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Lonomia Obliqua Caterpillar Envenoming

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Lonomia Obliqua Caterpillar Envenoming Arq Neuropsiquiatr 2006;64(4):1030-1032 FATAL INTRACEREBRAL HEMORRHAGE SECONDARY TO LONOMIA OBLIQUA CATERPILLAR ENVENOMING Case report Pedro André Kowacs1, Juliana Cardoso1, Marlene Entres2, Edison Mattos Novak1, Lineu César Werneck1 ABSTRACT - The case of a 70 year-old, previously healthy woman who developed a severe bleeding diathe- sis shortly after touching a Lonomia obliqua caterpillar and finally died from multiple intracerebral hem- o rrhages is described. Brain hemorrhages are the leading cause of death in patients envenomed by the Lonomia species. The pertinent literature is reviewed and the most relevant clinical features highlighted, with emphasis on diagnosis. The use of new therapeutic options such as anti-Lonomia serum is discussed. KEY WORDS: intracerebral hemorrhage, Lonomia obliqua, caterpillar envenoming. Hemorragia intracerebral fatal causada por acidente com Lonomia obliqua: relato de caso RESUMO - O caso de uma mulher de 70 anos, previamente hígida, que desenvolveu diátese hemorrágica grave após contato com uma lagarta Lonomia obliqua, resultando em óbito por hemorragia intracere b r a l é relatado. Hemorragias cerebrais são uma das causas de morte em acidentes por Lonomia. A literatura p e rtinente é revisada, sendo as características clínicas e laboratoriais mais relevantes discutidas com ênfase para o diagnóstico, e o uso de novas abordagens terapêuticas como o soro anti-Lonomia. PALAVRAS-CHAVE: hemorragia intracerebral, Lonomia obliqua, envenenamento, lagartas urticantes. First described by Arocha-Pinango and Layrisse in CASE Venezuela in 19671, the hemorrhagic diathesis caused A 70 year-old, previously healthy woman developed a in humans by touching the Lonomia species begins sudden coma. Four days before, she had started to pre s e n t with inflammatory changes at the site of envenom- hematuria. Shortly after admission, her coma was rated as Glasgow 3. Physical examination revealed several skin hem- ing, followed by systemic symptoms such as headache, o rrhages, and gross hematuria was present. Based on infor- f e v e r, vomiting and malaise. After 24 hours, a severe mation in a note left by the patient, two small hyperemic bleeding disorder ensues, leading to echimosis, hema- lesions were identified on the tip of her left toe. Along turia, pulmonary and intracranial hemorrhages, and with the note was the the green caterpillar (Fig 1) which acute renal failure2.TwospeciesofLonomia a r e was hidden inside of her slipper. CT-scan imaging re v e a l e d known to cause the hemorrhagic syndrome, L o n o m i a multiple intracerebral hemorrhages (Fig 2). She died sev- achelous, found in Venezuela and the north of Brazil, en days after being envenomed. Her laboratory data is sum- and Lonomia obliqua, found in the south of Brazil1 , 3 , 4. marized in the Table. Although there are diff e rences in the effect of the venom of both species, both venoms may lead to DISCUSSION intense fibrinolytic activity associated with consump- P resentation of the symptoms of caterpillar enven- tion coagulopathy, resembling a diffuse intravascu- oming can generally be classified as follows: a) eru- lar coagulation5 - 7 . A case of accidental Lonomia obli - cism (a local inflammatory reaction); b) lepidopter- qua envenoming is described, and its implications ism (systemic reactions); c) dendrolimiasis (a chronic a re discussed. The re p o rt was approved by the insti- f o rm of lepidopterism characterized by derm a t i t i s , tutional regulatory committee. m i g r a t o ry inflammatory polyarthritis or polychondri- 1N e u rology Division of the Internal Medicine Department, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brazil; 2Center for Poisoning Control of the State of Paraná Health Office, Curitiba, Brazil. Received 6 September 2005, received in final form 28 June 2006. Accepted 15 August 2006. Dr. Pedro André Kowacs - Serviço de Neurologia / Departamento de Clínica Médica / Hospital de Clínicas da Universidade Federal do Paraná - Rua General Carneiro 181 / 12º andar / sala 1236 - 80060-900 Curitiba PR - Brasil. E-mail: [email protected] Arq Neuropsiquiatr 2006;64(4) 1031 Table. Laboratory results. Admission Sixth Seventh Reference (fifth day) day day values Hematocrit (%) 36 28 30.3 35 - 45 Leukocyte count x103/µl 17,700 12,100 8,500 4,800 - 10,800 Platelet count x103/µl 169,000 114,000 110,000 150,000 - 450,000 PT (seconds) 18.5 19.7 17.5 11-15 PTT (seconds) 58.6 47 >100 25 - 35 Creatinine (mg/dL) 0.8 – 1.1 0.6 - 1.2 Na+ (meq/L) 138 135 - 145 K+ (meq/L) 4.0 3.5 - 5.0 Glucose (mg/dL) 75 60 - 110 Fibrinogen (mg/dL) 92.4 175 - 433 *Conventional units. Fig 1. Lonomia obliqua caterpillar. tis, chronic osteoarthritis and acute scleritis); d) oph- thalmia nodosa (caused by specific families of cater- pillars); and e) comsumptive coagulopathy with sec- ondary fibrinolysis8. Fig 2. Ct-scan imaging with multiple intracerebral hemorrh a g e s . The clinical manifestations of Lonomia sp e n v e n- oming can include a local inflammatory re a c t i o n , which starts immediately after contact; systemic re a c- l i 1 1 , 1 2 . The best characterized toxin in this venom is tions such as headache, fever, vomiting and asthe- known by its acronym LOPA P, Lonomia obliqua p ro- nia, which start some hours after exposure; and a thrombin activator protease13. bleeding diathesis, characterized by hematomes and Lonomia e n v e n o m i n g i s f r eq u en t i n Br a zil . In t h e e c c h y m o s e s , h e m a t u r i a , p u l m o n a r y h e m o r r h a g e , state of Paraná alone, in the south of Brazil, 354 cas- 2 , 7 , 9 i n t r a c e rebral hemorrhage and acute renal failure . es were re p o rted between 1989 and 20051 4 . In the D ue to their gr eater ex po sur e t o t he env iro n m e n t , same State, lethality has been decreasing, and fell men are more frequently envenomed than women. from 20% in 1995 to 1.5% in 1998, but, interesting- The site of envenoming usually involves the upper ly enough, intracranial hemorrhage was confirm e d limbs, as the catterpillars live in fru c t i f e rous tre e s4 , 1 0. as the leading cause of death in three out of the six The severity of the envenoming is related not only fatal cases re p o rted. In the remaining three fatal cas- to the number of caterpillars involved but also to the es this data was unavailable due to insuffient ancil- 10,14 intensity of the exposure, since the venom is pre s e n t lary support in the rural areas . not only in the caterpillars’ spines but also in their Attempts to clarify the underlying mechanisms of skin, which consists of a complex tegument with sev- intracranial hemorrhage focused on the blood-brain eral cuticular specializations such as spicules or sco- barrier in Wistar rats six hours after exposure to Lo - 1032 Arq Neuropsiquiatr 2006;64(4) nomia obliqua venom. Hippocampal and cere b e l l a r ly intervention lead to fewer hemorrhagic complica- edema were observed, and these resolved 72 hours tions. after the envenoming. Only a single rat out of 2 8 , h o w e v e r, developed intracerebral hemorrh a g e1 5 . In Acknowledgements – The authors express their thanks to Giselia Burigo Guimarães Rubio, Chefe da Divisão de Zo- another study, the venom could not be traced in the onoses da Saúde do Estado do Paraná, for releasing SESA brain 6 and 18 hours after administration, but could datafiles for analysis. be found in the kidneys and liver. This evidence sug- gests that the brain is less vulnerable to LOPAP and REFERENCES that toxins other than LOPAP may also be the cause 1. A rocha-Piñango CL, Layrisse M. Fibrinolysis produced by contact with a caterpillar. Lancet 1969;1:810-812. of brain damage in Lonomia envenoming. It also 2. Veiga ABG, Pinto AFM, Guimarães JA. Fibrinogenolytic and pro c o a g- points to an interaction between both the venom ulant activities in the hemorrhagic syndrome caused by Lonomia obli - qua caterpillars. Thromb Res 2003;111:95-101. 1 5 and individual factors . I n d e e d , u n t i l t h e p r e s e n t 3. L e m a i re C. Révision du genre Lonomia Walker (Lep.Attacidae). A n n case, intracranial hemorrhages leading to death had Soc Entomol France 1972;8:767-861. 4. Fariha Neto H, Ballarini AJ, Leão RNQ, Costa D Jr , Dias LB. Síndro m e only been described in cases of severe envenoming hemorrágica por contato com larvas de mariposa (Lepidóptera, after exposure to multiple Lonomia caterpillars at Saturnidae). Instituto Evandro Chagas, 50 anos de contribuição às ciên- cias biológicas e à medicina tropical. Fundação SESP 1986;2:811-820. the same time. 5. A rocha-Piñango CL, Blumenfeld-Bosch N, Nouel AL, et al. Fibrinolytic L a b o r a t o r y f i n d i n g s i n c l u d e a n o r m a l p l a t e l e t and procoagulant agents from a saturniidae moth caterpillar. In Pirkle H, Markland FS Jr (eds).
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