Viscerocutaneous Loxoscelism Manifesting with Myocarditis: A Case Report

Abstract

Patient: Male, 16-year-old Final Diagnosis: Toxic myocarditis Symptoms: Cardiogenic shock • disseminated intravascular coagulation • heart failure Medication: — Clinical Procedure: Immunoglobulin therapy • plasmapharesis Specialty: Critical Care Medicine • Toxicology Objective: Rare coexistence of disease or pathology Background: Envenomation from the brown recluse spider ( Loxosceles reclusa ) is described to cause both local and systemic symptoms. We report a case of an adolescent boy who developed severe systemic loxoscelism, and his clinical course was complicated by myocarditis, which has not been previously reported in association with loxoscelism. Case Report: A 16-year-old boy presented with non-specific symptoms and forearm pain following a suspected spider bite, which subsequently evolved into a necrotic skin lesion. During his clinical course, he developed a characteristic syndrome of systemic loxoscelism with hemolysis, disseminated intravascular coagulopathy, and severe systemic inflammatory response syndrome, necessitating transfer to the Intensive Care Unit. The diagnosis was confirmed with an enzyme-linked immunosorbent assay that detected Loxosceles venom in the wound. Additionally, he developed pulmonary edema and cardiogenic shock secondary to myocarditis, which was confirmed with cardiac magnetic resonance imaging. Steroids and plasmapheresis were initiated to manage the severe inflammatory syndrome, and the myocarditis was treated with intravenous immunoglobulins, resulting in resolution of symptoms and improvement of cardiac function. Conclusions: This is the first reported case of myocarditis associated with loxoscelism, providing evidence for Loxosceles toxin-associated cardiac injury, which has been previously described in animal models only. Furthermore, this case provides further support for the use of confirmatory testing in the clinical diagnosis of loxoscelism.

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“…Steroids and plasmapheresis were utilized to treat the severe inflammatory condition, and intravenous immunoglobulins were administered to treat myocarditis, which resulted in symptom resolution and improvement of cardiac function. 17 In a report of a brown spider bite on the lower lip of a 32-year-old man during the coronavirus disease 2019 (COVID-19) pandemic in southern Brazil, the patient was described as having oedema, pustules, necrotic regions, and ulcerations; lower back pain; fever; and dyspnoea. 18 Leukocytosis, increased D-dimer levels, C-reactive protein, creatine phosphokinase, procalcitonin, and fibrinogen were detected in laboratory tests, and the medical team diagnosed loxoscelism with moderate changes.…”

“…In 2021, Langner et al. 17 reported a possible spider bite on a 16-year-old boy. In addition to a necrotic skin lesion, the patient developed a typical syndrome of systemic loxoscelism with haemolysis, DIC, and severe systemic inflammatory response syndrome, necessitating transfer to the intensive care unit.…”

Kounis Syndrome: Acute Coronary Syndrome Induced by a Loxosceles Laeta Bite in a 9-Year-Old Boy

“…The case presented is interesting because when loxoscelism affects the myocardium, it generally manifests as myocarditis or a perimyocarditis with symptoms of chest pain and, in some cases, with positive cardiac biomarkers analysis. 5 …”

Challenges and Opportunities in Clinical Diagnostic Routine of Envenomation Using Blood Plasma Proteomics

“…The diagnosis is mainly clinical and focused on the skin wound; however, the clinical team also uses laboratory tests, although nonspecific, to obtain a possible differential diagnosis [ 52 , 53 , 54 ]. The laboratory diagnosis relies on the presence of several hematological tests (analysis of the red series and WBC) to identify hemolysis and leukocytosis, hemostatic tests (fibrinogen, APTT, PT, and D-dimer assay) to assess the presence of disseminated intravascular coagulopathy, and biochemical tests (ALT, AST, total and direct bilirubin, urea, creatinine, CRP, lactate, lactate dehydrogenase, CK, sodium, potassium, glucose, and venous blood gases) to diagnose and monitor kidney injury [ 55 ].…”