.E. Brown recluse spider (Loxosceles reclusa) envenomation leading to acute hemolytic anemia in six adolescents.J Pediatr. 2010; 156: 155-157Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 3Malaque C.M. Santoro M.L. Cardoso J.L. Conde M.R. Novaes C.T. Risk J.Y. et al.Clinical picture and laboratorial evaluation in human loxoscelism.Toxicon. 2011; 58: 664-671Crossref PubMed Scopus (48) Google Scholar Loxosceles venom contains enzymes (hyaluronidase, alkaline phosphatase, esterase, and sphingomyelinase D2) responsible for tissue destruction and cytotoxicity.1Dyachenko P. Ziv M. Rozenman D. Epidemiological and clinical manifestations of patients hospitalized with brown recluse spider bite.J Eur Acad Dermatol Venereol. 2006; 20: 1121-1125Crossref PubMed Scopus (30) Google Scholar, 2McDade J. Aygun B. Ware R.E. Brown recluse spider (Loxosceles reclusa) envenomation leading to acute hemolytic anemia in six adolescents.J Pediatr. 2010; 156: 155-157Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 3Malaque C.M. Santoro M.L. Cardoso J.L. Conde M.R. Novaes C.T. Risk J.Y. et al.Clinical picture and laboratorial evaluation in human loxoscelism.Toxicon. 2011; 58: 664-671Crossref PubMed Scopus (48) Google Scholar The diagnosis is rarely based on identification of the spider. A presumptive diagnosis is made clinically, based on a combination of history, signs, and symptoms.1Dyachenko P. Ziv M. Rozenman D. Epidemiological and clinical manifestations of patients hospitalized with brown recluse spider bite.J Eur Acad Dermatol Venereol. 2006; 20: 1121-1125Crossref PubMed Scopus (30) Google Scholar, 3Malaque C.M. Santoro M.L. Cardoso J.L. Conde M.R. Novaes C.T. Risk J.Y. et al.Clinical picture and laboratorial evaluation in human loxoscelism.Toxicon. 2011; 58: 664-671Crossref PubMed Scopus (48) Google Scholar, 4Efrati P. Bites by Loxosceles spiders in Israel.Toxicon. 1969; 6: 239-241Crossref PubMed Scopus (17) Google Scholar Loxoscelism—including dermonecrosis and systemic manifestations such as thrombocytopenia—is not familiar to most pediatricians and medical staff. Healthcare should consider loxoscelism in the appropriate clinical setting for correct diagnosis and optimal treatment of this disease.