Advertisment Nexovas Cilnidipine
Indian Journal of Nephrology About us |  Subscription |  e-Alerts  | Feedback | Login   
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size
 Home | Current Issue | Archives| Ahead of print | Search |Instructions |  Editorial Board  

Users Online:273

Official publication of the Indian Society of Nephrology
  Search
 
  
 ~  Similar in PUBMED
 ~  Search Pubmed for
 ~  Search in Google Scholar for
 ~Related articles
 ~  Article in PDF (862 KB)
 ~  Citation Manager
 ~  Access Statistics
 ~  Reader Comments
 ~  Email Alert *
 ~  Add to My List *
* Registration required (free)  

 
   Abstract
  Introduction
  Case Report
  Discussion
   References
   Article Figures

 Article Access Statistics
    Viewed2179    
    Printed54    
    Emailed0    
    PDF Downloaded117    
    Comments [Add]    

Recommend this journal

 


 
  Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 24  |  Issue : 4  |  Page : 246-248
 

Acute kidney injury and dermonecrosis after Loxosceles reclusa envenomation


Department of Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India

Date of Web Publication10-Dec-2013

Correspondence Address:
S Mondal
Doctor's Hostel, 242, A.J.C Bose Road, Kolkata - 700 020, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-4065.133017

Rights and Permissions

  Abstract 

Spiders of the Loxosceles species can cause dermonecrosis and acute kidney injury (AKI). Hemolysis, rhabdomyolysis and direct toxin-mediated renal damage have been postulated. There are very few reports of Loxoscelism from India. We report a case of AKI, hemolysis and a "gravitational" pattern of ulceration following the bite of the brown recluse spider (Loxosceles spp).


Keywords: Dermonecrosis, renal failure, spider bite


How to cite this article:
Nag A, Datta J, Das A, Agarwal A K, Sinha D, Mondal S, Ete T, Chakraborty A, Ghosh S. Acute kidney injury and dermonecrosis after Loxosceles reclusa envenomation. Indian J Nephrol 2014;24:246-8

How to cite this URL:
Nag A, Datta J, Das A, Agarwal A K, Sinha D, Mondal S, Ete T, Chakraborty A, Ghosh S. Acute kidney injury and dermonecrosis after Loxosceles reclusa envenomation. Indian J Nephrol [serial online] 2014 [cited 2019 May 24];24:246-8. Available from: http://www.indianjnephrol.org/text.asp?2014/24/4/246/133017



  Introduction Top


Spider bite is endemic in parts of North America, Mexico, tropical belt of Africa and Europe and can cause serious systemic manifestations. [1],[2],[3],[4],[5] Loxosceles spiders belong to the family Loxoscelidae/Sicariidae. Of the 13 species of Loxosceles identified, at least 5 have been associated with necrotic arachnidism. Loxosceles reclusa, or the brown recluse spider, is the spider most commonly responsible for this injury. [6] Dermonecrotic arachnidism refers to the local skin and tissue injury as a result of spider-bite. Loxoscelism is the term used to describe the systemic clinical syndrome caused by envenomation from the brown spiders. Cutaneous manifestations occur in around 80% cases around the site of bite, predominantly the lower limbs. [3] The initial cutaneous manifestation is that of an erythematous halo with edema around the bite site. The erythematous margin around the site continues to enlarge peripherally, secondary to gravitational spread of the venom into the tissues. This gradually gives way to vesicles and finally a dark eschar or a necrotic ulcer. [7] Mild systemic effects such as fever, malaise, pruritus and exanthema are common, whereas intravascular hemolysis and coagulation, sometimes accompanied by thrombocytopenia and renal failure, occur in approximately 16% of those who receive the bite. [8] Rarely (<1% of the cases of suspected L. reclusa bites with a higher incidence in South American loxoscelism), recluse venom may cause hemolysis, disseminated intravascular coagulation, which can lead to serious injury and possibly death. [9] Although India is a home to a diverse array of arachnids, according to the latest updated list of spider species found in India, [6] Loxosceles rufescens is the only member of the Loxosceles genus described in India. Systemic envenomation (especially renal failure) from Loxosceles bite has been rarely described from India. [10]


  Case Report Top


A 23-year-old male was bitten by a spider in the dorsal aspect of his right forearm. He developed a painful blister with red margins in the distal forearm, around the site of bite, which subsequently turned into a necrotic lesion. After a few hours, he developed nausea, vomiting and malaise. On the next day, he developed oliguria and brownish discoloration of urine. He had excruciating pain and erythematous swelling of the right hand and around the bite site. Initial blood urea was 133 mg/dl, creatinine 3.4 mg/dl, serum Na + 131.6 meq/L and K + 4.67 meq/L. Hemoglobin was 6.2 g/dl, total leucocyte count 12,000/cmm (N 84 L 12 E 2 M 2 B 0 ) with normal platelet counts. He was referred to our hospital for worsening renal function and deteriorating skin lesions.

On arrival 5 days after the bite, he was conscious and alert. There was blackish discoloration of the right distal forearm and hands and a "gravitational" pattern of involvement from the bite site down into the hands [Figure 1]. Radial pulse was palpable and he had preserved sensation in the fingers of his right hand. He had a normal heart rate while blood pressure was 160/90 mm of Hg. Arterial Doppler of the right forearm revealed normal flow up to the radial arteries. Physical examination was normal otherwise. Though the spider was not brought, it was identified to be the brown recluse spider (Loxosceles spp) based on the description and on showing representative pictures.
Figure 1: "Gravitational pattern" of dermonecrosis following the bite of brown recluse spider (Loxosceles spp), day 5

Click here to view


Investigations revealed hemoglobin of 4.3 gm/dl with normal leucocyte and platelet counts with a reticulocyte count of 9.1%. Urine showed 1 + proteinuria with no red blood cells or cast. He had advanced renal failure with normal electrolytes, serum urea 206 mg/dl and creatinine 6.6 mg/dl. Liver function tests were normal with mild unconjugated hyperbilirubinemia (total bilirubin was 2.4 mg/dl with unconjugated bilirubin of 1.9 mg/l). Serum creatine phosphokinase (CPK) was 90 U/l, lactate dehydrogenase (LDH) 588 U/l (normal range: <200 U/l) and serum haptoglobin was 18 mg/dl (normal). Serum and urine myoglobin were normal.

He received hemodialysis for 2 weeks before renal function eventually recovered. The hand ulcer also healed gradually with conservative management. He was discharged after 3 weeks with a daily urine output of 1.8 L, serum creatinine of 1.8 mg/dl, hemoglobin 9.2 gm/dl and LDH of 180 mg/dl. He was seen 4 weeks after discharge. Renal function had normalized (serum creatinine 0.9 mg/dl, normal urine microscopy) and ulcer had healed with desquamation of the involved skin [Figure 2].
Figure 2: Healed skin lesion of the same patient at 6 weeks

Click here to view



  Discussion Top


Acute intravascular hemolysis is a hallmark of loxoscelism. [11] In our case, intravascular hemolysis was evidenced by low hemoglobin level, elevated reticulocyte counts with elevated unconjugated bilirubin, high serum LDH and low serum haptoglobin levels. The likely etiology of renal failure in our case is hemolysis leading to acute tubular injury. There was no evidence of myonecrosis/rhabdomyolysis as evidenced by normal serum CPK and urine myoglobin levels. Although the spider was not brought by the patient for identification, the features were typical of loxoscelism, especially the "gravitational" pattern of dermonecrosis. Most of the case series of Loxoscelism have documented dermonecrosis with a few cases of hemolysis and rare cases of renal injury. [12] However, there have been very few reports from the Indian sub-continent.

Loxoscelism can manifest as necrotic, cutaneous or viscerocutaneous involvement. [2] No specific anti-venom is available for Loxoscelism. Treatment depends on the severity of the disease. Wound debridement, elevation, application of ice and immobilization of the affected area may help ameliorate the extent of cutaneous damage. Tetanus prophylaxis is warranted. [13] Dapsone has been recommended by some authorities to treat dermonecrosis on account of its leucocyte inhibiting properties. Antibiotics are recommended only for documented infection. Patients exhibiting signs of systemic toxicity should be admitted and evaluated for evidence of coagulopathy and renal failure. Urinalysis can provide early evidence of systemic involvement (e.g. hemoglobinuria, myoglobinuria). Hemodialysis support helps to tide over the renal injury. [14]

Spiders of the genus Loxosceles can cause complement-dependent intravascular hemolysis. [8] Glycophorins protect the erythrocytes against complement-mediated hemolysis. It has been found that sphingomyelinase activity of the Loxosceles toxin induces activation of an endogenous metalloproteinase, which then cleaves glycophorins thus rendering it susceptible to complement mediated lysis. Tambourgi et al., in their study observed the transfer of complement-dependent hemolysis to other cells, suggesting that the Loxosceles toxins can act on multiple cells. [8] This observation can explain the relatively significant extent of hemolysis observed in patients with inoculation of small amounts of the toxin (max 30 mg). Loxoscelism causes necrotic dermatologic injury through a unique enzyme; sphingomyelinase D. Loxosceles toxin has also been shown to have hyaluronidase, alkaline phosphatase and esterase activity. These cause degradation of the extracellular matrix and contribute to the spread of the toxin in tissue compartment. This may account for the 'gravitational' pattern of dermonecrosis. The dermatohistopathology of Loxosceles bites include dermal edema, thickening of blood vessel endothelium, leukocyte infiltration, intravascular coagulation, vasodilatation, destruction of blood vessel walls and hemorrhage. [15] Renal injury in loxoscelism has been attributed to pigmentary nephropathy due to hemoglobin or myoglobin, secondary to hemolysis or rhabdomyolysis. [16]

India, belonging to the tropical belt, is home to several insects. However, in the absence of effective reporting systems, many fatal or near-fatal envenomations go unreported. This is reflected by the paucity of case reports of Arachnid bites. Careful clinical and entomological studies should be done to look into this neglected disease entity. It should be borne in mind that a case presenting with acute dermal inflammation or ulceration in a "gravitational" pattern, along with features of hemolysis or rhabdomyolysis or, in rare instances, acute kidney injury could be due to Loxoscelism and it is a close mimicker of hemotoxic snake bite.

 
  References Top

1.Gendron BP. Loxosceles reclusa envenomation. Am J Emerg Med 1990;8:51-4.  Back to cited text no. 1
    
2.Futrell JM. Loxoscelism. Am J Med Sci 1992;304:261-7.  Back to cited text no. 2
    
3.Schenone H, Saavedra T, Rojas A, Villarroel F. Loxoscelism in Chile. Epidemiologic, clinical and experimental studies. Rev Inst Med Trop Sao Paulo 1989;31:403-15.  Back to cited text no. 3
    
4.Sezerino UM, Zannin M, Coelho LK, Gonçalves Júnior J, Grando M, Mattosinho SG, et al. A clinical and epidemiological study of Loxosceles spider envenoming in Santa Catarina, Brazil. Trans R Soc Trop Med Hyg 1998;92:546-8.  Back to cited text no. 4
    
5.White J, Cardoso J, Fan H. Clinical toxinology of spider bites. In: Meier J, White J. Handbook of Clinical Toxinology of Animal Venoms and Poisons. Boca Raton, FL: CRC Press; 1995. p. 259.  Back to cited text no. 5
    
6.Manju S, Molur S, Biswas B. Indian spiders (Arachnida: Araneae): updated checklist 2005. Zoos′ Print J 2005;20:1999-2049.  Back to cited text no. 6
    
7.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.  Back to cited text no. 7
    
8.Tambourgi DV, Morgan BP, de Andrade RM, Magnoli FC, van Den Berg CW. Loxosceles intermedia spider envenomation induces activation of an endogenous metalloproteinase, resulting in cleavage of glycophorins from the erythrocyte surface and facilitating complement-mediated lysis. Blood 2000;95:683-91.  Back to cited text no. 8
    
9.Anderson PC. Missouri brown recluse spider: A review and update. Mo Med 1998;95:318-22.  Back to cited text no. 9
    
10.Golay V, Desai A, Hossain A, Roychowdhary A, Pandey R. Acute kidney injury with pigment nephropathy following spider bite: A rarely reported entity in India. Ren Fail 2013;35:538-40.  Back to cited text no. 10
    
11.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.  Back to cited text no. 11
    
12.Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Dart RC. 2010 Annual Report of the American Association of Poison Control Centers′ National Poison Data System (NPDS): 28 th Annual Report. Clin Toxicol (Phila) 2011;49:910-41.  Back to cited text no. 12
    
13.Swanson DL, Vetter RS. Loxoscelism. Clin Dermatol 2006;24:213-21.  Back to cited text no. 13
    
14.Rees R, Campbell D, Rieger E, King LE. The diagnosis and treatment of brown recluse spider bites. Ann Emerg Med 1987;16:945-9.  Back to cited text no. 14
    
15.Pereira N, Kalapothakis E, Vasconcelos A, Chatzaki M, Campos L, Vieira F, et al. Histopathological characterization of experimentally induced cutaneous loxoscelism in rabbits inoculated with Loxosceles similis venom. J Venom Anim Toxins Incl Trop Dis 2012;18:277-86.  Back to cited text no. 15
    
16.Wright SW, Wrenn KD, Murray L, Seger D. Clinical presentation and outcome of brown recluse spider bite. Ann Emerg Med 1997;30:28-32.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]



 

Top
Print this article  Email this article
 

    

Indian Journal of Nephrology
Published by Wolters Kluwer - Medknow
Online since 20th Sept '07