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Case report
DOI: 10.1016/j.sedeng.2019.10.004
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Available online 9 April 2020
Systemic loxoscelism in an epileptic patient. Case report
Loxoscelismo sistémico en un paciente epiléptico. Reporte de caso
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Rafael Pichardo-Rodrigueza, J. Antonio Grandez-Urbinab,
Corresponding author
jagrandez@gmail.com

Corresponding author.
, Saarah Zegarra del Rosario-Alvaradoa, Victor A. del Carpio-Yañeza, Marcos Saavedra-Velascoa, Herney Andrés Garcia-Perdomoc
a Instituto de Investigaciones en Ciencias Biomédicas (INICIB), Universidad Ricardo Palma, Lima, Peru
b Universidad Continental, Lima, Peru
c Escuela de Medicina, Universidad del Valle, Cali, Colombia
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Abstract
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Table 1. Laboratory test findings.
Abstract

Loxoscelism is the clinical problem produced by the bite of a spider of the genus Loxosceles. The most severe presentation is systemic loxoscelism that can compromise the patient's life if it is not diagnosed and treated in time. There are no reports about how it presents in patients with an epilepsy diagnosis. We present the case of a 28-year-old male patient, with a prior history of epilepsy in treatment with anticonvulsants. He developed systemic loxoscelism after a spider bite in the posterior middle third of the right arm. However, the patient did not develop seizures despite the unfavourable course of his clinical symptoms.

Keywords:
MeSH
Spider venom
Epilepsy
Brown recluse spider
Resumen

El loxoscelismo es el cuadro clínico producido por la picadura de una araña del género Loxosceles. Tiene 2 presentaciones clínicas, siendo el loxoscelismo sistémico el cuadro más grave, que puede comprometer la vida del paciente si no es diagnosticada y tratada a tiempo. No existen reportes acerca de su presentación en pacientes con diagnóstico de epilepsia. Presentamos el caso de un paciente varón de 28 años, con historia previa de epilepsia en tratamiento con anticonvulsivantes que desarrolló loxoscelismo sistémico posterior a la picadura de una araña en el tercio medio posterior del brazo derecho. El paciente no desarrolló convulsiones pese al curso desfavorable del cuadro clínico.

Palabras clave:
DeCS-BIREME
Veneno de araña
Epilepsia
Araña reclusa parda
Full Text
Introduction

Loxoscelism is the clinical problem caused by the bite of a spider of the genus Loxosceles. It can manifest itself in cutaneous (83.3%) or systemic (16%) form.1,2 A variant of the skin condition called loxoscelism with oedematous predominance has been described, which occurs when the bite is at the level of the face.1,2

The systemic form is the most severe presentation of loxoscelism, compromising the patient's life if not diagnosed and treated in time. Its physiopathology has not been fully determined and clinically it greatly compromises general condition, with fever, jaundice, pallor, haematuria, haemoglobinuria that can reach acute renal failure generally within 12–24h after the sting.1 There are no reports on its presentation in patients with a diagnosis of epilepsy and associated clinical manifestations.

The aim is to present the case of a patient with a history of epilepsy who developed systemic loxoscelism after a spider bite and did not develop seizures despite the unfavourable picture as the beginning of a case series that supports the prophylactic use of anticonvulsants to prevent seizures in patients with systemic loxoscelism.

Clinical case

A 28-year-old male with a history of epilepsy, hyperactivity and impulsivity under treatment with valproic acid 500mg oral (po) every/12h, fluoxetine 20mg po every/24h and risperidone 2mg po every/24h. He attended the emergency department with clinical symptoms of 2 days’ duration characterised by the appearance of an ecchymotic lesion located on the posterior middle third of the right arm limiting movement, jaundice and haemoglobinuria of 2 days’ duration of insidious onset that originated after a spider bite. The patient reported no seizures. He added that one day prior to admission he experienced numbness at the site of the bite and hyporexia. He reported that inflammation and pain decreased with the application of ice packs.

On examination, his blood pressure was 140/100mmHg. Skin and mucous membrane jaundice was observed, and a purplish ecchymotic lesion was found on the posterior middle third of the right arm extending to the axillary region associated with vesicles and haemorrhagic blistering, which was painful on palpation with increased volume and limited movement (Fig. 1). The patient was hospitalised with a presumptive diagnosis of systemic loxoscelism and associated cellulitis and auxiliary laboratory and ultrasound tests were requested. Treatment was initiated with clindamycin, 600mg intravenous (iv) every/8h, hydrocortisone, 100mg iv every/6h and chlorphenamine, 10mg iv every/6h and intravenous hydration. And his anticonvulsant treatment was continued.

Figure 1.

Violaceous ecchymotic lesion in posterior middle third of the right arm following a spider bite.

(0.06MB).

Laboratory findings indicated the presence of acute haemolytic anaemia, acute inflammatory process with leukocytosis and left shift, eosinophilia, monocytosis, haematuria, leukocyturia, acute renal failure and possible acute liver damage, with coagulation tests within normal parameters. The results are summarised in Table 1. Ultrasound ruled out the possibility of deep tissue involvement and revealed only superficial involvement and the presence of laminar fluid at the site of the bite.

Table 1.

Laboratory test findings.

  Result 
LeukocytesNeutrophilsMonocytesEosinophils  42,700cel/μl37,060cel/μl3060cel/μl530cel/μl 
Indirect bilirubin  8.13mg/dl 
Dehydrogenase lactateGlucoseCreatinineUreaGOT  456U/l281mg/dl1.48mg/dl77mg/dl175U/l 
GPT  23U/l 
Prothrombin time  15.2
INRCoagulation timeUrine test  1.108minGranular cylindersColour: brownLeukocytes: 10–12Haemoglobin: +++ 

INR: international normalised ratios (INR); GOT: glutamic-oxaloacetic transaminase; GPT: glutamic pyruvic transaminase.

During his hospital stay a nursing care plan was developed for the patient with possible systemic loxoscelism as protection against infection, treatment of hyperthermia, intravenous therapy, monitoring of vital signs, monitoring of the skin and wound care. However, the patient did not progress well, there was no improvement, and it was decided to refer him to a more complex hospital. During his stay in the referral hospital, the diagnosis of systemic loxoscelism was confirmed, the patient went into severe acute renal failure with a favourable response to dialysis treatment. He was discharged requiring outpatient management of the necrotic skin lesion by plastic surgery specialists.

Discussion

The association between systemic loxoscelism and epilepsy has not been reported in the literature. The possibility of seizures occurring when the systemic symptoms are severe has been described, however, our patient did not develop seizures during the course of his condition despite its being unfavourable, probably also due to the continuation of anticonvulsant treatment, which appeared to have a significant effect.3 Clinical manifestations such as jaundice, haematuria and haemoglobinuria together with the findings of the laboratory tests plus the history of the earlier spider bite confirmed the diagnosis of systemic loxoscelism.1,4

The presence of numbness or anaesthesia in the area of the lesion is not common in loxoscelism, because it is usually associated with burning pain that progresses as symptoms evolve. Moreover, some cases of necrotic cutaneous loxoscelism report constant, burning local pain with local inflammation.5,6

However, Gross et al.7 reported the presence of persistent segmental skin anaesthesia that appeared after the bite of a spider of the genus Loxosceles at the level of the distribution area of the transverse cervical skin nerve, evidencing an effect of the venom on the nervous system. We do not know if it could also be the result of anticonvulsant drug consumption. We added the hypothesis that the neurological effect of the poison was probably due to the action of peptides of the inhibitor cystine-knot family (ICK), a group of toxins with a molecular weight of approximately 5.6–7.9kDa likely to be involved in the development of seizures due to their effects on voltage-dependent channels of calcium and sodium.4 We assume that they affected the sensory skin innervation of our patient. However, there was a rapid improvement probably due to the anatomical characteristics and individual susceptibility of the affected limb. There is doubt as to why the central nervous system was not affected, probably because the poison could not cross the blood-brain barrier due to its physical–chemical characteristics.

Monocytosis and eosinophilia were observed, uncommon findings in loxoscelism. Monocytosis occurs more frequently in chronic infections and systemic inflammatory diseases such as tuberculosis, lupus and sarcoidosis, among others.8 Luiz Tavares et al.9 show in animal models that within 72–120h after exposure to the toxin left shift and monocytosis develop. In our patient, sampling took place within the range of 48–72h, outside the range reported in the literature, possibly due to individual patient susceptibility, physiological difference compared to animal models and their consumption of anticonvulsants. Eosinophilia is not a frequent finding in loxoscelism, although it is reported that it may occur 72h following exposure to the toxin in animal models.9 Although a study by Elston et al.10 has shown infiltration into skin tissue by eosinophils in rabbits inoculated with Loxosceles venom, there is no clear evidence of its increase in peripheral blood in humans. On the other hand, eosinophilia may be associated with drug consumption, with anticonvulsants reported to cause generally mild eosinophilia (>500 and <1500 eosinophils).11 In our case, the eosinophilia was possibly associated with the consumption of valproic acid, as well as systemic loxoscelism.

The treatment of systemic loxoscelism varies according to the time since onset. After 24–48h, the time recommended for using anti-venom, support measures become the essential procedures for management and strict surveillance should be maintained for a minimum of 3 days.3 It was impossible to use the anti-loxoscelic serum due to a time since onset of more than 48h. The support measures applied in the referral hospital due to the patient's clinical deterioration were essential for the management of the patient with favourable results.

Conclusion

This is the first report of systemic loxoscelism in a patient with epilepsy, who did not present with further seizures despite the severity of the case. In addition, monocytosis, eosinophilia and anaesthesia of the site of the bite are rare findings that may be associated with the action of certain components of the venom.

Funding

The authors received no funding for this paper.

Authors

RPR and VDY conceived the idea of the manuscript.

JGU, SZR and HAGP critically reviewed the manuscript and approved the final version.

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Please cite this article as: Pichardo-Rodriguez R, Grandez-Urbina JA, Zegarra del Rosario-Alvarado S, del Carpio-Yañez VA, Saavedra-Velasco M, Garcia-Perdomo HA. Loxoscelismo sistémico en un paciente epiléptico. Reporte de caso. Rev Cient Soc Esp Enferm Neurol. 2020. https://doi.org/10.1016/j.sedene.2019.10.004

Copyright © 2019. Sociedad Española de Enfermería Neurológica
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