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Severe Thrombocytopenia and Dermonecrosis after Loxosceles Spider Bite in a 3-Year-Old Child
Severe Thrombocytopenia and Dermonecrosis after Loxosceles Spider Bite in a 3-Year-Old Child
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.1-3 In Israel, certified bites of L rufescens have been reported and many cases of loxoscelism have been described.1,4 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.1-3 Loxosceles venom contains enzymes (hyaluronidase, alkaline phosphatase, esterase, and sphingomyelinase D2) responsible for tissue destruction and cytotoxicity.1-3 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.1,3,4 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. n Carina Levin, MD Pediatric Hematology Unit and Pediatric Department B Emek Medical Center The Ruth and Baruch Rappaport School of Medicine Technion, Israel Institute of Technology
Dganit Rozemman, MD Dermatological Department Emek Medical Center The Ruth and Baruch Rappaport School of Medicine Technion, Israel Institute of Technology
Waheeb Sakran, MD Raphael Halevy, MD Sarit Peleg, MD Pediatric Department B Emek Medical Center The Ruth and Baruch Rappaport School of Medicine Technion, Israel Institute of Technology
Ariel Koren, MD Pediatric Hematology Unit and Pediatric Department B Emek Medical Center Figure. Patient’s right foot showing petechial skin rash and a dermonectrotic lesion in the right big toe with swelling, redness, and a erythematous halo around the necrotic area with the typical gravitational spread of the venom.
J Pediatr 2013;163:1228. 0022-3476/$ - see front matter. Copyright ª 2013 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2013.04.057
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The Ruth and Baruch Rappaport School of Medicine Technion, Israel Institute of Technology
References available at www.jpeds.com
Vol. 163, No. 4 October 2013
References 1. Dyachenko P, Ziv M, Rozenman D. Epidemiological and clinical manifestations of patients hospitalized with brown recluse spider bite. J Eur Acad Dermatol Venereol 2006;20:1121-5. 2. McDade J, Aygun B, Ware RE. Brown recluse spider (Loxosceles reclusa) envenomation leading to acute hemolytic anemia in six adolescents. J Pediatr 2010;156:155-7.
3. Malaque CM, Santoro ML, Cardoso JL, Conde MR, Novaes CT, Risk JY, et al. Clinical picture and laboratorial evaluation in human loxoscelism. Toxicon 2011;58:664-71. 4. Efrati P. Bites by Loxosceles spiders in Israel. Toxicon 1969;6: 239-41.
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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.1-3 In Israel, certified bites of L rufescens have been reported and many cases of loxoscelism have been described.1,4 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.1-3 Loxosceles venom contains enzymes (hyaluronidase, alkaline phosphatase, esterase, and sphingomyelinase D2) responsible for tissue destruction and cytotoxicity.1-3 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.1,3,4 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. n Carina Levin, MD Pediatric Hematology Unit and Pediatric Department B Emek Medical Center The Ruth and Baruch Rappaport School of Medicine Technion, Israel Institute of Technology
Dganit Rozemman, MD Dermatological Department Emek Medical Center The Ruth and Baruch Rappaport School of Medicine Technion, Israel Institute of Technology
Waheeb Sakran, MD Raphael Halevy, MD Sarit Peleg, MD Pediatric Department B Emek Medical Center The Ruth and Baruch Rappaport School of Medicine Technion, Israel Institute of Technology
Ariel Koren, MD Pediatric Hematology Unit and Pediatric Department B Emek Medical Center Figure. Patient’s right foot showing petechial skin rash and a dermonectrotic lesion in the right big toe with swelling, redness, and a erythematous halo around the necrotic area with the typical gravitational spread of the venom.
J Pediatr 2013;163:1228. 0022-3476/$ - see front matter. Copyright ª 2013 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2013.04.057
1228
The Ruth and Baruch Rappaport School of Medicine Technion, Israel Institute of Technology
References available at www.jpeds.com
Vol. 163, No. 4 October 2013
References 1. Dyachenko P, Ziv M, Rozenman D. Epidemiological and clinical manifestations of patients hospitalized with brown recluse spider bite. J Eur Acad Dermatol Venereol 2006;20:1121-5. 2. McDade J, Aygun B, Ware RE. Brown recluse spider (Loxosceles reclusa) envenomation leading to acute hemolytic anemia in six adolescents. J Pediatr 2010;156:155-7.
3. Malaque CM, Santoro ML, Cardoso JL, Conde MR, Novaes CT, Risk JY, et al. Clinical picture and laboratorial evaluation in human loxoscelism. Toxicon 2011;58:664-71. 4. Efrati P. Bites by Loxosceles spiders in Israel. Toxicon 1969;6: 239-41.
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