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Loxoscelism: Proposal of a New Protocol for Treatment

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Loxoscelism: Proposal of a New Protocol for Treatment ical C lin as C e f R o l e a p n o r r t u s o J Journal of Clinical Case Reports Davanzo et al., J Clin Case Rep 2016, 6:3 ISSN: 2165-7920 DOI: 10.4172/2165-7920.1000738 Case Report Open Access Loxoscelism: Proposal of a New Protocol for Treatment Davanzo F1, Rebutti I1, Panzavolta GF1, Morina M2, Fumagalli R3, Scaglione F4* and Garuti F S5 1Poison Control Center, Niguarda Great Metropolitan Hospital, Milan, Italy 2Postgradute School of Clinical Pharmacology and Toxicology, University of Milan, Italy 3Intensive Care Unit 1, Niguarda Great Metropolitan Hospital, Milan, Italy 4Department of Oncology and Hemato-Oncology, University of Milan, Italy 5Hyperbaric Centre, Niguarda Great Metropolitan Hospital, Milan, Italy *Corresponding author: Scaglione F, Department of Hemato-Oncology, University of Milan, Italy, Tel:+390250316950; E-mail: [email protected] Rec date: Feb 04, 2016; Acc date: Mar 25, 2016; Pub date: Mar 28, 2016 Copyright: © 2016 Davanzo F, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited Abstract Loxoscelism is a rare but often underestimated cause of dermonecrosis in emergency departments. Different kinds of treatment are proposed in literature, but a shared management protocol is not yet available. We propose a therapeutic protocol considering a case which occurred in our emergency department, managed with the support of the Poison Control Center (PCC) and the Hyperbaric Unit. In particular, focusing on the risk of bacterial superinfection and necrotizing fasciitis, we suggest to consider the use of hyperbaric therapy. Keywords: Loxoscelism; Clostridia; Spider fangs; Cutaneous a day gradually decreasing, loperamide, and pain killers when loxosceles necessary. Symptoms did not regress and retro-bulbar pain appeared. The patient then contacted our Poison Control Center (PCC) for a Introduction toxicological opinion. The PCC, having consulted the Hyperbaric Unit, suggested she undergo hyperbaric treatment. The patient was Loxoscelism is a syndrome induced by the bite of a spider of the examined by the Hyperbaric Unit physicians on November 12th 2014. Loxosceles species [1]. Brown spider envenomation is a cause of During the examination the patient appeared awake, responsive, necrotizing skin lesion due to spider bites [2] and sometimes can eupneic, with headache accompanied by a severe sense of retro-bulbar provoke systemic complications, the diagnosis is often underestimated. oppression without vision alterations and pain localized to the lesion. In our case a patient was successfully treated with antibiotics, steroids Two lesions, 4 mm wide in diameter, were present on the right eyelid and hyperbaric oxygen therapy. This contribution remarks the and another one, partially secreting, 0.5 mm wide, in the right importance of a multidisciplinary approach in the event of dangerous zygomatic region. The area appeared as a red-violaceous welt with pain spider bites. at acupressure. No reactive lymph nodes were observed. We obtained an intralesional swab for microbiological analysis and we contacted an Case Report arachnologist by phone. According to the description, the spider was likely to be identified as a violin spider. Infection of soft tissues, skin A 39 years old woman consulted the general practitioner on necrosis, and ulcer were diagnosed, therefore hyperbaric oxygen November, 4th 2014 because of a probable spider bite in the right therapy was indicated. On the same day the patient underwent zygomatic region. She was most likely bitten the previous day. The hyperbaric treatment conducted according to the following profile: lesion was attributed to a spider bite because a spider was captured pressure descent rate 2 m/min up to a depth of -18 m, then: 30 minutes near the bed the next morning. The physician described a right in 100% oxygen, 5 minutes in open air, 30 minutes in 100% oxygen, 5 periorbital edema with a probable necrotic area and a severe headache. minutes in open air, 30 minutes in 100% oxygen, and final ascension in Thus he prescribed amoxicillin and clavulanic acid 1g twice a day, oxygen reaching a depth of -3 m at a rate of 2 m/min. After the first betamethasone 1mg once a day and topical gentamicin sulfate with treatment an impressive reduction of pain and edema was noted. The betamethasone valerate. During the following days the edema patient underwent another treatment the same day and other 4 expanded and almost the whole right half of the face was affected. treatments (twice a day for 2 days) using the same profile. Reduction of Moreover, the patient lamented a worsening headache, right ear pain, edema and pain at the lesion was observed again. Because of the diarrhea (4-5 surges a day) and nausea. For these reasons the patient persistent retro-bulbar pain, an magnetic resonance imaging (MRI) presented at Emergency Department on November 7th 2014. The was deemed necessary in order to exclude the presence of physician could observe a right periorbital edema with a probable inflammatory phlegmons. The MRI was carried out on November 14th necrotic area of 0.5 cm in diameter. A retro-auricular welt, attributed 2014 and a mild increase of signal was attributed to a past cellulitis. On to reactive lymphnodes and a reddening of the right half of the face November 14th 2014 the cultural analysis showed a superinfection by were present. Meanwhile, the headache was worsening without rigor Multi Resistant Staphylococcus haemoliticus. On the basis of the nucalis. Blood tests showed an increase of inflammatory markers and favourable results of the hyberbaric therapy another six treatments leucocytosis. Once the insect bite, headache, and diarrhea were were performed, according to table 9 of US NAVY manual, 6th review. diagnosed, a wide spectrum antibiotic therapy was instituted with Eventually, using these treatments, the patient obtained a complete ciprofloxacin 500 mg twice a day for 5 days, betamethasone 4 mg once J Clin Case Rep Volume 6 • Issue 3 • 1000738 ISSN:2165-7920 JCCR, an open access journal Citation: Davanzo F, Rebutti I, Panzavolta GF, Morina M, Fumagalli R, et al. (2016) Loxoscelism: Proposal of a New Protocol for Treatment. J Clin Case Rep 6: 738. doi:10.4172/2165-7920.1000738 Page 2 of 5 resolution of symptoms and the regression of skin lesions. Only a small reasonable first line treatments and useful in every poisonous insect necrotic area was still cicatrizing. bite [16]. Cyproheptadine is used to contrast the effect of serotonin on platelet aggregation and ischemia [2]. However, this treatment has Discussion been found useless in a controlled trial on white rabbits [17]. Antibiotics are frequently administered in order to avoid infective complications [4]. Considering the possible presence of Clostridia in Clinical aspects the fangs of the spider, Penicillin G is probably the best molecule in Early signs and symptoms of cutaneous loxosceles are pruritus, case of C. perfringens infection, but erythromycin and tetracyclines are burning pain, erythema and local induration [3]. Physicians are also possible alternatives [2]. The latter, in particular, besides their generally consulted 24 to 48 hours after the bite [4] and this often antibiotic properties, are known for their anti-inflammatory and causes a delayed therapy. Different evolutions are possible: most immunomodulatory action, which could be useful in this setting. Loxosceles envenomations provoke only a mild inflammatory reaction Using tetracyclines in envenomated rabbits, Paixao and Cavalcante et [5,6] and necrosis is unlikely to present if a lesion is absent 2 to 3 days al. [12,18] observed a decreased expression of metalloprotases 2 and 9 after the bite [7]. Cutaneous loxoscelism with severe edemas occurs in and an avoidance of keratinocyte cell death. Intralesional or systemic 4%, while systemic loxoscelism is far more rare: less than 1% of glucocorticoids are commonly used in clinical practice [19] and, even necrosis induced by Loxesceles reclusa [8]. A serious lesion can if not recommended in cutaneous loxoscelism, could have some increase in size and form a pustule while the erythema enlarges and benefit in viscerocutaneous loxoscelism according to some authors becomes violaceous. A blue macule appears presenting zones of [20,21]. necrosis [3]. An eschar may form in 3 to 7 days [8]. Histopathology in Inhibition of PMN chemotaxis and the consequent reduction of loxoscelism is characterized by thrombosis, hemorrhage, inflammatory skin necrosis are the rationale for the use of dapsone [22] although, infiltrate, dermatitis and liquefactive necrosis [9]. This pattern is even in this case, its use is not supported by strong evidence. Hobbs produced by the effects of toxins present in the venom. The venom [22], in a randomized controlled animal laboratory experiment, contains various enzymes including collagenases, peptidases, compared the treatment with dapsone, dapsone and hyperbaric hyaluronidases and Sphingomyelinase D [10]. Tambourgi et al. [11] oxygen, and a control, finding no clinically significant difference in the demonstrated that the hemolysis inducted by Sphingomyelinase D is three groups. In another study [23] dapsone was found to be able to due to the activation of the complement. Moreover Sphingomyelinase reduce the size of the lesions in guinea pigs. D decreases the EGFR (epidermal growth factor receptor) expression, which is involved in wound repair [12]. Polimorphonuclear leukocytes Hence, its use is still controversial and not free from adverse effects (PMN) infiltrate and metalloproteinases are also involved in tissue including hemolytic anemia. This could generate confusion because damage [10]. In case of infections (typically Clostridia) other factors the venom itself can produce the same effect [24]. Anti-venom is also contribute to the damage: in fact Clostridia is known as a producer of used for systemic loxoscelism, particularly in Brazil, where two sera are alpha toxin that causes myolisis, haemolisis and coagulation disorders available: an antiloxoscelic serum against venoms of [13].
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