Introduction The brown recluse spider (BRS) (Loxosceles reclusa) envenomation can lead to multiple complications, including hemolysis. We present a case of refractory hemolysis after a BRS bite treated with therapeutic plasma exchange (TPE). Case Report A 17-year-old female presented with fever, fatigue, and dyspnea. She was diagnosed with sepsis and received intravenous (IV) fluids, inotropic support, and antibiotics. On hospital day 1 she was noted to have skin lesion consistent with a BRS bite and developed hemolysis. Systemic loxoscelism with hemolysis was then suspected and methylprednisolone IV was initiated. She was discharged with a stable HGB on hospital day 3 on oral prednisolone. She was re-admitted 24 h later, with signs of worsening hemolysis. Methylprednisolone was restarted and she was transfused 4 units of packed red blood cells. TPE was initiated due to the refractory hemolysis. Shortly after the TPE session, her clinical and laboratory status improved. She required no further transfusions and was discharged on a steroid taper. Discussion TPE is an extra-corporeal method to remove substances from the blood by separating plasma from cellular blood components and replacing it with physiologic fluids. TPE has been used for snake envenomation but there are no reports detailing its use for BRS envenomations. Improvement was associated with TPE initiation and may have been due to removal of complement components activated by the spider venom. This report suggests that TPE could be a possible treatment modality for systemic loxoscelism with refractory hemolysis due to BRS envenomation. Further investigation is warranted.

Background Currently 20–35% of pregnant women are obese, posing a major health risk for mother and fetus. It is postulated that an abnormal maternal-fetal nutritional environment leads to adverse metabolic programming, resulting in altered substrate metabolism in the offspring and predisposing to risks of obesity and diabetes later in life. Data indicate that oocytes from overweight animals have abnormal mitochondria. We hypothesized that maternal obesity is associated with altered mitochondrial function in healthy neonatal offspring. Methods Overweight and obese (Body mass index, (BMI) ≥ 25 kg/m2, n=14) and lean (BMI < 25 kg/m2, n=8), African American pregnant women carrying male fetuses were recruited from the Barnes Jewish Hospital obstetric clinic. Maternal and infant data were extracted from medical records. Infants underwent body composition testing in the first days of life. Circumcision skin was collected for isolation of fibroblasts. Fibroblast cells were evaluated for mitochondrial function, metabolic gene expression, nutrient uptake and oxidative stress. Results Skin fibroblasts of infants born to overweight mothers had significantly higher mitochondrial respiration without a concurrent increase in ATP production, indicating mitochondrial inefficiency. These fibroblasts had higher levels of reactive oxygen species and evidence of oxidative stress. Evaluation of gene expression in offspring fibroblasts revealed altered expression of multiple genes involved in fatty acid and glucose metabolism and mitochondrial respiration in infants of overweight mothers. Conclusion This study demonstrates altered mitochondrial function and oxidative stress in skin fibroblasts of infants born to overweight mothers. Future studies are needed to determine the long-term impact of this finding on the metabolic health of these children.

Summary: Pityriasis versicolor is a common skin disease among Zambians and of the patients seen at the skin clinic at University Teaching Hospital, Lusaka, during the past 3 years, 7.4% were there primarily because of this superficial fungal infection.In an open clinical trial, 1% naftifme solution was given in two regimens: 3‐day or 6‐day therapy. Forty patients received the first regimen and of 30 who were followed for 6 weeks, 9 (30.0%) had a mycological cure. The 6‐day regimen was given to 79 patients and of 62 who were followed for 6 weeks, clinical cure was seen in 56 (903%) and mycological cure in 51 (82.3%) with residual hypopigmentation in 55% of patients.In view of the high prevalence of the disease and good results obtained with 1% naftifine (Exo‐deril®) solution, the 6‐day regimen is recommended for treatment.Zusammenfassung: Pityriasis versicolor ist eine häufig vorkommende Hauterkrankung in Zambia. 7.4% der Patienten, die in den letzten drei Jahren an der Universitätshautklinik Lusaka, Zambia, behandelt wurden, leiden an dieser oberflächlichen Pilzinfektion. In einer offenen klinischen Studie erprobten wir eine 1%ige Naftifin Lösung in 3tägiger oder 6tägiger Therapie. 40 Patienten erhielten die 3tägige Therapie, davon wurden 30 Patienten 6 Wochen klinisch überwacht. 9 (30%) hatten eine mykologische Heilung. Dem 6tägigen Therapieschema waren 79 Patienten zugeordnet und 62 wurden durch 6 Wochen beobachtet. Die klinische Heilung lag bei 90,3% (56 Patienten), die mykologische Heilung bei 823% (51 Patienten). 55% der Patienten hatten eine anhaltende Hypopigmentation. In Anbetracht der guten Wirksamkeit gegen Pityriasis versicolor und der erhaltenen guten Resultate mit 1% iger Naftifin‐Lösung (Exoderil®) kön‐nen wir das 6‐tägige Therapieschema gegen Pityriasis versicolor empfehlen.

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serum Na+ 191 mmol/l, BUN 245 mg/dl, Glucose 161 mg/dl, calculated serum osmolality 479 mOsm/l) complicated with prerenal AKI (serum Cr 4.1 mg/dl, and K+ 6.3 mmol/l), anuria, ATN, serum non-conjugated bilirubin of 27 mg/ dl, DIC (INR 2.3, PTT 55 s), and thrombocytopenia (platelet count 33,000/μl). Patient's weight on admission was 2.2 kg, with an estimated weight loss of 43% since birth. She had grayish skin discoloration with surprisingly normal vital signs, lactatemia and normal neurological status. Density of the dural venous sinuses was prominent on brain CT scan, likely reflecting hemoconcentration (Hg 22.5 g/dl). Current literature does not provide clear recommendations for correction of extreme hypertonic dehydration with co-existing life threatening complications. This clinical situation represents a very challenging scenario with potential for severe risks in case of too rapid or slow correction of fluid and electrolyte imbalance, including exacerbation of systemic hypoperfusion with hemodynamic instability, brain edema, dysrhythmias, irreversible kidney injury, cerebral sinus venous thrombosis, and kernicterus. Our therapeutic interventions included two 20-ml/kg NS boluses for peripheral perfusion optimization and then a third 20-ml/kg bolus for anuria. Patient was placed on D5 ½ NS (1.5 maintenance rate based on actual patient's weight), and oral rehydration with pedialyte. Double phototherapy was implemented for the first 12 hrs. No attempt was made at correcting DIC during the first 48 hrs. Patient diuresis was restored during first 5 hrs of therapy. Serum Na+, BUN and Cr levels steadily normalized over the next 96 hrs. Patient neurological status remained intact and she was discharged from the PICU after 7 days of treatment fully recovered.