Letters to Editor

GGurcharanurcharan Singh,Singh, G.G. AArchanarchana Department of Dermatology and STD, Sri Devaraj Urs Medical College, Tamaka, Kolar-563 101, India

AAddressddress fforor ccorrespondence:orrespondence: Dr. Gurcharan Singh, 108, A, Jal Vayu Vihar, Kamanahalli, Bangalore-560 043, India. E-mail: [email protected]

RREFERENCESEFERENCES

1. Pareek A, Khopkar U, Sacchidanand S, Chandurkar N, Naik GS. Comparative study of efficacy and safety of hydroxychloroquine and chloroquine in polymorphic light eruption: A randomized, double-blind, multicentric study. Indian J Dermatol Venereol Leprol 2008;74:18-22. 2. Nyberg F, Hasan T, Puska P, Stephansson E, Häkkinen M, Figure 1: Spider nevi Ranki A, et al. Occurrence of polymorphous light eruption in lupus erythematosus. Br J Dermatol 1997;136:217-21. Dermatological examination showed hundreds of 3. Murphy GM, Hawk JL.The prevalence of antinuclear erythematous macules 2–5 mm in size, mainly over the antibodies in patients with apparent polymorphic light front of the chest, upper abdomen and a few on the upper eruption. Br J Dermatol 1991;125:448–51. and back [Figure 1]. The central body and the vessels 4. Yam JC, Kwok AK. Ocular toxicity of hydroxychloroquine. radiating from it, could be seen clearly in a few lesions; Hong Kong Med J 2006;12:294-304. mucous membranes were spared. There was no other 5. Jones. SK Ocular toxicity and hydroxychloroquine: Guidelines dermatological evidence of chronic disease. for screening. Br J Dermatol 1999;140:3-7.

Hematological investigations revealed thrombocytopenia: 1,25,000 (Normal = 1,50,000–4,50,000); prothrombin time SSpiderpider nevi:nevi: A ppresentingresenting featurefeature = 17 s (control: 13 s ) and activated partial thromboplastin time = 36 s (control: 26 s) were prolonged. Viral markers for ooff cchronichronic lliveriver ddiseaseisease hepatitis were all absent. Total level was 85.7 pg/ mL (normal < 56 pg/mL) and the total testosterone level was 218 mg/dL (normal: 245–1836 mg/dL). Tests for antinuclear Sir, antibody and alpha fetoprotein were also negative. Liver The vascular spider, arterial spider or spider is the function tests showed elevated bilirubin (total 4.3 mg/dL) most classical vascular lesion that is sometimes a presenting and elevated enzyme levels (ALT: 93 IU/L, ALP: 328 IU/L) sign of chronic . Spider telangietasia occur (expand abbreviations). sugar and renal parameters in up to 15% of normal individuals and may also be seen were normal. An ultrasound of the whole abdomen showed in pregnant women. The main vessel of the spider is an a shrunken liver with a coarse and nodular echo texture, represented by a red point from which numerous, suggestive of chronic liver disease, splenomegaly and small, twisted vessels radiate. Application of pressure on the ascites. A liver biopsy was not done as the patient was central arteriole with the head of a pin or a match stick causes unwilling to have it done. Based on the above findings, a blanching of the whole lesion. We report here a case with diagnosis of cryptogenic was made. profusion of spider nevi predating the onset of liver disease. Spider angioma or araenus is a dilatation of preexisting A 36 year-old, non-alcoholic man presented to the vessels under several circumstatnces.[1] Common causes of Dermatology OPD for evaluation of multiple, eight months spider nevi are listed in Table 1. old, erythematous, asymptomatic macules distributed mainly over the front of the chest, with a few on the upper Spider nevi are commonly distributed over the face, arm and back [Figure 1]. The rash was earlier diagnosed as necklace area, forearms, hands and the upper part of chest, an allergic reaction and was treated with antihistamines by a i.e., mainly over the region drained by the superior vena general physician. Six months after the patient presented to cava.[2] Vascular spiders have been attributed to excessive us, he developed jaundice and was investigated and found levels of estrogen because cause blood vessels to to have chronic liver disease. enlarge and dilate.[3] Serum estradiol and total testosterone

Indian J Dermatol Venereol Leprol | July-August 2008 | Vol 74 | Issue 4 397 Letters to Editor

Dermatology in internal medicine. 5th ed. New York: Table 1: Causes of spider nevi McGrowHill; 1999. p. 1909–29. 10–15% normal adults and young children 2. Champion RH. Disorders of blood vessels. In: Champion RH, Burton JL, Ebling FJ, editors. Rook / Wilkinson / Ebling Familial Textbook of Dermatology. 5th ed. Oxford: Blackwell science Chronic liver disease Publishers; 1992. p. 1827–49. Thyrotoxicosis 3. Akiyama M, Inamoto N. Arteriovenous haemangioma in Estrogen therapy for rheumatoid arthritis chronic liver disease – clinical and hisopathologic features Oral contraceptive pills of four cases. Br J Dermatol 2001;144:604–9. 4. Whiting DA, Kallmeyer JC, Simson IW. Widespread arterial levels are altered particularly in male patients with cirrhosis spiders in a case of latent hepatitis with resolution after and spiders. Serum estradiol levels are increased and the therapy. Br J Dermatol 1970;82:32–6. 5. Requena L, Sangueza OP. Cutaneous vascular anomalies Part total free testosterone level is reduced, thus leading to I, Hamartomas, malformation and dilation of preexisting high estradiol/free testosterone ratios in male patients with vessels. J Am Acad Dermatol 1997;37:523–49. spiders. Regression of spiders in patients with liver disease 6. Zaman A, Hapke R, Flora K, Rosen HR. Bennerk in Factors is possible with an improvement in the underlying condition predicting the presences of esophageal or in although persistence of these spiders is more likely.[4] patients with advanced liver disease. Am J Gasteroenterol 1999;95:3292–6. Morphological studies and reconstruction methods demonstrated that spiders represent an arteriole and an organ with five separate parts: FFanconi’sanconi’s anemiaanemia 1. A cutaneous arterial net, 2. A central spider arteriole, 3. A subepidermal ampulla Sir, 4. A star-shaped arrangement of afferent spider vessels, Fanconi described a fatal disorder in three brothers, that was and characterized by pancytopenia, bone marrow hypoplasia [5] 5. and congenital anomalies.[1] Although rare, the disorder is sufficiently common that an international study group has Awareness of the association of spider nevi with systemic been established to register clinical experience.[2] The disorder illnesses is essential to determine the underlying pathology. is characterized by a variable clinical picture consisting of This case is presented for two reasons: 1. As spider nevi can pancytopenia, skeletal abnormalities, neurological and precede liver diseases, it would be advisable to screen the endocrine disorders, chromosomal instability, and an patients with spider nevi for liver disease as early detection increased risk of leukemia and other tumors. could prove to be beneficial to the patient, 2. The presence of spider nevi is also considered to be one of the physical A seven year-old female child born to nonconsanguineous findings predicting the presence of esophageal or gastric parents was brought to our out patient department for [6] varices in patients with advanced liver disease. It could three year-old pigmentary changes on the trunk and therefore be cost-effective to screen and identify a group of limbs. There was no similar history in the family. General patients who would most benefit from endoscopic screening examination revealed gross pallor, while cutaneous for varices. examination revealed hypo- and hypopigmented macules 0.1–1 cm in size, distributed on the , trunk, and the MMayaaya VVedamurthy,edamurthy, AmarAmar VVedamurthyedamurthy dorsae of the hands and feet. Axillae, groins and palms and Department of Dermatology, Apollo Hospitals, Chennai, India soles were also involved. A single café-au-lait macule was AAddressddress fforor CCorrespondence:orrespondence: Dr. Maya Vedamurthy, AB-76, I street, present on the chest. The left thumb showed syndactyly. Annanagar, Chennai-600 040, India. Hemoglobin (Hb) was 3.5 g%; sickling test was negative E-mail: [email protected] while Hb electrophoresis showed the presence of HbA and RREFERENCESEFERENCES HbF (15.7%). An X-ray of the left hand showed syndactyly of the left thumb. Ultrasonography of the abdomen showed 1. Robin AC Graham–Browne, Rathbone B, Marks J. The a mild echogenic center in the liver. Bone marrow biopsy and disorders of the alimentary tract. In: Freedberg IM, revealed a hypoplastic marrow of moderate degree. Eisen AZ, Austen KF, Goldsmith LA, Katz SI et al, editors. Histopathological examination of the skin showed a mild

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